Chapter 35: Burns

16. A patient is admitted after being burned in a car fire. The wound surface is red with patchy white areas that blanch with pressure but no blister formation. What kind of burn would the nurse document in the patient's record? a. Superficial partial-thickness burn b. Moderate partial-thickness burn c. Deep dermal partial-thickness burn d. Full-thickness burn

ANS: C Deep-dermal partial-thickness (second-degree) burns involve the entire epidermal layer and deeper layers of the dermis. A deep-dermal partial-thickness burn usually is not characterized by blister formation. Only a modest plasma surface leakage occurs because of severe impairment in blood supply. The wound surface usually is red with patchy white areas that blanch with pressure.

28. Roughly 80% of burns in children are classified as what type of burn? a. Radiation b. Chemical c. Electrical d. Thermal

ANS: D The most common type of burn is a thermal burn caused by steam, scalds, contact with heat, and fire injuries. About 80% of burns in children are caused by scalds (ie, contact with hot objects or liquids).

10. The nurse is caring for a patient with extensive burns. Which zone of injury is the site of the most severe damage? a. Zone of coagulation b. Peripheral zone c. Zone of stasis d. Zone of hyperemia

ANS: A The central zone, or zone of coagulation, is the site of most severe damage, and the peripheral zone is the least. The central zone is usually the site of greatest heat transfer, leading to irreversible skin death.

22. A patient is admitted to the burn unit after a house fire. The patient sustained extensive burns to the chest, back, left arm, right arm, right upper leg, and areas on the face. The nurse is unable to obtain a palpable pulse or a Doppler pulse in the right arm. What procedure should the nurse anticipate next? a. Escharotomy b. Silver sulfadiazine application c. Splint application d. Xenograft application

ANS: A An escharotomy may be required to restore arterial circulation and to allow for further swelling. The escharotomy can be performed at the bedside with a sterile field and scalpel.

29. Identify in the correct order the five layers of the skin from the surface inward. 1. Stratum granulosum 2. Stratum corneum 3. Stratum germinativum 4. Stratum lucidum 5. Stratum spinosum a. 2, 4, 1, 5, 3 b. 2, 4, 5, 1, 3 c. 4, 2, 5, 1, 3 d. 4, 5, 1, 3, 2

ANS: A From the surface inward, its five layers are the (2) stratum corneum, (4) stratum lucidum, (1) stratum granulosum, (5) stratum spinosum, and (3) stratum germinativum

19. A patient is brought to the emergency department with extensive burns after a house fire. What is an important nursing intervention for this patient during the resuscitation phase? a. Intravenous opiates and assessment of pulses in both arms b. Oral antiinflammatory drugs and preparation for insertion of an arterial line c. Measurement of sedimentation rate and systemic antibiotics d. Application of splints and initiation of total parenteral nutrition

ANS: A Pain management in burn injuries must be addressed early and frequently reassessed to determine the adequacy of interventions. Intravenous opiates, such as morphine sulfate, are indicated and titrated to effect. Edema formation may cause neurovascular compromise to the extremities; assessments are necessary to evaluate pulses, skin color, capillary refill, and sensation

18. A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. Total body surface area (TBSA) burn is estimated at 25% deep partial-thickness burns to areas of the chest, back, and left arm and 20% full-thickness burns to the right arm, right upper leg, and areas on the face. The patient's weight is estimated at 85 kg. What is the initial plan for fluid replacement? a. 5950 mL of Lactated Ringer (LR) solution for the first 8 hours; then 5950 mL of LR over the next 16 hours b. 2868 mL of normal saline (NS) for the first 8 hours; then 5737 mL of hypertonic NS over the next 16 hours c. 11,900 mL of dextran evenly divided over the first 24 hours d. 11,475 mL of LR evenly divided over the first 24 hours

ANS: A Per the Parkland formula, you would administer 5950 mL of Lactated Ringer (LR) solution for the first 8 hours and 5950 mL of LR over the next 16 hours (4 mL 85 kg 45% = 15,300 mL in first 24 hours)

14. Contracture development leading to impaired physical mobility can occur after a major burn injury. Splints are applied to prevent or correct contractures. Priority nursing interventions concerning this therapy include which action? a. Daily assessment for proper fit and effectiveness b. Removal of splints during showers and dressing changes c. Allowing for frequent breaks from splint use d. Passive and active range of motion may be used instead of splint

ANS: A Splints can be used to prevent or correct contracture or to immobilize joints after grafting. If splints are used, they must be checked daily for proper fit and effectiveness. Splints that are used to immobilize body parts after grafting must be left on at all times, except to assess the graft site for pressure points during every shift. Splints to correct severe contracture may be off for 2 hours per shift to allow burn care and range-of-motion exercises.

25. What are the goals of the rehabilitation phase of burn management? a. Recuperation and healing physically and emotionally b. Hydrotherapy and splinting c. Reverse wound isolation and surgical grafting d. Bed rest and splinting

ANS: A The rehabilitation phase is one of recuperation and healing physically and emotionally.

3. Using the "rule of nines," calculate the percent of injury in an adult who was injured as follows: the patient sustained partial and full-thickness burns to half of his left arm, his entire left leg, and his perineum. a. 28% b. 23.5% c. 45.5% d. 16%

ANS: B The arm represents 4.5%, the leg 18%, and the perineum 1%, totaling 23.5%.

4. A patient is admitted after being burned while lighting the barbecue. The injuries appear moist and red with some blister formation and the patient states they are very painful. What kind of burn would the nurse document in the patient's record? a. Superficial, first-degree burn b. Partial-thickness, second-degree burn c. Deep dermal partial-thickness, second-degree burn d. Full-thickness, third-degree burn

ANS: B A light to bright red or mottled appearance characterizes superficial second-degree burns. These wounds may appear wet and weeping, may contain bullae, and are extremely painful and sensitive to air currents. The microvessels that perfuse this area are injured, and permeability is increased, resulting in leakage of large amounts of plasma into the interstitium. This fluid, in turn, lifts off the thin damaged epidermis, causing blister formation. Despite the loss of the entire basal layer of the epidermis, a burn of this depth will heal in 7 to 21 days.

12. A patient has a partial-thickness burn wound that is being treated with porcine xenograft (pigskin). The nurse knows that pigskin usually dissolves in 5 to 7 days because of what reason? a. Infection b. Lack of blood supply c. Lack of lymphatic drainage d. Contamination

ANS: B After the pigskin is in place, it may be dressed with antibacterial-impregnated dressings or other forms of dressings. Pigskin usually is removed or dissolves because of a lack of blood supply in 5 to 7 days. The pigskin is packaged in a variety of ways and in various sizes. It can be treated with silver sulfadiazine and can be meshed or nonmeshed. Pigskin can be used for temporary coverage of full- and partial-thickness wounds, burn wounds, and donor sites.

24. The nursing management plan for a patient with full-thickness burns includes which intervention? a. Daily replacement of autografts b. Daily wound care with premedication c. Weekly wound care until all eschar is debrided d. Surgical skin grafting within 8 hours of admission

ANS: B Daily cleansing and inspection of the wound and unburned skin are performed to assess for signs of healing and local infection. Generally, this therapy is performed once or twice daily. Pain management and measures to reduce hypothermia are used. Patients should receive adequate premedication with analgesics and sedatives.

6. Using the Parkland formula for fluid resuscitation and your knowledge of injury calculations using the "rule of nines," calculate the estimated fluid requirements during the first 8 hours for a 75-kg patient with full-thickness burns to the anterior chest, perineum, and entire right leg. a. 2775 mL b. 5550 mL c. 8325 mL d. 11,100 mL

ANS: B In a 75-kg person with a 37% burn injury (based on a rule of nines calculation: 18%—chest, 1%—perineum, 18%—right leg = 37% total body surface area [TBSA] burn), the Parkland formula estimates fluid resuscitation needs at 4 mL 37 75 = 11,100 mL. In the first 8 hours after injury, half of the calculated amount of fluid is administered. This amount equals 5550 mL.

27. A patient is brought to the emergency department after a house fire. The patient sustained an inhalation injury. The nurse is aware that this injury predisposes the patient to the development of what complication? a. Tension pneumothorax b. Adult respiratory distress syndrome (ARDS) c. Asthma d. Lung cancer

ANS: B Inhalation injury predisposes the patient to the development of pneumonia and acute respiratory distress syndrome (ARDS). Management of ARDS necessitates mechanical ventilatory support and, in extreme cases, high-frequency oscillatory ventilation or extracorporeal membrane oxygenation.

1. What is a leading cause of death in the hospitalized burn patient? a. Smoke inhalation b. Infection c. Burn shock d. Renal failure

ANS: B Preventing infection in burn patients is a true challenge and involves complex decision making. Considerable debate has been going on about the infection control precautions to use with burn patients. The burn wound is the most common source of infection in burn patients.

17. A patient is brought to the emergency department after a house fire. He fell asleep with a lit cigarette, and the couch ignited. What is the nurse's first priority? a. Clean the wounds and remove blisters. b. Assess the airway and provide 100% oxygen. c. Place a urinary drainage catheter and assess for myoglobin. d. Place a central intravenous access and provide antibiotics.

ANS: B The first priority of emergency burn care is to secure and protect the airway. All patients with major burns or suspected inhalation injury are initially administered 100% oxygen.

1. According to the American College of Surgeons, burns to which body surfaces are best treated in a burn center? (Select all that apply.) a. Arms b. Perineum c. Chest d. Genitalia e. Face

ANS: B, D, E According to triage criteria from the American College of Surgeons, burns on the face, hands, feet, genitalia, major joints, and perineum are best treated in a burn center.

9. The nurse is caring for a patient with extensive burns. Which intervention should be included in the nursing management plan to prevent cross-contamination and decrease the risk of infection in the burn-injured patient? a. Gloves are the only personal protective equipment worn when changing dressings that are in direct contact of body fluids. b. Family members only have to wear a gown when visiting a patient because masks will increase anxiety in the patient. c. Changing gloves and handwashing should be done when moving from area to area on the same patient. d. Sharing of equipment between patients in the same room does not show evidence of cross-contamination.

ANS: C Cross-contamination by direct contact is a significant source of infection and a subsequent cause of sepsis. Effective handwashing technique cannot be overemphasized. Nurses must wash their hands and change gloves when moving from area to area on the same patient. For example, after changing the chest dressing, which may be contaminated with sputum from the tracheostomy, hands must be washed and gloves changed before the nurse moves to the legs. Gowns, gloves, and masks should be worn whenever contact with body fluids occurs. These garments also must be changed and hands washed before caring for a different patient. Maintaining patient-specific dressings and topical agents is recommended. Equipment such as thermometers, intravenous pumps, and stethoscopes should be designated for each patient or, when shared, should be cleaned with appropriate bactericidal cleansers between patients.

20. A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. What adjustment, if any, needs to be made to the fluid resuscitation plan? a. Continue as planned; everything looks good. b. IV rate should be decreased and colloids started. c. IV rate should be increased and fluid status closely watched. d. Fluids should be switched to packed red blood cells.

ANS: C Desired clinical responses to fluid resuscitation include a urinary output of 0.5 to 1 mL/kg/h; a pulse rate lower than 120 beats/min; blood pressure in normal to high ranges; a central venous pressure less than 12 cm H2O or a pulmonary artery occlusion pressure less than 18 mm Hg; clear lung sounds; clear sensorium; and the absence of intestinal events, such as nausea and paralytic ileus

7. What physiologic process can result in excessive burn edema and shock in a patient with injuries totaling more than 50% total body surface area (TBSA) burn? a. The heat from the burn leads to immediate vascular wall destruction and extravasation of intravascular fluid. b. A positive interstitial hydrostatic pressure occurs in the dermis leading to burn wound edema. c. Plasma colloid osmotic pressure is decreased because of protein leakage into the extravascular space. d. Capillary permeability decreases in burned and unburned tissue, leading to hypovolemia

ANS: C Negative interstitial hydrostatic pressure represents an edema-generating mechanism and occurs for approximately 2 hours after injury. Additionally, plasma colloid osmotic pressure is decreased as a result of protein leakage into the extravascular space. Plasma is then further diluted with fluid resuscitation. Thus osmotic pressure is decreased and further fluid extravasation can occur.

23. A patient is admitted to the burn unit after an electrocution. The patient sustained extensive burns. The nurse should have a high degree of suspicion for what complication associated with this type of burn injury? a. Rhabdomyolysis b. Stress ulcers c. Pneumothorax d. Venous thromboembolism

ANS: C The electrical burn process can result in a profound alteration in acid-base balance and rhabdomyolysis, resulting in myoglobinuria, which poses a serious threat to renal function. Myoglobin is a normal constituent of muscle. With extensive muscle destruction, it is released into the circulatory system and filtered by the kidneys. It can be highly toxic and can lead to intrinsic renal failure.

26. A nurse is caring for a patient who was burned 2 weeks ago. The nurse knows the patient has entered the next phase of healing, which is characterized by rapid synthesis of collagen. What phase is the patient in? a. Wound phase b. Inflammatory phase c. Proliferative phase d. Maturation phase

ANS: C The proliferative phase of healing occurs approximately 4 to 20 days after injury. The key cell in this phase of healing, the fibroblast, rapidly synthesizes collagen. Collagen synthesis provides the needed strength for a healing wound. The inflammatory phase begins immediately after injury. Vascular changes and cellular activity characterize this period. Changes in the severed vessels occur in an attempt to wall off the wound from the external environment. The maturation phase, or remodeling phase, of healing occurs from approximately 20 days after injury to longer than 1 year after injury. During this period, the wound develops tensile strength as collagen deposits form scar tissue.

15. Which topical antimicrobial agent is commonly used as a broad-spectrum and fights against gram-positive and -negative bacteria? a. Pure silver b. Bacitracin c. Mafenide acetate cream d. Silver sulfadiazine

ANS: D Silver sulfadiazine (SSD; Silvadene cream) is a broad-spectrum antimicrobial agent with bactericidal action against many gram-negative and -positive bacteria associated with burn wound infection. Mafenide acetate cream penetrates through burn eschar and is bacteriostatic against many gram-negative and -positive organisms. Its use is limited because the application is uncomfortable for the patient because it creates a burning sensation, and it is rapidly absorbed, requiring dressing changes two or three times daily. It is used routinely for coverage of small wounds. Bacitracin ointment is a topical agent applied to superficial burns and facial burns. Bacitracin is effective against gram-positive organisms but not against gram-negative organisms or fungal organisms. Silver has long been used for the treatment of wounds because of its broad-spectrum bacteriostatic properties. The wound moisture activates the silver and releases it into the wound. An advantage of silver dressings is that the dressing does not need to be changed daily because of the sustained release of silver. Silver dressings should be used judiciously and limited to 4 to 6 weeks despite the current absence of negative systemic or local consequences.

11. The nurse and a new graduate nurse are caring for a patient with extensive burns. They are discussing skin grafts. Which statement indicates the new graduate understood the information? a. Autografts are procured from both live and deceased donors. b. Autografts can placed at the bedside or in the operating room. c. Autografts can transmit disease and be rejected. d. Autografts provide permanent coverage and are the least expensive

ANS: D An autograft is a skin graft harvested from a healthy, uninjured donor site on the burn patient and then placed over the patient's burn wound to provide permanent coverage of the wound. Autografts must be done in the operating room and are the least expensive. Homografts can transmit disease and be rejected

2. A patient is admitted after being burned in a house fire. The nurse feels that the patient should be transferred to a burn center. Which factor is most important when determining whether or not to refer a patient to a burn center? a. The size and depth of burn injury and the burning agent b. The age and present medical history of the patient c. The depth of the burn injury and the presence of soot in the sputum d. The medical history of the patient and the size and depth of the burn injury

ANS: D Burns are classified primarily according to the size and depth of injury. However, the type and location of the burn and the patient's age and medical history are also significant considerations. Recognition of the magnitude of burn injury, which is based on the above-mentioned factors, is of crucial importance in the overall plan of care and in decisions concerning patient management and appropriate referral to a burn center.

5. Less than 24 hours ago a patient sustained full-thickness burns, to his face, chest, back, and bilateral upper arms, in a house fire. He also sustained an inhalation injury. The patient was intubated and ventilated and is now showing signs of increasing agitation and rising peak airway pressures. The nurse suspects the patient's change in condition is due to which problem? a. Uncontrolled pain b. Hypovolemia c. Worsening hypoxemia d. Decreased pulmonary compliance

ANS: D Circumferential full-thickness burns to the chest wall can lead to restriction of chest wall expansion and decreased compliance. Decreased compliance requires higher ventilatory pressures to provide the patient with adequate tidal volumes.

13. A patient with extensive burns is undergoing skin grafting. The nurse understands pain control is best achieved with what strategies during the early phase of recovery? a. Large doses of opioids given intramuscularly b. Intravenous opioids used in combination with oral antidepressants c. Large doses of opioids given subcutaneously d. Small doses of intravenous opioids titrated to effect

ANS: D Initially after burn injury, narcotics are administered intravenously in small doses and titrated to effect. The constant background pain may be addressed with the use of a patient-controlled analgesia device. When hemodynamic stability has occurred and gastrointestinal function has returned, oral narcotics can be useful. Intramuscular or subcutaneous injections must not be administered because absorption by these routes is unpredictable because of the fluid shifts that occur with burn injury.

21. A patient is admitted to the burn unit with extensive burns after a house fire. The patient's vital signs and physical exam include a heart rate of 140 beats/min, a urine output of 25 mL/h, and clear lung sounds. The nurse knows that the patient's symptoms are most likely attributable to what cause? a. Blood loss associated with burns and pain b. Hemodynamic stability related to adequate fluid resuscitation. c. Overresuscitation related to overestimation of the burn area involved d. Underresuscitation because of probable wound conversion

ANS: D The rate of fluid administration is adjusted according to the individual's response, which is determined by monitoring urine output, heart rate, blood pressure, and level of consciousness. Meticulous attention to the patient's intake and output is imperative to ensure that he or she is appropriately resuscitated. Underresuscitation may result in inadequate cardiac output, leading to inadequate organ perfusion and the potential for wound conversion from a partial-thickness to full-thickness injury. Overresuscitation may lead to moderate to severe pulmonary edema; to excessive wound edema causing a decrease in perfusion of unburned tissue in the distal portions of the extremities; or to edema-inhibiting perfusion of the zone of stasis, resulting in wound conversion.

8. A patient involved in a house fire is brought by ambulance to the emergency department. The patient is breathing spontaneously but appears agitated and does not respond appropriately to questions. The nurse knows the patient has inhaled carbon monoxide and probably has carbon monoxide (CO) poisoning. What action should the nurse take next? a. Ask the practitioner to order a STAT chest radiograph. b. Apply a pulse oximeter to one of his unburned fingers. c. Call the local hyperbaric chamber to check on its availability. d. Administer 100% high-flow oxygen via a nonrebreathing mask.

ANS: D The treatment of choice for carbon monoxide (CO) poisoning is high-flow oxygen administered at 100% through a tight-fitting nonrebreathing mask or endotracheal intubation. The half-life of CO in the body is 4 hours at room air (21% oxygen), 2 hours at 40% oxygen, and 40 to 60 minutes at 100% oxygen. The half-life of CO is 30 minutes in a hyperbaric oxygen chamber at three times the atmospheric pressure. Currently, the use of hyperbaric oxygen is of controversial benefit in care of burn patients.