Chapter 62: Burns

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? A. 1 B. 2 C. 3 D. 4

A. 1

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. A urine output consistently above 40 ml/hour B. A weight gain of 4 lb (2 kg) in 24 hours C. Body temperature readings all within normal limits D. An electrocardiogram (ECG) showing no arrhythmias

A. A urine output consistently above 40 ml/hour

The nurse is applying an occlusive dressing to a burned foot. What position should the foot be placed in after application of the dressing? A. Adduction B. Dorsiflexion C. External rotation D. Plantar flexion

A. Adduction

Which zone consists of the area where the injury is most severe and deepest? A. Coagulation B. Stasis C. Hyperemia D. Necrosis

A. Coagulation

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire? A. Roll the client in a blanket. B. Cover the client with a wet cloth. C. Place the client with the head positioned slightly below the rest of the body. D. Avoid immediate IV fluid therapy.

A. Roll the client in a blanket

Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply. A. Singed nasal hair B. Hoarseness C. Facial burns D. Yellow sputum E. Bradypnea

A. Singed nasal hair B. Hoarseness C. Facial burns

Which is a quick technique to assess the percentage of a burn injury? A. comparing the client's palm with the size of the burn wound B. observing the client's level of consciousness C. observing the color of the client's wound D. checking the client's vital signs

A. comparing the client's palm with the size of the burn wound

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)

What are some other body changes from burns?

Altered thermoregulation, immunodepression, hypermetabolism

What is lost only during burn injuries that is different from other traumatic events?

Plasma

What causes a Fourth Degree (full thickness that includes fat, fascia, muscle, and/or bone) burn?

Prolonged exposure or high voltage electrical injury

Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area? A. Prevent infection B. Fluid resuscitation C. Endotracheal tube placement D. Strict intake and output

B. Fluid resuscitation

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? A. Mechanical B. Natural C. Enzymatic D. Surgical

B. Natural

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? A. "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun." B. "I will drink a lot of fluids to prevent constipation since I am taking pain medications." C. "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." D. "I can work with the social worker to find funding assistance programs to help with my medical expenses."

C. "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? A. 9% B. 18% C. 27% D. 36%

C. 27%

A child tips a pot of boiling water onto his bare legs. The mother should: A. Avoid touching the burned skin and take the child to the nearest emergency department. B. Cover the child's legs with ice cubes secured with a towel. C. Immerse the child's legs in cool water. D. Liberally apply butter or shortening to the burned areas.

C. Immerse the child's legs in cool water.

What are some Cardiovascular changes with burns?

Cardiac depression, edema, hypovolemia

What skin is involved in third degree burns?

Epidermis, dermis, sometimes subcutaneous tissue, may involve connective tissue and muscle

What skin is involved in a second degree burn?

Epidermis, portion of dermis

What are some GI changes with burns?

Impaired motility and absorption, vasoconstriction, loss of mucosal barrier function with bacterial translocation, increased pH

excision

surgical removal of part or all of a structure

donor site

the area from which skin is taken to provide a skin graft for another part of the body

What is the Palmer method?

the patients hand equals 1% of the patient's TBSA

What are the most common sites of tissue destruction?

the skin and mucosa of the upper airways

What are some clinical manifestations of a first degree burn?

tingling, hyperesthesia, pain that is soothed by cooling, peeling, itching

What are Flash injuries?

when an electrical flash generates light and heat, injury caused by heat generated to exposed areas or by flames from ignition of clothing

Which age groups have increased morbidity and mortality with burns?

young children and older adults

What is the leading cause of fire death in the United States?

Smoking materials and cigarettes

What causes a First Degree (superficial) burn?

Sunburn, low-intensity flash, superficial scald

What are some Kidney changes with burns?

Vasoconstriction

What are some Pulmonary changes with burns?

Vasoconstriction, edema

Treatment of fourth degree burns?

amputations likely, grafting of no benefit, given depth and severity of the wounds

fasciotomy

an incision made through the fascia to release constriction of underlying muscle

What does a second degree burn look like?

blistered, mottled red base, disrupted epidermis, weeping surface, edema

What are Lightning injuries?

can results from a direct strike, a high-voltage DC injury that is usually fatal, or a side flash wherein the current discharges from an object nearby through the air to an adjacent person

What does a fourth degree burn look liked?

charred

treatment of first degree burns?

cool compresses, skin lubricants, topical antimicrobial agents not indicated, recovery in a few days

What are Conductive injuries?

occur when the current overcomes the skin's resistance and travels through the body

What are some advances in burn care?

optimal fluid resuscitation, infection control, early excision and grafting, an enhanced team approach, and the emergence of specialized burn centers

What are some clinical manifestations of a second degree burn?

pain, hyperesthesia, sensitive to air currents

What complications from burns to older adults experience?

pneumonia, UTIs, kidney injuries, dysrhythmias, septicemia, celluitis, respiratory infections, and other infections

What does a first degree burn look like?

reddened, blanches with pressure, dry, minimal or no edema, possible blister

debridement

removal of foreign material and devitalized tissue until surrounding healthy tissue is exposed

Methods commonly used to estimate the TBSA affected by burns?

rule of 9s, Lund method, Browder method, and palmer method

What causes a Second Degree (Partial thickness) burn?

scalds, flash flame, contact

What are some clinical manifestations of a Fourth degree burn?

shock, myoglobinria, possible hemolysis

contracture

shrinkage of burn scar through collagen maturation

Treatment of second degree burns?

some scarring and depigmentation possible, may require grafting, recovery in 2-3 weeks

What is the most frequent age group to have burns?

20-30 years old

During the acute phase of burn injury, the nurse knows to assess for signs of potassium shifting during what time frame? A. Within 24 hours B. Between 24 and 48 hours C. At the beginning of the third day D. Beginning on day 4 or day 5

D. Beginning on day 4 or day 5

What skin is involved in a Fourth degree burn?

Deep tissue, muscle, and bone

What skin is involved in a first degree burn?

Epidermis

Women have twice the incidence of burn injuries. True or False?

False. Men have twice the incidence of burn injuries

What is the most common etiology of burns in older adults?

Flame/fire

When does the greatest fluid leak happen? When does it peak?

The first 24 to 36 hours, peaks at 6-8 hours

carboxyhemoglobin

a compound of carbon monoxide and hemoglobin, formed in the blood with exposure to carbon monoxide

autograft

a graft derived from one part of a patient's body and used on another part of that same patient's body

xenograft

a graft obtained from an animal of a species other than that of the recipient (e.g., pigskin); also called heterograft

homograft

a graft transferred from one human (living or cadaveric) to another human; also called allograft

escharotomy

a linear excision made through eschar to release constriction of underlying tissue

collagen

a protein present in skin, tendon, bone, cartilage, and connective tissue

What are Electrical burns?

devastating and complex, heat generated by electricity, visual examination is not predictive of burn size and severity

When does hypokalemia happen with burns?

develops later with fluid shifts

eschar

devitalized tissue resulting from a burn or wound

What does a third degree burn look like?

dry, pale white, red brown, leathery or charred, coagulated vessels may be visible, edema

Treatments for edema?

elevation of extremity, removal of eschar, or decompression of edema formation via fasciotomy to restore tissue perfusion

Treatment of a third degree burn?

eschar may slough, grafting necessary, scarring and loss of contour and function

What causes a Third Degree (Full thickness) burn?

flame, prolonged exposure to hot liquids, electric current, chemical, contact

What are some factors to determining burn depth?

how the injury occurred, causative agent, temp and duration of contact with the causative agent, and thickness of the skin at the injury site

When does hyperkalemia happen with burns?

immediately after

What is a Inhalation injury?

inhalation of thermal and/or chemical irritants. can be upper or lower

What are some clinical manifestations of a third degree burn?

insensate, shock, myoglobinuria (red pigment in urine), possible hemolysis (blood cell destruction), possible contact points (entrance or exit wounds in electrical burns)