7215 test 1 ch 24 (burns)

______ is most important especially when burns are around the neck or face.

Airway

To maintain tissue perfusion and organ function while avoiding complications of inadequate fluid therapy a nurse must insert what?

2 large bore IVs

The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patients total body surface area (TBSA) has been injured?

27% When using the rule of nines, the anterior trunk is considered to cover 18% of the patients body and each arm is 9%.

Red Painful Large Blisters or skin can be open Heals in 14-21 days what type of burn is this

2nd degree

deep partial thickness burn

2nd degree burn

Charred Appearance Black or white in color Dry and leathery to touch Insensate Surgical intervention is required for healing what type of burn is this

3-4

Adult Thermal / Chemical - normal urine = ______-_______

30-50 ml/hr

Parkland formula

4 X weight(kg) X TBSA

what are the two commonly used tools in assessing total body surface area (TBSA) of wounds?

Lund-Browder chart and Rule of Nines

Acute phase goals

Prevent complications Vital signs hourly Assess respiratory function Tetanus booster Anti-infective Analgesics Strict surgical asepsis Turn and perform passive range of motion q2h to prevent further breakdown of the skin and contractures Emotional support

This phase is also known as the Fluid Resuscitation Stage. It occurs w/in the first 2 days post burn. The patient will present with a decreased cardiac output, and a decrease in fluid volume. (FVD) Here, the patient is in a state of dehydration and shock.

emergent phase

in the emergent phase Immediate problem is

fluid loss, edema, reduced blood flow (fluid and electrolyte shifts)

Burned in an enclosed space Singed nasal hairs Burns to the face, neck, or lips Darkened oral/ nasal mucosa Carbonaceous (soot) material around nose/ mouth Hoarseness, stridor or respiratory changes what type of burn is this

smoke and inhalation

rehabilitation phase of burns

-begins when burn injury has healed and ends when highest level of function achieved -occupational, ADLs, and self-care therapy (includes family member) -involves both physical and psychological therapy and care -pressure garments are worn: minimizes and reduces scarring (compliance a real issue) -reintegrate into society (community, employement) -evaluation of home life: how stress is dealt with will help determine type of support group that will be needed -this phase may last years

emergent phase goals

1. secure airway 2. support circulation by fluid replacement 3. keep the client comfortable with analgesics 4. prevent infection through wound care 5. maintain body temperature 6. provide emotional support

IV Opioids with sedatives ____ minutes prior to dressing changes

15

Red Painful No blisters Heals in 7-10 days what type of burn is this

1st degree

superficial partial thickness burn

1st degree burn

An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringers solution that the nurse will administer during the first 8 hours?

600 mL The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours and then the last half is given over 16 hours: 4 80 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.

Adult Electrical normal urine = ______-_______

75-100 ml/hr

Rule of Nines (adult)

9% per arm 9% for head 18% each leg 18% anterior trunk 18% posterior trunk

Circumferential burns

Burns on the neck or chest that may compress the airway or on an extremity that might act like a tourniquet.

burn complications

Contractures Scarring Infection Non-Healing burns

labs to look at for burns

Electrolytes Creatinine BUN Glucose. Urinalysis CBC count Creatine phosphokinase Coagulation profile Carboxyhemoglobin

what are the three phases of burn management?

Emergent (resuscitative) Acute (wound healing) Rehabilitative (restorative)

Circumferential burns tx

Escharotomy Fasciotomy

A 35 year old female patient has deep partial-thickness burns on the front and back of both arms, anterior trunk, back of left leg, anterior and posterior sides of the right leg, posterior head and neck, and perineum. What is the total body surface area percentage that is burned?

FRONT and BACK of both arms: 18% ANTERIOR trunk: 18% BACK of left leg: 9% ANTERIOR and POSTERIOR of right leg: 18% POSTERIOR head and neck: 4.5% Perineum: 1% Total: 68.5%

_________ is important in 2nd and 3rd degree burns over 20%- 30% TBSA

Fluid resuscitation

nutrition for burns >30 TBSA

Initially NPO Begin oral fluids after bowel sounds return Do not give ice chips or free water lead to electrolyte imbalance High protein, high calorie Tube Feedings

types of burn injuries

Thermal Chemical Smoke and inhalation injuries Electrical

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patients lung sounds. b. Determine the extent and depth of the burns. c. Infuse the ordered lactated Ringers solution. d. Administer the ordered hydromorphone (Dilaudid).

a

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Insert a feeding tube and initiate enteral feedings. b. Infuse total parenteral nutrition via a central catheter. c. Encourage an oral intake of at least 5000 kcal per day. d. Administer multiple vitamins and minerals in the IV solution.

a

A patient with a burn inhalation injury is receiving albuterol for the treatment of bronchospasm. What is the most important adverse effect of this medication for the nurse to monitor? Tachycardia Restlessness Hypokalemia Gastrointestinal (GI) distress

a

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes on both feet.

a

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require an intervention by the charge nurse? a. The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2 F (35.1 C). c. The new nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health care provider for a possible insulin order when a nondiabetic patients serum glucose is elevated.

a Sterile gloves should be worn when applying medications or dressings to a burn

The nurse is caring for a 71-kg patient during the first 12 hours after a thermal burn injury. Which outcomes indicate adequate fluid resuscitation (select all that apply.)? Select all that apply. Urine output is 46 mL/hr. Heart rate is 94 beats/min. Urine specific gravity is 1.040. Mean arterial pressure is 54 mm Hg. Systolic blood pressure is 88 mm Hg.

a b Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be 0.5 to 1 mL/kg/hr (or 75 to 100 mL/hr for an electrical burn patient with evidence of hemoglobinuria/myoglobinuria). Cardiac factors include a mean arterial pressure (MAP) greater than 65 mm Hg, systolic BP greater than 90 mm Hg, heart rate less than 120 beats/min. Normal range for urine specific gravity is 1.003 to 1.030.

what problems can develop during the acute phase of burn treatment?

a) wound infection progressing to sepsis as a result of manipulation (e.g., after showering and debridement) and prolonged presence of eschar. b) Paralytic ileus if the patient becomes septic. c) Patients can become extremely agitated, withdrawn, or combative during this phase of recovery. d) As scar tissue forms, there may be the development of limited range of motion with contractures.

When assessing a patient with a partial-thickness burn, the nurse would expect to find (select all that apply) a. blisters.b. exposed fascia.c. exposed muscles.d. intact nerve endings.e. red, shiny, wet appearance

ade

A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck.

b

A patient has 25% TBSA burn from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. The nurse's priority intervention for wound care would be to a. reapply a new dressing without disturbing the wound bed. b. observe the wound for signs of infection during dressing changes. c. apply cool compresses for pain relief in between dressing changes. d. wash the wound aggressively with soap and water three times a day

b

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, Im sorry that Im still alive. My life will never be normal again. Which response by the nurse is best? a. Most people recover after a burn and feel satisfied with their lives. b. Its true that your life may be different. What concerns you the most? c. It is really too early to know how much your life will be changed by the burn. d. Why do you feel that way? You will be able to adapt as your recovery progresses.

b

A patient is admitted to the burn unit with second- and third-degree burns covering the face, entire right upper extremity, and right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? 18% 22.5% 27% 36%

b Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Because the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore, adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction

b With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain.

A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? The total 24-hour fluid requirement should be administered in the first 8 hours. One half of the total 24-hour fluid requirement should be administered in the first 4 hours. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. One third of the total 24-hour fluid requirement should be administered in the first 4 hours.

c

A patient is recovering from second- and third-degree burns over 30% of his body and the burn care team is planning for discharge. The first action the nurses hould take when meeting with the patient would be to a. arrange a return-to-clinic appointment and prescription for pain medications. b. teach the patient and the caregiver proper wound care to be performed at home. c. review the patient's current health care status and readiness for discharge to home. d. give the patient written information and websites for information for burn survivors

c

IV opioids and sedatives only in the ______ phase

emergent

A patient is admitted to the burn center with burns to his head, neck, and anterior and posterior chest after an explosion in his garage. On assessment, the nurse auscultates wheezes throughout the lung fields. On reassessment, the wheezes are gone and the breath sounds are greatly diminished. Which action is the most appropriate for the nurse to take next? a. Encourage the patient to cough and auscultate the lungs again. b. Obtain vital signs, oxygen saturation, and a STAT arterial blood gas. c. Document the findings and continue to monitor the patient's breathing. d. Anticipate the need for endotracheal intubation and notify the physician.

d

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check the oxygen saturation.

d

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patients skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patients orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask.

d

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.

d

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what is observed? Serum sodium and potassium increase. Serum sodium and potassium decrease. Edema and arterial blood gases improve. Diuresis occurs and hematocrit decreases.

d

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? Full liquids only Whatever the patient requests High-protein and low-sodium foods High-calorie and high-protein foods

d

In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patients chest? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Administer IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze.

decab

full thickness burn

third degree burn

Hallmark of inadequate fluid resuscitation

urine output

A therapeutic measure used to prevent hypertrophic scarring during the rehabilitation phase of burn recovery is a. applying pressure garments. b. repositioning the patient every 2 hours. c. performing active ROM at least every 4 hours. d. massaging the new tissue with water-based moisturizers

a

An employee spills industrial acids on both arms and legs at work. What is the priority action that the occupational health nurse at the facility should take? a. Remove nonadherent clothing and watch. b. Apply an alkaline solution to the affected area. c. Place cool compresses on the area of exposure. d. Cover the affected area with dry, sterile dressings

a

The injury that is least likely to result in a full-thickness burn is a. sunburn.b. scald injury.c. chemical burn.d. electrical injury.

a

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function? a. Continue to monitor the urine output. b. Monitor for increased white blood cells (WBCs). c. Assess that blisters and edema have subsided. d. Prepare the patient for discharge from the burn unit.

a

The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the patient 30 minutes before the scheduled dressing change? Morphine Sertraline Zolpidem Enoxaparin

a

The nurse is providing emergent care for a patient with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. What is the priority action by the nurse? Administer 100% humidified oxygen. Teach the patient deep breathing exercises. Encourage the patient to express his feelings. Assist the patient to a high Fowler's position.

a

To maintain a positive nitrogen balance in a major burn, the patient must a. eat a high-protein, high-carbohydrate diet. b. increase normal caloric intake by about three times. c. eat at least 1500 calories/day in small, frequent meals. d. eat a gluten-free diet for the chemical effect on nitrogen balanc

a

Which patient should the nurse assess first? a. A patient with smoke inhalation who has wheezes and altered mental status b. A patient with full-thickness leg burns who has a dressing change scheduled c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour

a

Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? a. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings. b. A 67-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration c. A 46-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest d. A 65-year-old patient who has twice-daily burn debridements and dressing changes to partial- thickness facial burns

a An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients.

The nurse is planning care for the patient in the acute phase of a burn injury. What nursing action is important for the nurse to perform after the progression from the emergent to the acute phase? Begin IV fluid replacement. Monitor for signs of complications. Assess and manage pain and anxiety. Discuss possible reconstructive surgery.

b

The patient in the emergent phase of a burn injury is being treated for severe pain. What medication should the nurse anticipate administering to the patient? Subcutaneous (SQ) tetanus toxoid Intravenous (IV) morphine sulfate Intramuscular (IM) hydromorphone Oral oxycodone and acetaminophen

b

While the patients fullthickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? a. Use sterile gloves when removing old dressings. b. Wear gowns, caps, masks, and gloves during all care of the patient. c. Administer IV antibiotics to prevent bacterial colonization of wounds.

b

The nurse is caring for a patient who sustained a deep partial-thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? Skin is hard with a dry, waxy white appearance. Skin is shiny and red with clear, fluid-filled blisters. Skin is red and blanches when slight pressure is applied. Skin is leathery with visible muscles, tendons, and bones.

b

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? Blisters Reddening of the skin Destruction of all skin layers Damage to sebaceous glands

b

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? a. Obtain the blood pressure. b. Stabilize the cervical spine. c. Assess for the contact points. d. Check alertness and orientation.

b Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management.

A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? a. Bananas b. Orange gelatin c. Vanilla milkshake d. Whole grain bagel

c

A patient with type 2 diabetes mellitus is in the acute phase of burn care with electrical burns on the left side of the body and a serum glucose level of 485 mg/dL. What is the nurse's priority intervention for this patient? Replace the blood lost. Maintain a neutral pH. Maintain fluid balance. Replace serum potassium.

c

An older adult patient is moving into an independent living facility. What teaching will prevent this patient from being accidently burned in the new home? Cook for her. Stop her from smoking. Install tap water anti-scald devices. Be sure she uses an open space heate

c

Fluid and electrolyte shifts that occur during the early emergent phase of a burninjury include a. adherence of albumin to vascular walls. b. movement of potassium into the vascular space. c. sequestering of sodium and water in interstitial fluid. d. hemolysis of red blood cells from large volumes of rapidly administered fluid.

c

Knowing the most common causes of household fires, which prevention strategy would the nurse focus on when teaching about fire safety? a. Set hot water temperature at 140° F. b. Use only hardwired smoke detectors. c. Encourage regular home fire exit drills. d. Never permit older adults to cook unattended

c

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now? a. Monitor urine output every 4 hours. b. Continue to monitor the laboratory results. c. Increase the rate of the ordered IV solution. d. Type and crossmatch for a blood transfusion.

c

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? Mannitol 75 g IV Urine for myoglobulin Lactated Ringer's solution at 25 mL/hr Sodium bicarbonate 24 mEq every 4 hours

c

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess oral temperature. b. Check a potassium level. c. Place on cardiac monitor. d. Assess for pain at contact points.

c After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor.

A patient has just arrived in the emergency department after an electrical burn from exposure to a high- voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light

c All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status.

Which patient should the nurse prepare to transfer to a regional burn center? A 25-yr-old pregnant patient with a carboxyhemoglobin level of 1.5% A 39-yr-old patient with a partial-thickness burn to the right upper arm A 53-yr-old patient with a chemical burn to the anterior chest and neck A 42-yr-old patient who is scheduled for skin grafting of a burn wound

c Patients with chemical burns should be referred to a burn center

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a. Keep the right arm in a position of comfort. b. Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.

d

Eight hours after a thermal burn covering 50% of a patients total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Serous exudate is leaking from the burns. c. Cardiac monitor shows a pulse rate of 108. d. Urine output is 20 mL per hour for the past 2 hours.

d The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed

A patient arrives in the emergency department after sustaining a full-thickness thermal burn to both arms while putting lighter fluid on a grill. What manifestations should the nurse expect? Severe pain, blisters, and blanching with pressure Pain, minimal edema, and blanching with pressure Redness, evidence of inhalation injury, and charred skin No pain, waxy white skin, and no blanching with pressure

d With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy-looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns.