Prep-U Ch. 66: Caring for Clients with Burns

A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do? A. Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. B. Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly. C. Remove his burned pants so that the air can help cool the wound. D. Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area.

A. Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. - After the flames are extinguished, the burned area and adherent clothing are soaked with cool water, briefly, to cool the wound and halt the burning process.

Following a burn injury, the nurse determines which area is the priority for nursing assessment? A. Pulmonary system B. Cardiovascular system C. Pain D. Nutrition

A. Pulmonary system - Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs.

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? A. The causative agent B. The client's pre-injury health status C. The client's prognosis for recovery D. The circumstances of the accident

A. The causative agent - The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. The client's pre-injury status, circumstances of the accident, and prognosis for recovery are important, but are not considered when determining the depth of the burn.

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? A. To prevent neuropathies B. To prevent wound breakdown C. To prevent contractures D. To prevent heterotopic ossification

C. To prevent contractures - To prevent the complication of contractures, the nurse will establish a goal to maintain position of joints in alignment. Gentle range-of-motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures. Joint alignment is not maintained specifically for preventing neuropathy, wound breakdown, or heterotopic ossification.

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? A. BUN: 28 mg/dL B. K+: 5.0 mEq/L C. Na+: 145 mEq/L D. Ca: 9 mg/dL

A. BUN: 28 mg/dL - The elevated BUN would cause the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.

A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care? A. Fluid status B. Risk of infection C. Nutritional status D. Psychosocial coping

A. Fluid status - 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. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? A. Related to fat emboli B. Related to infection C. Related to femoral artery occlusion D. Related to circumferential eschar

D. Related to circumferential eschar - As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn't likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn't alter physical mobility. A client with burns on the lower portions of both legs isn't likely to have femoral artery occlusion.

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? A. The length of time since the burn B. The location of burned skin surfaces C. The source of the burn D. The total body surface area (TBSA) affected by the burn

D. The total body surface area (TBSA) affected by the burn - Systemic effects are a result of several variables. However, TBSA and wound severity are considered the major factors that affect the presence or absence of systemic effects.

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. A patient-controlled analgesia (PCA) system B. Oral opioids supplemented by NSAIDs C. Distraction and relaxation techniques supplemented by NSAIDs D. A combination of benzodiazepines and topical anesthetics

A. A patient-controlled analgesia (PCA) system - The goal of treatment is to provide a long-acting analgesic that will provide even coverage for this long-term discomfort. It is helpful to use escalating doses when initiating the medication to reach the level of pain control that is acceptable to the client. The use of patient-controlled analgesia (PCA) gives control to the client and achieves this goal. Clients cannot normally achieve adequate pain control without the use of opioids, and parenteral administration is usually required.

A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared leathery. What depth of burn injury does the client have? A. full thickness (third degree) B. superficial (first degree) C. superficial partial-thickness or deep partial-thickness (second degree) D. fourth degree

A. full thickness (third degree) - Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appearance varies and can be dry, pale white, red, brown, leathery, charred or lifeless. Superficial (first degree) burn is similar to a sunburn. The epidermis is injured, but the dermis is unaffected. Superficial partial-thickness burn heals within 14 days, with possibly some pigmentary changes but no scarring. The deep partial-thickness (second degree) burn takes more than 3 weeks to heal, may need debridement, and is subject to hypertrophic scarring. A fourth-degree burn can involve ligaments, tendons, muscles, nerves, and bone.

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? A. inflammatory B. neuroendocrine C. intravascular fluid excess D. hypertension

A. inflammatory - The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury.

A client was burned in a home accident. The ED physician indicated the client's wound, with proper care, should heal within 2 weeks. How was this client's wound classified? A. second degree B. first degree C. third degree D. fourth degree

A. second degree - A partial-thickness burn (second-degree burn) is classified as either superficial or deep partial thickness, depending on how much dermis is damaged. A superficial partial-thickness burn heals within 14 days, with possibly some pigmentary changes but no scar; it requires no surgical intervention.

Which antimicrobial is not commonly used to treat burns? A. tetracycline B. silver sulfadiazine (Silvadene) C. mafenide (Sulfamylon) D. silver nitrate (AgNO3) 0.5% solution

A. tetracycline - Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns.

A nurse who is taking care of a client with burns is asked by a family member why the client is losing so much weight. The client is currently in the intermediate phase of recovery. What would be the nurse's most appropriate response to the family member? A. "He's on a calorie-restricted diet in order to divert energy to wound healing." B. "His body has consumed his fat deposits for fuel because his calorie intake is lower than normal." C. "He actually hasn't lost weight. Instead, there's been a change in the distribution of his body fat." D. "He lost many fluids while he was being treated in the emergency phase of burn care."

B. "His body has consumed his fat deposits for fuel because his calorie intake is lower than normal." - Clients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized as a result of hypermetabolism. Clients are not placed on a calorie restriction during recovery and fluid losses would not account for weight loss later in the recovery period. Changes in the overall distribution of body fat do not occur.

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: A. Epidermal layer only. B. Epidermis and a portion of deeper dermis. C. Entire dermis and subcutaneous tissue. D. Dermis and connective tissue.

B. Epidermis and a portion of deeper dermis. - A deep partial-thickness burn includes the epidermis, upper dermis, and a portion of the deeper dermis. A burn limited to the epidermal layer is classified as a superficial partial-thickness burn. The last two choices refer to a full-thickness burn.

A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include A. monitoring the client for the development of respiratory acidosis. B. premedicating the client with an analgesic prior to application. C. monitoring the client's Na+ and K+ serum levels and replace as prescribed. D. protecting the bed linens and client's clothing from contact to prevent staining.

B. premedicating the client with an analgesic prior to application. - Mafenide is a strong carbonic anhydrase inhibitor and may cause metabolic acidosis. Application may cause considerable pain initially, thus premedicating the client is an appropriate intervention. The other nursing implications are not associated with mafenide.

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? A. Instruct the client to keep the wound site in a dependent position B. Administer PRN analgesia as prescribed C. Assess the client's peripheral pulses distal to the dressing D. Assist with passive range-of-motion exercises to "set" the new dressing

C. Assess the client's peripheral pulses distal to the dressing - Dressings can impede circulation if they are wrapped too tightly. The peripheral pulses must be checked frequently and burned extremities elevated. Dependent positioning does not need to be maintained. PRN analgesics should be given prior to the dressing change. ROM exercises do not normally follow a dressing change.

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? A. Confusion B. High fever C. Decreased blood pressure D. Sudden agitation

C. Decreased blood pressure - As fluid loss continues and vascular volume decreases, cardiac output continues to decrease and the blood pressure drops, marking the onset of burn shock. Shock and the accompanying hemodynamic changes are not normally accompanied by confusion, fever, or agitation.

The nurse recognize what as an early sign of sepsis in a client with a burn injury? A. Normal body temperature B. Decreased heart rate C. Elevated serum glucose D. Widened pulse pressure

C. Elevated serum glucose - In clients with burn injuries early sepsis can be hard to detect. Clients with burn injuries exhibit tachycardia, tachypnea, and elevated body temperature, all typical indications of sepsis. In the client with burn injury, indications of sepsis include elevated serum glucose values, increased heart rate, and narrowing mean arterial pressure. Both the typical elevated temperature and a temperature of less than 96.8 F (36 C) can indicate sepsis in a client with a burn injury.

The nurse knows that which topical antibacterial agent does not penetrate eschar? A. Acticoat B. Mafenide acetate C. Silver nitrate 0.5% D. Silver sulfadiazine 1%

C. Silver nitrate 0.5% - Silver nitrate 0.5% does not penetrate eschar.

Leukopenia within 48 hours is a side effect associated with which topical antibacterial agent? A. Cerium nitrate solution B. Gentamicin sulfate C. Sulfadiazine, silver (Silvadene) D. Mafenide (Sulfamylon)

C. Sulfadiazine, silver (Silvadene) - All topical antibacterial agents for burn wounds have associated nursing implications. Leukopenia is a side effect found with Silvadene. Refer to Table 53-5 in the text. Reference:

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? A. Complaints of intense thirst B. Moderate to severe pain C. Urine output of 70 ml the first hour D. Hoarseness of the voice

D. Hoarseness of the voice - Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.

A nurse is caring for a client with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A. Maintenance of bed rest to aid healing B. Choosing appropriate splints and functional devices C. Administration of beta adrenergic blockers D. Prevention of venous thromboembolism

D. Prevention of venous thromboembolism - Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the client is important. The nurse monitors the splints and functional devices, but these are selected by occupational and physical therapists. The hemodynamic changes accompanying burns do not normally require the use of beta blockers.

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? A. Apply ice to the site of the burn for 5 to 10 minutes. B. Wrap the client's affected extremity in ice until help arrives. C. Apply an oil-based substance to the burned area until help arrives. D. Wrap cool towels around the affected extremity intermittently.

D. Wrap cool towels around the affected extremity intermittently. - Once the burn has been sustained, 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. However, never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns. Oils are contraindicated.

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to A. increase metabolic rate. B. increase glucose demands. C. increase skeletal muscle breakdown. D. decrease catabolism.

D. decrease catabolism. - The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: A. fluid resuscitation. B. infection. C. body image. D. pain management.

D. pain management. - With a superficial partial-thickness burn such as a solar burn, 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.