chapter 24: Burns
A nurse notes decreased reflexes during the physical assessment of a patient who was admitted with brain injury. Which is the likely cause for this clinical manifestation?
decreased potassium levels a decreased level of potassium, known as hypokalemia, results from the loss of potassium from the burn wounds. Clinical manifestations include muslce weakness, leg cramps, paresthesias, and decreased reflexes
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 occur?
diuresis occurs and hematocrit decreases in the emergent phase, the immediate, life-threatening probloms from the burn-- hypovolemic shock and edema-- are treated and resolved. Toward the end of the emergent phase, fluid loss and edema formation end. Interstitial fluid returns to the vascular space and diuresis occurs. Urinary output is the most commony used parameter to assess the adequacy of fluid resuscitation.
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
Which burn injury would the nurse identify as resulting in tissue anoxia?
electrical injury Electrical injury causes tissue anoxia due to nerve damage and nerve death. The injury sustained by a thermal burn is dependent on the temperature of the burning agent and the length of exposure. Chemical burns can cause tissue damage and eyes can be injured if a splash occurs. Smoke and inhalational injury result in hypoxia.
the nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. upon assessment, the nurse expects to find which manifestation?
reddening of the skin the clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.
A full-thickness scald injury is characterized by
redness and edema at the affected site. It is caused by immersion of the body part in hot water
A burn patient with moist, red, shiny vesicles and blister formation reports severe pain when the site is exposed to air. Which type of burn would the nurse document in the patient's medical record?
second-degree burn
The nurse is assessing a patient admitted after inhalation of toxic chemicals. Which finding by the nurse indicates a lower airway injury?
singed nasal hairs
A nurse is assessing a patient who was burned after contact with gasoline. which complication would the nurse monitor?
systemic toxicity gasoline is an organic compound that causes chemical burns. this compound produces systemic toxicity in patients.
Following fluid resuscitation, which parameter would indicate to the nurse that the patient is in a stable condition?
systolic BP more than 90 mm Hg
Following fluid resuscitation, which parameter would indicate to the nurse that the patient is in a stable condition?
systolic BP more than 90 mm Hg hourly assessment of the adequacy of fluid resuscitation are best made using clinical parameters. Urine and cardiac parameters are most commonly used.
When assessing the patient with severe electrical burns, which symptoms does the nurse known would indicate this patient is hyperkalemic?
*Electrocardiogram (ECG) changes * muscle weakness * cardiac dyshythmias electrical burns cause massive deep muscle injury, which leads to a release of large amounts of potassium into the bloodstream. This can lead to hyperkalemia, which can be noted by related ECG changes. Muscle weakness can occur due to increased potassium levels. Cardiac dysrhythmias can be a result of elevated potassium levels.
What are the clinical manifestations of a upper airway lung injury associated with burns?
edema and blisters
Which degree of burn would the nurse document for a patient with erythema, pain, and mild swelling following a burn injury?
first
Which clinical manifestations would the nurse anticipate while caring for a patient with third-degree burns?
*Hard, leathery skin * insensitivity to pain
Which characteristics of a second-degree thermal burn would the nurse expect to find during a patient's physical assessment?
*severe pain *mild edema *fluid-filled vesicles
A nurse is planning care for a patient with a 30% body surface area burn injury. Which statement by the nurse regarding the nutritional status of this patient is true?
A hypermetabolic state results in poor healing and inceased protein and lipid needs. A burn injury causes a hypermetabolic state, resulting in protein and lipid catabolism that can inhibit wound healing. Therefore the patient with a burn injury requires increased calories and protein to enable the healing process. Protein intake in the burn patient should be increased to promote wound healing. Renal function is monitored for complications, which is low risk with burns, because the need for protein is increased.
A nurse is providing care to a patient admitted to the burn unit. Which pathophysiologic changes does the nurse anticipate in this patient?
* increased viscosity * decreased blood volume * increased vascular permeability * increased hematocrit * increased peripheral resistance
What are the clinical manifestations of a lower airway lung injury associated with burns?
*dyspnea *wheezing *altered mental status
which clinical manifestation would the nurse observe in a patient during the emergent phase of a burn injury?
*increased heart rate * decreased BP
According to the Rule of Nines for calculating the percentage of burns, the nurse should assign what percentage to a burn in the genitalia?
1% the Rule of nines is a formula used for calculating the percentage of burns during initial assessment of a burn patient. The genitals are assigned 1%. Burns in the head and arms are assigned 9% each. Burns on the lower extremities are assigned 18% each. Burns in the chest and back are assigned 18% for each side.
Using the Rule of Nines, which percentage of burn surface area would the nurse document for a patient with burns over the entire surface of both arms, the anterior trunk, and the right leg?
54% The "rule of nines" is a method used to determine the body surface area (BSA) of a burn injury. It assigns 9% to each arm, 9% to the head, 18% to the anterior torso, 18% to the posterior torso, 18% to each leg, and 1% to the genitals. The other answer options are incorrect applications of the rule of nines BSA estimate.
A patient who sustained burns develops a paralytic ileus. Which would the nurse suspect to be the cause of this complication?
Sepsis
Which compliation would the nurse monitor for in a burn injury patient who is experiencing premature ventricular contractions (PVCs) and shows signs of myoglobinuria?
acute tubular necrosis (ATN) Electrical burns often cause dysrhythmias and myglobinuria. the myoglobin pigments travel to the kidneys and block the renal tubules, resulting in ATN
A nurse is providing care to patient with a partial-thickness burn. Which clinical manifestation would the nurse anticipate?
damage to epidermis and dermis involving varying depthns Burns may be superficial or deep thickness. Partial-thickness burns involve damage to the epidermis and dermis at varying depths. Coagulation necrosis, damage to all skin elements, and the destruction of nerve endings are observed in full-thickness burn injuries.
Which clinical manifestation would the nurse anticpate due to thrombosis in the capillaries of the burned tissue of a patient?
decreased erythrocyte count thrombosis in the capillaries of burned tissued results in a loss of circulating erthrocytes (red blood cells).
The nurse notes a bright-red area with blisters that blanches with the application of pressure on a burn patient. The patient reports severe pain when the burn is exposed to air. which type of burn is present?
deep partial-thickness burn
Which degree of burn would the nurse document for a patient with erythema, pain, and mild swelling following a burn injury?
first burns that are painful, erythematous, and associated with mild swelling are first-degree burns. Second-degree burns are associated with vesicles and appear shiny. Third and fourth-degree burns are white, waxy, and insensitive to pain due to nerve destruction.
Which type of burn injury would the nurse identify as occurring on the layers of subcutaneous fat, muscle, or deeper structures?
full-thickness burn
Patients with ear and nose burns are susceptible to
infection because of poor blood supply to the cartilage
A nurse is providing care to patient who suffered burns to the perineum. Which would the nurse suspect the patient is at risk of developing?
infection from urine contamination a patient with burns to the buttocks or perineum is at an increased risk for infection from urine or feces contamination.
A patient with burns to the face and neck is susceptible to
infection of the respiratory tract
Burns to the hands and feet put the patient at risk for
infection of the vascular and never supply
A burn patient newly arrived at the emergency department is confused, has difficutly breathing, and has nasal burns. Which condition would the nurse suspect?rcether
lower airway injury
which complication would the nurse be alert for in a patient with an electrical burn?
myoglobinuria electric burns often cause the release of myoglobin from injured muscle tissues into circulation, causing myoglobinuria.
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 with full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain; the tissue is dry and waxy looking or may be charred, and there is no blanching with pressure.
Which factors lead the nurse to believe that a patient with severe burns on the legs and feet may have full-thickness burns?
* touch sensation is impaired * lack of blanching with pressure is observed * wounds appear waxy white, dark brown, or charred Touch sensation is impaired due to impaired nerve endings in full-thickness burns. Lack of blanching with pressure is observed, because all skin elements are destroyed. Wounds appear waxy white, dark brown, or charred in full-thickness burns, because all skin elements and local nerve endings are destroyed, and coagulation necrosis is present.
A patient has sustained burns on the face, neck, and chest. Which additional assessment findings would alert the nurse to an upper airway injury?
* hoarseness * singed nasal hair * difficulty in swallowing upper airway injury may be caused by thermal burns or the inhalation of hot air, steam or smoke. Hoarseness occurs due to laryngeal edema. Singed nasal hair is an obvious sign of inhalation of burned particles or smoke. Difficutly in swallowing is present due to edema and blistering of the oropharynx.
Which complications would the nurse assess for in a patient with metabolic asphyxiation?
* hypoxia * hydrogen cyanide poisoning Metabolic asphyxiation is a type of smoke and inhalation injury that occurs due to inhalation of carbon monoxide or hydrogen cyanide. In this condition, the oxygen delivery or consumption is impaired, resulting in hypoxia. Hydrogen cyanide poisoning also occurs in metabolic asphyxiation in the absence of burn injury to the skin. Cardiac standstill occurs in an electrical injury. Protein hydrolysis occurs in a chemical injury. Acute respiratory distress syndrome occurs in a lower airway injury.
When assessing a patient suffering from inhalation burns on the face and chest, which findings would the nurse anticipate?
* increasing hoarseness * darkened oral or nasal membranes * productive cough with black sputum In inhalation burns, either the respiratory tract is exposed to intense fumes or heat, or the patient inhales noxious chemicals or smoke. Increasing hoarseness is seen due to irritation of the upper airway during inhalation and the laryngeal edema caused by inhalation injury. Some other signs include darkened oral or nasal membranes and productive cough with black sputum, which are evident due to charring of the membranes of the respiratory tract. Location of contact points is done in case of electrical burns. In this case, the skin may appear leathery white and charred.
the nurse would monitor a patient who was injured using heavy industrial cleanser for which complications?
* melting * protein hydrolysis a chemical burn results from contact with an alkali, such as an industrial cleanser. When the alkalis come in contact with skin, they adhere to the tissue, resulting in protein hydrolysis and melting.
A nurse working in a burn unit identifies that which patients are at an increased risk of developing venous thromboembolism?
* morbid obesity * prolonged immobility these patients may develop stasis of blood due to immobility, which results in development of venous thromboembolism.
For which complications would the nurse monitor an unconscious patient who suffered an electrical burn?
* myoglobinuria * cervical spine injury * severe metabolic acidosis Patients with an electrial injury are at risk from myoglobinuria, cervical spine injury and severe metabolic acidosis. Myoglobinuria occurs because myoglobin from the injured tissue is released into circulation, causing muscle and blood vessel damage. Contact with electrical currents causes muscle contractions, which can fracture the vertebrae and bones. Electrial injury carries the risk of severe metabolic acidosis
Laboratory tests indicate the burn patient is experiencing hypernatremia. For which clinical manifestations should the nurse monitor?
* seizures * dried, furry tongue hypernatremia is an excess amount of sodium in the body, which is seen after successful fluid resuscitation required in the treatment of a significant burn injury. The manifestations of hypernatremia include seizures and a dried, furry tongue.
When assessing a patient with a second-degree burn, which clinical manifestations would the nurse anticipate?
* severe pain * red, shiny vesicles * mild to moderate edema
when assessing a patient with a second-degree burn, which clinical manifestations would the nurse anticipate?
* severe pain * red, shiny vesicles * mild to moderate edema
Which assessment findings would alert the nurse to the presence of an inhalation injury in a burn patient?
* singed nasal hair * increasing hoarseness * painful swallowing * history of being trapped in an enclosed space reliable clues to the occurrence of inhalation injury include the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being trapped in an enclosed space, altered mental status, and "cherry red' skin color
Which findings would the nurse expect a patient with full-thickness burns to exhibit?
* the patient is shivering * the patient has low BP * the patient has absence of bowel sounds the patient with severe burns is likely to be in shock from hypovolemia and may have low BP. the patient experiences shivering as a result of chilling that is caused either by heat loss, anxiety or pain. The patient with a larger burn area may develop a paralytic ileus, which may be accompanied by absent or decreased bowel sounds
While assessing a patient with severe burns, the nurse suspects hypokalemia. Which possible causes would the nurse evaluate?
* vomiting * IV therapy without potassium * prolonged gastrointestinal GI suction Hypokalemia occurs due to lack of potassium. Excessive vomiting causes loss of body fluids leading to a loss of potassium. Prolonged GI suction also causes fluid loss and decreases potassium levels. The IV therapy without potassium fails to compensate for the loss of potassium, and the deficiency persists thus resulting in hypokalemia.
The nurse suspects a burn injury patient has superficial partial-thickness burn. Which findings would the nurse expect to find?
* wounds are red and painful * There is blanching with pressure * the burned area has minimal edema d/t superficial epidermal damage.
Which characteristics would the nurse likely find when performing an examination of a patient's deep partial-thickness burn?
* wounds are wet and shiny * wounds are painful to touch * wounds appear pink to cherry-red
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 During the emergent phase, sodium and water rapidly shift to the interstital spaces and remain there until edema formation ceases. The hematocrit is elevated because of hemoconcentration related to fluid loss. Fluid also moves to areaqs that normally have minimal to no fluid, a phenomenon termed third spacing. Albumin also shifts into the intestitial spaces, contributing to the edema. A potassium shift initally develops because injured cells and hemolyzed red blood cells release potassium into the circulation.
the nurse is caring for a patient with burns covering the face, the entire right upper extremity, and the right upper trunk area. Using the Rule of Nines, the nurse would calculate the extent of these burns as which percentage?
22.5% Using the rule of nines, for these second- and third-degree burns, the face encompasses 4.5% of the body area, the entire right arm encompasses 9% of the body area, and the entire anterior trunk encompasses 18% of the body area. Because the patient has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore adding the three areas together (4.5 + 9 + 9), the nurse would correctly calculate the extent of this patient's burns to cover approximately 22.5% of the total body surface area.
A patient sustains a second-degree (partial-thickness) burn. Which layer (s) of skin would the nurse inspect for damage?
epidermis and dermis In a second-degree, or partial-thickness, burn, both the epidermis and dermis are damaged. A first-degree superficial burn, such as sunburn, involves only the epidermis. A third- or fourth-degree full-thickness burn may involve muscle and bone. A third-degree deep partial- to full-thickness burn may include the epidermis, dermis, and subcutaneous tissue.
The nurse understands that which fluid and electrolyte change occurs during the early emergent phase of burn injury?
movement of sodium and water into interstitial spaces After the burn, in the emergent phase, the capillary walls become more permeable, causing the movement of sodium, water, and plasma proteins into the interstitial spaces and surrounding tissues.
The nurse recalls which description as the most accurate regarding a deep partial-thickness burn?
painful with weeping blisters A deep partial-thickness burn involves the epidermal and dermal layers of the skin. Ir is characterized by a wet, shiny, weeping surface marked by blisters and is painful and very sensitive to the touch.
The nurse notes a patient who experienced a chemical burn is exhibiting decreased muscle coordination. the nurse would monitor the patient for which complications?
paralysis chemicals that remain in contact with the skin for a long time reach the nerve supply, which can result in paralysis.
