1900: Don Johnson is a 23-year-old client who was admitted

1900: Don Johnson is a 23-year-old client who was admitted for burn injuries sustained in a warehouse fire yesterday morning while trying to rescue a coworker. The client has superficial burns to their back, right side of their face and ear, and partial thickness burns to their right arm. The client went to the operating room this morning at 0500 for debridement and returned to the unit from the post anesthesia care unit (PACU) at 1000. The right arm has a skin graft wrapped in gauze and covered with an ace bandage, and there are gauze dressings covering the burns to the back, face, and ear. The skin graft donor site is on the client’s left thigh and is covered with a transparent dressing. All are clean, dry, and intact. The client has an indwelling urinary catheter in place that is draining clear, yellow urine. They are receiving morphine for pain as needed. The last dose was at 1800 and can be administered every 3 hr PRN. Current vitals are temperature 37.6 C (99.7 F), pulse 72/min, respirations 16/min, BP 112/74 mm Hg, and Sp02 96% on room air. Lungs are clear, respirations shallow, S1 and S2 noted, regular rhythm, bowel sounds hypoactive, abdomen is soft and mildly distended. Right arm pulse 2+ and capillary refill 3 seconds, other extremity pulses 3+ and capillary refill 2 seconds. Earlier laboratory results showed mild hyperkalemia. The provider reduced the IV fluid rate to 150 mL/hr and prescribed a repeat blood draw, which was done, and the results are pending. The client’s partner is at the bedside. After receiving handoff report, the nurse should determine the client’s priority needs. Indicate if the client is a high priority or low priority using each of the priority frameworks below. Maslow’s Hierarchy of Needs O High Priority O Low Priority Airway, Breathing, Circulation High Priority O Low Priority Safety and Risk Reduction High Priority O Low Priority Urgent vs Nonurgent O High Priority O Low Priority Chronic vs Acute/Stable vs Unstable High Priority O Low Priority

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