Rachel is a 28-year-old female, recently graduated from an Esthetician program at her community college. She is working in the kitchen of a local restaurant while trying to find a job in her new profession. She lives with her partner of 4 years. Her partner’s name is Chris.
One-night Rachel stayed late at work to empty the fryer; her co-worker was supposed to turn the heat off before he left for the night but forgot. When Rachel went to empty the fryer, the oil spilled on her. Immediately after the incident, she was rushed to the hospital by ambulance with the following:
- Full thickness burns to the entire right side of her face (anterior)
- Full thickness burns to both arms (anterior and posterior) from the shoulder to the wrist as well as both hands.
- Partial thickness burns bilaterally to her legs (anterior – groin to foot).On route to hospital the paramedics inserted a large bore angiocath into the right antecubital fossa with 0.9% NaCl is infusing at 150mls/hr. Rachel remained alert and orientated explaining what occurred.
On arrival to hospital, in the resuscitation room:
She arrived at the hospital complaining of severe pain to her legs. She reports no pain to her face or arms. She is alert, orientated and responds appropriately to questions.
Vital signs: T: 35.9, HR: 132, RR. 24, B/P: 88/42, SPO2: 95% (r/a)
Weight: 62 kg
Lab Values:
- Serum sodium is 130 (135-145)
- Serum potassium is 3.7 (3.5-5.0)
- Creatinine is 120 mmol/L (60-110 mmol/L)
- BUN is 12 mmol/L (2.5-7.1 mmol/L)
Consider the following questions and answer fully:
- Document the significant objective and subjective data from Rachels case and explain why it is important (or could be important).
- Identify what the total body surface area (TBSA) is for Rachel using the Rule of Nines. (Show your work)
- Based on your calculation, using the Parkland formula, what is the 24-hour fluid resuscitation that should be given to Rachel? (Include complete formula and breakdown of fluid delivery over the 24 hours)
- Explain in detail how would assess if the fluid resuscitation was working? (Support your work)
- Create 3 relevant cue/data clusters and identify what the clusters infer/suggest.
- Identify one data gap for each cluster and explain how this data would further inform the cluster. (Support your work)
- Based on the clusters created in question #5, what would be your Priority area of Assessment during the Emergent phase of Rachel’s burn injury? (Explain why and support your answer)
- Based on the clusters created list 3 Nursing Diagnosis for Rachel. (Proper formatting required)
- Consider the three potential diagnosis (above) and identify the primary/priority nursing diagnosis for Rachel in the Emergent phase of a burn injury? (Proper formatting required)
- Write one (SMART) goal for Rachel based on the primary diagnosis you have determined.