Presenting Complaint: Burn injuries sustained from campfire accident (20% TBSA burns to anterior chest and right forearm total circumference) Noted 1hr 10 min post burn.

Medical Progress Note

Called in to review patient following Primary & Secondary Survey completed by nursing staff.

Airway: Patent. Singed nasal hairs present. No stridor or respiratory distress noted. No clinical evidence of inhalation injury at this stage, but ongoing monitoring required.

Breathing: RR 20, SpO₂ 98% on room air. Mild dyspnoea reported. Equal breath sounds bilaterally. No wheezing or accessory muscle use.

Circulation: HR 125, BP 128/85. Borderline tachycardia, likely secondary to pain. Capillary refill <2s. Urine output 20mL/hr – borderline, requires ongoing assessment.

Disability: GCS 15. Alert and oriented. Complains of significant pain, currently rated 8/10 despite initial IV analgesia.

Exposure: No other traumatic injuries noted. Burns affecting anterior chest (~10%) and right forearm (~10%). No signs of compartment syndrome. Weight 87kg. Height 189cm

Social History: Reports heavy alcohol use but no current signs of acute withdrawal. AWS scale to be commenced

Assessment:

• Superficial and full-thickness burns (20% TBSA) – risk of fluid shifts and evolving burn shock.

• Significant pain requiring escalation of analgesia.

• Potential inhalation injury – close airway monitoring required.

• At risk for alcohol withdrawal – requires monitoring.

• Awaiting retrieval to tertiary burns unit- photos sent

Plan:

1. Pain Management: IV fentanyl 50mcg PRN, add oral paracetamol 1g.

2. Fluid Resuscitation: Continue IV Hartmann’s solution,370mls/hr first 8 hours (per parkland formula)- targeted urine output ≥43mL/hr

3. Airway Monitoring: Maintain observation for signs of delayed airway compromise, repeat ABGs if symptoms progress.

4. Strict Fluid Balance: Maintain hourly urine output monitoring, reassess for evolving burn shock.

5. Alcohol Withdrawal Screening: Continue AWS scale, initiate benzodiazepines if AWS score reaches 4.

6. Give IV thiamine as ordered

7. Retrieval Planning: Confirm handover completed, update retrieval team with latest observations and management.

8. Prior to transfer: Chest burn- clean & dress occlusive non-adherent dressing. Right arm-clean & cover with plastic cling film lengthways (avoid wrapping circumferentially)

Signature: [Dr Seva Constance]
Designation: GP/VMO
Facility: [Level 2 Rural Emergency Department]

1. The patient is awaiting retrieval to a tertiary burns unit. What nursing considerations are essential when preparing this patient for transfer, including wound care, fluid management during transport, ongoing pain control, and potential complications that might arise during transfer?

2. The patient is awaiting retrieval to a tertiary burns unit. What nursing considerations are essential when preparing this patient for transfer, including wound care, fluid management during transport, ongoing pain control, and potential complications that might arise during transfer?

Patient: Alex Rivera
Date/Time: 16 March 2025 / 16:15
URN: 52973041

Assessment Following Nursing Primary & Secondary Survey:

I have reviewed the nursing primary and secondary survey findings and assessed the patient.

Clinical Presentation:

26-year-old male presented following low-speed MVA (15-20 km/h) involving collision with a tree after swerving to avoid a wallaby. Patient reports chest pain on inspiration and facial pain from lacerations. Nursing assessment revealed tenderness over right lateral chest wall (ribs 5-7).

Examination Findings:

• Vitals: BP 130/80, HR 110, RR 20, SpO2 95% on RA, Temp 36.8°C

• Respiratory: Decreased breath sounds at right lower base. Slight asymmetry in chest wall movement with reduced right-sided expansion. Normal percussion note elsewhere.

• Cardiovascular: Tachycardic but regular rhythm. Dual heart sounds. No elevated JVP.

• Chest Wall: Tenderness over right 5-7th ribs laterally. No surgical emphysema.

• Pain: 7/10, primarily in right chest wall with inspiration

Imaging Results:

• CXR: Confirms fractures of right 6th and 7th ribs without obvious pneumothorax.

• C-spine: No acute abnormalities. Cervical collar removed as per protocol.

Assessment:

Patient with rib fractures following low-speed MVA showing signs of potential respiratory compromise. The reduced breath sounds at the right base and oxygen saturation of 95% warrant close observation for developing complications such as small pneumothorax or pleural effusion. Pain appears inadequately controlled with paracetamol alone.

Plan:

1. Monitoring:

   • Oxygen via nasal prongs at 2L/min to maintain SpO2 >95%

   • Observations q1h for next 4 hours

   • Repeat respiratory assessment in 2 hours

2. Analgesia:

   • Paracetamol 1g QID regular

   • Oral oxycodone 5mg for breakthrough pain

3. Investigations:

   • Repeat CXR in 4 hours to evaluate for developing pneumothorax/effusion

   • ECG to assess for any cardiac contusion given tachycardia

4. Management:

   • IV fluids - Normal saline 80ml/hr

   • Maintain semi-fowlers position

5. Disposition planning:

   • Likely admission for observation given rib fractures and evolving symptoms

   • Surgical team notified for potential review if symptoms progress

Will review after repeat CXR and adjust management plan accordingly.

Emergency Department Registrar: Dr. Sarah Mitchell

1.      What specific respiratory assessment findings in this patient would prompt you to escalate care, and why are these findings particularly concerning in the context of rib fractures?

2.      How would you prioritise your nursing interventions for this patient in the next hour, and what is the rationale behind your prioritisation?

3.      What psychological aspects of care should you consider for this patient given their pre-existing anxiety disorder, and how might the traumatic event affect their pain experience and recovery?

1. What is the role of the RN in responding to a suspected child protection concern, and how should concerns be escalated and documented?

2. How would you prepare Emily for cast or splint application in a developmentally appropriate way, and what distraction techniques might you employ during the procedure?

R) arm injury

Hx: No clear mechanism.

Grandmother reports child reluctant to use arm since yesterday

Teacher noticed during swimming

PMHx: Nil

O/E:

• Alert, withdrawn when discussing injury

• R) wrist swollen; deformity noted

• Point tenderness R) distal radius

• Limited ROM due to pain

• Incidental finding: Multiple bruises varying ages noted on back and R) hip

Plan:

• XR R) wrist

• Analgesia

• For ortho review

Dr S. Tony, ED Registrar

1. What specific nursing assessments would you perform for Emily's right wrist injury, and how frequently would you repeat these assessments while she awaits medical treatment?

2. Emily's vital signs show a heart rate of 115. Differentiate between normal age-appropriate tachycardia, pain-related tachycardia, and anxiety-related tachycardia in a pediatric patient, and explain how you would address each cause.

3. Emily's vital signs show a heart rate of 115. Differentiate between normal age-appropriate tachycardia, pain-related tachycardia, and anxiety-related tachycardia in a pediatric patient, and explain how you would address each cause.

Observations:

• HR: 125 bpm

• RR: 24 breaths/min (shallow breathing)

• BP: 128/85 mmHg

• Temp: 36.8°C

• SpO₂: 95% on room air

• Pain Score: 8/10

• Mental Status: Alert, distressed

Visible Injuries:

• Bilateral arm burns with redness and blistering observed (partial thickness, approximately 18% TBSA estimated using Rule of Nines).

• Patient complains of throat irritation and occasional cough.

• Singed nasal hairs observed

Immediate Actions Taken:

• Cool running water applied to burns.

• Burns first aid commenced.

• Oxygen therapy considered if respiratory distress worsens.

• GP VMO en route (ETA 25 min).

Student Activity:

• Predict primary and secondary survey findings.

• What key concerns arise from the mechanism of injury?

• What questions should the nurse ask to gather more information?

Observations:

• HR: 98 bpm

• RR: 20 breaths/min

• BP: 130/85 mmHg

• Temp: 36.9°C

• SpO₂: 99% on room air

• Pain Score: 6/10

• Mental Status: Alert, cooperative

• Visible Injuries:

  • Small facial laceration (forehead, ~3cm, actively bleeding)

  • Bilateral seatbelt sign across chest

  • Complains of chest pain, worse on deep inspiration

• Reports no loss of consciousness but states he felt "shaken up" after the crash.

• Immediate Actions Taken:

  • Wound pressure applied for bleeding control

  • Oxygen applied at 2L/min via nasal prongs for comfort

  • C-spine precautions maintained

    
    

Student Activity:

• Predict primary and secondary survey findings.

• What injuries might be hidden?

• What diagnostic tests should be considered?

Observations:

• HR: 115 bpm

• RR: 22 breaths/min

• BP: 100/65 mmHg

• Temp: 36.8°C

• SpO₂: 99% on room air

• Pain Score: 7/10 (faces scale)

• Mental Status: Quiet but cooperative at triage

• Visible Injuries:

  • Right wrist appears swollen

  • Child reluctant to move arm

  • No visible bruising at triage

• Grandmother states:

  • Noticed child avoiding use of the arm but thought she was “just being cautious.”

  • Took the child to ED because a teacher expressed concern during swimming class today.

• Immediate Actions Taken:

  • Arm supported in a sling for comfort

  • Ice pack applied

Student Activity:

• Predict primary and secondary survey findings.

• What are the red flags for a paediatric fracture?

• What questions should the nurse ask to clarify the injury mechanism?