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?