HESI Case Studies--Pediatrics-Burns (David Harper)

HESI Case Studies--Pediatrics-Burns (David Harper) 45% according to the Rule of Nines: Bottom to top: Deep partial-thickness burn (red area); full-thickness burn (white area); full-thickness burn with eschar (brown area). Choose matching term 1 2. Some parents call the local emergency rooms in an attempt to learn where their children will be transferred. Which action should be implemented to help these family members? 2 21. Which interventions will meet David's needs during his hospital stay? (Select all) 3 7. The RN should document which percentage of body surface? 4 10. Which action should the RN take concerning this request? Don't know? Terms in this set (32) 1. Which action is included when a level 1 disaster is declared? All local hospitals prepare to receive casualties Classification as a Level I disaster indicates that local emergency response personnel and organizations can contain and effectively manage the disaster and its aftermath. 2. Some parents call the local emergency rooms in an attempt to learn where their children will be transferred. Which action should be implemented to help these family members? Designate specific family areas that are staffed with counselors 3. Paramedics are triaging clients at the accident site. Which action is implemented by the triage personnel. Place a disaster tag securely on each victim Victim tracking is a critical component in casualty management. Disaster tags are color-coded and numbered to indicate triage priority. They include the client's name, address, and age, as well as a description and location of the client's injuries 4. Which of the following clients would be given a red tag? (Select all) -A client whose vitals signs are as follows: RR 22, HR 120, BP 85/52 *Client is going into shock and should be seen immediately* -A client with a pulsating femur wound *client has an arterial bleed and can go into shock and therefore should be seen immediately** -A client with full-thickness burns over 50% of the body *client should be attended to immediately* 5. Into which triage category should David be placed? Red—Most urgent; first priority First-priority patients have life-threatening injuries and are experiencing hypoxia or nearing hypoxia. Examples of injuries in this category include shock, chest wounds, internal hemorrhage, head injuries producing increased loss of consciousness, partial- or full-thickness burns over 20% to 60% of the body surface, and chest pain. Yellow—Urgent; second priority Second-priority patients have injuries with systemic effects and complications but are not yet hypoxic or in shock. The patients appear stable enough to withstand up to a 2-hour wait without immediate risk. Examples of injuries in this category include multiple fractures, open fractures, spinal injuries, large lacerations, partial- or full-thickness burns over 10% to 20% of the body surface, and medical emergencies, such as diabetic coma, insulin shock, and epileptic seizure. Patients with second-priority status might need to be observed closely for signs of shock, at which time they would be re-categorized to first priority. Green—Third priority Third-priority patients have minimal injuries unaccompanied by systemic complications. Usually these patients can wait more than 2 hours for treatment without danger. Examples of injuries in this category include closed fractures, minor burns, minor lacerations, sprains, contusions, and abrasions. Black—Dying or dead Dying or dead patients are hopelessly injured patients or dead victims. These patients have catastrophic injuries (e.g., crushing injuries to the head or chest) and would not survive under the best of circumstances. These patients create the greatest difficulty, because failure to treat patients conflicts with nursing philosophy. In a disaster, triage must give the chance of survival to the greatest number of victims rather than to one individual. Personnel and equipment must be reserved for the greatest number of viable patients. Contaminated—Might have a color code or a hazardous material (HAZ MAT) triangle tag These patients are contaminated with bacteriologic or chemical hazards. They will be routed to a decontamination sector to eliminate hazards before additional treatment is provided. 6. What is the priority nursing intervention upon admission? Establish and maintain an open airway The burns can cause constriction leading to a restricted airway. Additionally, smoke inhalation is always a concern following a fire. remember Maslow's Hierarchy of Needs: ensuring an open airway is always the highest priority nursing intervention 7. The RN should document which percentage of body surface? 45% according to the Rule of Nines: Bottom to top: Deep partial-thickness burn (red area); full-thickness burn (white area); full-thickness burn with eschar (brown area). 8. Which intervention will the RN implement? Administer the LR solution as prescribed via an infusion pump will help prevent potential fluid overload 9. Which action should the RN take? Inform the officer that he must first speak to David's parents pt is a minor, so his parents must be present when he is talking to a representative of the police dept. 10. Which action should the RN take concerning this request? Allow the police officer access to the requested medical records according to HIPAA of 1996, the police dept. does have the right to view client records concerning accidents. if possible, permission should be sought from the victim or the person authorize to sign for the victim, such as a parent. 11. Which nursing diagnosis has the highest priority in the emergent phase? Fluid volume deficit related to increased capillary permeability