Burn NCLEX

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• 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.

• The nursing instructor is going over burn

injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care?

• Emergent
• Immediate resuscitative
• Acute
• Rehabilitation

ACUTE **The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (ie, wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, and wound grafting), pain management, and nutritional support are priorities at this stage and are discussed in detail in the following sections.Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.

• A patient in the emergent/resuscitative phase of a burn

injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what?

• Hyperkalemia, hyponatremia, elevated hematocrit,

and metabolic acidosis

• Hypokalemia, hypernatremia, decreased hematocrit,

and metabolic acidosis

• Hyperkalemia, hypernatremia, decreased hematocrit,

and metabolic alkalosis

• Hypokalemia, hyponatremia, elevated hematrocrit,

and metabolic alkalosis

HYPERKALEMIA, HYPONATREMIA, ELEVATED HEMATOCRIT AND METABOLIC

ACIDOSIS

**Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amount of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis.

• The patient you are caring for has an electrical burn

and has developed thick eschar over the burn wound.Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound?

• Silver sulfadiazine 1% (Silvadene) water-soluble cream
• Mafenide acetate 10% (Sulfamylon) hydrophilic-based

cream

• Silver nitrate 0.5% aqueous solution
• Acticoat

MAFENIDE ACETATE 10% (SULFAMYLON) HYDROPHILIC-BASED CREAM

**Mafenide acetate 10% hydrophilic-based cream is the agent of choice for electrical burns because of its ability to penetrate thick eschar.

• The occupational health nurse is called to

the floor of the factory where a patient has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How will the nurse cool the burn?

• Apply ice to the site of the burn for 5 to 10 minutes.
• Wrap the patient's affected extremity in ice until help

arrives.

• Apply an oil-based substance or butter to the burned

area until help arrives.

• Wrap cool towels around the affected extremity

intermittently.

WRAP COOL TOWELS AROUND AFFECTED EXTREMITY INTERMITTANTLY

**Once the burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage. However, 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.

• The emergency department nurse has just admitted a

patient with a burn. The nurse recognizes that the patient is likely to experience a local and systemic response to the burn when the burn exceeds a total body surface area (TBSA) of what?

A) 10%

B) 15%

C) 20%

D) 25%

25% **If the burn exceeds 20% to 25% TBSA, a nasogastric tube is inserted and connected to low intermittent suction. Often, patients with large burns become nauseated as a result of the gastrointestinal effects of the burn injury, such as paralytic ileus, and the effects of medication such as opioids. All patients who are intubated should have a nasogastric tube inserted to decompress the stomach and prevent vomiting.

• The nurse on a burn unit is caring for a

patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury?

• 2 days
• 3 days
• 5 days
• A week

2 DAYS

**Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. Changes detected by x-ray and arterial blood gases may occur as the effects of resuscitative fluid and the chemical reaction of smoke ingredients with lung tissues become apparent.

• A patient has sustained a severe burn

injury and is thought to have an impaired intestinal mucosal barrier. Since this patient is considered at an increased risk for infection, what intervention will assist in avoiding increased intestinal permeability and prevent early endotoxin translocation?

• Early enteral feeding
• Administration of prophylactic antibiotics
• Bowel cleansing procedures
• Administration of stool softeners

EARLY AND ENTERAL FEEDING

**If the intestinal mucosa receives some type of protection against permeability change, infection could be avoided. Early enteral feeding is one step to help avoid this increased intestinal permeability and prevent early endotoxin translocation. Antibiotics are seldom prescribed prophylactically because of the risk of promoting resistant strains of bacteria. A bowel cleansing procedure would not be ordered for this patient. The administration of stool softeners would not assist in avoiding increased intestinal permeability and prevent early endotoxin translocation.

• 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 with a partial-thickness burn injury had

Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the appropriate nursing intervention when this separation occurs?

• Reinforce the Biobrane dressing with another piece of

Biobrane.

• Remove the Biobrane dressing and apply a new

dressing.

• Trim away the separated Biobrane.
• Notify the physician for further emergency related

orders.

TRIM AWAY THE SEPARATED BIOBRANE

**As the Biobrane gradually separates, it is trimmed, leaving a healed wound.When the Biobrane dressing adheres to the wound, the wound remains stable and the Biobrane can remain in place for 3 to 4 weeks. You would not reinforce the Biobrane, or remove it and apply a new dressing. Nor would you notify the physician for further orders.

• An emergency department nurse learns from the

paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What factors does the nurse know are considered when determining the depth of burn?

• Causative agent
• Visual observation of burned area
• Area of body burned
• Circumstances of the accident

CAUSATIVE AGENT

**The following factors are considered in determining the depth of a burn: how

the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. To determine the depth of the burn you do not take into consideration you visual observation of the burned area, how much of the body is burned, or the circumstances of the accident.

• The nurse is caring for a patient who has sustained a

deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?

• Activity intolerance
• Anxiety

C) Impaired nutrition: less than body requirements

• Acute pain

ACUTE PAIN

**Pain is inevitable during recovery from any burn injury. Pain in the burn patient has been described as one of the most severe causes of acute pain. Management of the often-severe pain is one of the most difficult challenges facing the burn team. While the other nursing diagnoses listed are valid diagnoses, the presence of pain may contribute to these diagnoses and management of the patient's pain is priority as it may have a direct correlation to these nursing diagnoses.

• The triage nurse in the emergency department (ED)

receives a phone call from a frantic father who saw his 4- year-old child tip a pot of boiling water onto her chest.The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do?

• Cover the burn with ice and secure with a towel.
• Apply butter to the area that is burned.
• Immerse the child in a cool bath.
• Avoid touching the burned area and seek medical

attention.

IMMERSE THE CHILD IN A COOL BATH

**After the flames or heat source have been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first-aid measure. You do not put ice on the burn, nor do you put butter on the burn. You do not need to avoid touching the burn.

• The nurse is teaching a patient with a partial-thickness

wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment?

• 4 to 6 hours a day for 6 months
• Daily for 2 to 3 months after the injury
• Continuously
• At night while sleeping for a year after the injury

CONTINUOUSLY

Garments are worn continuously (ie, 23 hours a day).

• 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.