Pathophysiology behind Symptoms of a Burnt Patient
Firstly, on chest examination, an expiratory wheeze characterized with a coarse crackle on both upper lobes with a decrease of the lung sounds on the mid zones bilaterally. In addition to this, his sputum is carbonaceous which is an indication that the patient has inhalational burns. Her partial pressure of oxygen (PaO2) is 126mmHg, partial pressure of carbon dioxide (PaCO2) is 46mmHg, pH 7.31, HCO3 17, BE -2.3, K+ 5.1, Na+ 132, BGL 5.6 mmol/l, carboxyhaemoglobin > 25% and the Hct 51%. The PaO2 is elevated, the PaCO2 is slightly above the normal, the pH is acidic, there is a base deficit of -2.3, the potassium levels are elevated while the sodium levels are normal, and the bicarbonate level is low. This clearly shows that the patient is having metabolic acidosis as explained in the pathophysiology, there is decreased tissue perfusion which has led to the anaerobic respiration. In addition to this, there is bronchoconstriction as a result of the release of the serotonin, histamine, and thromboxane which are very powerful vasoconstrictors and the patient has a circumferential full-thickness burn on the chest. This two causes constriction of the chest reducing the lung volumes which reduces CO2 clearance. An expiratory wheeze with a crackle is as a result of the air trying to get out of the lung through the constricted pathways (Kreimeier, 2016).
Secondly, his systolic blood pressure is 138mmHg while his diastolic pressure is 72mmhg. His heart rate is 138 beats per minute this is a sinus tachycardia. His capillary refill is longer than 4 seconds. He has cool peripheries and his esophageal temperature is at 36’ c. This manifestation results from the pathophysiology of the burn. As explained above, there is hypovolemia as a result of the burn wound. This reduces the cardiac output which initially causes a drop in the blood pressure. In response to this, the catecholamine’s are released which causes vasoconstriction, increasing the peripheral resistance which in turn causes an increase in the heart rate. Due to inflammation and the release of the cytokine necrosis factor, there is a reduction in myocardial contractility which further causes a drop in the blood pressure (Balk, 2015). Our patient’s blood pressure and heart rate are high which are an indication that the patient is in shock at the compensatory phase. The capillary refill, cool extremities, and low body temperatures also indicate poor tissue perfusion as a result of reduced cardiac out. They are also significant signs of hypovolemic shock (Jindal, Hollenberg & Dellinger 2015).
Using an ABCDE approach, outline the immediate nursing care priorities in the management of this patient in the first hour following his admission to the ED.
In managing a burnt patient, the management given to the patient is divided into three phases; the resuscitative/emergent phase, the intermediate phase/acute and lastly the rehabilitation phase. These phases overlap and also in every phase, there are priorities. In our case, the intervention we shall discuss is the emergent/resuscitation. This management follows the ABCDE assessment that is the airway, breathing, circulation, disability, and exposure (Rauen, & Munro, 2015). The following nursing diagnosis were priorities; firstly, on the airway assessment, there was ineffective airway clearance related to inhalational burns as evidenced by decreased breath sounds, wheezing and coarse crackles. This was intervened by intubating her with a size 8mm endotracheal tube and connected to an intermittent positive pressure ventilation, IPPV on volume cycled ventilation, synchronized intermittent mechanical ventilation, SIMV, VT 440ml flow rate of 60l/min, with an f of 16, flow rate of O2 is 1.0, positive expiratory pressure of 5cmH20 with PIP 45cm H2O and oxygen was administered to him at a rate of 7l/minute. This normalized her oxygen saturation to 98% improving her tissue perfusion (Olgers, Dijkstra, Drost-de Klerck, & Maaten, 2017).
Ineffective Airway Clearance
Secondly, there is ineffective breathing related to bronchoconstriction as a result of inhalational burns and circumferential burns on the chest as evidenced by the decreased breath sounds, wheezing and coarse crackles. He is intubated and put on intermittent positive pressure ventilation (IPPV) of volume cycled ventilation that is synchronized intermittent mechanical ventilation (SIMV). This is to facilitate breathing (Hinkle &Cheever, 2013).
Thirdly, on circulation, there is inadequate tissue perfusion related to hypovolemia as evidenced by tachycardia, cool extremities, and decreased body temperatures. This clearly indicates that he is getting into hypovolemic shock. He was put intravenous fluids (volume expanders) via the brachial veins and the right external jugular. To liters of Hartmann’s fluid was running freely and at the moment he had already received 3500mls. This quantity was obtained through Parkland/Baxter formula which calculates the volume of the Ringer’s lactate solution by finding the product of 4ml by the body weight of the patient and by the percentage of the total body surface area burnt. His total body surface area burned is calculated using the rule of nines. He is burnt on the chest and abdomen which makes up 18%, the two forearms make a percentage of 18%, the legs and feet make a percentage of 36% and the face is 9%. This totals up to 81%. Therefore, the volume of fluid she requires is;
=4ml×%TBSA× kgs (body)
=4mls×81×84kgs
=27,216ml/24hours
The first eight hours he should get 13600ml the first half of the volume, while the next 16 hours he should get the second half. This justifies why he has already been transfused 3500ml and 2000ml is running. This is important so as to expand the blood volume as Ringer’s lactate is a colloid. In addition to this, the patient’s skin is covered so as to minimize fluid loss (Glynn & Drake 2014).
Fourthly, on disability assessment, the patient is in pain related to the burn wounds as evidenced by the increased heart rate. This is a disabling factor. The patient is sedated and paralyzed. He is put on ketamine, morphine, fentanyl, propofol, and rocuronium. These drugs will keep him sedated, paralyzed and are analgesic relieving him of his pain (Colledge, Walker & Ralston, 2013).
Lastly, on exposure assessment, he was saved from the burning houses by the firefighters while semi-conscious to safety. His skin as cooled using sterile water, dressed with hydrogel and as wrapped with cling wraps. This was important as the cold water prevented further burning and the wrappings reduced fluid loss from the broken skin (Thim, Krarup, Grove & Lofgren 2012) Using evidence based research and current recommendations, calculate the percentage of Johnno’s total body surface area (TBSA) burned using the Wallace Rules of Nines and based on Johnno’s pre-burn weight, guided by the Parkland formula, calculate his ongoing fluid requirements for the first twenty-four hours post injury. Outline the likely fluid resuscitation regime for this patient in the second 24 hours post his injury?
His total body surface area burned is calculated using the rule of nines. He is burnt on the chest and abdomen which makes up 18%, the two forearms make a percentage of 18%, the legs and feet make a percentage of 36% and the face is 9%. This totals up to 81%.
Ineffective Breathing
Therefore, the volume of fluid she requires using the parkland’s formula will be;
=4ml×%TBSA× kgs (body)
=4mls×81×84kgs
=27,216ml/24hours
The first eight hours he should get 13600ml, that is, the first half of the volume, while the next 16 hours he should get the second half. This justifies why he has already been transfused 3500ml and 2000ml is running.
Question 4: Outline the ongoing nursing care you would implement to manage him in relation to:
- Maintain adequate oxygenation and ventilation.
The emergency department nurse places very vital roles, firstly, he/she assesses and maintains adequate oxygenation and ventilation. The nurse does this by providing the patient with humidified oxygen, constantly assesses his breath sounds, the respiratory rate, depth, rhythm and symmetry and looks out for signs of hypoxia, monitors the arterial blood gas values, carboxyhaemoglobin levels and the pulse oximetry, monitors the patient closely on the mechanical ventilator and adjusts it accordingly for example in case of decreased oxygenation this can be adjusted by increasing the tidal volume and flow rate given per minute. In addition to this, the nurse should ensure that the patient is positioned properly so as to maintain a patent airway and also suctioning should be done so as to clear the airway (Beck, 2015).
- Maintain adequate circulation.
Secondly, on circulation assessment so as to maintain adequate circulation the nurse should constantly observe the patient’s vital signs that is the central venous pressure, the pulmonary artery pressure, the urine output hourly, signs for hypovolemia or the signs of fluid overload as he is on intravenous fluids. Should maintain the intravenous lines and regulate/monitor the fluids to be given at the prescribed rates. Should observe the signs of increased or decreased sodium, potassium, calcium, phosphorous and the bicarbonates. Should also elevate the patient’s head and the extremities that are burnt. Lastly, on circulation, in case of any changes on the urine output, the blood pressure and pulse rates/heart rate the physician should be notified immediately by the nurse (Kumar, Haery & Parrillo 2015).
- Maintain thermoregulation.
Thirdly, on managing the thermoregulation, the nurse should ensure the patient is kept in a warm environment by using a heat shield, heat lights, space blankets or blankets. This will aid in minimizing the heat loss via evaporation. The nurse should work quickly in the event of wound exposure. This will ensure that there is minimal exposure, therefore, minimizing the heat loss. Lastly, the nurse should frequently assess the core body temperature of the patient so as to detect signs of hypovolemia early (Choi, Yip, Quinonez & Cook, 2014).
- Managing potential early complication as a result of the burn injury.
This patient is at the risk of getting into acute respiratory failure, acute renal failure, distributive shock, curling’s ulcer, paralytic ileus and compartment syndrome. To avoid this, the nurse should monitor the patient’s respiration closely, the oxygen saturation, partial pressure of oxygen, the partial pressure of carbon dioxide. For the renal function, the nurse should monitor the urine output, the creatinine levels, the blood urea nitrogen. She should also ensure that she administers the prescribed fluids accordingly. For the compartment syndrome, the nurse should assess the peripheral pulses every hour using a Doppler ultrasound device (Barrett, Barman, Boitano 2017). The nurse should also assess the warmth and the capillary refill of the extremities hourly. The nurse should elevate the patient’s extremities and in case of loss of sensation, the nurse should report this immediately. In case the patient needs an escharotomy the nurse should be prepared to assist. For the paralytic ileus, the nurse should maintain a nasogastric tube in situ and ensure low suctioning until the bowel sounds returns. This will relieve the abdominal and gastric distension. The nurse should also auscultate for the bowel sounds and the abdominal distension. Lastly, on curling’s ulcers, the nurse should aspirate the gastric content and assess its pH. The nurse should also assess the stool for occult blood. Lastly, the nurse should administer anti-acids and histamine blockers so as to reduce the gastric acidity (Lewis, Dirksen, McLean, 2013; Vincent & Ferreira, 2016)
Inadequate Tissue Perfusion
In addition to this the patient is on positive pressure mechanical ventilation, the intermittent positive pressure ventilation (IPPV), which gives the patient’s compressed gas under positive pressure until the patient’s preset pressure is reached. It allows self-exhalation. A specific pressure and volume are preset with regards to patient’s needs. Its harmful effects include; pneumothorax, increased intracranial pressure, mucosal drying, gastric distention, possible aspiration, vomiting, hyperventilation, psychological dependency and cardiovascular problems. In patients with circumferential burns of the chest and the inhalation burns positive pressure mechanical pressure have been known to cause early mortality as they cause an increase in the thoracic pressure which causes a reduction of the venous return which causes a reduction of both the cardiac and the urine output. To avoid this the nurse should suction the airway regularly, sedate the patient and keep him paralyzed, monitor the arterial blood gas values, should check the ventilator circuit for patency, should avoid giving the air at high pressures as it causes trauma, should maintain a sterility and regularly wash the mouth to avoid pulmonary infection (Abraham et. al., 2014).
- Management of analgesia and sedation
He is on ketamine, morphine, fentanyl, propofol, and rocuronium. These drugs will keep him sedated, paralyzed and are analgesic relieving him of his pain (Colledge, Walker & Ralston, 2013). The IPPV harmful effects include; pneumothorax, increased intracranial pressure, barotrauma, volutrauma, mucosal drying, gastric distention, possible aspiration, vomiting, hyperventilation, psychological dependency and cardiovascular problems. These effects are worsened when the patient is alert and conscious therefore to avoid this the patient is sedated and paralyzed.
References.
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