Chap. 51: Patient with Burns notes
own skin Patient's own unburned skin May be meshed to cover larger areas or placed as a sheet on faces and hands for a smoother, more cosmetic appearance Permanent This is the ideal coverage for all patients' burns and has the highest chance of wound closure. May be delicate if meshed widely before application. Staple removal may be tedious.
◼Autograft -
skin grafts
◼Autograft - own skin ◼Homograft - from living or recently deceased, amniotic membrane ◼Heterograft - from animals, pigs ◼Biosynthetic/Artificial skin
A patient recovering from 25% total body surface area burns has a low-grade fever. What should the nurse do to reduce this patient's risk of developing an infection? 1) Follow contact precautions 2) Implement protective isolation 3) Use sterile technique for all dressing changes 4) Administer prophylactic antibiotics as prescribed
ANS: 1 Cross-contamination among burn patients is common, and as a result, isolation guidelines are widespread practices among burn centers. Contact precautions may be used when entering all patient rooms.
A patient with 35% total body surface area burns is in the rehabilitative phase of care. Which approach should be used to reduce the risk of developing contractures? 1) Apply splints 2) Physical therapy two hours a day 3) Passive range of motion exercises 4) Occupational therapy one hour every other day
ANS: 1 Splinting is the most common method used to help prevent the formation of contractures.
A patient with several deep partial-thickness burns asks how long it will take for the burn to heal. What should the nurse respond to this patient? 1) "More than two weeks." 2) "Within one to two weeks." 3) "Within 24 to 72 hours." 4) "You will need skin grafts."
ANS: 1 The majority of deep partial-thickness burns take more than two weeks to heal.
The nurse is caring for a patient who sustained chemical burns. What would have caused these injuries? Select all that apply. 1) Lime 2) Gasoline 3) Bleach 4) Fabric softener 5) Hydrofluoric acid
ANS: 1, 2, 3, 5 1. Lime can cause a chemical burn. 2. Gasoline can cause a chemical burn. 3. Bleach can cause a chemical burn. 5. Hydrofluoric acid can cause a chemical burn.
A patient is diagnosed with several superficial partial-thickness burns. What treatment would be indicated for this patient? Select all that apply. 1) Apply bacitracin ointment 2) Cover with a nonadherent bandage 3)Apply mafenide acetate 10% cream 4)Wash with antiseptic soap and warm water 5)Apply collagenase and cover with roll gauze
ANS: 1, 2, 4 1. Care of a superficial partial-thickness burn includes applying bacitracin ointment. 2. Care of a superficial partial-thickness burn includes covering with nonadherent bandage. 4. A superficial partial-thickness burn is to be washed with antiseptic soap and warm water.
A patient has been recovering for 18 months from burns that affected 60% total body surface area. For which problems should the nurse anticipate providing continuing care to this patient? Select all that apply. 1) Anxiety 2) Depression 3) Spiritual distress 4) Body image disorder 5) Post-traumatic stress disorder (PTSD)
ANS: 1, 2, 4, 5 The burn patient may endure many psychological and emotional challenges throughout his or her lengthy course of treatment and recovery. The patient may experience anxiety, depression, body image disorder, and PTSD.
The school nurse is preparing material for National Fire Prevention week. What information should be added to the classroom posters? Select all that apply. 1) Never leave a burning candle unattended. 2) Set heating pads on "low" when sleeping. 3) Keep a flashlight and telephone near the bed. 4) Check smoke alarm batteries every six months. 5) Never use the oven as a method to warm the home.
ANS: 1, 3, 4, 5 1. To prevent fires, never leave a burning candle unattended. 3. To respond to a fire, keep a flashlight and telephone near the bed. 4. To prevent fires, check smoke alarm batteries every 6 months. 5. To prevent fires, never use the oven as a method to warm the home.
A patient has full-thickness burns over 30% of total body surface area. Which intervention will least likely provide comfort initially to this patient? 1) Elevate injured extremities 2) Medicate for pain around the clock 3) Apply medicated ointment to all areas 4) Elevate the head of the bed 30 degrees
ANS: 2 A full-thickness burn involves destruction of the epidermis, the dermis, and portions of the subcutaneous tissue. All epidermal and dermal structures are destroyed including hair follicles, sweat glands, and nerve endings. As a result of the extensive damage to the nerve endings, full-thickness burns are insensate to palpation and often are not painful. Pain medication would be least likely to provide comfort to this patient initially.
A patient with deep partial-thickness wounds is receiving enzymatic debridement. What assessment made by the nurse would indicate that wound care treatment has been successful? 1) Gray wound bed 2) Separation of eschar 3) Development of eschar 4) Presence of purulent exudate
ANS: 2 Enzymatic debridement involves the application of a proteolytic ointment that hastens eschar separation.
The nurse is caring for a patient with 70% total body surface area chemical burns. Which approach should the nurse anticipate to meet this patient's nutritional needs? 1) Parenteral nutrition 2) Duodenal tube feedings 3) Nasogastric tube feedings 4) Six small high-calorie meals per day
ANS: 2 In large burn injuries, longer nutritional support is required, and placement of a duodenal feeding tube is often recommended to help prevent aspiration and allow for feeding up to and during procedures.
A patient recovering from full-thickness burns rates pain as a 9 on a scale of 0 to 10 when hydrotherapy is performed. For which type of pain should this patient be treated? 1) Referred 2) Procedural 3) Background 4) Breakthrough
ANS: 2 Procedural pain is associated with therapeutic activities such as wound care and physical therapy.
The nurse is caring for a patient with 45% total body surface area thermal burns. Which laboratory value change would be expected? 1) Increased pH 2) Increased sodium 3) Increased potassium 4) Decreased hematocrit
ANS: 3 Hyperkalemia is expected because of massive cellular trauma causing the release of potassium into extracellular fluid.
A patient recovering from deep and full thickness burns is nauseated. Which medication should the nurse provide to help this patient? 1) Ranitidine (Zantac) 2) Esomeprazole (Nexium) 3) Metoclopramide (Reglan) 4) Polyethylene glycol (Miralax)
ANS: 3 Metoclopramide (Reglan) promotes stomach emptying and decreases nausea.
A victim of a house fire is brought to the emergency department for burn treatment. What assessment finding indicates that the patient may have an inhalation injury? 1) Coughing 2) Soot on the face 3) Singed facial hair 4) Heart rate 98 bpm
ANS: 3 Patients with an inhalation injury may present with singed facial hair.
A patient is ending the first year of recovery after having burns to both legs. Which observation indicates that the patient needs to be encouraged to wear the pressure garment? 1) Skin warm and moist 2) Pedal pulses present but faint 3) Scattered areas of scarring noted 4) Nonpitting edema of both ankles
ANS: 3 Specialty pressure garments are intended to provide continuous and uniform pressure over the area of burn to prevent hypertrophic scarring. These garments are to be worn 23 hours a day for up to a year or more after injury in some patients. The presence of scarring indicates the garment has not been worn consistently.
A patient with 55% total body surface area burned received two-thirds of the required fluid resuscitation. For which potential problem should the nurse prepare to provide care to this patient? 1) Increased zone of stasis 2) Increased zone of hyperemia 3) Increased zone of coagulation 4) Decreased zone of coagulation
ANS: 3 The zone of stasis immediately surrounds the zone of coagulation and is characterized by damaged cells and impaired circulation. It is this area of the burn that is most at risk for conversion if the patient does not receive adequate resuscitation. Improper resuscitation or under-resuscitation may cause the burn to become deeper because of limited blood flow, causing the zone of stasis to convert into the zone of coagulation.
The nurse is assisting with the secondary survey of a patient with 50% total body surface area electrical burns. Which test would be a priority for this patient? 1) Chest x-ray 2) Bronchoscopy 3) CT scan of the head 4) 12-lead electrocardiogram
ANS: 4 A 12-lead electrocardiogram is indicated for an electrical injury.
It is documented that a patient has superficial partial-thickness burns over both anterior lower arms. What should the nurse expect when assessing this patient? 1) Dry with no blisters 2) Waxy appearance and cherry red in color 3) Dry leathery appearance and pale or brown in color 4) Open or closed blisters, mild edema, easily blanches
ANS: 4 A superficial partial-thickness burn has blisters that may be closed or open and weeping; pink or red; mild edema; and blanches easily.
A victim of a car fire is confused, dizzy, and nauseated. What diagnostic test should be done to determine if this patient is experiencing carbon monoxide poisoning? 1) Chest x-ray 2) Bronchoscopy 3) Pulse oximeter 4) Carboxyhemoglobin level
ANS: 4 Because carbon monoxide binds to the hemoglobin molecule with an affinity 200 times greater than that of oxygen, tissue hypoxia results when carbon monoxide levels are above normal. Carboxyhemoglobin levels will detect the amount of carbon monoxide in the patient.
A patient is admitted for a suspected inhalation injury. What should the nurse emphasize when caring for this patient? 1) Increase oral fluids 2) Turn in bed every two hours 3) Monitor strict intake and output 4) Deep breathing and coughing every hour
ANS: 4 Deep breathing and coughing should be done every hour to assist with airway clearance and mobilization of secretions.
An 11-year-old child received burns over both upper and lower arms, both hands, anterior upper and lower legs, anterior chest, and the neck. Using the following as a guide, what is this child's total body surface area burned? 1) 30 % 2) 42 % 3) 57 % 4) 65 %
ANS: 4 Feedback: Select the percentage burn column for 10-14-year-old. The neck is 2; the anterior trunk is 13; the right upper arm is 4; the right lower arm is 3; the left upper arm is 4; the left lower arm is 3; the right hand is 2.5; the left hand is 2.5; the right thigh is 9; the left thigh is 9; the right lower leg is 6.5; and the left lower leg is 6.5. The total body surface area burned is 65%. The other answer choices are miscalculations or incorrect use of the graphic provided.
The nurse is caring for a patient with 50% total body surface area burns. Which finding indicates that burn shock is resolving? 1) Heart rate 112 bpm 2) Respirations 24 per minute 3) Blood pressure 90/60 mm Hg 4) Urine output 800 mL over 2 hours
ANS: 4 In the postburn shock phase, which begins 24 to 48 hours after injury, the capillaries begin to regain integrity. Burn shock slowly begins to resolve, and the fluid gradually returns to the intravascular space. Urinary output continues to increase secondary to patient diuresis.
The nurse is evaluating care provided to a patient with burns during the emergent phase. Which data indicates that additional fluid resuscitation is required? 1) Blood pH 7.39 2) Heart rate 112 bpm 3) Blood pressure 110/60 mm Hg 4) Central venous pressure 2 mm Hg
ANS: 4 Indications of adequate fluid resuscitation include a central venous pressure between 5-10 mm Hg. A pressure of 2 mm Hg indicates fluid volume deficit. More fluid would be indicated.
The nurse is caring for a patient who sustained electrical burns. Why should the nurse monitor this patient for compartment syndrome? 1) Potential for undiagnosed injuries 2) Injuries from being thrown bruise soft tissue 3) Electrical current alters integrity of blood vessels 4) Fluid seeps from intravascular spaces into the interstitium
ANS: 4 Pulses are closely monitored in all affected extremities for the first 48 hours postinjury in order to assess for the potential development of compartment syndrome. As fluid seeps from the intravascular spaces into the interstitium, pressure within the tissues continues to rise and confines swelling inside muscle compartments.
A patient weighing 187 lbs. has 38% total body surface area burns. Using the Parkland formula, how much fluid should this patient receive over the first eight hours after the burn occurred? Record your answer as a whole number. ______
ANS: 6460 mL Feedback: First calculate the patient's weight in kg by dividing the weight in lbs. by 2.2 or 187/2.2 = 85 kg. Next use the formula 4 mL x kg of body weight x TBSA % to calculate the total fluid amount needed. For this patient that would be 4 mL x 85 x 38 = 12,920 mL. Since one-half of the total fluid amount should be provided in the first 8 hours, divide the total amount of fluid by 2 or 12,920/2 = 6460 mL. The patient should receive 6460 mL of fluid in the first 8 hours after the burn injury.
The assessment of the patient's airway takes top priority. A nonrebreather mask is placed on all patients with burn injuries, and 100% oxygen is administered. Patients at risk for intubation include those with facial burns, changes in voice (such as hoarseness), carbon noted in the sputum, and with injury associated with a fire in an enclosed space. If intubation is warranted, the most experienced person performs the procedure, and special care is taken to secure the endotracheal tube, especially if facial burns are present. It is essential to secure the patient's endotracheal tube with UMBILICAL TWILL or commercially prepared ENDOTRACHEAL TUBE HOLDERS and not adhesive tape because tape does not stick to the burned face and does not allow for swelling.
Airway Maintenance
Results from burns in an enclosed space with findings such as: headache, weakness, dizziness, confusion, edema, followed by sloughing of the respiratory tract mucosa.
CARBON MONOXIDE INHALATION
account for approximately 3% of all burn center admissions and occur in both the industrial and household settings. The three subclasses of chemical burns include acids, alkalines, and organic compounds. Some examples of chemical burns include those caused by cement, gasoline, lime, hydrofluoric acid, and bleach. The extent of a chemical injury is dependent on many factors, including the agent, the mechanism of action, the concentration and volume of the agent, and the duration of contact with the agent.
Chemical burns
Area: Damage to all layers of skin, extends to muscle, tendons, and bones. Appearance: Black, no blisters, no edema Sensation/Healing: NO PAIN Heals within weeks to months, scarring, grafting Example:Electrical Burns, Flames (Eschar hard and inelastic)
DEEPFULL THICKNESS (4th degree)
HGB/HCT-Decreased (hemodilution) due to the fluid shift from the interstitial space back into vascular fluid SODIUM-Remains decreased due to renal and wound loss POTASIUM-Decreased due to renal loss and movement back into cells (hypokalemia) WBC-Initial Increase then decrease with left shift BLOOD GLUCOSE-Elevated due to the stress response ABG-Slight hypoxemia and metabolic acidosis TOTAL PROTEIN AND ALBUMIN-Low due to fluid loss
Fluid Remobilization-(Starts at about 24hr; diuretic stage begins at 48 to 72 hr after injury). ACUTE PHASE
Findings of _______________ include: -Singed Nasal Hair -Singed Eyebrow -Singed Eyelashes -Sooty Sputum -Hoarseness -Wheezing -Edema of the Nasal Sputum -Smoky Smelling Breath
INHALATION DAMAGE
Broad-spectrum, effective against Pseudomonas but has little anti-fungal coverage -against gram pos and neg Cream used on full-thickness burns to ears only; solution used on partial-thickness burn wounds and grafts Cream is applied 1/16 in. thick and left open to air. Solution is applied to nonadherent gauze and roll gauze. Cream is changed every 12 hours; solution dressings are changed every 24 hours and may be wet down at 12 hours. Cream penetrates eschar. Solution is only a once-per-day dressing change. Solution is awet-type dressing and may not be used on initial large burn wounds because it may cause hypothermia. Some patientsmay complain of stinging upon application to partial-thickness burn wounds. Frequent sensitivities noted. -plainful to apply and remove can cause metabolic acidosis
Mafenide acetate 10% cream or 5% solution (Sulfamylon Cream or Slurry)
are the least common type of burn injury, and the severity of complications is dependent on the type, dose, and length of exposure. These injuries are often associated with the industrial use of ionizing radiation, nuclear accidents, and therapeutic radiation treatment. Sunburn is also considered a radiation burn because it is caused by ultraviolet radiation and is the most common type of radiation burn seen in healthcare settings. Localized radiation injuries often appear similar in nature to thermal burns because they are characterized by erythema, edema, blisters, and pain. Prolonged full-body exposure to ionizing radiation often causes nausea, vomiting, diarrhea, fatigue, headache, and fever.
Radiation burns
GLUCOSE-Elevated BUN-Elevated HCT/HGB-Elevated (hemoconcentration) due to loss of fluid and shift SODIUM-Decreased (d/t third spacing) POTASIUM-Increased (d/t cell destruction) CHLORIDE- Increased due to fluid volume loss and chlorine reabsorption in the urine CARBOXYHEMOGLOBIN-More then 10% strongly indicates smoke inhalation PLASMA LACTATE- elevated if the client has cyanide toxicity OTHER- Total protein and blood albumin(decreased) ABG (possible metabolic acidosis), liver enzymes. urinalysis, and clotting studies) -fluid resuscitation should be initiated at 2 mL per kilogram; for children age 14 or younger, including infants, resuscitation should be initiated at 3 mL per kilogram; and for electrical injuries in all ages, resuscitation should be initiated at 4 mL per kilogram.
Resuscitation Phase: Initial fluid shift (occurs in the first 12hrs and continues for 24 to 36hr) EMERGENT
Broad-spectrum and Candida coverage -effective against gram neg and pos and yeast Partial- and full-thickness burn wounds ¼-in.-thick application with roll gauze to cover; dressing changes every 12 hours Cooling effect when applied; easy, painless application May cause transient leukopenia(neutropenia); may also cause a wound film on partial-thickness burns, making it hard to assess healing Avoid in patients with a documented sulfa allergy. Avoid application to face -penetrates eschar minimally -can cause a gray or blue - green discoloration -decreases granulocyte formation
Silver sulfadiazine (Silvadene)
Area: Damage to entire Epidermis, some dermis Appearance: pink to red, *blisters*, mild-mod edema Sensation/Heal: Painful, Within 3 weeks, no scars Example: Flash Flame and Scalds, Brief contact w hot objects(No eschar) - the cool helps
Superficial partial thickness (2nd degree)
Area: Damage to Epidermis Appearance: Pink to red, no blisters, mild edema Sensation/Heal: Painful/Tender, Sensitive to heat, 3-6d, no scarring Example: Sunburn, Fast Burn (Sudden Intense Heat(No eschar)
Superficial thickness (1st degree)
can be the result of a flash(ELECTRICAL CURRENT THAT TRAVELS THOUGH THE AIR FROM ONE CONDUCTOR TO ANOTHER), scald(HOT LIQUID OR STEAM), or contact with hot objects or flames, and common causes include house fires, car fires, cooking accidents, or injuries as a result of careless smoking. Associated accelerant use (e.g., gasoline, kerosene, or propane) may increase the severity of the burn and associated inhalation injury because this adds a chemical insult in addition to the thermal injury. Contact burns(HOT METAL, TAR OR GREASE) are also thermal in nature and are often associated with cooking or heating incidents. Scald injuries are most prevalent among the young and may be associated with accidents or even abuse. The two factors that determine the depth of a thermal injury are the temperature to which the skin is heated and the duration of contact with the heat.
Thermal burns
Indications of the impending loss of the ____________ include hoarseness, brassy cough, drooling or difficulty swallowing, audible wheezing, crowing, and stridor
airway
Area: Damage to entire epidermis & deep dermis Appearance: Red to white, no blisters, mod edema Sensation/Heal: Painful/Sens to Touch, Heals within 2-6weeks, scarring likely, possible grafting Example: Flame and Scalds, Grease, Tar, Chemical Burns, Prolonged Exposure to hot objects(Eschar soft and dry) -sensitive to cold air
deep partial thickness burn (3rd degree)
The fluid of choice for resuscitation is lactated Ringer's. Intravenous access is essential and should be obtained as soon as possible. Ideally, two large-bore, preferably No. 20 gauge or larger, peripheral IV catheters are placed through unburned skin. However, if no such areas exist, the IV lines can be inserted through burned tissue but must be well secured. If obtaining a peripheral IV catheter is extremely difficult, an intraosseous line is also acceptable. Major burn injuries often require the placement of a central venous catheter because of the large volumes of fluid that need to be administered during the emergent phase. administer colliod solluitions (albumin or synthetic plasma expanders) after the first 24 hrs
fluid resusitation
Area: Damage to entire epidermis& dermis, can extend into the SQ tissue, nerve damage Appearance: Red, black, brown, yellow, white. No blisters, severe edema, Sensation/Healing: Sensation minimal or absent, heals within weeks to months, scarring, grafting Example: Scalds, grease, tar, chemical, or electrical burns, prolonged exposure to hot objects(Eschar hard and inelastic)
full thickness burn
- aminnoglycoside anti-infective agent ADVANTAGES- bactericidal DISADVANTAGES-monitor kideneys NEPHROTOXIC monitor hearing loss OTOTOXIC
genTAmycin
- A loss of 10% or more body weight indicates a need for additional calorie intake -large burn areas create a hypermetabolic to hypercatabolic state requiring 5000 cal/day. body needs double or triple 4-12 days after burn -increase caloric intake to meet metabolic demands and prevent HYPOGLYCEMIA -increase protein intake to prevent tissue breakdown and increase carbohydrates(55%-60%) to decrease protein catabolism -decrease GI motility AND INCREASE caloric needs requires enteral therapy or TPN -perform calorie count daily
nutrition
xenograft Pig (most common) or bovine (cow) skin Temporary Used as a temporary covering once eschar is removed to help close and protect wound Will eventually reject and have to be replaced by permanent grafting
◼Heterograft -
from living or recently deceased, amniotic membrane Cadaver skin Temporary Used as a temporary covering once eschar is removed to help close and protect wound Will eventually reject and have to be replaced by permanent grafting
◼Homograft -
The nurse is preparing an educational tool to instruct community members on burn prevention. What should the nurse include as the most common injury in children under age 5? 1) Scald 2) Flame 3) Chemical 4) Carbon monoxide poisoning
ANS: 1 Scald injuries are most prevalent in children under the age of 5.
The nurse is evaluating nutritional teaching provided to a patient recovering from 24% total body surface area burns. Which information indicates that teaching has been effective? 1) Weight loss 3 kg 2) Serum protein level 7.1 g/dL 3) Serum albumin level 2.8 g/dL 4) +1 pitting edema of lower extremities
ANS: 2 A normal serum protein level is 6.4 to 8.3 g/dL.
A patient comes into the emergency room seeking treatment for radiation burns. What should be considered prior to providing care to this patient? 1) Pathway of flow through the body 2) Duration of contact with the agent 3) Type, dose, and length of exposure 4) Temperature to which the skin is heated
ANS: 3 The severity of a radiation burn is dependent upon the type, dose, and length of exposure.
Electrical injuries are associated with an overall increase in the length of hospital stay, morbidities, and number of required surgeries. This is due to the fact that electrical injuries often are linked to other types of ensuing trauma due to subsequent falls and the potential cardiac injury(CK-MB). In addition, as electricity passes through the body, it has the potential to cause damage to multiple organs, which then must also be addressed and treated in conjunction with any burns that have occurred. Electrical burn injuries can be associated with extensive burns that may even require amputation. Patients may present with cardiac and/or neurological problems as well as associated trauma and/or flame burns. Electrical injury may occur by direct contact with the source, by an arc between two objects, or as a result of a flame injury caused by ignition of the surroundings. The effects of electricity on the body depend on certain factors, including the type and strength of the current, the duration of contact, the pathway of flow through the body, and local tissue resistance. The epidermis is the body's best insulation, but once breached, the body acts as a volume conductor. Bone is more resistant to the flow of electricity, and the electricity tends to flow along the top of the bone, often damaging the overlying muscles, nerves, and vessels. Consequently, deep muscle injury may be present even when skin and superficial muscle may appear uninjured. When a person comes into contact with alternating current, the body often becomes part of the circuit. In alternating current, the movement of an electric charge sporadically changes direction, creating a tetany effect, or involuntary state of muscle contraction that interferes with the person's ability to easily break free from the source. This muscle contraction enables the electric current to flow continuously back and forth between the person and the source, which may either throw the person or draw the person into continual contact with the source. As a result, the current may pass through the body for a greater period of time, exacerbating the severity of the associated injury. Direct current is a one-directional, constant flow of electricity. In the United States, direct current injuries occur from lightning strikes, contact with car or boat batteries, and contact with railway train lines. Electrical current also disrupts the electrical activity of the body and may result in immediate cardiac and/or pulmonary arrest on scene. The common household electric circuit carries a charge of 120 volts. High-voltage injuries occur when a person comes into contact with 1,000 volts or greater. These types of injuries are often work related and are more common in men. Patients who sustain high-voltage injuries often present with very deep burns and sequela from associated trauma. Flash injuries and/or flame burns may also occur as a result of possible ignition of clothing. The hands and mouth are the most frequently injured sites for low-voltage electrical injuries in children as they may have oral contact with electrical cords or sockets. Surgical management and extensive rehabilitation may be required for the best functional outcomes. FOR ELECTRICAL INJURIES OF ALL AGES 3ML/KG
Electrical