BURNS (PART 4)

The nurse is assessing an 80-year-old client who has scald burns on the hands and both forearms (first- and second-degree burns on 10% of the body surface area). What should the nurse do first? 1. Clean the wounds with warm water. 2. Apply antibiotic cream. 3. Refer the client to a burn center. 4. Cover the burns with a sterile dressing.

3. The nurse should have the client transported to a burn center. The client's age and the extent of the burns require care by a burn team, and the client meets triage criteria for referral to a burn center. Because of the age of the client and the extent of the burns, the nurse should not treat the burn. Scald burns are not at high risk for infection and do not need to be cleaned, covered, or treated with antibiotic cream at this time.

The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider? 1. The client is complaining of severe pain. 2. The client's pulse oximeter reading is 95%. 3. The client has T 100.4˚F, P 100, R 24, and BP 102/60. 4. The client's urinary output is 50 mL in two (2) hours.

4. Fluid and electrolyte balance is the priority for a client with a severe burn. Fluid resuscitation must be maintained to keep a urine output of 30 mL/hr. Therefore, a 25-mL/hr output would warrant immediate intervention.

During the early phase of burn care, the nurse should assess the client for: 1. hypernatremia. 2. hyponatremia. 3. metabolic alkalosis. 4. hyperkalemia.

4. Immediately after a burn, excessive potassium from cell destruction is released into the extracellular fluid. Hyponatremia is a common electrolyte imbalance in the burn client that occurs within the first week after being burned. Metabolic acidosis usually occurs as a result of the loss of sodium bicarbonate

Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply. 1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 4. Change invasive lines once a week. 5. Administer antibiotics as prescribed.

ANS : 1,2,3,5 1. Hand washing is the number-one intervention used to prevent infection, which is priority for the client with a burn. 2. Aseptic techniques minimize risk of crosscontamination and spread of bacteria. 3. Aseptic techniques minimize risk of crosscontamination and spread of bacteria. 4. Invasive lines and tubing should be changed daily. 5. Antibiotics reduce bacteria

The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement? 1. Encourage the client's family to bring favorite foods. 2. Provide a low-fat, low-cholesterol diet for the client. 3. Monitor the client's weight weekly in the same clothes. 4. Make a referral to the hospital social worker.

. 1. The client needs sufficient nutrients for wound healing and increased metabolic requirements, and homemade nutritious foods are usually better than hospital food. This also allows the family to feel part of the client's recovery

The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client? 1. Replace fluids and electrolytes. 2. Prevent contractures of extremities. 3. Monitor urine output hourly. 4. Prepare to assist with an escharotomy

1. After airway, the most urgent need is preventing irreversible shock by replacing fluids and electrolytes.

During the emergent (resuscitative) phase of burn injury, which finding indicates that the client requires additional volume with fluid resuscitation? 1. serum creatinine level of 2.5 mg/dL(221 μmol/L) 2. little fluctuation in daily weight 3. hourly urine output of 60 mL 4. serum albumin level of 3.8 mg/dL(38 g/L)

1. Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine. Urine output should be frequently monitored and adequately maintained with intravenous fluid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/h. Fluid replacement is based on the Parkland or Brooke formula and also the client's response by monitoring urine output, vital signs, and CVP readings. Daily weight is important to monitor for fluid status. Little fluctuation in weight suggests that there is no fluid retention and the intake is equal to output. Exudative loss of albumin occurs in burns, causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5 g/dL(35 to 50 g/L)

Which client with burns will most likely require an endotracheal or tracheostomy tube? A client who has: 1. electrical burns of the hands and arms causing arrhythmias. 2. thermal burns to the head, face, and airway resulting in hypoxia. 3. chemical burns on the chest and abdomen. 4. secondhand smoke inhalation.

2. Airway management is the priority in caring for a burn client. Tracheostomy or endotracheal intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who have experienced burns to the face and neck usually will be compromised within 1 to 2 hours. Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of the chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation does influence an individual's respiratory status but does not require intubation unless the individual has an allergic reaction to the smoke.

The client sustained a hot grease burn to the right hand and calls the emergency room for advice. Which information should the nurse provide to the client? 1. Apply an ice pack to the right hand. 2. Place the hand in cool water. 3. Be sure to rupture any blister formation. 4. Go immediately to the doctor's office.

2. Cool water gives immediate and striking relief from pain and limits local tissue edema and damage

The client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? 1. Superficial partial thickness. 2. Deep partial thickness. 3. Full thickness. 4. First degree.

2. Deep partial-thickness burns are scalds and flash burns that injure the epidermis, upper dermis, and portions of the deeper dermis. This causes pain, blistered and mottled red skin, and edema

The rate at which IV fluids are infused is based on the burn client's: 1. lean muscle mass and body surface area (BSA) burned. 2. total body weight and BSA burned. 3. total BSA and BSA burned. 4. height and weight and BSA burned.

2. During the first 24 hours, fluid replacement for an adult burn client is based on total body weight and BSA burned. Lean muscle mass considers only muscle mass; replacement is based on total body weight. Total surface area is estimated by taking into account the individual's height and weight. Height is not a common variable used in formulas for fluid replacement.

The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower extremity burn. Which assessment data would require immediate attention by the nurse? 1. The client complains of pain when the medication is administered. 2. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L. 3. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20. 4. The client is able to perform active range-of-motion exercises.

3 Sulfamylon is a strong carbonic anhydrase inhibitor that may reduce renal buffering and can cause metabolic acidosis. These ABGs indicate metabolic acidosis and therefore require immediate intervention.

The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to: 1. correct water and electrolyte imbalances. 2. allow the gastrointestinal tract to rest. 3. provide supplemental vitamins and minerals. 4. ensure adequate caloric and protein intake.

4. Nutritional support with sufficient calories and protein is extremely important for a client with severe burns because of the loss of plasma protein through injured capillaries and an increased metabolic rate. Gastric dilation and paralytic ileus commonly occur in clients with severe burns, making oral fluids and foods contraindicated. Water and electrolyte imbalances can be corrected by administration of IV fluids with electrolyte additives, although TPN typically includes all necessary electrolytes. Resting the gastrointestinal tract may help prevent paralytic ileus, and TPN provides vitamins and minerals; however, the primary reason for starting TPN is to provide the protein necessary for tissue healing.

The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer? 1. A 22-gauge intravenous line with normal saline infusing. 2. Wounds covered with moist sterile dressings. 3. No intravenous pain medication. 4. Adequate peripheral circulation to both feet ensured.

4. The client's legs should have pedal pulses and be warm to the touch, and the client must be able to move the toes

The nurse should plan to begin rehabilitation efforts for the burn client: 1. immediately after the burn has occurred. 2. after the client's circulatory status has been stabilized. 3. after grafting of the burn wounds has occurred. 4. after the client's pain has been eliminated.

2. Rehabilitation efforts are implemented as soon as the client's condition is stabilized. Early emphasis on rehabilitation is important to decrease complications and to help ensure that the client will be able to make the adjustments necessary to return to an optimal state of health and independence. It is not possible to completely eliminate the client's pain; pain control is a major challenge in burn care.

In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain? 1. oral analgesics such as ibuprofen or acetaminophen 2. intravenous opioids 3. intramuscular opioids 4. oral antianxiety agents such as lorazepam

2. The severe pain experienced by burn clients requires opioid analgesics. In addition, opioids such as morphine sedate and alleviate apprehension. Oral analgesics such as ibuprofen or acetaminophen are unlikely to be strong enough to effectively manage the intense pain experienced by the client who is severely burned. Because of the altered tissue perfusion from the burn injury, intravenous medications are preferred. Antianxiety agents are not effective against pain

A client is admitted to the hospital after sustaining burns to the chest, abdomen, right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client's body. Using the "rule of nines," estimate what percentage of the client's body surface has been burned. 1. 18% 2. 27% 3. 45% 4. 64%

3. According to the rule of nines, this client has sustained burns on about 45% of the body surface. The right arm is calculated as being 9%, the right leg is 18%, and the anterior trunk is 18%, for a total of 45%.

The nurse is caring for a client with severe burns who is receiving fluid resuscitation. Which finding indicates that the client is responding to the fluid resuscitation? 1. pulse rate of 112 bpm 2. blood pressure of 94/64 mm Hg 3. urine output of 30 mL/h 4. serum sodium level of 136 mEq/L(136 mmol/L)

3. Ensuring a urine output of 30 to 50 mL/h is the best measure of adequate fluid resuscitation. The heart rate is elevated, but is not an indicator of adequate fluid balance. The blood pressure is low, likely related to the hypervolemia, but urinary output is the more accurate indicator of fluid balance and kidney function. The sodium level is within normal limits

At about one-half hour before the daily whirlpool bath and dressing change, the nurse should: 1. soak the dressing. 2. remove the dressing. 3. administer an analgesic. 4. slit the dressing with blunt scissors.

3. Removing dressings from severe burns exposes sensitive nerve endings to the air, which is painful. The client should be given a prescribed analgesic about one-half hour before the dressing change to promote comfort. The other activities are done as part of the whirlpool and dressing change process and not one-half hour beforehand.

A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 97.1°F (36.2°C), heart rate 122 bpm, blood pressure 84/42 mm Hg, central venous pressure (CVP) 2 mm Hg, and urine output 25 mLfor the last 2 hours. The IV rate is currently at 375 mL/h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the healthcare provider (HCP) with a recommendation for: 1. furosemide. 2. fresh frozen plasma. 3. IV rate increase. 4. dextrose 5%.

3. The decreased urine output, low blood pressure, low CVP, and high heart rate indicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding. Fluid replacement used for burns is lactated Ringer's solution, normal saline, or albumin.

After the initial phase of the burn injury, the client's plan of care will focus primarily on: 1. helping the client maintain a positive self-concept. 2. promoting hygiene. 3. preventing infection. 4. educating the client regarding care of the skin grafts.

3. The inflammatory response begins when a burn is sustained. As a result of the burn, the immune system becomes impaired. There are a decrease in immunoglobulins, changes in white blood cells, alterations of lymphocytes, and decreased levels of interleukin. The human body's protective barrier, the skin, has been damaged. As a result, the burn client becomes vulnerable to infections. Education and interventions to maintain a positive self-concept would be appropriate during the rehabilitation phase. Promoting hygiene helps the client feel comfortable; however, the primary focus is on reducing the risk for infection