M 4.6 Swift River- Burns
Glenn Massey
Glenn Massey, ,post 2nd and 3rd degree burns on 18% of his body. Burns
are located on his arms and upper torso. The patient works at a chemical
refinery; this was an occupational injury after an explosion at the plant. You
receive the following report from the trauma burn ICU nurse, "Situation is
Glenn Massey is now stable to be transferred to the floor. Background is
patient was admitted 7 days ago after an occupation injury resulting in
burns to 18% of his body. Patient arrived via ambulance in critical condition
and was intubated upon arrival. The assessment is vital signs are BP:
142/91, T: 99.4 F, 37.4 C, P: 102, R: 28, PaO2: 96% on room air. Patient is
AAO x4. He is receiving 5mg Morphine IV q3 hours PRN for pain control. IV
at 150 mL/hr D5 ½ NS to a right subclavian. Foley catheter is draining clear
urine, I&O in chart. Patient requires dressing changes every shift.
Recommendation is patient is ready to be transferred to the floor, and will
need strict wound isolation. Family has been notified of his transfer, and
patient believes he can return to work in a few days."
Maslow- high
ABC- high
Safety-high
Urgent vs nonurgent-highly
Chronic vs avute- low
Initial Nursing Assessment
0745: The nurse reviews the information received in report.
Which of the following concerns should the nurse address while
providing client care? (Select all that apply.)
Self care
Fluid
Tissue integrity
Comfort
Infection
Glenn Massey
Glenn Massey, ,post 2nd and 3rd degree burns on 18% of his body. Burns
are located on his arms and upper torso. The patient works at a chemical
refinery; this was an occupational injury after an explosion at the plant. You
receive the following report from the trauma burn ICU nurse, "Situation is
Glenn Massey is now stable to be transferred to the floor. Background is
patient was admitted 7 days ago after an occupation injury resulting in
burns to 18% of his body. Patient arrived via ambulance in critical condition
and was intubated upon arrival. The assessment is vital signs are BP:
142/91, T: 99.4 F, 37.4 C, P: 102, R: 28, PaO2: 96% on room air. Patient is
AAO x4. He is receiving 5mg Morphine IV q3 hours PRN for pain control. IV
at 150 mL/hr D5 ½ NS to a right subclavian. Foley catheter is draining clear
urine, I&O in chart. Patient requires dressing changes every shift.
Recommendation is patient is ready to be transferred to the floor, and will
need strict wound isolation. Family has been notified of his transfer, and
patient believes he can return to work in a few days."
Maslow- high
ABC- high
Safety-high
Urgent vs nonurgent-highly
Chronic vs avute- low
Initial Nursing Assessment
0745: The nurse reviews the information received in report.
Which of the following concerns should the nurse address while
providing client care? (Select all that apply.)
Self care
Fluid
Tissue integrity
Comfort
Infection
