Med-Surg II: Final Exam: Burns and Emergency Nursing
primary survey focuses on
-Airway -Breathing -Circulation -Disability - Exposure
Fluid resuscitation for burns:
1st 24H: 2 large bore IVs, lactated ringers 2nd 24H: colloids used to replace intravascular volume after 48-72H: Dextrose 5% if indicated, assess electrolytes
expected urine output for burn patients after fluid resuscitation
30-50 mL/H
Which area is MOST important for the nurse to assess for fluid balance in a client with full-thickness burns of the anterior trunk and thigh when monitoring fluid balance during the first 2-3 days after the burn? A. UOP every hour B. weight every day C. BP Q15 min D. extent of peripheral edema Q4H
A. UOP every hour
Which response would the nurse give to a client with third-degree burns who asks, "why do I need a temporary pigskin graft?" A. "it helps debride necrotic tissue" B. "it promotes rapid healing of the wound" C. "When sutured in place, it provides better adherence D. "topical lotions can be used concurrently with the graft"
B. "it promotes rapid healing of the wound"
A client, admitted with full thickness burns two weeks ago, has lost an average of 1 lb of weight each day. Which dietary adjustment would the nurse recommend? A. increase low-sodium milk intake B. provide high-protein drinks C. Increase foods low in potassium D. Provide 10% more calories in the form of fat
B. provide high-protein drinks
The nurse is caring for a patient with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion? A. decreased glomerular filtration rate B. Extensive blood clots through burned tissues C. Plasma proteins moving out of the intravascular compartment D. Sodium retention occurring as a result of the aldosterone mechanism
C. Plasma proteins moving out of the intravascular compartment
Which complication will it prevented administering a histamine H-2 antagonist to a client who has extensive burns? A. Colitis B. Gastritis C. Stress ulcer D. Metabolic acidosis
C. Stress ulcer
A client in the acute phase of burn recovery may exhibit an increase in which value? A. Serum sodium B. Hematocrit level C. Serum potassium D. Urinary output
D. Urinary output
The client has full thickness burns to40% of the body, including both legs,is being transferred from acommunity hospital to the burncenter. Which measure should beinstituted before the transfer? A. 22 gauge IV line w/ lactated ringers infusion B. Wounds covered w/ moist sterile dressings C. No IV pain medication D. ensure adequate peripheral circulation to both feet
D. ensure adequate peripheral circulation to both feet
A client has full-thickness burns to65% of the body, including the chestarea. After establishing a patentairway, which collaborativeintervention is a priority for the client? A. replace fluid and electrolytes B. prevent contractors of the extremities C. monitor urine output hourly D. prepare to assist wit escharotomy
D. prepare to assist wit escharotomy
For a client experiencing the emergent phase secondary to serious burns involving a large surface of the skin, which action is the nurse's priority during this phase? A. Alleviating pian B. preventing infection C. Replacing blood loss D. restoring fluid volume
D. restoring fluid volume
primary survey: disability
GCS and pupil test
What do we never give burn patients in the emergent phase?
IM/SQ injections
Risks with burns, watch for these
capillary leak syndrome DVT infection hypovolemic shock
Triage: black
dead
second degree burn
deep partial thickness; extend through epidermis and involve part of dermis red/cherry red, painful, blistering common nerves are intact
When evaluating fluid loss for a client with burns, which relationship between a client's burned BSA and fluid loss would the nurse consider?
directly proportional
Which type of burn should be scheduled for an EKG?
electrical
third degree burn
full thickness; burn through epidermis, dermis, and involves subcutaneous tissues. PAINLESS white skin with eschar
How do we maintain the cervical spine when assessing the posterior portion of the body?
logroll the patient
priority focus of rehabilitation phase of burns
minimize functional loss and provide psychosocial support
How are grafts used in full thickness burns?
patient's skin grafted to burn site (donor site is more painful that the graft site) remove serum accumulation from grafts imobilize and elevate graft site assess for rubor and edema
primary survey: Exposure
Remove all clothing for a complete physical assessment; Prevent hypothermia by covering patient w/blankets, using heating devices, infusing warm solutions
A firefighter is admitted to the emergency department with severe dermal and inhalation burns. On assessment, the nurse identifies tachycardia, tachypnea, and dyspnea. The nurse auscultates the client's lungs and expects to hear what type of breath sound?
Stridor
Fasciotomy
a surgical incision through the fascia to relieve tension or pressure
what is the order to put on PPE
(**GMEG**) gown, mask, eyewear, gloves
if a patient is receiving breaths from a non-rebreather bag, how many to they receive if they have a pulse?
1 breath every six seconds
expected urine output for electrical burn patients
100mL/H
parkland formula
4ml/kg of body weight 1/2 within the first 8 hours 1/4 next 8H 1/4 next 8H
Based on priority for care, which client condition would the nurse assign a red tag? A. Closed fracture B. third-degree burns over 25% of the body C. Severe abdominal pain D. Bruises and superficial lacerations
B. third-degree burns over 25% of the body
what do we avoid the first 12H after burns?
colloids (albumin)
biggest concern with circumferential burn
compartment syndrome
Phases of burn treatment: emergent: acute: rehabilitation
emergent: ends when fluid resuscitation is complete acute: begins at end of emergent and lasts until all full thickness wounds are healed rehabilitation phase: begins when patient is healed and capable of self care
In which order would the nurse take these actions when a client arrives in the ER with burns on the chest? 1. Cover the client with a warm blanket 2. Insert an IV 3. Assess client's RR 4. Calculate the extent of the client's burns
3. Assess client's RR 2. Insert an IV 1. Cover the client with a warm blanket 4. Calculate the extent of the client's burns
A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. which action will the nurse take FIRST? A. remove the client's clothing B. Evaluate weather the client has inhaled smoke C. insert IV catheter in unaffected arm D. Determine the extent of the burns using rule of 9s
B. Evaluate weather the client has inhaled smoke
Which intervention would be used as first aid for a client who has burn injuries from an electrical current until the client is transferred to a health care facility? A. Cover burns w/ ice B. Leave adherent clothing in place C. wrap client in clean, dry sheet D. remove as much burned clothing as possible E. Immerse the burned body part in cool water
B. Leave adherent clothing in place C. wrap client in clean, dry sheet D. remove as much burned clothing as possible
Which change would the nurse instruct the client to go see a PCP for when a client who sustained deep partial-thickness burns refuses to seek medical attention? A. blisters appear B. UOP decreases C. edema and redness occur D. white patches develop
B. UOP decreases
The nurse evaluates the condition of a client with upper body burns. Which assessment finding indicates potential respiratory obstruction? (Select all that apply) A. Soot on legs B. brassy cough C. deep breathing D. Singed nasal hair E. Dark mucus membranes
B. brassy cough D. Singed nasal hair E. Dark mucus membranes
Which action might have led to increased edema in the tissues surrounding chemical burns after a factory explosion? A. stabilizing cervical spine B. lowering burned limbs below the heart C. Brushing dry chemical from skin before irrigation D. flushing chemical from wound with NS
B. lowering burned limbs below the heart
primary survey: breathing
ensure O2 sat and O2 delivery
how do we feed burn patients?
enteral feedings; high protein, high calorie
Triage: blue
expected to die, nothing you can do
primary survey: circulation
feel for pulse (central), assess skin color/temp, assess cap refill; start 2 large bore IVs (14 or 16) LACTED RINGERS, aggressive fluid resuscitation
Which type of burn would the nurse suspect in a client admitted with a burn injury that has erythema and mild swelling?
first degree burn
primiroty concerns for emergent phase of burn care
fluid resuscitation
focus areas in the acute phase of burns
fluid resuscitation prevent infection metabolic support pain management wound care
Describe the difference in full-thickness and partial-thickness burns
full-thickness burns extend into the subcutaneous tissue partial-thickness burns extend through the epidermis and part of the dermis
what are burn patients at risk for in the emergent phase?
hypovolemic shock hyperkalemia hyponatremia
primary survey: Airway
jaw-thrust maneuver, protect cervical spine
Triage: red
life-threatening injury
Triage: Green
minor injury
Triage: yellow
non-life threatening injury
When is EET preferred?
patient cannot protect airway
biggest cause of death for inhalation injury
pneumonia
how do we position burn patients
position of comfort is NOT the best to prevent contractors.
escharotomy
removal of burn scar tissue
What are s/s of an inhalation injury?
respiratory distress horsiness black around nares or in throat
Which type of burns would the nurse assessing burn injuries identify on fire survivors with pink to cherry-red skin with blisters?
second degree burns
what is the process of medications for intubation?
sedate, paralize, intubate
what are the first things we do when a burn patient comes in?
tetanus shot, remove jewelry, contact lenses, and non-adherent clothing
fourth degree burns
thick and penetrating to muscle or bone
rule of nines
used to calculate body surface area
What can make burns more complicated?
age, health status, site of injury, mechanism of injury, depth of burn
Tx of inhalation injury
aggressive pulmonary toileting intubation 100% O2