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specific
patient?
Anterior chest= 9%
neck=4.5%
Right leg=9%
Face and
Right arm=4.5%
Total=27%
6. Why the blood pressure of the client was so low and his heart rate was so high
upon arrival at the emergency department?
His heart rate was so high because of hypovolemic shock that
occurs to him. His blood or fluid in his body loss that may cause the
heart impossible to pump a sufficient amount of blood to the body. The
heart failure occurs can decrease the cardiac output that cause the
hypotension to the patient
7. Why was it important to immediately administer intravenous fluids to this
client?
-To prevent the burn shock occur
-To maintain circulatory volume as it is important for normal
cardiac output, rebal perfusion and tissue perfusion
-To provide metabolic water for body
8. Using Parkland formula, how much fluid should the client receive for the first 8
hours after burn injury? The client weighs 60kg. (Show your steps of calculation)
Parkland formula
24hr fluid requirement= 4ml X kg X %TBSA burn
24hr fluid requirement= 4ml X 60kg X 27%
=3240 ml
12hr fluid requirement= 3240ml/2
= 1620ml
9. Formulate 2 nursing diagnosis of the client and then develop the nursing care
plan for the client.
-Impaired gas exchange related to smoke inhalation as evidence by patient heart
rate increase up to 40 breaths per minute
-Fluid volume deficit related to increase capillary permeability as evidence by
low blood pressure below than normal range which is 65/40 mmHg
Assessment
Subjective:
Patient heart
rate is 40
breaths per
minute
Objective:
Patient look
pale
Assessment
Diagnosis
Impaired gas
exchange
related to
smoke
inhalation as
evidence by
patient heart
rate increase
up to 40
breaths per
minute
Planning/Goal
Patient will be
able to breath
normally
about 12-20
breaths per
minute within
4 hours
Intervention
-Assess
patients
condition to
ensure patient
in comfort
-Provide the
humidified
oxygen to
reduce the
breath of
patient to
normal
-Report depth
of respiration
for the
preparation of
intubation
-Maintain
proper
position of
patient to
promote
optimal chest
expansion
Evaluation
Patient
breaths back
to normal
about 12-20
breaths per
minute
Diagnosis
Planning/Goal
Intervention
Evaluation
Subjective:
Patient blood
pressure is
65/40 mmHg
Objective :
Patient look
discomfort
Fluid volume
deficit related
to increase
capillary
permeability
as evidence
by low blood
pressure
which is 65/40
mmHg
Patients
blood
pressure will
be back to
normal range
within 6 hours
-Monitor vital
signs to
ensure the
blood
pressure is
normal
- Note and
report signs of
hypovolemia
to ensure
patient s fluid
volume is in
normal range
- Maintain IV
lines and
regular fluids
at appropriate
rates
as prescribed
to promote
patient body
fluid level in
adequate
range
-Monitor
patient
position to
prevent
contrectures
Patient blood
pressure back
to normal
range