Chapter 24: burn management
Which actions would the nurse perform as part of wound care during the emergent phase of treatment for a patient with partial-thickness burns on the hands and legs?
* administer a tetanus antitoxin * perform debridement as required * assess the extent and depth of the burns
Which actions would the nurse perform when caring for a patient who experienced an inhalation injury and is not intubated?
* assist in performing a fiberoptic bronchoscopy (to assess the lower airway) * reposition the patient every one to two hours ( to clear airway) * encouraged deep breathing and cough every hour (clear air passages and provide relief
A patient is being treated for burns on the face and ears due to a fire at home. what precautions should the nurse take to protect the ears from damage?
* avoid using pillows (pressure on ear cartilage may cause chondritis) * keep ears free from pressure (poor vascularization/tendency to become infected) * elevate the patient's head by placing a rolled towel under the shoulders. (reduce pressure over the ears, helps to prevent pressure necrosis)
Which initial interventions would the nurse perform as a part of emergency burn management for a patient who has sustained full-thickness burns covering more than 20% of the total body surface area?
* being fluid replacement (compensate for loss) * cover burned areas with dry dressings (begin healing process/prevent contamination) * establish IV access with two large-bore catheters (enable large amounts of fluid replacements)
Which nursing interventions are appropriate for providing enteral feeding to a patient who is intubated and has burns of more than 5% of the total body surface area (TBSA)?
* check gastric residuals frequently * assess bowel sounds every eight hours * determine whether the nasogastric tube is in place * increasing the feeding to the goal rate within 24-48 hours.
A nurse is instructing a patient about the immediate steps that need to be taken in the case of electrical burns. What precautions should the nurse instruct as necessary to perform?
* do not cover the burned part with ice (hypothermia/vasoconstriction: reduces blood flow) * do not immerse the burned part in cool water (extenseive heat loss) * cool large burns for not more than 10 minutes (hypothermia)
Which interventions would the nurse iclude in the plan of care for a patient with partial-and full-thickness burns on the lower extremities?
* eschartomoy care (a scalpel incision through full-thickness eschar) frequently is required to restore circulation to compromised extremities. * daily cleansing and debridement (minimize infection) * application of topical antimicrobial agent (enhance wound healing) * IV and oral pain medications (essential for the burn patient)
Which actions would the nurse perform when caring for a ptient who received burns from hydrochloric acid on the hands and face?
* flush affected area with lost of water * remove all chemical particales on the skin * remova all clothing containing the chemical
Complications of emergent phase
*dysrhythmias *hypovolemic shock * impaired circulation * venous thromboembolism (VTE) * Respiratory distress * cardiopulmonary issues such as heart failure or pulmonary edema
which action is most appropriate for the nurse to take during the early course of the care of a patient who has sustained burns covering 35% of the body surface area and weights 100 kg?
adminstering 7000 ml of crystalloid IV fluids over the 8 hours after injury crystalloid solutions, such as Ringer's lactate, are indicated for use in the initial IV fluid therapy for a burn patient.
A patient's partial-thickness burn injuries were debrided and covered with a silver-impregnanted dressing a week ago. Today the nurse notes the wounds have been fully debrided. Which would be the nurse's priority intervention for wound care at this time?
apply fine-meshed petroleum gauze to the debrided areas
Which type of burn injury would the nurse identify as occurring on the layers of subcutaneous fat, muscle, or deeper structures?
full-thickness burn
When planning for burn management, which patients would the nurse refer to a burn center?
* Patients with hydrocholoric acid burns * patients of all ages with third-degree burns * patients with 25% deep partial-thickness burns
The nurse would recognize which as clinical manifestations of a lower airway lung injury associated with burns?
* dyspnea * wheezing * altered mental status
the patient in the early postburn period is being treated for pain. Which medication would the nurse recognize as appropriate for use with this patient?
IV morphine sulfate IV medcations are used for burn injuries in the emergent phase to deliver relief rapidly and prevent unpredictable absorption as would occur with the IM route.
A patient who sustained burn injuries is receiving daily wound treatments and tells the caregiver, "The nurses enjoy hunting me." Which would the nurse suspect?
This is a normal reaction to an extraordinary life event.
A burn patient has not received any active tetanus immunization within the previous 12 years. Which is the primary nursing measure to help prevent the development of tetanus in the patient?
admisniter tetanus immunoglobulin
Which treatment would the nurse recognize as appropriate and within the scope of nursing practice when caring for a patient with partial-thickness second-degree burns to the chest, abdomen, and both anterior thighs?
daily would cleaning with debridement and sterile dressing changes
Which manifestations would the nurse expect when admitting a patient with a full thickness thermal burn?
no pain, waxy white skin, and no blanching with pressure
The nurse recalls which description as the most accurate regarding a deep partial-thickness burn?
painful with weeping blisters
Which factors would the nurse consider regarding the use of antibiotics for a patient with burns?
* It is essential to check the patient for allergies to sulfa * silver-impregnated dressings can be left in place from 3-14 days * topical antimicrobial agents may be applied after the wound cleansing.
Which patients are appropriate for the nurse to refer to the burn center?
* a patient with burns of the feet * a patient with an inhalation injury * an elderly patient with third-degree burns
what are some patient priorities during the emergent phase of burn management?A
* fluid volume * respiratory status * nutrtition
which cardiac parameters would the nurse assess to determine the adequancy of fluid resuscitation in a patient who has sustained burns?
* heart rate less than 120 beats/minutes * arterial line systolic BP greater than 90 mm Hg * Arterial line mean arterial pressure greater than 65 mm Hg
Which patient signs and symptoms noted during triage would indicate to the nurse an upper airway injury?
* hoarseness * difficulty swallowing * copious secretions
The nurse is teaching a community group about immediate actions to be taken in the case of burns to more than 10% of body surface area. Which reason would the nurse provide for avoiding the use of ice on the burned body part?
* ice can cause hypothermia * ice can cause vasoconstriction * ice can reduce blood flow to the burned area ice can cause hypothermia, resulting in excessive cooling of the burned part and reduction of blood flow to that area. Ice can also cause vasocontriction, thus causing the blood vessels supplying the burned area to narrow and supply less blood and oxygen.
A patient with burns needs permanent skin grafting. Which grafts should the nurse consider?
* integra *alloderm * autograft
A burn patient has lower extremity bilateral dressings and is receiving a continuous infusion of hydromorphone. Which medications would be appropriate for the patient to receive before a dressing change is initiated?
* lorazepam, an anxiolytic, would be appropriate * IV fentanly, a short-acting opiod, would be appropriate
A nurse working in a burn unit identifies that which patients are at an increased risk of developing venous thromboembolism?
* morbid obesity * prolonged immobility
While planning physical therapy for a patient suffering from burns, which intervention would the nurse include in the plan of care?
* perform passive/active ROM on all joints * perform exercises during and after wound cleansing.
which discharge instructions would the nurse include when teaching a patient with partial-thickness burns on the hands about rehabilitation?
* recommend exercises * take low-dose antihistamines. * protect healed areas from direct sunlight * apply water-based creams on healed areas
complications of the rehabilitative phase of burns
* skin and/or joint contractures * hypertrophic scarring
The nurse is reviewing the fluid and electrolyte shifts that occur during burn injury. Which of these occur during the emergent stage of a burn injury?
*edema in nonburned areas (third spacing) * elevated hematocrit caused by hemoconcentration * movement of water and sodium to the interstitial fluid
Complications of acute phase of burns
*infection * coardiovascular and respiratory compromise * limited range of motion * skin and joint contractures * gastrointestinal issues * increased blood glucose levels
A patient is presenting with bright red lips, headache, and nausea. the physician suspects carbon monoxide posioning. As the nurse, you know the patient needs?
100% oxygen via non-rebreather mask for carbon monoxide poisoning.
the nurse recognizes which fluid as recommended for the first 24 hours after a burn?
2 - 4 ml lactated ringer's/kg/% TBSA burned
A nurse is providing care to a patient with a partial-thickness burn. Which clinical manifestation would the nurse anticipate?
Damage to epidermis and dermis involving varying depths
A burn patient's caregiver asks the nurse why an enzymatic debriding agent is being applied to the wounds. Which response by the nurse is appropriate?
The enzymatic debriding agent helps remove dead tissue from the healthy wound bed.
A patient recovering from third-degree burns over 30% of the body is ready for discharve and ask the nurse, 'what's going to happen to me?" Will I ever look normal again?" The nurse recognizes that this patient is exhibiting which emotional response to the burn injury?
anxiety
A patient has sustained thermal injuries amounting to approximately 30% of the total body surface area (TBSA). Which action would the nurse take first?
check for a patent airway, breathing, and circulation
A patient has thermal burns on the face, including the cheeks and the area around the eyes. Which action would the nurse take?
cover the face with ointment and gauze the face is highly vascular and may become edematous after a thermal burn. It should be covered with ointment and guaze to prevent vascularization and swelling.
A patient with a burn injury is brought to the emergency department, and the nurse notes white, leathery skin, dysrhythmias, and a loss of consciousness. Which type of burn injury would the nurse suspect?
electrical
A patient sustains a second-degree (partial-thickness) burn. Which layer (s) of skin would the nurse inspect for damage?
epidermis and dermis
Which intervention would the nurse expect to incorporate into the nutritonal plan of care of a burn patient who has been intubated?
provide enteral tube feeding, starting at 20ml/hour nonintubated patients with a burn of less than 20% total body surface area will generally be able to eat enough to meet their nutritional needs. Intubated patients and those with larger burns require additional support.
Which intervention would the nurse provide when caring for a patient with a burn injury during the acute phase?
provide teaching about the physical aspects of recovery
The patient received a cultured epithelial autograft (CEA) to the entire left leg. Which would the nurse include in the discharge teaching for this patient?
refer the patient to a counselor for psychosocial support in the rehabilitation phase, the patient will work toward resuming a functional role in society, but there are frequently body image concerns and grieving for the loss of the way the body looked and functioned before the burn, so continued counseling helps the patient in this phase as well.
A patient who sustained burns develops a paralytic ileus. which would the nurse suspect to be the cause of this complication?
sepsis paralytic ileus is caused when the burn patient experiences sepsis
Which interventions would the nurse expect to include in the nutritional plan of care for a patient with severe burns who has been intubated?
* assess bowel sounds every 8 hours * begin early enteral feeding with small-bore tubes * begin the feeding slowly at a rate of 20 to 40 mL/hr
Which actions would the nurse perform for a patient who just sustained partial-thickness burns on the hands and chest caused by a fire?>
* assess for inhalation injury * provide 100% humidified oxygen * assess airway, breathing, and circulation
When teaching the patient about the use of range-of-motion (ROM), what explanations should the nurse give to the patient?
* ROM will show the patient that movement still is possible * active and passive ROM maintain function of body parts * movement facilitates mobilization of leaked exudates back into the vascular bed the explanations that should be used are that active and passive ROM maintain the fucntion of body parts and reassure the patient that movement still is possible.
A nurse plans to provide an antioxidant regimen for a patient with partial-thickness burns in the acute phase. Which are antioxidants and therefore should be included in the protocol?
* Zinc (supports cell growth/development) * selenium (helps to prevent cell damage) * multivitamins (help to compensate for nutritional deficiencies)
When assessing a patient suffering from inhalation burns on the face and chest, what findings should a nurse anticipate?
* increasing hoarseness (d/t irritation of the upper airway during inhalation/laryngeal edema) * Darkened oral or nasal membranes (d/t charring of the membranes of the respiratory tract) * Productive cough with black sputum.
A patient with partial-thickness burns is being treated with zolpidem, and the family inquires why the patient is receiving the medication. Which responses by the nurse are appropriate?
* it is used to help promote sleep * it is used to reduce anxiety * it is used to provide short-term amnesic effects. zolpidem is a sedative-hypnotic medicine and is given to patients suffereing from burns.
Which types of food and drinks would the nurse provide to the patient who is recovering from a full-thickness burn and is in a hypermetabolic state?
* milkshakes * protein powder * high-caloric food
When caring for a patient in the acute phase of a burn injury, which actions would the nurse take?
* monitor for signs of complications * continue assessing oxygenation needs * continue to monitor respiratory status
When teaching patients and caregivers about the strategies to reduce burn injury, which essential instructions would the nurse include?
* never leave burning candles unattended or near windows or curtains * ensure an electrical power source s shut off before beginning repairs * check the temperature of bathrwater with the back of the hand or a bath thermometer
While planning physical therapy for a patient suffering from burns, which intervention would the nurse include in the plan of care?
* perform passive and active range of motion (ROM) on all joints * perform exercises during and after wound cleaning
A patient with severe inhalation burns has been receiving treatment for 24 hours. When assessing the patient, what findings would indicate respiratory distress?
* restlessness (d/t resp distress) * increased agitation (d/t attemps to compensate for increase oxygen) * increased rate of breathing (d/t compensatory mechanism for increased oxygen demands)
A patient with partial-thickness burns is now allowed oral feedings. What nursing interventions should the nurse perform to maintain the patient's nutrition?
* suggest a high-protein diet * suggest a high-carbohydrate diet * ask caregivers to get the patient's favorite food
While caring for a patient with burns, a nurse wraps the patient's wound with tubular elastic gauze. Which are the reasons behind this action?
* to decrease pain * to prevent blistering * to decrease itchiness
Which actions would the nurse take to protect the eyes of a patient with partial-thickness burns on the face, including corneal burns?
* use antibiotic ointments * instill methylcellulose eyedrops * arrange for ophthalmology examination
Which precautions would the nurse take when changing a burn wound dressing?
* use sterile gloves when applying ointments and sterile dressings * wear nonsterile, disposeable gloves when washing the dirty wound * always wear personal protective equipment, such as masks gowns and gloves
When instructing a community group about caring for a person with burns of more than 10% of total body surface area, which would the nurse advise?
* wrap the patient in a blanket * gently remove burned clothing * leave adherent clothing in place
A nurse is attending to a patient with extensive burns. What prophylactic treatment should the nurse plan to prevent a Curling's ulcer in this patient?
*Antacids (used prophylactically to neutralize the acids present in the stomach) * H2- histamine blockers (used to inhibit histamine, which causes an increase in acid levels) * proton pump inhibitors (help to inhibit the secretion of hydrochloric acid, which increases as a stress response to the decreased blood flow to the GI tract after burns)
A patient who is being treated for partial thickness burns on 60% of the body is now in the acute phase of burn management. The nurse assesses the patient for a possible Curling's Ulcer. what signs and symptoms can present with this condition?
Burning, gnawing sensation pain in the stomach and vomiting.
When caring for a patient with burns to the back, the nurse recognizes that the patient is moving out of the emergent phase of burn injury when which occurs?
Diuresis occurs and hematocrit decreases
which types of foods would the nurse encourage for a patient who sustained a chemical burn on 15% of the total body surface area (TBSA)?
high protein and high carbohydrate foods high in protein and high in carbohydrates are important for tissue regeneration and promote wound healing. The daily estimated caloric needs should be calculated and regularly reassessed according to the patient's changing condition.
The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. when planning nutritional interventions for this patient, which dietary choices would the nurse implement?
high-protein foods a hypermetabolic state occurs proportional to the size of the burn area. massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Caloric needs are often in the 5000-kcal range.
which advice would the nurse give to the family of an elderly patient to help prevent accidental burns?
install tap water anti-scald devices
When caring for a patient with an electrical burn injury, which prescription from the health care provider would the nurse question?
lactated ringer's at 25 ml/hr electrical injury puts the patient at risk for myoglobinuria, which can lead to acute tubular necrosis (ATN). Treatment consists of infusing lactated Ringer's at 2-4 ml/kg/%total body surface area (TBSA), a rate sufficient to maintain urinary output at 75-100 ml/hr. An infusiton rate of 25 ml/hr is not sufficient to maintain adequate urine output in the prevention and treatment of ATN
During the emergent phase of burn management, you would expect the following lab values?
low sodium, high potassium, high potassium, high glucose, high hematocrit
A burn patient newly arrived at the emergency department is confused, has difficulty breathing, and has nasal burns. which condition would the nurse suspect?
lower airway injury
A nurse is caring for a patient with second- and third-degree burns to 50% of the body. the nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation?
one half of the total 24-hour fluid requirement should be administered in the first eight hours fluid resuscitation withe the Parkland (baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours.
A patient has an emergency escharotomy performed on the right leg. The patient has full-thickness circumferential burns on the leg. Which finding below demonstrates the procedure was successful?
the right foot's capillary refill is less than two seconds