Expectedassessment out comes
Copies secretions usually black tinged
Sub sternal retractions
2.Diagnostic lab/studies Normal values and expected abnormalities
Complete blood count
Urea electrolytes and cretinines
Liver function test
3.All Nanda Nursing Diagnosis
Ineffective airways clearance due to smoke inhalation that results in increased lung congestion.
A deficiency in the fluid volume of the burn injuries victims due to abnormal fluid loss.
Peripheral constriction caused by the circumferential wound of the left arm resulting in ineffective tissue perfusion.
Burns beyond 40%
Burns affecting the airways
Full administration of resuscitation to compensate the fluid loss.
Therule of nine is a formula used in the calculation the total burnsurface area in percentage and helps both in management decisionsthat include fluid therapy and becomes part and determination ofpatient transfer to burn unit[ CITATION Rob111 l 2057 ]. For this patient
Neckand chest = 9%
Theleft arm = 9%
Thereforethe total burn surface area (TBSA) will be
9+ 9+ 9 = 27%
TheParkland formula is applied in the calculation of the total amount ofthe resuscitation fluid needed in the first twenty-four hours of aburn patient to maintain their hemodynamic state[ CITATION All12 l 2057 ].The first half of the total fluid isgiven in the first eight hours, and the remaining half isadministered for the remaining sixteen hours.
V= 4 *m* (A * 100), where m is a mass in kegs and V is the volume ofMl.
V= 4 * 50 * 31.5 = 6300ml
Inthe first eight hours 3150 ml is given to this patient and theremaining 3150ml, is given for the remaining sixteen hours evenly.
Forthe neck burns, there will be breathing problems due to obstructionof the airways abused by inflammation and swelling leading to enemaof the airways.
Forthe circumferential burns in the chest, the will be inadequatebreathing due to tissue damage that restricts motion of the chest.
Circumferentialburns of the arms reduce blood flow to the extremities due to theconstriction that come as a result of the burns.
6.Write a plan for each nursing diagnosis
Forcyanosis give hyperbaric oxygen (100%) via mask or by use of amechanical ventilator. For copious secretions and stridor givebronchodilators and mucolytic agent to assist in expelling them.
Fordehydration insert an intravenous line and administer fluids likecrystalloids that include ringers lactate, normal saline, andHartmann’s solutions in the 24 hours. In the next 24-48 give 2000Ms of colloids + amount of 5% dextrose which can give urine output of50-70 ml/hr[ CITATION Dav12 l 2057 ].
7.Write interventions for your plan
Early intubation to prevent tracheal placement
Humidified O2 100%
ABG’s (respiratory acidosis or alkalosis?)
Serial CXR’s and fiber optic bronchoscopy
8.Scientific rationale for interventions
The airway patency is maintained by the way of prophylactic nasotracheal intubation.
Escharotomies of the upper extremities is performed
The fluid resuscitation process is initiated using Parkland formula.
9.Write how you would evaluate your plan
Thewoman is connected to the hyperbaric air supply from a T-piecethrough the nasotracheal tube. Her ABGs has shown some signs ifimprovements so far. The bronchodilators administered and themucolytic added have reduced the tracheal secretions. Also, the fluidresuscitation assessment from the hourly urine shows adequateresuscitation. Her blood pressure consequently has reduced to 100/64and the pulse rate to 100.
10.List of medications typical for the medical diagnosis
Broad spectrum antibiotics
Hagan, A. ( 2012). Suri`s Burn Book: Well-Dressed Commentary from Hollywood`s Little Sweetheart. New york: Running Press Book Publishers,.
Herndon, D. N. (2012). Total Burn Care: Expert Consult – Online. New York: Elsevier Health Sciences.
Sheridan, R. L. (2011). Burns: A Practical Approach to Immediate Treatment and Long Term Care. Chicago: CRC Press.