Burns Complex Chpt 25
A patient with burns covering 40% total body surface area (TBSA) is in the acute phase of burn treatment. Which snack would be best for the nurse to offer to this patient? a. Bananas b. Orange gelatin c. Vanilla milkshake d. Whole grain bagel
ANS: C A patient with a burn injury needs high protein and calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake. Gelatin is likely high in sugar. The bagel is a good carbohydrate choice, but low in protein. Bananas are a good source of potassium, but are not high in protein and calories
A patient with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first? a. Assess oral temperature. b. Check a potassium level. c. Place on cardiac monitor. d. Assess for pain at contact points.
ANS: C After an electrical burn, the patient is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. Assessing the oral temperature is not as important as assessing for cardiac dysrhythmias. Checking the potassium level is important. However, it will take time before the laboratory results are back. The first intervention is to place the patient on a cardiac monitor and assess for dysrhythmias, so that they can be treated if occurring. A decreased or increased potassium level will alert the nurse to the possibility of dysrhythmias. The cardiac monitor will alert the nurse immediately of any dysrhythmias. Assessing for pain is important, but the patient can endure pain until the cardiac monitor is attached. Cardiac dysrhythmias can be lethal
How do we treat treatment-induced pain for a burn patient?
Analgesic Anxiolytic (sedative and hypnotic)
What are the clinical manifestation of a patient in the Emergent Phase of a burn?
Shock from hypovolemia, Blisters, Paralytic ileus, Shivering, Altered mental status
Chemical burns can result in injuries to what areas of the body?
Skin Eyes Respiratory system Liver and kidney
What is done during the Multiple dressing change or closed method?
Sterilized gauze dressings are laid over topical antibiotic Dressings may be changed from every 12 to 24 hours to once every 14 days
T or F smoke inhalation injuries are a major predictor pf mortality in burn victims and need to be treated quickly?
T
The patient should move the burned body parts as much as possible, T or F?
T
How can contractors be minimized for a burn victim?
proper positioning, splining, and exercise
What does performing enzymatic debriment speed up?
removal of dead tissue from healthy wound bed
What are the proper steps for prehospital care for a thermal burn?
remove burned clothing if loose wrap patient in dry sheet or blanket to prevent contamination and provide warmth
A burn to the face, neck, chest, will create what kind of complication for a person?
respiratory obstruction
A central line may be considered for burns over what percentage?
30%
What is the Parkland (Baxter) formula?
4mL*(mass) kg* total BSA= total fluid in 24 hr / 2 and give that in the first 8 hr 4 mL Lactated Ringers solution per Kg of bodyweight per percent of total body surface area (%TBSA) = total fluid requirements for first 24 hours. ½ of total in first 8 hours ¼ of total in second 8 hours ¼ of total in third 8 hours
What are the three types of smoke inhalation injury types?
Metabolic asphyxiation Upper airway injury Lower airway injury
What are some common Analgesics and sedatives given to burn patients?
Morphine Hydromorphone (Dilaudid) Lorazepam (Ativan)
Should feeding be slowed if glucose gets too high for a patient?
No, give IV insulin
How can you get a Burn?
Occur when there is injury to tissues of the body caused by heat, chemicals, electrical current, or radiation.
Who should be involved in helping with ROM with a burn patient?
physical and occupational therapist
After debiment what is applied to the burn?
split-thickness autograft
What treatment occurs if intubation does not occur for the burn victim?
100% humidified O2, High Fowlers, encourage deep breathing and coughing every hour
A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first? a. Auscultate the patient's lung sounds. b. Determine the extent and depth of the burns. c. Infuse the ordered lactated Ringer's solution. d. Administer the ordered hydromorphone (Dilaudid).
ANS: A A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured
Which patient is most appropriate for the burn unit charge nurse to assign to a registered nurse (RN) who has floated from the hospital medical unit? a. A 34-year-old patient who has a weight loss of 15% from admission and requires enteral feedings. b. A 67-year-old patient who has blebs under an autograft on the thigh and has an order for bleb aspiration c. A 46-year-old patient who has just come back to the unit after having a cultured epithelial autograft to the chest d. A 65-year-old patient who has twice-daily burn debridements and dressing changes to partial-thickness facial burns
ANS: A An RN from a medical unit would be familiar with malnutrition and with administration and evaluation of response to enteral feedings. The other patients require burn assessment and care that is more appropriate for staff who regularly care for burned patients
A patient has just been admitted with a 40% total body surface area (TBSA) burn injury. To maintain adequate nutrition, the nurse should plan to take which action? a. Insert a feeding tube and initiate enteral feedings. b. Infuse total parenteral nutrition via a central catheter. c. Encourage an oral intake of at least 5000 kcal per day. d. Administer multiple vitamins and minerals in the IV solution.
ANS: A Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24 to 48 hours to the goal rate. During the emergent phase, the patient will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the patient's caloric needs. Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn patients
The charge nurse observes the following actions being taken by a new nurse on the burn unit. Which action by the new nurse would require an intervention by the charge nurse? a. The new nurse uses clean latex gloves when applying antibacterial cream to a burn wound. b. The new nurse obtains burn cultures when the patient has a temperature of 95.2° F (35.1° C). c. The new nurse administers PRN fentanyl (Sublimaze) IV to a patient 5 minutes before a dressing change. d. The new nurse calls the health care provider for a possible insulin order when a nondiabetic patient's serum glucose is elevated.
ANS: A Sterile gloves should be worn when applying medications or dressings to a burn. Hypothermia is an indicator of possible sepsis, and cultures are appropriate. Nondiabetic patients may require insulin because stress and high calorie intake may lead to temporary hyperglycemia. Fentanyl peaks 5 minutes after IV administration, and should be used just before and during dressing changes for pain management
A patient with circumferential burns of both legs develops a decrease in dorsalis pedis pulse strength and numbness in the toes. Which action should the nurse take? a. Notify the health care provider. b. Monitor the pulses every 2 hours. c. Elevate both legs above heart level with pillows. d. Encourage the patient to flex and extend the toes on both feet.
ANS: A The decrease in pulse in a patient with circumferential burns indicates decreased circulation to the legs and the need for an escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the legs or increasing toe movement will not improve the patient's circulation
The nurse caring for a patient admitted with burns over 30% of the body surface assesses that urine output has dramatically increased. Which action by the nurse would best ensure adequate kidney function? a. Continue to monitor the urine output. b. Monitor for increased white blood cells (WBCs). c. Assess that blisters and edema have subsided. d. Prepare the patient for discharge from the burn unit.
ANS: A The patient's urine output indicates that the patient is entering the acute phase of the burn injury and moving on from the emergent stage. At the end of the emergent phase, capillary permeability normalizes and the patient begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some patients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the patient's immune status and any infectious processes. The WBC count does not indicate kidney function. The patient will likely remain in the burn unit during the acute stage of burn injury
Which nursing action is a priority for a patient who has suffered a burn injury while working on an electrical power line? a. Obtain the blood pressure. b. Stabilize the cervical spine. c. Assess for the contact points. d. Check alertness and orientation.
ANS: B Cervical spine injuries are commonly associated with electrical burns. Therefore stabilization of the cervical spine takes precedence after airway management. The other actions are also included in the emergent care after electrical burns, but the most important action is to avoid spinal cord injury
A patient is admitted to the burn unit with burns to the head, face, and hands. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take? a. Encourage the patient to cough and auscultate the lungs again. b. Notify the health care provider and prepare for endotracheal intubation. c. Document the results and continue to monitor the patient's respiratory rate. d. Reposition the patient in high-Fowler's position and reassess breath sounds.
ANS: B The patient's history and clinical manifestations suggest airway edema and the health care provider should be notified immediately, so that intubation can be done rapidly. Placing the patient in a more upright position or having the patient cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur
A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position? a. Place the right arm and hand flexed in a position of comfort. b. Elevate the right arm and hand on pillows and extend the fingers. c. Assist the patient to a supine position with a small pillow under the head. d. Position the patient in a side-lying position with rolled towel under the neck.
ANS: B The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow because the head should be maintained in an extended position in order to avoid contractures
A young adult patient who is in the rehabilitation phase 6 months after a severe face and neck burn tells the nurse, "I'm sorry that I'm still alive. My life will never be normal again." Which response by the nurse is best? a. "Most people recover after a burn and feel satisfied with their lives." b. "It's true that your life may be different. What concerns you the most?" c. "It is really too early to know how much your life will be changed by the burn." d. "Why do you feel that way? You will be able to adapt as your recovery progresses."
ANS: B This response acknowledges the patient's feelings and asks for more assessment data that will help in developing an appropriate plan of care to assist the patient with the emotional response to the burn injury. The other statements are accurate, but do not acknowledge the anxiety and depression that the patient is expressing
While the patient's full-thickness burn wounds to the face are exposed, what is the best nursing action to prevent cross contamination? a. Use sterile gloves when removing old dressings. b. Wear gowns, caps, masks, and gloves during all care of the patient. c. Administer IV antibiotics to prevent bacterial colonization of wounds. d. Turn the room temperature up to at least 70° F (20° C) during dressing changes.
ANS: B Use of gowns, caps, masks, and gloves during all patient care will decrease the possibility of wound contamination for a patient whose burns are not covered. When removing contaminated dressings and washing the dirty wound, use nonsterile, disposable gloves. The room temperature should be kept at approximately 85° F for patients with open burn wounds to prevent shivering. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction c. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction
ANS: B With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain.
A patient has just arrived in the emergency department after an electrical burn from exposure to a high-voltage current. What is the priority nursing assessment? a. Oral temperature b. Peripheral pulses c. Extremity movement d. Pupil reaction to light
ANS: C All patients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data are also necessary but not as essential as determining the cervical spine status
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids? a. 350 mL/hour b. 523 mL/hour c. 938 mL/hour d. 1250 mL/hour
ANS: C Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours. In this case, the patient should receive half of the initial rate, or 938 mL/hr
The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse? a. Hematocrit 53% b. Serum sodium 147 mEq/L c. Serum potassium 6.1 mEq/L d. Blood urea nitrogen 37 mg/dL
ANS: C Hyperkalemia can lead to fatal dysrhythmias and indicates that the patient requires cardiac monitoring and immediate treatment to lower the potassium level. The other laboratory values are also abnormal and require changes in treatment, but they are not as immediately life threatening as the elevated potassium level
On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now? a. Monitor urine output every 4 hours. b. Continue to monitor the laboratory results. c. Increase the rate of the ordered IV solution. d. Type and crossmatch for a blood transfusion.
ANS: C The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours; likely every1 hour
A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first? a. Stay at the bedside and reassure the patient. b. Administer the ordered morphine sulfate IV. c. Assess orientation and level of consciousness. d. Use pulse oximetry to check the oxygen saturation.
ANS: D Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient
Which action will the nurse include in the plan of care for a patient in the rehabilitation phase after a burn injury to the right arm and chest? a. Keep the right arm in a position of comfort. b. Avoid the use of sustained-release narcotics. c. Teach about the purpose of tetanus immunization. d. Apply water-based cream to burned areas frequently.
ANS: D Application of water-based emollients will moisturize new skin and decrease flakiness and itching. To avoid contractures, the joints of the right arm should be positioned in an extended position, which is not the position of comfort. Patients may need to continue the use of opioids during rehabilitation. Tetanus immunization would have been given during the emergent phase of the burn injury
What complications occur in the Urinary system during a burn?
Decreased blood flow to kidneys causes renal ischemia Acute tubular necrosis (ATN)
When does Wound care take place for a burn patient?
Delayed until a patent airway, adequate circulation, and fluid replacement have been established
Severity of a Burn Injury is determined by?
Depth of burn Partial or full thickness burns Extent of burn in percent of TBSA Location of burn Patient risk factors
What happens during the Acute Phase and its Pathophysiology?
Diuresis from fluid mobilization occurs, and patient is less edematous Bowel sounds return Healing begins as WBCs surround burn wound and phagocytosis occurs Necrotic tissue begins to slough Granulation tissue forms Partial-thickness burn wounds heal from edges and from dermal bed Full-thickness burns must have eschar removed and skin grafts applied
What can hyperkalemia cause?
ECG changes, cardiac dysrhythmias and ventricular failure Muscle weakness
How are we going to treat a patient who was in a fire and has rapid shallow breathing, coughing, restless, with a decreased O2 saturation?
First access their airway Then stabilize their cervical spine, Provide 100% humidified O2, intubate, remove clothing, insert fly, elevate burned limbs, IV angalgesia, cover burned areas with dry sheet
What are Superficial partial-thickness burns categorized as?
First degree burns
What causes Smoke Inhalation Injuries?
From inhalation of hot air or noxious chemicals
What is the greatest threat to a burn victim?
Greatest threat is hypovolemic shock
What state is a burns patient metabolism in?
Hyper metabolic state, Resting metabolic expenditure may be increased by 50% to 100% above normal Core temperature is elevated
When a patient has renal failure, adrenocortical insufficiency, or massive muscle injury, large amounts of K is released from the cells causing?
Hyperkalemia
What are the Types of Burn Injuries?
Thermal burns Chemical burns Smoke inhalation injury Electrical burns Cold thermal injury- frost bite
Why is it important to have a cardiac monitor and measure fluid output in a burn patient?
These determine the parameters for fluid resuscitation and need to be taken hourly
A full thickness burn is catogorized as a?
Third and fourth degree burns
What do you do for Fluid therapy for patient who is in the emergent phase of burns?
Two large-bore IV lines for >15% TBSA Type of fluid replacement based on size/depth of burn, age, and individual considerations
How long can the emergent phase last up to?
Up to 72 hours
What is the caloric needs of a burn patient?
about 5000 kcal/day Early, continuous enteral feeding promotes optimal conditions for wound healing Supplemental vitamins and iron may be given
A third and fourth degree burn involves?
all skin elements, nerve endings, fat, muscle, bone All skin elements and local nerve endings are destroyed Necrosis develops Surgical intervention
Why must we check patent for sulfa allergies?
antimicrobial creams used for burns contain sulfa.
What is the goal of wound care?
prevent infection by Cleansing Debridement to promote re-epithelialization
A burn on the Hands, feet, joints, eyes will lead to what complications?
problems with future function and self-care
Infection, Localized inflammation, induration, and suppuration can cause what to happen to Partial-thickness burns?
become full-thickness wounds in the presence of infection
Initially what complications occur with a burn victim?
blood viscosity increases due to dehydration and microcirculation is impaired, both are termed sludging
The abnormal condition of a joint flexing or fixated due to the shortening of scar tissue is termed what?
contracture
What is a common complication of healing for a burn patient?
contracture
What can be done for a small thermal burn?
covered with clean cool dampened towel
How does the ABA categorize burns according to what?
depth of skin destruction Partial-thickness burn Full-thickness burn
How can you avoid water intoxication?
drink Juices and nutritional supplements Restrict sodium in IVs, oral feedings
Why do we want a burn patient to have a high protein, high carbohydrate, high caloric, all their favorite foods from home diet?
to promote healing
What are these drugsSilver sulfadiazine (Silvadene) and Mafenide acetate (Sulfamylon)
topical antimicrobial agent sulfa drugs
Tissue destruction from a chemical burn can continue for how long after exposure?
up to 72 hours after chemical injury
What does the rehabilitation phase begin for a burn patient?
when the wounds have healed and the patient can take part in self care
How do you treat a person with CO poisoning?
100% humidified air
What Labs are you going to get for a burn victim?
ABGs, carboxyhemoglobin levels, Chest X ray
The nurse estimates the extent of a burn using the rule of nines for a patient who has been admitted with deep partial-thickness burns of the anterior trunk and the entire left arm. What percentage of the patient's total body surface area (TBSA) has been injured?
ANS: 27% When using the rule of nines, the anterior trunk is considered to cover 18% of the patient's body and each arm is 9%.
An 80-kg patient with burns over 30% of total body surface area (TBSA) is admitted to the burn unit. Using the Parkland formula of 4 mL/kg/%TBSA, what is the IV infusion rate (mL/hour) for lactated Ringer's solution that the nurse will administer during the first 8 hours?
ANS: 600 mL The Parkland formula states that patients should receive 4 mL/kg/%TBSA burned during the first 24 hours. Half of the total volume is given in the first 8 hours and then the last half is given over 16 hours: 4 ´ 80 ´ 30 = 9600 mL total volume; 9600/2 = 4800 mL in the first 8 hours; 4800 mL/8 hr = 600 mL/hr.
In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a patient's chest? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Apply sterile gauze dressing. b. Document wound appearance. c. Apply silver sulfadiazine cream. d. Administer IV fentanyl (Sublimaze). e. Clean wound with saline-soaked gauze.
ANS: D, E, C, A, B Because partial-thickness burns are very painful, the nurse's first action should be to administer pain medications. The wound will then be cleaned, antibacterial cream applied, and covered with a new sterile dressing. The last action should be to document the appearance of the wound
Which patient should the nurse assess first? a. A patient with smoke inhalation who has wheezes and altered mental status b. A patient with full-thickness leg burns who has a dressing change scheduled c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour
ANS: A This patient has evidence of lower airway injury and hypoxemia and should be assessed immediately to determine the need for oxygen or intubation. The other patients should also be assessed as rapidly as possible, but they do not have evidence of life-threatening complications
An employee spills industrial acids on both arms and legs at work. What is the priority action that the occupational health nurse at the facility should take? a. Remove nonadherent clothing and watch. b. Apply an alkaline solution to the affected area. c. Place cool compresses on the area of exposure. d. Cover the affected area with dry, sterile dressings.
ANS: A With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Remove nonadherent clothing, shoes, watches, jewelry, glasses, or contact lenses (if face was exposed). Flush chemical from wound and surrounding area with copious amounts of saline solution or water. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended
Esomeprazole (Nexium) is prescribed for a patient who incurred extensive burn injuries 5 days ago. Which nursing assessment would best evaluate the effectiveness of the medication? a. Bowel sounds b. Stool frequency c. Abdominal distention d. Stools for occult blood
ANS: D H2 blockers and proton pump inhibitors are given to prevent Curling's ulcer in the patient who has suffered burn injuries. Proton pump inhibitors usually do not affect bowel sounds, stool frequency, or appetite
The nurse is reviewing the medication administration record (MAR) on a patient with partial-thickness burns. Which medication is best for the nurse to administer before scheduled wound debridement? a. Ketorolac (Toradol) b. Lorazepam (Ativan) c. Gabapentin (Neurontin) d. Hydromorphone (Dilaudid)
ANS: D Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effects of opioids
A patient who was found unconscious in a burning house is brought to the emergency department by ambulance. The nurse notes that the patient's skin color is bright red. Which action should the nurse take first? a. Insert two large-bore IV lines. b. Check the patient's orientation. c. Assess for singed nasal hair and dark oral mucous membranes. d. Place the patient on 100% oxygen using a non-rebreather mask.
ANS: D The patient's history and skin color suggest carbon monoxide poisoning, which should be treated by rapidly starting oxygen at 100%. The other actions can be taken after the action to correct gas exchange
Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider? a. Blood pressure is 95/48 per arterial line. b. Serous exudate is leaking from the burns. c. Cardiac monitor shows a pulse rate of 108. d. Urine output is 20 mL per hour for the past 2 hours.
ANS: D The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase
A young adult patient who is in the rehabilitation phase after having deep partial-thickness face and neck burns has a nursing diagnosis of disturbed body image. Which statement by the patient indicates that the problem is resolving? a. "I'm glad the scars are only temporary." b. "I will avoid using a pillow, so my neck will be OK." c. "I bet my boyfriend won't even want to look at me anymore." d. "Do you think dark beige makeup foundation would cover this scar on my cheek?"
ANS: D The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance, but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image
During the emergent phase of burn care, which assessment will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor. b. Monitor daily weight. c. Assess mucous membranes. d. Measure hourly urine output.
ANS: D When fluid intake is adequate, the urine output will be at least 0.5 to 1 mL/kg/hour. The patient's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion
How do we treat a person with electrical burns that exhibits impaired touch, minimal or absent pain, fractures and dislocations from current?
Access airway, stabilize spine, O2, monitor vitals, remove clothing, cover burns with dry dressing, IV for fluid replacement, elevate burned limbs, IV analgesia.
What can be done after you remove the person from the burning source for a large burn?
Check their airway breathing circulation
Acute Phase
Begins with the mobilization of extracellular fluid and subsequent diuresis Concludes when Partial thickness wounds are healed and/or Full thickness burns are covered by skin grafts
What is done with the Open method of wound treatment?
Burn is covered with topical antibiotic with no dressing over wound
How do we rate burns?
Burns have been defined by degrees (first, second, third, and fourth)
If someone gets a chemical burn what should be removed from the skin quickly?
Chemical should be quickly removed from the skin Clothing containing the chemical should be removed- bagged pull it away
What is metabolic asphyxiation?
Carbon monoxide (CO) poisoning CO is produced by the incomplete combustion of burning materials Inhaled CO displaces oxygen Hypoxia Carboxyhemoglobinemia Death
What is carbon monoxide poisoning?
Carbon monoxide (CO) poisoning Hypoxia and ultimately death when CO levels are 20% or greater Treat with 100% humidified oxygen CO poisoning may occur in the absence of burn injury to the skin
What does Smoke Inhalation Injuries damage?
Cause damage to respiratory tract
Why are the alkali burns hard to manage?
Cause protein hydrolysis and liquefaction Damage continues after alkali is neutralized
What guides do we use to determine the Extent of the Burn and the total body surface area? ?
Lund-Browder chart rule of nines
What do you do for Airway management for patient who is in the emergent phase of burns?
Early endotracheal intubation Escharotomies of the chest wall Fiberoptic bronchoscopy Humidified air and 100% oxygen
What complications occur in the upper airways during a burn?
Edema formation Mechanical airway obstruction and asphyxia
What are the Phases of Burn Management?
Emergent (resuscitative) Acute (wound healing) Rehabilitative (restorative)
What is the Emergent Phase of burn management?
Emergent (resuscitative) phase is time required to resolve immediate problems resulting from injury
What will happen to the patients sodium levels when there is fluid replacement with hypertonic solutions, improper tube feedings/ fluid administration?
Hypernatremia may develop
Lengthy IV therapy without potassium Vomiting, diarrhea and Prolonged gastrointestinal suction can cause?
Hypokalemia
What will happen to the patients sodium levels when there is GI suction, diarrhea, and water intake?
Hyponatremia can develop
What is the primary concern for the nurse during the emergent phase?
Hypovolemic shock Edema
Drugs need to be taken how with a burn patient?
IV
How do we treat Continuous background pain for a burn patient?
IV infusion of an opioid Or slow-release, twice-a-day oral opioid
What is a serious threat during wound care for a burn patient?
Infection
What do First degree burns involve?
Involves the epidermis Heat flash
Why do burn patients take enoxaparin?
Low molecular weight heprin to prevent VTE
What complications occur in the lower airways during a burn?
Lower airway injury Pneumonia Pulmonary edema
What complications can the GI have during the acute phase?
Paralytic ileus Diarrhea, constipation Curling's ulcer (peptic ulcer)
How do we calculate how much fluid to give a burn victim?
Parkland (Baxter) formula
What are the two types of thickness burn categories?
Partial-thickness burn Full-thickness burn
What are some alternative ways for managing pain or Nonpharmacologic strategies?
Relaxation breathing Visualization, guided imagery
Electrical Burns
Result from coagulation necrosis caused by intense heat generated from an electric current May result from direct damage to nerves and vessels, causing tissue anoxia and death Severity of injury depends on Amount of voltage Tissue resistance Current pathways Surface area Duration of the flow
What causes a Chemical Burn?
Result of contact with acids, alkalis, and organic compounds
Deep partial-thickness burn is categorized as a?
Second degree burns
Disorientated and combative, Hallucinations, and Delirium are indicators of what for the Neurologic system?
Severe hypoxia from respiratory injuries or complications from electrical injuries
Why is the Location of the Burn important?
Severity of burn injury is determined by location of burn wound
What is Cultured epithelial autographs CEAs?
Skin grown in a lab from a patients own skin
What does the severity of the injury depend on with a thermal burn?
Temperature of burning agent Duration of contact time
When is a good time for exercise for a burn patient?
during wound cleaning
What classic symptoms occur due to hypovolemic shock?
edema, Decreased blood pressure, increased heart rate
Increased blood glucose levels, Increased insulin production, and Hyperglycemia are complications for what system?
endocrine system
What are Thermal Burns caused by?
flame, flash, scald, or contact with hot objects
How can slugging be corrected in a person with burns?
fluid replacement
After removing burned clothing for a chemical burn what should be done next?
flush wound with running water for 20 minutes to 2 hours
What may the burn victim need to replace?
hematocrit
A burn on the Ears, nose, buttocks, perineum will lead to what type of complication?
infection
Hypothermia or hyperthermia, Increased heart and respiratory rate, Decreased BP, Decreased urine output are warning signs of what?
infection
What is the rule of nines used for?
initial assessment of total body surface area
What causes hypovolemic shock?
massive fluid, electrolytes and proteins shift out of blood vessels into interstitial space from increased permeability
Should you immerse burn in cool water or cover with ice?
no it will slow healing from vasoconstriction
How long should you cool a burn?
no more than 10min to prevent hypothermia
What complications occur with the cardiovascular system during the Emergent Phase of a burn?
sludging, dysrhythmias and hypovolemic shock, edema
Second degree burn involves?
the dermis Flash, scald, contact burns Chemical and electrical current
