Chapter 57 Management of Patients with Burn injury

A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A) 2 days B) 3 days C) 5 days D) 1 week

A) 2 days Rationale: Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. Changes detected by x-ray and arterial blood gases may occur as the effects of resuscitative fluid and the chemical reaction of smoke ingredients with lung tissues become apparent.

A nurse who provides care on a burn unit is preparing to apply a patient's ordered topical antibiotic ointment. What action should the nurse perform when administering this medication? A) Apply the new ointment without disturbing the existing layer of ointment. B) Apply the ointment using a sterile tongue depressor. C) Apply a layer of ointment approximately 1/16 inch thick. D) Gently irrigate the wound bed after applying the antibiotic ointment.

C) Apply a layer of ointment approximately 1/16 inch thick. Rationale: After removing the old ointment from the wound bed, the nurse should apply a layer of ointment 1/16-inch thick using clean gloves. The wound would not be irrigated after application of new ointment.

Which of the following intravenous solutions is an apropriate choice to administer during the first 24 hours of fluid resuscitation following a burn injury? - Lactated Ringer's - D5W - 0.45% normal saline - D5W 1/2 normal saline with 20mEq KCl

Lactated Ringer's

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? - Avoid immediate IV fluid therapy - Place the client with the head positioned slightly below the rest of the body - Cover the client with a wet cloth - Roll the client in a blanket

Roll the client in a blanket Rationale: At the scene of a fire, the client should be rolled in a blanket to smother the fire. The client should be placed in a horizontal position to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passage. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital.

The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application? - Gentamicin sulfate - Mafenide (Sulfamylon) - Cerium nitrate solution - Sulfadiazine, silver (Silvadene)

Sulfadiazine, silver (Silvadene) Rationale: With use of silver sulfadiazine (Silvadene), the nurse should watch for leukopenia 2 to 3 days after initiation of therapy. (Leukopenia usually resolves within 2 to 3 days.)

A burn patient is transitioning from the acute phase of the injury to the rehabilitation phase. The patient tells the nurse, "I can't wait to have surgery to reconstruct my face so I look normal again." What would be the nurse's best response? A) "That's something that you and your doctor will likely talk about after your scars mature." B) "That is something for you to talk to your doctor about because it's not a nursing responsibility." C) "I know this is really important to you, but you have to realize that no one can make you look like you used to." D) "Unfortunately, it's likely that you will have most of these scars for the rest of your life."

A) "That's something that you and your doctor will likely talk about after your scars mature." Rationale: Burn reconstruction is a treatment option after all scars have matured and is discussed within the first few years after injury. Even though this is not a nursing responsibility, the nurse should still respond appropriately to the patient's query. It is true that the patient will not realistically look like he or she used to, but this does not instill hope.

BURN - QSNA

Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing a patent airway and giving humidified 100% oxygen. If qualified personnel and equipment are available and the patient with burns has severe respiratory distress and/or airway edema, the rescuers must insert an endotracheal tube and initiate mechanical ventilation. No food or fluid is given by mouth, and the patient is placed in a position that will prevent aspiration of vomitus, because nausea and vomiting may occur, and protection of the airway is always a priority.

The nurse is preparing the patient for mechanical débridement and informs the patient that this will involve which of the following procedures? A) A spontaneous separation of dead tissue from the viable tissue B) Removal of eschar until the point of pain and bleeding occurs C) Shaving of burned skin layers until bleeding, viable tissue is revealed D) Early closure of the wound

B) Removal of eschar until the point of pain and bleeding occurs Rationale: Mechanical débridement can be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical débridement can also be accomplished through the use of topical enzymatic débridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural débridement. Shaving the burned skin layers and early wound closure are examples of surgical débridement.

The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings? - Apply an elastic stocking to the extremity and administer SQ heparin per order - Document the finding and instruct the client to report numbness of the extremity - Contact the primary care provider and prepare for an escharotomy - Elevate the leg on pillow and reassesses the leg in 1 hour

Contact the primary care provider and prepare for an escharotomy Rationale: The nurse assesses peripheral pulses frequently with a Doppler ultrasound device, if needed. Frequent assessment also includes warmth, capillary refill, sensation, and movement of extremity. It is necessary for the nurse to report loss of pulse or sensation or presence of pain to the physician immediately and to prepare to assist with an escharotomy. The other interventions are inappropriate when the nurse has detected a loss of peripheral pulses.

A nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following? A) Assess the patient for signs of electrolyte imbalances B) Administer fluids as ordered. C) Assess the risk for injury recurrence. D) Assess the patient's psychosocial state.

D) Assess the patient's psychosocial state. Rationale: Recovery from burns can be psychologically challenging; the nurse's assessments must address this reality. Fluid and electrolyte imbalances are infrequent during the rehabilitation phase of recovery. Burns are not typically a health problem that tends to recur; the experience of being burned tends to foster vigilance.

A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patient's arm? A) Superficial partial-thickness B) Deep partial-thickness C) Full partial-thickness D) Full-thickness

D) Full-thickness Rationale: A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis; the patient will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis; the patient will complain of pain and sensitivity to cold air. Full partial thickness is not a depth of burn.

A nurse is caring for a patient with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? A) Maintenance of bed rest to aid healing B) Choosing appropriate splints and functional devices C) Administration of beta adrenergic blockers D) Prevention of venous thromboembolism

D) Prevention of venous thromboembolism Rationale: Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the patient is important. The nurse monitors the splints and functional devices, but these are selected by occupational and physical therapists. The hemodynamic changes accompanying burns do not normally require the use of beta blockers.

A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client - Prevent infection - Fluid resuscitation - Strict intake and output - Endotracheal tube placement

Fluid resuscitation Rationale: Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts.

A client with a burn over the lower leg asks why surgery is planned to remove the dead burned tissue. Which response will the nurse make? - It encourages your body'a natural processes to liquefy and damaged tissue - It reduces the amount of scarring that will occur on the skin - It reduces the risk of complications from an infection - It reduces the amount of wound care that you will need as the skin heals

It reduces the risk of complications from an infection Rationale: Early surgical excision to remove devitalized tissue along with early burn wound closure has long been recognized as one of the most important factors contributing to survival in a client with a major burn injury. When conducted in a timely and efficient manner, surgical excision results in shorter lengths of hospital stay and decreased risk of complications from invasive burn wound sepsis. Surgical debridement is not done to reduce the amount of scarring or the amount of wound care that will be needed. Natural debridement is a bodily process that liquefies any damaged tissue and may take weeks to months to occur.

Pt has a nasojejunal tube inserted for enteral feeding after burn injury. Which of the following statements should the nurse include when explaining the rationale for the procedure? - Major burn injuries can increase your caloric needs by 200 kcals/day - We will have to institute a plan to decrease your risk for aspiration now this tube is in place - Nutrition is important in preventing infection and promoting wound healing - Supplemental vitamins and minerals are not necessary once the deeding is started

Nutrition is important in preventing infection and promoting wound healing Rationale: Hypermetabolism occurs immediately after a burn injury. Caloric needs may double after major burn injury. Supplemental vitamins and minerals are administered because the patient's hyper-metabolic and at risk for infection. By placing a feeding tube past the pyloric sphincter, the risk for aspiration is decreased.

The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn? - Diverticulitis - Hematemesis - Paralytic ileus - Ulcerative colitis

Paralytic ileus Rationale: Patients who are critically ill, including those with burns, are predisposed to altered gastrointestinal (GI) motility for many reasons, which may include impaired enteric nerve and smooth muscle function, inflammation, surgery, medications, and impaired tissue perfusion. Three of the most common GI alterations in burn-injured patients are paralytic ileus (absence of intestinal peristalsis), Curling's ulcer, and translocation of bacteria. Decreased peristalsis and bowel sounds are manifestations of paralytic ileus.

A home care nurse is performing a visit to a client's home to perform wound care following the client's hospital treatment for severe burns. While interacting with the client, the nurse should assess for evidence of what complication? A. Psychosis B. Posttraumatic stress disorder C. Delirium D. Vascular dementia

Posttraumatic stress disorder Rationale: Posttraumatic stress disorder (PTSD) is the most common psychiatric disorder in burn survivors, with a prevalence that may be as high as 45%. As a result, it is important for the nurse to assess for this complication of burn injuries. Psychosis, delirium, and dementia are not among the noted psychiatric and psychosocial complications of burns.

A client brought to the emergency department has been exposed to smoke and flames from a house fire. What assessment finding is most important to the nurse in determining care of the client? - Partial-thickness burns to hands and wrists - Fracture of the fibula with displacement - Presence of soot around nasal passages - Elevation of blood pressure and heart rate

Presence of soot around nasal passages Rationale: If the client has soot or evidence of carbon about the nasal passages, the nurse should anticipate respiratory difficulties. Edema and swelling of the internal airways may not be present initially but can progress quickly. Elevation of heart rate without hypotension is not as significant. Fracture to any bone as well as care of burns should be managed once the airway, breathing, and circulation are assessed and managed.

Which is the primary reason for placing a client in a horizontal position while smothering flames are present? - To promote blood flow to the brain and vital organs - To keep fire and smoke away from airway - To prevent collapse and further injuries - To extinguish flames more quickly

To keep fire and smoke away from airway Rationale: The primary reason the client is placed in a horizontal position while smothering flames is to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passages. The stop, drop, and roll method is a quick and efficient means to extinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head.

Assessment of Burn Injuries

- First goal is prevention of a burn injury. - When a burn injury does occur, it is typically a thermal burn and requires holistic care.

When caring for a graft site, the nurse needs to observe which of the following key points? Select all that apply. - The dressing of a graft site should be changes every 12 hours - When turning or positioning the patient, care should be taken to avoid pressure on the graft side - The extremity that has been grafted should be elevated - Occlusive dressings and splints may be used to immobilize the graft

- When turning or positioning the patient, care should be taken to avoid pressure on the graft side - The extremity that has been grafted should be elevated - Occlusive dressings and splints may be used to immobilize the graft Rationale: Immobilization is an important part of nursing care for a patient with a burn injury. The initial dressing change is usually not performed until 2 to 5 days after surgery

Abdominal Compartment Syndrome (ACS)

- the abdomen has become a fixed compartment with increased pressure resulting in ischemia and organ dysfunction - Early indications include: abdominal distention, oliguria, and difficulties with mechanical ventilation

A goal of fluid resuscitation following a burn injury is ...

0.5 ml of urine/ kg body weight/ hour.

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned? - 18% - 9% - 27% - 36%

36% Rationale: According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities that have sustained burns to entire surfaces will equal to 36% of total surface area.

A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications? A) A 4-year-old scald victim burned over 24% of the body B) A 27-year-old male burned over 36% of his body in a car accident C) A 39-year-old female patient burned over 18% of her body D) A 60-year-old male burned over 16% of his body in a brush fire

A) A 4-year-old scald victim burned over 24% of the body Rationale: Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the patient.

A patient has sustained a severe burn injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will best assist in avoiding increased intestinal permeability and prevent early endotoxin translocation?A) Early enteral feeding B) Administration of prophylactic antibiotics C) Bowel cleansing procedures D) Administration of stool softeners

A) Early enteral feeding Rationale: If the intestinal mucosa receives some type of protection against permeability change, infection could be avoided. Early enteral feeding is one step to help avoid this increased intestinal permeability and prevent early endotoxin translocation. Antibiotics are seldom prescribed prophylactically because of the risk of promoting resistant strains of bacteria. A bowel cleansing procedure would not be ordered for this patient. The administration of stool softeners would not assist in avoiding increased intestinal permeability and prevent early endotoxin translocation.

BURNS - QSNA

Dressings can impede circulation if they are wrapped too tightly. The peripheral pulses must be checked frequently and burned extremities elevated. If the patient's pulse is diminished, this is a critical situation and must be addressed immediately.

Formulas are only a guide for burn care fluid resuscitation. How often must the patient' s response to fluid therapy (heart rate, blood pressure, and urine output) be evaluated? A. Every hour B. Every 2 hours C. Every 3 hours D. Every 4 hours

Every hour Rationale: The patient's response to fluid therapy should be evaluated at least hourly.

What are the expected findings in the fluid remobilization phase (acute phase, diuresis) that the nurse should monitor for? Select all that apply. - Hemodilution - Sodium deficit - Hypoglycemia - Increased urinary output - Metabolic alkalosis

Hemodilution* Sodium deficit* Increased urinary output Rationale: Hemodilution (decreased hematocrit), increased urinary output, metabolic acidosis (not alkalosis), sodium deficit, and hypokalemia (not hypoglycemia) are typical fluid and electrolyte changes that occur in the acute phase (fluid remobilization phase, state of diuresis).

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply. - Percentage of meals eaten - Hourly urine output - Daily weights - Oxygen saturation - Skin turgor

Hourly urine output* Daily weights* Skin turgor

The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first? - Infection - Tissue hypoxia - Hypovolemia - Renal failure

Hypovolemia Rationale: After a burn, fluid from the body moves toward the burned area, which leads to intravascular fluid deficit. Steps must be taken to prevent irreversible hypovolemic shock in the initial stages of treatment. The inflammatory processes that affect the tissues cause additional injury, which contributes to tissue hypoxia. Myoglobin and hemoglobin that were destroyed during the burn can result in acute renal failure. Destruction of the skin barrier results in colonization of bacteria and can lead to life-threatening infection in days following the burn.

Which of the following are further indications of possible pulmonary damage after a burn injury? Select all that apply. - Labored respirations - Voice changes, stridor - Tachycardia - Soot-tinged sputum

Labored respiration* Voice changes, stridor* Soot-tinged sputum

The nurse determines which statement reflects current research regarding the utilization of non-pharmacological measures in the management of burn pain? - Humor therapy has not proven effective in the management of burn pain - Pet therapy has proven effective in the management of pain - Music therapy may provide reality orientation, distraction, and sensory stimulation - Music therapy diverts the client's attention toward painful stimulus

Music therapy may provide reality orientation, distraction, and sensory stimulation Rationale: Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the client's attention away from the painful stimulus. Music may also provide reality orientation, distraction, and sensory stimulation. It allows for client self-expression. Humor therapy has proven effective in the management of burn pain. Pet therapy has not proven effective in the management of burn pain.

A client with a superficial partial-thickness solar burn (sunburn) of the chest, face, and arms is seen in urgent care. The nurse's primary concern should be: - Pain management - Fluid resuscitation - Infection - Body image

Pain management Rationale: With a superficial partial- thickess burn such as solar burn, the nurse's main concern is pain managemnet. In this patient, fluid resucitation, body image disturbance, and infections are concern; hwever they have a lower priority than pain managemnet.

Which of the following are possible pulmonary damage after a burn injury? Select all that apply. - Incident occurred in an enclosed space - Singed nasal hair - Hypotension - Facial and/or neck burns

- Incident occurred in an enclosed space - Singed nasal hair - Facial and/or neck burns Rationale: Oxygenation to the peripheral tissues can also be affected by bronchoconstriction, hyper-metabolism, and the catecholamine release after a burn injury. Supplemental oxygenation is administered to ensure adequate oxygenation to body tissues.

Phases of burn care

1) Emergent (resuscitative) phase: rapid fluid replacement in first 24-48 hours to maintain tissue perfusion and prevent hypovolemic shock 2) Acute (intermediate): end of fluid resuscitation-->end of wound covering 3) Rehabilitative

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? - 45% - 27% - 18% - 36%

27% Rationale: The TBSA would be 27%. That is 18% of the body surface for the anterior trunk and 9% for the left arm.

A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation? A. Pain B. Fluid balance C. Anxiety and fear D. Airway management

Airway management Rationale: Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early post-burn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.

Allograft/ Homograft: Cadaver skin Xenograft/ Heterograft: Animal skin Autograft: Patient's own skin

Biologic dressings such as homografts and heterografts are used as temporary dressings. Autografts are used for a permanent wound covering.

The nurse caring for a client who is recovering from full-thickness burns is aware of the client's risk for contracture and hypertrophic scarring. How can the nurse best reduce this risk? A. Apply skin emollients as prescribed after granulation has occurred. B. Keep injured areas immobilized whenever possible to promote healing. C. Administer oral or IV corticosteroids as prescribed. D. Encourage physical activity and range-of-motion exercises.

Encourage physical activity and range-of-motion exercises. Rationale: Exercise and the promotion of mobility can reduce the risk of contracture and hypertrophic scarring. Skin emollients are not normally used in the treatment of burns, and these do not prevent scarring. Steroids are not used to reduce scarring, as they also slow the healing process.

Why are full-thickness burns generally pain free?

Full-thickness burns involve the epidermis, dermis, and subcutaneous tissues; therefore, the nerve endings are destroyed.

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary? - Altered tissue perfusion - Risk for impaired gas exchange - Infection risk - Acute pain

Risk for impaired gas exchange Rationale: During the initial assessment of a burn victim, the nurse must look for evidence of inhalation injury. Once oxygen saturation and respirations are determined, pain intensity is evaluated. The assessment of damage to the tissues and prevention of infection are secondary to airway issues.

Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply. - Singed nasal hair - Bradypnea - Facial burns - Hoarseness - Yellow sputum

Singed nasal hair* Hoarseness* Facial burns

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to - increase glucose demands - increase metabolic rate - decrease catabolism - increase skeletal muscle breakdown

decrease catabolism Rationale: The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? - inflammatory - hypertension - neuroendocrine - intravascular fluid excess

inflammatory Rationale: The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury.

Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of: - coagulation - stasis - hyperemia - hypotension

stasis Rationale: The zone of stasis is the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. The zone of coagulation is at the center of the injury, and it is the area where the injury is most severe and usually deepest. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. The zone of hypotension is not the name of one of the zones.

Acute/ Intermediate Phase

- Phase begins 48-72 hours after the burn injury - Pulmonary complications can take 48 hours to develop - 48 hours after injury fluid moves from the interstitial space to the intravascular compartment and diuresis begins - If cardiac or renal function is inadequate, fluid overload may occur and s/s of CHF may result - Administration of Fluid and electrolytes continue cautiously - Early Surgical Intervention - Hyperthermia is common; do not give Tylenol; may masks/s of infection/sepsis - Risk for infection

A nurse is providing discharge teaching for a client with a burn wound on the leg. What instructions are important to give the client? Select all that apply. - Apply lubricating wound to the wound bed - Wash the wound with soap and water - Remain on bed rest - Report increased redness and wound drainage to the healthcare provider - Take pain medications daily

- Report increased redness and wound drainage to the healthcare provider - Wash the wound with soap and water

A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as - 27% - 36% - 18% - 9%

18% Rationale: The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the total body surface area (TBSA), quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%). In this case the client's abdomen (9%) and front of the left leg (9%) add up to 18%.

The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care? - Emergent - Immediate resuscitative - Acute - Rehabilitation

Acute Rationale: 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 (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound débridement, and wound grafting), pain management, and nutritional support are priorities at this stage. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching? - I can work with the social worker to find funding assistance programs to help with my medical expenses - I will drink a lot of fluids to prevent constipation since I am taking pain medications - I will wear sun block with the highest SPF possible to protect exposed burned skin form the sun - As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help

As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help Rationale: Itching is a normal part of healing. Many clients describe this as one of the most uncomfortable aspects of burn recovery. The client can apply mild moisturizers to decrease itching from dryness. Medications can be discussed with your treatment team. The client should pat the areas; scratching is contraindicated. The other statements indicate that teaching has been effective.

Which complication is common for victims of electrical burns? - Infection - Inhalation injury - Cardiac dysrhythmia - Hypovolemic shock

Cardiac dysrhythmia Rationale: Cardiac dysrhythmias are common for victims of electrical burns. If the patient has an electrical burn, a baseline electrocardiogram (ECG) is obtained and continuous monitoring is initiated. Any burn injury can lead to complications, such as inhalation injury, infection, and hypovolemic shock.

A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client? - Hemoconcentration - Lack of erythropoietin factor - Hemodilution - Metabolic acidosis

Hemodilution Rationale: Reduced hematocrit is caused by hemodilution 48 hours after a burn, in which volume overload resulting from interstitial-to-plasma fluid shift lowers the concentration of erythrocytes and other blood elements. Hemoconcentration results from hypoalbuminemia, which causes the movement of fluid from the vascular component to the interstitial space. Metabolic acidosis does cause the red blood cell components to be fragile, but it isn't related to reduced hematocrit level in this situation. Erythropoietin factor is reduced if kidney failure occurs; however, lack of erythropoietin factor doesn't affect hematocrit level.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? - Complains of intense thirst - Urine output of 70 ml the first hour - Moderate to severe pain - Hoarseness of the voice

Hoarseness of the voice Rationale: Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate.

Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation? - Myoglobin in the urine - Hypernatremia - Increase in antidiuretic hormone (ADH) - Elevation of blood glucose levels

Myoglobin in the urine Rationale: Myoglobin from muscle tissue destruction is transported to the kidneys for excretion and can cause tubular necrosis and acute renal failure. Increase in fluid intake until urine output clears is recommended in serious burns. An increase in ADH release is expected as the body tries to prevent hypovolemic shock. Elevation in glucose levels occurs when the adrenal cortex is stimulated. Sodium levels rise in response to aldosterone levels, which directly leads to peripheral edema.

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? - The client has experienced partial-thickness burns - The paramedic administered high doses of opioids during transport - The client is in hypovolemic shock - The client has experienced extensive full-thickness burns

The client has experienced extensive full-thickness burns Rationale: In full-thickness burns, nerves are damaged and consequently painless. Behavior change is not a significant symptom of hypovolemic shock. Opioids are used in the management of pain associated with partial-thickness burns but not significant in the behavior exhibited. Partial-thickness burns are associated with increased pain to the area of involvement.

A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood? A. The client is likely experiencing a delayed onset of respiratory complications B. The client has likely developed a systemic infection C. The client's respiratory complications are likely related to psychosocial stress D. The client is likely experiencing an anaphylactic reaction to a medication

The client is likely experiencing a delayed onset of respiratory complications Rationale: Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. A systemic infection would be less likely to cause respiratory complications. This problem is more likely to be caused by physiologic factors at this phase, not psychological factors. Anaphylaxis must be ruled out, but it is less likely than a response to the initial injury.

A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area? - allograft - silvadene application - escharotomy - debridement

escharotomy Rationale: Debridement is the removal of necrotic tissue. An escharotomy is an incision into the eschar to relieve pressure on the affected area. An allograft would not be the treatment. Silvadene may be part of the treatment regimen but not specifically for this situation.

A nurse who is taking care of a client with burns is asked by a family member why the client is losing so much weight. The client is currently in the intermediate phase of recovery. What would be the nurse's most appropriate response to the family member? A. "The client is on a calorie-restricted diet in order to divert energy to wound healing." B. "The client's body has consumed fat deposits for fuel because calorie intake is lower than normal." C. "The client actually hasn't lost weight. Instead, there's been a change in the distribution of body fat." D. "The client lost many fluids while being treated in the emergency phase of burn care."

"The client's body has consumed fat deposits for fuel because calorie intake is lower than normal." Rationale: Clients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized as a result of hypermetabolism. Clients are not placed on a calorie restriction during recovery, and fluid losses would not account for weight loss later in the recovery period. Changes in the overall distribution of body fat do not occur.

A client is cared for in a burn unit after suffering partial-thickness burns. The client's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine to be applied to the client's burns. The nurse provides information to the client about the medication. Which statement made by the client indicates an understanding about this treatment? Select all that apply. - This medication will stain my skin permanently - This medication is an antibacterial - This medication will help my burn heal - This medication will be applied directly to the wound

- This medication is an antibacterial - This medication will help my burn heal - This medication will be applied directly to the wound Rationale: This medication is an antibacterial, which has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to the wound. This medication will not stain the client's skin, but it will help heal the client's burned areas

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? - 27% - 9% - 36% - 18%

27% Rationale: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.

An emergency department nurse has just received a patient with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the patient's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? A) Administer IV fluids B) Administer broad-spectrum antibiotics C) Administer IV potassium chloride D) Administer packed red blood cells

A) Administer IV fluids Rationale: Pathophysiologic changes resulting from major burns during the initial burn-shock period include massive fluid losses. Addressing these losses is a major priority in the initial phase of treatment. Antibiotics and PRBCs are not normally administered. Potassium chloride would exacerbate the patient's hyperkalemia.

Which of the following measures can be used to cool a burn? - Using cold soaks or dressings for at-least 1 hour - Wrapping the person in ice - Application of ice directly to burn - Application of cool water

Application of cool water Rationale: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis? A) Activity Intolerance B) Anxiety C) Ineffective Coping D) Acute Pain

D) Acute Pain Rationale: Pain is inevitable during recovery from any burn injury. Pain in the burn patient has been described as one of the most severe causes of acute pain. Management of the often-severe pain is one of the most difficult challenges facing the burn team. While the other nursing diagnoses listed are valid, the presence of pain may contribute to these diagnoses. Management of the patient's pain is the priority, as it may have a direct correlation to the other listed nursing diagnoses.

Rule of 9's

Head and neck = 9% Upper Ex = 9% each Lower Ex = 9% each Front trunk (abdomen and chest) = 18% Back trunk = 18%

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: - Hypocalcemia - Hyperkalemia - Hypoglycemia - Hypernatremia

Hyperkalemia Rationale: Circulating blood volume decreases dramatically during burn shock due to severe capillary leak with variation of serum sodium levels in response to fluid resuscitation. Usually, hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? - Wash the wounds with soap and water and apply a barrier cream - Do nothing until the chemical agent is identified - Insert a 20 gauge IV catheter and infuse normal saline solution at 150 ml/hour - Irrigate the wounds with water

Irrigate the wounds with water Rationale: The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage. Washing the wounds with soap and water might cause a chemical reaction that may further damage tissue. The client may require I.V. fluid; however, the wounds should be irrigated first.

A client who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment? A. Monitoring fluid and electrolyte imbalances B. Providing education to the client and family C. Treating infection D. Promoting thermoregulation

Providing education to the client and family Rationale: Client and family education is a priority during rehabilitation. There should be no fluid and electrolyte imbalances in the rehabilitation phase. The presence of impaired thermoregulation or infection would suggest that the client is still in the acute phase of burn recovery.

Which of the following is to be expected soon after a major burn? Select all that apply. - Hypertension - Bradycardia - Tachycardia - Anxiety - Hypotension

Tachycardia* Anxiety* Hypotension

While performing a client's ordered wound care for the treatment of a burn, the client has made a series of sarcastic remarks to the nurse and criticized the nurse's technique. How should the nurse best interpret this client's behavior? A. The client may be experiencing an adverse drug reaction that is affecting cognition and behavior. B. The client may be experiencing neurologic or psychiatric complications of the client's injuries. C. The client may be experiencing inconsistencies in the care being provided. D. The client may be experiencing anger about current circumstances that the client is deflecting toward the nurse.

The client may be experiencing anger about current circumstances that the client is deflecting toward the nurse. Rationale: The client may experience feelings of anger. The anger may be directed outward toward those who escaped unharmed or toward those who are now providing care. While drug reactions, complications, and frustrating inconsistencies in care cannot be automatically ruled out, it is not uncommon for anger to be directed at caregivers.

Medical management of Emergent/ Resuscitative Phase

- Stabilization!!! - ABC - Assessment. for secondary injuries - Remove all clothing and jewelry - Contact lenses? Removal - Monitor temperature - Validate history of injury - Indwelling catheter - Burns >20% TBSA need NGT to LIS - Tetanus prophylaxis if not given within last 5 years

Classification of Burns

- Superficial partial-thickness (First degree): red and dry, blanches to pressure (Burn involving the epidermal layer of the skin) - Deep partial-thickness (Second degree): red and moist with blisters. (Burn involving epidermal and portions of the dermal layer of the skin) Pain is a common symptom of partial-thickness burns. - Full thickness (Third degree): dry, leathery, and pain free (Burn involving epidermal and entire layer of dermal layers of the skin that may extend into the subcutaneous layer down to the muscle and bone)

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this patient's care? A) Fluid status B) Risk of infection C) Nutritional status D) Psychosocial coping

A) Fluid status Rationale: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.

Pathophysiology in Burn Injury

Following a major burn injury - capillary permeability increases, resulting in fluid shifting from the intravascular space to the interstitial space. - This fluid shift is called edema or third spacing (mobilization of body fluid to a non-contributory space rendering it unavailable to the circulatory system) - Larger burns are associated with generalized edema, including edema of the airway. - The loss of fluid from the intravascular space alters circulation by decreasing cardiac output and perfusion to vital organs. For smaller burns - Edema is localized Treatment includes aggressive fluid resuscitation.

A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patient's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? A) Ischemia B) Referred pain C) Cellulitis D) Venous thromboembolism (VTE)

A) Ischemia Rationale: As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. Referred pain, cellulitis, and VTE are not noted complications that occur distal to the injury site.

Fluid replacement calculation for Burn injury

For adults within 24 hours post thermal/ chemical or electrical burns 4ml LR * patient's weight in kilograms * % TBSA second, third and fourth degree burns - Half of the calculated amount is administered in the first 8 hours - Remainder half administered over the next 16 hours. Effective fluid replacement can be evaluated by the heart rate, blood pressure, and urine output.

Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided? - Removal of clothing - Removal of hair - Application of ice - Irrigation of the wound

Application of ice Rationale: Application of ice causes vasoconstriction and diminishes needed blood flow to the zone of injury. Clothing and hair are removed from perimeter of burned area in an effort to remove course of bacterial contamination. Irrigation of the wound assists in the removal of debris.

A client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client's laboratory studies, the nurse will expect the results to indicate what findings? - Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis - Hypokalemia, hypernatremia, decreased hematocrit, metabolic acidosis - Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis - Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosisrr

Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis Rationale: Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amounts of sodium lost in trapped edema fluid, and hemoconcentration that leads to an increased hematocrit.

A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? A) Instruct the patient to keep the wound site in a dependent position. B) Administer PRN analgesia as ordered. C) Assess the patient's peripheral pulses distal to the dressing. D) Assist with passive range of motion exercises to "set" the new dressing.

C) Assess the patient's peripheral pulses distal to the dressing. Rationale: Dressings can impede circulation if they are wrapped too tightly. The peripheral pulses must be checked frequently and burned extremities elevated. Dependent positioning does not need to be maintained. PRN analgesics should be administered prior to the dressing change. ROM exercises do not normally follow a dressing change.

A patient with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the patient closely for what signs of the onset of burn shock? A) Confusion B) High fever C) Decreased blood pressure D) Sudden agitation

C) Decreased blood pressure Rationale: As fluid loss continues and vascular volume decreases, cardiac output continues to decrease and the blood pressure drops, marking the onset of burn shock. Shock and the accompanying hemodynamic changes are not normally accompanied by confusion, fever, or agitation.

A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? A) To prevent neuropathies B) To prevent wound breakdown C) To prevent contractures D) To prevent heterotopic ossification

C) To prevent contractures Rationale: To prevent the complication of contractures, the nurse will establish a goal to maintain position of joints in alignment. Gentle range of motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures. Joint alignment is not maintained specifically for preventing neuropathy, wound breakdown, or heterotopic ossification.

An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury? A) The length of time since the burn B) The location of burned skin surfaces C) The source of the burn D) The total body surface area (TBSA) affected by the burn

D) The total body surface area (TBSA) affected by the burn Rationale: Systemic effects are a result of several variables. However, TBSA and wound severity are considered the major factors that affect the presence or absence of systemic effects.

A client presents with a full-thickness burn to the anterior chest. The leathery skin is tight, making breathing difficult. The nurse anticipates which treatment management technique in the care of this client? - Escharotomy - Tracheostomy - Endotracheal tube insertion - Ventilator associated breathing

Escharotomy Rationale: In areas of full-thickness burns, eschar constricts the area and can impair circulation or expansion of the anterior chest wall. An escharotomy is performed to release the burn tissue on the anterior chest, freeing the chest for expansion with inspiration. Endotracheal tube insertion, tracheostomy, and ventilation do not correct the tightening of the chest and poor expansion issue.

A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do? - Lie down, have someone cover him with a blanket, and cover his legs with a petroleum jelly - Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel - Remove his pants so that the air can help cool the wound - Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area

Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel Rationale: After the flames are extinguished, the burned area and adherent clothing are soaked with cool water, briefly, to cool the wound and halt the burning process.

The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs immediately after burn injury? - Hypernatremia - Hypokalemia - Hypercalcemia - Hyperkalemia

Hyperkalemia Rationale: Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. During burn shock, serum sodium levels vary in response to fluid resuscitation. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss. Hyponatremia may also occur during the first week of the acute phase, as water shifts from the interstitial space and returns to the vascular space.

The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn? - Family history - Weight - Preexisting conditions - Age

Preexisting conditions Rationale: Preexisting disease disorders including trauma and infections can modify the inflammatory response and movement of fluid from the vascular to the interstitial space. Age, weight, and family history are not as significant in the inflammatory response following a burn.

A nurse is caring for a client in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values? A. Sodium deficit B. Decreased prothrombin time (PT) C. Potassium deficit D. Decreased hematocrit

Sodium deficit Rationale: Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include sodium deficit, potassium excess, and elevated hematocrit. PT does not typically decrease.

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? - Rectal temperature of 100.4 C - Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg - White pulmonary secretions - Urine output of 20 ml/hour

Urine output of 20 ml/hour Rationale: A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevate

A patient is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what? A) Hemodynamic instability B) Gastrointestinal hyper-motility C) Respiratory arrest D) Hypokalemia

A) Hemodynamic instability Rationale: The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. This precedes GI changes. Respiratory arrest may or may not occur, largely depending on the presence or absence of smoke inhalation. Hypokalemia does not take place in the initial phase of recovery.

A triage nurse in the emergency department (ED) receives a phone call from a frantic parent who saw their 4-year-old child tip a pot of boiling water onto themselves. The parent has called an ambulance. What should the nurse in the ED receiving the call instruct the parent to do? A. Cover the burn with ice and secure with a towel. B. Apply butter to the area that is burned. C. Immerse the child in a cool bath. D. Avoid touching the burned area under any circumstances.

Immerse the child in a cool bath. Rationale: After the flames or heat source have been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first-aid measure. Ice and butter are contraindicated. Appropriate first aid necessitates touching the burn.

In a client with burns on the legs, which nursing intervention helps prevent contractures? - Elevating the foot of the head - Applying knee splints - Hyperextending the client's palms - Performing shoulder range of motion exercises

Applying knee splints Rationale: Applying knee splints is one method which can help prevent leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs which is the focus for this individual's treatment and care.