Burn NCLEX

Burn NCLEX Leave the first rating Terms in this set (13) Science MedicineNursing Save A patient is brought to the Emergency Department from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When you assess the patient he verbalizes no pain in the right arm and the skin appears charred. Based upon these assessment findings, what is the depth of the burn on the patient's right arm?

• Superficial partial-thickness
• Deep partial-thickness
• Full partial-thickness
• Full-thickness

FULL THICKNESS

**A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed.Edema may also be present. Full partial thickness is not a depth of burn. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis and the patient will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis and the patient will complain of pain and sensitivity to cold air.

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. What would be the nurse's priority concern about this patient?

• Fluid status
• Risk of infection
• Body image
• Level of pain

FLUID STATUS

**During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin.Infection, body image, and pain are significant areas of concern, but are less urgent than fluid status.The nurse is preparing the patient for mechanical debridement and informs

the patient that this will involve:

• A spontaneous separation of

dead tissue from the viable tissue

• Use of surgical scissors, scalpels

or forceps to remove the eschar until the point of pain and bleeding occurs

• Shaving of burned skin layers until

bleeding, viable tissue is revealed

• Early closure of the wound

USE OF SURGICAL SCISSORS, SCALPELS OR

FORCEPS TO REMOVE THE ESCHAR UNTIL THE

POINT OF PAIN AND BLEEDING OCCURS

**Mechanical debridement can be achieved through the use of surgical scissors, scalpels, or forceps to remove the eschar until the point of pain and bleeding occurs. Mechanical debridement can also be accomplished through the use of topical enzymatic debridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural debridement. Early wound closure and shaving the burned skin layers are examples of surgical debridement.

A patient is brought to the ED by paramedics who report the patient has partial-thickness burns on the chest and legs. The patient has also suffered smoke inhalation. What is a priority in the care of a patient who has been burned and suffered smoke inhalation?

• Pain
• Fluid balance
• Anxiety and fear
• Airway management

AIRWAY MANAGEMENT

**Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early postburn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.A patient arrives in the emergency department after being burned in a house fire. The patient's burns cover the face and the left forearm. What percentage of burn does the patient have?

A) 10%

B) 25%

• 9%

D) 18%

18% **When estimating the percentage of body area or burn surface area that has been burned, the Rule

of Nines is used: the face is 9%, and the forearm is

9% for a total of 18% in this patient.

A 45-year-old man is brought in by Life-Flight after a motor vehicle accident is which he was trapped in a burning vehicle. The burn team is estimating the patient's likelihood of survival based on the severity of the burn injury. The emergency department nurse knows that the severity of the injury is based on what factors? (Mark all that apply.)

• Age
• Depth of the burn
• Presence of inhalation injury
• Family support
• Psychological state of the patient

A, B, C

AGE, DEPTH OF THE BURN, PRESENCE OF

INHALATION INJURY

**The severity of each burn injury is determined by multiple factors that when assessed help the burn team estimate the likelihood that a patient will survive and plan the care for each patient. These factors include age of the patient; depth of the burn; amount of surface area of the body that is burned; presence of inhalation injury; presence of other injuries; location of the injury in special care areas such as the face, perineum, hands, and feet; and presence of a past medical history. Options D and E are not factors that bear on the severity of the injury.A nurse on the burn unit is caring for a patient who has gone into the acute phase of her burn. What would be important for the nurse to monitor the patient for?

• Hypometabolism
• Hyponatremia
• Hyperkalemia
• Hypoglycemia

HYPONATREMIA

**Hyponatremia is common during the first week of the acute phase, as water shifts from the interstitial space to the vascular space. Hypermetabolism can occur up to 1 year after the burn. Hyperkalemia occurs in the emergent phase of the burn. In a burn patient there is a hyperglycemic response, not a hypoglycemic response.