Burns

The nurse is providing emergent care for a 62-year-old man with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. Which action should the nurse take first?

Administer 100% humidified oxygen

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what happens?

Diuresis occurs and hematocrit decreases.

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question?

Lactated Ringer's at 25 mL/hr

The patient in the acute phase of burn care has electrical burns on the left side of her body, type 2 diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse's priority intervention to prevent a life-threatening complication of hyperglycemia for this burned patient?

Maintain fluid balance. This patient is most likely experiencing hyperosmolar hyperglycemic syndrome (HHS). HHS dehydrates a patient rapidly. Thus HHS combined with the massive fluid losses of a burn tremendously increase this patient's risk for hypovolemic shock and serious hypotension. This is clearly the nurse's priority because the nurse must keep up with the patient's fluid requirements to prevent circulatory collapse caused by low intravascular volume. There is no mention of blood loss. Fluid resuscitation will help to correct the pH and serum potassium abnormalities.

During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progressed from the emergent phase?

Monitor for signs of complications. Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.

The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the 70-year-old female patient 30 minutes before the scheduled dressing change?

Morphine sulfate

The ambulance reports that they are transporting a patient to the ED who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect?

No pain, waxy white skin, and no blanching with pressure

when assessing a patient with partial-thickness burns, the nurse would expect to find

blisters intact nerve endings red, shiny, wet appearance

which allows microorganisms to grow

bone marrow suppressed decrease of circulating immunoglobulins

↓ Na+ ↓ Albumin

capillaries leaking water, sodium, and lytes

electrical shock can cause

cardiac standstill or dysrhythmias as well as delayed dysrhythmias during the 1st 24 hours

how shivering happens

chilling caused by heat loss, anxiety or pain

identify factors that increase nutritional need of the patient during the emergent and acute phases of burn injury

core temp elevation calories and protein for tissue repair massive catabolism characterized by protein breakdown and increased gluconeogenesis

when assessing a patient's full-thickness burns during the emergent phase, what would the nurse expect to find

dry, waxy, leathery, or hard skin

which type of burn injury would cause myoglobulinuria, long bone fractures, and cardiac dysrhythmias and/or cardiac arrest?

electrical

arrived 42 hours after burn what is the phase of burn management

emergent phase 24-72 hours focuses on fluid resuscitation

electrolyte imbalance has more effect of the

fluid resuscitation than the nutritional needs

The appearance of partial-thickness (deep) burns may include

fluid-filled vesicles (blisters) that are red, shiny, or wet (if vesicles have ruptured). Patients may have severe pain caused by exposure of nerve endings and may have mild to moderate edema.

increases the core temperature

hypermetabolic state proportional to the size of the burn

how is the immune system altered in a burn injury

impaired function of WBC

when fever is a sign

in later burn phases

↑ K+

injured cells and hemolyzed RBCs release their K+

buprenorphine (Buprenex)

is an opioid agonist/antagonist and cannot be used with other opioids

med with morphine before dressing changes

midazolam (Versed)

at the end of the emergent phase and the initial acute phase of burn injury, a patient has a high sodium, and a low potassium. what causes these imbalances

mobilization of fluid and electrolytes in the acute phase. fluid mobilization moves potassium back into the cells and sodium returns to the vascular space causing low K and high Na

metabolic acidosis

more common in electrical burns

NG insertions for burns

often develop a paralytic ileus within a few hours

deep partial thickness burns in the emergent phase

red, shiny and have blisters

1. 62 old female just admitted with partial thickness burns to chest, face, and neck 2. 76 old mal with partial thickness burs of arms and abdomen c/o severe pain 3. 40 old female who is returning from PACU 4. 18 male refusing dressing changes

1. Airway inhalation 2. Severe pain high physiological need 3. PACU soon to assess vs, loc, IV fluids, ad woulds

Which patient should the nurse prepare to transfer to a regional burn center?

A 53-year-old patient with a chemical burn to the anterior chest and neck

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions should the nurse expect to include in this patient's care ()? (select all that apply)?

A. Escharotomy Correct B. Administration of diuretics Incorrect C. IV and oral pain medications Correct D. Daily cleansing and debridement Correct E. Application of topical antimicrobial agent Correct

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert you to the presence of an inhalation injury? (select all that apply)?

A. Singed nasal hair Correct B. Generalized pallor Correct C. Painful swallowing Correct D. Burns on the upper extremities Incorrect E. History of being involved in a large fire Correct

The nurse is caring for a 46-year-old female patient during the first 12 hours after a thermal burn injury. She weighed 71 kg on admission to the burn unit. Which outcomes if observed by the nurse would indicate adequate fluid resuscitation? (select all that apply)

A. Urine output is 80 mL/hour. Correct B. Heart rate is 86 beats/minute. Correct C. Urine specific gravity is 1.025. Correct D. Mean arterial pressure is 54 mm Hg. Incorrect E. Systolic blood pressure is 88 mm Hg. Incorrect

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation?

Reddening of the skin

The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient?

Refer the patient to a counselor for psychosocial support. In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way they looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours per day for as long as 12 to 18 months. Sunlight should be avoided to prevent injury, and sunscreen should always be worn when the patient is outside.

The nurse is caring for a 34-year-old male patient who sustained a deep partial thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn?

Skin is shiny and red with clear, fluid-filled blisters

A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage?

Tachycardia

myoglobulinuria

released when massive muscle damage occurs

fluid and electrolytes shifts that occur during the early emergent phase of a burn injury include

sequestering of sodium and water in interstitial fluid

one of the clinical manifestations expect to find during the emergent phase with full-thickness burn over the lowe half of the body

shivering

During the emergency phase

sodium rapidly shifts to the interstitial spaces and remains there until edema formation ceases.

↑ Hct

water loss into the interstitium causing hemoconcentration

labs during the early emergent phase

↑ Hct ↑ K+ ↓ serum albumin ↓ serum Na+

early signs of sepsis

↑temp ↑pulse ↑rr ↓bp later decrease urine output and perhaps paralytic ileus