Patients with Multiple Disorders
Scenario
You are working in the emergency department (ED) of a community hospital when the ambulance arrives with A.N., an 18-year-old woman who was caught in a house fire. She was sleeping when the fire started and managed to make her way out of the house through thick smoke. The emergency medical system crew initiated humidified oxygen at 15 L/min per nonrebreather mask and started a 16-gauge IV with lactated Ringer’s solution. On arrival to the ED, her vital signs are 100/66, 125, 34, SaO2 93%. An additional 16-gauge IV is inserted. She appears anxious and in pain.
1. As you perform your initial assessment, you note superficial partial-thickness burns on A.N.’s right anterior leg, left anterior and posterior leg, and anterior torso. Shade the affected areas, then using the “rule of nines,” calculate the extent of A.N.’s burn injury.
2. Because you are concerned about possible smoke inhalation, what signs will you monitor A.N. for?
3. Interpret A.N.’s laboratory results.
4. A.N. is undergoing burn fluid resuscitation using the standard Baxter (Parkland) formula. She was admitted at 0400. She weighs 110 pounds. Calculate her fluid requirements, specify the fluids used in the Baxter (Parkland) formula, specify how much will be given, and indicate what time intervals will be used.
5. A.N. is in severe pain. What is the drug of choice for pain relief following burn injury, and how should it be given?
Case Study Progress
A.N. does not exhibit any signs of smoke inhalation injury and is admitted to the medical unit for further treatment. As her nurse, you are concerned about meeting her needs for infection prevention, skin integrity, nutrition, fluids, and psychological support.
6. Because of her significant burn injury, A.N. is at high risk for infection. What measures will you institute to prevent this?
7. A.N.’s burns are to be treated by the open method with topical application of silver sulfadiazine (Silvadene). When caring for A.N., which interventions will you perform? (Select all that apply.)
a. Maintain the room temperature at 85° F (29.4° C).
b. Use clean technique when changing A.N.’s dressings.
c. Monitor CBC frequently, particularly the white blood cells.
d. Do not allow her to bathe for the initial 72 hours following injury.
e. Apply a 
-inch film of medication, covering entire burn.
8. A.N. has one area of circumferential burns on her right lower leg. What complication is she in danger of developing, and how will you monitor for it?
9. What interventions will facilitate maintaining A.N.’s peripheral tissue perfusion?
10. A special burn diet is ordered for A.N. She has always gained weight easily and is concerned about the size of the portions. What diet-related teaching will you provide?
11. Describe interventions that you could use to assist in meeting A.N.’s nutrition goals.
Case Study Progress
Eighteen hours after the injury, the NAP reports these vital signs for A.N. and states that the urine output for the past hour was 20 mL.
12. What do you suspect is occurring, and why does this concern you?
13. What treatment do you anticipate?
14. The physician orders a new set of lab work. Compare A.N.’s current lab results with those from admission.
15. Tissues under and around A.N.’s burns are severely swollen. She looks at you with tears in her eyes and asks, “Will they stay this way?” What is your answer?
16. A.N. is concerned about visible scars. What will you tell her to allay her fears?
Scenario
You are admitting a 30-year-old woman, J.L., to your telemetry unit with the diagnosis of status post-cardiac transplantation and fever of unknown origin. She was healthy until the birth of her only child at 27 years of age. She developed idiopathic cardiomyopathy after childbirth and underwent cardiac transplantation 10 months ago. All of her endomyocardial biopsies have been negative for signs of rejection; her last one was 3 weeks ago. She is currently maintained on a regimen of baby aspirin, multivitamins, tacrolimus (Prograf), nifedipine (Procardia), and metolazone (Zaroxolyn).
1. Admitting has assigned J.L. to a semiprivate room. Her roommate is on day 4 of IV antibiotic treatment for pneumonia and now has a near normal WBC count. Is this assignment appropriate?
2. Fever is a sign of two major complications of organ transplantation. What are they?
3. What is the purpose of tacrolimus (Prograf), and what role does that play in your assessment?
4. Compare and contrast the signs and symptoms of organ rejection and sepsis that you need to assess for in J.L.
Case Study Progress
J.L.’s BUN and creatinine are within normal limits, and the physician determines that an infection, and not renal dysfunction, is the reason for J.L.’s symptoms. The physician orders IV vancomycin (Vancocin) 500 mg every 8 hours, and he sends J.L. to interventional radiology for placement of a peripherally inserted central catheter (PICC). Her first dose of vancomycin arrives from the pharmacy just as J.L. returns to the floor.
7. What other information do you need to know before you begin the vancomycin (Vancocin)?
8. What interventions do you need to implement to safely administer vancomycin? (Select all that apply.)
a. Obtain a trough level 6 hours after each infusion
b. Administer each infusion over a minimum of 1 hour
c. Hold the infusion if J.L. complains of tinnitus
d. Assess for the onset of hypertension during the infusion
e. Monitor urine output, BUN, and creatinine levels
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