Maryam Ahmarinejad March 20,

2020
4NUR2 CA 2 –
MS
CASE 1
BURNS
Mr. MJ, 56 years old is brought to the Emergency Room after gas tank explosion
accident. He is alert and oriented and experiencing severe pain associated with burn injuries.
He appears very anxious. The eyebrows, eyelashes and hair are singed. There is soot in the
nares and mouth. There is thick, white, leathery eschar on the chest, neck, whole part of his back
and circumferential burns on his right arm. The skin of the face is pink, moist and blistered.
A. As the ER nurse, what priorities should be set for the client’s care? What immediate
interventions, nursing and medical should be undertaken?
B. What priority nursing diagnoses do you establish with this client? What expected
outcomes do you establish in the nursing care plan?
C. Show would you classify MJ’s burns. What is your estimate of his TBSB?
D. What systemic effects do you expect after this major injury?
Initial assessment revealed heart rate is 142 bpm, RR- 36 breaths/min and
labored. BP- 98/60, Temp-36.8 C. Lung sounds indicate inspiratory and expiratory
wheezing and a persistent cough reveals sooty sputum production. He states that his pain
10/10. Bowel sounds are absent. Weight – 176 pounds.
The physician inserted a large bore central line into Mr MJ’s subclavian vein
and started a rapid infusion of lactated Ringer’s solution. Mr. MJ is receiving 40%
humidified O2 via face mask. Initial ABG are as follows: ph – 7.49, pCO2 – 32 mmHg,
HCo3 – 22 meq/L . PO2- 60 mmHG. A Foley catheter is inserted and initially drains a
moderate amount of dark, concentrated urine. A nasogastric tube is inserted and MJ was
placed on NPO till further notice.
E. Explain the rationale of the assessment findings and the rationale of the procedures
done to MJ.
F. What drugs would you give and by what route would you administer them to control
MJ’s pain?
 MJ was started on fluid resuscitation using the Parkland formula as a guide. The
lab studies sent were CBC, ABG, urinalysis, BUN, Na, K det., total protein and revealed
the following findings: H.gb -20g/dl; Hct – 52%; glucose – 168 mg/dl; BUN – 27mg/dl.
Urinalysis – 20-30 pus cells/hpf.
G. Using the Parkland formula, calculate the amount of fluid this patient would require
for the first 24 hours. What information is needed for this formula? What type of fluid
is administered?
H. How would you interpret the lab values of MJ? What should be your next step?
I. What other clinical indicators would you use to assess the adequacy of fluid
resuscitation?
J. What is the most likely cause of his abnormal glucose level?
Day 2 lab test revealed Lab values – Na -126 meq/L, K – 6.0 meq /L,. ABG
revealed – pH -7.30, pCO2- 35 mmHG, HCO3 -18 meq/L. , Decreasing urine output.
The decision to initiate dialysis was reached after thoughtful discussion with the family
members. Double lumen cuffed hemodialysis IJ catheter was used in acute hemodialysis.
K. What is the rationale of these lab and ABG findings? What would be your next step?
L. Discuss the different phases that happens in major burns, assessment findings and
management.
M. What complications can happen in these different phases of burns?
N. Discuss Shock as a result of burn injury. What are the different kinds of shock that can
happen in major burns, causes and management?
O. Discuss the rationale of placing the patient in acute hemodialysis and the nursing care
for the procedure.
Maryam Ahmarinejad March 20,
2020
4NUR2 CA 2 –
MS
CASE 2
CARDIO / PULMO
Mr. DJ, 56 years old, carpenter, hypertensive and diabetic, is brought to the
Emergency Room because of shortness of breath. He has been having episodes of
dyspnea while at work for the past 2 years but says that these episodes would resolve
spontaneously even without medications. He noticed that the dyspnea would occur
specially during the days when there would be a lot of sawdust. In the past month, he has
had 3 episodes when he would be awakened around 4am because of shortness of breath.
He also could not climb to the 2nd floor anymore and noted that his shortness of breath
worsened for the past 6 months even with less strenuous activities and also been
experiencing chest heaviness for the past 2 days.
Family history (+) for HPN, DM, PTB, Asthma.
The patient has been smoking 1 pack per day for the past 35 years. He is allergic
to crabs. He was diagnosed to have an “airway disease” last year and was prescribed an
inhaler which he has been taking irregularly.
A. As the ER nurse, what are the relevant questions you need to ask Mr. DJ? Why do you
consider these questions significant?
B. What clinical features points to Bronchial Asthma and COPD? What diagnostic test
will you anticipate to be requested for Mr. DJ once stable?
C. What are the causes of COPD? What’s the significance to your plan of care to your
patient?
On physical examination, the patient is awake, with preference for a semi-
recumbent position. BP:90/70, CR:142/min. RR: 36/min and labored, Temp: 37.5 C.
Chest expansion was symmetrical, with intercostal retractions, hyper resonant on the
 left, lung sounds indicate inspiratory and expiratory wheezing. Apex beat was at the 5th
LICS MCL. No clubbing nor cyanosis. He is thin and lanky, wt: 63 kg, ht: 5’6”.
D. What priorities should be set for the client’s care? What immediate interventions,
nursing and medical should be undertaken?
E. What priority nursing diagnosis do you establish with this client? What expected
outcomes do you establish in the nursing care plan?
At the ER, O2 saturation is at 80%, oxygen at 3L/min.
F. What laboratory/ancillary tests you expect to be requested by the physician? Explain
reason and expected findings.
G. How do you explain the concept of “hypoxic drive” in a patient with COPD?
H. Explain the pathophysiology of COPD using a flowchart including the pathophysiologic
basis of the physical findings in Mr. DJ.
I. Based on the laboratory/ancillary tests requested what would be your appropriate
nursing interventions?
While at the ER, he became more dyspneic and suddenly developed cyanosis.
There was loss of consciousness. He went into respiratory failure. He was eventually
intubated and was hooked on a mechanical ventilator. His ABG prior to intubation
showed pH: 7.30, pCO2: 70, pO2: 55, HCO3: 25. VS post intubation BP: 80/60, CR:
110/min., RR: 16/min. A chest tube was also inserted.
J. Explain the rationale of the clinical manifestations of Mr. DJ? What are the different
types of respiratory failure? What will be your initial action?
K. Explain the rationale of the procedure done to Mr. DJ. Enumerate priority problems
and plan of care in a patient on mechanical ventilator with a chest tube.
12 L-ECG requested at the ER showed ST segment changes with occasional
PVC’s. BP: 90 palpatory. He was referred to a cardiologist. The cardiologist writes his
diagnosis: CAD, HPN.
L. Enumerate modifiable and non-modifiable risk factors for this patient to develop CAD.
What laboratory tests/diagnostic procedures appropriate for Mr. DJ? Which of the
tests requested would confirm the diagnosis of CAD? Any invasive procedures to be
done at this point? Enumerate and discuss its rationale.
M. What medications would you expect to be started? Explain mechanism of action and
characteristic side effects. What are your nursing responsibilities regarding giving of
these drugs?
N. What will be your most appropriate nursing interventions?
Mr. DJ was started on fluid resuscitation however no improvement in blood
pressure and urine output is 10cc/hour. You noticed in the ECG monitor runs of PVC’s.
Repeat CXR showed pulmonary edema.
O. Enumerate what do you expect to be included in the hemodynamic monitoring.
Mr. DJ’s wife approaches you and anxiously tells you “I don’t want to lose my
husband. I have often heard of people like him who suddenly die because their heart
stopped.”
P. What will be your most appropriate nursing response and action?
Mr. DJ went into cardiac arrest.
Q. What specific procedure is followed in our hospital setting for such an emergency? List
the emergency drugs used in case of cardiopulmonary arrest.