NU272 Case Study: Burns (week 3)
Fluid replacement is noted to be ideal if client produces how much output/hour?
Urine is recorded as hourly output of 30 mL/kg (30 mL/2.2 lbs). - A child who weighs more than 30 kg (66 lbs) should produce 30 mL/kg (30 mL/2.2 lbs) to 50 mL/kg (50 mL/2.2 lbs) per hour.
Which response by the nurse has the highest priority?
"Have you thought about how you would kill yourself?" - It is the nurse's priority to assess the seriousness of the client's statement about killing himself. The more specific the plan, the higher the chance of a suicide attempt. His remarks must be taken seriously, and he should be referred to the proper professional for help.
According to Erikson, which statement by the client indicates that the client is achieving the tasks of his stage of growth and development?
"I really hate it when my mom kisses me in front of my friends." - Adolescents have ambivalence toward independence. They feel too grown up for kisses from parents, but they still fall asleep with their favorite teddy bear. This statement reflects that client is developing a sense of identity based on Erikson's stage of identity vs. role confusion.
How should the nurse explain to the client the rationale for wearing these pressure garments?
"The pressure stocking will help prevent scarring that could occur while the burn is healing." - Pressure garments help the areas that are prone to hypertrophic scarring. The client may have to wear pressure garments for up to 1 year. This response also addresses his developmental stage because scarring represents a threat to the client's body image.
How should the nurse respond?
"The skin will probably be taken from your son's back." - An autograft is a procedure in which the skin is taken from one part of the body and grafted to another site on the same individual. Autografts are useful because they are not rejected by a client's immune system.
A client with a burn injury is at significant risk for hypovolemia from fluid loss and fluid movement from increased capillary permeability and vasodilation. The ED HCP inserts a central venous catheter via the subclavian vein and prescribes sodium lactate/Hartmann's solution (RL) at 1,000 mL/hr. Fluid volume requirements are calculated using an accepted formula such as the Parkland Formula to adequately hydrate client.
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A young man is carried to the triage area. He is alert and screaming in pain. He appears to have deep partial-thickness and full-thickness burns on his lower abdomen and on both of his anterior and posterior lower legs. He states his name and he is 14 years old. A disaster tag is placed on his left wrist. A large bore IV is started in his right antecubital area, and a sterile drape is placed over the lower part of his body.
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The nurse should document which percentage of body surface?
45%. - According to the Rule of Nines, lower extremities are 18% each. The front trunk is 18%, with the upper torso receiving 9% and the abdomen receiving 9%. Therefore, if the abdomen (9%) and both legs (36%) are burned, the total percentage is 45%.
Safety and Infection Control
After arriving on the scene, the immediacy of the situation is apparent and paramedics notify the county hospital emergency department (ED). The ED personnel initiate the emergency operations plan (EOP) and a Level I disaster is declared.
Which action is included when a Level I disaster is declared?
All local hospitals prepare to receive casualties. - Classification as a Level I disaster indicates that local emergency response personnel and organizations can contain and effectively manage the disaster and its aftermath.
The police officer then asks to see client's ED medical record. Which action should the nurse take concerning this request?
Allow the police officer access to the requested medical records. - According to the Health Insurance Portability and Accountability Act (HIPAA) of 1996, the police department does have the right to view client records concerning accidents. If possible, permission should be sought from the victim or the person authorized to sign for the victim, such as a parent.
Burn clients who surpass 20% Total Body Surface Area (TBSA) have massive shifts of fluid and electrolytes from intravascular to extravascular spaces, which can lead to cardiovascular collapse. Which assessment relates most directly to a diagnosis of Curling's ulcer?
Assess the gastric aspirate for pH and blood the color of coffee grounds. - Curling's ulcer is a duodenal ulcer that develops in clients who have severe body surface burns. Coffee ground vomitus, or aspirate, is a term to describe hemoglobin that is darker because it has been denatured by acid in the stomach. Gastric ulceration does not occur at a pH above 7.
Safety and Infection Control
Client arrives at the county hospital emergency department (ED) via ambulance from the accident site. He is crying, in severe pain, and asking for his mom and dad.
Reduction of Risk Potential
Client continues his recovery both physically and mentally. The nurse discusses wound care and surgical debridement of the burn wounds with client and his parents.
The nurse assesses both of the client's graft sites and notes that the gauze dressing over the donor site is moist and intact. What action should the nurse implement?
Document this assessment in the client's chart. - This assessment finding is normal. A moist gauze dressing is applied to the donor site to maintain pressure and to stop any oozing. The nurse should document that the dressing is intact.
Which intervention has the highest priority?
Ensure meticulous hand washing before and after the client's care. - Proper hand washing is the most important intervention to help minimize the risk of cross-contamination and the spread of bacteria.
The client has many physical, emotional, and psychosocial needs. Which intervention is most important for the nurse to implement upon admission?
Establish and maintain an open airway. - The burns on client's trunk can cause constriction leading to a restricted airway. Additionally, smoke inhalation is always a concern following a fire. Remember Maslow's Hierarchy of Needs: ensuring an open airway is always the highest priority nursing intervention.
Which action should the nurse take?
Inform the officer that he must first speak to the client's parents. - The client is a minor, so his parents must be present when he is talking to a representative of the police department.
Which action should the nurse implement?
Outline the drainage on the dressing and write the date and time. - The amount of drainage, the date and time, and the nurse's initials should be labeled on the bandage to assist the caregivers in monitoring the client for complications.
Client grimaces in pain as the nurse assesses his red and blistered wounds that are affecting his epidermis and dermis. Based on this assessment, which finding best describes the his burns?
Partial thickness or second degree burns. - Partial thickness wounds are painful, red, and moist and are known for their blistering appearance.
EMS personnel triage clients, with multiple casualties noted. Which action should the triage nurse implement first?
Place a disaster tag securely on each victim. - Victim tracking is a critical component in casualty management. Disaster tags are color-coded and numbered to indicate triage priority. They include the client's name, address, and age, as well as a description and location of the client's injuries.
The HCP has prescribed mafenide acetate for the client's burned areas for application to the burn wounds twice a day. Topical agents such as mafenide acetate solution that deeply penetrate tissue are used to cover the wound. To prepare the client for this treatment, which intervention should the nurse implement?
Premedicate with an opioid analgesic 20 minutes prior to applying this medication. - This medication causes severe burning pain for up to 20 minutes after the application. Premedicating a client with an analgesic helps reduce this pain.
Which triage category should the nurse assign to client?
Priority 1, Color Red. - A client with deep partial-thickness and full-thickness burns on 15% to 40% of his total body surface area is placed in this immediate category in which injuries are life threatening but survivable with intervention. Treatment cannot be delayed.
Which discharge preparation has the highest priority?
Provide specific written instructions for the client's home care before releasing him to go home. - Written instructions are the best teaching tool and resource for a client and family. The pressure garments must be worn 23 hours a day. Therefore, the client's parents can put the garment on and take them off at bath time. This action does not have the highest priority.
Which action should the nurse implement?
Refer the client to an adolescent burn support group. - Through a support group, the client can meet others with similar experiences and learn coping strategies to help him deal with his fears and concerns.
A Complication Occurs
The burn unit nurse assesses the client's dorsalis pedal pulses and notes that the right pedal pulse, which was present 2 hours ago, is no longer palpable and cannot be heard with a Doppler ultrasound device.
Health Promotion and Maintenance
The nurse needs to complete the psychosocial component of the client assessment now since it was not a priority when the client was admitted to the burn unit from the ED.
How should the nurse respond to client?
"If I'm concerned that it will affect your care, then I will have to tell someone." - The nurse can keep some information confidential, but if it affects the client's physical or mental health, the nurse must intervene and report the information.
The client is receiving an escharotomy to treat his burn complications. Which information is accurate for the nurse provide to his parents?
"The HCP will make an incision in his leg to relieve the pressure." - An escharotomy is a surgical incision into the eschar to relieve the constricting effect of the burned tissue. It is appropriate for the nurse to give a client's mother accurate information.
After the autograft, the client is returned to his room. One hour after he returns to his room, he is experiencing pain at the donor site, as well as the graft site, rated as a 6 out of 10 on the pain scale, even though he is receiving morphine via patient-controlled analgesic (PCA) pump. There is a prescription for morphine 4 mg IV push every 4 to 6 hours PRN for break through pain.
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After the client's discharge is discussed with his parents, it is determined that the client's 65-year-old grandmother is able to stay with him during the day. She lives 3 miles from his home and is very willing to stay with him as long as he needs her. The nurse meets with the client, his parents, and his grandmother for discharge teaching.
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Client shares with the nurse, "Sometimes I hurt so much I just want to kill myself. I don't want any more surgery. I don't know what I did to deserve this."
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The ED nurse evaluates client and determines the percentage of body surface burned according to the Rule of Nines. His burns are noted to be painful, red, moist, and blistered to the areas to his upper abdomen, and full-thickness burns (third degree) on his lower abdomen and on both of his anterior and posterior lower legs.
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The client has a positive attitude toward his rehabilitation. He adheres to the prescribed regimen and works with the physical and occupational therapists. He is looking forward to going home, although he expresses concern about how the students will act and whether he will be able to participate in band and soccer when he is able to return to school.
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The client is referred to a counselor who addresses his depression and meets with him daily. The counselor discusses the situation with his parents. Previous Section
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The client returns to the room after a surgical excision of the full-thickness burns to both lower extremities. The nurse assesses the dressings on the lower extremities and notes bright red blood on the dressing.
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The fire fighters quickly extinguish the flames from the bus and it is noted by EMS personnel that the situation is escalating quickly. The parents of some of the band members were following the bus to the football game and witnessed the accident. While EMS personnel try to care for students, parents are asking questions and attempting to get to the bus. Some parents call the EDs in an attempt to learn where their children will be transferred.
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Triage determines in what order a client is seen by a healthcare provider (HCP). Which of the following clients would the nurse identify with a red tag? (Select all that apply.)
- A client whose vital signs include respirations at 22 breaths/min, pulse at 120 beats/min, and blood pressure at 85/52 mmHg. (This client is going into shock and should be seen immediately) - A client with a pulsating femur wound. (This client has an arterial bleed and can go into shock and therefore should be seen immediately.) - A client with full thickness burns over 50% of the body. (This client should be attended to immediately.)
Cleaning the wound and preventing infection are priorities of care. The client is scheduled for daily total immersion hydrotherapy. Which intervention should the nurse implement during his hydrotherapy? (Select all that apply.)
- Active range of motion exercises of his extremities. (Hydrotherapy provides an excellent opportunity for exercising the extremities, an important action to help prevent contractures.) - Wash burn areas thoroughly and gently with mild soap and water. (This is the procedure used during hydrotherapy to debride the client's burns.)
The client will be in the hospital for at least 1 month. The multidisciplinary healthcare team discusses how to best meet his growth and development needs. Which interventions will meet the client's needs during his hospital stay? (Select all that apply.)
- Allow his parents to bring in CD's and video games. (Adolescents usually enjoy listening to music and playing video games. These types of activities should be good distractions for the client.) - Inform the parents that a laptop computer with internet access would be good for their son's socialization needs. (The client is an adolescent with need for peer contact. The computer could keep him in touch with peers and provide a distraction for him.)
While caring for a client who has burns, which nursing intervention is essential in minimizing client's potential for infection? (Select all that apply.)
- Inform the client's family members that plants and flowers are not allowed in his room. (Plants and flowers are not allowed because stagnant water is a potential source of bacterial growth.) - Provide visitors with isolation gowns and instruction in hand hygiene. (A major responsibility of the nurse is detecting infection and protecting client from infection. This must be balanced with the need for 14-year-old client to be able to visit with family and friends.)
The nurse determines that the client could use a PRN dose of morphine for his break through pain. The morphine is in a vial labeled 10 mg/mL. How much morphine will the nurse administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
0.4 - 4 mg x 1 mL/10 mg
Meet the client
A high school band is enroute to a Friday night football game. As the bus attempts to pass an 18-wheeler on a two lane highway, the bus loses traction and lands on its side, sliding 500 feet before coming to a stop and then catching on fire. Witnesses immediately dial 911 and Emergency Medical Services personnel (EMS) arrive within 10 minutes of the first phone call. A 14-year-old male student is trapped by debris and is unable to get out of the bus.
A burn injury such as the client's produces a profound metabolic need. The client requires sufficient nutrients for wound healing and increased metabolic demands. The client can take oral nutrients and requests an evening snack. Which snack is best for the nurse to provide?
A peanut butter sandwich. - The client needs a high-calorie, high-protein diet. Peanut butter is high in protein and calories. Adolescents typically enjoy finger foods, such as sandwiches.
Management of Care
A police officer comes to the ED nursing station and asks to speak to the client concerning the bus accident because he was sitting at the front of the bus and may have witnessed the accident.
Which action is most important for the nurse to take before the assessment?
Ask the parents to leave the room before obtaining information from the client. - the client is developing his sense of identity. There may be questions that the client would rather not answer with his parents in the room. Questions in the psychosocial assessment include topics such as drug use, alcohol use, and sexual activity. It is important that the nurse obtain an accurate history related to these risky behaviors, which often begin in early adolescence.
Which action should the nurse implement to help these family members cope with this tragedy?
Designate specific family areas that are staffed with counselors. - Family and friends converging on the scene and at local hospitals should be cared for in designated areas by competent personnel to help decrease anxiety and provide correct information.
Which action should be implemented to address this issue?
Determine if there is a family member who can stay with the client during the day. - This action may identify someone the client knows and trusts who can stay with him without straining the family's resources.
Psychosocial Integrity
The client continues to improve and is scheduled for surgery to graft the burned areas. A nurse with whom he has established a bond is helping him with his morning care. The client says, "If I tell you something, will you promise not to tell anyone?"
Safety and Infection Control
The client has been admitted to the hospital's burn unit and his parents have been notified that he is in stable, but critical condition. The nurse should continuously monitor the client for any potential complications from his second and third-degree burns.
Management of Care
The client has been in the burn unit for 72 hours. Many friends and family members are coming to the hospital with gifts and cards, requesting to visit.
Reduction of Risk Potential
The client's graft sites are healing, and he is transferred to the burn rehabilitation unit. The nurse teaches client about the importance of wearing pressure garments for about a year after going home.
Reduction of Risk Potential
The client's partial-thickness and full-thickness burns require an autograft to both of his lower extremities. The procedure is explained to the client and his parents, and informed consent is obtained from his parents. The client's father asks the nurse, "Where do they get the skin to do the graft? I know the HCP told us about it, but I still don't understand."
Safety and Infection Control
The multidisciplinary healthcare team is discussing discharge planning for the client. The team is apprehensive because both of the client's parents work outside the home, and he is not ready to be home alone.
Based on the nurse's understanding of the Parkland Formula, which rate correctly describes the time the fluid is given to the client?
The nurse administers the first half of the fluid from the time the burn occurred over 8 hours, and the second half over the following 16 hours. - The first half is given over the first 8 hours from the time the burn occurred, and the second half over the following 16 hours.
Reduction of Risk Potential
The nurse determines if the client is adequately hydrated with the fluid therapy provided. The client weighs 112 lbs (50. 9 kg).