Chapter 24 Burns Lewis
Thermal burns occur due to...?
...hot liquids or flames, resulting in skin injuries ranging from superficial to full-thickness.
Electrical burns occur from...?
...the intense heat of an electrical current. Electrical burns present with dry and leathery skin, dysrhythmia, and a loss of consciousness.
The emergency department nurse is caring for a patient whose skin is discolored and edematous, and the patient is exhibiting decreased muscle coordination. Which complication is the patient at risk of developing? a.Paralysis b.Cardiac fibrillation c.Acute tubular necrosis d.Acute respiratory distress
A Discoloration of skin, edema, and decreased muscle coordination indicate chemical burns. Chemical burns occur due to contact with acids, alkalis, or organic compounds. Chemicals that remain in contact with the skin for a long time reach the nerve supply, which can result in paralysis. Cardiac fibrillation and acute tubular necrosis may occur in patients with electrical injury. Acute respiratory distress may be observed in patients with smoke or inhalation injury to the lower airways.
A patient who sustained burns in a house fire develops a paralytic ileus. What does the nurse suspect to be the cause of this complication? a.Sepsis b.Enteral feedings c.Opioid analgesics d.Increased gastric acid secretion
A Paralytic ileus is caused when the burn patient experiences sepsis. Enteral feedings may cause the patient to experience diarrhea. Constipation is a side effect for opioid analgesics, which are required for pain management. Curling's ulcer occurs as a result of increased gastric acid secretion. p. 443
What is a Deep partial-thickness burn?
A bright red area with blisters, blanching upon pressure, and severe pain in the patient indicates a deep partial-thickness burn. p437
While caring for a patient with burns, a nurse wraps the patient's wound with tubular elastic gauze. What are the reasons behind this action? Select all that apply. a.To decrease pain b.To prevent blistering c.To decrease itchiness d.To reduce venous return e.To enhance local immunity
A,B,C
A patient is admitted to the burn unit with second-degree thermal burns. Which characteristics of a second-degree thermal burn should the nurse expect to find during the physical assessment? Select all that apply. a.Severe pain b.Mild edema c.Fluid-filled vesicles d.Waxy, white, hard skin e.Visible thrombosed vessels
A,B,C Second-degree burns show epidermal and dermal involvement to varying depths. These burn injuries are characterized by fluid-filled vesicles that are erythematous, glossy, and damp. The patient may complain of severe pain caused by nerve injury. Mild to moderate edema may be present. Waxy, white, hard skin and visible thrombosed vessels are found in third-degree burns.
A patient with burns of more than 5% of the total body surface area is intubated, and enteral feedings are ordered to meet nutritional demands. Which nursing interventions are appropriate for the enteral feeding of this patient? Select all that apply. a.Check gastric residuals frequently. b.Assess bowel sounds every eight hours. c.Determine whether the nasogastric tube is in place. d.Begin the feedings slowly at the rate of 10 to 20 mL/hr. e.Increase the feeding to the goal rate within 24 to 48 hours
A,B,C,E A patient who is intubated and has suffered burns to more than 5% of the body surface area may need gastric feedings to meet adequate nutritional requirements. Early enteral feeding helps to preserve gastrointestinal function, increase intestinal blood flow, and promote optimal conditions for wound healing. The nurse should check the placement of the nasogastric tube and assess bowel sounds every eight hours. The enteral feedings should be started at 20 to 40 mL/hr and slowly increased to the goal rate within 24 to 48 hours. Gastric residuals should be checked to rule out delayed gastric emptying. p. 442
A patient is brought to the emergency department (ED) with partial-thickness burns on the hands and chest caused by a fire at the patient's house. What actions should the nurse perform to provide appropriate burn management for this patient? Select all that apply. a.Assess for inhalation injury. b.Provide 100% humidified oxygen. c.Avoid dry dressings on the wounds. d.Assess airway, breathing, and circulation. e.Avoid mechanical ventilation for 24 hours.
A,B,D The patient should be assessed for inhalation injury. Because these burns are caused by a fire, there is a high likelihood that the patient might have inhaled fumes. After assessing the airway, the nurse should provide 100% humidified oxygen to ensure adequate ventilation. The nurse should assess the patency of the airway as well as respirations and plan for the need for intubation accordingly. Dry dressings on the wounds may be applied to cover the wounds, if required. Mechanical ventilation may be required in case of significant inhalation injury. p435
A nurse is attending to a patient with extensive burns. What prophylactic treatment should the nurse plan to prevent a Curling's ulcer in this patient? Select all that apply. a.Antacids b.Antidiarrheal c.H 2-histamine blockers d.Proton pump inhibitors e.Calcium channel blockers
A,C,D Antacids are used prophylactically to neutralize the acids present in the stomach. H 2-histamine blockers (e.g., ranitidine) are used to inhibit histamine, which causes an increase in acid levels. Proton pump inhibitors (e.g., esomeprazole) help to inhibit the secretion of hydrochloric acid, which increases as a stress response to the decreased blood flow to the gastrointestinal tract after burns. Antidiarrheals are useful in providing symptomatic relief for diarrhea. They cannot prevent a Curling's ulcer. Calcium channel blockers have no effect on protecting the gastrointestinal tract or on preventing development of Curling's ulcers. p. 441
A nurse is attending to a patient with partial-thickness burns on the face, including corneal burns. What should she do to protect the eyes of the patient? Select all that apply. a.Use antibiotic ointments. b.Wait for laboratory reports. c.Instill methylcellulose eye drops. d.Arrange for ophthalmology examination. e.Inform the patient that periorbital edema is serious.
A,C,D Eye care for corneal burns or edema includes antibiotic ointments. An ophthalmology examination should be conducted on all patients who have sustained facial burns. The use of methylcellulose drops or artificial tears is recommended for moisture and additional comfort. Waiting for laboratory reports does not help the patient; rather, the nurse can start the basic examination and treatment in the process mentioned above. Avoid giving any misleading information, such as telling the patient that periorbital edema is serious. This can frighten the patient and prevent eye opening. The nurse should assure the patient that the swelling is not permanent. p.441
A nurse is providing care to a patient admitted to the burn unit. Which pathophysiologic changes does the nurse anticipate in this patient? Select all that apply. a.Increased viscosity b.Decreased hematocrit c.Decreased blood volume d.Increased vascular permeability e.Decreased peripheral resistance
A,C,D In a burn injury, the viscosity of body fluids is increased, the blood volume is reduced, and vascular permeability is increased. Hematocrit and peripheral resistance are increased in burn injuries.
Which complications occur in a patient with metabolic asphyxiation? Select all that apply. a.Hypoxia b.Cardiac standstill c.Protein hydrolysis d.Hydrogen cyanide poisoning e.Acute respiratory distress syndrome
A,D Metabolic asphyxiation is a type of smoke and inhalation injury that occurs due to inhalation of carbon monoxide or hydrogen cyanide. In this condition, the oxygen delivery or consumption is impaired, resulting in hypoxia. Hydrogen cyanide poisoning also occurs in metabolic asphyxiation in the absence of burn injury to the skin. Cardiac standstill occurs in an electrical injury. Protein hydrolysis occurs in a chemical injury. Acute respiratory distress syndrome occurs in a lower airway injury. p. 430
An unconscious patient who suffered an electrical burn is admitted to the emergency department. For which complications will the nurse monitor? Select all that apply. a. Myoglobinuria b.Systemic toxicity c.Pulmonary edema d.Cervical spine injury e.Severe metabolic acidosis
A,D,E Patients with an electrical injury are at risk from myoglobinuria, cervical spine injury, and severe metabolic acidosis. Myoglobinuria occurs because myoglobin from the injured tissue is released into circulation, causing muscle and blood vessel damage. Contact with electrical currents causes muscle contractions, which can fracture the vertebrae and bones. Electrical injury carries the risk of severe metabolic acidosis. Systemic toxicity occurs in patients with chemical burns. Pulmonary edema occurs due to smoke and inhalation injuries. p. 431
A nurse plans to provide an antioxidant regimen for a patient with partial-thickness burns in the acute phase. Which are antioxidants and therefore should be included in the protocol? Select all that apply. a.Zinc b.Water c.Calcium d.Selenium e.Multivitamins
A,D,E Zinc is an antioxidant and also a part of the antioxidant protocol because it supports cell growth and development. Selenium is used in the antioxidant protocol, because it helps to prevent cell damage. Multivitamins are a part of the antioxidant protocol because they help to compensate for the nutritional deficiencies of essential vitamins and minerals. Water is useful for the patient but does not form a part of the antioxidant protocol. Calcium is important to maintain strong bones and teeth, but it is not included in the antioxidant protocol. p. 446
A patient who escaped from a burning building, which was enclosed with no ventilation, is brought to the emergency department. The patient is confused, has difficulty breathing, and has nasal burns. Which condition does the nurse suspect? a.Pulmonary edema b.Lower airway injury c.Upper airway injury d.Carbon monoxide poisoning
B A patient who was trapped in an enclosed burning building with no ventilation and is exhibiting confusion, dyspnea, and nasal burns is most likely experiencing a lower airway burn injury. Pulmonary edema may occur but not until 12 to 24 hours after the initial insult. Clinical manifestations of an upper airway injury include blisters, edema, difficulty in swallowing, and total airway obstruction. Carbon monoxide poisoning results in hypoxia, in which oxygen consumption is impaired. p 431
When caring for a patient with an electrical burn injury, which prescription from the health care provider should the nurse question? a.Urine for myoglobin b.Lactated Ringer's at 25 mL/hr c.Mannitol 75 gm intravenous (IV) d.Sodium bicarbonate 24 mEq every 4 four hours
B Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's at 2 to 4 mL/kg/% total body surface area (TBSA), a rate sufficient to maintain urinary output at 75 to 100 mL/hr. An infusion rate of 25 mL/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN. Mannitol also can be used to maintain urine output. The urine would be monitored also for the presence of myoglobin. Sodium bicarbonate may be given to alkalinize the urine. p. 439c
A nurse is assessing a patient who was burned after contact with gasoline. For which complication does the nurse monitor? a.Liquefaction b.Systemic toxicity c.Protein hydrolysis d.Severe metabolic acidosis
B Gasoline is an organic compound that causes chemical burns. This compound produces systemic toxicity in patients. Liquefaction and protein hydrolysis occur due to chemical burns resulting from alkalis. Electrical injury results in severe metabolic acidosis. pp. 429-430
When teaching the patient about the use of range-of-motion (ROM), what explanations should the nurse give to the patient? Select all that apply. a.The exercises are the only way to prevent contractures b.ROM will show the patient that movement still is possible c.Active and passive ROM maintain function of body parts d.Movement facilitates mobilization of leaked exudates back into the vascular bed e.Active and passive ROM can be done only while the dressings are being changed
B, C, D Active and passive ROM maintain function of body parts and reassure the patient that movement still is possible are the explanations that should be used. Contractures are prevented with ROM as well as splints. Movement facilitates mobilization of fluid in interstitial fluid back into the vascular bed. Although it is good to collaborate with physical therapy to perform ROM during dressing changes because the patient already has taken analgesics, ROM can and should be done throughout the day. p. 441
A nurse is attending to a patient with partial-thickness burns on the hands and legs. What actions should the nurse perform as a part of the wound care for the emergent phase of treatment? Select all that apply. a.Avoid using topical antibiotics. b.Administer a tetanus antitoxin. c.Perform debridement as required. d.Avoid using antimicrobial dressings. e.Assess the extent and depth of the burns.
B,C,E The burn management involves emergent phase, acute phase, and rehabilitation phase. The emergent phase involves early management of the burns patient and includes airway management, and fluid and wound therapy. Tetanus antitoxin should be administered to prevent sepsis. Assessment of extent and depth of burns should be done to determine the severity of burns, plan burns management, and consider referring to a burn center. Debridement should be performed as required to keep the wound clean, remove any chemical causing the burn, or to prevent further tissue damage. Use of topical antibiotics and antimicrobial dressings are not of prime importance in the emergent phase; they are usually used in the acute and rehabilitation phases. p. 438
A nurse is assessing a patient who was injured using heavy industrial cleanser while working at a factory. For which complications will the nurse monitor? Select all that apply. a.Hypoxia b.Liquefaction c.Tissue anoxia d.Protein hydrolysis e.Metabolic acidosis
B,D A chemical burn results from contact with an alkali, such as an industrial cleanser. When the alkalis come in contact with skin, they adhere to the tissue, resulting in protein hydrolysis and liquefaction. Hypoxia occurs in smoke and inhalation injuries. Tissue anoxia and metabolic acidosis occur in patients with electrical burns. pp. 429-430
When attending to a patient with severe burns, what precautions should the nurse take to maintain adequate nutrition? Select all that apply. a.Assess respiratory rate every two hours. b.Assess bowel sounds every eight hours. c.Begin large amounts of feeding within first six hours. d.Begin early enteral feeding with smaller-bore tubes. e.Begin the feedings slowly at a rate of 20 to 40 mL/hr.
B,D,E The nurse should assess bowel sounds every eight hours to ensure proper functioning of the bowels before starting oral nutrition. The nurse should also begin early enteral feeding with smaller-bore tubes, because this preserves gastrointestinal (GI) function, increases intestinal blood flow, and promotes optimal conditions for wound healing. The feedings should begin slowly at a rate of 20 to 40 mL/hr to protect the GI function and gradually increase as the patient improves. Assessing the respiratory rate every two hours is not related to nutritional therapy. Large amounts of feeding within the first six hours may overload the system and affect the GI function. p. 442
Which clinical manifestations are observed in a patient in the emergent phase of a burn injury? Select all that apply. a.Increased appetite b.Increased heart rate c.Increased urine output d.Decreased respiratory rate e.Decreased blood pressure
B,E During the emergent phase of a burn injury, the patient exhibits tachycardia and hypotension. Other clinical manifestations during this phase include a loss of appetite, a decreased urine output, and tachypnea. pp. 437-438
Which fluid and electrolyte change occurs during the early emergent phase of burn injury? a.Increased excretion of urine b.Increased colloidal osmotic pressure c.Return of interstitial fluid to the vascular space d.Movement of sodium and water into interstitial fluids
D After the burn, in the emergent phase, the capillary walls become more permeable, causing the movement of sodium, water, and plasma proteins into the interstitial spaces and surrounding tissues. An increased excretion of urine and the return of interstitial fluid to the vascular spaces occurs toward the end of the emergent phase. During the early emergent phase, colloidal osmotic pressure is decreased with progressive protein loss from the vascular spaces. pp. 434, 436
The nurse collaborates with the health care team regarding the treatment of partial-thickness second-degree burn to the chest, abdomen, and both anterior thighs sustained by a patient. Which treatment does the nurse recognize as appropriate and within the scope of nursing practice? a.Application of autografts and daily sterile dressing changes b.Twice-weekly wound cleaning and sterile dressing changes c.Daily wound cleaning with debridement and sterile dressing changes d.Daily wound cleaning with hydrotherapy and clean dressing changes
C Daily wound cleansing with debridement and sterile dressing changes is appropriate care for a major burn wound. As a means of promoting healing and preventing infection, wound care and dressing changes are performed once or twice a day with a sterile procedure. The other answer options are not within the scope of nursing practice and may not be appropriate treatment for the burn injury sustained. pp. 439-440
A patient has thermal burns on the face, including the cheeks and the area around the eyes. Which action would the nurse take? a.Turn eyelashes inward towards the eyeball. b.Wrap sterile gauze around the face. c.Cover the face with ointment and gauze. d.Apply ointment only without the use of gauze.
C The face is highly vascular and may become edematous after a thermal burn. It should be covered with ointment and gauze to prevent vascularization and swelling. The nurse should ensure that eyelashes are not turned inward. Wrapping gauze around the face will create pressure on delicate facial structures. The gauze is required to cover the face after the application of ointment to prevent infection. p. 441
A patient presents in the emergency department (ED) with burns on the hands and face after handling hydrochloric acid at work. What actions should the nurse perform toward the patient's burn management? Select all that apply. a.Apply ice to the burned area. b.Never wash the burn with water. c.Flush affected area with lots of water. d.Remove all chemical particles on skin. e.Remove all clothing containing the chemical.
C,D,E Remove all chemical particles on skin to remove the burn-causing agent from the patient's body. Remove all clothing containing the chemical, because the burning process continues while the chemical is in contact with the skin. Flush affected area with copious amounts of water to irrigate the skin from 20 minutes to two hours after chemical exposure to clear off the chemical on or around the affected area. Applying ice to the burned area does not help to wash away the chemical. Washing the burnt area with water helps to clean off the chemical. p. 433
A patient is brought to the emergency department (ED) following an inhalation injury. The patient has sustained burns on the face, neck, and chest due to a fire in the home. Which would help to confirm the diagnosis of upper airway injury? Select all that apply. a.Dyspnea b.Wheezing c.Hoarseness d.Singed nasal hair e.Difficulty in swallowing
C,D,E Upper airway injury may be caused by thermal burns or the inhalation of hot air, steam, or smoke. Hoarseness occurs due to laryngeal edema. Singed nasal hair is an obvious sign of inhalation of burned particles or smoke. Difficulty in swallowing is present due to edema and blistering of the oropharynx. Dyspnea can be observed where there has been an inhalation injury to the lower airway that is caused by breathing toxic chemicals or smoke that affects the trachea, bronchioles, and alveoli. Wheezing is a symptom found in an inhalation injury affecting the lower airway. p. 435
Why does the nurse apply enzymatic debriding agents to a patient with severe wounds? a.To decrease blood loss b.To remove the old microbial agent c.To protect the reepithelializing keratinocytes d.To remove dead tissue from the healthy wound bed
D Enzymatic debriding agents are made of natural products like collagen. Enzymatic debriding agents speed up the removal of dead tissue from the healthy wound bed. Skin grafting, a part of wound care, promotes massive blood loss in patients. To prevent this, topical application of epinephrine is advised. Washing the patient's wound with normal saline-moistened gauze removes the old antimicrobial agent. Paraffin gauze dressing protects the re-epithelializing keratinocytes from damage. This dressing resurfaces and closes the open bed wound. p. 443
What are manifestations of a lower airway lung injury associated with burns?
Dyspnea, wheezing, and an altered mental status are manifestations of a lower airway lung injury associated with burns. p431
A nurse is assessing a patient with a burn injury. Which clinical manifestation does the nurse anticipate due to thrombosis in the capillaries of the burned tissue? a.Elevated heart rate b.Elevated hematocrit c.Decreased blood pressure e.Decreased erythrocyte count
E Thrombosis in the capillaries of burned tissue results in a loss of circulating erythrocytes (RBCs). An elevated heart rate and decreased blood pressure are signs of hypovolemic shock, which is caused by a massive shift of fluids out of the blood vessels. Hematocrit is elevated in burn injuries due to the hemoconcentration that results from fluid loss. p. 434
What type of burn can lead to Acute Tubular Necrosis?
Electrical burn Electrical burns often cause dysrhythmias and myoglobinuria. The myoglobin pigments travel to the kidneys and block the renal tubules, resulting in acute tubular necrosis (ATN). Pulmonary edema, metabolic asphyxiation, and acute respiratory distress syndrome are complications associated with smoke and inhalation burn injury. p431
What type of burn causes tissue anoxia?
Electrical injury causes tissue anoxia due to nerve damage and nerve death.
What can we expect to see in superficial partial-thickness burns?
Erythema (superficial Redness) Blanching with pressure Pain Minimal swelling No vesicles or blistering during the first 24 hours. p. 432
The nurse is assessing a patient admitted to the emergency department after the inhalation of toxic chemicals. Which finding indicates a lower airway injury? a.Blisters b.Singed nasal hairs c.Total airway obstruction d. Substernal retractions
Singed nasal or facial hair is one of the manifestations of a lower airway injury, involving the trachea, bronchioles, and alveoli. Blisters, total airway obstruction, and substernal retractions can be seen in patients suffering from an upper airway burn injury. Text Reference: p. 431
A deep partial-thickness burn involves what layers of skin? How is it characterized?
The epidermal and dermal layers of the skin. It is characterized by a wet, shiny, weeping surface marked by blisters and is painful and very sensitive to the touch.
What is is the most commonly used parameter to assess the adequacy of fluid resuscitation in emergent phase?
Urinary output
What is an upper airway injury ?
a type of smoke or inhalation injury that affects the mouth, oropharynx, or larynx. p431