Video Case Study - Caring for Patients With Burn Injuries

Nurse Kamala works in a rehabilitation center and is caring for Raul, a 42-year-old who was admitted following a thermal burn in a house fire.

In collaboration with the registered nurse, RN Amy, 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 temperature 98.4 F or 36.9 C, heart rate 100 beats per minute, respirations 21 breaths per minute, and blood pressure 128/88 mmHg.

Nurse Kamala notes that Raul has partial- and full-thickness burns on his right lower extremity, extending up to his lower abdomen.

The dressings over Raul’s burns have a small amount of serosanguineous drainage and the surrounding skin is reddened. 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.

She also sees that he’s prescribed medication for pain management, and he received his last dose 4 hours ago. She knows that dressing changes will facilitate healing and untreated pain can make dressing changes difficult to tolerate.

Nurse Kamala realizes that Raul needs effective pain management so the prescribed wound care can be performed for his burns.

Now, using the information she’s gathered, along with Raul’s medical history, Nurse Kamala reports her findings to RN Amy, and they choose a priority hypothesis of impaired skin integrity.

Then, they generate solutions to address Raul’s impaired skin integrity using nonpharmacologic and pharmacologic interventions; and they establish 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 4 hours since Raul’s last dose of pain medication and it’s time to change his dressings.

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 5 out of 10 along my leg.

I can usually tolerate a pain level of 3 out of 10. I’d really like to have some pain medication before the dressing change.

Nurse Kamala: Yes, your health care provider has ordered pain medication every 2 hours and you can receive 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.

She proceeds to administer his prescribed PO pain medication using safe medication administration principles. Nurse Kamala then informs Raul that she’ll return in 1 hour to complete the dressing change once the medication has taken effect.

When Nurse Kamala returns, she asks Raul to rate his pain. He states that his pain is now a 3 out of 10, so she proceeds to perform the dressing changes.

She gently cleanses his wounds using strict aseptic technique. Then, she applies the prescribed topical antimicrobial cream to gauze and applies the dressing to Raul’s wounds.

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. 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 2 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 in collaboration with RN Amy, prioritized hypotheses and generated solutions to address this problem.

Nurse Kamala and RN Amy then implemented pharmacologic and nonpharmacologic interventions and evaluated Raul’s outcomes and compared them to the expected outcome.

Since Raul’s pain was managed and he tolerated dressing changes, they determined the