Ch. 25 BURNS 1
Nutritional therapy for burn pt
50-100% more calories than normal
After a chemical burn how long can tissue destruction continue to occur?
72 hours
How long can chemical burns cause issues after the initial exposure has occurred?
72 hours out
While reviewing the arterial blood gas values of a client with emphysema, the nurse should identify which of the following PaCO2 values as indicating the need for immediate intervention?
80 mm Hg.
A nurse is caring for a client with burns on his legs. Which nursing intervention will help to prevent contractures?
Applying knee splints
A nurse is teaching a 62-year-old female who has had a left modified radical mastectomy with axillary node dissection about lymphedema. The nurse should tell the client that lymphedema occurs:
At any time after surgery or not at all.
A client with heart failure hasn't slept for the past 3 nights because of dyspnea. Arterial blood gas (ABG) analysis reveals pH, 7.32; PaO2, 79 mm Hg; PaCO2, 50 mm Hg; and HCO3-, 29 mEq/L. Which nursing diagnosis takes highest priority for this client?
Impaired gas exchange
Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?
Inform the physician immediately.
A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?
LR
A nurse is developing a teaching plan for a client who has just been diagnosed with breast cancer. The nurse should include information about:
Tamoxifen
Goals of care for burn pts
Would healing, prevention of infection, pain management, return to pre injury function
Chemical burns are caused by
acids, alkalis, and organic compds (over and drain cleaners, fertilizers, heavy industrial cleaners).
Kayaxcelete enema check
bowel sounds
Smoke inhalation & breathing
pulmonary edema may not occur until 12 to 24 hours after the burn
Assessment findings in a 1st degree burn (partial thickness burn)
redness, pain, tenderness, minimal edema, blanching with pressure
Chemical burn interventions
remove all materials with chemicals on it, flush with lots of water for 20mins- 2 hrs postexposure.
Burn patient and clothing
remove burned clothing to prevent tissue damage, if adherent clothing should be left in place, wrap pt in a clean, dry sheet to prevent contamination of the wound and provide warmth
A 76-year-old client tells the nurse that she has lived long and does not need mammograms. Which is the nurse's best response?
risk for breast cancer increases with age
A 57-year-old woman with breast cancer who does not speak English is admitted for a lumpectomy. Her daughter, who speaks English, accompanies her. In order to obtain admission information from the client, what should the nurse do?
trained medical interpreter
A client with advanced breast cancer is ordered tamoxifen (Nolvadex). When teaching the client about this drug, the nurse should emphasize the importance of reporting which adverse reaction immediately?
vision changes
A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should:
wrap elastic bandages distally to proximally on dependent areas.
What would you treat carbon monoxide poisoning with?
100% oxygen
A client experiencing a severe asthma attack has the following arterial blood gas: pH 7.33; PCO2 48 (6.4 kPa); PO2 58 (7.7 kPa); HCO3- 26 (26 mmol/L). Which of the following orders should the nurse perform ?
Albuterol nebulizer
A 10-year-old has just spilled hot liquid on his arm, and a 4-inch (10.2-cm) area on his forearm is severely burned. His mother calls the emergency department. What should the nurse advise the mother to do?
Apply cool water to the burned area.
A client's diagnosis of cystic fibrosis was made 13 years ago, and he has since been hospitalized several times. On the latest admission, the client has labored respirations, fatigue, malnutrition, and failure to thrive. Which nursing actions are most important initially?
Applying an oximeter and initiating respiratory therapy.
What would a patient with carbon monoxide poisoning look like?
Bright red skin
What is the cause of death for a larger majority of house fires?
CO poisoning
Greatest threat to pt with major burn
Hypovolemic shock
A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?
Metabolic alkalosis
A client exhibits increased restlessness. The results of the arterial blood gas test are as follows: pH, 7.52; partial pressure of carbon dioxide, 38 mm Hg (5.1 kPa); bicarbonate, 34 mg/L (34 mmol/L). The nurse should plan care based on the fact that these findings indicate which of the following acid-base imbalances?
Metabolic alkalosis.
The nurse is reviewing sterile procedures with a student nurse. The nurse understands that the student requires additional teaching when the student identifies which procedure as requiring sterile technique?
Nasogastric (NG) tube placement
Criteria to refer to a burn center
Partial thickness burns greater than 10% TBSA, burns involving face, hands, genitalia, any 3rd degree burn, electrical, thermal, or chemical burns
Which of the following would provide the most effective emergency care for a burn victim at the accident site?
Pour cold water over the burned area
Nursing intervention during wound care for burn patient
Pre medicate!!! Give pain killers prior to dressing change
The nurse should plan to begin rehabilitation efforts for the burn client:
after the circulatory system is stable
What can happen with smoke inhalation?
airway swelling and edema. Maintain a patient airway
A client is beginning external beam radiation therapy to the right axilla after a lumpectomy for breast cancer. Which of the following should the nurse include in client teaching?
apply deodorant only under left arm
Hypovolemic shock and burns
begins as early as 20mins postburn, massive shift of fluids out of the blood vessels, Third spacing fluid shifting
A nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
fine needle aspiration
A client is receiving fluid replacement with Lactated Ringer's after 40% of his body was burned 10 hours ago. The assessment reveals: temperature 97.2 (36.2° C); heart rate 122; blood pressure 84/42; CVP 2 mm Hg; and urine output 25 ml for the last 2 hours. The IV rate is currently at 375 ml/hr. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the healthcare provider with the recommendation for:
iv rate increase
Systemic affects of hypovolemia
kidney issues, acute necrotic glomerulonephritis
Second degree burns (partial thickness burn)
moist blebs, blisters, pink to cherry red color, hypersensitive to air and touch, blanching with pressure, pain
Primary concerns during the emergent phase?
onset of hypovolemic shock and edema formation (1st- 72 hours after burn)
Burn center referral criteria
partial thickness burns over 10% TBSA, burns involving the face, hands, feet, and genitalia, 3rd degree burns, electrical, chemical, inhalation
A 62-year-old female is taking long-acting morphine 120 mg every 12 hours for pain from metastatic breast cancer. She can have 20 mg of immediate-release morphine every 3 to 4 hours as needed for breakthrough pain. The physician should be notified if the client uses more than how many breakthrough doses of morphine in 24 hours?
seven
Compartment syndrome **
swelling due to burns, can cause loss of a limb
A client asks the nurse how frequently she should have a mammogram. The nurse assesses that there is no family history of breast cancer and no risk factors with this particular client. Which statement, if made by the client, shows an understanding of the nurse's teaching regarding the frequency of mammograms?
"I should have a mammogram every year beginning at age 40."
Nutritional therapy for burn pt
5,000 kilocalorie/daily, feeding tube, monitor for aspirations,
A client who's receiving chemotherapy for breast cancer develops myelosuppression. Which instructions should the nurse include in the client's discharge teaching plan?
Avoid people who have recently received attenuated vaccines. wash hands, avoid activities that cause bleeding, avoid crowded places.
After teaching the mother of a child with severe burns about the importance of specific nutritional support in burn management, which of the following, if chosen by the mother from the child's diet menu, indicates the need for further instruction?
Bacon, lettuce, and tomato sandwich; milk; and celery and carrot sticks.
A 42-year-old husband and father of a 7-year-old girl and a 10-year-old boy is concerned about what he should tell his children regarding his wife's impending death from aggressive breast cancer. The nurse should:
Begin education about strategies for communication with his children.
The nurse is preparing an educational program on breast cancer for women at a Black community center. What information is important for the nurse to consider for the discussion?
Breast cancer concerns vary between socioeconomic levels of Black women.
Smoke inhalation can cause
Carbon monoxide poisoning
A 65-year-old client is admitted to the emergency department with a fractured hip. The client has chest pain and shortness of breath. The health care provider orders nitroglycerin tablets. Which should the nurse instruct the client to do?
Chew the tablet until it is dissolved.
A postmenopausal woman is worried about pain in the upper outer quadrant of her left breast. The nurse's best course of action is to:
Do a breast examination and report the results to the physician
Risk factors for the development of breast cancer include:
Early onset of menstruation.
A 56-year-old female is currently receiving radiation therapy to the chest wall for recurrent breast cancer. She has pain while swallowing and burning and tightness in her chest. The nurse should further assess the client for indications of:
Esophagitis.
A nurse is administering daunorubicin (Daunoxome/Cerubidine) through a peripheral I.V. line when the client complains of burning at the insertion site. The nurse notes no blood return from the catheter and redness at the I.V. site. The client is most likely experiencing which complication?
Extravasation
While caring for the client with a burn injury who is experiencing hypersecretion of gastric acid, the nurse should observe the client for:
GI ulceration
Pt Undergoing skin graft with use of cultured epithelial autographs. Nurse explains this is...
Growing small specimens in a petri-dish, of their own skin from the groin
A woman in menopause is a good candidate for hormone replacement therapy (HRT) if she:
Has severe hot flashes.
The client is advised by the physician to have mammography screening annually. Measures to improve adherence with mammography screening include:
Making sure that the individual barriers to screening are minimized.
Which of the following is most effective in assessing the client suspected of developing diabetes insipidus?
Measuring urine output hourly.
When instructing the client with severe burns about proper nutrition, the nurse should encourage the client to choose which of the following meals for lunch?
Roast beef sandwich, milkshake, cottage cheese.
What is the most common type of burn?
Thermal Burn
The client with breast cancer is prescribed tamoxifen (Nolvadex) 20 mg daily. The client states she does not like taking medicine and asks the nurse if the tamoxifen is really worth taking. The nurse's best response is which of the following?
This drug has been found to decrease metastatic breast cancer."
A daughter is concerned that her mother is in denial when discussing her diagnosis of breast cancer because she sometimes says that breast cancer isn't that serious and changes the subject. The nurse informs the daughter that denial can be a healthy defense mechanism if it is used:
To allow her mother to continue in her role as a mother.
A young woman would like to lower her risk of developing cancer and is following a low-fat diet. Which type of cancer is not associated with excess dietary fat intake?
breast cancer
Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg?
breath into paper bag
Inhalation below the glottis caused by
chemicals, smoke, or toxic fumes. Monitor for pulmonary edema.
Monitor burn patients for
daily weight and urine output
Signs of hypovolemic shock include...
decreased BP, increased heart rate, decreased urine output
Ice and burns
don't ice for longer than 10 mins due to risk of hypothermia and decreased blow flow to the area
3rd degree burns assessment
dry- leathery eschar , waxy white, dark brown, or charred appearance, burn odor, impaired sensation to touch, no pain on burn or surrounding tissue due to nerve damage, lack of blanching with pressure
Electrical injury puts the patient at risk for
dysrthymias, cardiac arrest, severe metabolic acidosis, and myoglobimuria which can lead to acute tubular necrosis. May occur for the first 24 hours after injury
Which areas of the body are at increased risk for infection after a burn?
ears, nose due to poor circulation
Primary nursing intervention for a patient with an inhalation injury above the glottis
edema and mechanical obstruction to the larynx and occur quickly. Monitor breathing and maintain patent airway
Thermal Burns are caused by
flame, flash, scald, and contact with hot objects
A client with advanced stomach cancer is scheduled for chemotherapy. As part of the chemotherapy regimen, the nurse expects the physician to order:
fluorouracil
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?
hoarseness of the voice
Injury above glottis (upper airway injury) is caused by
hot steam, air, or smoke
The most common reason for unconsciousness or altered mental status is
hypoxia associated with smoke inhalation
On admission, a client has the following arterial blood gas (ABG) values: PaO2, 50 mm Hg; PaCO2, 70 mm Hg; pH, 7.20; HCO3-, 28 mEq/L. Based on these values, the nurse should prioritize which nursing diagnosis for this client?
impaired gas exchange
An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first?
A middle-aged man with no injuries who has rapid respirations and coughs.
Interventions for thermal burns
A,B,C'S, stabilize cervical spine, assess inhalation injury, admin O2, vitals, LOC, respirations, pulse ox, cover with dry sheet, establish two large bore catheters, fluid replacement, catheter
Nursing assessment for a burn pt in the emergent phase
A,B,C's, vitals, cardiac rhythm, oxygenation, and LOC
What should you monitor with chemical burns?
ALT, AST, and other lab values due to system toxicity
The nurse is caring for a client who has experienced severe multiple trauma. The client's arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. The nurse is aware that this finding is a major indicator of the development of which of the following conditions?
Acute respiratory distress syndrome (ARDS).
Nursing priorities/ assessment: If the burn is large (10% or ^ TBSA), or electrical or inhalation burn...
Airway: patency, soot around nares or on tongue, singed nasal hair, darkened oral or nasal areas. Breathing: check for adequacy of ventilation Circulation: pulses, elevate burned limb above heart level to decrease pain and swelling
A client with breast cancer has abdominal bloating and cramping with no bowel movement for 5 days. She says she usually has a bowel movement every day after her morning coffee. Bowel sounds are present in all four quadrants. She received 80 mg of doxorubicin hydrochloride (Adriamycin)10 days ago. The nurse should contact the health care provider to request an order for which of the following?
An oral cathartic until the client has a bowel movement; then evaluate the need for daily stool softeners
The nurse is conducting a focused assessment of the gastrointestinal system of a client with a burn injury. The nurse should assess the client for:
Curling's ulcer.
The nurse teaches a client about heat and cold treatments to manage arthritis pain. Which of the following client statements indicates that the client still has a knowledge deficit
Heat-producing liniments can be used with other heat devices."
A nurse provides care for a client with deep partial-thickness burns. What could cause a reduced hematocrit (HCT) in this client?
Hemodilution
The nurse should assess a client who is in the emergent phase of burn management for:
Hyperkalemia.
Six months after undergoing a radical modified mastectomy to treat breast cancer, a client is admitted for chemotherapy. When the nurse enters the client's room, the client is sobbing and states, "I thought the chemotherapy would help, but now I feel worse." Which response by the nurse is most therapeutic?
Ill be glad to discuss anything you need
On admission, the client's arterial blood gas (ABG) values were: pH, 7.20; PaO2, 64 mm Hg (8.5 kPa); PaCO2, 60 mm Hg (8 kPa); and HCO3-, 22 mEq/L (22 mmol/L). A chest tube is inserted, and oxygen at 4 L/minute is started. Thirty minutes later, his repeat blood gas values are: pH, 7.30; PaO2, 76 mm Hg (10.1 kPa); PaCO2, 50 mm Hg (6.7 kPa); and HCO3-, 22 mEq/L (22 mmol/l). This change would indicate:
Improving respiratory status.
The nurse is caring for a client who has suffered deep partial-thickness and full-thickness burns. During the emergent (resuscitative) phase of burn management, the nurse would anticipate a fluid shift from the:
Intravascular to the interstitial compartment.
A client in the postanesthesia care unit is being actively rewarmed with an external warming device. How often should the nurse monitor the client's body temperature?
Q 15mins
A client appears flushed and has shallow respirations. The arterial blood gas report shows the following: pH, 7.24; partial pressure of arterial carbon dioxide (PaCO2), 49 mm Hg (6.5 kPa); bicarbonate (HCO3-), 24 mEq/L (24 mmol/L). These findings are indicative of which of the following acid-base imbalances?
Respiratory acidosis
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate?
Respiratory alkalosis
A client complains of a dull headache and dizziness and has an increased pulse rate. The results of arterial blood gas analysis are as follows: pH, 7.26; partial pressure of carbon dioxide, 50 mm Hg (6.7 kPa); and bicarbonate, 24 mEq/L (24 mmol/l). These findings indicate which of the following acid-base imbalances?
Respiratory alkalosis.
A 35-year-old female client is requesting information about mammograms and breast cancer. She isn't considered at high risk for breast cancer. What should the nurse tell this client?
She should eat a low-fat diet to further decrease her risk of breast cancer.
The nurse is teaching a client and family about phenelzine (Nardil). Which of the following foods should the nurse instruct the client to avoid?
Sour cream.
A 42-year-old female highway construction worker is concerned about her cancer risks. She reveals that she has been married for 18 years, has two children, smokes one pack of cigarettes per day, and drinks one to two beers with her husband after work almost every day. She is 30 lb overweight, eats fast food often, and rarely eats fresh fruits and vegetables. Her mother was diagnosed with breast cancer 2 years ago. Her father and an aunt both died of lung cancer. She had a basal cell carcinoma removed from her cheek 3 years earlier. What combination of behavioral changes should the nurse instruct this client to make first?
Stop smoking, use sun protection, and lose weight
When the open method is used for treating burns, which of the following actions should the nurse take to help prevent discomfort caused by air currents over the client's burned skin surfaces?
Support the bed linens on a cradle.
A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.72 kPa); HCO3-, 24 mEq/L (24 mmol/l). Based upon the client's PaO2, which of the following conclusions would be accurate?
The client is severely hypoxic.
A nurse is preparing a care plan for a client burned over 36% of his body 2 days previously. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care?
The client's complete blood count readings reflect a reduced hematocrit.
When bandaging the burned client's hand, the nurse should make certain that:
The hand and finger surfaces do not touch.
A postmenopausal client with an intact uterus asks the nurse why her hormone medicine has two drugs, estrogen and progesterone. Which of the following statements by the nurse provides the client with accurate information?
The progesterone will help prevent endometrial cancer."
Changes you would expect to see in a pt with burns
elevated hematocrit (caused by hemo-concentration resulting from fluid loss), sodium and potassium changes
Three phases of burn management
emergent (resuscitative), acute (wound healing), rehabilitative (restorative)
After a plane crash, a client is brought to the emergency department with severe burns and respiratory difficulty. The nurse helps to secure a patent airway and attends to the client's immediate needs, then prepares to perform an initial neurologic assessment. The nurse should perform an:
evaluation of the corneal reflex response.
Which set of arterial blood gas (ABG) results requires further investigation?
pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?
pH, 7.25; PaCO2 50 mm Hg
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:
pain management