NSG - 252: Burns

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. Reduced self-image D. Potential for infection

C. Reduced 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

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

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. D. Urine output since admission is 370 mL.

C. The serum potassium level is 6.1 mEq/L.

The nurse is caring for a client with burns. Which question does the nurse ask the client and family to 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 before?" D. "Would you like to see a counselor?"

C. "How have you handled similar situations before?"

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."

Which strategy does the nurse include when teaching a college student about fire prevention in the dormitory room? A. Use space heaters to reduce electrical costs B. Check water temperature before bathing C. Do not smoke in bed D. Wear sunscreen.

C. Do not smoke in bed

A client with burn injuries is being 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

Physiologic Effects of CO Poisoning

- 1-10% (Normal): Increased threshold to visual stimuli and increased blood flow to organs - 11-20% (Mild Poisoning): Headache, decreased cerebral function, Decreased visual acuity, slight breathlessness - 21-40% (Moderate Poisoning): Headache, Tinnitus, Nausea, Drowsiness, Vertigo, AMS, Confusion, Stupor, Irritability, Decreased BP, Increased and irregular HR, Depressed ST segment on ECg and dysrhythmias, Pale to reddish purple skin - 41-60% (Severe Poisoning): Coma, Convulsions, Cardiopulmonary instability - 61-80% (Fatal Poisoning): Death

Factors that increase risk of death in Burn Victim

- Age older than 60 - A burn greater than 40% TBSA - Presence of an inhalation injury

Acute Phase: Systemic Indicators of Infection

- Altered LOC - Changes in VS: Increased BP, Increased RR, Hypotension, Temperature instability - Increased fluid requirements for maintenance of a normal urine output - Hemodynamic instability - Oliguria (Small amounts of pee) - GI Dysfunction: Diarrhea, vomiting, abdominal distention, paralytic ileus - Hyperglycemia - Thrombocytopenia (Low Platelet count) - Change in total WBC count: Above normal or below normal - Metabolic Acidosis - Hypoxemia

Acute Phase: Musculoskeletal Assessment

- Assess active and passive ROM on all joints, including neck

General Emergency Management of Burns

- Assess for airway patency - Administer O2 as needed - Cover the patient with a blanket - Keep the pt NPO - Elevate extremities if no fractures are obvious - Obtain vital signs - Initiate an IV line, and begin fluid replacement - Administer tetanus toxoid for prophylaxis - Perform a head-to-toe assessment

Resuscitation Phase: Managing Pain NI

- Assess the patient's pain level, using appropriate pain-reducing strategies, and preventing complications Non-Surgical Drug Therapy - Usually requires opioid or nonopioid analgesics - Useful for reducing pain - Does not touch procedure pain - IV Route for drugs - Anesthetic Agents also reduce pain - PCA Pump: Initial bolus of 5-10mg Complementary and Alternative Therapy - Relaxation techniques, meditative breathing, guided imagery, music therapy, massage Environmental Changes - Quiet environment and increasing the patients control can increase comfort - Ensure adequate rest - Change positions every 2 hours to reduce pressure, improved circulation to painful areas and ease pain Surgical - Early surgical excision of the burn wound, reduces the PAIN from daily debridement at the bedside or during hydrotherapy

Electrical Burns Emergency Management

- At the scene, separate the patient from the electrical current - Smother any flames that are present - Initiate CPR - Obtain an ECG

Acute Phase of Burn Injury

- Begins about 36 to 48 hr after injury; lasts until wound closure is completed Care directed toward - Continued assessment and maintenance of CV, respiratory systems - Continued assessment and maintenance of GI and nutritional status - Burn wound care - Pain control - Psychosocial interventions

Acute Phase: Immune Assessment

- Burn wound sepsis is a serious complication of burn injury and infection is the leading cause of death during the acute phase - HANDWASHING!

Electrical Injuries

- Burns occurring when an electrical current enters the body - Surface injuries look small but the associated internal injuries can be huge - Extent of injury depends on type of current, pathway of flow, local tissue resistance and duration of contact - Difficult to know path it takes, course of flow determined by location of contact sites which are the entrance and exit wounds - Can occur as thermal, flash or true electrical injury

Resuscitation Phase Assessment: History

- Circumstances of the injury? - Time and place of injury? - Source and cause of injury? - How did the burn occur? - What happened between calling help and help arriving? - Demographic data (Age, Weight, Height) - Health history (Kidney problems? Cardiac problems? Chronic alcoholism? Substance abuse? Diabetes?) - Drug use (Allergies, Current Drugs, Immunization Status, Last dose taken and amount taken?) - Any other injuries and PAIN - Increase risk of complications and death (Fractures, Chest injuries, Abdominal trauma) - Obtain dry weight and height (TBSA to calculate nutrition needs)

Acute Phase: Minimizing Weight Loss NI

- Collaborate with dietitian to ensure daily caloric needs are met - Diet high in protein is needed for wound healing - Pt cannot always eat depending on severity of burns, institute tube feedings soon after admission to decrease likelihood of wt loss - Parenteral nutrition may be used when the GI tract is not functional or when caloric needs cannot be met by oral or enteral feedings - LAST RESORT

Circumferential

- Completely surrounds an extremity or the chest May cause blood flow and breathing to be reduced by tight eschar in full-thickness wounds.

Acute Phase: Local Indicators of Infection

- Conversion of a partial-thickness injury to a full-thickness injury - Ulceration of healthy skin at the burn site - Erythematous, nodular lesions in uninvolved skin and vesicular lesions in healed skin - Edema of healthy skin surrounding the burn wound - Excessive burn wound drainage - Pale, boggy, dry or crusted granulation tissue - Sloughing of grafts - Wound breakdown after closure - Odor

GI Changes in Response to Burn

- Decrease blood flow to Gi tract d/to fluid shift and decreased Co - SNS stress response releases epi and norepi which decrease GI motility and further reduce blood flow to the area - Abdominal distention d/to trapped secretions and gas r/to paralytic ileus - Curling's Ulcer: Acute gastroduodenal ulcer that occurs with the stress of severe injury - May develop w/in 24 hours of severe burn injury d/to decreased blood flow

Resuscitation Phase Assessment: GI

- Decreased blood flow and SNS stimulation reduce motility and promote paralytic ileus (S/S: N/V, Abdominal Distention) - Bowel sounds reduced or absent - 25% TBSA or Intubated: NG tube needed to prevent aspiration and remove gastric secretions - Assess stool for blood ("coffee ground" - appearing crumbs) - Test for occult blood in vomit and stool

Resuscitation Phase Assessment: Kidney/Urinary Assessment

- During fluid shift, blood flow to kidneys may be inadequate for filtration = Decreased urine output - Other substances can be present in blood that flows through kidneys (Destroyed RBC = Hgb or Potassium) - Myoglobin released from muscle damage and circulates to kidneys - All these large molecules end up in kidneys and can cause a "sludge" to form which blocks kidneys blood and urine flow = possible kidney failure - MEASURE I&O HOURLY: Desired is 30-50ml/hr (4 ml/kg/ %TBSA), Fluid resuscitation is dependent on output - ASSESS RESPONSE TO FLUID RESUSCITATION: Measure urine specific gravity, BUN, Serum Creatinine, Serum Sodium Levels, - EXAMINE URINE: Color, Odor, Particles?

Needs to Address Before Discharge of the Patient with Burns

- Early patient assessment - Financial assessment - Evaluation of family resources - Weekly d/c planning meeting - Psychological referral - Patient and family teaching (Home Care) - Designation of principal learners (specific family members or significant others that will help with care) - Development of teaching plan - Training for wound care - Rehabilitation referral - Home assessment (on-site visit) - Medical equipment - Public health nursing referral - Evaluation of community resources - Visit to referral agency - Re-entry programs for school or work environment - Long-term care placement - Environmental interventions - Auditory testing - Speech therapy Prosthetic rehabilitation

Radiation Injuries

- Exposure to large doses of radioactive material -Most common is therapeutic exposure-injury minor - Industrial- isotopes used damage from alpha, beta, and gamma rays

Cardiac Changes in Response to Burn

- HR increases - Cardiac Output decreases

Education for Health Promotion and Maintanence

- Hot water tanks set below 140 degrees - Test shower/bath water with hand before immersing body - Use pot holders when removing food from oven - Never add a flammable substance to an open flame - Use sunscreen and protective clothing - Do not smoke in bed, do not smoke when drinking or taking sedative pills, keep matches and lighters out of reach of children or the cognitively impaired - Space heaters need to be kept away from clothing, bedding and flammable surfaces - Sweep chimney every year and keep screens in front of them - If on oxygen, do not smoke or be near open flame (O2 is combustible) - Smoke detectors: Each bedroom, each hallway, kitchen, each stairwell and each entrance/exit - Develop a planned escape route with alternatives - NEVER ENTER A BURNING BUILDING TO RETRIEVE ANYTHING

Chemical Burns Emergency Management

- If dry chemicals are present on skin or clothing. DO NOT WET THEM. - Brush off any dry chemicals present on the skin or clothing - Remove the patients clothing - Ascertain the type of chemical causing the burn - Do not attempt to neutralize the chemical unless it has been positively identified and the appropriate neutralizing agent is present

Escharotomies

- Incisions through the eschar May be needed to relieve pressure and allow normal blood flow or breathing.

Fasciotomies

- Incisions through the eschar and fascia May be needed to relieve pressure and allow normal blood flow or breathing.

Metabolic Changes in Response to Burns

- Increases metabolism by increasing secretion of catecholamines, antidiuretic hormone, aldosterone and cortisol - Oxygen use and calorie needs are high - Depending on burn pts caloric intake needs double or triple normal energy needs - peak 4-12 days after and may stay elevated for months - Low grade fever

Compensatory Response to Burn

- Inflammatory Compensation is helpful by triggering the injured tissues to heal and is also responsible for the initial fluid shift. Short term response, increase length causes tissue damage. - SNS Compensation is the stress response. Changes caused by SNS are most evident in the cardiovascular, respiratory and GI systems. i.e. Increased HR, Thirst, Tachypnea, Slowed or no gastric motility, Decreased bowel sounds, Abdominal distention, N/V, Increased metabolic rate and caloric needs, Fluid retention, Generalized edema, Weight gain, Hemoccult-positive stools, Decreased urine output and increased specific gravity, Skin vasoconstricted, Extremities pale, cool, Cap refill slow, Increased BS levels

Fluid Resuscitation of the Burn Patient NI

- Initiate and maintain at least one large-bore IV in an area of intact skin (if possible) - Coordinate with MD to determine correct fluid and total volume to be infused over the first 24 hours - Administer one half of the total 24-hour prescribed amount within the first 8 hours, and the remaining volume over the next 16 hours - Assess IV access site, infusion rate and infused volume at least hourly - Monitor these vital signs at least hourly >BP > HR > RR >Breath Sounds > Voice Quality (if not intubated) >O2 Saturation > End-tidal CO2 levels - Assess urine output at least hourly > Volume > Color > Specific Gravity > Character > Presence of Protein - Assess for fluid overload > Formation of dependent edema > Engorged neck veins > Rapid, thready pulse > Presence of lung crackles or wheezes on auscultation - Measure additional body fluid output hourly

Resuscitation Phase Assessment: Respiratory System

- Injured in a closed space - Extensive burns or burns on face - Intra-oral charcoal, especially on teeth and gums - Unconscious at time of injury - Singed scalp hair, nose hair, eyelids or eyelashes - Coughing up carbonous sputum - Changes in voice such as hoarseness or brassy cough - Use of accessory muscles or stridor - Poor oxygenation or ventilation - Edema, Erythema and ulceration of airway mucosa - Wheezing, bronchospasm - Smokey smell to breath Pulmonary Injury Signs - Pt becomes progressively hoarse - Develop a brassy cough - Drool or have difficulty swallowing - Exhalation wheeze, crowing and stridor - PATIENT IS ABOUT TO LOSE AIRWAY - INTUBATE IF INHALATION INJURY IS SUSPECTED Carbon Monoxide Poisoning - CO is rapidly transported across the lung membrane and binds tightly to hemoglobin in place of O2 to form carboxyhemoglobin (COHb), which impairs O2 unloading at tissue level - O2 carry capacity is reduced but the blood gas value of PaO2 is normal Thermal (Heat) Injury - Limited to upper airway above the glottis (Nasopharynx, Oropharynx, and Larynx) - Can cause edema and upper airway obstruction (Especially Epiglottitis) - If pt is resuscitated edema may be delayed d/to hypovolemia - Fluid resuscitation rehydrates tissues and then they swell - INTUBATE PATIENT BEFORE OBSTRUCTION OCCURS Smoke Poisoning - Toxic by-products are produced when plastics or home furnishings are burned, the products impair respiratory cell function Pulmonary Fluid Overload - Edema can occur even if no direct injury to lung tissue - Other damaged tissues releases such large amounts of inflammatory mediators causing capillary leak that even lung capillaries leak fluid into the pulmonary tissue space - Circulatory overload from fluid resuscitation may cause CHF which creates high pressure within the pulmonary blood vessels that pushes fluid into the lung tissue spaces - Excess lung tissue fluid makes gas exchange difficult - PATIENT IS SOB AND HAS DYSPNEA IN SUPINE POSITION AND CRACKLES ARE HEARD ON AUSCULTATION External Factors - Tight eschar from deep circumferential chest burns - Eschar restricts chest movement, compresses structures in the neck and throat = airflow impaired - CONTINUOUS PULSE OX - HOURLY INSPECTION: EASE OF RESPIRATION, AMOUNT OF CHEST MOVEMENT, RATE OF BREATHING AND EFFORT

Resuscitation Phase

- Massive fluid shift, edema and hypovolemia - Onset of injury to 24-48 hours post-burn. ends when fluid resuscitation complete

Full-Thickness Burns

- Nerve endings are completely destroyed. At first, these wounds may not transmit sensation except at wound edges. Patients often have dull or pressure type of pain.

Partial-Thickness Burns

- Nerve endings are exposed, increasing sensitivity and pain

Chemical Burns

- Occur in home, industrial accidents or the result of an assault - Severity depends on duration of contact, concentration of chemical, amount of tissue exposed, and the action of the chemical - Alkalis: Oven cleaners, fertilizers, drain cleaners or heavy industrial cleaners damage tissue by causing the skin and its proteins to liquify - deeper spread and more severe burns - Acids: Bathroom cleaners, Rust removers, Pool chemicals, and Industrial drain cleaners damage tissue integrity by coagulating cells and skin proteins - can limit depth of damage - Chemical disinfectants and gasoline: Easily absorbed through the skin and have toxic effects on kidneys and liver

Thermal Burns

- Occur when clothes ignite from heat or flames produced by electrical sparks - External burn injuries can occur when the electrical current jumps, or "arcs" between two body surfaces

Minor Burns

- Partial thickness burns of less than 10% of body area - Full thickness burns covering less than 2% of body area - No burns of eyes, ears, face, hands, feet, or perineum - No electrical burns - No complicated concomitant injury - No inhalation injury - Under age 60 and has no chronic cardiac, pulmonary, or endocrine disorders Emergency care at scene than transferred to a hospital. Burn center not usually needed.

Moderate Burns

- Partial-thickness burns 15-25% of body area - Full-thickness burns 2-10% of body area - No burns of eyes, ears, face, hands, feet, or perineum - No electrical burns - No inhalation injury - No complicated additional injury - Under age 60 and has no chronic cardiac, pulmonary, or endocrine disorders Emergency care at scene and then be transferred to a special expertise hospital or a designated burn center.

Manifestations of Infected Burn Wound

- Pervasive odor - Color changes: Focal, dark red, brown discoloration in the eschar - Change in texture - Purulent drainage - Exudate - Sloughing grafts - Redness of wound edges to non burned skin

Resuscitation Phase: Preventing Acute Respiratory Distress Syndrome (ARDS)

- Positive End-Expiratory Pressure (PEEP): Provides a continuous positive pressure in the airway and alveoli - This enhances the diffusion of O2 across the alveolar-capillary membrane - Monitor ABG levels and pulse ox to assess changes in respiratory status

Acute Phase: Cardiopulmonary Assessment

- Priority NI: Assess cardiovascular and respiratory system - Pt may develop pneumonia which may result in respiratory failure requiring mechanical ventilation - At risk for Infection and Sepsis

Radiation Burns

- Remove the patient from the radiation source - If the patient has been exposed to radiation from an unsealed source, remove clothing (use tongs or lead protective gloves) - If radioactive particles are on skin, send to nearest designated radiation decontamination site - Help patient bathe or shower

Resuscitation Phase Assessment: Cardiovascular

- Shock as a result of disrupted fluid and electrolyte balance - Monitor degree of edema, assess central and peripheral pulses, BP (invasive monitoring may be needed depending on degree of burns and location of burns), capillary refill and pulse ox - Initially patient is tachycardic, hypotensive, has decreased peripherals, peripheral cap refill is slow or absent ECG Monitoring - Changes can indicate damage to the heart as a result of electrical burn injury or stress that can induce a MI - Obtain baseline ECG at admission and continue ECG monitoring throughout resuscitation phase - COMPARE TO DETERMINE IF INJURY IS OCCURING

Pulmonary Changes in Response to Burn

- Smoke inhalation: Cause edema and obstruct the trachea - Resp failure can result from airway edema during fluid resuscitation, pulmonary capillary leak, chest burns and restrict chest movement, and carbon monoxide poisoning. - The lining of the airway may slough 48-72 hours after and cause an obstruction in lower airways

Flame Burn Emergency Management

- Smother the flames - Remove smoldering clothing and all metal objects

Acute Phase: Supporting Positive Self-Image NI

- Understanding the stages of grief - Reassure pt that feelings of grief, loss, anxiety, anger, fear and guilt are normal - Let them participate in treatment, do as much as they can without helping - Develop a support system - Join a support group - Reconstructive and cosmetic surgery may be done to improve appearance and self-image - Teach about expected outcomes

Diagnostic Assessments

- Used when deep organ trauma is suspected - Renal scans, CT, Ultrasonography, Bronchoscopy, and MRI - If eye is involved, an ophthalmic evaluation is performed to detect corneal damage

Better Outcomes from Burn Injuries Occur Because of...

- Vigorous fluid resuscitation - Early burn wound excision - Improved critical care monitoring - Early enteral nutrition - Antibiotics - Use of specialized burn centers

Dry Weight

- Weight before edema forms - Used to calculate fluid rates, energy requirements and drug doses

Acute Phase: Neuroendocrine Assessment

- Weight patient daily without dressings or splints and compare to preburn weight

What happens in the reusciation phase?

- injury is evaluated and the immediate problems of fluid imbalance (loss), edema and reduce blood flow are assessed

Dry Heat Injuries

-Caused by open flame. The most common flame injuries occur in house fires and explosions.

Moist Heat (scald) Injuries

-Contact with hot liquids or steam -Hot liquid spills usually involve upper, front areas of the body - Scalding hot water immersions usually involve the lower body

Contact Burns

-Occur when hot metal, tar, or grease contacts the skin often leading to full-thickness injury

Major Burns

-Partial-thickness greater than 25% of body -Full thickness greater than 10% of body - Any burn involving eyes, ears, face, hands, feet, perineum - Electrical Injury - Inhalation injury - Patient is older than 60yrs - Complicated with other injuries (fractures, etc) - Patient has cardiac, pulmonary, or other chronic metabolic disorders. Emergency care at the nearest ER, then be transferred to a designated burn center ASAP.

When manifestations of pulmonary edema are present what do you do?

1. Elevate the HOB to at least 45 degrees 2. Apply Oxygen 3. Notify the burn team or call a rapid response

Burn Outcomes

1. Maintain adequate oxygenation and circulation to all vital organs 2. Maintain a patent airway 3. Have CO restored to normal 4. Have pain alleviated or restored 5. Experience no further loss of skin tissue integrity 6. Have wounds healed without complications 7. Have wounds healed without complications 8. Remain free from infection 9. Not experience sepsis 10. Maintain adequate nutrition for meeting the body's caloric needs 11. Regain and maintain an opitmal ability to move purposefully 12. Have a positive perception of own appearance and body functions

Resuscitation Phase Priorities for Management

1. Secure the airway 2. Support circulation and organ perfusion by fluid replacement 3. Keep pt comfortable with analgesics 4. Prevent infection through careful wound care 5. Maintain body temperature 6. Provide emotional support

Acute Phase Nursing Diagnosis

1. Wound care management related to burn injury, skin grafting procedures and immobilization 2. Risk for infection related to open burn wounds, the presence of multiple invasive catheters, reduced immune function and poor nutrition 3. Excessive weight loss related to increased metabolic rate, reduced caloric intake, and increased urinary nitrogen losses 4. Impaired Mobility: Physical related to open burn wounds, pain, and scars and contractures 5. Reduced self-image related to trauma, changes in physical appearance and lifestyle, and alterations in sensory and motor function

A newly admitted client has deep partial-thickness burns. The nurse expects to see which clinical manifestations? A. Painful red and white wounds B. Painless, brownish yellow eschar C. Painful reddened blisters D. Painless black skin with eschar

A) Painful red and white wounds

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. Watch for early signs of infection.

A. Change gloves when handling wounds on different areas of the body.

Which action by the nurse changing the dressings on the client who has burns on the right arm, the left arm, and the upper chest is most effective at preventing auto-contamination? A. Changing gloves after cleaning and dressing one wound area before cleaning and dressing the next wound area B. Using sterile gloves to remove the old dressings and changing to fresh sterile gloves before applying the new dressings C. Ensuring that the blood pressure cuff used on another client is thoroughly cleaned before using it on this client. D. Warning the client's family not to bring fresh fruits and vegetables or house plants into the client's environment.

A. Changing gloves after cleaning and dressing one wound area before cleaning and dressing the next wound area.

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. Dry, crusty granulation tissue D. Edema of the skin around the wound E. Tachycardia

A client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? A. Encouraging participation in wound care 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

Silver Sulfadiazine (Silvadene, Thermazene)

Action: Adheres to bacterial cell membranes inhibiting DNA synthesis and bacterial replication Interventions - Watch for allergic reaction causing a drop in WBC count - Do not use if reaction to sulfonamide has occurred - Use on deep partial-thickness or full-thickness wounds - Monitor wounds for infection

Gentamicin Sulfate (Garamycin, Gentamar)

Action: Aminoglycoside antibacterial that inhibits bacterial protein synthesis and results in bacterial responses Interventions - Nephrotoxic: Monitor kidney function closely, especially changes in serum creatinine and BUN - Ototoxic: Monitor hearing weekly

Mafenide acetate (Sulfamylon)

Action: Bacteriostatic action against many gram-positive and gram-negative organisms Interventions - Premedicate for pain before application - Monitor blood gas and serum electrolyte levels - Monitor wounds for infection

Collagenase (Santyl) w/ Polysporin Powder

Action: Digests Collagen in necrotic tissue Interventions - Apply once a day - Use on partial-thickness wounds with eschar - Monitor wounds for infection - May be used with barrier dressing such as Xeroform

PolyMem

Action: Dressing material containing silver granules that suppress bacterial growth Interventions - Normally leave in place for 7 days - Remove earlier if exudate is visible through other membranes - Use on partial-thickness wounds and on donor site - Cover with a secondary dressing - Monitor wounds for infection

Mepilex Ag

Action: Dressing material containing silver ions that begin to inactivate wound pathogens within 30 minutes of application Interventions - Do not use along with oxidizing agents such as hydrogen peroxide - Cover with secondary dressing - May be used with partial-thickness burns, full-thickness burns, skin grafts, and donor-sites

Aquacel Ag

Action: Dressing material that releases ionic silver in a controlled manner as exudate is absorbed into dressing to support wound healing Interventions - Use on partial-thickness wounds and on donor sites - Cover with a secondary dressing - Do not use for patients who have allergic reactions to the dressing or any of its components - Moisten with sterile water or normal saline to easily remove - Do not use with oil-based products

Polymyxin B-Bacitracin (Poly-Bac, Polysporin)

Action: Inhibits bacterial cell wall synthesis and destroys bacterial membranes, leading to bacterial killing effects Interventions - Apply every 2-8 hours to keep area moist

Nitrofurazone (Furacin)

Action: Wide spectrum antibacterial agent Intervention - Observe closely for signs of allergic reaction and evidence of superinfection

Acticoat

Action: releases antimicrobial silver ions when moistened with sterile water Interventions - Do not use with oil-based products or other antimicrobials - Do not use for any patient with a known sensitivity to any of the components of this drug - May dry out and adhere to wound surface; soak off to remove

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 with 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!"

Which client response does the nurse interpret as an indication of fluid resuscitation adequacy? A. Decreasing pulse pressure B. Decreasing urine specific gravity C. Decreasing core body temperature D. Increasing respiratory rate and depth

B. Increasing urine specific gravity

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 C. Moderate to severe edema D. Absence of blisters

B. Painful

A nursing student is caring for a client with open-wound burns. Which nursing interventions does the nursing student provide for this client? Select all that apply. A. Provides cushions and rugs for comfort B. Performs frequent handwashing C. Places plants in the client's room D. Performs gloved dressing changes E. Uses disposable dishes

B. Performs frequent handwashing D. Performs gloved dressing changes E. Uses disposable dishes

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 B. Creatinine, 2.8 mg/dL C. Urine output, 40 mL/hr D. Urine specific gravity, 1.042

C. Urine output, 40 mL/hr

Deep-Full Thickness Burn

Color: Black Edema: Absent Pain: Absent Blisters: No Eschar: Yes, hard and inelastic Healing Time: Weeks to months Grafts Required: Yes Example: Flames, electricity, grease, tar, chemicals TX: Early excision and grafting. Grafting decreases pain and length of stay and hastens recovery. Amputation may be needed if on extremity.

Full-Thickness Burn

Color: Black, brown, yellow, white, red Edema: Severe Pain: Yes and No Blisters: No Eschar: Yes, hard and inelastic Healing Time: Weeks to months Grafts Required: Yes Example: Scalds; flames; prolonged contact with hot objects, tar, grease, chemicals, electricity

Superficial Burn

Color: Pink to Red Edema: Mild Pain: Yes Blisters: No Eschar: No Healing Time: 3-6 days Grafts Required: No Example: Sunburn, flash burns (welding)

Superficial Partial-Thickness Burn

Color: Pink to Red Edema: Mild to moderate Pain: Yes Blisters: Yes Eschar: No Healing Time: About 2 weeks Grafts Required: No Example: Scalds, flames, brief contact with hot objects

Deep Partial-Thickness Burn

Color: Red to white Edema: Moderate Pain: Yes Blisters: Rare Eschar: Yes, soft and dry Healing Time: 2 - 6 weeks Grafts Required: Can be used if healing is prolonged Example: Scalds; flames; prolonged contact with hot objects, tar, grease, chemicals

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? 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

For which type of burn injury is it most important for the nurse to assess the client for a respiratory injury? A. Hot liquid scald burn B. Liquid Chemical Burn C. Electrical Burn D. Dry Heat Burn

D. Dry Heat Burn

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 lose 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.

Imaging

Do not provide assessment of burns, only used if other injury is suspected

Acute Phase: Minimizing Infection NI

Drug Therapy for Preventing Infection - Tetanus toxoid 0.5 mL given IM enhances immunity to Clostridium tetani - Antimicrobial drugs Drug Therapy for Treating Infection - Systemic antibiotics if infection suspected - Give broad spectrum until lab results come back - Burn pts require higher level to maintain effective blood levels Providing a safe environment - No sick people should visit - Use as much disposable products as possible - Housekeeping to clean daily - Wear clean gloves - Clean any/all equipment in between patients

When intubation has not been performed in a patient whose upper airways were exposed to heat or toxic gases, continually assess the upper airway for recognition of __________________________.

Edema and Obstruction

Acute Phase: Managing Wound Care NI

Goal: No wound extension and have wounds healed Indicators: Presence of granulation, re-epithelialization and scar tissue formation; Has decreased wound size, Has no new wounds Nonsurgical Management Mechanical Debridement - Wounds are cleaned 1-2 times/day using hydrotherapy - Nurses, UAP and PT can perform hydrotherapy - Hydrotherapy: Performed by showering the patient on a special shower table or washing only small areas at the bedside - NO LONGER SUBMERGE IN WHIRLPOOL D/TO INFECTION RISK - Use forceps and scissors to remove loose, dead tissue during hydrotherapy - Leave small blisters alone as they have a protective barrier - Large blisters are opened - Washcloths or gauze sponges are used to debride cheesy eschar - Wash wounds with water and mild soap then rinse with room temp H2O Enzymatic Debridement - Autolysis: Disintegration of tissue by the action of the patient's own cellular enzymes - Topical enzymes (Santyl) can be used for rapid wound debridement - Once a day - Dissolve collagen in necrotic tissue Dressing the Burn Wound - Standard wound dressings: Multiple layers of gauze applied over the topical agents on the wound; changes every 12-24 hours - Biologic dressings: Skin or tissues from tissue donors (homograft or allograft) or pigskin (Heterograft or Xenograft) - Synthetic dressings: Can be grown from a small specimen of epithelial cells from an unburned part of the pts body - Artificial skin: Two layers, a Silastic epidermis and a porous dermis made from beef collagen and shark cartilage - Biosynthetic Wound dressings: Nylon fabric that is partially embedded into a silicone film; Nylon is skin side, silicone allows for drainage - Synthetic Dressings: Solid silicone and plastic membranes; helps to reduce pain d/to nerve endings not touching air; also used to cover graft sites; FASTER HEALING WITH LOW INFECTION RATES, MINIMAL PAIN AND REDUCED COST Surgical Management - Excision and wound coverage - Autografting: Early grafting reduces risk of infection and sepsis - Surgical Excision: Cut out necrotic tissue until healthy bloody tissue is reached; taken out in small, thin layers; within first 5 days and as needed thereafter - Wound Covering: Graft sites are covered with bulky cotton pressure dressings for 3-5 days after to allow vascularization, or "take"

Resuscitation Phase: Supporting Oxygenation NI

Goal: Patent Airway and Adequate Oxygenation Non-Surgical Airway Maintenance: Chin-lift or Head-Tilt - Assess endotracheal tube hourly to ensure patency and location in intubated patients - Bronchoscopy on admission and routinely thereafter for examination of respiratory tract, deep suctioning of lungs, and removal of sloughing necrotic tissue - Suction as indicated - Endotracheal or Nasotracheal tube suctioning is performed after chest physiotherapy and aerosol treatments - Painful so increased analgesia or sedation Promoting Ventilation - Chest movement can be restricted by eschar and by tight dressings that cover the neck, chest and abdomen - Observe for ease of respiratory movements and loosen tight dressings as needed to assist with ventilation Monitor for Gas Exchange - Using laboratory tests: ABG, Carboxyhemoglobin levels) - Assess for cyanosis, disorientation, and increased pulse rate - Additional monitoring: Chest X-Ray, Pulmonary Artery Catheter Pressures and Central Venous Pressure Measurement - Cyanide Poisoning: Elevated plasma lactate level can indicate Oxygen Therapy - Humidified oxygen by facemask, cannula or hood - Arterial oxygenation less than 60 mm Hg = Intubation or Mechanical Ventilation - Emergency airway equipment at bedside (O2, Masks, Cannulas, Manual Resuscitation Bags, Laryngoscope, Endotracheal tubes, and equipment for tracheostomy Drug Therapy - Antibiotics: Pneumonia or other pulmonary infections impair breathing - Beta-Blockers: Pts with pulmonary edema and any degree of heart failure to improve left ventricular function and to prevent or treat pulmonary edema - Diuretics: For pulmonary edema; may or may not be used depending on patient's blood volume and kidney function Paralytic Drug - Remove all breathing control from the patient, making mechanical ventilation easier - Must also receive drugs for sedation, analgesia, and antianxiety unless clinically contraindicated Positioning and Deep Breathing - Turn patient frequently and help out of bed as much as possible - Teach coughing and deep-breathing exercises - IC hourly while awake - Chest physiotherapy to mobilize secretions Surgical Management - Tracheotomy if long-term intubation is necessary - if airway becomes occluded and oral or nasal intubation cannot be achieved - Chest tubes to re-expand the lung - Escharotomy: Tight eschar around neck, chest or abdomen can restrict breathing

How do you give drugs for pain for a patient in resuscitation phase to prevent delayed rapid absorption leading to lethal blood levels?

IV

For a burn patient in the resuscitation phase who is hoarse, has a brassy cough, drools or has difficulty swallowing or produces an audible breath sound on exhalation __________________________________.

Immediately apply oxygen and call a Rapid Response

Blanch

Lighten

Preventing Hypovolemic Shock and Inadequate Oxygenation NI

Monitoring - Monitor urine output: Assesses Cardiac Output and tissue perfusion - Monitor central venous pressure, pulmonary artery pressures, and CO - Monitor ECG for changes: Compare to admission ECG Drug Therapy - DO NOT GIVE DIURETICS UNLESS ELECTRICAL BURN- THEY CAN CAUSE FURTHER DAMAGE - Rather, adjust IV fluid infusion rate/amount - Electrical Injury Burn: Tissue/muscle injury release myoglobin which can block kidneys and cause failure - Give Mannitol only after adequate urine output has been established

Carboxyhemoglobin

Normal Range: 0-10% Elevated as a result of inhalation of smoke and carbon monoxide (CO)

BUN

Normal Range: 10-20 mg/dL Elevated as a result of fluid volume loss

Sodium

Normal Range: 135-145 Decreased: Sodium is trapped in edema fluid and lost through plasma leakage

Albumin

Normal Range: 3.5-5 g/dL Low: Protein is lost through the wound and through vascular membranes because of increased permeability

Potassium

Normal Range: 3.5-5.0 Elevated as a result of disruption of the sodium-potassium pump, tissue destruction and RBS hemolysis

PaCO2

Normal Range: 35-45 Slightly increased from respiratory injury

Total Protein

Normal Range: 6.4-8.3 g/dL Low: Protein exudate is lost through the wound

pH

Normal Range: 7.35-7.45 Low as a result of metabolic acidosis

Glucose

Normal Range: 70-110 mg/dL Elevated as a result of stress response and altered uptake across injured tissues

PaO2

Normal Range: 80-100 Slightly decreased

Cloride

Normal Range: 98-106 Elevated as a result of fluid volume loss and reabsorption of chloride in urine

Hemoglobin

Normal Range: Men = 14-18 Women = 12-16 Elevated as a result of fluid volume loss

Hematocrit

Normal Range: Men = 42-52% Women = 37-47% Elevated as a result of fluid volume loss

Fungal Sepsis Manifestations

Onset: Delayed Cognition: Mild disorientation Ileus: Mild Diarrhea: Occasional Temperature: Fever Hypotension: Late WBC Count: Neutrophilia Platelets: Low

Gram-Positive Sepsis Manifestations

Onset: Insidious, 2-6 days Cognition: Sever disorientation and lethargy Ileus: Severe (Obstruction of the ileum) Diarrhea: Rare Temperature: Fever Hypotension: Late WBC Count: Neutrophilia Platelets: Normal

Gram-Negative Sepsis Manifestations

Onset: Rapid, 12-36 hours Cognition: Mild disorientation Ileus: Severe Diarrhea: Severe Temperature: Hypothermia Hypotension: Early WBC Count: Neutropenia Platelets: Low

Desquamation

Peeling of dead skin

Acute Phase: Maintaining Mobility NI

Positioning - Maintain the patient in a neutral position with minimal flexion as it may lead to contracture - Splints may be used for maintaining good positioning ROM - Actively 3 x day - If cannot actively move, we passively move for them - Active ROM on hands hourly Ambulation - 2-3 x day and progress in length each time Compression Dressings - Applied after grafts, Help to prevent contractures and tight hypertrophic scars which can inhibit mobility - Wear at least 23 hours a day to achieve desired benefits

Age Related Changes Increasing Complications from Burn Injury

Thinner Skin, Sensory Impairment, Decreased Mobility - Sensory impairment and decreased mobility increase the risk for burn injury. - Thinner skin increase the depth of injury even when the exposure to the cause of injury is shorter in duration Slower Healing Time - Longer time with open area results in a greater risk for infection, metabolic derangements, and loss of function from contracture formation and scar tissue More Likely to Have Cardiac Impairments - Limits the aggressiveness fluid resuscitation - Increases the risk for shock and acute kidney injury (AKI) Reduced Inflammatory and Immune Response - Increases the risk for infection and sepsis - Patient may not have a fever when infection is present Reduced Thoracic and Pulmonary Compliance - Increased risk for atelectasis, hypoxia and other pulmonary complications More likely to have pre-existing medical conditions such as DM, kidney impairment or pulmonary impairment - Any of these disorders compromise vital organ function and can interfere with fluid resuscitation efforts or other treatments