SG Lewis Ch 25 Burns

1. Which type of burn injury would cause myoglobinuria, long bone fractures, and cardiac dysrhythmias and/or cardiac arrest? a. Thermal b. Electrical c. Chemical d. Smoke and inhalation

1. b. An electrical injury causes tissue damage from intense heat generated by the electrical current passing through tissue, including muscle contractions that can fracture long bones and vertebrae. Myoglobin is released into the circulation when massive muscle damage occurs. The electric shock even can cause cardiac standstill or dysrhythmias as well as delayed dysrhythmias during the first 24 hours after injury.

10. What is one clinical manifestation the nurse would expect to find during the emergent phase in a patient with a full-thickness burn over the lower half of the body? a. Fever b. Shivering c. Severe pain d. Unconsciousness

10. b. Shivering often occurs in a patient with a burn as a result of chilling that is caused by heat loss, anxiety, or pain. Severe pain is not common in full-thickness burns, nor is unconsciousness unless other factors are present. Fever is a sign of infection in later burn phases.

11. A patient has a 20% TBSA deep partial-thickness and full-thickness burn to the right anterior chest and entire right arm. What is important for a nurse to assess in this patient? a. Presence of pain b. Swelling of the arm c. Formation of eschar d. Presence of pulses in the arms

11. d. In circumferential burns, circulation to the extremities can be severely impaired and pulses should be monitored closely for signs of obstruction by edema. Swelling of the arms would be expected but it becomes dangerous when it occludes blood vessels. Pain and eschar are also expected.

12. Which burn patient should have nasotracheal or endotracheal intubation? a. Carbon monoxide poisoning b. Electrical burns causing cardiac dysrhythmias c. Thermal burn injuries to the face, neck, or airway d. Respiratory distress from eschar formation around the chest

12. c. Patients with major injuries involving burns to the face and neck require intubation within 1 to 2 hours after burn injury to prevent the need for emergency tracheostomy, which is done if symptoms of upper respiratory obstruction occur. Carbon monoxide poisoning is treated with 100% oxygen and eschar constriction of the chest is treated with an escharotomy.

13. A patient is admitted to the emergency department at 10:15 pm following a flame burn at 9:30 pm. The patient has 40% TBSA deep partial-thickness and full-thickness burns and weighs 132 lb. a. According to the Parkland formula, the type of fluid prescribed for the patient would be ____________________ and the total amount to be administered during the first 24 hours would be ______ mL. b. The schedule for the fluid administration would be mL between and ___________ (time), ________mL between ___________ and ___________, and ______ mL between __________ and __________. c. Colloidal solutions are given in the second 24 hours. Based on the patient's body weight, what amount of these solutions will be given during this time? d. The adequacy of the patient's fluid replacement is determined by and .

13. To calculate fluid replacement, the patient's weight in pounds must be converted to kilograms: 132 lb = 60 kg. a. lactated Ringer's solution; 4 mL × 60 × 40 = 9600 mL b. 4800 mL between 10:15 pm and 5:30 am; 2400 mL between 5:30 am and 1:30 pm; 2400 mL between 1:30 pm and 9:30 pm c. 720-1200 mL (0.3-0.5 mL/kg/%/TBSA or 0.3 or 0.5 mL × 60 × 40) d. urine output (0.5 to 1 mL/kg/hr = 30-50 mL/hr) and vital signs (systolic BP 90, HR <120 bpm, RR 16-20).

14. A patient's deep partial-thickness burns are treated with the open method. What should the nurse do when caring for the patient? a. Ensure that sterile water is used in the debridement tank. b. Wear a cap, mask, gown, and gloves during patient contact. c. Use sterile gloves to remove the dressings and wash the wounds. d. Apply topical antimicrobial ointment with clean gloves to prevent wound trauma.

14. b. When the patient's wounds are exposed with the open method, the staff must wear caps, masks, gowns, and gloves. Sterile water is not necessary in the debridement tank and topical antiinfective agents should be applied with sterile gloves. If some dressings are used with the open method, they are removed and wounds are washed with clean gloves.

15. A patient with deep partial-thickness burns over 45% of his trunk and legs is going for debridement in the cart shower 48 hours post burn. What is the drug of choice to control the patient's pain during this activity? a. IV morphine b. Midazolam (Versed) c. IM meperidine (Demerol) d. Long-acting oral morphine

15. a. Morphine is the drug of choice for pain control and during the emergent phase it should be administered IV because GI function is impaired and IM injections will not be absorbed adequately.

16. The nurse assesses that bowel sounds are absent and abdominal distention is present in a patient 12 hours post burn. The nurse notifies the health care provider and anticipates doing what action? a. Withhold all oral intake except water b. Insert a nasogastric tube for decompression c. Administer a H2-histamine blocker such as cimetidine (Tagamet) d. Administer nutritional supplements through a feeding tube placed in the duodenum

16. b. The patient with large burns often develops paralytic ileus within a few hours and a nasogastric tube is inserted and connected to low, intermittent suction. After GI function returns, feeding tubes may be used for nutritional supplementation and H2 histamine blockers may be used to prevent Curling's ulcers. Free water is not given to drink because of the potential for water intoxication.

17. How should the nurse position the patient with ear, face, and neck burns? a. Prone b. On the side c. Without pillows d. With extra padding around the head

17. c. Patients with ear burns are not allowed to use pillows because of the danger of the burned ear sticking to the pillowcase and patients with neck burns are not allowed to use pillows because contractures of the neck can occur.

18. Identify the factors that increase nutritional needs of the patient during the emergent and acute phases of burn injury (select all that apply). a. Electrolyte imbalance b. Core temperature elevation c. Calories and protein are used for tissue repair d. Hypometabolic state secondary to decreased gastrointestinal (GI) function e. Massive catabolism characterized by protein breakdown and increased gluconeogenesis

18. b, c, e. There is a hypermetabolic state proportional to the size of the burn, which increases the core temperature. Massive catabolism can occur and lead to malnutrition and delayed healing without adequate calorie and protein supplementation. The electrolyte imbalance has more effect on the fluid resuscitation than the nutritional needs.

19. At the end of the emergent phase and the initial acute phase of burn injury, a patient has a serum sodium level of 152 mEq/L (152 mmol/L) and a serum potassium level of 2.8 mEq/L (2.8 mmol/L). What could have caused these imbalances? a. Free oral water intake b. Prolonged hydrotherapy c. Mobilization of fluid and electrolytes in the acute phase d. Excessive fluid replacement with dextrose in water without potassium supplementation

19. c. At the end of the emergent phase, fluid mobilization moves potassium back into the cells and sodium returns to the vascular space, causing hypokalemia and hypernatremia. As diuresis in the acute phase continues, sodium will be lost in the urine and potassium will continue to be low unless it is replaced. Excessive fluid replacement with 5% dextrose in water without potassium supplementation can cause hyponatremia with hypokalemia. Prolonged hydrotherapy and free oral water intake can cause a decrease in both sodium and potassium.

2. Which characteristics are true about chemical burns (select all that apply)? a. Metabolic asphyxiation may occur. b. Metabolic acidosis occurs immediately following the burn. c. The visible skin injury often does not represent the full extent of tissue damage. d. Lavaging with large amounts of water is important to stop the burning process with these injuries. e. Alkaline substances that cause these burns continue to cause tissue damage even after being neutralized.

2. d, e. With chemical burns, removing the chemical from the skin is important. Lavaging the skin for 20 minutes to 2 hours post exposure may be needed. Alkali tends to adhere to skin and causes prolonged damage with protein hydrolysis and liquefaction. Metabolic asphyxiation is from the inhalation of carbon monoxide or hydrogen cyanide. Metabolic acidosis is most common in electrical burns, as is the "iceberg effect" of tissue injury below the skin.

20. A burn patient has a nursing diagnosis of impaired physical mobility related to a limited range of motion (ROM) resulting from pain. What is an appropriate nursing intervention for this patient? a. Have the patient perform ROM exercises when pain is not present. b. Provide analgesic medications before physical activity and exercise. c. Teach the patient the importance of exercise to prevent contractures. d. Arrange for the physical therapist to encourage exercise during hydrotherapy.

20. b. The limited ROM in this situation is related to the patient's inability or reluctance to exercise the joints because of pain and the appropriate intervention is to help control the pain so that exercises can be performed. The patient is probably never without some pain and although exercises and enlisting the help of the physical therapist are important, neither of these interventions addresses the cause.

21. The nurse initially suspects the possibility of sepsis in the burn patient based on what changes? a. Vital signs b. Urinary output c. Gastrointestinal function d. Burn wound appearance

21. a. Early signs of sepsis include an elevated temperature and increased pulse and respiratory rate accompanied by decreased blood pressure and, later, decreased urine output and perhaps paralytic ileus. A burn wound may become locally infected without causing sepsis.

23. Complete the following sentences. a. A permanent skin graft that may be available for the patient with large body surface area burns who has limited skin for donor harvesting is . b. Early excision and grafting of burn wounds involve excising down to clean viable tissue and applying an whenever possible. c. Blebs can be removed from skin grafts by .

23. a. cultured epithelial autograft. b. eschar (or necrotic tissue); autograft. c. aspirating the fluid with a tuberculosis syringe, performed by individuals instructed in this skill.

24. The burn patient has developed an increasing dread of painful dressing changes. What would be the most appropriate treatment to ask the health care provider to prescribe? a. Midazolam (Versed) to be used with morphine before dressing changes b. Morphine in a dosage range so that more may be given before dressing changes c. Buprenorphine (Buprenex) to be administered with morphine before dressing changes d. Patient-controlled analgesia so that the patient may have control of analgesic administration

24. a. Midazolam is useful when patients' anticipation of the pain experience increases their pain because it causes a short-term memory loss and, if given before a dressing change, the patient will not recall the event. A dosage range of morphine is useful, as is patient-controlled analgesia, but seldom will these doses effectively relieve the discomfort of dressing changes. Buprenorphine is an opioid agonist/ antagonist and cannot be used with other opioids.

25. During the rehabilitation phase of a burn injury, what can control the contour of the scarring? a. Pressure garments b. Avoidance of sunlight c. Splinting joints in extension d. Application of emollient lotions

25. a. Pressure garments help to keep scars flat and prevent elevation and enlargement above the original burn injury area. Lotions and splinting are used to prevent contractures. Avoidance of sunlight is necessary for at least 3 months to prevent hyperpigmentation and sunburn injury to healed burn areas.

26. A 24-year-old female patient does not want the wound cleansing and dressing change to take place. She states, "What difference will it make anyway?" What will the nurse encourage the patient to do? a. Have the wound cleaned and the dressing changed b. Have a snack before having the treatments completed c. Talk about what is troubling her with the nurse and/or her family d. Call the chaplain to come and talk to her and convince her to have the care

26. c. There is tremendous psychologic impact with a burn injury. Open communication with caregivers, close friends, and the burn team about fears regarding loss of life as she once knew it, loss of function, temporary or permanent deformity and disfigurement, return to routine life, financial burdens, rehabilitation, and her future are all essential. Simply convincing her to have the wound cared for ignores her psychologic, emotional, and perhaps spiritual needs.

27. Priority Decision: The nurse has received the change-of-shift report on his group of patients. Indicate the priority order in which the nurse should see these patients. ______a. A 40-year-old female who is returning from the postanesthesia care unit (PACU) following surgical debridement of her back and legs ______b. A 76-year-old male with partial-thickness burns of his arms and abdomen who is complaining of severe pain ______c. A 62-year-old female who was just admitted following partial-thickness burns to her anterior chest, face, and neck ______d. An 18-year-old male with full-thickness burns of his lower extremities who is refusing to go for his scheduled dressing change

27. a. 3; b. 2; c. 1; d. 4. Face and neck burns are frequently associated with airway inhalation. Therefore this patient requires airway assessment (priority = ABCs). Severe pain would be the next priority (high physiologic need). The patient returning from the PACU will need to be seen soon to assess vital signs, level of consciousness, IV fluids, and wounds. However, at the current time the transport personnel should be with her. The 18-year-old is not at risk related to ABCs and it will probably take a few minutes to talk with him about why he doesn't want to go for the dressing change.

3. When assessing a patient's full-thickness burn injury during the emergent phase, what would the nurse expect to find? a. Leathery, dry, hard skin b. Red, fluid-filled vesicles c. Massive edema at the injury site d. Serous exudate on a shiny, dark brown wound

3. a. Dry, waxy white, leathery, or hard skin is characteristic of full-thickness burns in the emergent phase and it may turn brown and dry in the acute phase. Deep partial-thickness burns in the emergent phase are red and shiny and have blisters. Edema may not be as extensive in full-thickness burns because of thrombosed vessels.

4. A patient has the following mixed deep partial-thickness and full-thickness burn injuries: face, anterior neck, right anterior trunk, and anterior surfaces of the right arm and lower leg. a. According to the Lund-Browder chart, what is the extent of the patient's burns? ______% total body surface area (TBSA) b. According to the rule of nines chart, what is the extent of the patient's burns? ______% TBSA c. Is it possible to determine the actual extent and depth of burn injury during the emergent phase of the burn? Why or why not?

4. a. 3½ + 1 + 6½ + 2 + 1½ + 3½ = 18% TBSA b. 4½ + 9 + 4½ + 4½ = 22½% TBSA c. No, because edema and inflammation obscure the demarcation of zones of injury.

5. Priority Decision: Number the following actions in the order they should be done in the emergency management of a burn of any type, beginning with number 1 for the first action. ______a. Establish and maintain an airway. ______b. Assess for other associated injuries. ______c. Establish an IV line with a large-gauge needle. ______d. Remove the patient from the burn source and stop the burning process.

5. a. 2; b. 4; c. 3; d. 1. The first intervention in emergency management of a burn injury is to remove the burn source and stop the burning process. Airway maintenance would be second, then establishing IV access, followed by assessing for other injuries.

6. The patient was admitted to the burn center with a full-thickness burn 42 hours after the thermal burn occurred. The nurse will apply actions related to which phase of burn management for this patient's care? a. Acute b. Emergent c. Postacute d. Rehabilitative

6. b. The emergent phase is usually 24 to 72 hours after the time the burn occurred and focuses on fluid resuscitation. The acute phase is after the emergent phase and may last weeks to months after the burn occurred but begins when the extracellular fluid is mobilized and diuresis occurs. There is no postacute phase. The rehabilitative phase begins weeks to months after the injury, when the wounds have healed and the patient participates in self-care.

7. During the early emergent phase of burn injury, the patient's laboratory results would most likely include a. ↑ Hct, ↓ serum albumin, ↓ serum Na, ↑ serum K. b. ↓ Hct, ↓ serum albumin, ↓ serum Na, ↓ serum K. c. ↓ Hct, ↑ serum albumin, ↑ serum Na, ↑ serum K. d. ↑ Hct, ↑ serum albumin, ↓ serum Na, ↓ serum K.

7. a. With increased capillary permeability, water, sodium, and plasma proteins leave the plasma and move into the interstitial spaces, decreasing serum sodium and albumin. Serum potassium is elevated because injured cells and hemolyzed red blood cells (RBCs) release potassium from cells. An elevated hematocrit is caused by water loss into the interstitium, creating a hemoconcentration.

8. What is the initial cause of hypovolemia during the emergent phase of burn injury? a. Increased capillary permeability b. Loss of sodium to the interstitium c. Decreased vascular oncotic pressure d. Fluid loss from denuded skin surfaces

8. a. Although all of the selections add to the hypovolemia that occurs in the emergent burn phase, the initial and most pronounced effect is caused by fluid shifts out of the blood vessels as a result of increased capillary permeability

9. How is the immune system altered in a burn injury? a. Bone marrow stimulation b. Increase in immunoglobulin levels c. Impaired function of white blood cells (WBCs) d. Overwhelmed by microorganisms entering denuded tissue

9. c. Burn injury causes widespread impairment of the immune system, with impaired WBC functioning, bone marrow depression, and a decrease in circulating immunoglobulins, which allows microorganisms to grow.

22. Identify one major complication of burns that is believed to be stress-related that may occur in each of the following systems during the acute burn phase. Neurologic: Gastrointestinal: Endocrine:

Neurologic: Confusion or delirium Gastrointestinal: Curling's ulcer Endocrine: Hyperglycemia