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!!!!!!!!!!!!!CNP!2!2016!
!!!!!!Clinical!Skills!Exam!
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Case study:
BURNS CASE STUDY
James McCormack Male
MRN 321892 DOB 11/12/1992
17 Railway Pde BAYSWATER 6051

After a very busy Saturday night at work, James McCormack (11/12/92) is riding home down the
freeway on his motorcycle at 2am when a tired driver changes lanes without looking and hits James
bike at 100km/hr. Both James and the motorcycle are thrown across 3 lanes of traffic and land up
against the centre barrier. James is knocked unconscious by the impact and the motorcycle lands on
top of him, pinning his legs underneath the engine. James was wearing an open-faced helmet, t-shirt,
jeans and jogging shoes. The force of the impact sent James right shoe flying off his foot and it
landed 25m down the road. The driver of the car has minor bruising but is generally uninjured.
The police, paramedics and fire service are called and arrive in 15minutes. The motorcycle is
removed from on top of James, he is stabilised (in-line cervical stabilisation) and transferred to RPH
Emergency Department. James is brought into the Resuscitation Area in the Emergency Department
where a primary and secondary survey is completed. James has severe abrasions to his face and the
bone on the right side of his mandible is visible. James has a tender area on palpation at C5
(cervical). The impact with the ground caused the majority of his shirt to be torn on the right side. His
right shoulder is deformed but neurovascular observations are intact. There is paradoxical movement
on the right side of his chest (when he breathes in the ribs move out and vice versa) due to a flail
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chest (4 broken ribs). He has extensive burns on the back of his left thigh, left calf, back of his left
forearm, hand and fingers, as well as an irregularly shaped burn on his right foot. There are minor
abrasions to his arms, hands, hips and legs. His right ankle is severely swollen and excessively
mobile although no bone is visible.
Initial Vital Signs:

BP: 100/60mmHg, MAP 70mmHg


SaO2: 92% on room air;
Pulse: 100/min
Respiratory rate: 22 Breaths/minute
Temperature: 36.0
GCS 13
BGL 5.2mmol

James has a blood test taken and the results are:

Hb: 69g/L

WCC: 15 x10 /L

Platelets: 100x10 /L

Na : 145mmol

K : 5.6mmol

Mg : 1.04mmol

PO 4: 2.0mmol

Ur: 23 mmol

Cr: 353 mmol

CK: 10,000 IU/L

INR: 1.5

aPTT: 55 seconds

BGL: 9.4mmol

ABGs: pH: 7.29 PaCO2: 32mmHg PaO2 60mmHg HCO3 14 lactate 4.0

2+
2-

James is showing signs of shock and requires further antibiotic therapy, vasopressors and fluid
replacement (Blood Transfusion and CSL). A central venous catheter (CVC) is inserted in his right
subclavian vein, for central venous pressure (CVP) monitoring and for the administration of fluid and
medications. An arterial line was inserted in his right brachial artery for continuous and accurate blood
pressure and mean arterial pressure (MAP) monitoring. James was placed on TPN as a nutritional
requirement to help wound healing due to his extensive burns and an increase in metabolic
requirements.

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Blood Transfusion Exam:

Safely initiate, maintain and terminate a blood transfusion


Provide nursing care for early detection of a transfusion reaction
Rationalise why James is having a blood transfusion

Answer the following questions with regards to Jamess nursing care:


1.
2.
3.
4.
5.

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Why is James having a RBC transfusion?


Why do we need to gain consent?
What do you need to explain to James regarding RBC reactions?
What information will you give James regarding a reaction before the transfusion begins?
If James Becomes short of breathe within the first 5 Minutes and develops temperature what
will your course of action be?