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This case requires knowledge of burns, child abuse, as well as an understanding of the client’s background, personal situation, and mother-child attachment relationship. Client Profile Kyla is an 8-month-old infant who lives with her mother, grandmother, and great grandmother in Cincinnati, Ohio. Her mother, Sierra, is a 16-year-old who stopped going to school after she became pregnant by her on-again, off-again 18-year-old boyfriend, Kyle, who visits Sierra but shows no interest in Kyla. He frequently becomes annoyed and leaves when Kyla needs to be fed or have her diapers changed. Sierra’s father was very abusive to both Sierra and her mother as Sierra was growing up. He died 6 months ago because of a knife wound that occurred during a fight at a local tavern. He and Sierra’s mother lived together with their five children and when he worked, he worked for a minimum wage that barely fed his family. Kyla’s aunts and uncles (Sierra’s three sisters and one brother) keep in contact with their mother and sister but are busy with their own lives and families. Although Sierra participates in Kyla’s care, her mother is the stable caregiver when she is not working. The relationship between Sierra and her mother has been strained since Sierra became pregnant and frequently the two engage in heated arguments over the increased financial stress related to Kyla’s needs and Sierra’s refusal to seek employment. Sierra’s grandmother is in poor health and requires frequent visits to the emergency room because of unstable angina. Case Study At 2135 hours, Kyla is brought wrapped in a bath towel by her grandmother to the emergency department at the local hospital. The admitting nurse observes that Kyla is crying vigorously and is unable to be consoled. She is in no apparent respiratory distress. According to the grandmother, Kyle came over to see Sierra while Kyla’s grandmother was out at the grocery store. When she returned, Kyla was screaming. Sierra said that she and Kyle were talking and Kyla “got really fussy, so we decided to give her a bath to get her to quiet down, but she just kept screaming.” Kyla’s grandmother wrapped Kyla in a bath towel and brought her to the hospital because she thought that she was sick because “she was so red.” On further assessment the nurse notes that Kyla has blisters on her feet, lower legs, and buttocks, and bruises on her upper arms. The health care provider examines Kyla and arranges for her to be transferred by Air Flight to Cincinnati Shriners’ Hospital to be admitted with second-degree burns of her buttocks, genitalia, legs, and feet. Health care providers at the burn center estimate Kyla’s burns as 34% of her total body surface area (TBSA) using the “Estimation of the Extent of Burns in Children” chart. Although Sierra calls every other day to ask about Kyla’s condition, she doesn’t visit her daughter. Kyla’s grandmother stays at the hospital with Kyla. Questions 1. Discuss your impressions about the above situation. 2. Discuss the factors in this situation that would place Kyla at risk for child abuse. 3. Using developmental theory, discuss Sierra’s level of growth and development. 4. The health care providers determined that Kyla’s development was appropriate for an 8-month-old infant. Discuss what you would expect when assessing Kyla’s growth and development. 5. Discuss how the health care providers arrived at 34% of Kyla’s TBSA experiencing second-degree burns. 6. Describe the characteristics of second-degree burns. 7. Using the 4:2:1 rule for calculating maintenance rate of intravenous fluids for Kyla, who weighed 3.18 kg (7 lb) at birth and has experienced a weight gain within normal limits for her age, calculate her hourly IV rate. 8. Determine Kyla’s priority nursing diagnoses on admission to the burn center, discussing why each is a priority. 9. Discuss your impressions about why Sierra doesn’t visit Kyla at the hospital. 10. Discuss what members of the health care team should be involved in Kyla’s care and recovery. 11. Discuss your feelings about child abuse and how you would feel if you were a nurse caring for Kyla in this situation. CASE NO.2 SMOKE INHALATION AND CYANIDE POISONING At 3:15 AM fire department crews were dispatched to a dwelling fire. A brick row home was found fully engulfed in flames. A second alarm was sounded. Neighbors believed that George Johnson was at home when the fire started. At 3:40 A M the rescue crew exited the home with a middle-aged black male, unconscious with nasal respirations. The paramedic crew that had been standing by began treating the patient by ventilating him with positive pressure oxygen. George had a pulse and had no apparent bleeding, so the crew quickly moved him into the ambulance to complete the secondary survey. George was unresponsive to deep pain: his pupils were dilated and reacted sluggishly to light. His mustache and nasal hair were singed. His entire body was covered with soot. and his sputum was carbonaceous. George’s skin was warm and dry. his capillary refill time delayed, color dusky, and mucous membranes gray. The rescue officer reported that George was found in a third-floor smoke-filled bedroom with no open fire near him. It appeared that the source of the fire was the living room couch on the first floor. As the paramedic attempted intubation, George gagged on the tube and aroused slightly. Therefore, oxygen was applied at 15 liters/min via a non-rebreather mask. George’s vital signs currently were BP 160/100. pulse 110. and respirations 28. Breath sounds were heard bilaterally. with coarse rhonchi throughout all lung fields. The ECG showed that George was in a sinus tachycardia with occasional unifocal PVCs. An intravenous line was established with an 18-gauge catheter and D-, W solution infused slowly. En route to the hospital the paramedic notified the ED of George’s condition, field assessment, treatment, and estimated time of arrival. The paramedic also requested and was granted an order from the ED physician for 2 mg intravenous Narcan and 25 g intravenous D50 W, to be administered en route. Triage Assessment, Acuity Level IV: Inhalation injury, hair singed: color pale. dusky: severe pulmonary congestion. Based on the field report, the paramedics bypassed the triage area and immediately brought George to the resuscitation area. Upon arrival George is noted to be approximately 60 years old, weighing 80 kg. George is somewhat combative, pulling at his oxygen mask and attempting to sit up on the stretcher. He is not comprehending instructions given by the resuscitation team, and he is nonverbal. George appears healthy and is ventilating spontaneously, though mildly tachypneic. George’s physical exam remains the same as that reported by the paramedics, and all other systems are clear of injury. Among the initial treatments/or George in the ED are intubation, mechanical ventilation with oxygen at 100%, positive end expiratory pressure (PEEP) 5cm and a second intravenous line. Blood samples are drawn for routine analysis. The ABG sample as well as the venous sample drawn at the scene are both sent to the lab for carboxyhemoglobin levels for comparison. A Foley catheter is inserted. Alupent nebulization is initiated. The team leader then uses a fiber-optic bronchoscope to visualize the damage to the lower airway. Bronchial inflammation and mucosal ulceration are noted. George’s updated ABG results are Pa02 62, PaCO2 56, and pH 7.28. The field COHb is 36% and ED COHb is 24%. Three-hundred milligrams of sodium nitrate is administered intravenously followed by 12.5 g of sodium thiosulfate intravenously. Throughout the resuscitation George’s vital signs remained stable. Hyperbaric oxygenation therapy is considered, and transportation arrangements are made for u helicopter to fly George to the closest chamber, located at a naval hospital 100 mile-away. QUESTIONS What is the etiology and complications of smoke inhalation? What assessment parameters can be used to determine the risk of airway compromise? What is the risk of cyanide toxicity, and how is it treated? What is hyperbaric oxygen therapy, and why is it used for CO inhalation? What nursing diagnoses are applicable to this situation?

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