Nursing Management of Burn Injuries (Sherpath)

What is the total 24-hour fluid requirement in milliliters for a 55-kg adult patient with 75% TBSA burned? __

16500 4 mL lactated Ringer's solution per kilogram (kg) of body weight per percent of total body surface area (% TBSA) burned = Total fluid requirements for first 24 hours after burn 4 mL × 55 kg × 75 = 16500 mL

A nurse is providing nutritional support to a patient with severe burns. The nurse anticipates the patient will receive which type of diet?

High protein, high carbohydrate A high-protein, high-carbohydrate diet promotes tissue healing.

A nurse is caring for a patient with burns in the rehabilitative phase. Which complication is the nurse most likely to see during this phase?

Hypertrophic scarring Hypertrophic scarring, such as keloids, is a potential complication during the rehabilitative phase of burn management.

A nurse is caring for a newly admitted patient in the emergent phase after a severe electrical burn. Which provider orders should the nurse question?

Obtain an ECG in 8 hours The patient should have an ECG performed now, not delayed for 8 hours. The patient with an electrical burn injury is at risk for cardiac dysrhythmias. The nurse should question this provider order. Administer PO pain medication Patients in the emergent phase of burn management should be treated for pain, but PO is not an appropriate management technique because pain medications will be administered intravenously. The nurse should question this provider order.

Based on the assessment data provided for Mr. Dickson, which emergent phase interventions should be performed by the nurse? Select all that apply.

Prepare for central line IV placement. Mr. Dickson has 45% TBSA burned, and a central IV line can be placed if the patient has more than 30% TBSA burned. This is an expected intervention during the emergent phase of burn management. Assess and manage the patient's pain. Assessing and managing the patient's pain is a nursing intervention that should be performed during the emergent phase. Mr. Dickson states that he is in pain, so the nurse should give pain medication accordingly. Monitor blood pressure continuously. Mr. Dickson has a history of high blood pressure, and his painful burns may cause further blood pressure elevation. Thus the nurse should ensure continuous monitoring of his blood pressure during the emergent phase once he has started receiving fluids.

The nurse would anticipate a patient with leg and hand contact burns to need which diagnostic tests during the acute phase of burn management? Select all that apply.

Serum electrolytes Serum electrolytes is an expected diagnostic test for a patient with burns during the acute phase of burn management to monitor fluid and electrolyte shifts Complete blood count (CBC) A complete blood count (CBC) is used to detect anemia and an immunologic response to a burn injury. This test is appropriate during the acute and emergent phases of burn management.

A patient with facial burns frequently asks the nurse, "When will I look normal again?" Which is an appropriate response by the nurse?

"You seem to be very anxious. Would you like to talk about how you're feeling?" The patient is verbally expressing signs of anxiety. The nurse should attend to the patient's psychologic and emotional needs at this time.

A patient is admitted to the burn center with burns to the neck and chest after a gasoline explosion at work. Emergency transport reported wheezing in the upper lung fields. Upon initial assessment, the nurse notes no current wheezing and diminished breath sounds throughout. What is the appropriate action for the nurse to take?

Contact the health care provider and prepare for emergency intubation. The patient is likely to have inhalation burn injuries, and intubation is necessary to maintain oxygenation and ventilation.

Which interventions should the care team implement during the acute phase of the burn injury?

Nutritional therapy Nutritional therapy would be implemented during the acute phase of burn management to support wound healing. Graft donor site(s) care Nursing care for graft donor sites is a concern during the acute phase of a burn injury. Physical and occupational therapy Physical and occupational therapy should be started during the acute phase of burn management, once the patient has begun healing.

A nurse is caring for a patient with a chemical burn to the left extremity who is in the rehabilitative phase of burn management. Which order would the nurse anticipate from the health care provider?

Provide patient education on wound care The rehabilitation phase begins when the patient's wounds are healed and he or she is engaging in some form of self-care. It is appropriate to provide the patient with education on wound care during this phase.

The nurse is caring for a patient who was just transported by EMS to the hospital for burns to the legs, chest, arms, and face. Which nursing interventions are appropriate at this time?

repare to initiate tube feeding as indicated The nurse is caring for a patient in the emergent phase of burn management. If indicated, the nurse will need to prepare the patient for tube feeding, which will help with wound healing and nutritional and electrolyte balances Insert urinary catheter to monitor intake and output The nurse is caring for a patient in the emergent phase of burn management. It is appropriate to insert a catheter to monitor the intake and output during this phase to effectively assess fluid status. Monitor oxygen status and provide supplemental oxygen as needed The nurse is assessing a patient in the emergent phase of burn management. It is appropriate to monitor oxygen and provide supplemental oxygen as needed because the patient may be at risk for impaired perfusion and ventilation.

A nurse is caring for a patient with severe burns to the face and chest who is preparing for discharge. Which action is appropriate by the nurse?

rovide the patient with information on support groups Patient support groups may be beneficial for meeting the emotional needs of the patient during the recovery process and coping with possible disfigurement.