PNE 103. Ch 66 - Caring for Clients with Burns. Intro Medical-Surgical Nursing. Timby/Smith 12th. Ed.

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

27%

How many people die of burn injuries each year in the United States?

3300

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

36%

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?

36%

A burn client is transitioning from the acute phase of the injury to the rehabilitation phase. The client tells the nurse, "I can't wait to have surgery to reconstruct my face so I look like I used to." What would be the nurse's best response?

"That's something that you and your doctor will likely talk about after your scars mature."

Following a burn to a large area of the body, the client receives an Oasis porcine graft. Which statement by the client indicates an understanding of the use of this grafting material?

"This graft will not become a permanent part of my skin."

IV analgesics are administered for pain - often severe:

- Morphine sulfate- drug of choice. dose as high as 50mg/hr necessary for adults who are severely burned. -naloxane ( narcan) administered for respiratory depression. -tetanus immunizations also adminstered.

Allograft or homograft

- is a biological source of skin similar to that of the client. -it can be obtained from another a cadaver, from human donor cells such as stem cells from umbilical cord blood, or infrequently from amniotic membranes. -cadaver skin tissues are screened for HIV and hepatitis. -transCyte- temporary skin graft that contain human neonatal fibroblast cells that are cultured aseptically and incorporated within a nylon mesh membrane.

Extent of burn injury

-besides determining the burn depth and zones, the severity of a burn also is determined "Rule of Nines"- i Percentage of TBSA Burned Client's Palm: 1% of TBSA

Autograft

-client's own skin, which is transplanted from one part of the body to another. -autograft from an identical twin can become permanent part of the client's own skin. - besides actually harvesting and grafting the skin from an unburned area, autologous, epithelial keratinocytes (skin cells) are cultured. - To do so, a postage stamp-sized specimen of the client's epidermis is removed. - keritonocytes are isolated from the specimen, they are then cultured in a flask for 2-3 weeks -the sheet of cultured epithelial cells is then transferred to the burn area -the cultured cells promote rapid healing without the potential for rejection

Blood samples are drawn- fluid resuscitation with:

-crystalloid and colloids solutions begin according to the severity of the burn injury - fluid replacement regimen is calculated from the time the they burn injury occurred. - the goals of fluid resuscitation is restoration of intravascular vol., prevention of tissue and cellular ischemia, and maintenance of vital organ function. -successful fluid resuscitation is gauged by a urinary output of 0.3-0.5 mL/kg/hr. via indwelling catheter. -a low dose infusion of dopamine (Intropin) may be necessary to ensure renal perfusion.

Medical Management

-depends on the initial first aid provided and the subsequent tx in the hosp. or burn center. Potential life-threatening complications: 1. Inhalation injury; 2. Hypovolemic shock; 3. Infection Major burns: Transport to regional burn center

After the burn

-fluid from the body move toward the burned area, which accounts for edema at the burn site. -fluid is then trapped in this area and rendered unavailable for the use by the body, leading the intravascular fluid deficit. -fluid is also lost from the burned area, often in extremely large amt, in the forms of water vapor and seepage. -decreased BP follow, -if physiologic changes are not immediately recognized and corrected, irreversible shock is likely. -these changes happen so rapidly, and the client's status may change from hour to hour, requiring that the client's burns receive intensive care by skilled personnel.

American Burn Association Referral criteria: (Box 66-2 p. 1231)

-parital or full thickness burn greater than 10% TBSA -burns that involve the face, hands, feet, genitalia, perineum, and major joints. -full-thickness burns in any age group -electrical burns, including lightening injury -chemical burns -inhalation burns -burn injury with a preexisting medical disorder that could complicate management, prolong recovery, or affect mortality -burns accompanied by trauma in which the burn injury poses the greatest risk for morbidity and mortality -burned children in hospitals without qualified personnels or equipment for the care of children -burn injury for those who will require social, emotional, or rehabilitative intervention,

Sources for Skin Grafts-

-temporary or permanent. -manufactured synthetically, obtained from a biologic source, or a combination of the two. Autograft: Client's own skin Allograft: Human skin from cadaver Heterograft: Animal skin

Patient teaching - use of a pressure garment

-wear the pressure garment at least 23 hours each day. -follow the manufacturer's instructions for donning and removing the pressure garment -contact the physician or PT if the garment causes discomfort or does not seem to fit properly. - ensure that holes or nonfunctioning zippers are repaired immediately or as soon as possible -hand-wash the pressure garments daily with mild laundry detergent -rinse the garment thoroughly to remove detergent residue, salt water, or chlorinated water from a swimming pool -squeeze and roll the garment in a towel to remove as much moisture as possible; do not dry the garment in the sun or in a clothes dryer -massage any moisturizer, lotions, cream, and petroleum-based ointment completely into the skin because these can cause deterioration of the garment

Skin substitute and skin grafts

-when a wound dressing alone is no longer appropriate for covering large areas of burned tissues, use of -skin substitutes- a temporary covering -skin grafting- transferring the client's own skin to another area, becomes advantageous. -either or both techniques are used when skin layers responsible for regeneration have been destroyed. -Large burns may not be able to granulate fully, resulting in chronic open wounds and delayed healing.

Harvesting the clients own tissue has several disadvantages.

1) it compounds the client's pain because it creates a new wound. 2) the donor site has the potential for scarring and atypical pigment changes. 3) there is a potential for donor site infection . 4) there is a delay in wound closure while waiting for the donor site to heal and be reharvested 5) delay caused by waiting for harvest sites to heal increases costs and challenge the client's ability to cope with a prolonged hospitalization. -it may be impossible to harvest sufficient skin to totally close a full-thickness burn wound that is greaer than 60 TBSA. regardless of the source of the skin graft, it is imperative to limit movement for some time to prevent disrupting the graft.

Impaired ventilation is associated with a burn involving the upper airway and result from:

1) swelling of the airway 2) inhalation of carbon monoxide 3) acute respiratory failure, may or all of which are manifested within the first 12-24 hours after the burn injury. -difficulty breathing, stridor, tachypnea, edema of the face or neck, -bronchoscopy may be performed to assess the internal airway. -warm, humidified O2 is administered, and an endotracheal tube should be available for insertion. -if full-thickness burn around in neck area, eschar, may compress the neck and pull it into flexion, making a tracheostomy the preferred technique for maintaining patent airway.

Heat: Cell damage

1) the temp of the heat source, 2) duration of contact, 3) the thickness of the tissue exposed to the heat source. The location of the burn also is significant. 4. burns in the perineal area at increased risk for infection from organisms in stool. 5. Burns of the face, neck and chest have the potential to impair ventilation. 6. burns involving the hand or major joints eventually can affect dexerity and mobility.

Diagnostic Findings

1. Physical inspection: Radiographs- to identify secondary injuries such as fractures, or compromised lung function in inhalation injuries.

The most common causes of thermal burns in older adults are:

1. scalding and home fires; 2. secondary to smoking, 3. alcohol ingestion, 4. flammable substances that ignite materials.

Signs of heat or smoke inhalation injury:

1. soar throat singed nasal hairs, eyebrows, eyelashes. 2. Hoarseness -carbon in sputum -soot around mouth and nose -SOB -Stridor

A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this client's needs?

A patient-controlled analgesia (PCA) system

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement?

A urinary output of 30 mL/hr

Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided?

Application of ice.

Acute Care:

Assess extent of burn injury, additional trauma Interventions: Ventilation; Fluid resuscitation Endotracheal tube; Bronchoscopy Mechanical ventilation; Tracheostomy; Hyperbaric oxygen treatment IV analgesics; Tetanus immunization

A client has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?

Assess the client's peripheral pulses distal to the dressing

Which of the following skin substitutes is a nylon-silicone membrane coated with a protein derived from pig tissue?

Biobrane

Which of the following is a disadvantage of surgical debridement?

Bleeding

Which zone consists of the area where the injury is most severe and deepest?

Coagulation

Depth of Burn Injury

Color Skin Characteristics Sensation in Burn Area Classification Superficial Partial thickness Full thickness

The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings?

Contact the primary care provider and prepare for an escharotomy.

A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort?

Education about workplace health threats

Pathophysiology of initial burn

Effect of inflammatory process- affect layers of the tissues below the initial surface injury. ex, protease enzymes and chemical oxidants are proteolytics, causing additional injury to healing tissues and deactivatation of tissue growth factor. -neutrophils-phagocytize debris, consume available O2 at the wound sit- contribute to tissue hypoxia. -injured capillaries thrombose, causing localized ischemia and tissue necrosis. -bacterial colonization, mechanical trauma, and even topically applied antimicrobial agents can cause further damage viable tissue.

The spouse of a victim, who was struck by lightning, asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse?

Electrical burns usually follow an internal path.

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:

Epidermis and a portion of deeper dermis.

A client presents with a full-thickness burn to the anterior chest. The leathery skin is tight, making breathing difficult. The nurse anticipates which treatment management technique in the care of this client?

Escharotomy

Skin grafts are necessary for which of the following burns?

Full thickness

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following?

Full-thickness

Which type of burn injury requires skin grafting?

Full-thickness

Which type of skin graft is more comparable in appearance to normal skin?

Full-thickness graft

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client?

Gastric ulcers

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

Hoarseness of the voice

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply.

Hourly urine output Daily weights Skin turgor

The nurse is caring for a patient who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report immediately when reviewing laboratory studies?

Hyperkalemia

Following a serious thermal burn, which complication will the nurse take action to prevent first?

Hypovolemia

The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns?

Identification by the destruction of the dermis and epidermis

A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What should the nurse in the ED receiving the call instruct the father to do?

Immerse the child in a cool bath.

NCLEX-Style Review Questions (PrepU)#4: A treatment plan for a burn victim includes using the open method of burn wound management, what is the most appropriate for the nurse to monitor when caring for a client being treated by the open method?

Infection

Burn Injury Wound Management

Infection prevention measures; Debris removal- HCP wear powder free gloves- may cause complicated healing. -the body hair around the perimeter of the burn is shaved, because hair is a source of bacterial wound contamination. -eye ointment or irrigation remove dirt -blisters are ruptured removed with scissors.

Burn Injury Medical Management

Initial First Aid: First priority: Prevent further injury; Observe for respiratory difficulty for people who have been burned around the face or neck or who may have inhaled smoke, chemicals, steam, or flames. -inhalations can damage or severely irritate the mucous membranes lining the respiratory passages, resulting in edema in the resp tract. -secretions of mucus may be excessive-make breathing difficult. -O2 is administered, and begin IV fluid therapy

The closed method is the current preferred method of wound management for many reasons. What is not one of those reasons?

It leads to the formation of a hard crust over a burn.

A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid?

Lactated Ringer's

Which of the following is the preferred IV fluid for burn resuscitation?

Lactated Ringer's (LR)

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first?

Lactated Ringer's solution

Burn injury s/s

Light pink to black skin color-depending on depth of burn Edema; Blistering; Pain-except those affected by full thickness burn Compromised breathing; Symptoms of hypovolemic shock; In electric woundds, there usually are Entrance and exit wounds

When providing initial assessment to a client who has suffered an electrical burn, which assessment finding will provide the most important data?

Location of entry and exit wounds

A young child is being evaluated for area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool?

Lund and Browder method

NCLEX-Style Review Questions (PrepU)#1: A nurse stops to give first aid to a burn victim running from a home that is on fire. The nurse rolls the victim on the ground to smother the flames. The chest and the neck of the victim are burned. What is the next priority for the nurse?

Monitor the victim for respiratory distress.

Which of the following is the analgesic of choice for burn pain?

Morphine sulfate

Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation?

Myoglobin in the urine

Which type of debridement occurs when nonliving tissues sloughs away from uninjured tissues?

Natural

Serious burns

Neuroendocrine changes within the first 24 hours ACTH and ADH are released in response to stress and hyvolemia. =when adrenal cortex is stimulated, it released glucocorticoids, which cause hyperglycemia, and aldosterone, a mineralocorticoid, which cause Na retention. Na retention leads to edema as a result of flui shift and oliguria. -The client eventually enters a hypermetabolic state that requires increased oxygen and nutrition to compensate for the accelerated tissue catabolism

The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn?

Paralytic ileus

After being exposed to smoke and flames from a house fire, which assessment finding is most important in determining care of the client?

Presence of soot around nasal passages.

Which instruction is the most important to give a client who has recently had a skin graft?

Protect the graft from direct sunlight.

Following a burn injury, the nurse determines which area is the priority for nursing assessment?

Pulmonary system

Surgical Management: Skin Grafting

Purpose: Lessen infection Minimize fluid loss by evaporation diminish pain promote regeneration of tissue. Hasten recovery Reduce scarring Prevent loss of function Keratinocytes regenerate epidermis Used for deep partial-thickness and full-thickness burns Unassisted Healing: Granulation tissue; Contractures; Chronic open wounds

The nurse is providing education to the client with multiple burns and lists the options for skin grafting and application techniques. Which is the primary benefit for using an autograft slit graft versus other types of grafts?

Rejection is unlikely.

Surgical Management: Debridement

Removal of necrotic tissue -the procedure is potentially painful and warrants premedication with an analgesic. Four ways: Naturally-nonliving tissues sloughs away from uninjured tissue. Mechanically-- when dead tissues adheres to dressings or is detached during cleansing Enzymes--through the application of topical enzymes to the burn wound. Surgery-- with the use of forceps and scissors during dressing changes or wound cleansing. Disadvantage: Bleeding because burn victims already have secondary problems with healing, because of low RBCs . Covering of healthy tissue: Skin graft; Temporary skin substitute; Cultured skin

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to:

Replace lost fluids and electrolytes.

A client, who has sustained burns to the anterior chest and upper extremities, is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary?

Risk for Impaired Gas Exchange

Leukopenia within 48 hours is a side effect associated with which topical antibacterial agent?

Sulfadiazine, silver (Silvadene)

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?

Superficial

Which burn assessment chart is the most accurate method for estimating percentage of body surface area burned according to age and growth size?

The Lund and Browder

Zone of Coagulation

The area of the burn that received the most severe injury with irreversible cell damage.

An emergency department nurse learns from the paramedics that the team is transporting a client who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn?

The causative agent

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior?

The client has experienced extensive full-thickness burns.

While performing a client's ordered wound care for the treatment of a burn, the client has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this client's behavior?

The client may be experiencing anger about his circumstances that he is deflecting toward the nurse.

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation?

The client's urinary output is 0.3 to 0.5 mL/kg/hour.

Which is the primary reason for placing a client in a horizontal position while smothering flames are present?

To keep fire and smoke from airway.

A nurse is developing a care plan for a client with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention?

To prevent contractures

T/F: An infection within a burn wound can be life-threatening.

True. An infection within a burn wound can be life-threatening. Outcome of a burn injury depends on the initial first aid and subsequent acute treatment. Three complications of burns can be life-threatening: inhalation injury, hypovolemic shock, and infection.

NCLEX-Style Review Questions (PrepU)#3: The blood pressure of a burn victim has stabilized. what is the next best means of assessing the client's response to the initial burn treatment?

Urinary output

The blood pressure of a burn victim has stabilized. what is the next best means of assessing the client's response to the initial burn treatment?

Urinary output

When the area of burn is irregular in shape and is scattered over multiple areas of the body, which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn?

Use client's palm size.

Which of the following actions should a nurse perform to help reduce the accumulation of debris within the burn wound?

Use powder-free sterile gloves.

NCLEX-Style Review Questions (PrepU)#2: In the ED, it is determined that a burn victim has deep-partial- and full-thickness burns over 35% of the upper body. During the nursing assessment of the burn injury, what characteristics will the nurse use to identify the initial appearance of the Full-thickness burn?

White and leathery.

Nursing management---Assessment

Wound and how the burn injury has affected the Client's status Calculation and infusion—fluid replacement requirements Treatment of shock; -administer prescribed analgesics for Pain relief Wound care: Antimicrobials; Dressings; Monitoring for infection; Emotional support Client teaching: Exercise; adequate nurition intake , Pressure garments; Skin care measures

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn?

Wrap cool towels around the affected extremity intermittently.

Which is at the center of the injury , is the area where the injury is most severe and usually deepest?

Zone of Coagulation

Zones of burn injury:

Zone of Coagulation Zone of Stasis Zone of Hyperemia

Following a burn, the nurse understands that the focused management of which burn zone is of greatest concern?

Zone of stasis

Burn injuries

a burn is a traumatic injury to the skin and underlying tissues. Heat; Chemicals; Electricity cause burn injuries -Burns cause by electricity are characteristically the most severe because they are deep. -electricity moving through the body follows an undetermined course from entrance to exit, causing major damage in its path.

As the first priority of care, a patient with a burn injury will initially need:

a patent airway established.

Skin substitutes

can be applied all over the burn wound as soon as the skin is cleaned and debrided instead of having to wait until enough skin is available for grafting purposes.

The risk for acquiring a burn injury is highest among,

children and adults older than 60 years of age.

Fluid shift, electrolyte deficits, and loss of ectracellular proteins such as albumin from the burn wound affect

fluid and electrolyte status. -anemia develops-heat destroys erythrocytes -the client experiences hemocontration when the plasma components of blood is lost or trapped. - the sluggish flow of blood cells through blood vessels results in indequate nutrition to healthy body cells and organs

Unassisted healing

healing without the use of a skin substitute or skin graft, results in the proliferation of granulation tissue. -Granulation tissue contains fibroblast, which creates hypertrophic scars that contract and pull the edges of the wound together, causing an uneven appearance in the healed tissue and contractures.

Types of Autografts

human skin from the client with a burn is harvested under general anesthesia. Either a split thickness or full-thickness graft is removed. Split-thickness; Full-thickness; Slit Disadvantages; Pressure garments; Sunscreen

A client has been burned significantly in a workplace accident. Which conditions create the need for intensive care by specifically trained personnel?

hypotension fluid loss fluid shift

Full-thickness graft

includes epidermis, dermis, and some subcutaneous -is used when the burn area is fairly small and involves that hands, face, or neck -are more compareable in appearance to normal skin and can tolerate more stress once they become permanently attached to the burn wound.

A treatment plan for a burn victim includes using the open method of burn wound management, what is the most appropriate for the nurse to monitor when caring for a client being treated by the open method?

infection

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury?

inflammatory

Rules of nine

is a quick initial method of estimating how much of the client's skin surface is involved. 1. Head = 9% (Front 4.5% & back 4.5%) 2. Trunk = 36% (Front 18% & Back 18%) 3. Arms = 18% (2 Front 9% & 2 back 9%) 4. Peri area = 1% 5. Legs = 36% (2 Front 9% & 2 back 9%)

Xenograft or heterograft

is obtained from animals, pigs or cows. -are used temporary cover large areas, they are rejected in days to weeks and must be removed and replaces at that time.

Zone of Hyperemia

is the area of least injury, where the epidermis and dermis are only minimally damaged. because of early appearance of the burn injury can change, the estimate of burn depth may be revised in the first 24-72 hours.

Mechanical ventilation

may be necessary to maintain normal blood gases and prevent repiratory failure. -victims of carbon monoxide poisoning may require hyperbaric O2 tx- administration of 100% O2 at 3times greater than atmospheric pressure in a specially designed chamber-- to increase the binding of O2 rather than Carbon monoxide to hemoglobin molecules.

A nurse stops to give first aid to a burn victim running from a home that is on fire. The nurse rolls the victim on the ground to smother the flames. The chest and the neck of the victim are burned. What is the next priority for the nurse?

monitor the victim for respiratory distress

Once the skin graft heals

pressure garment made elasticized cloth or plastic are applied over the grafted area. -these garments smooth the grafted skin, reducing scarring amd the potential for wound contractures. - the client may need to wear a pressure garment for up to 2 years.

Which antimicrobials is not commonly used to treat burns?

tetracycline

Zone of Stasis

the area of immediate burn injury -blood vessels are damaged, but the tissues has the potential to survive. -if circulations is secondarily impaired, however, injured tissues in the zone of stasis can convert to a zone of coagulation

The release of histamine as a consequence of the stress response increases gastric acidity.

the client with a burn is prone to developing gastric ulcers.

Split-thickness

the epidermis and a thin layer of dermis are harvested from the client's skin. -vary in thickness, size, and shape. -Usually obtained from the buttocks or thighs. -have more successful outcomes than other types, however, appearance is less than desireable, they are less elastic, and hair does not grow from their surface.

OA may be at higher risk for burn injuries if concurrent change in

vision, hearing, or touch have developed. Reduced mobility may influence ability to provide self-care or home maintenance. Risk in the home environment such as adequate fire protection and safe heating systems. -additional risk for burns may include peripheral neuropathy. careful assessment and teaching must include setting water temp no higher than 110.

Myoglobin and hemoglobin are transported to the kidneys

where they may cause tubular necrosis and acute renal failure.

Electrical burns and lightening also produce heat

which is greatest at the point of entry to and exit from the body. -because deep tissues cool more slowly than those at surface, it is difficult initially to determine the extent of internal damage.

In the ED, it is determined that a burn victim has deep-partial- and full-thickness burns over 35% of the upper body. During the nursing assessment of the burn injury, what characteristics will the nurse use to identify the initial appearance of the Full-thickness burn?

white and leathery

During the recovery of an extensive burn, the client is complaining about wearing the tight-fitting custom garment. Which is the best response by the nurse?

"A snug fit is needed to minimize scarring and overgrowth of skin."

A client is scheduled for an allograft to a burn wound, and the client asks for an explanation. What information will the nurse include in the client teaching?

"An allograft is a temporary wound covering obtained from cadaver skin."

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims?

"Are the burns associated with chemicals used in the plant?"

Skin substitutes are often used after the wound is debrided and cleaned. Which of the following supports a primary purpose for the use of a skin substitute? Select all that apply. A)Lessen potential for infection B)Maximizes fluid loss C)Promotes granulation of tissue D)Covers the unattractiveness of the wound E)Slows regeneration of tissue F)Diminishes pain

A)Lessen potential for infection F)Diminishes pain

A nurse is caring for a client who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?

Acute Pain

NCLEX-Style Review Questions (PrepU)#5: A burn wound periodically is debrided using hydrotherapy. What nursing action is essential shortly before each debridement?

Administer a prescribed analgesic.

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?

BUN: 28 mg/dL

Which of the following are benefits that support the use of a closed method wound care in the management of a client with burns? Select all that apply. A)Provides a drier environment B)Promotes heat loss C)Creates antimicrobial barrier D)Prevents exudate accumulation E)Discourages hypertrophic scarring F)Promotes slower healing

C)Creates antimicrobial barrier E)Discourages hypertrophic scarring

Which complication is common for victims of electrical burns?

Cardiac dysrhythmia

Common complications for electrical burn victims

Cardiac dysrhythmias and Central nervous system

Thermal Burns - Protein coagulation

Chemicals: Liquefy tissue; Loosen cell attachment

One major antimicrobial used in the treatment of burns is silver sulfadiazine (Silvadene) ointment. When providing instructions for the use of silver sulfadiazine (Silvadene), which teaching measure should be stressed?

Cleanse skin prior to application.

Skin Substitutes

Cover wound; Promote healing Direct interaction with body tissues Applied soon after skin is healed and débrided

Closed Method- wound is covered:

Current, preferred method because it creates a microbial barrier, reduces heat loss through evaporation, and provides moist environment that facilitates healing. Use of dressings: Nonadherent; Absorbent; Occlusive, semiocclusive; Dressing changes change wound dressing frequently enough to maintain antimicrobial effectiveness, check for infection, and monitor for healing process, = done Q8hours to once a week. -necessary for wound changes when wound is infected and when there is significant saturation with wound exudate.

A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock?

Decreased blood pressure

Full thickness (4th degree)

Depth: Epidermis, dermis, subcutaneous tissue; may include may be fat , fascia, muscle, and bone, ligament, tendons. The most serious full-thickness burn. Characteristics: black, depressed, painless, scarring. Healing: the tissue appears charred or lifeless. If not debrided, this type of burn injury leads to sepsis, extensive scarring, and contractures. Skin graft is necessary because the skin cells no longer are alive to regenerate.

Deep partial thickness (2nd degree)

Depth: deeper layer of the dermis with damage to sweat and sebaceous glands (second degree ). Characteristics: variable color from patchy red to white, wet or waxy dry, does not blanch with pressure, sensitive to pressure only. Healing: takes more than 3 weeks to heal, may need debridement, is subject to hypertrophic scarring, and may be require skin grafts.

Superficial partial thickness burn (2nd degree)

Depth: epidermis and dermis; hair follicles intact (second degree). classified as either superficial or deep partial thickness, depending on how the much the dermis is damaged. Characteristics: mottled pink to red, painful, blistered, or exuding fluid, blanches with pressure Healing: burns heals within 14 days, with 14 days, w/possibly some pigmentary changes but no scarring; it requires no surgical intervention.

Superficial burn (1st degree)

Depth: epidermis and part of dermis (first degree) Characteristics: painful, pink or red edema, but subsides quickly; no scarring ex) sunburn Healing: heals less then 5 days, usually spontaneously with symptomatic tx, infection, increased metabolism, and scarring do not occur,

Full thickness (3rd degree)

Depth: epidermis, dermis, subcutaneous tissue (third degree). Characteristics: red, white, tan, brown, or black; leathery covering (eschar) painless. Healing: tissue appears charred or lifeless. If not debrided, this type of burn injury injury leads to sepsis, extensive scarring, and contractures. Skin grafts are necessary for a full-thickness burn BC the skins skin cells no longer are alive to regenerate.

Open Method- wound is left uncovered

Exposes burned areas to air; Used only for areas where it is difficult to apply dressings (face, perineum) Isolation- HCP and visitors wear sterile gowns and mask -clients skin is sensitive to draft and temp changes- bed cradles or sheets are placed over client's - room is kept warm and humidified. Escharotomy- an incision into the eschar-done to relieve pressure on the affected area.

Nutritional considerations

Extensive burns increase metabolism by as much as 100% -calorie needs may increase to 4000-5000 calories/day -protein needs are typically 2.0-2.5g/kg esp if burns are >10 TBSA . -calorie and protein needs increase if complications develop, and they lessen as wound healing progresses. -fluid needs increases significantly. with damages cells and skin, the body not only loses fluids but also struggles to retain fluids. Strict I&O records, wt loss is the result of fluid loss, wt daily, sufficient fluid added to reflect the fluids lost in wt change. Enteral and parenteral nutritional support -used with extreme precaution because of the increased risks for infection and sepsis. Vitamins and minerals; C, B-complex, iron, zinc -selenium and and copper have been shown to promote healing and decrease the risk of infection in burn clients.

Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area?

Fluid resuscitation

A nurse is required to care for a client with facial burns who is prescribed the open method treatment. Which of the following nursing interventions should a nurse perform?.

Place a bed cradle or sheets over the client.

The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn?

Preexisting conditions

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire?

Roll the client in a blanket.

Antimicrobial Therapy

Silver sulfadiazine; Mafenide; Silver nitrate; Acticoat- a dressing that contains a thin, soluble film coat of silver and can remain on the burn for up to 5 days, which greatly reduces the pain associated with dressing changes. all drugs are applied using sterile technique.

The client is admitted with full-thickness burn to the forearm. Which is the most accurate interpretation made by the nurse?

Skin grafting will be necessary.

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

The total body surface area (TBSA) affected by the burn

Inhalation of hot air, smoke or toxic chemicals

accompanying injuries such as fractures, concurrent medical problems, and the client's are increases the mortality rate from burn injuries.

Surgical management

additional treatment modalities to promote healing include debridement, applications of a skin substitute, or skin grafting.

An emergency department nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period?

administer iv fluids

A burn wound periodically is debrided using hydrotherapy. what nursing action is essential shortly before each debridement?

adminster a prescribed analgesic.

When caring for a client with burns, a nurse should change the wound dressing at least once every:

day.