Ch. 57 Burns

Cardiac

A burn client came in. What will the nurse be the first priority?

18%

A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as:

A 4-year-old scald victim burned over 24% of the body

A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications?

Sodium deficit

A nurse is caring for a patient in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values?

Continuously (23hrs a day)

A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment?

2 days

A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury?

"His body has consumed his fat deposits for fuel because his calorie intake is lower than normal."

A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurse's most appropriate response to the family member?

18%

A patient arrives in the emergency department after being burned in a house fire. The patient's burns cover the face and the left forearm. What extent of burns does the patient most likely have?

Survey of all body systems Obtain a history of incident & pertinent patient history Treat pts with falls & electrical injuries for potential cervical spine injury

A patient comes in the emergent or resuscitative phase. What will you be doing in the assessment?

Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream

A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound?

Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidos

A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what?

Layers of skin being shed

A patient with immunologic alterations is susceptible to infection because?

total body surface area (TBSA) affected by the burn

An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury?

Acute

Burn pain has been described as one of the most severe form of ________ pain.

Fluid shifts Tissue hypoperfusion Organ hypo function Needs nutritional assistance

Burn patients more than 20% is considered local and systemic. What is included in local and systemic?

Redness Inflammation Blisters

Burn patients with less than 20% is considered a primarily local response. What is included in local response?

Sleep deprivation

Effect of _______ ______________ on pain.

Protect fragile skin Promote better circulation of damaged tissues Decrease extremity pain through vascular support Decrease itching Reduce thick, hard scars *Wear as much as possible with the goals of 23hrs per day*

Elastic pressure garments promote and protect the patient how?

FULL PPE Mask Goggles Hair cover Gown Gloves

For dressing changes for burn patients. What will the nurse be required to wear?

Acute or intermediate phase

From beginning of diuresis (pee) to wound closure

Rehabilitation phase

From wound closure to return to optimal physical & psychosocial adjustment. Begins as early as possible in the emergent phase and extends for a long period after the injury.

Paralytic ileus Curling ulcer Translocation of bacteria

GI alterations from effects of major burn injury result in?

Airway

If a patient has a neck burn. What is the most priority ?

ECG

In the emergent phase the patients with electrical burns should have an _______.

IV; small, repeated

In the emergent phase, address pain only ______ medication should be administered because of poor tissue perfusion. Give in _______ , __________ doses.

Thermoregulation

Inability exhibit low body temps in *early hours* after burn injury

Conduction injury

Patient got electrocuted by an outlet. What type of injury is this?

20-25%;NG

Patients with burns exceeding ____-______% should have an _____ tube inserted & placed to *low intermittent suction*

Hypermetabolism

Patients with burns have great nutritional needs related to stress response, _____________________, and wound healing

Bronchconstriction; full-thickness

Pulmonary injury: Results also in restrictive defects which results in ________________________ & chest constriction secondary to circumferential torso burns. It may occur with _____- ___________ burns encircling the thorax resulting in decreased tidal volume.

Wound healing Psychosocial support Self image Lifestyle Restoring maximal functional abilities

Rehabilitation phase: What will the nurse focus on the patient when comes to a burn victim during rehabilitation phase?

Mechanical debridement

Use of *surgical tools* to separate and remove the devitalized tissue/

Black ** wound cannot heal until the eschar is removed, must be removed

Wound appearance: What color is eschar?

Grayish, blue, black (lack of perfusion)

Wound appearance: What color indicates poor wound healing & oxygenation of tissues?

Red & beefy (granulated tissue)

Wound appearance: What color is a good sign?

*HAS TO BE COMPATIBLE* Deep wounds Decrease risk of infection Prevents loss of protein, fluid & electrolytes Minimizes heat loss Reduces contractures

Wound grafting is considered for?

Natural debridement

*Devitalized* tissue separates form the underlying viable tissue spontaneously

Hyperthermia

After initial few hours, physiologic and metabolic responses cause persistent increases in core temp.

48-72hrs

Acute or Intermediate Phase: Occurs _____-______ hours after injury. Nurse will continue to assess and maintain respiratory & circulatory support.

True

Cardiac over nutritional is always priority. T/F?

Surgical debridement

Carried out before natural separation of eschar occurs

Removal of eschar until the point of pain and bleeding occurs

The nurse is preparing the patient for mechanical débridement and informs the patient that this will involve which of the following procedures?

True- 73%

Do most burns occur in the home? T/F

Probiotics will help to maintain intestinal barrier Avoiding increased of bacteria

How do you treat a patient with translocation of bacteria?

Acute

The current phase of a patient's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care?

Skin & wound care Mental health Exercise & activity Nutrition Thermoregulation & clothing Sexual issues

What are some home care instructions that the nurse will give to the patient ?

Relaxation techniques Distraction Guided imagery Music

What are the non pharmacologic measure for pain?

- prevention of infection - wound care - pain management - nutritional support - early positioning & mobility

What are the nurses priorities in acute or Intermediate Phase?

Treat with pantoprazole/prozac Teach about acidic foods Gastric/dudcenal erosion (burning of stomach/intestine)

What are we doing for the patient who has an ulcer?

Hyponatremia ( sodium lost) Hypokalemia (losing potassium) Metabolic acidosis Increased urinary output Hemodilution Fluid Rene tears the vascular space from the interstitial space Everything drops

What happens during the acute phase when it comes to fluid and electrolyte shifts?

Hyperkalemia ( potassium leaking into the blood stream) ^ elevated Hyponatremia (losing sodium) Metabolic acidosis ( bicarb going away) Dehydration Reduced blood volume Decreased urine output

What happens during the emergent phase when it comes to fluid and electrolyte shifts?

Bacterial infection effects the whole body (blood stream) Body shuts down

What happens to the patient when they contract sepsis?

Sluggish bowel Absence of peristalsis Treat with fluids, fibers, change positions

What happens to the patient with paralytic ileus, and how do we treat it?

Decreased blood volume Renal failure (acute kidney failure) —-injury to kidney & lack of blood flow Nurse will give FLUIDS

What happens when Renal alterations have been effected?

Prevention Prevention of disability & disfigurement through early specialized and individualized care Rehabilitation through reconstructive surgery

What is the number #1 goal for burns?

Serum sodium level of 140 mEq/L

What laboratory value observed by the nurse is unexpected during the acute phase of a major burn?

- has to have a entrance wound & exit wound - electricity destroys everything in its path - contracts muscles as it travels through the body

What makes up a condition injury?

- cardiac dysrhythmias - spinal injuries - can cause lifelong neuromuscular problems

What makes up a lightning injury?

Edema - which forms rapidly after a burn injury

What occurs in fluid and electrolyte shifts?

Morphine Fentanyl Dilaudid Anxiety (benzodiazepines)

What pain medications are used for our burn patients?

Emergent phase

What phase is this? Onset of injury of completion of fluid resuscitation. Stop the injury - tempid baths - submerge in cool water (not ice) - irrigate chemical burns - ABCs - establish an airway - start oxygen & large-bore IVs (16,18,20) - Remove restrictive objects & cover the wound

Silver sulfadiazine

What topical agent will the nurse use for burn wound care?

Background or resting Procedural Breakthrough

What types of burn pain?

BP above 100mm Hg systolic and MAP >60 mm Hg Maintain using out put of 30-50 mL/hr Maintain sure sodium and other electrolytes at near-normal levels

What vitals will you want your burn patient to maintain?

Monitor for respiratory & cardiac status Monitor BP via arterial Cather ( no BP CUFF) Assess peripheral pulses *palpate* or *Doppler* Monitor intake & output IV site *Elevate burned extremities* ( get blood flow back) Foley catheter Monitor for infection (no gauze)

What will the nurse monitor for when caring for a burn patient?

Hydrotherapy

What would the nurse use for wound cleaning?

Enteral route (NG tube)

When giving nutritional support, ____________ __________ is preferred.

30 minutes Before dressing changes

When will you give pain medication before or after the dressing changes?

Neuropathy patients Young children Elderly

Which patients are at the highest risk for burns?

IV; emergent

_____ use during __________ & acute phases.

Fluid loss

_______ _______ is the result from hypovolemia from plasma volume loss and continues due *capillary leakage*

Foley catheter

__________ ____________ is inserted to monitor kidney function & fluid needs. In the emergent phase.

Jejunal; lower; poor

__________ feedings are frequently used to maintain nutritional status with _________ risk aspiration in a patient with _______ appetite, weakness.

Ischemia

______________ from *increased* edema.

Cardiovascular effects

_________________ effects: - hypovolemia due to plasma volume loss - low cardiac output - low BP - shock!

Escharotomy

_________________ surgical excision of *devitalized tissue*

Hyponatremia

__________________ result of *plasma loss* or in acute phase as water shifts form the interstitial space and returns to the vascular space

Pulmonary injury

___________________ injury: - inhalation injuries above the glottis- Upper airway injury - inhalation injuries below the glottis - Lower airway injury - carbon monoxide poisoning - contributes to lower airway injuries - factor in most fatalities at the scene of a fire

Hyperkalemia

____________________, immediately after burn injury form *massive cell destruction*.