Ch. 26 Care of Patients with Burns

caloric needs post burn are

2 - 3 times normal caloric needs the increaed rates peak at 4 - 12 hours but can remain elvated for months until after wounds are closed

blood transfusions are needed if the patient's HCT is less than

20 - 25% and the patient has sx of hypoxia

airway edema becomes pronounced

8 - 12 hours after the beginning of fluid resuscitation

genital area

< 1%

weigh the patient daily without dressings or splints and compare the weight to preburn or dry weight. A 2% weight loss indicates

a mild deficit 10% weight loss requires evaluation and modification of calorie intake

Which nursing intervention(s) decrease(s) the risk for cross-contamination in the client with a severe burn injury? (Select all that apply.) a. Place client in isolation. b. Encourage multiple visitors to support client. c. Ensure that no plants or flowers are in the client's room. d. Teach family members not to bring fresh fruits and vegetables to the client. e. Change gloves after cleaning and dressing of one wound area, before cleaning and dressing another.

a, c, and d

legs

anterior: 9% posterior: 9%

the disintegration of tissue by the patient's own cellular enzymes

autolysis

contact with hot metal, tar, or grease

contact burns

peeling of the sea skin occurs 2 -3 days after superficial burn

desquamination

damaged muscle cells that are injured in major burns or electrical burns release

myoglobin that further damage muscle and the kidney

Atracurium

neuromuscular blocking agent patient must be on mechanical ventilation to recieve this drug also give sedative, analgesic, and antianxiety meds

massive fluid shift, edema, and hypovolemia that occurs in first 24 - 48 hours after burn

resuscitation phase

progressively hoarse develop a brassy cough drool or have difficulty swallowing wheezes, crowing, and stridor on exhalation

signs that indicate pulmonary injury

pink to red blisters form no eschar 2 weeks to heal

superficial partial thickness

Patient is SOB, has dyspnea, and crackles on auscultation

sx of circulatory overload

fluid boluses are avoided because

they increase capillary pressure and worsen edema

parkland formula for burns

% BSA x weight (kg) x 4 mL give 1/2 fluids in first 8 hours. remaining 1/2 in last 16 hours. Total fluids in by 24 hours

water tanks should be set below

140 F or 60 C

back

18%

chest/truck area

18%

hypoactive or absent bowel sounds increase risk for GI ulcer, illeus

GI changes post burn

destroyed RBC release

Hgb and K+

partial-tichkness burns less than 10% TBSA Full thickness bruns less than 2% TBSA

Minor burns ER then to hospital for care

patients with burns of 25% TBSA or who are intubated generally require a

NG tube

1) secure the airway 2) support circulation and organ perfussion by fluid replacement 3) keep the patient comfortable with IV analgesics 4) prevent infection through careful wound care 5) provide emotional support

Priorities for emergency management of burns

increased HR, RR, glucose decreased GI motility, hypo/absent bowel sounds urine retention and increaed urine specific gravity increased metabolic neeeds thirst and generalized edema fluid retention and weight gain

SNS activation causes

bleeding indicates that

a bed of healthy dermis or subQ tissue has been reached

successful skin grafting requires

a clean and granulating or freshly excised wound bed

Which factors indicate that a client's burn wounds are becoming infected? Select all that apply. a. Dry, crusty granulation tissue b. Elevated blood pressure c. Hypoglycemia d. Edema of the skin around the wound e. Tachycardia

a, d, and e

When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors? a. "Every bedroom should have a separate smoke detector." b. "Every room in the house should have a smoke detector." c. "If you have a smoke detector, you don't need a carbon monoxide detector." d. "The kitchen and the bedrooms are the only rooms that need smoke detectors."

a. "Every bedroom should have a separate smoke detector."

What is the best method to prevent autocontamination for a client with burns? a. Change gloves when handling wounds on different areas of the body. b. Ensure that the client is in isolation therapy. c. Restrict visitors. d. Use sterile gloves when changing dressings.

a. Change gloves when handling wounds on different areas of the body.

A client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client? a. Encouraging participation in wound cares b. Encouraging visitors c. Reassuring the client that he or she will be fine d. Telling the client that these feelings are normal

a. Encouraging participation in wound care

A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first? a. Give oxygen per facemask. b. Infuse lactated Ringer's solution at 150 mL/hr. c. Give morphine sulfate 4 to 10 mg IV for pain control. d. Insert a 14 Fr retention catheter.

a. Give oxygen per facemask.

The nurse is reviewing the health history for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client's history reveals which condition? a. Heart failure b. Diverticulitis c. Hypertension d. Emphysema

a. Heart failure

To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow? a. In a neutral position b. In a position of comfort c. Slightly flexed d. Slightly hyperextended

a. In a neutral position

The nurse is caring for a client with a burn injury who is receiving silver sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? a. Reduction of bacterial growth in the wound and prevention of systemic sepsis b. Prevention of cross-contamination from other clients in the unit c. Enhanced cell growth d. Reduced need for a skin graft

a. Reduction of bacterial growth in the wound and prevention of systemic sepsis

slower healing times thinner skin sensory impairment decreaed mobilty reduced inflammatory and immune response reduced thoracic and pulmonary compliance more likelt ot have pre-exsisting medical condition (DM, renal impairment, pulmonary impairment)

age-related changes

head and arms

anterior: 4.5% posterior: 4.5%

The nurse is encouraging range-of-motion exercises for the client, who states, "this hurts terribly; I don't want to do this." Identify the appropriate nursing response(s). (Select all that apply.) a. "You have to do the exercises to get well." b. "Range-of-motion helps promote mobility." c. "Just visualize a beach to get your mind off of the pain." d. "Let me check when you were last given pain medication." e. "What techniques for pain management have you used in the past that were helpful?" f. "The health care provider has ordered these exercises, and it is important that you do them as instructed."

b, d, and e

Which nursing interventions does the nursing student provide for this client? Select all that apply. a. Provides cushions for comfort b. Performs frequent handwashing c. Places plants in the client's room d. Performs gloved dressing changes e. Uses disposable dishes

b, d, and e

A client with a burn injury due to a house fire is admitted to the burn unit. The client's family asks the nurse why the client received a tetanus toxoid injection on admission. What is the nurse's best response to the client's family member? a. "The last tetanus injection was less than 5 years ago." b. "Burn wound conditions promote the growth of Clostridium tetani." c. "The wood in the fire had many nails, which penetrated the skin." d. "The injection was prescribed to prevent infection from Pseudomonas."

b. "Burn wound conditions promote the growth of Clostridium tetani."

The nurse is caring for a client who has burns to the face. Which statement by the client requires further evaluation by the nurse? a. "I am getting used to looking at myself." b. "I don't know what I will do when people stare at me." c. "I know that I will never look the way I used to, even after the scars heal." d. "My spouse does not stare at the scars as much now as in the beginning."

b. "I don't know what I will do when people stare at me."

The nurse on a burn unit has just received change-of-shift report about these clients. Which client does the nurse assess first? a. Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain b. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!" c. An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the health care provider immediately about discharge plans d. Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr

b. Firefighter with smoke inhalation and facial burns who has just arrived on the unit and whispers, "I can't catch my breath!"

A client is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the client? a. Intramuscular b. Intravenous c. Sublingual d. Topical

b. Intravenous

Which wound assessment characteristics suggest a superficial partial-thickness burn injury? a. Black-brown coloration b. Painful blisters c. Moderate to severe edema d. Absence of blisters

b. Painful blisters

Several clients have been brought to the emergency department after an office building fire. Which client is at greatest risk for inhalation injury? a. Middle-aged adult who is frantically explaining to the nurse what happened b. Young adult who suffered burn injuries in a closed space c. Adult with burns to the extremities d. Older adult with thick, tan-colored sputum

b. Young adult who suffered burn injuries in a closed space

The nurse is caring for a client who has burns. Which question does the nurse ask the client and family to best assess their coping strategies? a. "Do you support each other?" b. "How do you plan to manage this situation?" c. "How have you handled similar situations?" d. "Would you like to see a counselor?"

c. "How have you handled similar situations?"

A client who was the sole survivor of a house fire says, "I feel so guilty. Why did I survive?" What is the best response by the nurse? a. "Do you want to pray about it?" b. "I know, and you will have to learn to adapt to a new body image." c. "Tell me more." d. "There must be a reason."

c. "Tell me more."

A client with burn injuries is admitted. Which priority does the nurse anticipate within the first 24 hours? a. Range-of-motion exercises b. Emotional support c. Fluid resuscitation d. Sterile dressing changes

c. Fluid resuscitation

In assessing a client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate? a. Intense pain b. Potential for inadequate oxygenation c. Impaired self-image d. Potential for infection

c. Impaired self-image

Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury? a. Pale, boggy, dry, or crusted granulation tissue b. Increasing wound drainage c. Scar tissue formation d. Sloughing of grafts

c. Scar tissue formation

Which assessment is the nurse's highest priority in caring for a client in the acute phase of burn injury? a. Bowel sounds b. Muscle strength c. Signs of infection d. Urine output

c. Signs of infection

Which assessment information about a 60-kg client admitted 12 hours ago with a full-thickness burn over 30% of the total body surface area is of greatest concern to the nurse? a. Bowel sounds are absent. b. The pulse oximetry level is 91%. c. The serum potassium level is 6.1 mEq/L (6.1 mmol/L). d. Urine output since admission is 370 mL.

c. The serum potassium level is 6.1 mEq/L (6.1 mmol/L).

The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? a. Blood urea nitrogen (BUN), 36 mg/dL (12.9 mmol/L) b. Creatinine, 2.8 mg/dL (248 mcmol/L) c. Urine output, 40 mL/hr d. Urine specific gravity, 1.042

c. Urine output, 40 mL/hr

burn completely surrounds an extremity or the chest constriction reduced blood flow

circumferential injury

severe carbon monoxide poisoning (41 - 60%)

coma convuslions cardiopulmoary instabillity

acute gastroduocenal ulcer that occurs with the stress of severe injury may develop within 24 hr after severe burn

curling's ulcer

The client asks about ways to prevent carbon monoxide poisoning. Which teaching will the nurse provide? a. "You can see black smoke when carbon monoxide is in the air." b. "If you are experiencing carbon monoxide poisoning, your skin will begin turning blue." c. "The only way to get poisoned from carbon monoxide gas is if you are in the presence of a fire." d. "It is important to have carbon monoxide detectors in your home, because this is an odorless gas."

d. "It is important to have carbon monoxide detectors in your home, because this is an odorless gas."

When delegating care for clients on the burn unit, which client does the charge nurse assign to an RN who has floated to the burn unit from the intensive care unit (ICU)? a. Burn unit client who is being discharged after 6 weeks and needs teaching about wound care b. Recently admitted client with a high-voltage electrical burn c. A client who has a 25% total body surface area (TBSA) burn injury, for whom daily wound débridement has been prescribed d. Client receiving IV lactated Ringer's solution at 150 mL/hr

d. Client receiving IV lactated Ringer's solution at 150 mL/hr

Which assessment finding does the nurse interpret as demonstrating a client's fluid resuscitation adequacy? a. Decreased skin turgor b. Decreased pulse pressure c. Decreased core body temperature d. Decreased urine specific gravity

d. Decreased urine specific gravity

A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian? a. Discouraging having food brought in from the client's favorite restaurant b. Providing more palatable choices for the client c. Helping the client maintain a desirable weight d. Planning additions to the standard nutritional pattern

d. Planning additions to the standard nutritional pattern

The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first? a. Administer a diuretic. b. Provide a fluid bolus. c. Recalculate fluid replacement based on time of hospital arrival. d. Titrate fluid replacement.

d. Titrate fluid replacement.

Fatal carbon monoxide poisoning (61 - 80%)

death

removal of eschar and other cellular debris from the burn wound

debridement

black hard and inelastic eschar with skin graft

deep full thickness

Red to white soft dry eschar 2 - 6 weeks to heal

deep partial thickness

the number of gauze layers depends on

depth of injury amount of drainage expected area injured patient's mobilty frequency of dressing changes

sweat and oil glands and the hair follicles are the

dermal appendages

made up of collagen, fibrous connective tissue, and elastic fibers contains BV, lymph vessels, sensory nerves, hair follicles, sebaceous glands, and sweat glands

dermis

starts 48 - 72 hour after burn blood flow and urinary output increase

diuretic stage

if patient receives a paralytic/neuromuscular blockade drug then the patient must also receive

drugs for sedation, analgesia, and anti-anxiety

caused by open flame in house fire and explosions

dry heat injuries

patient's preburn weight

dry weigtht important becasue it is used in calculations to determine fluid rates, energy rates, and drug doses

entering and exit wounds deep muscle injury or oran injury may be present

electrical burns

only give diuretic with

electrical burns usually prescribed mannitol (OSmitrol)

oxygen, masks, cannulas, manual resuscitation bags, laryngoscope, endotracheal tubes, and equitment for tracheostomy

emergency airway equipment at bedside

top layer has no BVs

epidermis

dead tissue must be sloughed off or removed from the wound before healing can occur

eschar

age older than 60 a burn greater than 40% TBSA the presence of inhalation injury

factors that increase risk for death

fluid shift with excessive weight gain occurs within

first 12 hours after burn and can continue for 24 - 36 hours

nerve endings are completely destroyed absence of pain

full thickness burns

black, brown, yellow, white, and red hard and inelastic eschar weeks to months to heal with skin graft

full-thickness burns

delayed onset mild disoreintation mild illeus ocasional diarrhea fever late hypotension low platelets

fungal sepsis

rapid, 12 - 36 hour mild disorientation severe illeus severe diarrhea hypothermia early hypotension low platelets

gram negative sepsis

insidious, 2 - 6 days severe disorientation and lethargy severe illeus fever late hypotension normal platelet levels

gram positive sepsis

Mild Carbon Monoxide Poisoning (11 - 20%)

headache decrease cerebral functioning decreaed visual acuity slight breathlessness

Moderate Carbon Monoxide Poisoning (21- 40 %)

headache tinnitus nausea drowsy vertigo altered mentla status confusion stupor irritable decreaesd BP incread irregular HR depresesd ST segment on ECG dsyrhythmias pale to reddish-purple skin

Homografts or allograft

human skin obtained from cadavers expensive and risk for blood borne infection

burn wounds are derided and cleaned one or two times a day during

hydrotherapy application of water for treatment

paO2 of less that 60 is an indication for

intubation or mechanical ventilation

if TBSA burned is greater than 35% then

invasive cardiac and pulmonary monitoring may be needed

xenograft or heterograft

is obtained from animals, pigs or cows. -are used temporary cover large areas -pigskin or porcine most common

cardiac changes after a burn

low BP and CO increased HR

partial-thickness burns >25% TBSA full-thickness burns >10% TBSA burn involving eyes, ears, face, hands, feet, or perineum Electrical or inhalation injury Patient is older than 60 y.o. Burn complicated with other injuries (fractures) patient has cardiac, pulmonary, or other chrnic etablism disorders

major burns

partial-thickness burns 15 - 25% TBSA full-thickness burns 2 - 10% TBSA

moderate burns emergency care at scene then to burn clinic

caused by hot liquid or steam

moist heat (scald) injury

fluid replacement formulas are calculated from the time

of injury NOT time of admission to hospital

burns greatly increase

oxygen demand and metabolic needs

nerve endings are exposed increased pain and sensativity

partitical thickness burns

Signs of carbon monoxide poisoning

patient is "cherry-red" color carboxyhemoglobin > 10%

caused by superheated air, steam, toxic fumes, or smoke most likely to occur iwth a bunr that happened indoors

pulmonary changes

opioids as well as ketamine and nitrous oxide are given to

reduce pain