Chapter 66: Caring for Clients with Burns

To meet early nutritional demands for protein, a 198-lb (90-kg) burned patient will need to ingest a minimum of how much protein every 24 hours?

180 g/day

A sample consensus formula for fluid replacement recommends that an isotonic solution be administered in the first 24 hours of a burn in the range of 2 to 4 mL/kg/% of burn with 50% of the total given in the first 8 hours postburn. A 176 lb (80 kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours?

2,400 mL

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%

A client has experienced burns covering the back and front of both legs. Using the Rule of Nines, what percentage would the nurse assign to the client's injury when documenting? Fill in the blank with a number.

36

A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?

36%

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement?

A urinary output of 30 mL/hr

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?

A urine output consistently above 40 ml/hour

A nurse is caring for a client 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?

Acute Pain

A client has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?

Assess the client's peripheral pulses distal to the dressing

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?

BUN: 28 mg/dL

Which complication is common for victims of electrical burns?

Cardiac dysrhythmia

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?

Contact the primary care provider and prepare for an escharotomy.

A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort?

Education about home safety

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:

Epidermis and a portion of deeper dermis.

The nurse in the emergency department receives a patient who sustained a severe burn injury. What is the priority action by the nurse in this situation?

Establish a patent airway.

A client 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 client's arm?

Full thickness

A client 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?

Hemodynamic instability

A client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response?

Inform the primary care provider promptly because the graft may need to be removed.

The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient?

Intravenous

A client's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid?

Lactated Ringer's

Which of the following is the preferred IV fluid for burn resuscitation?

Lactated Ringer's (LR)

In a client who has been burned, which medication should the nurse expect to use to prevent infection?

Mafenide (Sulfamylon)

Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar?

Mechanical

Which of the following is the analgesic of choice for burn pain?

Morphine sulfate

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?

Paralytic ileus

Which instruction is the most important to give a client who has recently had a skin graft?

Protect the graft from direct sunlight.

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?

Related to circumferential eschar

The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire?

Roll the client in a blanket.

Leukopenia within 48 hours is a side effect associated with which topical antibacterial agent?

Sulfadiazine, silver (Silvadene)

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?

Superficial

An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury?

The total body surface area (TBSA) affected by the burn

A nurse is developing a care plan for a client 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?

To prevent contractures

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote

decreased catabolism.

Specific potential complications are common to specific types of burns. Which burns can impair ventilation?

face, neck, chest

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury?

inflammatory

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

pain management.

Which antimicrobials is not commonly used to treat burns?

tetracycline

Which type of burn injury requires skin grafting?

Full-thickness

What quick assessment technique should the nurse use to assess the percentage of burn injury?

Compare the client's palm with the size of the burn wound

A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What should the nurse in the ED receiving the call instruct the father to do?

Immerse the child in a cool bath.

A client has a skin graft and is also using a pressure garment as part of the recovery following a burn injury. Which of the following measures would the nurse advise the client to follow?

Use a sunscreen with a high SPF while outdoors to protect against pigment changes.

An occupational health nurse is called to the floor of a factory where a worker has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn?

Wrap cool towels around the affected extremity intermittently.

An emergency department nurse has just received a client 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 client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period?

administer IV fluids