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vague111

vague111

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scared new nursing student

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  1. vague111

    Urgent! Case study of the child with a burn

    Can anybody give me more comments?
  2. vague111

    Urgent! Case study of the child with a burn

    Thank you for your contribution with your precious experience.
  3. I have a case study and I need your tips for these two questions. My answers are general and I don't think I got the point. Here is a senario. Charge Nurse Report: We floated you over from the burn unit to care for Kim Danner who's 11 and ½ years old. She's the middle Danner child. Since the burn unit is full and we needed a burn RN to care for her as she was the last person removed from the wreckage because she was blocked in by her brother that was paralyzed, and unfortunately by that time a grass fire stated from the sparks of the accident under and near the vehicle. She was sitting in the center of the backseat. She has a second-degree burn on her anterolateral left side stretching from her nose to her perineal region. It also spreads out halfway across her chest. It covers about 25 % of her total body area. We thought that her left eyebrow and eyelashes were singed but it turned out to be soot that washed right off. We turned her room into an isolation room, and put her in it because it the farthest away from the other patients and the staff areas. As soon as a bed opens up in the burn unit, we'll transfer her over. Kim has no medical history other than a tonsillectomy at 8 years old. Her vitals are T 37.0, HR 106, R 24, and BP of 90/64. She has sinus tachycardia. Lungs are clear with sats around 98 on room air. Her voice is a little scratchy. Hourly urine outputs have been around 45 ml/hr, and dark-brown. Her bowel tones are slightly hypoactive. She has a high protein tube feeding running through a Dobhoff tube, 45 ml/hr. She has a PICC in her right arm with LR running at 80ml/hr. The skin around the burns is grossly edematous. The wound gets washed gently BID with mild soap, no scrubbing. Loose skin flaps are cut off, but blisters are to be left intact. Then it's covered with Silvadene gauze, then surgical netting. Kim has been on a fentanyl PCA, with a basal rate of 10-20 mcg/hr and a bolus for her wound care. The debridements are terribly painful otherwise. Today we are starting to switch her over to Oxycontin BID with Oxycodone for breakthrough. If you can get her pain to a level of "2", she seems to be OK. Here are two questions and my answers. 1. Why do burn patients have such significant pain? Pain is inevitable during recovery from any burn injury. Burn pain travels through peripheral receptors to central detection via nociceptive tracts. The inflammatory response of the burn injury exacerbates the pain responses during dressing changes. The outstanding features of burn pain are its intensity and long duration. Furthermore, necessary wound care carries with it the anticipation of pain and anxiety. 1. Factors contribute to the patient's pain experience - The adequacy of the health care provider's assessment of the pain. - The appropriateness and adequacy of pharmacologic treatment of pain - The appropriateness and adequacy of pharmacologic treatment of pain - The multiple procedures involved in burn care (e.g. wound care, rehabilitative exercises). - The appropriate evaluation of the effectiveness of pain relief measures. 2. Types of burn and causes of pain - Partial-thickness burns: Nerve endings are exposed, resulting in excruciating pain with exposure to air current. - Full-thickness burn: Although nerve endings are destroyed, the margins of the burn wound are hypersensitive to pain, and there is pain in adjacent structure. Healing of full-thickness burns creates significant discomfort as regenerating nerve endings become entrapped in scar formation. 3. Types of burn pain - Background or resting pain: Pain that exists on a 24-hour basis. - Procedural pain: Pain caused by manipulation of the wound bed during dressing changes or range-of-motion exercises. - Breakthrough pain: Pain occurs when blood levels of analgesic agents decrease below the level required to control background pain. 2. Considering her age, are there any other pain interventions that you would consider? Overview The patient is 11 and ½ years old. Therefore, she can understand the relationship between an event and pain, have a more complex awareness of physical and psychologic pain such as moral dilemmas and mental pain. She may be able to describe intensity and location with more characteristics and to describe psychologic pain. The predicted behavioral response is to pretend comfort to project bravery, or to regress with stress and anxiety. She might attempt to maintain her composure during painful or invasive procedures because school-age children tend to believe they need to be brave. Intervention - To reduce the stress of burn dressing procedures, give her as many choices as possible. Children with some perceived control tend to demonstrate less maladaptive behavior. - The child's anxiety and fear often will be reduced if the nurse explains what is going to happen and demonstrates how the procedure will be done. Children who have understanding of the procedure also demonstrate less maladaptive behavior. - Ask her to give a history of painful procedures with reactions. - Assess how she copes with and manages pain. The child with several past pain experiences may not exhibit the same types of stressful behaviors as the child with few pain experiences. - Identify what works best to reduce her pain. - Identify the parent's and child's preferences for analgesic use and other pain interventions
  4. vague111

    case study help!

    Thank you for your comment. Pt's confusion is from metabolic acidosis. When blood pH is low, neurons don't function well. Is dyspnea related to confusion, and can O2 sat be under confusion? By the way, this case study is a kind of senario from my theory class.
  5. vague111

    case study help!

    I think pt is in life-threatening situation, so pt care is more important than teaching.
  6. vague111

    case study help!

    i want somebody to give some advice. I need to prioritize to make a care plan based on data. Here are the data. Family Members & Profiles 13 years old, Type I Diabetic Introduction/ Background: An anxious-looking, just arrived without report or notification on a gurney from the ED Situation: Chart data: History reveals that pt is a 13-year-old student attending middle school who was diagnosed with type 1 diabetes a year ago. Last weekend, pt and several of his friends traveled with his family to a beautiful beach in Mexico for a weekend of sun, swimming, and fun. On the last day of the weekend, pt stubbed his right toe on a nearby rock during a volleyball game that resulted in a small, open cut. At the time, pt didn't pay much attention to it; he kept on playing. After the game, he put his sandals on and headed back to the motel room to pack for the drive home. When getting out of the car, pt noticed his right toe was swollen and reddened. The first thing he did when returning home was to rinse his toe with cool water before going to bed. pt awoke in the early hours of the next morning with vomiting, fever, and diarrhea. His flu-like symptoms and continued anorexia lasted about a week. Pt stopped taking his usual insulin regimen two days prior to admission to the ED because of his inability to eat. Pt was admitted to the ED via ambulance and presented with the typical signs and symptoms of DKA. Pt experienced a drop in his BP to 88/50 mm Hg and was stabilized in the ED with an infusion of 0.9% NaCl, the same crystalloid solution that was infusing as he arrived on the medical unit. Initial lab results from the ED include: blood glucose (540 mg/dL) serum sodium (129 mEq/L) serum potassium (5.0 mEq/L) serum chloride (94 mEq/L) BUN (70) serum osmolality (319 Osm/L) pH (7.23) partial pressure of carbon dioxide (pCO2) (22) HCO3 (8) New orders included the establishment of a regular insulin intravenous (IV) drip along with serum glucose, electrolyte labs, and other blood studies per protocol; oxygen via nasal cannula; activity restrictions; and other ongoing monitoring orders necessary for managing quick changes in health status secondary to treatment modalities. Unfolding data: Client Assessment Data as documented by Nurse on admission: VS: T99.0, P120, R28, 105/72 Assessment: Neuro: Oriented to self, but confused to time and place. Unsteady gait. CV: Regular rate and rhythm; diminished peripheral pulses; positive skin tenting, capillary refill >3 seconds. Respiratory: Lung sounds clear but dyspnea with increased rate. Fruity breath. GI: Nausea and vomiting with emesis of 50 mL of green bile fluid during admission process. GU: Subjective: "I peed a cup full this morning." Integumentary: Skin flushed, dry and warm. R great toe is swollen and inflamed with an open laceration midline above the nail of great toe-draining slight amount of yellow fluid. Musculoskeletal: Generalized weakness. This is what I did. Three priorities 1. Acute confusion 2.Risk for electrolyte Imbalance (hyperkalemia/hypokalemia). 3. Deficient fluid volume related to hyperglycemia. This is my care plan 1. Acute confusion Evidenced by ↓pH (7.23). Confused to time and place Infuse IV fluid Intervention Give regular insulin by IV infusion. Check CBG. Measure pt's VS every 15 minutes. Check pt's blood glucose level. Check pt's intake & output. Check urine ketones. Assess neurological status. Check ECG. Speak slowly with a low voice pitch. Refer to time of day and place. Provide pt with a clock and calendar. Use nightlights or dim light at night. Offer simple explanations of tasks. Do not argue with pt. 2. Risk for electrolyte Imbalance (hyperkalemia/hypokalemia). Evidenced by Hyperkalemia: anxious -looking, diarrhea, pH (7.23), insulin deficiency evidenced by blood glucose (540 mg/dL), severe hypovolemia (evidenced by ↑Blood glucose (540 mg/dL), ↑Serum osmolarity (319 Osm/L), ↑BUN (70), ↑P (120), ↑RR (28), ↓BP (88/50 mmHg → 105/72 mmHg) vomiting, fever, and diarrhea); Risk for Hypokalemia: confusion, hypotension, Regular insulin IV drip (↓ potassium). Intervention Monitor ECG. When give IV potassium, make sure pt produces at least 30mL/hr of urine. Listen to the lung & heart. Assess for S/S of Hyperkalemia: irritability, anxiety, abdominal cramping, diarrhea, weakness of lower extremities, paresthesia, irregular pulse, cardiac standstill; Assess for S/S of hypokalemia: fatigue, malaise, confusion, muscular weakness, cramping or pain, and shallow respirations. 3.Deficient fluid volume related to hyperglycemia Evidenced by Vomiting, fever, and diarrhea. Nausea and vomiting with emesis of 50 mL of green bile fluid during admission process. ↑ Blood glucose (540 mg/dL) ↑Serum osmolarity (319 Osm/L). ↑BUN (70). ↑P (120), ↑RR (28), ↓BP (88/50 mmHg → 105/72 mmHg). ↑Serum potassium (5.0 mEq/L). Diminished peripheral pulse, Positive skin tenting, Capillary refill >3 seconds. Intervention Infuse IV fluid. Give regular insulin by IV infusion. Check CBG. Measure pt's VS every 15min. Check pt's blood glucose level. Check pt's intake & output. Check hematocrit/hemoglobin. Check urine specific gravity. Weigh pt daily. Assess skin turgor, dry mucous membranes, or complaints of thrist. Assess VS every 15 minutes until stable. I am not sure about my 3 priorities. Also, I want somebody to point out if there are any missing info?