Burns advanced medsurge
A client sustained burns on the back. These areas appear dry, blotchy cherry red, blistering, doesn't blanch, no capillary refill, and reduced or absent sensation. This type of burn depth is classified as? A. Superficial partial-thickness burn B. Superficial dermal C. Deep partial-thickness burn D. Full-thickness burn
C. Deep partial-thickness burn Deep partial-thickness burn: blistering, dry, blotchy cherry red, doesn't blanch, no capillary refill, and reduced or absent sensation. Generally, heals in 3-6 weeks, but scar formation results and skin grafting may be required.
The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client's family asks why this drug is being given, what is the nurse's best response? A. "To increase urine output and prevent kidney damage." B. "To stimulate intestinal movement and prevent abdominal bloating." C. "To decrease hydrochloric acid production in the stomach and prevent ulcers." D. "To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock."
C. "To decrease hydrochloric acid production in the stomach and prevent ulcers." Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. Cimetidine inhibits the production and release of hydrochloric acid.
The nursing instructor is going over burn injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care? A. Emergent Phase B. Immediate Resuscitative Phase C. Acute Phase D. Rehabilitation Phase
C. Acute Phase The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care that includes wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, and wound grafting, pain management, and nutritional support are priorities at this stage and are discussed in detail in the following sections.
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? A. Emergent B. Acute C. Rehabilitative
B. Acute This 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.
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: A. 1st degree (superficial) burn B. 2nd degree (partial-thickness) burn C. 3rd degree (full-thickness) burn D. 4th degree (deep full-thickness) burn
A. 1st degree (superficial) burn
A client is brought to the emergency unit with third-degree burns on the posterior trunk, right arm, and left posterior leg. Using the Rule of Nines, what is the total body surface area (TBSA) that has been burned? A. 36% B. 54% C. 45% D. 27%
A. 36% The Rule of Nines, also known as the Wallace Rule of Nines, is a tool used by trauma and emergency medicine providers to assess the total body surface area (TBSA) involved in burn patients. Based on the rule of nines, the posterior trunk equals 18%, right arm equals 9%, and the left posterior leg equals 9%. Therefore, a total of 36%.
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? A. 63% B. 81% C. 72% D. 54%
A. 63% The answer is A. 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%.
A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated? A. 921 mL/hr B. 938 mL/hr C. 158 mL/hr D. 789 mL/hr
A. 921 mL/hr 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 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following: Select all that apply: A. Acute kidney injury B. Dysrhythmia C. Iceberg effect D. Hypernatremia E. Bone fractures F. Fluid volume overload
A. Acute kidney injury B. Dysrhythmia C. Iceberg effect E. Bone fractures Electric burns are due to an electrical current passing through the body that leads to damage to the skin but also the muscles and bones that are underneath the skin. The patient is at risk for AKI (acute kidney injury) because when the muscles become affected they release myoglobin and the red blood cells release hemoglobin in the blood, which can collect in the kidneys leading to injury. In addition, the heart's electrical system can become damaged leading to dysrhythmia. The iceberg effect can present as well because the extent of damage is not clearly visible on the skin (there can be severe damage underneath). In addition, if the electrical current is strong enough it can lead to bone fractures (specifically cervical spine injuries) due to the severe contraction of the muscles involved.
Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery? A. Changing gloves between wound care on different parts of the client's body. B. Avoiding sharing equipment such as blood pressure cuffs between clients. C. Using the closed method of burn wound management. D. Using proper and consistent handwashing.
A. Changing gloves between wound care on different parts of the client's body. 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. Use gowns, gloves, masks, and strict aseptic techniques during direct wound care and provide sterile or freshly laundered bed linens or gowns.
Which is the priority nursing diagnosis during the first 24 hours for a client with chemical burns to the legs and arms that are red in color, edematous, and without pain? A. Decreased Tissue Perfusion B. Disturbed Body Image C. Risk for Disuse Syndrome D. Risk for Ineffective Breathing Pattern
A. Decreased Tissue Perfusion During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, causing decreased tissue perfusion and necessitating the intervention of an escharotomy.
What are some patient priorities during the emergent phase of burn management? A. Fluid volume B. Respiratory status C. Psychosocial D. Wound closure E. Nutrition
A. Fluid volume B. Respiratory status This phase starts from the onset of the burn and ends with the restoration of capillary permeability. Wound closure, and nutrition would be during the acute phase, and would continue into the rehabilitative phase. Psychosocial would be in the rehab phase.
Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery? A. Increased urine output, decreased urine specific gravity B. Increased peripheral edema, decreased blood pressure C. Decreased peripheral pulses, slow capillary refill D. Decreased serum sodium level, increased hematocrit
A. Increased urine output, decreased urine specific gravity The "fluid remobilization" phase improves renal blood flow, increasing diuresis and restoring fluid and electrolyte levels. The increased water content of the urine reduces its specific gravity. Injured capillaries heal approximately 24 to 36 hours after a burn, so intravascular fluid loss typically ceases at this time, and fluid begins to shift back into the intravascular compartment. This stage is called the fluid remobilization period.
Rehabilitation is the final phase of burn care. Which of the following are the goals during this phase? Select all that apply. A. Provide emotional support. B. Prevent hypovolemic shock. C. Promote wound healing and proper nutrition. D. Fluid replacement. E. Help the client in gaining optimal physical functioning.
A. Provide emotional support. C. Promote wound healing and proper nutrition. E. Help the client in gaining optimal physical functioning. The rehabilitation phase starts after wound closure and ends upon discharge and beyond. The goals of this phase include minimizing functional loss, promoting psychosocial support, promoting wound healing, and proper nutrition.
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: A. 1st Degree (superficial) B. 2nd Degree (partial-thickness) C. 3rd Degree (full-thickness) D. 4th Degree (deep full-thickness)
B. 2nd Degree (partial-thickness)
The nurse notes a patient has full-thickness circumferential burns on the right leg. The nurse would: select all that apply A. Place cold compressions on the burn and elevate the right leg below the heart level B. Assess the distal pulses in the right extremity C. Elevate the right leg above the heart level D. Place gauze securely around the leg to prevent infection
B. Assess the distal pulses in the right extremity C. Elevate the right leg above the heart level The patient has burns that completely surround the front and back of the right leg. This can lead to compartment syndrome where the edema from the burn compromises circulation to the distal extremity. The nurse should elevate the extremity ABOVE heart level to decrease swelling and assess distal pulses in the extremity to confirm circulation is present.
Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery? A. Colloids B. Crystalloids C. Fresh-frozen plasma D. Packed red blood cells
B. Crystalloids Although not universally true, most fluid resuscitation for burn injuries starts with crystalloid solutions, such as normal saline and Ringer's lactate. Burn patients receive a larger amount of fluids in the first hours than any other trauma patients. Initial resuscitation is based on crystalloids because of the increased capillary permeability occurring during the first 24 h. After that time, some colloids, but not all, are accepted.
During the acute phase of burn management, what is the best diet for a patient who has experienced severe burns? A. High fiber, low calories, and low protein B. High calorie, high protein and carbohydrate C. High potassium, high carbohydrate, and low protein D. Low sodium, high protein, and restrict fluids to 1 liter per day
B. High calorie, high protein and carbohydrate This type of diet promotes wound healing and meets the caloric demands of the body.
The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness
B. Partial-thickness superficial The characteristics of the wound meet the criteria for a superficial partial-thickness injury (color that is pink or red; blisters; pain present and high). Superficial partial-thickness (second-degree) involves the superficial dermis. It appears red with blisters and is wet. The erythema blanches with pressure. The pain associated with superficial partial-thickness is severe. Healing typically occurs within 3 weeks with minimal scarring.
The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury? A. Place a towel roll under the client's neck or shoulder. B. Keep the client in a supine position without the use of pillows. C. Have the client turn the head from side to side 90 degrees every hour while awake. D. Keep the client in a semi-Fowler's position and actively raise the arms above the head every hour while awake.
C. Have the client turn the head from side to side 90 degrees every hour while awake. The function that would be disrupted by a contracture to the posterior neck is flexion. Moving the head from side to side prevents such a loss of flexion. Deformities and contractures can often be prevented by proper positioning. Maintaining proper body alignment when the patient is in bed is vital. This movement is what would prevent contractures from occurring.
The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? A. Decreased heart rate B. Increased urinary output C. Increased Blood Pressure D. Elevated hematocrit
D. Elevated hematocrit The resuscitation/emergent phase begins at the time of injury and ends when restoration of capillary permeability, usually 48-72 hours following injury. During this phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts.
The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness
D. Full thickness The characteristics of the wound meet the criteria for a full-thickness injury (color that is black, brown, yellow, white, or red; no blisters; pain minimal; outer layer firm and inelastic). With pressure, no blanching occurs. The burn is leathery and dry. There is minimal to no pain because of decreased sensation. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.
During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent? A. Increased wound pain 30 to 40 minutes after drug application B. Presence of small, pale pink bumps in the wound beds C. Decreased white blood cell count D. Increased serum creatinine level
D. Increased serum creatinine level 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. Characteristically, gentamicin reaches high concentrations in the renal cortex and the inner ear.
During the emergent phase of burn management, you would expect the following lab values: A. Low sodium, low potassium, high glucose, low hematocrit B. High sodium, low potassium, low glucose, high hematocrit C. High sodium, high potassium, high glucose, low hematocrit D. Low sodium, high potassium, high glucose, high hematocrit
D. Low sodium, high potassium, high glucose, high hematocrit Think about the increase in the capillary permeability that happens with severe burns, which causes the plasma to leave the intravascular system and enter the interstitial tissue: Low sodium..why: sodium leaves with the plasma to the interstitial tissue and drops the levels in the blood; High potassium...why? damaged cells lysis and leak potassium which increases the leave in the blood; high glucose...why? stress response leads the liver to release glycogen and this increases levels; high hematocrit...why? when the plasma leaves the intravascular system (the fluid) it causes the blood to become more concentrated so hematocrit increases (this will decrease when the patient's fluid is replaced).
Which finding is characteristic during the emergent period after a deep full-thickness burn injury? A. Blood pressure of 170/100 mm Hg B. Foul-smelling discharge from wound C. Pain at site of injury D. Urine output of 10 mL/hr
D. Urine output of 10 mL/hr During the fluid shift of the emergent period, blood flow to the kidney may not be adequate for glomerular filtration. As a result, urine output is greatly decreased. Urine output of 0.5 mL/kg or about 30 - 50 mL/hr in adults and 0.5-1.0 mL/kg/hr in children less than 30kg is a good target for adequate fluid resuscitation. Option A: Blood pressure is usually low. During this inflammatory response, there is a fluid loss that can cause a sharp and potentially deadly drop in blood pressure known as shock. Option B: A foul-smelling discharge does not occur during the emergent phase. Third-degree involves the full thickness of skin and subcutaneous structures. It appears white or black/brown. With pressure, no blanching occurs. The burn is leathery and dry. Option C: Pain does not occur with deep full-thickness burns. There is minimal to no pain because of decreased sensation. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.