Chapter 51 continued

compliance with treatment and rehab regimen

Helps to prevent tightening of the skin and the development of contractures and scarring

traction

After the placement of the CEA, the patient is often placed in _________, which allows elevation of extremities and pressure relief.

unable to expand as the child grows

Contractures are especially devastating in the pediatric population because burned or grafted skin is?

prophylactic antibiotics

NOT recommended because of the potential of breeding antibiotic-resistant pathogens, and instead treatment is based on positive culture results.

post-traumatic stress disorder (PTSD), body image disorder, anxiety, and/or depression

psychosocial responses to rehabilitation phase of burn care

splinting

the most common method used to help prevent the formation of contractures

6.4 to 8.3; 3.5 to 5.0 fluid remaining in the intravascular space.

Assessment of nutritional status includes monitoring total protein and albumin levels. Normal serum total protein is _________ g/dL, and serum albumin is _______ g/dL. Adequate albumin also supports oncotic pressure that promotes ?

oral pain meds as soon as tolerated

IV narcotics are continued with pain management of burns while severe and unrelenting, however all efforts are made to transition to?

Stevens Johnson Syndrome and Toxic Epidermal Necrolysis

In both disorders, the epidermis separates from the dermal layer and sloughs

duodenal

In large burn injuries, longer nutritional support is required, and placement of a __________ feeding tube is often recommended to help prevent aspiration and allow for feeding up to and during procedures.

30%

Stevens-Johnson syndrome may involve less than ___% TBSA, whereas TEN may involve greater than ___% TBSA.

rehabilitative phase

This stage begins from the time the patient is admitted to the burn center and may last for several years, even extending well beyond discharge.

scheduled

with burns, pain medication is given on a _________ basis instead of on an as-needed (prn) basis, as this helps to better manage the pain over time and hopefully prevents it from becoming intolerable

Avoid pressure or disturbing it!

with grafts, avoid this!!

separates naturally; may take weeks/months (think of scabs)

with wound debridement, Natural devitalized tissue can ??? but may take ??

5-7 d post graft

when can the patient begin exercising the graft site post graft?

it is the growth of only thhe epidermal layer

why are CEAs so delicate ?

surgical wound debridement

performed as soon as possible after the burn; one of the most important factors in surviving a major burn

C. Location of the burn When using the urgent vs. non-urgent approach to client care, the nurse determines the priority is to assess the location of the burns that can lead to respiratory distress. (airway) _____________________ other answers and why they are wrong: Age of the client Answer Rationale: The client's age is important in the assessment of the client's burns, but is not the priority action by the nurse. Associated medical history Answer Rationale: The client's associated medical history is important in the assessment of the client's burns, but is not the priority action by the nurse. Cause of the burn Answer Rationale: The client's cause of the burns is important in the assessment of the client's burns, but is not the priority action by the nurse.

A nurse is assessing the depth and extent of injury on a client who has severe burns. Which of the following is the priority assessment? A. Age of the client B. associated medical history C. Location of the burn D. Cause of the burn

splinting and encouragement of rehabilitation exercises and ADLs

Essential to help prevent development of contractures and maintain joint function

371.4 mL/hr Correct Answer Rationale: The nurse should infuse half of the total volume prescribed for 24 hr for a client who has sustained a burn injury over the first 8 hr. Therefore, the nurse should complete the calculation using half of 5,200 mL, which is 2,600 mL. STEP 1: What is the unit of measurement the nurse should calculate? mL/hr STEP 2: What is the volume the nurse should infuse? 2,600 mL STEP 3: What is the total infusion time? 7 hr STEP 4: Should the nurse convert the units of measurement? No STEP 5: Set up an equation and solve for X. Volume (mL)/Time (hr) = X mL/hr 2,600 mL/7 hr = X mL/hr X = 371.428571 STEP 6: Round if necessary. STEP 7: Reassess to determine if the amount to administer makes sense. If the amount prescribed is 2,600 mL to infuse over 7 hr, it makes sense to administer 371.4 mL/hr.

IV LR for a burn client ordered: 5,200 mL in 1st 24 hr. He was burned 1hr ago. How many mL/hr should the nurse set the pump for the first hr?

pressure garments and specialty face masks

apply continuous and uniform pressure over the area of burn to prevent hypertrophic scarring. These garments are to be worn 23 hours a day for up to a year or more after injury in some patients.

oral mucosa, conjunctiva, vaginal canal, gastrointestinal tract, and urethral lining

areas which slough in SJS and TEN

procedural pain

associated with therapeutic activities such as wound care and physical therapy.

adverse medication reaction, viral infection, or reaction to the staphylococcal toxin.

cause of SJS and TEN

contractures

characterized as permanent tightening of the skin that may involve underlying muscles and tendons and result in limited mobility. The patient's personal motivation and compliance with therapy regimens play important roles

increased 2-3x

caloric needs for a burn patient can be increased as much as ?

allografts and xenografts

grafts that are intended to temporarily cover a wound

isolation guidelines some require contact precautions when entering all patient rooms

guidelines followed by most burn care centers to prevent cross contamination among burn patients

daily weight I&O calories counted

how to ensure that your patient is getting the right amount of calories with burn care

painful

if the donor site is partial thickness, it is typically very ?

PT and OT

important in the rehabilitation phase to begin working with the burn patient immediately, working on ROM, positioning, splinting, ambulation, and ADLs

enteral or PO nutrition; ileus and stress ulcers

in burn patients for nutrition, Early_________ is associated with a reduction in ___________ because it reduces the inflammatory mediators released by the body.

full thickness wound

includes both epidermis and dermis so donor site will not heal spontaneously

D. 54 percent Answer Rationale: Each arm represents 9% of the client's TBSA and each leg represents 18% of the client's TBSA _________________________ other answers and why they are wrong: 9 percent Answer Rationale: The rule of nines allows for an estimation of the extent of the body that has been burned by dividing anatomical regions into multiples of nines. Each arm represents 9% of the client's TBSA. 18 percent Answer Rationale: Each leg (anterior and posterior) represents 18% of the client's TBSA. 36 percent Answer Rationale: Both legs represent 36% of the client's TBSA.

A client has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which % of TBSA? A. 9 percent B. 18 percent C. 36 percent D. 54 percent

THE ANSWER IS : D, Administer IV fluids. Answer Rationale: Using the airway, breathing, circulation framework, the priority action the nurse should take is to initiate fluid resuscitation to maintain blood volume and preserve cardiac output. The nurse can utilize large bore peripheral IV cannulas. However, in extensive burns a central line should be inserted to allow for rapid infusion of fluids. other answers and why they are wrong: Clean and dress the wound. Answer Rationale: It is important for the nurse to clean and dress the wound in order to prevent the wound from becoming infected and to provide pain relief. However, there is another action that the nurse should take first. Administer pain medication. Answer Rationale: The client who has a burn injury can experience severe pain. It is important for the nurse to assess and treat the client's pain to provide comfort and make the cleansing and dressing of the wound more tolerable. However, there is another action that the nurse should take first. Administer a tetanus booster. Answer Rationale: The client who experiences a significant injury, such as a large burn, is at increased risk for developing an infection involving Clostridium tetani. While it is important to administer a tetanus booster to prevent infection, there is another action that the nurse should take first.

A client in the ED has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first? A. Clean and dress the wound B. Administer pain meds C. administer a tetanus booster D. administer IV fluids

Erythema Answer Rationale: Erythema is an indication that the client has experienced a superficial burn with damage limited to the epidermis. Other manifestations include edema, pain, and increased sensitivity to heat. _______________ other answers and why they are wrong: Blistering Rationale: Blistering is an indication of a superficial partial thickness burn, involving injury to the upper third of the dermis. These injuries also are pink and moist, blanch to pressure and are very painful. Eschar Answer Rationale: Eschar is seen in clients who have a full thickness wound involving the epidermis and dermis. This is dead tissue that must be removed for healing to occur Absence of pain Answer Rationale: A thermal injury that is not painful can be classified as a deep full-thickness burn which extends into muscle, bone, or tendons.

A nurse is assessing a client using a heating pad. Which of the following is the first indication that the client is experiencing a superficial burn? A. blistering B. erythema C. Eschar D. Absence of pain

C. Talk with the client during wound care. Answer Rationale: Talking with the client while providing care assists in the development of the nurse-client relationship and demonstrates caring. ________________________ other answers and why they are wrong: Assign assistive personnel to keep his room neat and clean. Answer Rationale: This intervention is important for infection control but does not address the client's need for emotional support. Rotate nursing staff so he can have varied interactions. Answer Rationale: This intervention inhibits the development of a trusting, nurse-client relationship, which is an important component of providing emotional support. Keep family members aware of his condition. Answer Rationale: This intervention does not address the client's need for emotional support and may violate client confidentiality.

A nurse is developing a care plan for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include? A. Assign assistive personnel to keep his room neat and clean. B. Rotate nursing staff so he can have varied interactions. C. Talk with the client during wound care. D. Keep family members aware of his condition.

deep partial or full-thickness burns

what wounds is wound grafting used for ?

nutritional supplementation, often with placement of an NG tube along with supplemental vitamins and minerals

in patients with burns approx. 20% or greater, it is difficult to consume the amount of calories and protein needed for wound healing. So this is provided and often required

Monitor temperature (hyperthermia common for ~2 weeks)

in the acute / intermediate phase, you should monitor this for how long ?

• Wound color and consistency • Wound drainage • Eschar • Responses to therapeutic interventions • Graft sites • Pain • Weight • Serum total protein and albumin • Infection

in the intermediate phase the nurse observes for ?

ROM exercises

initiated on admission; may need to "hold" for new graft; collaborate with PT/OT

hyper metabolic and catabolic state

large burn injuries place the patient in this state

pain management meet caloric needs modulate hypermetabolism treat post burn pruritus DVT prevention (high risk) ROM exercises psychosocial support

main nursing actions in the acute and intermediate phase of burn care

decreases cosmetic result

meshed increases surface area but ?

infection from sepsis and multi organ failure

most common cause of death after the emergent phase of burn care

TPN

not often utilized among patients with burns because of its complication rates, including an increased risk for infection and hyperglycemia.

- Aerosolized heparin may be used - Balance between need for airway protection/support and risk of VAP(Ventilator Acquired Pneumonia) - Humidified oxygen (loosens secretions) - Turn, cough & deep breathe/incentive spirometer

nursing actions to promote respiratory status in the acute/intermediate phase of care for burns

psychological and rehabilitative support

of primary importance in the rehabilitation phase

procedural pain

often the most intense pain associated with a burn injury, and medication must be timed to allow for maximum absorption, as well as to time the most painful procedures during the peak effectiveness times of medications.

breakthrough pain

pain related to specific episodes associated with ADLs like walking

scarring to the face or hands

particularly traumatic to the patient and may result in appearance changes and disfigurement.

DVT

patient with burns in acute intermediate phase is at high risk for this, so practice prevention strategies

anxiolytics

patients are often given these during wound care procedures because they have a lot of fear regarding pain, appearance changes

morphine sulfate (morphine), fentanyl (Sublimaze), and/or hydromorphone (Dilaudid)

recommended IV narcotics especially used with dressing changes

- psychological considerations - improve body image and self concept - prevent and treat scars - promote activity tolerance

rehabilitation phase includes these nursing actions

- importance of applying pressure garments and or face masks - teach about burn prevention, sun protection and prevention of hyperthermia (lack of sweat glands)

teaching for patients with major burns in rehabilitation phase

background pain

the underlying pain from the primary injury that is continuous and ongoing

split thickness wound

these wounds can used sheetss or meshed grades

antimicrobial so still need antimicrobials

topical enzymatic agents are not ????—make sure they don't interfere with each other

oral antipruritic agents/gabapentin, environmental conditions, frequent lubrication of skin, diversional activities, educate: "pat don't scratch"

treatments for post burn pruritus

mechanical wound debridement

use of surgical tools, usually with daily dressing changes

chemical wound debridement

use of topical enzymatic agents

elevated HR (hypovolemia, pain, anxiety) elevated RR and BP (anxiety, pain) elevated temp (infection) low temp (hypothermia)

vital signs in the acute and intermediate phase burn care

• Pain/discomfort • Contractures • Scarring • Disfigurement • Limited mobility • Decreased mood • Flat affect • Fear • Anxiety

what does the nurse observe for in the rehabilitative phase ?

sunscreen, cover with clothes, avoid all irritating substances (perfumes in soaps, dyes in clothes, tight clothes), keep clean

what measures should the patient take to protect newly healed skin?