Care of Patients with Burns

The home health nurse is visiting an older couple for the initial visit. In observing the household, the nurse identifies several behaviors and environmental macros to address. Which identified factors increase the risk for burns and/or household fires?

-Ashtray with old cigarette butts on the bedside table -Space heater very close to the bed -Single smoke detector in the kitchen -Back exit hall of the house used as a storage space

The nurse is caring for several patients on the burn unit. Which patients have the greatest risk for developing respiratory problems?

-Patient who was in a storage room where chemicals caught fire -Patient who was working in an area where steam escaped from a pipe -Patient who sustained a circumferential burn to the chest area -Patient who was found unconscious in a slow-burning house fire

The nurse is caring for a burn patient about to undergo hydrotherapy. Which complementary therapies are appropriate for pain management in this patient?

-Playing music in the background -Use of meditative breathing -Use of guided imagery

The nurse is assessing a patient with a burn wound to the back and chest area. Which assessment findings are consistent with a superficial-thickness burn wound?

-Redness -Pain -Mild edema

Which feelings are most typically expressed by the burn patient?

-Regression -Denial -Anger

The nurse has just received report on a patient admitted for steam inhalation burns. The patient is alert and conversant, but reports that his throat feels raw. His wife says that he sounds hoarse compared to usual. Considering these findings, which order should the nurse question?

Vital signs and airway assessment every shift

A burn patient refuses to eat. The potential problem of weight loss related to increased metabolic rate and reduced calorie intake is identified for this patient. What method does the nurse use to correctly weigh this patient?

Weigh daily without dressing or splints and compare to pre burn weight.

The family reports that the burn patient is unable to perform self-care measures, so someone has been "doing everything for her." The nurse finds the patient has the knowledge and the physical capacity to independently perform self-care. What is the nurse's best response?

What has been happening since you were discharged from the hospital

A patient has severe burns to the anterior surface of the body from a short exposure to high temperatures at a worksite furnace. Which area of the body is most vulnerable to deep burn injuries?

Eyelids

The nurse is monitoring the nutritional status of a burn patient. Which indicators will the nurse use?

-Amount of food the patient eats -Weight to height ratio -Serum albumin -Blood glucose

At what point does fluid mobilization occur in patient's with burns?

After 36 hours when the fluid is reabsorbed from the interstitial tissue

The priority expected outcome during the resuscitation phase of a burn injury is to maintain which factor?

Airway

Several patients are transported from an industrial fire to a local ED> Which factors increase the risk of death for these patients?

-Age greater than 60 years -Brun greater than 40% TBSA -Presence of an inhalation injury

A patient comes to the clinic to be treated for burns from a barbecue fire. Although the patient does not appear to be in any respiratory distress, the nurse suspects inhalation injury after observing which findings?

-Burns to the face -Singled nose hairs -Edema of the nasal septum -Black carbon particles around the mouth

A burn patient in the fluid resuscitation phase is experiencing dyspnea. What are the priority interventions for this patient?

-Elevate HOB to 45 degress -Notify RRT -Apply humidified oxygen

The nurse is caring for young woman who sustained burns on the upper extremities and anterior chest while attempting to put out a kitchen grease fire. Which lab results does the nurse expect to see during the resuscitation phase?

-Glucose level of 180 mg/dL -Hematocrit of 49% -pH of 7.20

What does the process of full-thickness wound healing include?

-Healing occurs by wound contraction -Eschar must be removed -Skin grafting may be necessary -Fasciotomy may be needed to relieve pressure and allow normal blood flow

As a result of third-spacing, during the acute phase, which electrolyte imbalances may occur?

-Hyperkalmia -Hyponatremia

The student nurse is preparing to assist with hydrotherapy for a burn patient. The supervising nurse instructs the student to obtain the necessary equipment before beginning the procedure. What equipment does the student nurse obtain?

-Scissor and forceps -Mild soap or detergent -Washcloths and gauze sponges

A patient with burn injuries is being discharged from the hospital. What important points does the nurse include in the discharge teaching?

-Signs and symptoms of infection -Drug regimens and potential medication side effects -Correct application and care of pressure garments -Dates for follow-up appointments

Which criterion describes a full-thickness burn wound?

-There is destruction to the epidermis and dermis -There are no skin cells for regrowth -The burned tissue is avascular

A patient in the burn ICU weighed 80 kg (pre burn weight). The provider orders titration of IV fluid to achieve 0.5 mL/kg/hr urine output. What is the minimal hourly urine output for this patient?

40 mL/hr

An adult patient is admitted to the burn unit after being burned in a house fire. Assessment reveals burns to the entire face, back of the head, anterior torso, and circumferential burns to both arms. Using the rule of nines, what is the extent of the burn injury?

45%

A patient has sustained a relatively large burn. The nurse anticipates that the patient's nutritional requirements may exceed how many kcal/day?

5000

A patient who lives in a rural community sustained severe burns during a house fire at 10 AM. The rural emergency medical services started a peripheral IV at 11:00 Am at a KVO rate. The patient was admitted to the hospital at 1:00 PM. In calculating the fluid replacement, at what time is the fluid for the first 8-hour period completed?

6:00 PM

Which patient has the highest risk for a fatal brain injury?

77-year-old man

A patient was involved in a house fire and suffered extensive full-thickness burns. In the long-term, what issue may this patient have trouble with?

Activation of vitamin D

The release of myoglobin from damaged muscle in patients with major burns can result in which potential complication?

Acute kidney injury

A 28-year-old male patient sustained second and third degree burns on his legs (30%) when his clothing caught fire while he was burning leaves. He was hosed down by his neighbor and has arrived at the ED is severe discomfort. What is the priority problem for this patient at this time?

Acute pain related to damaged or exposed nerve endings

For which patient would the rule of nines method of calculating burn size be most appropriate?

Adult whose weight is appropriate to height

The nurse is reviewing the lab results for several burn patients who are approximately 24 to 36 hours post injury. What lab results related to fluid remobilization in these patients does the nurse expect to see?

Anemia

During shift report, the nurse learns that a new patient was admitted for an inhalation injury. Auscultation of the lungs has revealed wheezing over the mainstream bronchi since admission. During the nurse's assessment of the patient, the wheezing sounds are absent. What does the nurse do next?

Assess for respiratory distress because of potential airway obstruction

A patient is transported to the ED for severe and extensive burns that occurred while he was trapped in a burning building. The patient is severely injured with respiratory distress and the resuscitation team must immediately begin multiple interventions. Which task is delegated to the UAP?

Assist the RT to maintain a seal during bag-valve-mask ventilation

What is the primary reason to prevent infection with burn injuries?

Avoid sepsis

A patient has sustained a burn which appears red and moist. The nurse gently applies pressure to the area to assess for what sign/symptom?

Blanching

A patient was admitted for burns to the upper extremities after being trapped in a burning structure. the patient is also at risk for inadequate oxygenation related to inhalation of smoke and superheated fumes. Which diagnostic test best monitors this patient's gas exchange?

Carboxyhemoglobin level

The vasodilation effets of carbon monoxide in patient with carbon monoxide poisoning cause what clinical manifestation?

Cherry-red skin color

The nurse is applying to cover a burn on a patient's left leg. What technique does the nurse use?

Consider the depth of the injury and amount of drainage, and work distal to proximal

Which type of burn wound damages the epidermis, dermis, fascia, and tissues?

Deep full thickness

The nurse is caring for several patients who have sustained burns. The patient with which initial injury is the least likely to experience severe pain when a sharp stimulus is applied?

Deep full-thickness electrical accident

Because of fluid shifts in burn patients, what effects on cardiac output does the nurse expect to see?

Depressed up to 36 hours after the burn

The nurse observes peeling of dead skin on the legs of a patient with a superficial-thickness burn wound. What is the most accurate description of this assessment finding?

Desquamation

A patient has been depressed and withdrawn since her injury and has expressed that "life will never be the same." Which nursing intervention best promotes a positive image for this burn patient?

Discussing the possibility of reconstructive surgery with the patient

A patient has sustained a burn to the right ankle. The provider has applied the initial dressing to the ankle, and the nurse assists the patient into bed and positions the ankle to prevent contracture. What is the correct position the nurse uses?

Dorsiflexion

A burn patient with which condition is most likely to have mannitol (Osmitrol) ordered as part of the drug therapy?

Electrical burn and myoglobin in the urine

A patient who sustained severe burns to the face with significant scarring and disfigurement will soon be discharged from the hospital. Which intervention is best to help the patient make the transition into the community?

Encourage visits from friends and short public appearances before discharge

A patient in the burn ICU is receiving vecuronium (Norcuron). What is the priority nursing intervention for this patient?

Ensure that all the equipment alarms are on and functional

The nurse is interviewing and assessing an electrician who was brought to the emergency department after being "electrocuted." Bystanders report he was holding onto the electrical source "for a long time". The patient is currently alert with no respiratory distress. During the interview, what does the nurse assess for?

Entrance and exit wounds

The nurse is educating a patient who has sustained burns to the dominant hand. What kind of active range-of-motion exercises does the nurse instruct the patient to perform?

Exercise the hand, thumb, and fingers every hour while awake

Which type of burn destroys the sweat glands, resulting in decreased excretory ability?

Full thickness

To prevent the complications of Curling's ulcer, what does the nurse anticipate the provider will order?

H2 histamine blockers

The provider has ordered an escharatomy for a patient because of constriction around the patient's chest. The nurse is teaching the patient and family about the procedure. Which statement by the family indicates a need for additional teaching?

He doesn't do well under general anesthesia

A patient sustained a superficial-thickness burn over a large area of the body. The patient is crying with discomfort and is very concerned about the long-term effects. What does the nurse tell the patient to expect?

Healing should occur in 3 to 6 days with no scarring or complications

The nurse is reviewing the hemoglobin and hematocrit results for patient recently admitted for a severe burn. Which result is most likely related to vascular dehydration?

Hematocrit of 58%

The nurse is caring for several patient on the burn unit who have sustained extensive tissue damage. The nurse should monitor for which electrolyte imbalance that is typically associated with the initial third-spacing fluid shift?

Hyperkalemia

During the early phase of a burn injury, there is a drastic increase in capillary permeability. What does this physiologic change place the patient at risk for?

Hypovolemic shock

A burn patient must have pressure dressings applied to prevent contractors and reduce scarring. For maximum effectiveness, what procedure pertaining to pressure garments is implemented?

Worn at least 23 hours a day until the scar tissue matures

A patient has sustained significant burns which have created a hyper metabolic state. In planning care for this patient, what does the nurse consider?

Increased caloric needs

A patient was admitted to the burn unit approximately 6 hours ago after being rescued from a burning building. In the ED, he reported dry, irritated throat "from breathing the fumes" but otherwise has no airway complaints. During the shift, the nurse nots that the patient has suddenly developed marked stridor. The nurse anticipates preparing the patient for which emergency procedure?

Intubation

Which statement about the resuscitation phase of a burn injury is accurate?

It continues for about 48 hours after the burn

Which statement about the third-spacing or capillary leak syndrome in a patient with sever burns is accurate?

It is a leak of plasma fluids into the interstitial space

A patient was burned on the forearm after tripping and falling against a wood-burning stove. There are currently several small blisters over the burn area. What does the nurse advise the patient to do about the blisters?

Leave the blisters intact because they protect the wound from infection

The nurse is caring for a burn patient who was stabilized by and transferred from a small rural hospital. The patient develops a new complaint of shortness of breath. On auscultation, the nurse hears crackles throughout the lung fields. What does the nurse suspect is causing this patient's symptoms?

Pulmonary fluid overload due to fluid resuscitation

The nurse is caring for a patient with chronic pain associated with an old burn injury. Which nonpharmacologic intervention does the nurse use to help relieve the patient's pain?

Massaging non burned areas

A patient has sustained a sever burn greater than 30% TBSA. What is the best way to assess renal function in this patient?

Measure mine output and compare this value with fluid intake

The nurse is reviewing arterial blood gas (ABG) results for a patient with 35% TBSA burn in the resuscitation phase: pH is 7.26; PCO2 is 36 mm Hg; HCO-3 is 19 mEq/L. What condition does the nurse suspect the patient has?

Metabolic acidosis

The nurse is caring for a firefighter who was brought in for burns around the face and upper chest. Airway maintenance for this patient with respiratory involvement includes what action?

Monitoring for signs and symptoms of upper airway edema during fluid resuscitation

The nurse is caring for a burn patient who received rigorous fluid resuscitation in the ED for hypotension and hypovolemic shock. In assessing renal function for the first 24 hours, what finding does the nurse anticipate?

Output will be decreased compared to fluid intake

A patient with a burn injury has an autograft. The nurse learns in report that the donor site is on the upper thigh. What type of wound does the nurse expect to find at donor site?

Partial thickness

The nurse is caring for a patient who sustained carbon monoxide poisoning while working on his car engine in an enclosed space. What assessment finding does the nurse anticipate?

Patient will report a headache

What is the most effective intervention for preventing transmission of infection to a burn patient?

Performing hand hygiene correctly and when appropriate

The nurse has just received a phone report on a burn patient being transferred from the burn ICU to the step-down burn unit. Which of these tasks are appropriate to delegate to UAP in order to prepare the room?

Place a new disposable stethoscope in the room

What is the most essential patient data needed for calculating the fluid rates, energy requirements, and drug doses for the burn patient?

Preburn weight

A patient was rescued from a burning house and treated with oxygen. Initially, the patient has audible wheezing and wheezing on auscultation, but after approximately 30 minutes the wheezing stopped. The patient now demonstrates substernal retractions and anxiety. What action does the nurse take at this time?

Recognize an impending airway obstruction and prepare for immediate intubation

The nursing student notes on the care plan that the burn patient she is caring for is at risk for organ ischemia. Based on the student's knowledge of the pathophysiology of burns, which etiology does the nursing student select?

Related to hypovolemia and hypotension

The nurse is caring for a patient brought to the ED after bending over the engine of his car when it exploded in his face. What is the priority for this patient?

Secure the airway

The nurse is caring for an African-American patient with a burn injury. The patient appears to be having severe pain and discomfort that are unrelated to the burned areas. The nurse advocates that the provider order which additional test?

Sickle cell for trait

The nurse is caring for a firefighter who was trapped for a prolonged period of time by burning debris. During the shift, the nurse notes a progressive hoarseness, a brassy cough, and the patient reports increased difficulty with swallowing. How does the nurse interpret these changes?

Signs indicating a pulmonary injury and possible airway obstruction

Which drug therapy reduces the risk of wound infection for burn patients?

Silver sulfadiazine (Silvadene) on a full-thickness injuries every 4 hours

Local tissue resistance to electricity varies in different parts of the body. Which tissue has the most resistance?

Skin epidermis

The nurse is caring for a patient who has 30% total body surface area (TBSA) burn. During the first 12 to 36 hours, the nurse carefully monitors the patient for which status changes related to capillary leak syndrome?

Tachycardia and hypotension

The student nurse is caring for a patient who has been in the burn unit for several weeks. The patient needs assistance with the bedpan to have a bowel movement, and the student nurse notes that the stool is black with a tarry appearance. What is the most important priority action at this time?

Test for the presence of occult blood with a hemoccult cared and reagent

Which vaccine is routinely administered when a burn patient is admitted to the hospital?

Tetanus

The nurse is performing a morning assessment on a patient admitted for serious burns to the extremities. For what reason does the nurse assess the patient's abdomen?

To assess for a paralytic ileus secondary to reduced blood flow

The nurse scarring for several patients on the burn unit. Which of these patients has the most acute need for cardiac monitoring?

Youg woman who was struck by lightening while jogging on the beach