Chapter 26: Care of Patients with Burns

An emergency room nurse implements fluid replacement for a client with severe burn injuries. The provider prescribes a liter of 0.9% normal saline to infuse over 1 hour and 30 minutes via gravity tubing with a drip factor of 30 drops/mL. At what rate should the nurse administer the infusion? (Record your answer using a whole number and rounding to the nearest drop.) ____ drops/min

333 drops/min 1000 mL divided by 90 minutes, then multiplied by 30 drops, equals 333 drops/min.

An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first? a.Apply oxygen and continuous pulse oximetry. b.Provide small quantities of ice chips and sips of water. c.Request a prescription for an antitussive medication. d.Ask the respiratory therapist to provide humidified air.

ANS: A Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the client's pain? a.Administer the prescribed intravenous morphine sulfate. b.Apply ice to skin around the burn wound for 20 minutes. c.Administer prescribed intramuscular ketorolac (Toradol). d.Decrease tactile stimulation near the burn injuries.

ANS: A Drug therapy for pain management requires opioid and nonopioid analgesics. The IV route is used because of problems with absorption from the muscle and the stomach. For the client to avoid shivering, the room must be kept warm, and ice should not be used. Ice would decrease blood flow to the area. Tactile stimulation can be used for pain management.

The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury? a."It is normal to feel some depression." b."I will go back to work immediately." c."I will not feel anger about my situation." d."Once I get home, things will be normal."

ANS: A During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming.

A nurse administers topical gentamicin sulfate (Garamycin) to a client's burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a.Creatinine b.Red blood cells c.Sodium d.Magnesium

ANS: A Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Topical gentamicin will not affect the red blood cell count or the sodium or magnesium levels.

A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity? a."Keep the water temperature constant when showering the client." b."Assess the wound beds during the hydrotherapy treatment." c."Apply a topical enzyme agent after bathing the client." d."Use sterile saline to irrigate and clean the client's wounds."

ANS: A Hydrotherapy is performed by showering the client on a special shower table. The UAP should keep the water temperature constant. This process allows the nurse to assess the wound beds, but a UAP cannot complete this act. Topical enzyme agents are not part of hydrotherapy. The irrigation does not need to be done with sterile saline.

A nurse cares for a client with burn injuries who is experiencing anxiety and pain. Which nonpharmacologic comfort measures should the nurse implement? (Select all that apply.) a.Music as a distraction b.Tactile stimulation c.Massage to injury sites d.Cold compresses e Increasing client control

ANS: A, B, E Nonpharmacologic comfort measures for clients with burn injuries include music therapy, tactile stimulation, massaging unburned areas, warm compresses, and increasing client control.

A nurse plans care for a client with burn injuries. Which interventions should the nurse implement to prevent infection in the client? (Select all that apply.) a.Ask all family members and visitors to perform hand hygiene before touching the client. b.Carefully monitor burn wounds when providing each dressing change. c.Clean equipment with alcohol between uses with each client on the unit. d.Allow family members to only bring the client plants from the hospital's gift shop. e.Use aseptic technique and wear gloves when performing wound care.

ANS: A, B, E To prevent infection in a client with burn injuries the nurse should ensure everyone performs hand hygiene, monitor wounds for signs of infection, and use aseptic technique, including wearing gloves when performing wound care. The client should have disposable equipment that is not shared with another client, and plants should not be allowed in the client's room.

A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? a.Increase the client's oxygen and obtain blood gases. b.Draw blood for a carboxyhemoglobin level. c.Increase the client's intravenous fluid rate. d.Perform a thorough Mini-Mental State Examination.

ANS: B These manifestations are consistent with moderated carbon monoxide poisoning. This client is at risk for carbon monoxide poisoning because he or she was in a fire in an enclosed space. The other options will not provide information related to carbon monoxide poisoning.

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first? a.Assess the level of consciousness and pupillary reactions. b.Ascertain the time food or liquid was last consumed. c.Auscultate breath sounds over the trachea and bronchi. d.Measure abdominal girth and auscultate bowel sounds

ANS: C Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.

A nurse cares for a client who has facial burns. The client asks, "Will I ever look the same?" How should the nurse respond? a."With reconstructive surgery, you can look the same." b."We can remove the scars with the use of a pressure dressing." c."You will not look exactly the same but cosmetic surgery will help." d."You shouldn't start worrying about your appearance right now."

ANS: C Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The nurse should provide accurate information that includes something to hope for. Pressure dressings prevent further scarring; they cannot remove scars. The client and the family should be taught the expected cosmetic outcomes.

After assessing an older adult client with a burn wound, the nurse documents the findings as follows: Heart rate: 110 beats/min Blood pressure: 112/68 mm Hg Respiratory rate: 20 breaths/min Oxygen saturation: 94% Pain: 3/10 Red blood cell count: 5,000,000/mm3 White blood cell count: 10,000/mm3 Platelet count: 200,000/mm3 Left chest burn wound, 3 cm ´ 2.5 cm ´ 0.5 cm, wound bed pale, surrounding tissues with edema present Based on the documented data, which action should the nurse take next? a.Assess the client's skin for signs of adequate perfusion. b.Calculate intake and output ratio for the last 24 hours. c.Prepare to obtain blood and wound cultures. d.Place the client in an isolation room.

ANS: C Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection, such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The burn wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis. Placing the client in an isolation room, calculating intake and output, and assessing the client's skin should all be implemented but these actions do not take priority over determining whether the client has an infection.

A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this client's discharge teaching? a."You should change the batteries in your smoke detector once a year." b."Join a program that assists burn clients to reintegration into the community." c."I will demonstrate how to change your wound dressing for you and your family." d."Let me tell you about the many options available to you for reconstructive surgery."

ANS: C Teaching clients and family members to perform care tasks such as dressing changes is critical for the progressive goal toward independence for the client. All of the other options are important in the rehabilitation stage. However, dressing changes have priority.

A nurse reviews the following data in the chart of a client with burn injuries: 36-year-old female with bilateral leg burns NKDA Health history of asthma and seasonal allergies Bilateral leg burns present with a white and leather-like appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0-10. Based on the data provided, how should the nurse categorize this client's injuries? a.Partial-thickness deep b.Partial-thickness superficial c.Full thickness d.Superficial

ANS: C The characteristics of the client's wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness deep burns are deep red to white and painful. Superficial burns are pink to red and are also painful.

A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately? a.Arterial pH: 7.32 b.Hematocrit: 52% c.Serum potassium: 6.5 mEq/L d.Serum sodium: 131 mEq/L

ANS: C The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury.

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next? a.Administer furosemide (Lasix). b.Perform chest physiotherapy. c.Document and reassess in an hour. d.Place the client in an upright position.

ANS: D Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Although Lasix may be used to treat pulmonary edema in clients who are fluid overloaded, a client with a burn injury will lose a significant amount of fluid through the broken skin; therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid.

An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) _____ mL/hr

1500 mL/hr The Parkland formula is 4 mL/kg/% total body surface area burn. This client needs 18,000 mL of fluid during the first 24 hours postburn. Half of the calculated fluid replacement needs to be administered during the first 8 hours after injury, and half during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 postburn hours.

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a.Administer analgesics. b.Prevent wound infections. c.Provide fluid replacement. d.Decrease core temperature. e.Initiate physical therapy.

ANS: A, B, C Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support. Physical therapy is inappropriate during the resuscitation phase but may be initiated after the client has been stabilized.

A nurse cares for an older client with burn injuries. Which age-related changes are paired appropriately with their complications from the burn injuries? (Select all that apply.) a.Slower healing time - Increased risk for loss of function from contracture formation b.Reduced inflammatory response - Deep partial-thickness wound with minimal exposure c.Reduced thoracic compliance - Increased risk for atelectasis d.High incidence of cardiac impairments - Increased risk for acute kidney injury e.Thinner skin - May not exhibit a fever when infection is present

ANS: A, C, D Slower healing time will place the older adult client at risk for loss of function from contracture formation due to the length of time needed for the client to heal. A pre-existing cardiac impairment increases risk for acute kidney injury from decreased renal blood flow, and reduced thoracic compliance places the client at risk for atelectasis. Reduced inflammatory response places the client at risk for infection without a normal response, including fever. Clients with thinned skin are at greater risk for deeper wounds from minimal exposure.

A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this client's plan of care to ensure adequate nutrition? (Select all that apply.) a.Provide at least 5000 kcal/day. b.Start an oral diet on the first day. c.Administer a diet high in protein. d.Collaborate with a registered dietitian. e.Offer frequent high-calorie snacks.

ANS: A, C, D, E A client with a burn injury needs a high-calorie diet, including at least 5000 kcal/day and frequent high-calorie snacks. The nurse should collaborate with a registered dietitian to ensure the client receives a high-calorie and high-protein diet required for wound healing. Oral diet therapy should be delayed until GI motility resumes.

A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? a.Partial pressure of arterial oxygen (PaO2) of 80 mm Hg b.Urine output of 20 mL/hr c.Productive cough with white pulmonary secretions d.Core temperature of 100.6° F (38° C)

ANS: B A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If fluid replacement is not adequate, the client may become hypotensive and have decreased perfusion of organs, including the brain and kidneys. A low urine output is an indication of poor kidney perfusion. The other manifestations are not complications of burn injuries.

The nurse is caring for a client with an acute burn injury. Which action should the nurse take to prevent infection by autocontamination? a.Use a disposable blood pressure cuff to avoid sharing with other clients. b.Change gloves between wound care on different parts of the client's body. c.Use the closed method of burn wound management for all wound care. d.Advocate for proper and consistent handwashing by all members of the staff.

ANS: B Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between performing wound care on different parts of the client's body can prevent autocontamination.

A nurse receives new prescriptions for a client with severe burn injuries who is receiving fluid resuscitation per the Parkland formula. The client's urine output continues to range from 0.2 to 0.25 mL/kg/hr. Which prescription should the nurse question? a.Increase intravenous fluids by 100 mL/hr. b.Administer furosemide (Lasix) 40 mg IV push. c.Continue to monitor urine output hourly. d.Draw blood for serum electrolytes STAT.

ANS: B The plan of care for a client with a burn includes fluid and electrolyte resuscitation. Furosemide would be inappropriate to administer. Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr. Based on this client's inadequate urine output, fluids need to be increased, urine output needs to be monitored hourly, and electrolytes should be evaluated to ensure appropriate fluids are being infused.

A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the client's body that sustained burns? a.9% b.18% c.27% d.36%

ANS: C According to the rule of nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to the back (18%) and one arm (9%), totaling 27% of the body.

The nurse teaches burn prevention to a community group. Which statement by a member of the group should cause the nurse the greatest concern? a."I get my chimney swept every other year." b."My hot water heater is set at 120 degrees." c."Sometimes I wake up at night and smoke." d."I use a space heater when it gets below zero."

ANS: C House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140° F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding.

A nurse assesses a client who has a burn injury. Which statement indicates the client has a positive perspective of his or her appearance? a."I will allow my spouse to change my dressings." b."I want to have surgical reconstruction." c."I will bathe and dress before breakfast." d."I have secured the pressure dressings as ordered."

ANS: C Indicators that the client with a burn injury has a positive perception of his or her appearance include a willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications but will not enhance self-perception.

A nurse prepares to administer intravenous cimetidine (Tagamet) to a client who has a new burn injury. The client asks, "Why am I taking this medication?" How should the nurse respond? a."Tagamet stimulates intestinal movement so you can eat more." b."It improves fluid retention, which helps prevent hypovolemic shock." c."It helps prevent stomach ulcers, which are common after burns." d."Tagamet protects the kidney from damage caused by dehydration."

ANS: C Ulcerative gastrointestinal disease (Curling's ulcer) may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and a decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine is a histamine2 blocker and inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent hypovolemic shock or kidney damage.

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a.Document the findings and reassess in 1 hour. b.Loosen any constrictive dressings on the chest. c.Raise the head of the bed to a semi-Fowler's position. d.Gather appropriate equipment and prepare for an emergency airway.

ANS: D Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation. The other options do not address this emergency situation.

The registered nurse assigns a client who has an open burn wound to a licensed practical nurse (LPN). Which instruction should the nurse provide to the LPN when assigning this client? a."Administer the prescribed tetanus toxoid vaccine." b."Assess the client's wounds for signs of infection." c."Encourage the client to breathe deeply every hour." d."Wash your hands on entering the client's room."

ANS: D Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission

A nurse cares for a client who has burn injuries. The client's wife asks, "When will his high risk for infection decrease?" How should the nurse respond? a."When the antibiotic therapy is complete." b."As soon as his albumin levels return to normal." c."Once we complete the fluid resuscitation process." d."When all of his burn wounds have closed."

ANS: D Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open. Although the other options are important goals in the client's recovery process, they are not as important as skin closure to decrease the client's risk for infection.