Chapter 25 Burns

Partial Thickness 2nd degree

A light to bright red or mottled appearance characterizes superficial second-degree burns. These wounds may appear wet and weeping, may contain bullae, and are extremely painful and sensitive to air currents. These burns blanch painfully. The microvessels that perfuse this area are injured, and permeability is increased, resulting in leakage of large amounts of plasma into the interstitium. This fluid lifts off the thin, damaged epidermis, causing blister formation. Despite the loss of the entire basal layer of the epidermis, a burn of this depth heals in 7 to 21 days. Minimal scarring can be expected.

Which part of a burn is the site of greatest heat transfer and has been damaged most severely? A.Zone of coagulation B.Zone of hyperemia C.Zone of stasis D.Peripheral zone

A.Zone of coagulation The central zone, or zone of coagulation, is the site of most severe damage. The central zone is usually the site of greatest heat transfer. The zone of coagulation is surrounded by the zone of stasis, which is characterized by impaired circulation that can lead to cessation of blood flow caused by a pronounced inflammatory reaction. This area is potentially salvageable; however, local or systemic factors can convert it into a full-thickness injury. It may take 48 to 72 hours to determine the full extent of injury. The outermost area, the zone of hyperemia, has vasodilation and increased blood flow but minimal cell involvement. Early spontaneous recovery can occur in this area. The peripheral zone is the site of least damage.

Which phase of burn care is hypermetabolic and can be complicated by wound infection and sepsis? A.Initial phase B.Resuscitative phase C.Acute care phase D.Rehabilitative phase

C.Acute care phase The resuscitative phase begins with initial hemodynamic response to the injury and lasts until capillary integrity is restored and the repletion of plasma volume by fluid replacement occurs. After the resuscitative phase of burn patients, the acute care phase of wound healing, wound closure, and prevention of infection begins. This hypermetabolic phase can be complicated by wound infection and sepsis. The rehabilitative phase of the burn patient care starts from admission of the burn-injured patient and may last years, depending on future surgical procedures, therapy needs, contracture prevention, and psychological or emotional needs of the patient.

Which type of burn involves the destruction of skin layers from the epidermis down to and including the subcutaneous tissue? A.Superficial (first-degree) burns B.Partial-thickness (second-degree) burns C.Deep-dermal, partial thickness (second-degree) burns D.Full-thickness (third-degree) burns

D.Full-thickness (third-degree) burns Size and depth of burns are divided into four main categories: (1) superficial (first-degree) burns, which are injuries to epidermis (2) partial-thickness (second-degree) burns, which involve the epidermis and dermis of the skin (3) deep-dermal, partial thickness (second-degree) burns, which involve the entire epidermal layer of the skin and part of the dermis (4) full-thickness (third-degree) burns, which involve destruction of skin layers from the epidermis down to and including the subcutaneous tissue.

Superficial 1st degree

Erythema and mild discomfort characterize superficial partial-thickness wounds. Pain, the chief symptom, usually resolves in 48 to 72 hours. Common examples of first-degree burn injuries are sunburns and minor steam burns such as may occur while cooking. These wounds usually heal in 2 to 7 days and do not require medical intervention aside from pain relief, management of pruritus (itching), monitoring for edema, and encouraging oral fluids. Superficial burns are not included in the calculation of percent burn.

Chemical Burns management

Irrigation with neutralizing solutions is no longer advocated, because neutralizing agents may cause reactions that are exothermic (produce heat), thereby increasing the extent and depth of the burn. Instead, large amounts of water are used to flush the area.

deep dermal partial thickness 2nd degree

Only a modest plasma surface leakage occurs because of severe impairment in blood supply. The wound surface usually is red with patchy white areas that blanch with pressure. The appearance of the deep-dermal wound changes over time. Dermal necrosis and surface coagulated protein turn the wound from white to yellow

Resuscitation Phase (Shock phase) Goal

To maintain vital organs function and perfusion remember Risk for infection! Some centers advocate routine wound surveillance cultures and wound biopsy to identify infection early. Frequent wound inspection is needed to assess for changes in appearance such as an increase in exudate, odor, or color to minimize the risk of bacteremia. Patients should not be treated with antibiotics prophylactically; rather, treatment should be tailored to positive culture results.

A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. Total body surface area (TBSA) burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. The patient's weight is estimated at 85 kg. What is the initial plan for fluid replacement according to ABA consensus (3mL)? a. 5738 mL of Lactated Ringer solution (LR) for the first 8 hours; then 5738 mL of LR over the next 16 hours b. 2868 mL of normal saline (NS) for the first 8 hours; then 5737 mL of hypertonic NS over the next 16 hours c. 11,475 mL of dextran evenly divided over the first 24 hours d. 11,475 mL of LR evenly divided over the first 24 hours

a. 5738 mL of Lactated Ringer solution (LR) for the first 8 hours; then 5738 mL of LR over the next 16 hours Dose: mL/kg/% burned 25% + 20%= 45% ABA 3mL/85/45%=11,475 11,475/2=5,737.50 for 8 hrs then the rest for the next 16hrs

Contracture development leading to impaired physical mobility can occur after a major burn injury. Splints are applied to prevent or correct contractures. Priority nursing interventions concerning this therapy include which action? a. Daily assessment for proper fit and effectiveness b. Removal of splints during showers and dressing changes c. Allowing for frequent breaks from splint use d. Passive and active range of motion may be used instead of splints

a. Daily assessment for proper fit and effectiveness Splints can be used to prevent or correct contracture or to immobilize joints after grafting. If splints are used, they must be checked daily for proper fit and effectiveness. Splints that are used to immobilize body parts after grafting must be left on at all times except to assess the graft site and pressure points during every shift. Splints to correct severe contracture may be off for 2 hours per shift to allow burn care and range-of-motion exercises.

A patient is admitted to the burn unit after a house fire. The patient sustained extensive burns to the chest, back, left arm, right arm, right upper leg, and areas on the face. The nurse is unable to obtain a palpable pulse or a Doppler pulse in the right arm. What procedure should the nurse anticipate next? a. Escharotomy b. Silver Sulfadiazine application c. Splint application d. Xenograft application

a. Escharotomy An escharotomy may be required to restore arterial circulation and to allow for further swelling. The escharotomy can be performed at the bedside with a sterile field and scalpel. b. SSD: painless application (topical antimicrobial), disadvantage: may produce transient leukopenia by bone marrow suppression (monitor WBC) c. Splint application to immobilize body part while healing d. Xenograft: A xenograft (heterograft) is a graft transferred between two different species to provide temporary wound coverage. The most common and widely accepted xenograft is pigskin (porcine skin).

A patient is brought to the emergency department with extensive burns after a house fire. What is an important nursing intervention for this patient during the resuscitation phase? a. Intravenous opiates and assessment of pulses in both arms b. Oral anti-inflammatory drugs and preparation for insertion of an arterial line c. Measurement of sedimentation rate and systemic antibiotics d. Application of splints and initiation of total parenteral nutrition

a. Intravenous opiates and assessment of pulses in both arms (can't find)

A patient is admitted to the burn unit after an electrocution. The patient sustained extensive burns. The nurse should have a high degree of suspicion for what complication associated with this type of burn injury? a. Rhabdomyolysis b. Stress ulcers c. Pneumothorax d. Venous thromboembolism

a. Rhabdomyolysis The electrical burn process can result in a profound alteration in acid-base balance and rhabdomyolysis resulting in myoglobinuria, which poses a serious threat to kidney function. If hemoglobinuria is identified, the clinician should assume that the patient has myoglobinuria and acidosis and treat accordingly. Sodium bicarbonate may be administered to bring the pH level into the normal range, to correct a documented acidosis, or to alkalize urine to promote myoglobin excretion.

Which topical antimicrobial agent is commonly used as a broad-spectrum agent and is activated by the wound moisture? a. Silver b. Bacitracin c. Mafenide acetate cream d. Silver sulfadiazine

a. Silver Pure Silver: Advantage > broad spectrum including fungus and resistant organisms. Silver has long been used for the treatment of wounds because of its broad-spectrum bacteriostatic properties against gram-negative and gram-positive bacteria. Silver has minimal side effects and minimal bacterial resistance. Bacitracin: Disadvantage > NO gram-negative or fungal coverage Mafenide acetate cream: Advantage > broad spectrum (specially pseudomonas coverage) Silver Sulfadiazine: Broad spectrum

The nurse is caring for a patient with extensive burns. Which zone of injury is the site of the most severe damage? a. Zone of coagulation b. Peripheral zone c. Zone of stasis d. Zone of hyperemia

a. Zone of coagulation The central zone, or zone of coagulation, is the site of most severe damage. The central zone is usually the site of greatest heat transfer. The zone of coagulation is surrounded by the zone of stasis, which is characterized by impaired circulation that can lead to cessation of blood flow caused by a pronounced inflammatory reaction. This area is potentially salvageable; however, local or systemic factors can convert it into a full-thickness injury. It may take 48 to 72 hours to determine the full extent of injury.

Using the "rule of nines," calculate the percent of injury in an adult who was injured as follows: the patient sustained partial- and full-thickness burns to half of his left arm, his entire left leg, and his perineum. a. 28% b. 23.5% c. 45.5% d. 16%

b. 23.5% Half his arm 4.5% Full leg 9%+9% Perineum 1% = 23.5%

Using the Parkland formula for fluid resuscitation and knowledge of injury calculations using the "rule of nines," calculate the estimated fluid requirements during the first 8 hours for a 75-kg patient with full-thickness burns to the anterior torso, perineum, and entire right leg. a. 2775 mL b. 5550 mL c. 8325 mL d. 11,100 mL

b. 5550 mL The extent and depth of the burn are assessed. The extent of TBSA of the burn is calculated for estimation of fluid resuscitation requirements the Parkland formula is the most widely used method of calculation Dose: mL/kg/% burned Parkaland: Ringers Lactate is 4mL/kg/% burned Ant. Torso 18% Perineum 1% Entire Right Leg 9% + 9% = 18% =37% 4mL/75kg/37% = 11,100 11,100/2= 5,550 According to the Parkland formula 50% of the calculated amount of fluid is administered to the patient in the first 8 hours after injury; 25% is given in the second 8 hours, and 25% is given in the third 8 hours.

A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. What is the nurse's first priority? a. Clean the wounds and remove blisters. b. Assess the airway and provide 100% oxygen. c. Place a urinary drainage catheter and assess for myoglobin. d. Place a central intravenous access and provide antibiotics.

b. Assess the airway and provide 100% oxygen. The first priority of emergency burn care is to secure and protect the airway. Inhalation injury should be suspected in patients with facial burns. Patients with major burns or suspected inhalation injury are initially administered 100% oxygen.

The nursing management plan for a patient with full-thickness burns includes which intervention? a. Daily replacement of autografts b. Daily wound care with premedication c. Weekly wound care until all eschar is debrided d. Surgical skin grafting within 8 hours of admission

b. Daily wound care with premedication Wound cleansing •w/ sterile N/S, Tap water, or mild antimicrobial cleansing agent •Wound exposure to be limited for hypothermia, infection, & pain •Adequate premedication required Wound care •Maintaining a moist wound environment •Preventing infection •Nonstick dressing w/ or w/o topical antimicrobial agent (can't find a correct answer that connects both)

What is a leading cause of death in the hospitalized burn patient? a. Smoke inhalation b. Infection c. Burn shock d. Renal failure

b. Infection A burn wound infection can delay healing and increase scarring, and invasive infection can result in death of the patient

A patient has a partial-thickness burn wound that is being treated with porcine xenograft (pigskin). The nurse knows that pigskin usually dissolves in 5 to 7 days because of what reason? a. Presence of infection b. Lack of blood supply c. Lack of lymphatic drainage d. Contamination of the graft

b. Lack of blood supply After the pigskin is in place, it may be dressed with antibacterial-impregnated dressings or other forms of dressings. Pigskin usually is removed or dissolves because of lack of blood supply in 5 to 7 days. If sloughing or purulent drainage occurs, the xenograft is removed.

A patient is admitted after being burned while lighting the barbecue. The injuries appear moist and red with some blister formation and the patient states they are very painful. What kind of burn would the nurse document in the patient's record? a. Superficial (first-degree) burn b. Partial-thickness (second-degree) burn c. Deep dermal partial-thickness (second-degree) burn d. Full-thickness (third-degree) burn

b. Partial-thickness (second-degree) burn (2) partial-thickness (second-degree) burns, which involve the epidermis and dermis of the skin A light to bright red or mottled appearance characterizes superficial second-degree burns. These wounds may appear wet and weeping, may contain bullae, and are extremely painful and sensitive to air currents. These burns blanch painfully.5 The microvessels that perfuse this area are injured, and permeability is increased, resulting in leakage of large amounts of plasma into the interstitium. This fluid lifts off the thin, damaged epidermis, causing blister formation. Despite the loss of the entire basal layer of the epidermis, a burn of this depth heals in 7 to 21 days. Minimal scarring can be expected.

According to the American College of Surgeons, burns to which body surfaces are best treated in a burn center? (Select all that apply.) a. Arms b. Perineum c. Chest d. Shoulder joint e. Genitalia f. Face g. Hands

b. Perineum d. Shoulder joint e. Genitalia f. Face g. Hand Burns of face, hands, feet, genitalia, perineum, or major joints that may result in cosmetic or functional disability

A patient is admitted after being burned in a car fire. The wound surface is red with patchy white areas that blanch with pressure but no blister formation. What kind of burn would the nurse document in the patient's record? a. Superficial partial-thickness burn b. Moderate partial-thickness burn c. Deep dermal partial-thickness burn d. Full-thickness burn

c. Deep dermal partial-thickness burn •A superficial (first-degree) burn involves only the first two or three of the five layers of the epidermis. These wounds usually heal in 2 to 7 days. •A partial-thickness (second-degree) burn involves all of the epidermis and part of the underlying dermis. Despite the loss of the entire basal layer of the epidermis, a burn of this depth will heal in 7 to 21 days. •Deep-dermal partial-thickness (second-degree) burns involve the entire epidermal layer and deeper layers of the dermis. Only a modest plasma surface leakage occurs because of severe impairment in blood supply. The wound surface usually is red with patchy white areas that blanch with pressure. The appearance of the deep-dermal wound changes over time. Dermal necrosis and surface coagulated protein turn the wound from white to yellow. •A full-thickness (third-degree) burn involves destruction of all the layers of the skin down to and including the subcutaneous tissue. A full-thickness burn appears pale white or charred, red or brown, and leathery. The surface of the burn may be dry, and if the skin is broken, fat may be exposed. Full-thickness burns usually are painless and insensitive to palpation. Because all of the epithelial elements are destroyed, the wound will not heal by reepithelialization. Wound closure of small full-thickness can be achieved with healing by contraction.

A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/hr, and clear lung sounds. What adjustment, if any, needs to be made to the fluid resuscitation plan? a. Continue as planned; everything looks good. b. IV rate should be decreased and colloids started. c. IV rate should be increased and fluid status closely watched. d. Fluids should be switched to packed red blood cells.

c. IV rate should be increased and fluid status closely watched. Fluid resuscitation is a dynamic process. The rate of fluid administration is adjusted according to the individual's response, which is determined by monitoring urine output, heart rate, blood pressure, and level of consciousness. Meticulous attention to the patient's intake and output is imperative to ensure that he or she is appropriately resuscitated.

What physiologic process can result in excessive burn edema and shock in a patient with injuries totaling more than 50% total body surface area (TBSA) burn? a. The heat from the burn leads to immediate vascular wall destruction and extravasation of intravascular fluid. b. A positive interstitial hydrostatic pressure occurs in the dermis leading to burn wound edema. c. Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space. d. Capillary permeability decreases in burned and unburned tissue, leading to hypovolemia.

c. Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space.

A nurse is caring for a patient who was burned 2 weeks ago. The nurse knows the patient has entered the next phase of healing which is characterized by rapid synthesis of collagen. What phase is the patient in? a. Wound phase b. Inflammatory phase c. Proliferative phase d. Maturation phase

c. Proliferative phase Inflammatory phase up to 3-5 days after injury Inflammatory responses: Vascular changes & Cellular activity Platelets aggregate; blood coagulation; smooth muscle contraction Proliferative phase 4 to 20 days after injury Granulation tissue formation (Epithelialization) Fibroblasts synthesize collagen Maturation (remodeling) phase 20 days to more than a year after injury Scar tissue formation

The nurse and a new graduate nurse are caring for a patient with extensive burns. They are discussing skin grafts. Which statement indicates the new graduate understood the information? a. "Autografts are procured from both live and deceased donors." b. "Autografts can be placed at the bedside or in the operating room." c. "Autografts can transmit disease and be rejected." d. "Autografts provide permanent coverage and are the least expensive."

d. "Autografts provide permanent coverage and are the least expensive." An autograft is a skin graft harvested from a healthy, uninjured donor site on the burn patient and then placed over the patient's burn wound to provide permanent coverage of the wound. Preferred sites for obtaining the grafts are the thighs, back, and abdomen. Skin substitutes can be used until the patient's own skin is available for harvesting in the case of large TBSA burns.

A patient involved in a house fire is brought by ambulance to the emergency department. The patient is breathing spontaneously but appears agitated and does not respond appropriately to questions. The nurse knows the patient has inhaled carbon monoxide and probably has carbon monoxide (CO) poisoning. What action should the nurse take next? a. Ask the practitioner to order a STAT chest radiograph. b. Apply a pulse oximeter to one of his unburned fingers. c. Call the local hyperbaric chamber to check on its availability. d. Administer 100% oxygen via a nonrebreathing mask.

d. Administer 100% oxygen via a nonrebreathing mask. The treatment of choice for carbon monoxide poisoning is high-flow oxygen administered at 100% through a tight-fitting nonrebreathing mask or endotracheal intubation. The half-life of carbon monoxide in the body is 4 hours at room air (21% oxygen), 2 hours at 40% oxygen, and 40 to 60 minutes at 100% oxygen.

Less than 24 hours ago a patient sustained full-thickness burns, to his face, chest, back, and bilateral upper arms, in a house fire. He also sustained an inhalation injury. The patient was intubated and ventilated and is now showing signs of increasing agitation and rising peak airway pressures. The nurse suspects the patient's change in condition is due to which problem? a. Uncontrolled pain b. Hypovolemia c. Worsening hypoxemia d. Decreased pulmonary compliance

d. Decreased pulmonary compliance

A patient with extensive burns is undergoing skin grafting. The nurse understands pain control is best achieved with what strategies during the early phase of recovery? a. Large doses of opioids given intramuscularly b. Intravenous opioids used in combination with oral antidepressants c. Large doses of opioids given subcutaneously d. Small doses of intravenous opioids titrated to effect

d. Small doses of intravenous opioids titrated to effect Initially after burn injury, opiates are administered intravenously in small doses and titrated to effect. The constant background pain may be addressed with the use of a patient-controlled analgesia (PCA) device.

A patient is admitted after being burned in a house fire. The nurse feels that the patient should be transferred to a burn center. Which factor is most important when determining whether or not to refer a patient to a burn center? a. The size and depth of burn injury and the burning agent b. The age and present medical history of the patient c. The depth of the burn injury and the presence of soot in the sputum d. The medical history of the patient and the size and depth of the burn injury

d. The medical history of the patient and the size and depth of the burn injury Burns are classified primarily according to the size and depth of injury. However, the type and location of the burn and the patient's age and medical history are also significant considerations. Recognition of the magnitude of burn injury is crucial in the overall plan of care and in appropriate referral to a burn center.

A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/hr, and clear lung sounds. The nurse knows that the patient's symptoms are most likely attributable what cause? a. Blood loss associated with burns and pain. b. Hemodynamic stability related to adequate fluid resuscitation. c. Over-resuscitation related to overestimation of the burn area involved. d. Under-resuscitation because of probable wound conversion.

d. Under-resuscitation because of probable wound conversion. Underresuscitation may result in inadequate cardiac output, leading to inadequate organ perfusion and the potential for wound conversion from a partial-thickness to full-thickness injury. Overresuscitation may lead to moderate to severe pulmonary edema, to excessive wound edema causing a decrease in perfusion of unburned tissue in the distal portions of the extremities, or to edema inhibiting perfusion of the zone of stasis resulting in wound conversion.

Full thickness 3rd degree

involves destruction of all the layers of the skin down to and including the subcutaneous fat. The subcutaneous tissue is composed of adipose tissue, includes the hair follicles and sweat glands, and is poorly vascularized. A full-thickness burn appears pale white or charred, red or brown, and leathery. The surface of the burn may be dry, and if the skin is broken, fat may be exposed. Full-thickness burns usually are painless and insensitive to palpation.