NURSING 1140 Case Study 116 Acute Brain Injury.

NURSING 1140 Case Study 116 Acute Brain Injury. Class/Group PN3 Case Study 116 Acute Brain Injury You are working in the emergency department (ED) of a community hospital when the ambulance arrives with A.N., a 28-year-old woman who was involved in a house fire. She was sleeping when the fire started and managed to make her way out of the house through thick smoke. The emergency medical system crew started 100% humidified oxygen at 15 L/min per non-rebreather mask and started a 16-gauge IV with lactated Ringer’s solution. On arrival in the ED, her vital signs are 100/66, 125, 34, SpO 2 93%. She is alert and oriented x 4 and appears anxious and in pain. 1. Describe the interventions needed to care for A.N. on her arrival in the ED. Assess pt throat and nose for soot (inhalation), swelling/blistering (thermal damage), have intubation try ready and prepare for need to mechanically ventilate 2. Because you are concerned about smoke inhalation, what will you assess for in A.N.? We must listen to lung sounds (possible wheezing, rhonchi), we must check her O2 stat; assuring it is 95% and above 3. As you perform your initial assessment, you note burns on A.N.’s right anterior leg, left anterior and posterior leg, and anterior torso. Shade the affected areas, and then, using the rule of nines, calculate the extent of A.N.’s burn injury. 45% NURSING 1140 Case Study 116 Acute Brain Injury. (Modified from Ignatavicius DD, Workman ML: Medical-surgical nursing, ed. 6, St. Louis, 2010, Saunders.) 4. You suspect that A.N. has deep partial-thickness burns. Which best describes this type of burn? a.The skin is blackened; the charred skin is insensitive to pain. b.The wounds are red, blanch, and have accompanying edema. c.The skin is shiny, red, moist, has fluid filled blisters and is painful. d.The wounds are dry, waxy white and hard; burned area has insensitivity to pain.