Chapter 57: Management of Patients with Burn Injury Show
ANS: DRationale: 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.
ANS: CRationale: 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., 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.
ANS: ARationale: 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.
ANS: BRationale: 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.
ANS: DRationale: 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.
ANS: DRationale: 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.
ANS: ARationale: 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.
ANS: ARationale: 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.
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.
ANS: CRationale: Elastic pressure garments are worn continuously (i., 24 hours a day).
ANS: DRationale: 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.
ANS: ARationale: Anticipated fluid and electrolyte changes that occur during the emergent/resuscitative phase of burn injury include sodium deficit, potassium excess, and elevated hematocrit. PT does not typically decrease.
ANS: CRationale: To prevent the complication of contractures, the nurse will establish a goal to maintain position of joints in alignment. Gentle range-of-motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures. Joint alignment is not maintained specifically for preventing neuropathy, wound breakdown, or heterotopic ossification.
ANS: BRationale: An infected graft may need to be removed, thus the care provider should be promptly informed. ROM exercises will not resolve this problem, and the nurse would not independently perform débridement.
ANS: BRationale: Clients lose a great deal of weight during recovery from severe burns. Reserve fat deposits are catabolized as a result of hypermetabolism. Clients are not placed on a calorie restriction during recovery, and fluid losses would not account for weight loss later in the recovery period. Changes in the overall distribution of body fat do not occur.
ANS: ARationale: Young children and older adults continue to have increased morbidity and mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the client.
ANS: ARationale: The initial systemic event after a major burn injury is hemodynamic instability, which results from loss of capillary integrity and a subsequent shift of fluid, sodium, and protein from the intravascular space into the interstitial spaces. This precedes GI changes. Respiratory arrest may or may not occur, largely depending on the presence or absence of smoke inhalation. Hypokalemia does not take place in the initial phase of recovery.
ANS: CRationale: As fluid loss continues and vascular volume decreases, cardiac output continues to decrease and the blood pressure drops, marking the onset of burn shock. Shock and the accompanying hemodynamic changes are not normally accompanied by confusion, fever, or agitation.
ANS: DRationale: Recovery from burns can be psychologically challenging; the nurse's assessments must address this reality. Fluid and electrolyte imbalances are infrequent during the rehabilitation phase of recovery. Burns are not typically a health problem that tends to recur; the experience of being burned tends to foster vigilance.
ANS: CRationale: Dressings can impede circulation if they are wrapped too tightly. The peripheral pulses must be checked frequently and burned extremities elevated. Dependent positioning does not need to be maintained. PRN analgesics should be given prior to the dressing change. ROM exercises do not normally follow a dressing change.
ANS: DRationale: Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the client is important. The nurse monitors the splints and functional devices, but these are selected by occupational and physical therapists. The hemodynamic changes accompanying burns do not normally require the use of beta blockers.
ANS: 18, 18%Rationale: 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 client.
ANS: BRationale: Client and family education is a priority during rehabilitation. There should be no fluid and electrolyte imbalances in the rehabilitation phase. The presence of impaired thermoregulation or infection would suggest that the client is still in the acute phase of burn recovery.
response? A. "That's something that you and your doctor will likely talk about after your scars mature." B. "That is something for you to talk to your doctor about because it's not a nursing responsibility." C. "I know this is really important to you, but you have to realize that no one can make you look like you used to." D. "Unfortunately, it's likely that these scars will look like this for the rest of your life." ANS: ARationale: Burn reconstruction is a treatment option after all scars have matured and is discussed within the first few years after injury. Even though this is not a nursing responsibility, the nurse should still respond appropriately to the client's query. It is true that the client will not realistically look like he or she used to, but this does not instill hope.
ANS: ARationale: The goal of treatment is to provide a long-acting analgesic that will provide even coverage for this long-term discomfort. It is helpful to use escalating doses when initiating the medication to reach the level of pain control that is acceptable to the client. The use of client-controlled analgesia (PCA) gives control to the client and achieves this goal. Clients cannot normally achieve adequate pain control without the use of opioids, and parenteral administration is usually required.
ANS: DRationale: Exercise and the promotion of mobility can reduce the risk of contracture and hypertrophic scarring. Skin emollients are not normally used in the treatment of burns, and these do not prevent scarring. Steroids are not used to reduce scarring, as they also slow the healing process.
ANS: DRationale: The client may experience feelings of anger. The anger may be directed outward toward those who escaped unharmed or toward those who are now providing care. While drug reactions, complications, and frustrating inconsistencies in care cannot be automatically ruled out, it is not uncommon for anger to be directed at caregivers.
What are the first priorities immediately after a burn?The area of tissue damage should be cooled with cool running water for 20 minutes. Ensure the unburnt areas of the patient are covered and warm to prevent hypothermia.
Which of the following is the priority when dealing with a patient with burns?The first priority in treating the burn victim is to ensure that the airway (breathing passages) remains open. Associated smoke inhalation injury is very common, particularly if the patient has been burned in a closed space, such as a room or building. Even patients burned in an open area may sustain smoke inhalation.
What are the priority nursing interventions during the emergent phase of burn injury?During the emergent phase, the priority of client care involves maintaining an adequate airway and treating the client for burn shock. The eyes should be irrigated with water immediately if a chemical burn occurs.
Which zone of burn injury sustains the most damage?Zone of coagulation – this is the primary site of injury and the site of maximum damage. This zone comprises irreversible tissue loss due to exposure to heat, electricity and/or chemicals. Zone of stasis – this surrounding zone has decreased tissue perfusion and is a penumbra of potentially salvageable tissue.
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