Med Surg II Week 4 contd

13. Which client factors should alert the nurse to potential increased complications with a burn injury?

...13. Answer C Burns of the perineum increase the risk for sepsis. Burns of the hands require special attention to ensure the best functional outcome.

Use of the Nursing Process in the Care of the Patient in the Acute Phase of Burn Care—Diagnoses

Excessive fluid volume Risk for infection Imbalanced nutrition Acute pain Impaired physical mobility Ineffective coping Interrupted family processes Deficient knowledge

Effects of Major Burn Injury

Fluid and electrolyte shifts Immunologic alterations Effect upon thermoregulation

Fluid and Electrolyte Shifts—Acute Phase

Fluid reenters the vascular space from the interstitial space Hemodilution Increased urinary output Sodium is lost with diuresis and due to dilution as fluid enter vascular space: hyponatremia Potassium shifts from extracellular fluid into cells: potential hypokalemia Metabolic acidosis

Phases of Burn Injury Acute or intermediate phase

From beginning of diuresis to wound closure

Phases of Burn Injury Rehabilitation phase

From wound closure to return to optimal physical and psychosocial adjustment

Use of the Nursing Process in the Care of the Patient in the Acute of Burn Care—Collaborative Problems/Potential Complications

Heart failure and pulmonary edema Sepsis is the leading cause of death following burn injury Acute respiratory failure Visceral damage (electrical burns)

Factors to Consider in Determining Burn Depth

How the injury occurred Causative agent Temperature of agent Duration of contact with the agent Thickness of the skin

Use of the Nursing Process in the Care of the Patient in the Emergent Phase of Burn Care—Diagnoses

Impaired gas exchange Ineffective airway clearance Fluid volume deficit Hypothermia Acute Pain Anxiety

Fluid and Electrotype Shifts—Emergent Phase

Reduced blood volume and hemoconcentration Decreased urine output Trauma causes release of potassium into extracellular fluid: hyperkalemia Sodium traps in edema fluid and shifts into cells as potassium is released: hyponatremia Metabolic acidosis

14. The patient, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse's best action?

...Answer: D These findings are associated with systemic gram-negative infection and sepsis. This is a medical emergency and requires prompt attention.

12. The burned patient on admission is drooling and having difficulty swallowing. What is the nurse's best first action?

12. Answer C Difficulty swallowing and drooling are indications of oropharyngeal edema and can precede pulmonary failure. The client's airway is in severe jeopardy and intubation is highly likely to be needed shortly.

15. A male patient with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:

15. Answer D With a superficial partial thickness burn such as a solar burn (sunburn), the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management.

2. In a female patient with burns on the legs, which nursing intervention helps prevent contractures?

2. Answer A. Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

A male client is diagnosed with herpes simplex. Which statement about herpes simplex infection is true?

3. Answer A. Herpes simplex may be passed to the fetus transplacentally and, during early pregnancy, may cause spontaneous abortion or premature delivery. Genital herpes simplex lesions typically are painful, fluid-filled vesicles that ulcerate and heal within 1 to 2 weeks. Herpetic keratoconjunctivitis usually is unilateral and causes localized symptoms, such as conjunctivitis. A client with genital herpes lesions should avoid all sexual contact to prevent spreading the disease.

4.While in a skilled nursing facility, a female client contracted scabies, which is diagnosed the day after discharge. The client is living at her daughter's home, where six other persons are living. During her visit to the clinic, she asks a staff nurse, "What should my family do?" The most accurate response from the nurse is:

4. Answer A. When someone in a group of persons sharing a home contracts scabies, each individual in the home needs prompt treatment whether he's symptomatic or not. Towels and linens should be washed in hot water. Scabies can be transmitted from one person to another before symptoms develop.

Acute or Intermediate Phase:

48-72 hours post injury -Airway obstruction caused by upper airway edema can take as long as 48 hours to develop Continue assessment and maintain respiratory and circulatory support Prevention of infection, wound care, pain management, and nutritional support are priorities in this stage

5.The nurse in Wound Clinic is changing a dressing and providing wound care. Which activity should she perform first?

5. Answer C. When caring for a patient, the nurse must first wash her hands. Putting on gloves, removing the dressing, and observing the drainage are all parts of performing a dressing change after hand washing is completed.

7. A male patient is diagnosed with primary herpes genitalis. Which instruction should the nurse provide?

7. Answer C. A patient with primary herpes genitalis should apply topical acyclovir ointment in sufficient quantities to cover the lesions every 3 hours, six times a day for 7 days. Terconazole and tioconazole are used to treat vulvovaginal candidiasis. Sulconazole nitrate is used to treat tinea versicolor.

8.In an industrial accident, a male patient that weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which observation shows that the fluid resuscitation is benefiting the patient?

8. Answer A. In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 100 ml/hour is more than adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators.

Other Major Care Issues

Pulmonary care Psychological support of patient and family - Alteration in body image is a major psychosocial stressor associated with a burn injury. Patient and family education Restoration of function

Use of Biobrane Dressing

A semi transparent synthetic sterile dressing Protects the skin from fluid loss and bacterial invasion Can remain in place until epithelialization and would healing occurs

Use of the Nursing Process in the Care of the Patient in the Emergent Phase of Burn Care—Potential Complications/ Collaborative Problems

Acute respiratory failure Acute renal failure Compartment syndrome Paralytic ileus Curling's ulcer

6. Following a full-thickness (third-degree) burn of his left arm, a male client is treated with artificial skin. The patient understands postoperative care of artificial skin when he states that during the first 7 days after the procedure, he will restrict:

Answer A. To prevent disruption of the artificial skin's adherence to the wound bed, the client should restrict range of motion of the involved limb. Protein intake and fluid intake are important for healing and regeneration and shouldn't be restricted. Going outdoors is acceptable as long as the left arm is protected from direct sunlight.

When planning care for a male patient with burns on the upper torso, which nursing diagnosis should take the highest priority?

Answer A. When caring for a client with upper torso burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, option A should take the highest priority. Option B isn't appropriate because burns aren't a disease. Option C and D may be appropriate, but don't command a higher priority than option A because they don't reflect immediately life-threatening problems.

What statement by the client indicates the need for further discussion regarding the outcome of skin grafting (allografting) procedures?

Answer B Factors other than tissue type, such as circulation and infection, influence whether and how well a graft "takes." The patient should be prepared for the possibility that not all grafting procedures will be successful.

10.The burned patient newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this patient by the intravenous route?

Answer C Although providing some pain relief has a high priority, and giving the drug by the IV route instead of IM, SC, or orally does increase the rate of effect, the most important reason is to prevent an overdose from accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.

11.Which statement by the patient indicates correct understanding of rehabilitation after burn injury?

Answer D. Although a return to pre burn functional levels is rarely possible, burned patients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical, social, and emotional functioning.

Burn Injuries

Approximately 1.1 million people require medical attention of burns every year, and about 4500 persons die from burns and associated inhalation injuries every year. Most burns occur in the home. Young children and the elderly are at high risk for burn injuries. Nurses must play an active role in the prevention of burn injuries by teaching prevention concepts and promoting safety legislation.

Nutritional Support

Burn injuries produce profound metabolic abnormalities, and patient with burns have great nutritional needs related to stress response, hypermetabolism, and requirement for wound healing. Goal of nutritional support is to promote a state of nitrogen balance and match nutrient utilization. - Nutritional management of the burn patient is promotion of protein anabolism Nutritional support is based upon patient preburn status and % of TBSA burned. Enteral route is preferred. Jejunal feedings are frequently utilized to maintain nutritional status with lower risk of aspiration in a patient with poor appetite, weakness, or other problems.

Pain Management

Burn pain has been described as one of the most severe forms of acute pain Pain accompanies care, and treatments such as wound cleaning and dressing changes Types of burn pain Background or resting Procedural Breakthrough

Pathophysiology of Burns

Burns are caused by a transfer of energy form a heat source to the body. Thermal (includes electrical) Radiation Chemical

Physiologic Changes

Burns less than 25% TBSA produce primarily a local response. Burns more than 25% may produce a local and systemic response, and are considered major burns. Systemic response includes release of cytokines and other mediators into systemic circulation. Fluid shifts and shock result in tissue hypoperfusion and organ hypofunction.

Fluid and Electrotype Shifts—Emergent Phase Generalized dehydration

During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin

Effects of Major Burn Injury Renal and GI alterations

Early enteral feeding is one step to help avoid this increased intestinal permeability and prevent early endotoxin translocation

Management of Shock—Fluid Resuscitation

Maintain blood pressure of greater than 100 mm Hg systolic and urine output of 30-50 mL/hr, maintain serum sodium at near-normal levels Consensus formula Evans formula Brooke Army formula Parkland Baxter formula Hypertonic saline formula Note: Adjust formulas to reflect initiation of fluids at the time of injury

Home Care Instruction

Mental health Skin and wound care Exercise and activity Nutrition Pain management Thermoregulation and clothing Sexual issues

Burn Wound Care Wound debridement

Natural debridement Mechanical debridement Surgical debridement

Phases of Burn Injury Emergent or resuscitative phase

Onset of injury to completion of fluid resuscitation

Pain Management

Pain is inevitable during recovery from any burn injury. Pain in the burn patient has been described as one of the most severe causes of acute pain. Analgesics IV use during emergent and acute phases Morphine Fentanyl Other Role of anxiety in pain Effect of sleep derivation on pain Nonpharmacologic measures

Rehabilitation Phase

Patient and family education is a priority in the acute and rehabilitation phases Rehabilitation is begun as early as possible in the emergent phase and extend for a long period after the injury. Focus is upon wound healing, psychosocial support, self-image, lifestyle, and restoring maximal functional abilities so the patient can have the best quality life, both personally and socially. The patient may need reconstructive surgery to improve function and appearance. Vocational counseling and support groups may assist the patient

Elastic Pressure Garments

Prevent hypertrophic burn scarring

Emergent or Resuscitative Phase— On-the-Scene Care

Prevent injury to rescuer Stop injury: extinguish flames, cool the burn, irrigate chemical burns ABCs: Establish airway, breathing, and circulation Start oxygen and large-bore IVs Remove restrictive objects and cover the wound Do assessment surveying all body systems and obtain a history of the incident and pertinent patient history Note: treat patient with falls and electrical injuries as for potential cervical spine injury

Goals Related to Burns

Prevention Institution of lifesaving measures for the severely burned person Prevention of disability and disfigurement through early specialized and individualized care Rehabilitation through reconstructive surgery and rehabilitation programs

Use of the Nursing Process in the Care of the Patient in the Emergent Phase of Burn Care—Potential Complications/ Collaborative Problems Distributive shock

Prompt fluid resuscitation maintains the blood pressure in the low-normal range and improves cardiac output.

Emergent or Resuscitative Phase

The application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage. Patient is transported to emergency department Fluid resuscitation is begun Foley catheter is inserted Patient with burns exceeding 20-25% should have an Ng inserted and placed to suction Patient is stabilized and condition is continually monitored Patients with electrical burns should have ECG Address pain; only IV medication should be administered Psychosocial consideration and emotional support should be given to patient and family

Effects of Major Burn Injury Cardiovascular effects

The initial systemic event after a major burn injury is hemodynamic instability

Formulas are only a guide for burn care fluid resuscitation. How often must the patient' s response to fluid therapy (heart rate, blood pressure, and urine output) be evaluated?

The patient' s response to fluid therapy (heart rate, blood pressure, and urine output) should be evaluated at least hourly.

Effects of Major Burn Injury Pulmonary injury

Upper airway Inhalation below the glottis Carbon monoxide poisoning Restrictive defects

Burn Wound Care

Wound cleaning Hydrotherapy Use of topical agents Wound dressing, dressing changes, and skin grafting Because of their bacteriostatic and bacteriocidal properties, topical agents containing silver are commonly used for treating burns.

Methods to Estimate Total Body Surface Area (TBSA) Burned Lund and Browder method-

is the most precise method for determining the extent of a burn injury; percentage of total body surface area to person as it relates to age of the patient

Superficial partial-thickness

similar to 1st degree burn(sun burn, low intensity flash)

Deep partial-thickness-

similar to 2nd degree burn (scald, flash flame, contact)

Full thickness-

similar to 3rd degree burn (flame, prolonged exposure to hot liquids, electric current, chemical, contact)

Methods to Estimate Total Body Surface Area (TBSA) Burned Rule of nines-

the system divides the body in multiples of nine

Methods to Estimate Total Body Surface Area (TBSA) Burned Palm method-

useful for quick pre hospital assessment; uses the patient's palms