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Zorluk: Çok zorPhysiological Adaptation

A triage nurse in the emergency department receives a 4545-year-old client who was rescued from an enclosed structural fire. The client sustained deep partial-thickness and full-thickness burns to the face, anterior chest, and bilateral entire upper extremities.

The nurse assesses the following initial clinical data:

ParameterValue
Blood Pressure84/52 mmHg84/52\text{ mmHg}
Heart Rate136 beats/min136\text{ beats/min}
Respiratory Rate28 breaths/min28\text{ breaths/min}
SpO2SpO_298%98\% on room air
pH7.327.32
PaCO2PaCO_234 mmHg34\text{ mmHg}
PaO2PaO_292 mmHg92\text{ mmHg}
HCO3−HCO_3^-18 mEq/L18\text{ mEq/L}
Carboxyhemoglobin (COHbCOHb)22%22\%

Physical assessment reveals a hoarse voice, singed nasal hairs, and carbonaceous sputum.

Which interventions should the nurse anticipate incorporating into the immediate plan of care? (Select all that apply)

  1. Prepare equipment for rapid sequence endotracheal intubation.Cevap
  2. B
    Calculate the 2424-hour intravenous fluid resuscitation volume starting from the time of hospital arrival.
  3. Initiate continuous 100%100\% oxygen via a tight-fitting non-rebreather mask.Cevap
  4. D
    Administer a prescribed intravenous loop diuretic if the hourly urine output falls below 30 mL/hr30\text{ mL/hr}.
  5. E
    Place the client in a supine position with the head of the bed flat to manage hypotension.
  6. Insert an indwelling urinary catheter to continuously monitor hourly urine output.Cevap

Cevap

The correct interventions are preparing for rapid sequence intubation, administering continuous 100% oxygen via a non-rebreather mask, and inserting an indwelling urinary catheter.
The client is exhibiting classical signs of severe inhalation injury (hoarse voice, singed nasal hairs, carbonaceous sputum, and a history of an enclosed space fire). Prophylactic rapid sequence intubation is required before profound airway edema causes complete obstruction. Furthermore, the client has carbon monoxide poisoning, indicated by a carboxyhemoglobin level of 22%. Because standard pulse oximetry cannot differentiate between oxyhemoglobin and carboxyhemoglobin, the oxygen saturation reading of 98% is falsely reassuring. The standard treatment for carbon monoxide toxicity is the immediate application of 100% oxygen via a non-rebreather mask (prior to intubation) to rapidly decrease the half-life of the carboxyhemoglobin. Lastly, aggressive fluid resuscitation is required to combat hypovolemic burn shock. An indwelling urinary catheter is essential because hourly urine output is the most reliable physiological indicator of adequate tissue perfusion and fluid resuscitation.

Adım Adım Çözüm

1
Analyze the primary survey and airway security.
The client has facial burns, singed nasal hairs, hoarseness, and carbonaceous sputum, all indicating impending airway loss.
Airway protection takes absolute priority in emergency burn management, especially with evident inhalation injuries.
2
Evaluate the arterial blood gas and oxygenation status.
Despite a normal pulse oximetry reading of 98%, the carboxyhemoglobin is dangerously elevated at 22%, indicating severe carbon monoxide poisoning.
Standard pulse oximetry cannot distinguish between oxygen and carbon monoxide bound to hemoglobin, necessitating 100% oxygen therapy to reduce the half-life of carboxyhemoglobin.
3
Assess the client's hemodynamic status and perfusion.
The client is in hypovolemic (burn) shock, evidenced by a blood pressure of 84/52 mmHg and a heart rate of 136 beats/min.
Massive fluid shifts into the interstitial space occur rapidly after severe burns, requiring aggressive, calculated fluid resuscitation.
4
Determine the prioritized nursing interventions based on the assessment.
The immediate needs are prophylactic intubation, 100% oxygen administration, and strict intake and output monitoring via a urinary catheter.
These actions directly address the life-threatening airway compromise, cellular hypoxia, and evaluation of fluid resuscitation adequacy.

Anahtar Kavram

Burn Shock Resuscitation and Inhalation Injury Management
Tahmini Süre:3m 0s
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Konular

Physiological Adaptation

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