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Source:

Nursing2015

May 2011, Volume 41 Number 5 , p 72 - 72

Author

  • Heather Brown-Guttovz BSN, RN

Abstract

MS. B, 39, IS BROUGHT to your ED by ambulance after being rescued from a house fire. She has burns involving the anterior aspects of her left arm and leg, as well as her anterior thorax. The paramedics removed her clothing and jewelry at the scene. You quickly help transfer her to a stretcher.Ms. B. is responsive to noxious stimuli only. You quickly assess her ABCs and note soot in her mouth and nostrils. Her breathing is labored, she has audible stridor, and she's using accessory muscles of respiration. She is manually ventilated with 100% oxygen while you establish venous access. A colleague attaches her to a cardiac monitor, automatic noninvasive BP monitor, and pulse oximeter. Her vital signs are: temperature, 98.4[degrees] F (36.9[degrees]C); heart rate, 118, sinus tachycardia; respirations, 30; BP, 90/42; and SpO2, 86% on room air.The burn injuries appear waxy white, dry, and hard, and don't blanch with pressure. The surrounding areas are blistered, nonblanchable, and appear wet,

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