Chapter 57 Management of Patients with Burn Injury

Chapter 57 Management of Patients with Burn Injury 4.8 (4 reviews) Students also studied Terms in this set (42) Keiser University-Ft LauderdaleNUR 1140 Save

CH 57: Management of Patients with...

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Chapter 67: Emergency Nursing

40 terms Jose_Martinez2884 Preview Chapter 11 - Shock, Sepsis, and Multi...98 terms awithem240Preview Chapte 50 terms A49 A client is brought to the emergency department from the site of a chemical fire, where the client suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the client's arm?

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

Rationale: 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. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis; the client will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis; the client will report pain and sensitivity to cold air. Full partial thickness is not a depth of burn.The current phase of a client's treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the client is in what phase of burn care?

• Emergent
• Immediate resuscitative
• Acute
• Rehabilitation
• Acute

Rationale: 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 (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound débridement, and wound grafting), pain management, and nutritional support are priorities at this stage. 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 client in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the client's laboratory studies, the nurse will expect the results to indicate what findings?

• Hyperkalemia, hyponatremia, elevated hematocrit, and

metabolic acidosis

• Hypokalemia, hypernatremia, decreased hematocrit,

metabolic acidosis

• Hyperkalemia, hypernatremia, decreased hematocrit,

and metabolic alkalosis

• Hypokalemia, hyponatremia, elevated hematocrit, and

metabolic alkalosisrr

• Hyperkalemia, hyponatremia, elevated hematocrit

Rationale: 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 amounts of sodium lost in trapped edema fluid, and hemoconcentration that leads to an increased hematocrit.A client has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the health care provider 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

Rationale: Mafenide acetate 10% hydrophilic-based cream is the agent of choice

when there is a need to penetrate thick eschar. Silver products do not penetrate eschar; Acticoat is a type of silver dressing.An occupational health nurse is called to the floor of a factory where a worker 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 should the nurse cool the burn?

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

arrives.

• Apply an oil-based substance to the burned area until

help arrives.

• Wrap cool towels around the affected extremity

intermittently.

• Wrap cool towels around the affected extremity intermittently.

Rationale: 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. Oils are contraindicated.An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury?

• The length of time since the burn
• The location of burned skin surfaces
• The source of the burn
• The total body surface area (TBSA) affected by the

burn

• The total body surface area (TBSA) affected by the burn

Rationale: Systemic effects are a result of several variables. However, TBSA and wound severity are considered the major factors that affect the presence or absence of systemic effects.

A nurse on a burn unit is caring for a client who experienced burn injuries 2 days ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood?

• The client is likely experiencing a delayed onset of

respiratory complications

• The client has likely developed a systemic infection
• The client's respiratory complications are likely related

to psychosocial stress

• The client is likely experiencing an anaphylactic

reaction to a medication

• The client is likely experiencing a delayed onset of respiratory complications

Rationale: Airway obstruction caused by upper airway edema can take as long as

48 hours to develop. A systemic infection would be less likely to cause respiratory complications. This problem is more likely to be caused by physiologic factors at this phase, not psychological factors. Anaphylaxis must be ruled out, but it is less likely than a response to the initial injury.A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body.After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care?

• Fluid status
• Risk of infection
• Nutritional status
• Psychosocial coping
• Fluid status

Rationale: 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 control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.The nurse is providing education to a client that is scheduled for mechanical débridement of a wound. The nurse knows that mechanical débridement involves which element?

• A spontaneous separation of dead tissue from the

viable tissue

• Removal of 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
• Removal of eschar until the point of pain and bleeding occurs

Rationale: Mechanical débridement 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 débridement can also be accomplished through the use of topical enzymatic débridement agents. The spontaneous separation of dead tissue from the viable tissue is an example of natural débridement. Shaving the burned skin layers and early wound closure are examples of surgical débridement.A client with a partial-thickness burn injury had a xenograft applied 2 weeks ago. The nurse notices that the xenograft is separating from the burn wound. What is the nurse's most appropriate intervention?

• Reinforce the xenograft dressing with another piece of

Biobrane.

• Remove the xenograft dressing and apply a new

dressing.

• Trim away the separated xenograft.
• Notify the health care provider for further emergency-

related orders.

• Trim away the separated xenograft.

Rationale: Xenografts adhere to granulation tissue. As the tissue heals the

xenograft will become removed from the scar tissue. Applying more of the xenograft will not continue to heal the wound (as it is already healed). It is not an emergency and reinforcement is not necessary.

An emergency department nurse learns from the paramedics that the team is transporting a client who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn?

• The causative agent
• The client's pre-injury health status
• The client's prognosis for recovery
• The circumstances of the accident
• The causative agent

Rationale: 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. The client's pre-injury status, circumstances of the accident, and prognosis for recovery are important, but are not considered when determining the depth of the burn.A nurse is caring for a client 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
• Ineffective coping
• Acute pain
• Acute pain

Rationale: Pain is inevitable during recovery from any burn injury. Pain in the burn client has been described as one of the most severe types 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, the presence of pain may contribute to these diagnoses. Management of the client's pain is the priority, as it may have a direct correlation to the other listed nursing diagnoses.A triage nurse in the emergency department (ED) receives a phone call from a frantic parent who saw their 4-year-old child tip a pot of boiling water onto themselves. The parent has called an ambulance. What should the nurse in the ED receiving the call instruct the parent 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 under any

circumstances.

• Immerse the child in a cool bath.

Rationale: 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.Ice and butter are contraindicated. Appropriate first aid necessitates touching the burn.A nurse is teaching a client with a partial-thickness wound how to wear the elastic pressure garment. How often should the nurse instruct the client to wear this garment?

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

Rationale: Elastic pressure garments are worn continuously (i.e., 24 hours a day).A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation.What is the priority in the care of a client who has been burned and suffered smoke inhalation?

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

Rationale: Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early post-burn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.