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...
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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