chapter 57: Burn management

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary? Risk for Impaired Gas Exchange Altered Tissue Perfusion Infection Risk Acute Pain

Risk for Impaired Gas Exchange

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? Roll the client in a blanket Avoid immediate IV fluid therapy Cover the client with a wet cloth Place the client with the head positioned slightly below the rest of the body

Roll the client in a blanket

The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement? A urinary output of 80 mL/hr A urinary output of 100 mL/hr A urinary output of 10 mL/hr A urinary output of 30 mL/hr

A urinary output of 30 mL/hr

In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? Body temperature readings all within normal limits A weight gain of 4 lb (2 kg) in 24 hours An electrocardiogram (ECG) showing no arrhythmias A urine output consistently above 40 ml/hour

A urine output consistently above 40 ml/hour

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to increase metabolic rate. increase skeletal muscle breakdown. decrease catabolism. increase glucose demands.

Decreased catabolismCorrectExplanation: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 patient 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.

The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse? Moisture intensifies the damage inflicted. Electrical burns usually follow an internal path. Lightning is higher in voltage than electricity. The skin is a good conductor of electricity.

Electrical burns usually follow an internal path.Expl: Electrical current follows the path of less resistance. Becausethe skin is the most resistant organ, the current follows nerves, blood vessels, and muscles, causing organ damage along the way. Lightning is high-voltage electricity. Presence of water acts as a conductor of electrical current. 1850

A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the: Entire dermis and subcutaneous tissue. Dermis and connective tissue. Epidermal layer only. Epidermis and a portion of deeper dermis.

Epidermis and a portion of deeper dermis. Explanation:A deep partial-thickness burn includes the epidermis, upper dermis, and a portion of the deeper dermis. A burn limited to the epidermal layer is classified as a superficial partial-thickness burn. The last two choices refer to a full-thickness burn

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? allograft escharotomy silvadene application debridement

Escharotomy CorrectExplanation: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.

A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared leathery. What depth of burn injury does the client have? fourth degree superficial partial-thickness or deep partial-thickness (second degree) full thickness (third degree) superficial (first degree)

full thickness (third degree) Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appearance varies and can be dry, pale white, red, brown, leathery, charred or lifeless. Superficial (first degree) burn is similar to a sunburn. The epidermis is injured, but the dermis is unaffected. Superficial partial-thickness burn heals within 14 days, with possibly some pigmentary changes but no scarring. The deep partial-thickness (second degree) burn takes more than 3 weeks to heal, may need debridement, and is subject to hypertrophic scarring. A fourth-degree burn can involve ligaments, tendons, muscles, nerves, and bone.

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

Biobrane

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

hypovolemia 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.

Which of the following is a potential cause of a superficial partial-thickness burn? Scald Flash flame Sunburn Electrical current

sunburn A potential cause of a superficial partial-thickness burn is a sunburn or low-intensity flash. Causes of deep partial-thickness burns are scalds and flash flames. Full-thickness burns may be caused by an electrical current or prolonged exposure to hot liquids.

A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims? "Are any of the victims expected to have electrical burns?" "Are the victims suffering from thermal burns?" "How many victims are anticipated for transport?" "Are the burns associated with chemicals used in the plant?"

"Are the burns associated with chemicals used in the plant?"

A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? Superficial partial-thickness Full-thickness Deep partial-thickness Superficial

Full-thickness

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

daily weights houlry urine output skin turgor

The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching? "I will drink a lot of fluids to prevent constipation since I am taking pain medications." "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun." "I can work with the social worker to find funding assistance programs to help with my medical expenses." "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."

"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."Itching is a normal part of healing. Many clients describe this as one of the most uncomfortable aspects of burn recovery. The client can apply mild moisturizers to decrease itching from dryness. Medications can be discussed with your treatment team. The client should pat the areas; scratching is contraindicated.

A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours? 2,400 mL 1,200 mL 4,800 mL 3,600 mL

2,400 mL

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? 9% 18% 27% 36%

27% Explanation: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body.

The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn? Family history Weight Age Preexisting conditions

Preexisting conditions Explanation: Preexisting disease disorders including trauma and infections can modify the inflammatory response and movement of fluid from the vascular to the interstitial space. Age, weight, and family history are not as significant in the inflammatory response following a burn

Which type of burn injury requires skin grafting? Superficial Full-thickness Deep partial-thickness Superficial partial-thickness

Full-thickness

A client recovering from burn injuries over both forearms reports itching of the wounds. Which action will the nurse take to enhance the client's comfort? Apply warm compresses over the areas. Provide pain medication as needed. Elevate the extremities above heart level. Instruct to pat and not scratch the areas.

Instruct to pat and not scratch the areas.

Which of the following measures can be used to cool a burn? Application of ice directly to burn Application of cool water Using cold soaks or dressings for at least 1 hour Wrapping the person in ice

Application of cool water Explanation: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? Mechanical Surgical Natural Enzymatic

Natural

Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase?

Reduction in blood volume

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? Related to infection Related to circumferential eschar Related to fat emboli Related to femoral artery occlusion

Related to circumferential eschar

A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? Superficial partial-thickness Full-thickness Superficial Deep partial-thickness

Superficial

Which type of burn is similar to a sunburn? Full-thickness Superficial partial-thickness Electrical Deep partial-thickness

Superficial partial-thickness Explanation: A superficial partial-thickness burn is similar to a sunburn. Deep partial thickness burns may need debridement and may scar. Full-thickness burns destroy all layers of the skin and consequently are painless. Electrical burns are a type of burn but not a category of burn thickness.

A client with a burn over the lower leg asks why surgery is planned to remove the dead burned tissue. Which response will the nurse make? "It reduces the risk of complications from an infection." "It reduces the amount of wound care that you will need as the skin heals." "it encourages your body's natural processes to liquefy any damaged tissue." "It reduces the amount of scarring that will occur on the skin."

"It reduces the risk of complications from an infection."

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

Immerse the child's 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. (less)

Which of the following is the effect of protein catabolism in a client with severe burns? It maximizes the risk of sodium retention and hypotension. It compromises wound healing and immunocompetence. It maximizes the risk of impaired ventilation. It compromises dexterity and mobility.

It compromises wound healing and immunocompetence.Expl: Protein catabolism in a client with severe burns compromises wound healing and immunocompetence. Burns of the face, neck, or chest have the potential to impair ventilation, while burns involving the hands or major joints may affect dexterity and mobility. Release of aldosterone, not protein catabolism, causes sodium retention. 1865

A nurse is preparing a care plan for a client burned over 36% of his body 2 days ago. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care? The client's complete blood count readings reflect a reduced hematocrit. The client's urinary output has fallen below 30 ml/hour. The client exhibits metabolic alkalosis. The client's serum sodium levels are elevated.

The client's complete blood count readings reflect a reduced hematocrit.

A child is brought to the emergency department by his parents. The child has been experiencing significant diarrhea over the past 36 hours. Further evaluation reveals infectious diarrhea with moderate dehydration. The physician orders oral rehydration solution, 100 mL/kg over the next 4 hours. The child weighs 77 lbs. How much would the nurse expect to administer?

3500mL

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? 18% 36% 9% 27%

36% each leg is 18%

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. 7:30 p.m. to 9:30 p.m.; 24 to 36 hours 10:30 p.m. to 12:30 a.m.; 40 to 50 hours 4:30 p.m. to 6:30 p.m.; 6 to 8 hours 5:30 p.m. to 6:30 p.m.; 9 to 12 hours

7:30 p.m. to 9:30 p.m.; 24 to 36 hours

Burn shock is characterized by which of the following? Elevated blood pressure (BP) Severe hypervolemia Organ hyperperfusion Capillary leak

Capillary leak Explanation: Burn shock is characterized by capillary leak, "third spacing" of fluid, severe hypovolemia, and decreased cardiac output (CO). Progressive edema develops in unburned tissue and organs, causing hypoperfusion and hypovolemic shock. As fluid loss continues and vascular volume decreases, the CO and BP falls. This is the onset of burn shock.

In a client with burns on the legs, which nursing intervention helps prevent contractures? Applying knee splints Performing shoulder range-of-motion exercises Elevating the foot of the bed Hyperextending the client's palms

Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

The nurse is teaching a client who underwent a skin graft for a burn injury about the use of pressure garments. What instruction(s) should the nurse include in the teaching? Select all that apply.

Contact the primary provider if the garment does not seem to fit properly Massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment.

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? Gastric ulcers Hyperthyroidism Anemia Cardiac arrest

Gastric ulcers

A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do? Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly. Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area. Remove his burned pants so that the air can help cool the wound.

Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel.

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? hypertension intravascular fluid excess neuroendocrine inflammatory

inflammatory

Which antimicrobials is not commonly used to treat burns? silver nitrate (AgNO3) 0.5% solution mafenide (Sulfamylon) silver sulfadiazine (Silvadene) tetracycline

tetracycline

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

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? Full-thickness Superficial partial thickness Fourth degree Deep partial-thickness

Deep partial-thickness

A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client Endotracheal tube placement Fluid resuscitation Prevent infection Strict intake and output

Fluid resuscitation

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: Hypernatremia. Hyperkalemia. Hypoglycemia. Hypocalcemia.

Hyperkalemia. CorrectExplanation:Circulating blood volume decreases dramatically during burn shock due to severe capillary leak with variation of serum sodium levels in response to fluid resuscitation. Usually, hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority? Impaired physical mobility related to the disease process Disturbed sleep pattern related to facility environment Risk for infection related to breaks in the skin Ineffective airway clearance related to edema of the respiratory passages

Ineffective airway clearance related to edema of the respiratory passages Explanation: When caring for a client with upper torso burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, Ineffective airway clearance related to edema of the respiratory passages should take the highest priority. Impaired physical mobility related to the disease process isn't appropriate because burns aren't a disease. Disturbed sleep pattern related to facility environment and Risk for infection related to breaks in the skin may be appropriate, but they don't command a higher priority than Ineffective airway clearance because they don't reflect immediately life-threatening problems.

The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse? Skin grafting will be necessary. Ligaments, tendons, muscles, and bone are not involved. Pain management will be a challenge. The wound will take up to 3 weeks to heal.

Skin grafting will be necessary. Explanation: In a full-thickness burn, all layers of the skin are destroyed and will result in the need for skin grafts. Full-thickness burns are painless. A deep partial-thickness burn may take 3 or more weeks to heal. In the most serious full-thickness burns, ligaments, tendons, muscles, and bone may be involved.

The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application? Cerium nitrate solution Sulfadiazine, silver (Silvadene) Gentamicin sulfate Mafenide (Sulfamylon)

Sulfadiazine, silver (Silvadene)

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? The paramedic administered high doses of opioids during transport. The client has experienced extensive full-thickness burns. The client is in hypovolemic shock. The client has experienced partial-thickness burns.

The client has experienced extensive full-thickness burns. Explanation: In full-thickness burns, nerves are damaged and consequently painless. Behavior change is not a significant symptom of hypovolemic shock. Opioids are used in the management of pain associated with partial-thickness burns but not significant in the behavior exhibited. Partial-thickness burns are associated with increased pain to the area of involvement.

A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours? The wound is susceptible to infections. It helps determine the percentage of the total body surface area (TBSA) that is burned. The client's condition is likely to deteriorate after 72 hours. The early appearance of the burn injury may change.

The early appearance of the burn injury may change.

A client is cared for in a burn unit after suffering partial-thickness burns. The client's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine to be applied to the client's burns. The nurse provides information to the client about the medication. Which statement made by the client indicates an understanding about this treatment? Select all that apply. "This medication will help my burn heal." "This medication is an antibacterial." "This medication will stain my skin permanently." "This medication will be applied directly to the wound."

• "This medication is an antibacterial."• "This medication will be applied directly to the wound."• "This medication will help my burn heal."Expl: This medication is an antibacterial, which has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to the wound. This medication will not stain the client's skin, but it will help heal the client's burned areas. 1862

Which of the following is to be expected soon after a major burn? Select all that apply. Anxiety Bradycardia Hypertension Hypotension Tachycardia

• Anxiety• Hypotension• Tachycardia CorrectExplanation:Tachycardia, slight hypotension, and anxiety are expected soon after the burn.

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? K+: 5.0 mEq/L BUN: 28 mg/dL Na+: 145 mEq/L Ca: 9 mg/dL

BUN: 28 mg/dLThe elevated BUN would cause the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated.

A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client? Lack of erythropoietin factor Metabolic acidosis Hemoconcentration Hemodilution

Hemodilution

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

Pulmonary system

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: Monitor cardiac status. Replace lost fluids and electrolytes. Measure hourly urinary output. Prevent renal shutdown.

Replace lost fluids and electrolytes.

The six elements necessary for infection include a causative organism, a reservoir of available organisms, a portal or mode of exit from the reservoir, a mode of transmission from reservoir to host, a susceptible host, and

mode of entry into the host.