Case study - Burn injury: Nursing

Nurse Kamala works on an inpatient burn unit and is caring for Raul, a 42-year-old male who was recently admitted for a thermal burn following a house fire.

After being stabilized in the emergency department through airway management and fluid therapy, Nurse Kamala settles Raul into his room on the inpatient burn unit.

After introducing herself to Raul, Nurse Kamala goes through the steps of the Clinical Judgment Measurement Model to make clinical decisions about Raul’s care by recognizing and analyzing cues, prioritizing hypotheses, generating solutions, taking action, and evaluating outcomes.

First, Nurse Kamala recognizes important cues, including Raul’s vital signs, which include blood pressure 128/88 mmHg, heart rate 105 beats per minute, and respirations 22 breaths per minute.

From Nurse Kamala's assessment of Raul’s skin, she notes Raul has partial- and full-thickness burns on his right lower extremity, extending up to his lower abdomen.

The dressings over Raul’s burns are saturated with serosanguineous drainage and the surrounding skin is reddened and slightly swollen.

She also notices that he appears uncomfortable and restless. Next, Nurse Kamala analyzes these cues.

She reviews Raul’s electronic health record, or EHR, and notes an order for sterile dressing changes with wound debridement and cleansing.

She also sees that he’s prescribed medication for pain management and received his last dose in the emergency department 4 hours ago.

She knows that dressing changes will facilitate healing and untreated pain can make dressing changes intolerable. Nurse Kamala realizes that Raul needs effective pain management so the prescribed wound care can be provided for his burns.

Now, using the information she’s gathered, Nurse Kamala chooses a priority hypothesis of impaired skin integrity. Then, she generates solutions to address Raul’s impaired skin integrity using nonpharmacologic and pharmacologic interventions; and she establishes the expected outcome that Raul’s pain will be at a tolerable level to undergo all scheduled dressing changes.

Nurse Kamala then takes action to implement these solutions. She knows that it’s been 2 hours since Raul’s last dose of pain medication and it’s time for his dressing change.

Nurse Kamala: Raul, it’s time to change the dressings on your wounds. Before we begin, I’d like to make sure your pain is tolerable.

Can you rate your current pain level from 0 to 10 and what you consider to be a tolerable level? Raul: My pain level is 7 out of 10 along my leg.

I can usually tolerate a pain level of 4 out of 10. Can I have some pain medication before the dressing change?

Nurse Kamala: Yes, your health care provider has ordered pain medication every 2 hours and I can now administer another dose to help with your pain during the dressing change.

Raul: Okay, thank you. Nurse Kamala prepares the dose of pain medication and re-enters Raul’s room.

Nurse Kamala then proceeds administer his prescribed IV pain medication using safe medication administration principles.

She informs him that she’ll return in 15 minutes to complete the dressing change once the medication has taken effect. Once Nurse Kamala returns, she asks Raul to rate his pain.

He states that his pain is now a 4 out of 10, so she proceeds to begin the dressing change. She gently cleanses his wounds to remove any loose necrotic tissue, scabs, or dried blood using strict aseptic technique.

Then, she covers the wounds with topical antimicrobial creams as prescribed and applies a new dressing. Afterwards, Nurse Kamala repositions Raul and allows him time to rest while she documents her interventions.

A few days later, Nurse Kamala is reassigned Raul as her patient. She enters his room to evaluate the outcome of her actions and plan for long-term management of Raul’s burns.

She asks how Raul is feeling and if his pain is tolerable for his scheduled dressing change today. Raul states that his pain is currently a 3 out of 10 and that he’s willing to have Nurse Kamala change his dressing.

Raul also reports that physical therapy and occupational therapy have been working with him daily, and that he's looking forward to being discharged with home health care later in the week.

Alright, as a quick recap…Nurse Kamala recognized and analyzed cues related to Raul’s impaired skin integrity, and prioritized hypotheses, and generated solutions to address this problem.

Nurse Kamala then implemented pharmacologic and nonpharmacologic measures to address Raul’s wounds, and evaluated Raul’s outcomes, comparing them to the expected outcomes.

Since Raul’s pain was managed and he tolerated dressing changes, Nurse Kamala determined the plan of care was successful.