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NGN Burns EAQ Case Study Already Graded A+

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NGN Burns EAQ Case Study Already Graded A+ Burns - Patient 1 H&P Denies cardiac history. States excellent health. ️️NURSES' NOTES 1800: Received 59-year-old client via ambulance to the emergency department secondary to lightning strike. Client is alert and oriented to time, place, and...

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  • November 21, 2024
  • 10
  • 2024/2025
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NGN Burns EAQ Case Study Already Graded A+

Burns - Patient 1



H&P

Denies cardiac history. States excellent health. ✔️✔️NURSES' NOTES

1800: Received 59-year-old client via ambulance to the emergency department secondary to lightning
strike. Client is alert and oriented to time, place, and person; reports, "I was struck by lightning while
fishing and guess I passed out." Family member reports client passed out after the lightning strike but
woke up when shaken vigorously. Wounds loosely covered with sterile dressings.



1805: Blood pressure 189/108 mm HG; heart rate of 89 beats per minute, atrial fibrillation per cardiac
monitor since initial assessment by emergency medical technicians; respirations of 26 breaths per
minute, unlabored; oxygen saturation is 100% on 2 L per minute via nasal cannula; lung fields clear
bilaterally, unlabored.



Intravenous fluids: Lactated Ringers infusing via 18 g intravascular catheter in left antecubital at 150
mL/h. Bilateral second-degree wounds to client hands; shoes destroyed and third-degree burns to
bilateral feet.



1810: Urinary catheter inserted; returned 450 mL clear, straw-colored urine.



1820: Specimen to laboratory.



The nurse reviews the clinical data in the electronic health record to help formulate a plan of care for
this patient.

Complete the diagram by dragging from the choices below to specify which potential condition the
client is most likely experiencing, two actions the nurse should take to address that condition, and two
parameters the nurse should monitor to assess the client's progress.



POTENTIAL CONDITIONS

Ineffective tissue perfusion

, Hypothermia

Acute pain

Insufficient airway clearance



ACTIONS TO TAKE

Obtain an electrocardiogram (ECG)

Increase oxygen to 100% via nasal cannula

Initiate seizure precautions

Insert an indwelling urinary catheter

Implement the Parkland burn formula



PARAMETERS TO MONITOR

Pulse oximetry

Pain level and level of consciousness (LOC)

Cardiac telemetry

Arterial blood gases (ABGs)

Hourly intake and output ✔️✔️POTENTIAL CONDITIONS

Ineffective tissue perfusion



ACTIONS TO TAKE

Obtain an electrocardiogram (ECG)



Insert an indwelling urinary catheter



PARAMETERS TO MONITOR

Cardiac telemetry



Hourly intake and output

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