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Case Study Examples For Nursing Students In Burned Patient


Introduction

In the medical industry, doctors and nurses need to co-operate to ensure the hospital is working efficiently. There is a difference between their roles. Generally, doctors will diagnose the problem or the sickness and offer their opinions. Meanwhile, a nurse’s responsibility is to provide assistance to the doctor by carrying out the treatment (Stedman, 2008). It is wrong to put more importance on one role than the other. Nurses are pivotal in making sure that everyday task runs smoothly. Therefore, this article will examine the job scopes of a nurse by using a case study of an elderly burnt victim. It will look at the client’s pathophysiology condition, prescribed medications relevant to the client’s diagnosis and their side effects, the purpose and outcome of any medical procedures, recent advances in nursing care and management in regards to the client’s condition and a discharge plan for the client and family members to follow.

The case study

The case subject is Mr. Newton, a 54 years old man, who suffered from burnt injuries due to a fire accident at home. He has fallen asleep while smoking a cigarette and the bed linen caught on fire. He suffers from full thickness burns on the upper half of his chest, back and at the back or posterior aspects of both upper arms. Besides that, he also sustains superficial partial-thickness on his face, neck and hands. Mr. Newton arrives at the hospital 5 hours after the incident. Upon his admittance into the emergency room, he is inserted with a foley catheter and nasogastric or NG tube. Further assessment reveals that his lungs are clear with a productive cough of carbon-tinged sputum. His NG tube contains dark yellow-green liquid and his foley catheter has burgundy-colored urine. Since the foley catheter is inserted 2 hours ago, it has managed to drain a total of 150cc urine output. The pulses are difficult to palpate as his extremities are edematous. Mr. Newton’s blood pressure is 96/50, pulse rate is 100, respirations are 24 breaths per minute and his temperature measures at 1000F.

Pathophysiology of the client’s condition

According to Craft, Gordon and Tiziani (2011), pathophysiology can be defined as the functional changes associated with or resulting from disease or injury. In regards to the case study, Mr. Newton, there is a slight increment on his heart rate and peripheral vascular resistance. This can be due to the secretion of catecholamines from tissues that are injured during the fire (Brown & Edwards, 2008). The patient’s central nervous system secretes norepinephrine and dopamine as his body gets ready to response to the situation (Brown & Edwards, 2008). Aside from that, hypovolemia will also occur and this is caused by dehydration as well as a loss of about 10 to 20 percent of blood volume due to the burns (Brown & Edwards, 2008). In the beginning, the client’s cardiac output may decrease and this condition should return to normal after 24 hours if sufficient fluid is administered (Craft, Gordon & Tiziani, 2011). Due to an increase in the rate of metabolic activity in the patient’s body, cardiac output will eventually get a little higher. Besides that, a higher temperature should also be noted as tissues go through a phase of denaturation or the unfolding of proteins (Craft, Gordon & Tiziani, 2011).

Prescribed medications, side effects and contraindications in relevance to the client’s condition

Burns can be caused by different reasons. Generally, burns can be categorized into four types. They are thermal, electrical, chemical and radiation burns (Diepenbrock, 2010). Therefore, medication should be rightfully prescribed according to the different types of burns in order for them to work efficiently.

Due to the extremities of his injuries, nurses are likely to prescribed analgesics for the purpose of controlling the amount of pain (Diepenbrock, 2010). A few examples of analgesics are Morphine sulfate, Vicodin and Demerol. Some of the common side effects of this medication are nausea, vomiting, drowsiness, orthostatic hypotension, irregular heart rate and hypothermia. If analgesics are taken over a long period of time with a high dosage, it can also cause liver damage, respiratory depression as well as addiction. The contraindications of analgesics in the case subject, Mr. Newton should be stopped if he has a history of asthma attacks, respiratory problems, constipation or sustained a head injury.

Besides that, nurses will also prescribed topical antibiotics for the client in order to prevent infections and bacteria growth (Diepenbrock, 2010). One example of a topical antibiotic is Silvadene. It requires application on the burnt areas by using a sterile technique. The wounds need to be cleaned first before using the cream. This medication is known to cause allergic reaction on patients who are sensitive towards silver sulfadiazine. In some rare cases, the usage of Silvadene can also result in fungal infection and hemolysis. Therefore, Mr. Newton will be monitored all the time for any signs of allergy. Since this medication cannot be applied on the face, nurses may also prescribe other forms of antibiotics such as oxacillin, mezlocillin and gentamicin (Diepenbrock, 2010). Aside from analgesics and topical antibiotics, anabolic steroids like oxandrolone may also be given to the client in order to help shorten the time for the wounds to heal (Diepenbrock, 2010)l.

Medical procedures: Purpose and Outcomes

The first medical procedure is to check for cervical spine protection and airway maintenance (Gatford, 2006). This is to ensure that the client’s airways are not blocked. Intubation can also help doctors and nurses to administer certain types of drugs. Next, vascular access should be obtained by inserting a phlebocatheter into a blood vessel (Gatford, 2006). This procedure is an easy way for medical personnel to draw blood or giving medications or nutrient to the patient. Then, the client should be hooked up to monitoring devices for vital signs and follow by a thorough and systematic trauma survey.

Later, fluid resuscitation should be started by following the Rules of Nine. This medical procedure is important to ensure optimal blood flow and to replenish body fluid that is lost due to the injuries (Kralik, Trowbridge & Smith, 2008). After all that, managing the pain is the next step. Since the client has third and second degree burns, doses of analgesics will be administered to control the pain. Antibiotics and immunization against tetanus can also be given to the patient in order to avoid any forms of infections (Kralik, Trowbridge & Smith, 2008). If the patient is non-responsive, nasogastric tube with IV proton blocker should be inserted. Subsequently, a foley catheter is also put in for the purpose of urine observation. Since the client’s urine is burgundy in color, a sign of renal failure, fluid bolus is administered until the urine changes to straw color (Kralik, Trowbridge & Smith, 2008).

Finally, the patient should be applied with a thin layer of silver sulfadiazine and covered with sterile sheet (Lehne, 2010). This step will ensure that the patient will not suffer from hypothermia and the wounds are well taken care of. Further laboratory tests can be taken and a more comprehensive diagnosis can be given after receiving the results.

Nursing Outcomes

After all the necessary steps that have been taken above, there should be a few noticeable outcomes on the burn patient. Mr. Newton’s airway will remain open and provide adequate ventilation. The client should also feel relief from pain through the administration of analgesics and other medications. Besides that, the readings on body temperature, fluid volume and cardiac output will stay within an acceptable range. Wounds are cleaned, dressed and remained free from any signs of infections. Nurses will also get valuable information from the patients such as family history, special dietary needs and allergies that will help in a more precise diagnosis and better medical treatment (Sole, Klein & Moseley, 2009).

Recent advances in nursing practice for the caring of burn patients (Literature-based)

Experts have found there is no single theory that is adequate in addressing the different aspects of patients’ care (Sullivan, 2008). In Australia, they have found the evidence-based theory is not fully developed and sufficient to be used while caring for burn patients (Sullivan, 2008). However, nurses can choose to adopt suggestions based on Orem’s Self-Care Model as it is one of the closest to a comprehensive guide in caring for burn patients (Stedman, 2008). This model consists of three theories. They are known as the theory of self-care, the self-care deficit theory and the theory of nursing systems (Stedman, 2008). Orem’s Self-Care Model provides a sequence of actions that can be used by nurses on their patients at different stages. When the burn patients first arrive, nurses are supposed to adopt the wholly compensatory system. As the burn patients are in the process of healing, nurses will move on to the partially compensatory system. Finally, during the patients’ rehabilitation process, nurses will progress to the supportive-educative system. There are some weaknesses and limitations to Orem’s Self-Care Model. Therefore, Watson’s caring theory and Roy’s adaptation model can also be incorporated for a thorough nursing practice in caring for burn patients (Sullivan, 2008).

Discharge Plan

Burn patients are discharged from the hospital after a certain period of time that is determined by their physicians. There are some instructions which the patient will need to follow and normally, this involves the family members as well. The discharge plan will include informing the patients regarding their medications, diet restrictions, physical therapy and rehabilitation, ways to care for the wounds and dressings as well as instructions for follow ups (Tiziani, 2010).

Conclusion

Suffering from burn injuries can be devastating to a patient’s life. It is a painful and long journey to full recovery. On contrary belief, nurses hold an important role in ensuring the quality of treatment that patients receive during their stay in the hospital. Immediate actions taken by these medical personnel can prevent further damage to the tissues which lead to a lower percentage of scarring. After the initial diagnosis, the healing process and everyday tasks are taken over by the nurses. They ensure that patients receive their medication on time, monitor for any vital changes as well as the cleaning and dressing of the wounds. The support system given by nurses can help to reduce the patient’s suffering and make sure the road to recovery a more comfortable one. In order to perform efficiently, nurses are required to constantly educate themselves on the current advances in their respective field.

References

Brown, D & Edwards, H (2008). Lewis’s medical-surgical nursing: Assessment and management of clinical problems. Australia: Elsevier. New South Wales.

Craft, J, Gordon, C & Tiziani, A (2011). Understanding pathophysiology. Australia: Elsevier. New South Wales.

Diepenbrock, N (2010). Quick reference to critical care (4th edition). Lippincott Williams & Wilkins. Maryland.

Gatford, J. D (2006). Nursing calculations(7th edition). China: Elsevier. Beijing.

Kralik, D, Trowbridge, K & Smith, J (2008). A practice manual for community nursing in Australia. Wiley-Blackwell. New Jersey.

Lehne, R. A (2010). Pharmacology for nursing care (7th edition). Australia: Elsevier. New South Wales.

Sole, M. L, Klein, D. G & Moseley, M. J (2009). Introduction to critical care nursing (5th edition). Elsevier Saunders. St. Louis.

Stedman (2008). Medical dictionary for the health professions and nursing. Lippincott Williams & Wilkins. Maryland.

Sullivan, E. J(2008). Effective leadership and management in nursing (7th edition). Prentice Hall. New Jersey.

Tiziani, A (2010). Harvard’s nursing guide to drugs (8th edition). Elsevier Mosby. St Louise.

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A great fire in the city centre was reported just this morning. Seven people were killed and hundreds were injured. Among the injured were those who received burn injuries. Some only have blisters in their bodies but there are those who have total damage that reached their bones and muscles. There are victims who are crying out loud in pain because of the burns all over their body. The victims have experienced all three degrees of burn injury and were rushed to the nearest hospital.

Contents

Description


A nurse who cares for a patient with burn injury should be knowledgeable about the physiologic changes that occur after a burn, as well as astute assessment skills to detect subtle changes in the patient’s condition.

  • Burn injury is the result of heat transfer from one site to another.
  • Burns disrupt the skin, which leads to increased fluid loss; infection; hypothermia; scarring; compromised immunity; and changes in function, appearance, and body image.
  • Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries. Inhalation injuries in addition to cutaneous burns worsen the prognosis.
  • The severity of each burn is determined by multiple factors that when assessed help the burn team estimate the likelihood that a patient will survive and plan for the care for each patient.

Classification


Burns are classified according to the depth of tissue destruction as superficial partial-thickness injuries, deep partial thickness injuries, or full thickness injuries.

  • Superficial partial-thickness. The epidermis is destroyed or injured and a portion of the dermis may be injured.
  • Deep partial thickness. A deep partial thickness burn involves the destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis.
  • Full thickness. A full thickness burn involves total destruction of the epidermis and dermis and, in some cases, the destruction of the underlying tissue, muscle, and bone.

Pathophysiology


Tissue destruction results from coagulation, protein denaturation, or ionization of cellular components.

  • Local response.Burns that do not exceed 20% of TBSA according to the Rule of Nines produces a local response.
  • Systemic response.Burns that exceeds 20% of TBSA according to the Rule of Nines produces a systemic response.
  • The systemic response is caused by the release of cytokines and other mediators into the systemic circulation.
  • The release of local mediators and changes in blood flow, tissue edema, and infection, can cause progression of the burn injury.

Statistics and Epidemiology


A burn injury can affect people of all age groups, in all socioeconomic groups.

  • An estimated 500, 000 people are treated for minor burn injury annually.
  • The number of patients who are hospitalized every year with burn injuries is more than 40, 000, including 25, 000 people who require hospitalization in specialized burn centers across the country.
  • The remaining 5, 000 hospitals see an average of three burns per year.
  • Of those people admitted in burn centers, , 47% of their injuries occurred at home, 27% on the road, 8% are occupational, 5% are recreational, and the remaining 13% from other sources.
  • 40% of these injuries are flame related, 30% scald injuries, 4% electrical, 3% chemical, and the remaining unspecified.
  • Males have greater than twice the chance of burn injury than women.
  • The most frequent age group for contact burns is between 20 to 40 years of age.
  • The National Fire Protection Association reports 4, 000 fire and burn deaths each year.
  • Of the 4,000, 3, 500 deaths occur from residential fires and the remaining 500 from other sources such as motor vehicle crashes, scalds, or electrical and chemical sources.
  • The overall mortality rate, for all ages and for total body surface area burned is 4.9%.

Clinical Manifestations


The changes that occur in burns include the following:

  • Hypovolemia. This is the immediate consequence of fluid loss and results in decreased perfusion and oxygen delivery.
  • Decreased cardiac output. Cardiac output decreases before any significant change in blood volume is evident.
  • Edema. Edema forms rapidly after burn injury.
  • Decreased circulating blood volume. Circulating blood volume decreases dramatically during burn shock.
  • Hyponatremia.Hyponatremia is common during the first week of the acute phase, as water shifts from the interstitial space to the vascular space.
  • Hyperkalemia. Immediately after burn injuryhyperkalemia results from massive cell destruction.
  • Hypothermia. Loss of skin results in an inability to regulate body temperature.

Prevention


To promote safety and avoid burns, the following must be done to prevent burns:

  • Advise that matches and lighters be kept out of reach of children.
  • Emphasize the importance of never leaving children unattended around fire or in bathroom/bathtub.
  • Caution against smoking in bed, while using home oxygen, or against falling asleep while smoking.
  • Caution against throwing flammable liquids onto an already burning fire.
  • Caution against using flammable liquids to start fires.
  • Recommend avoidance of overhead electrical wires and underground wires when working outside.
  • Advise that hot irons and curling irons be kept out of reach of children.
  • Caution against running an electrical cord under carpets or rugs.
  • Advocate caution when cooking, being aware of loose clothing hanging over the stove top.
  • Recommend having a working fire extinguisher in the home and knowing how to use it.

Complications


There are a lot of consequences involved in burn injuries that may progress without treatment.

  • Ischemia. As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow.
  • Tissue hypoxia. Tissue hypoxia is the result of carbon monoxide inhalation.
  • Respiratory failure. Pulmonary complications are secondary to inhalational injuries.

Assessment and Diagnostic Findings


Various methods are used to determine the TBSA affected by burns.

  • Rule of Nines. A common method, the rule of nines is a quick way to estimate the extent of burns in adults through dividing the body into multiples of nine and the sum total of these parts is equal to the total body surface area injured.
  • Lund and Browder Method. This method recognizes the percentage of surface area of various anatomic parts, especially the head and the legs, as it relates to the age of the patient.
  • Palmer Method. The size of the patient’s palm, not including the surface area of the digits, is approximately 1% of the TBSA, and the patient’s palm without the fingers is equivalent to 0.5% TBSA and serves as a general measurement for all age groups.

Medical Management


Burn care is a delicate task any nurse can have and being knowledgeable in the proper sequencing of the interventions is very essential.

  • Transport. The hospital and the physician are alerted that the patient is en route so that life-saving measures can be initiated immediately.
  • Priorities. Initial priorities in the ED remain airway, breathing, and circulation.
  • Airway. 100% humidified oxygen is administered and the patient is encouraged to cough so that secretions can be removed by coughing.
  • Chemical burns. All clothing and jewelry are removed and chemical burns should be flushed.
  • Intravenous access. A large bore (16 or 18 gauge) IV catheter is inserted in the non-burned area.
  • Gastrointestinal access. If the burn exceeds 20% to 25% TBSA, a nasogastric tube is inserted and connected to low intermittent suction because there are patients with large burns that become nauseated.
  • Clean beddings. Clean sheets are placed over and under the patient to protect the burn wound from contamination, maintain body temperature, and reduce pain caused by air currents passing over exposed nerve endings.
  • Fluid replacement therapy. The total volume and rate of IV fluid replacement is gauged by the patient’s response and guided by the resuscitation formula.

Nursing Management


Nursing management in burn care requires specific knowledge on burns so that there could be a provision of appropriate and effective interventions.

Nursing Assessment

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