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Background

Fatima, a single 32-year-old Muslim refugee female, has been living in the United State for six months with her two kids in a garage. She was cooking dinner to break her fast during Ramadan when a gas leak resulted in a explosion. Her kids were out playing in the front yard when they heard the explosion. Her eldest daughter immediately ran to her neighbor’s house and asked them to call 911. Upon arrival to the scene, firefighters rescued Fatima and emergency medical technicians (EMTs) were able to remove her burned clothing and hijab. She was conscious, alert and oriented, but sustained significant burn injuries to her face, neck, anterior torso, bilateral upper and lower extremities, and posterior trunk. As a result, the patient was intubated with 100% oxygen enroute to the hospital for airway protection due to inhalation injury and edema with facial burns. The EMTs started an 18 gauge in the left forearm and initiated an intravenous (IV) 1000 mL bolus of Lactated Ringer’s (LR).

Emergency Department (ED)

The EMTs radioed in their ETA at 10 minutes out and the West Hills trauma medical term and burn nurses were informed. Initial assessment at the hospital revealed a young woman that was orally intubated with bilateral clear breath sounds.

Vital signs were as followed:

• Heart Rate: 120
• Blood Pressure: 160/90 (113)
• Temperature: 98.4 F, 36.9 C
• Pain: 4 points on CPOT
• Respirations: 18 (AC ventilation)
• SaO2: 97%

The sustained burns to the face, neck, anterior torso, bilateral upper and lower extremities, and posterior trunk were classified as third degree burns to 51% of her total body surface area (TBSA). A chest X-ray confirmed accurate placement of the ET tube. Fluid resuscitation was continued in the ED with LR. The following initial pending labs were drawn: CBC, carboxyhemoglobin, electrolytes, and ABGs. A foley catheter was inserted to monitor renal function (Hinkle & Cheever, 2014).

Burn Intensive Care Unit (BICU)

Fatima was transferred to the BICU where fluid resuscitation was continued. Her reported height and weight in the ED was 157 cm and 50 kg. The Parkland Formula (4mL x % TBSA x kg = total fluid for the first 24 hours) was calculated to a total of 10,200 mL/24 hours (Mehta & Tudor, 2019). The first half of the fluids were administered within the first eight hours totaling 5,100 mL. The second half of the fluid was given over 318.8 mL/hour for a total of 16 hours.

Vitals signs were as followed:

• Heart Rate: 115
• Blood Pressure: 100/80 (90)
• Temperature: 96.o F, 35.6 C
• Pain: 3 points on CPOT
• Respirations: 17 (AC ventilation)
• SaO2: 98%

Hourly vital signs were documented. A continuous Dilaudid drip of 1 mg/hr was provided for pain management (Unbound Medicine, 2017). Fatima was assessed for any signs and symptoms of respiratory distress (labored breathing, pallor, hypotension, tachycardia, wheezing). A nasogastric tube (NG) tube was placed for nutritional needs. Urine output during was 40 mL/hr. The lab results revealed the following: K+ 5.3 mEq/L, Na+ 130 mEq/L, Cl+ 111 mEq/L, and glucose 120 mg/dL. Fatima was in a metabolic acidotic state. Her carboxyblin was at 11%.

While in the BICU, Fatima recieved multidisciplinary care from nutrition services, respiratory therapy, spiritual care services, physical therapy, social work, case management, nursing, and the physician team. Once the patient was stable, she underwent serial surgical debridement. The health care team members proposed a porcine xenograft as part of Fatima’s plan of care; however, due to conflicting Islamic religious beliefs the plan of care was revised. After consulting with Fatima and the Mullah (Islamic spiritual leader) they both agreed to a Halal bovine xenograft for treatment. It is important to note that the patient with continue to undergo wound preparation procedures over the next couple of weeks. Due to the %TBSA, the team and Fatima decided to culture epidermal autographs for the optimal skin/wound healing. The nurses and physicians continued to provide aseptic would and graft care (Hinkle & Cheever, 2014).

Questions

1. Why is it critical to initiate fluid resuscitation in burn patients?
2. How would you address Fatima’s cultural beliefs and what type of support systems could be integrated into the patient’s plan of care?
3. Fatima had a 51 %TBSA, why is it important to calculate the TBSA in burn patients?

Answer Key

1. Burn patients tend to have third-spacing and re at an increased risk for shock and hypothermia. Therefore, it is critical to administer isotonic fluids (preferably Lactated Ringer’s) to replace the fluid loss. Continually assess the patient for signs and symptoms of hypovolemia and ensure they have adequate cardiac output and tissue perfusion.
2. As the nurse, it is vital to educate themselves about the patient’s Islamic values, beliefs, and preferences. Attempt to reach out to family members or the community members within the same Mosque. In addition, ensure that a spiritual team is on board. Lastly, communicate with the patient and family to address their wishes, cultural, and religious beliefs in the overall plan of care.
3. %TBSA helps determine the amount of fluid resuscitation and the extent of care that is needed. There is an increase chance of mortality with %TBSA greater than 50 because of the increased number of organs involved.

References

Critical Illness, brain Dysfunction, and Survivorship Center. (2019). Assess, prevent and manage pain. Retrieved from https://www.icudelirium.org/medical-professionals/assess-prevent-and-manage-pain

Hinkle, J.L., & Cheever, K.H. (2014). Brunner & Suddarth’s textbook of medical surgical nursing. Philadelphia, PA: Lippincott Williams & Wilkins

Litt, J.S. (2018). Evaluation and management of the burn patient: A case study and review. Missouri Medicine, 115 (5), 443-446. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6205272/

Mehta, M & Tudor, G.J. (2019) Parkland formula. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK537190/

Strauss, S. & Gillespie, G.L. (2018). Initial assessment and management of burn patients. American Nurse Association, 13 (6). Retrieved from https://www.americannursetoday.com/initial-assessment-mgmt-burn-patients/

Unbound Medicine, Inc. (2017). Nursing Central (1.31). [Mobile application software]. Retrieved from https://itunes.apple.com/us/app/nursing-central/id300420397?mt=8

University of Wisconsin Hospitals and Clinics. (2019). Emergency Medicine. UW Health. Retrieved from https://www.uwhealth.org/emergency-room/assessing-burns-and-planning-resuscitation-the-rule-of-nines/12698