CH. 57 MANAGEMENT OF PATIENTS WITH BURN INJURY PREPU
When using the Palmer method to estimate the extent of a small or scattered burn injury, the nurse recognizes the palm is equal to which percentage of total body surface area?
1
The palm represents which percentage of a person's TBSA?
1%
Burn shock is characterized by which of the following?
Capillary leak
Which complication is common for victims of electrical burns?
Cardiac dysrhytmia
he 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.
The spouse of a client 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.
The nurse recognize what as an early sign of sepsis in a client with a burn injury?
Elevated serum glucose
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 is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client
Fluid resuscitation
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
A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name?
Homografts
A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?
Irrigate the wounds with water.
Which of the following is the effect of protein catabolism in a client with severe burns?
It compromises wound healing and immunocompetence.
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
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
Specific potential complications are common to specific types of burns. Which burns can impair ventilation?
face, neck, chest
The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching?
"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."
Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply.
- Singed nasal hair - Hoarseness - Bradypnea
A sample consensus formula for fluid replacement recommends that an isotonic solution be administered in the first 24 hours of a burn in the range of 2 to 4 mL/kg/% of burn with 50% of the total given in the first 8 hours postburn. A 176 lb (80 kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours?
2, 400 ml
A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?
27%
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%
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?
A urine output consistently above 40 ml/hour
In a client with burns on the legs, which nursing intervention helps prevent contractures?
Applying knee splints
The nurse cares for a client with extensive burn injuries. Which parameter(s) would the nurse evaluate to determine if the client is receiving adequate fluid resuscitation? Select all that apply.
BP urine output Fluid resuscitation is administered to maintain adequate cardiac output and tissue perfusion. If adequate fluid is administered, tachycardia, hypotension, and oliguria will resolve. Expected outcomes of fluid resuscitation specifically include the following: urine output between 0.5 and 1.0 mL/kg/hr (30-50 mL/hr; 75 to 100 mL/hr if electrical burn injury), mean arterial pressure (MAP) pressure > 60 mm Hg, voids clear yellow urine with specific gravity within normal limits, and serum electrolytes are within normal limits.
Which of the following skin substitutes is a nylon-silicone membrane coated with a protein?
Biobrane
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 is teaching a client who underwent a skin graft for a burn injury about the use of pressure garments. What instruction(s) should the nurse include in the teaching? Select all that apply.
Contact the primary provider if the garment does not seem to fit properly. Massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment. When using a pressure garment, the nurse should instruct the client to wear the garment for at least 23 hours a day, not 12 hours a day. The client should contact the primary provider if the garment does not seem to fit. The nurse should instruct the client to hand wash, not machine wash, the pressure garment daily with a mild detergent. The garment should not be wrung dry. Instead, the client should squeeze and roll the garment in a towel to remove as much moisture as possible. The client should also massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment.
Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis?
Deep partial-thickness
A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client?
Gastric ulcers
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?
Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel.
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
Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is:
Hyperkalemia
Which of the following is to be expected soon after a major burn? Select all that apply.
Hypotension Tachycardia Anxiety
A child tips a pot of boiling water onto his bare legs. The mother should:
Immerse the child's legs in cool water.
Which zone of burn injury sustains the most damage?
Inner Each burned area has three zones of injury. The inner area (known as the zone of coagulation, where cellular death occurs) sustains the most damage. The middle area, or zone of stasis, has a compromised blood supply, inflammation, and tissue injury. The outer zone, the zone of hyperemia, sustains the least damage.
A client recovering from burn injuries over both forearms reports itching of the wounds. Which action will the nurse take to enhance the client's comfort?
Instruct to pat and not scratch the areas.
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
Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues?
Natural
At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Select all that apply.
Place the client in a horizontal position. Roll the client in a blanket to smother the fire.
Following a burn injury, the nurse determines which area is the priority for nursing assessment?
Pulmonary system
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
The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse?
Skin grafting will be necessary.
The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application?
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
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.
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 0.5 to 1 mL/kg/hour.
A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours?
The early appearance of the burn injury may change.
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 A quick assessment technique to use to evaluate an area of burn that is not restricted to one portion of the body is by using the client's palm size to approximate the total body surface. The palm is approximately 1% of a person's TBSA. The Parkland formula determines fluid resuscitation needs. Lund and Browder burns assessment provides a more precise estimate for determining TBSA that is burned and is especially more specific in children. The rule of nines quantitates burns that involve entire sections of the body, not scattered burns.
A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area?
escharotomy
A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury?
inflammatory
Which antimicrobials is not commonly used to treat burns?
tetracycline Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns.
