Nursing Management: BURNS

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 would expect to find which manifestation? 1 Blisters 2 Reddening of the skin 3 Destruction of all skin layers 4 Damage to sebaceous glands

2 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.

When instructing a patient's caregiver about caring for a person with burns of more than 10% of total body surface area (TBSA), what does the nurse advise? Select all that apply. 1. Leave the affected area open to air. 2. Wrap the patient in a blanket. 3. Gently remove burned clothing. 4. Leave adherent clothing in place. 5. Apply ice all over the burned area.

2. Wrap the patient in a blanket. 3. Gently remove burned clothing. 4. Leave adherent clothing in place. In case of severe burns, the patient should be wrapped in a blanket to avoid further contamination and to provide warmth. Burned clothing should be gently removed to prevent further tissue damage. Adherent clothing should be left in place until the patient is transferred to the hospital to avoid tissue damage. Leaving the affected area open to air can cause more contaminations and is not advisable. Applying ice all over the burned area can cause hypothermia and is not advisable

A nurse works in an emergency department. Which patients are appropriate for the nurse to refer to the burn care unit? Select all that apply. 1. A patient with an inhalation injury 2. A patient with burns of the feet 3. A patient with burns involving minor joints 4. An elderly patient with third-degree burns 5. A patient with partial thickness burns involving 8% of total body surface area

1. A patient with an inhalation injury 2. A patient with burns of the feet 4. An elderly patient with third-degree burns A burn care unit provides advanced care to burn patients to prevent complications and keep the condition from worsening. Inhalation injury increases the risk of airway obstruction and requires a referral to the burn unit. Burns of both feet is associated with complications like contractures, and needs to be referred to the burn care unit. Third-degree burns in any age-group require referral. Burns involving minor joints do not require referral to burn centers; however, burns of major joints require referral. Partial thickness burns require referral if they involve more than 10% of the body surface area.

A patient with burns of more than 5% of his total body surface area is intubated, and enteral feedings are ordered to meet his nutritional demands. Which nursing interventions are appropriate for the enteral feeding of this patient? Select all that apply. 1. Determine whether the nasogastric tube is in place. 2. Assess bowel sounds every 8 hours. 3. Increase the feeding to the goal rate within 24 to 48 hours. 4. Begin the feedings slowly at the rate of 10 to 20 mL/hr. 5. Check gastric residuals frequently

1. Determine whether the nasogastric tube is in place. 2. Assess bowel sounds every 8 hours. 3. Increase the feeding to the goal rate within 24 to 48 hours. 5. Check gastric residuals frequently A patient that is intubated and has suffered burns to more than 5% of the body surface area may need gastric feedings to meet adequate nutritional requirements. Early enteral feeding helps to preserve gastrointestinal function, increase intestinal blood flow, and promote optimal conditions for wound healing. The nurse should check the placement of the nasogastric tube and assess bowel sounds every 8 hours. The enteral feedings should be started at 20-40 mL/hr and slowly increased to the goal rate within 24-48 hours. Gastric residuals should be checked to rule out delayed gastric emptying. Text Reference - p. 463

When assessing a patient suffering from inhalation burns on the face and chest, what findings should a nurse anticipate? Select all that apply. 1. Increasing hoarseness 2. Location of contact points 3. Leathery white charred skin 4. Darkened oral or nasal membranes 5. Productive cough with black sputum

1. Increasing hoarseness 4. Darkened oral or nasal membranes 5. 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. Text Reference - p. 456

While caring for a patient with burns, a nurse wraps the patient's wound with tubular elastic gauze. What are the reasons behind this action? Select all that apply. 1. To decrease pain 2. To decrease itchiness 3. To prevent blistering 4. To reduce venous return 5. To enhance local immunity

1. To decrease pain 2. To decrease itchiness 3. To prevent blistering The interim pressure due to tubular elastic gauze decreases pain and itchiness, and prevents blistering. It promotes venous return rather than reducing it. It does not enhance local immunity.

A nurse is caring for a patient who has sustained burns over the entire surfaces of both arms, the anterior trunk, and the right leg. The nurse uses the rule of nines to estimate the percentage of the burn surface area as: 1. 27% 2. 36% 3. 54% 4. 72%

3. 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.

The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient? 1 Sit or lie in a position of comfort 2 Wear a pressure garment for eight hours each day 3 Refer the patient to a counselor for psychosocial support 4 Use the sun to increase the skin color on the healed areas

Correct3 Refer the patient to a counselor for psychosocial support In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way the body looked and functioned before the burn, so continued counseling helps the patient in this phase as well. Putting the leg in the position of comfort is more likely to lead to contractures than to help the patient. If a pressure garment is prescribed, it is used for 24 hours per day for as long as 12 to 18 months. Sunlight should be avoided to prevent injury and sunscreen should always be worn when the patient is outside. Text Reference - p. 466