Ch. 57 Management of Patients with Burn Injury

A patient is admitted to a burn treatment center at 2:30 p.m. with full-thickness burns over 40% of his body. The injury occurred at 1:30 p.m. at a paper-making plant. The nurse knows that burn shock has to be prevented or treated. Based on fluid volume shifts, the nurse knows that fluid loss would peak by __________ to __________ hours, with the greatest volume being lost from __________ to__________ hours after the burn. A. 7:30 p.m. to 9:30 p.m.; 24 to 36 hours B. 4:30 p.m. to 6:30 p.m.; 6 to 8 hours C. 5:30 p.m. to 6:30 p.m.; 9 to 12 hours D. 10:30 p.m. to 12:30 a.m.; 40 to 50 hours

A. 7:30 p.m. to 9:30 p.m.; 24 to 36 hours Explanation: The greatest volume of fluid loss occurs in the first 24 to 36 hours after the burn, peaking by 6 to 8 hours. P. 1870

A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area? A. escharotomy B. debridement C. allograft D. silvadene application

A. Escharotomy Explanation: Debridement is the removal of necrotic tissue. An escharotomy is an incision into the eschar to relieve pressure on the affected area. An allograft would not be the treatment. Silvadene may be part of the treatment regimen but not specifically for this situation. P. 1871

A child tips a pot of boiling water onto his bare legs. The mother should: A. Immerse the child's legs in cool water. B. Avoid touching the burned skin and take the child to the nearest emergency department. C. Liberally apply butter or shortening to the burned areas. D. Cover the child's legs with ice cubes secured with a towel.

A. Immerse the childs legs in cool water. Explanation: The application of cool water is the best first-aid measure. Soaking the burned area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage. P. 1867

At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Select all that apply. A. Place the client in a horizontal position. B. Roll the client in a blanket to smother the fire. C. Place the client in a vertical position. D. Open a door and encourage air in an enclosed space.

A. Place the client in a horizontal position. B. Place the client in a horizontal position. Explanation: If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire.

A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? A. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg B. Urine output of 20 ml/hour C. White pulmonary secretions D. Rectal temperature of 100.4° F (38°C)

B. Urine output of 20ml/hour Explanation: A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.

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 A. increased glucose demands. B. increased skeletal muscle breakdown. C. decreased catabolism. D. increased metabolic rate.

C. Decrease Catabolism Explanation: Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to the injury. The body's response has been classified as hyperdynamic, hypermetabolic, and hypercatabolic. The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism. P. 1885

The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs immediately after burn injury? A. Hypernatremia B. Hypokalemia C. Hyperkalemia D. Hypercalcemia

C. Hyperkalemia Explanation: Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. During burn shock, serum sodium levels vary in response to fluid resuscitation. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss. Hyponatremia may also occur during the first week of the acute phase, as water shifts from the interstitial space and returns to the vascular space.

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned? A. 9% B. 18% C.27% D.36%

D. 36% Explanation: According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities that have sustained burns to entire surfaces will equal to 36% of total surface area.

Which of the following skin substitutes is a nylon-silicone membrane coated with a protein? A. Mederma B. Integra C. Transcyte D. Biobrane

D. Biobrane Explanation: Biobrane is a nylon-silicone membrane coated with a protein. Mederma is a topical gel that can reduce scarring. Integra consists of a two-layer membrane: one is a synthetic epidermal layer , and the other contains cross-linked collagen fibers that mimic the dermal layer of skin. Transcyte is created by culturing human fibroblasts from the dermis with a biosynthetic semipermeable membrane attached to nylon mesh. P. 1883

Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis? A. Superficial partial thickness B. Full-thickness C. Fourth degree D. Deep partial-thickness

D. Deep partial-thickness Explanation: A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis as well as injury to deeper portions of the dermis. In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, destruction of underlying tissue, muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs with prolonged flame contact or high voltage injury that destroys all layers of the skin and damages tendons and muscles. P. 1888

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? A. Complaints of intense thirst B. Moderate to severe pain C. Urine output of 70 ml the first hour D. Hoarseness of the voice

D. Hoarseness of the voice Explanation: Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate. P. 1877

The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first? A. Tissue hypoxia B. Infection C. Renal failure D. Hypovolemia

D. Hypovolemia Explanation: After a burn, fluid from the body moves toward the burned area, which leads to intravascular fluid deficit. Steps must be taken to prevent irreversible hypovolemic shock in the initial stages of treatment. The inflammatory processes that affect the tissues cause additional injury, which contributes to tissue hypoxia. Myoglobin and hemoglobin that were destroyed during the burn can result in acute renal failure. Destruction of the skin barrier results in colonization of bacteria and can lead to life-threatening infection in days following the burn. P. 1870

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply. A.Skin turgor B. Percentage of meals eaten C. Hourly urine output D. Daily weights E. Oxygen saturation

A. Skin Turgor C. Hourly urine ouput D. Daily Explanation: Monitoring of hourly urine output and daily weights provides clues about fluid volume status. Skin turgor is a sign of fluid loss (dehydration). Percentage of meals eaten, and oxygen saturation would not be reliable indicators of fluid volume status in the client. P. 1885

Which zone of burn injury sustains the most damage? A. Outer B. Middle C. Inner D. Protective

C. Inner Explanation: The zone of stasis is the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. The zone of coagulation is at the center of the injury, and it is the area where the injury is most severe and usually deepest. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. The zone of hypotension is not the name of one of the zones.

Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of: A. stasis. B. coagulation. C. hyperemia. D. hypotension.

A. Stasis Explanation: The zone of stasis is the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. The zone of coagulation is at the center of the injury, and it is the area where the injury is most severe and usually deepest. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. The zone of hypotension is not the name of one of the zones. P. 1869

A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is: A.planning for the client's rehabilitation and discharge. B. preserving full range of motion in all affected joints. C. maintaining the client's fluid, electrolyte, and acid-base balance. D. providing emotional support to the client and family.

C. Maintaining the client's fluid, electrolyte, and acid base balance. Explanation: After maintaining respirations, the most important immediate goal of therapy for a client with a serious thermal burn is to maintain fluid, electrolyte, and acid-base balance to avoid potentially life-threatening complications, such as shock, disseminated intravascular coagulation, respiratory failure, cardiac failure, and acute tubular necrosis. Planning for the client's rehabilitation and discharge, providing emotional support, and preserving full range of motion in all affected joints are important aspects of care but don't take precedence over maintaining the client's fluid, electrolyte, and acid-base balance. P. 1871

Following a burn injury, the nurse determines which area is the priority for nursing assessment? A. Pulmonary system B. Cardiovascular system C. Pain D. Nutrition

D. Nutrition Explanation: Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs. P. 1874-1875

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: A. fluid resuscitation. B. infection. C. body image. D. pain management.

D. Pain Management Explanation: With a superficial partial-thickness burn such as a solar burn, the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management. P. 1867

Which of the following types of shock will a nurse observe in a client with extensive burns? A. Anaphylactic shock B. Neurogenic shock C. Septic shock D. Hypovolemic shock

D. Hypovolemia Explanation: Clients with extensive burns may exhibit hypovolemic shock due to the loss of blood or plasma. Clients with extensive burns are unlikely to display the symptoms of anaphylactic, neurogenic, or septic shock. P. 1870