Ch. 26 Care of Patients with Burns
caloric needs post burn are
2 - 3 times normal caloric needs the increaed rates peak at 4 - 12 hours but can remain elvated for months until after wounds are closed
blood transfusions are needed if the patient's HCT is less than
20 - 25% and the patient has sx of hypoxia
airway edema becomes pronounced
8 - 12 hours after the beginning of fluid resuscitation
genital area
< 1%
weigh the patient daily without dressings or splints and compare the weight to preburn or dry weight. A 2% weight loss indicates
a mild deficit 10% weight loss requires evaluation and modification of calorie intake
Which nursing intervention(s) decrease(s) the risk for cross-contamination in the client with a severe burn injury? (Select all that apply.) a. Place client in isolation. b. Encourage multiple visitors to support client. c. Ensure that no plants or flowers are in the client's room. d. Teach family members not to bring fresh fruits and vegetables to the client. e. Change gloves after cleaning and dressing of one wound area, before cleaning and dressing another.
a, c, and d
legs
anterior: 9% posterior: 9%
the disintegration of tissue by the patient's own cellular enzymes
autolysis
contact with hot metal, tar, or grease
contact burns
peeling of the sea skin occurs 2 -3 days after superficial burn
desquamination
damaged muscle cells that are injured in major burns or electrical burns release
myoglobin that further damage muscle and the kidney
Atracurium
neuromuscular blocking agent patient must be on mechanical ventilation to recieve this drug also give sedative, analgesic, and antianxiety meds
massive fluid shift, edema, and hypovolemia that occurs in first 24 - 48 hours after burn
resuscitation phase
progressively hoarse develop a brassy cough drool or have difficulty swallowing wheezes, crowing, and stridor on exhalation
signs that indicate pulmonary injury
pink to red blisters form no eschar 2 weeks to heal
superficial partial thickness
Patient is SOB, has dyspnea, and crackles on auscultation
sx of circulatory overload
fluid boluses are avoided because
they increase capillary pressure and worsen edema
parkland formula for burns
% BSA x weight (kg) x 4 mL give 1/2 fluids in first 8 hours. remaining 1/2 in last 16 hours. Total fluids in by 24 hours
water tanks should be set below
140 F or 60 C
back
18%
chest/truck area
18%
hypoactive or absent bowel sounds increase risk for GI ulcer, illeus
GI changes post burn
destroyed RBC release
Hgb and K+
partial-tichkness burns less than 10% TBSA Full thickness bruns less than 2% TBSA
Minor burns ER then to hospital for care
patients with burns of 25% TBSA or who are intubated generally require a
NG tube
1) secure the airway 2) support circulation and organ perfussion by fluid replacement 3) keep the patient comfortable with IV analgesics 4) prevent infection through careful wound care 5) provide emotional support
Priorities for emergency management of burns
increased HR, RR, glucose decreased GI motility, hypo/absent bowel sounds urine retention and increaed urine specific gravity increased metabolic neeeds thirst and generalized edema fluid retention and weight gain
SNS activation causes
bleeding indicates that
a bed of healthy dermis or subQ tissue has been reached
successful skin grafting requires
a clean and granulating or freshly excised wound bed
Which factors indicate that a client's burn wounds are becoming infected? Select all that apply. a. Dry, crusty granulation tissue b. Elevated blood pressure c. Hypoglycemia d. Edema of the skin around the wound e. Tachycardia
a, d, and e
When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors? a. "Every bedroom should have a separate smoke detector." b. "Every room in the house should have a smoke detector." c. "If you have a smoke detector, you don't need a carbon monoxide detector." d. "The kitchen and the bedrooms are the only rooms that need smoke detectors."
a. "Every bedroom should have a separate smoke detector."
What is the best method to prevent autocontamination for a client with burns? a. Change gloves when handling wounds on different areas of the body. b. Ensure that the client is in isolation therapy. c. Restrict visitors. d. Use sterile gloves when changing dressings.
a. Change gloves when handling wounds on different areas of the body.
A client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? a. Encouraging participation in wound cares b. Encouraging visitors c. Reassuring the client that he or she will be fine d. Telling the client that these feelings are normal
a. Encouraging participation in wound care
A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first? a. Give oxygen per facemask. b. Infuse lactated Ringer's solution at 150 mL/hr. c. Give morphine sulfate 4 to 10 mg IV for pain control. d. Insert a 14 Fr retention catheter.
a. Give oxygen per facemask.
The nurse is reviewing the health history for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client's history reveals which condition? a. Heart failure b. Diverticulitis c. Hypertension d. Emphysema
a. Heart failure
To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow? a. In a neutral position b. In a position of comfort c. Slightly flexed d. Slightly hyperextended
a. In a neutral position
The nurse is caring for a client with a burn injury who is receiving silver sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? a. Reduction of bacterial growth in the wound and prevention of systemic sepsis b. Prevention of cross-contamination from other clients in the unit c. Enhanced cell growth d. Reduced need for a skin graft
a. Reduction of bacterial growth in the wound and prevention of systemic sepsis
slower healing times thinner skin sensory impairment decreaed mobilty reduced inflammatory and immune response reduced thoracic and pulmonary compliance more likelt ot have pre-exsisting medical condition (DM, renal impairment, pulmonary impairment)
age-related changes
head and arms
anterior: 4.5% posterior: 4.5%
The nurse is encouraging range-of-motion exercises for the client, who states, "this hurts terribly; I don't want to do this." Identify the appropriate nursing response(s). (Select all that apply.) a. "You have to do the exercises to get well." b. "Range-of-motion helps promote mobility." c. "Just visualize a beach to get your mind off of the pain." d. "Let me check when you were last given pain medication." e. "What techniques for pain management have you used in the past that were helpful?" f. "The health care provider has ordered these exercises, and it is important that you do them as instructed."
b, d, and e
Which nursing interventions does the nursing student provide for this client? Select all that apply. a. Provides cushions for comfort b. Performs frequent handwashing c. Places plants in the client's room d. Performs gloved dressing changes e. Uses disposable dishes
b, d, and e
A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? a. "The last tetanus injection was less than 5 years ago." b. "Burn wound conditions promote the growth of Clostridium tetani." c. "The wood in the fire had many nails, which penetrated the skin." d. "The injection was prescribed to prevent infection from Pseudomonas."
b. "Burn wound conditions promote the growth of Clostridium tetani."
The nurse is caring for a client who has burns to the face. Which statement by the client requires further evaluation by the nurse? a. "I am getting used to looking at myself." b. "I don't know what I will do when people stare at me." c. "I know that I will never look the way I used to, even after the scars heal." d. "My spouse does not stare at the scars as much now as in the beginning."
b. "I don't know what I will do when people stare at me."
The nurse on a burn unit has just received change-of-shift report about these clients. Which client does the nurse assess first? a. Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain b. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" c. An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans d. Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr
b. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!"
A client is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the client? a. Intramuscular b. Intravenous c. Sublingual d. Topical
b. Intravenous
Which wound assessment characteristics suggest a superficial partial-thickness burn injury? a. Black-brown coloration b. Painful blisters c. Moderate to severe edema d. Absence of blisters
b. Painful blisters
Several clients have been brought to the emergency department after an office building fire. Which client is at greatest risk for inhalation injury? a. Middle-aged adult who is frantically explaining to the nurse what happened b. Young adult who suffered burn injuries in a closed space c. Adult with burns to the extremities d. Older adult with thick, tan-colored sputum
b. Young adult who suffered burn injuries in a closed space
The nurse is caring for a client who has burns. Which question does the nurse ask the client and family to best assess their coping strategies? a. "Do you support each other?" b. "How do you plan to manage this situation?" c. "How have you handled similar situations?" d. "Would you like to see a counselor?"
c. "How have you handled similar situations?"
A client who was the sole survivor of a house fire says, "I feel so guilty. Why did I survive?" What is the best response by the nurse? a. "Do you want to pray about it?" b. "I know, and you will have to learn to adapt to a new body image." c. "Tell me more." d. "There must be a reason."
c. "Tell me more."
A client with burn injuries is admitted. Which priority does the nurse anticipate within the first 24 hours? a. Range-of-motion exercises b. Emotional support c. Fluid resuscitation d. Sterile dressing changes
c. Fluid resuscitation
In assessing a client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? a. Intense pain b. Potential for inadequate oxygenation c. Impaired self-image d. Potential for infection
c. Impaired self-image
Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury? a. Pale, boggy, dry, or crusted granulation tissue b. Increasing wound drainage c. Scar tissue formation d. Sloughing of grafts
c. Scar tissue formation
Which assessment is the nurse's highest priority in caring for a client in the acute phase of burn injury? a. Bowel sounds b. Muscle strength c. Signs of infection d. Urine output
c. Signs of infection
Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area is of greatest concern to the nurse? a. Bowel sounds are absent. b. The pulse oximetry level is 91%. c. The serum potassium level is 6.1 mEq/L (6.1 mmol/L). d. Urine output since admission is 370 mL.
c. The serum potassium level is 6.1 mEq/L (6.1 mmol/L).
The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? a. Blood urea nitrogen (BUN), 36 mg/dL (12.9 mmol/L) b. Creatinine, 2.8 mg/dL (248 mcmol/L) c. Urine output, 40 mL/hr d. Urine specific gravity, 1.042
c. Urine output, 40 mL/hr
burn completely surrounds an extremity or the chest constriction reduced blood flow
circumferential injury
severe carbon monoxide poisoning (41 - 60%)
coma convuslions cardiopulmoary instabillity
acute gastroduocenal ulcer that occurs with the stress of severe injury may develop within 24 hr after severe burn
curling's ulcer
The client asks about ways to prevent carbon monoxide poisoning. Which teaching will the nurse provide? a. "You can see black smoke when carbon monoxide is in the air." b. "If you are experiencing carbon monoxide poisoning, your skin will begin turning blue." c. "The only way to get poisoned from carbon monoxide gas is if you are in the presence of a fire." d. "It is important to have carbon monoxide detectors in your home, because this is an odorless gas."
d. "It is important to have carbon monoxide detectors in your home, because this is an odorless gas."
When delegating care for clients on the burn unit, which client does the charge nurse assign to an RN who has floated to the burn unit from the intensive care unit (ICU)? a. Burn unit client who is being discharged after 6 weeks and needs teaching about wound care b. Recently admitted client with a high-voltage electrical burn c. A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed d. Client receiving IV lactated Ringer's solution at 150 mL/hr
d. Client receiving IV lactated Ringer's solution at 150 mL/hr
Which assessment finding does the nurse interpret as demonstrating a client's fluid resuscitation adequacy? a. Decreased skin turgor b. Decreased pulse pressure c. Decreased core body temperature d. Decreased urine specific gravity
d. Decreased urine specific gravity
A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian? a. Discouraging having food brought in from the client's favorite restaurant b. Providing more palatable choices for the client c. Helping the client maintain a desirable weight d. Planning additions to the standard nutritional pattern
d. Planning additions to the standard nutritional pattern
The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first? a. Administer a diuretic. b. Provide a fluid bolus. c. Recalculate fluid replacement based on time of hospital arrival. d. Titrate fluid replacement.
d. Titrate fluid replacement.
Fatal carbon monoxide poisoning (61 - 80%)
death
removal of eschar and other cellular debris from the burn wound
debridement
black hard and inelastic eschar with skin graft
deep full thickness
Red to white soft dry eschar 2 - 6 weeks to heal
deep partial thickness
the number of gauze layers depends on
depth of injury amount of drainage expected area injured patient's mobilty frequency of dressing changes
sweat and oil glands and the hair follicles are the
dermal appendages
made up of collagen, fibrous connective tissue, and elastic fibers contains BV, lymph vessels, sensory nerves, hair follicles, sebaceous glands, and sweat glands
dermis
starts 48 - 72 hour after burn blood flow and urinary output increase
diuretic stage
if patient receives a paralytic/neuromuscular blockade drug then the patient must also receive
drugs for sedation, analgesia, and anti-anxiety
caused by open flame in house fire and explosions
dry heat injuries
patient's preburn weight
dry weigtht important becasue it is used in calculations to determine fluid rates, energy rates, and drug doses
entering and exit wounds deep muscle injury or oran injury may be present
electrical burns
only give diuretic with
electrical burns usually prescribed mannitol (OSmitrol)
oxygen, masks, cannulas, manual resuscitation bags, laryngoscope, endotracheal tubes, and equitment for tracheostomy
emergency airway equipment at bedside
top layer has no BVs
epidermis
dead tissue must be sloughed off or removed from the wound before healing can occur
eschar
age older than 60 a burn greater than 40% TBSA the presence of inhalation injury
factors that increase risk for death
fluid shift with excessive weight gain occurs within
first 12 hours after burn and can continue for 24 - 36 hours
nerve endings are completely destroyed absence of pain
full thickness burns
black, brown, yellow, white, and red hard and inelastic eschar weeks to months to heal with skin graft
full-thickness burns
delayed onset mild disoreintation mild illeus ocasional diarrhea fever late hypotension low platelets
fungal sepsis
rapid, 12 - 36 hour mild disorientation severe illeus severe diarrhea hypothermia early hypotension low platelets
gram negative sepsis
insidious, 2 - 6 days severe disorientation and lethargy severe illeus fever late hypotension normal platelet levels
gram positive sepsis
Mild Carbon Monoxide Poisoning (11 - 20%)
headache decrease cerebral functioning decreaed visual acuity slight breathlessness
Moderate Carbon Monoxide Poisoning (21- 40 %)
headache tinnitus nausea drowsy vertigo altered mentla status confusion stupor irritable decreaesd BP incread irregular HR depresesd ST segment on ECG dsyrhythmias pale to reddish-purple skin
Homografts or allograft
human skin obtained from cadavers expensive and risk for blood borne infection
burn wounds are derided and cleaned one or two times a day during
hydrotherapy application of water for treatment
paO2 of less that 60 is an indication for
intubation or mechanical ventilation
if TBSA burned is greater than 35% then
invasive cardiac and pulmonary monitoring may be needed
xenograft or heterograft
is obtained from animals, pigs or cows. -are used temporary cover large areas -pigskin or porcine most common
cardiac changes after a burn
low BP and CO increased HR
partial-thickness burns >25% TBSA full-thickness burns >10% TBSA burn involving eyes, ears, face, hands, feet, or perineum Electrical or inhalation injury Patient is older than 60 y.o. Burn complicated with other injuries (fractures) patient has cardiac, pulmonary, or other chrnic etablism disorders
major burns
partial-thickness burns 15 - 25% TBSA full-thickness burns 2 - 10% TBSA
moderate burns emergency care at scene then to burn clinic
caused by hot liquid or steam
moist heat (scald) injury
fluid replacement formulas are calculated from the time
of injury NOT time of admission to hospital
burns greatly increase
oxygen demand and metabolic needs
nerve endings are exposed increased pain and sensativity
partitical thickness burns
Signs of carbon monoxide poisoning
patient is "cherry-red" color carboxyhemoglobin > 10%
caused by superheated air, steam, toxic fumes, or smoke most likely to occur iwth a bunr that happened indoors
pulmonary changes
opioids as well as ketamine and nitrous oxide are given to
reduce pain