Burns Nursing

a deep partial thickness burn = what degree burn?

2nd degree

Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the medication?

Stools for occult blood. H2 blockers and proton pump inhibitors are given to prevent Curling's ulcer in the patient who has suffered burn injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite.

The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require an intervention by the charge nurse?

The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound. Sterile gloves should be worn when applying medications or dressings to a burn.

Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line?

Stabilize the cervical spine. Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management.

the adequacy to determine a patients fluid replacement is determined by?

- urine output - blood pressure - heart rate

Parkland Formula for burn patients fluid resuscitation

4ml/kg/TBSA lactated ringers for 1st 24 hrs post burn

A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first?

Use pulse oximetry to check the oxygen saturation. Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first.

While collecting a medical history on a patient who experienced a severe burn, which statement by the patient's family member requires nursing intervention?

"I think it has been 10 years or more since he had a tetanus shot." Patients who have had burns need a tetanus shot if they have not had a vaccine within the past 5 to 10 years.

A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by the nurse is best?

"It's true that your life may be different. What concerns you the most?" This response acknowledges the patient's feelings and asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury.

a superficial partial thickness burn = what degree burn?

1st degree

a full thickness burn = what degree burn?

3rd degree

after assessing an airway patient what type of patient would be the next priority

a patient in severe pain as pain is a physiological need

during the rehabilitation phase of a burn injury, the contour of scarring can be controlled with what?

a pressure garment that can keep scar tissue flat and prevent elevation and enlargement above the original burn injury area

which type of burn is most associated with risk for coagulation necrosis?

electrical burn

Parkland fluid replacement formula: the remaining 16 hours how much fluid is administered?

half the fluid

a burn patient has a nursing diagnosis of impaired physical mobility related to limited ROM resulting from pain. an appropriate nursing intervention for this patient is to?

provide pain medications before physical activity and exercise

What are some patient priorities during the rehabilitation phase of burn management?

psychosocial

superficial partial thickness burns the appearance is what?

red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain.

During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion?

Measure hourly urine output.

a patient with deep partial thickness burns over 45% of his trunk and legs is going for debridement 48 hrs postburn. the drug of choice to control the patients pain during this activity would be?

Morphine is the drug of choice for the emergent phase post burn via IV as the GI tract function is impaired, and IM injections would not be adequately absorbed with damage.

A patient is receiving IV Lactated Ringers 950 mL/hr post 18 hours after a receiving a severe burn. The patient urinary output is 20 mL/hr. As the nurse your next nursing action is to:

Notify the HCP r/t The patient's urinary output is too low and needs more fluids.

A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take?

Notify the health care provider. The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy.

a deep partial thickness burn involves what part of the skin

epidermis & dermis

a superficial partial thickness burn involves which part of the skin

epidermis layer

a full thickness burn involves what skin

epidermis, dermis, fat, muscle and bone

Appearance of 1st degree superficial partial thickness burn

erythema, blanching on pressure, pain and mild swelling, no vesicles or blisters. after 24 hrs blisters could appear

true or false; A patient who experiences an alkali chemical burn is easier to treat because the skin will neutralize the chemical rather an with an acidic chemical burn

false; alkali burns are harder to treat than acidic chemical burns d/t the skin will neutralize acidic burns

possible causes of 2nd degree partial thickness burns

flame, flash, scald, contact burns, chemicals, tar, cement, electrical current

the response of the immune system to a burn injury includes

impaired WBC function d/t widespread impairment of the immune system, impaired immuglobulins, and bone marrow depression

the initial cause of hypovolemia during the emergent phase of burn injury is d/t?

increased capillary permeability

A patient arrives to the ER due to experiencing burns while in an enclosed warehouse. Which assessment findings below demonstrate the patient may have experienced an inhalation injury?

- Carbonaceous sputum - Hair singeing on the head and nose - Bright red lips - Hoarse voice

colloid solutions are given when post burn

24 hours

nontracheal or endotracheal intubation is instituted in burn patients who have what?

patients with major injuries involving burns to the face and neck require intubation within 1-2 hours after burn injury to prevent tracheostomy r/t symptoms of upper airway obstruction

which type of burn is most associated with carbon monoxide poisoning?

smoke and inhalation

prophylactic treatment circumferential burn

escharotomy

A patient who is being treated for partial thickness burns on 60% of the body is now in the acute phase of burn management. The nurse assesses the patient for a possible Curling's Ulcer. What signs and symptoms can present with this condition?

- Burning, gnawing sensation pain in the stomach and vomiting - This is a type of ulcer that occurs in the stomach, duodenum, due to a high amount of stress on the body from a burn. The blood supply to the factors that help protect the stomach lining from gastric erosion decreases and this allows for ulcers to form.

An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will administer during the first 8 hours?

600 mL; The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours and then the last half is given over 16 hours: 4 ´ 80 ´ 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.

A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned?

63% Anterior head and neck (4.5%), front and back of the left arm (9%), front of the right arm (4.5%), posterior trunk (18%), front and back of the right leg (18%), back of the left leg (9%) which equals 63%.

What is the break down for Rule of Nines Burn Chart?

Anterior: Head/ Neck 4.5% R. Arm/ Hand 4.5% L. Arm/Hand 4.5% Trunk 18% Genitalia 1% R. Leg/ Foot 9% L. Leg/Foot 9% Posterior: Head/ Neck 4.5% R. Arm/ Hand 4.5% L. Arm/Hand 4.5% Trunk 18% Genitalia 1% R. Leg/ Foot 9% L. Leg/Foot 9%

Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest?

Apply water-based cream to burned areas frequently. Application of water-based emollients will moisturize new skin and decrease flakiness and itching.

A patient has experienced full-thickness burns to the face and neck. As the nurse it is priority to:

Assess the airway Due to the location of the burns (face and neck), the patient is at major risk for respiratory issues due to damage to the upper airways and the risk of an inhalation injury.

A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first?

Auscultate the patient's lung sounds; A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.

Place priority interventions in any burn in order. a. assess for other injuries b. establish and maintain an airway c. remove the patient from the burn source and stop the burning process d. establish an IV line with a large gauge needle

C, B, D, A

The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function?

Continue to monitor the urine output. The patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients.

A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action?

Insert a feeding tube and initiate enteral feedings.

In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Administer IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze.

D, E, C, A, B Because partial-thickness burns are very painful, the nurse's first action should be to administer pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound.

Describe the Emergent Burn Phase and the approximate timeframe

Involved fluid loss and formation of edema 24-24Hr up to 5 days

A patient has full-thickness burns on the front and back of both arm and hands. It is nursing priority to:

Elevate and extend the extremities; This position will decrease edema, which will help prevent compartment syndrome.

A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position?

Elevate the right arm and hand on pillows and extend the fingers. The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow because the head should be maintained in an extended position in order to avoid contractures.

what is a circumferential burn

Goes all the way around and can cut off circulation

Parkland fluid replacement formula; the first 8 hours you administer how much fluid?

Half of the fluid

During the acute phase of burn management, what is the best diet for a patient who has experienced severe burns?

High calorie, high protein and carbohydrate

The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which medication is best for the nurse to administer before scheduled wound debridement?

Hydromorphone (Dilaudid). Opioid pain medications are the best choice for pain control.

Your patient with severe burns is due to have a dressing change. You will pre-medicate the patient prior to the dressing change. The patient has standing orders for IM morphine, PO morphine, IV morphine, SubQ morphine. which medication is best for this patient?

IV morphine as this is a predictable and easily absorbed medication via IV route in burn victims

After receiving report on a patient receiving treatment for severe burns, you perform your head-to-toe assessment. On arrival to the patient's room you note the room temperature to be 75'F. You will:

Increase the temperature to a minimum of 85'F. Patients with severe burns can NOT regulate their temperature and are at risk for hypothermia. The room temperature should be a minimum of 85'F.

Select the patient below who is at MOST risk for complications following a burn: A. A 42 year old male with partial-thickness burns on the front of the right and left arms and legs. B. A 25 year old female with partial-thickness burns on the front of the head and neck and front and back of the torso. C. A 36 year old male with full-thickness burns on the front of the left arm. D. A 10 year old with superficial burns on the right leg.

The patient in option B has 40.5% TSBA burned. Remember that the higher the total of the body surface area that is burned the higher the risk of complications due to an increase in capillary permeability (swelling, hypovolemic shock etc.). In addition, the location of the burn is a major issue with the patient in option B. The burns are on the head and neck and front and back of the torso. Therefore, with head and neck burns always think about respiratory issues because the airway can become compromised due to swelling or an inhalation injury.

when assessing priority patients remember ABC's. a patient with face and neck burns are more associated with what?

airway inhalation and requires airway assessment

what is a priority for a nurse that has received shift change report on a group of patients. Place the patients in priority order. a. a 40 year old female returning from the PACU following surgical debridement of her back and legs. b. a 76 year old male with partial thickness burns of his arms and abdomen who is complaining of severe pain. c. a 62 year old female just admitted following partial thickness burns to her anterior chest, face, and neck d. a 18 year old make with full thickness burns of his lower extremities who is refusing to go for his scheduled dressing change.

c, b, a, d

a patients deep partial thickness burns are treated with the open method. when caring for the patient, the nurse would wear what?

cap, mask, gown, and gloves during patient contact

You're providing education to a group of local firefighters about carbon monoxide poisoning. How would you describe carbon monoxide poisonings pathophysiology?

carbon monoxide binds to the hemoglobin of the red blood cell leading to a decrease in the ability of the hemoglobin to carry oxygen to the body

which type of burn is most associated with risk for tissue adherence with protein hydrolysis?

chemical burn

appearance of 3rd degree full thickness burns

dry waxy white leathery or hard skin. visible thrombose vessels. insensitivity to pain d/t nerve damage. possible involvement of muscle, tendons, and bones

An employee spills industrial acids on both arms and legs at work. What is the priority action that the occupational health nurse at the facility should take?

the initial action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if face was exposed). Flush chemical from wound and surrounding area with copious amounts of saline solution or water.

which type of burn is most associated with risk for hot cooking oil?

thermal burn

how would a nurse position a patient with ear, neck and face burns?

without pillows as patients ear burns are in danger of the ear sticking to the pillowcase and patients with neck burns are at risk of developing contractures

during the healing of a burn what is helpful to prevent contractures

lotions and splinting

Describe the Acute Burn Phase and the approximate timeframe

mobilization of fluid and diuresis weeks to months

what must a patient avoid for 1 year post burn to prevent hyperpigmentation in healed areas

sun and sunburns

possible causes of 1st degree superficial partial thickness burns

superficial sunburn, quick heat flash

What are some patient priorities during the emergent phase of burn management?

- Fluid volume - Respiratory status

A patient arrives to the ER with full-thickness burns on the front and back of the torso and neck. The patient has no spinal injuries but is disoriented and coughing up black sooty sputum. Vital signs are: oxygen saturation 63%, heart rate 145, blood pressure 80/56, and respiratory rate 39. As the nurse you will:

- Place patient in high fowlers position - prep for escharotomy - prep the patient for intubation - obtain IV access at two sites

what is one major complication of burns believed to be related to stress that may occur in the acute phase in the GI system

curling's ulcer

one clinical manifestation the nurse would expect to find during the emergent phase in a patient with a full thickness burn over the lower half of the body is?

shivering often occurs in a patient with a burn as a result of chilling that is caused by heat loss, anxiety, or pain. severe pain is not common in full thickness burns.

what is one major complication of burns believed to be related to stress that may occur in the acute phase in the neurological system

confusion & delirium

what type of skin graft would a patient that would require a permanent skin graft that may be available for the patient with a large body surface area burn who has limited skin for donor harvesting?

cultures epithelial autograft

which type of burn is most associated with risk for dysrhythmias or arrest?

electrical burns

what is the iceberg effect

electrical burns can burn from the inside out causing a miscalculation of the extent of the burn since a small visible area actually covers the large amount of burn inside the body.

as the nurse provides care to a patient who experienced a full thickness electrical burn you know to monitor for what in the patients urine

hemoglobin and myoglobin

what is one major complication of burns believed to be related to stress that may occur in the acute phase in the endocrine system

hyperglycemia

Why would a burn patients labs in the emergent phase show increased hematocrit, decreased sodium, and increased potassium levels?

increased capillary permeability, water, sodium, plasma proteins leave the plasma and move into the interstitial cellular space. Decreasing the sodium and albumin. Potassium is elevated d/t injured cells and hemolyzed RBS's released potassium from the cells. Elevated Hct d/t water loss into intersitial sace creating hemoconcentration

the nurse would assess absent bowel sounds and abd distention in a patient 12 hr postburn. the nurse notifies the doctor and anticipates what order?

insert an NG tube for decompression on low intermittent suction as patients with large burns often develop paralytic ileus w/in a few hours

a patient is admitted to the ED at 10:15pm following a flame burn at 9:30pm. the patient has 40% total body surface area deep partial thickness and full thickness burns. The patient weights 132 lbs. According to the parkland formula, the type of fluid prescribed for the patient would be what?

lactated ringers

the priority intervention in the emergency management of any burn type is to?

remove the source and stop the burning process.

You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as:

2nd degree partial thickness burn

the nurse suspects the possibility of early sepsis in a burn patient based on what changes?

- elevated temperature - increased HR, RR - decreased BP

the nurse suspects the possibility of late sepsis in a burn patient based on what changes?

- elevated temperature - increased HR, RR - decreased BP - decreased urinary output - paralytic ileus

early excising and grafting of burn wounds involves excising ___________down to clean viable tissue and applying ____________?

- eschar/ necrotic tissue - split thickness graft

identify three factors that increase nutritional needs during the emergent and acute phase of burn injury patients?

- hypermetabolic state d.t an increase in plasma catecholamines and substrate mobilization - mass catabolism d.t protein breakdown and increased gluconeogenesis - calories and protein used for tissue repair

Why does the patient in the emergent phase experience hyponatremia, hyperkalemia, hyperglycemia, and high hematocrit levels?

- increase in the capillary permeability with severe burns, which causes the plasma to leave the intravascular system and enter the interstitial tissue: - Low sodium: sodium leaves with the plasma to the interstitial tissue and drops the levels in the blood - High potassium: damaged cells lysis and leak potassium which increases the leave in the blood - high glucose: stress response leads the liver to release glycogen and this increases levels - low hematocrit: when the plasma leaves the intravascular system (the fluid) it causes the blood to become more concentrated so hematocrit increases

during the early emergent phase of burn injury, the patients labs results would most likely include?

- increased Hct - decreased Na - increased K

which type of burn is most associated with explosive flare?

- termal burn - smoke and inhalation burn

What are some patient priorities during the acute phase of burn management?

- wound closure - nutrition

Blebs can be removed from skin grafts by __________

aspirating the fluid with a TB syringe by ind instructed with the skill

what layer of the skin helps regulate the body temperature

hypodermis AKA

The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient's total body surface area (TBSA) has been injured?

27% When using the rule of nines, the anterior trunk is considered to cover 18% of the patient's body and each arm is 9%.

a 65 year old male Pt has experienced full thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for what medical complications?

- acute kidney injury - dysrhythmias - bone fractures - iceberg effect

You are about to provide care to a patient with severe burns. You will don what PPE

- gloves - gown - surgical mask - shoe coverings - hair cover

During the emergent phase of burn management, you would expect the following lab values:

- hyponatremia - hyperkalemia - hyperglycemia - high hematocrit

colloid solution formula for post 24 hr fluid resuscitation post burn

0.3-0.5mL/kg/TBSA

A patient is presenting with bright red lips, headache, and nausea. The physician suspects carbon monoxide poisoning. As the nurse, you know the patient needs:

100% oxygen via non-rebreather mask

A patient who weights 132 lbs with 50%TBSA partial thickness burn would need how much colloid solution would be administered after his 1st 24 hours on fluid resuscitation?

132/2.2 = 60kg 60 * 50 * 0.3-0.5ml = 900 - 1500 mL

A patient has a burn on the back of the torso that is extremely red and painful but no blisters are present. When you pressed on the skin it blanches. You document this as a:

1st degree (superficial) burn

a patient is admitted to the ED at 10:15pm following a flame burn at 9:30pm. the patient has 40% total body surface area deep partial thickness and full thickness burns. The patient weights 132 lbs. According to the parkland formula, the amount of fluid to be administered during the last 16 hours of a 24 hr post burn phase would be how many mL?

2400 ml 2nd 8 hr post burn then 2400 ml 3rd 8 hr post burn = 4800 ml

a PT has the following mixed deep partial thickness and full thickness burn injuries; face, anterior neck, right anterior trunk, and anterior surface of the right arm and lower leg. According to Lund- Browder chart what is the extent of the PTs burns?

3.5% + 1% + 7.5% + 2% + 3.5% = 17.5%

a PT has the following mixed deep partial thickness and full thickness burn injuries; face, anterior neck, right anterior trunk, and anterior surface of the right arm and lower leg. According to Rule of Nines chart what is the extent of the PTs burns?

4.5% + 9% + 4.5% = 18%

a patient is admitted to the ED at 10:15pm following a flame burn at 9:30pm. the patient has 40% total body surface area deep partial thickness and full thickness burns. The patient weights 132 lbs. According to the parkland formula, the amount of fluid to be administered during the 1st 8 hr phase would be how many mL?

4800 ml

Anterior head and neck (4.5%), front and back of the left arm (9%), front of the right arm (4.5%), posterior trunk (18%), front and back of the right leg (18%), back of the left leg (9%) which equals 63%.

921 mL/hr....First calculate the total amount of fluid needed with the formula: Total Amount of LR = 4 mL x BSA % x pt's weight in kg. The pt's weight 63 kg. BSA percentage: 58.5%...Front and back of right and left leg (36%), front of right arm (4.5%), anterior trunk (18%) which equals 58.5%. ......4 x 58.5 x 63 = 14,742 mL......Remember during the FIRST 8 hours 1/2 of the solution is infused, which will be 14,742 divided by 2 = 7371 mL......Hourly Rate: 7371 divide by 8 equals 921 mL/hr

A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?

938 mL/hour

A patient experienced a full-thickness burn 72 hours ago. The patient's vital signs are within normal limits and urinary output is 50 mL/hr. This is known as what phase of burn management?

Acute phase starts when capillary permeability has returned to normal and the patient's vitals are within normal limits and ends with wound closure. The phase after this is rehabilitative.

What is the break down of Lund Browder Burn Chart?

Anterior: head 3.5%, neck 1% R. Upper Arm 2% L. Upper Arm 2% R. Forearm 1.5% L Forearm 1.5% R. Hand 1.5% L Hand 1.5% Trunk 13% Genitalia 1% R. Upper Leg 4.75% L. Upper Leg 4.75% R. Lower Leg 3.5% L. Lower Leg 3.5% R. Foot 1.75% L. Foot 1.75% Posterior: head 3.5%, neck 1% R. Upper Arm 2% L. Upper Arm 2% R. Forearm 1.5% L Forearm 1.5% R. Hand 1.5% L Hand 1.5% Trunk 13% R. Buttock 2.5% L. Buttock 2.5% R. Upper Leg 4.75% L. Upper Leg 4.75% R. Lower Leg 3.5% L. Lower Leg 3.5% R. Foot 1.75% L. Foot 1.75%

A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient indicates that the problem is resolving?

Do you think dark beige makeup foundation would cover this scar on my cheek?" The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving.

A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment?

Extremity movement; All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data.

On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL, serum K+ 4.9 mEq/L, and serum Na+ 135 mEq/L. Which action will the nurse anticipate taking now?

Increase the rate of the ordered IV solution. The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours; likely every1 hour.

A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first?

Place on cardiac monitor; After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor.

to help burn patients who develop an increased dread of painful dressing changes, it would be most appropriate to ask the doctor to prescribe what?

Midazolam (Versed) in concurrent use with Morphine due to the fact that Midazolam has a short term memory loss and the patient will not recall the event

A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?

Notify the health care provider and prepare for endotracheal intubation. The patient's history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.

A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first?

Place the patient on 100% oxygen using a non-rebreather mask. The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%.

A patient is in the acute phase of burn management. The patient experienced full-thickness burns to the perineum and sacral area of the body. In the patient's plan of care, which nursing diagnosis is priority at this time?

Risk for infection d/t during this stage diuresis occurs and INFECTION.

he nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse?

Serum potassium 6.1 mEq/L; Hyperkalemia can lead to fatal dysrhythmias and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level.

You're assisting the nursing assistant with repositioning a patient with full-thickness burns on the neck. Which action by the nursing assistant requires you to intervene?

The nursing assistant places a pillow under the patient's head. If a patient has severe burns to the neck (head as well) a pillow should NOT be used under the head because this can cause wound contractions. Instead rolled towels should be placed under the shoulders.

A patient has an emergency escharotomy performed on the right leg. The patient has full-thickness circumferential burns on the leg. Which finding demonstrates the procedure was successful?

The right foot's capillary refill is less than 2 seconds. Escharotomy is performed when a full-thickness burn, due to eschar (which is burned tissue that is hard), is compromising blood flow to the distal extremity. The eschar is cut and this relieves pressure and allows blood to flow to the extremity.

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider?

Urine output is 20 mL per hour for the past 2 hours; The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase.

A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient?

Vanilla milkshake, A patient with a burn injury needs high protein and calorie food intake

While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination?

Wear gowns, caps, masks, and gloves during all care of the patient.

Describe the Rehabilitation Burn Phase and the approximate timeframe

burn area covered and wounds headed weeks to months

The nurse notes a patient has full-thickness circumferential burns on the right leg. The nurse would do what?

elevate the extremity ABOVE heart level to decrease swelling and assess distal pulses in the extremity to confirm circulation is present. A patient that has burns that completely surround an extremity is at risk for compartment syndrome where the edema from the burn compromises circulation to the distal extremity.

possible causes of 3rd degree full thickness burns

flame, scald, chemicals, tar, cement, electrical current

appearance of 2nd degree partial thickness burn

fluid filled vesicles that are red, shiny, wet. severe pain cause by nerve damage. mild to moderate edema

When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth?

full thickness skin destruction

when assessing a PT full thickness burn injury during the emergent phase, the nurse would expect to find what skin condition?

leathery dry hard skin that may turn brown and dry in the acute phase.

at the end of a patients emergent phase and initial acute phase the nurse notes a patients labs: 152 Na, 2.8K. The nurse recognizes this electrolyte imbalance is a result of?

mobilization of fluid at the end of the emergent phase moves potassium back into the cells and sodium returns to the vascular space causing hypokalemia and hypernatremia. As the acute phase begins the patients will begin diuresis in large quantity which will cause loss of sodium. potassium will need to be replaced

with full thickness skin destruction the appearance is what?

pale and dry or leathery and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn.

a patient has a 20% total body surface area deep partial thickness and full thickness burn to the right anterior chest and entire right arm. it is most important that the nurse assess the patient for what?

presence of pulses. circumferential burns, circulation t the extremities can be severely impaired and pulses should be monitors closely for signs of obstruction by edema.

which type of burn is most associated with risk for facial burns and hoarsness?

smoke and inhalation