Case Study: Burn Assessment and Management

00:01 So why don't we talk through how we would take those same cues and prioritize them? Remember I gave you four to focus on.

00:08 So let's talk about our patient.

00:10 Our patient is a 25-year-old male college student who was making ramen in his dorm room.

00:15 Now the mechanism of injury.

00:16 Boiling water. Location. Depth and extent.

00:20 It's the left arm. It looks like it went through the epidermis and the dermis.

00:24 He is screaming in pain. So the nerve bed is intact and it's only the left arm.

00:30 So that's 9%. The third one.

00:32 Was there any smoke in this situation? No. So there's no signs or symptoms of respiratory distress.

00:38 Number four, first set of vitals.

00:41 140 over 90. A little high for his age.

00:44 But remember, we've got a lot going on.

00:46 110 for heart rate. Again, sinus tachycardia.

00:49 That's elevated. Respiratory rate is elevated to 26.

00:54 Temperature is 99 and pulse ox is 100% on room air.

01:00 So let's prioritize. You've been told a million times to focus on airway.

01:06 He's screaming, and his pulse ox is 100% on room air.

01:10 The burn isn't on his neck, chest or face, all of which could threaten an airway, especially as the tissues become edematous during that secondary inflammatory process that can happen in Burns. Since there wasn't smoke involved, we're less concerned about inhalation injury or bronchial tissue damage.

01:27 Let's take a look at the burn itself.

01:29 Although it appears this is a second degree burn, it's not clear yet whether he will need only supportive care or surgical intervention.

01:36 Since we know the agent was water, we won't need to problem solve a neutralizing agent. Now, because the total surface area is only 9% for the burn, the situation is less serious and we have more time to work with.

01:49 So why don't we take a closer look at those vital signs? He is hypotensive and tachycardic.

01:55 Now his respiratory rate is elevated as well.

01:58 That would make sense because he's clearly in a lot of pain.

02:01 But why don't we see if the emergency medical team has given him anything? I love this part. This is the transition to prioritizing two to hypotheses.

02:11 So of course, your brains have already jumped ahead to thinking.

02:14 Of course, his heart rate is elevated.

02:16 He's in pain. Of course, his blood pressure is elevated.

02:19 He's injured. So, and you would be right.

02:22 But be careful. Don't get distracted.

02:24 There's more to think of.

02:26 We need to hypothesize what we as nurses need to do to prevent complications.

02:31 So considering our list of cues for burn clients, the mechanism of injury, the location of injury, airway and vital signs or signs of shock.

02:42 Which one of these should receive the focus of our attention? We're going to be looking at all four areas.

02:47 But you know, as a nursing student it's all about identifying which is most important or the highest priority. So what do you think? Which one should receive the focus of our attention? Well, even though we think airway isn't a concern, that doesn't mean we stop worrying about it.

03:04 But he said he was making ramen and it was just boiling water, and we see only burn injuries on the left arm.

03:10 But has anyone looked at the rest of him? Well, just because he's a young adult male and presumably healthy, it doesn't mean there isn't significant fluid loss from a burn that large.

03:21 How do the vital signs we have compared to the ones the emergency team took when they picked him up? Did they already give him pain medicine? Are those vitals with pain medication or without? So if you think we should take action by addressing those vital signs, you'd be right. Those vital signs are the most important aspects of this patient to manage.

03:40 While providers are making decisions about whether this patient will need a surgical intervention.

03:46 We are in the position to further assess our patient, to ensure there is an additional injury and see what we can do to stabilize those vitals.

03:54 The nursing role centers on implementing protocols and orders for pain management, fluid resuscitation, In wound care and coordinating the actions of the interdisciplinary team. But I don't want you to forget the power of explaining all of these steps to the patient.

04:10 A lot of things have happened to him in a very short amount of time.

04:14 Explaining what is happening and what is going to happen to the patient can have a dramatic effect on his vital signs. If it's not already established, high quality intravenous access is important.

04:26 You're probably going to want to have an 18 G or larger.

04:28 You should place a line. We're going to need this for pain management and for fluid replacement.

04:34 Now for fluid resuscitation in adults, most burn care protocols follow the parkland formula. It's four milliliters per kiloliter times a percentage of total body surface area that was burned. The standard solution is Lactated Ringer solution, because it's a composition in osmolality that most closely resembles normal body physiological fluids, and the lactate may buffer the metabolic acidosis in the early post burn phase.

04:59 Now, because second degree burns involve dermal tissue and this injury is significant.

05:03 Our patient is likely to need significant intravenous pain management.

05:07 Now, it's not unusual to involve pain management specialists in these situations.

05:11 Before we can begin to work with the wound care, we will need to control his pain.

05:16 Now, our initial wound care would involve placing cool, not cold, saline-soaked gauze on the burned area.

05:22 It's likely what the emergency providers first applied, but these had to be removed so the area could be assessed when the patient first arrived to the hospital. Our role now is to redress the wound, anticipating the patient may be admitted to the hospital, transferred to surgery, or discharged to home with wound care.

05:39 Follow-up, ideally providing the patient with information, comfort measures, fluid resuscitation and aggressive pain management will have all the intended effects. But how would you know? Well, let's do the next step.

05:53 Let's evaluate our outcomes later in our shift, the providers have decided to admit the patient for observation and wound care evaluation.

06:02 Now, the dressing we applied is intact since he weighs 180 pounds or 81kg.

06:07 He's receiving three liters of LR and is receiving IV morphine sulfate in a pain controlled analgesia pump. That means he can control it.

06:17 He appears to be resting comfortably.

06:19 Take a look at his vital signs.

06:21 They're much closer to normal.

06:23 The blood pressure is down to 120 over 80.

06:26 The heart rate is down to 70.

06:27 Respiratory rate is 14. Temperature 98 and the pulse ox is steady at 100%.

06:34 These are the type of outcomes that we're looking for.

06:37 This shows improvement in the patient's situation.

06:40 So let's review. When encountering a patient who has experienced a major burn, recognizing cues that there is an airway issue is the priority with the burn patient.

06:50 It's crucial that the team has information about the mechanism of injury.

06:54 And part of your role is the assessment and documentation of the location, depth and extent of the injury itself.

07:01 Now, in addition to all that other information, your patient's vital signs are communicating so much to the team. Rapid shifts of blood pressure and heart rate are warning signs of hypovolemic shock. Tachypnea or rapid breathing can indicate impending respiratory acidosis.

07:18 Temperature abnormalities might signal loss of thermal stability.

07:22 Hopefully, you saw a theme throughout the discussion that your clinical judgment and ability to take action is what has an impact on your patient.

07:30 Now, caring for younger and older adults with burns is much more complicated because their systems respond differently.

07:37 The protocols you will use to replace lost fluids in pediatrics are different.

07:42 And older adults may have chronic illnesses that also make treatment much more complicated.

07:47 There is so much more to know about burn care that this is just the beginning and an introduction for you in your role in the treatment of a client experiencing a burn.