burns with qand a

“Intelligence is like a river: the deeper it is,

the less noise it makes.” -- Milwaukee Journal Sentine

An adult’s shirt catches on fire and is now in flames. He panics and runs into his neighbor’s yard.Which of the following intervention is appropriate? Select all that apply.

____ 1. Dousing the flames with water.____ 2. Removing his burned clothing.____ 3. Removing his jewelry.____ 4. Rolling him on the ground.

1, 3, 4

A 78-year-old man is admitted with severeflame burns resulting from smoking in bed.The nurse can expect his room environment to include

a. Strict isolation techniques and policies.b. A semi-private room.c. Liberal unrestricted visiting.d. Equipment shared between the client and the other burn client in the unit.

A

A 23-year-old factory worker was burned severely in an industrial accident. He has 2nd degree burns on his right leg and arm and on his back. He has 3rd degree burns on his left arm. The triage nurse, using the rule of nines, estimates the extent of the client’s burns as ___%.

54%

A client has suffered a chemical burn. The best initial action is to:

a. Roll the client in a blanket.b. Secure lead-lined gloves and move the client away from the chemical.c. Flush the area with copious amounts of water or normal saline.d. If the chemical is an acid, neutralize with a base.

c.

Deep partial-thickness burns involves the

a. epidermis only b. entire epidermis and the upper portion of the dermis c. epidermis and the entire dermal layer d. epidermis, the dermis, and the muscle

c

Visual inspection of a full-thickness burn

would reveal:

a. A swollen reddened area that blanches when pressure is applied b. Blisters of varying sizes with a cherry-red base c. Moist skin surface with a mottled, reddened are d. Dry skin surface with a pearly-white or charred appearance

d

Burns- Refers to injuries that result

from direct contact with or

exposure to any thermal,

chemical, electrical or

radiation source.

- Destruction of the layers skin or other body parts causing loss of intracellular fluid and electrolytes.

- Involves painful treatment and long period

of rehabilitation

CAUSES:

• CHEMICAL• ELECTRICAL• MECHANICAL• RADIATION• THERMAL

Smoke inhalation

-Occurs when smoke(particular products of fire, gases & superheated air)

causes respiratory tissue damage

Classification of Burns

Burn injuries – described according to the a. DEPTH of the injury b. extent of surface area injured

Classification according to DEPTH

Superficial-Partial Thickness

“1st degree burn” Epidermis (upper dermis) Reddened; blanches with pressure Dry or with minimal or no edema Possible blisters (may be) painful

Soothed by cooling No scarring; Peeling Recovery in a week

Deep Partial Thickness

“2nd degree burn” Epidermis & entire dermis Blistered; mottled red base

Edema Painful Sensitive to cold air Depigmentation contractures Recovery in 2-4 weeks

Full-Thickness

“3rd degree burn” Epidermis; entire dermis & subcutaneous tissue Dry, pale white, leathery or charred

Edema Painless Shock; Hematuria Hemolysis Needs grafting Scarring and contractures

“4th degree burn”• extend through muscle, bone and internal tissues

Deep Full-Thickness

I. Partial thicknessa. Superficial partial thickness burn - 1st degree - epidermis, upper dermisb. Deep partial thickness burn - 2nd degree - epidermis, dermis

II. Full thickness burn- 3rd degree – (FT) skin and SQ tissue- 4th degree – (DFT) skin, SQ tissue, muscle, bones

BURN DEPTH

Burn Assessment (TBSA)

> Rule of Nines

> Lund and Browder Chart

> Palm Method

Classification according to EXTENT of

BODY SURFACED AREA INJURED

Rule of

Nines

Lund and Browder Chart

- More precise method of estimating the extent of burn injury

- “percentage of surface area of various anatomic parts (head and legs) changes with growth”

- “TBSA changes with age”

Palm Method

- Indicated for scattered burns- client’s palm is approximately 1% of the TBSA

The nurse is planning care for an adult man who is admitted with severe flame burns. Nursing care planning is based on the knowledge that the first 24-48 hours post-burn are characterized by:

a. An increase in the total volume of intravascular plasma.b. Excessive renal perfusion with diuresis.c. Fluid shift from interstitial spaces to plasma.d. Fluid shift from plasma to interstitial spaces.

d.

Stages of Burn Injury

I. Shock Phase 1st 24 - 48 hours Shifting of fluid, Na, CHON from IVC to interstitial spaces Hypovolemia/shock Release of Catecholamines Hyponatremia Hyperkalemia Decreased urine output Hemoconcentration Metabolic Acidosis

A nurse is providing care for a severely burned clientduring the shock phase of the burn injury. Which assessment findings would indicate that the client is receiving adequate fluid volume replacement?

a. Urine output 20 ml/h, CVP 3, weak pulses, K+ level of 5.3b. Urine output 50 ml/h, BP 100/60, oriented to person and place.c. Weak thready pulses, BP 70/40, pulse 130, Hct 52%.d. Restlessness, confusion, urine output 15 ml/h, rapidly increasing weight.

b

The nurse is caring for an adult who was admittedfollowing severe burns sustained in a house fire. The nurse understands that an acceptable range forhourly urine output during the first 2 days post-burn is:

a. 20 mlb. 30-50 mlc. 100-150 mld. 150-200 ml

b.

II. Diuretic Phase 48 to 72 hrs after injuryCapillaries regain integrityFluid returns to IVSIncreased blood volumeIncreased urine outputHypervolemiaHemodilutionDiuresisHypokalemiaHyponatremia


III. Recovery Phase

Convalescent phase 5th day onwards starts when diuresis is completed and wound healing and coverage begin


During the first 24 hours post burn,there is a shift of fluid from the intravascular compartment to the burn site. The nurse should expect a decreased:

a. Specific gravity of urine b. Hematocrit c. Serum potassium d. Urinary output

d

During the stage of diuresis there is resorption of fluid into the intravascular and increased urinary output. Which electrolyte imbalance is most frequently associated with this stage?

1.Hypernatremia, hyperkalemia, carbonic acid deficit 2.Hyponatremia, hyperkalemia, bicarbonate excess 3.Hyponatremia, hypokalemia, bicarbonate deficit 4.Hypernatremia, hypokalemia, carbonate acid excess

c.

Mr. W. H. is a 30-year-old man with three children, D., A., and S.

While barbecuing at an outdoor pool party,he sustains second and third degree burnsof the anterior portion of both arms,the upper half of his anterior trunk,and the anterior and posterior positionsof his left legs.

Immediate care of burns at the scene of the accident includes stopping the burningprocess. This can be done by:

a. immersing the burned in ice water b. applying Vaseline to the burned areas c. flushing the burned area with solution of tannic acid d. covering the burned area with moist, sterile dressings

d.

Mr. H. is brought to the emergency room. Based on the rule of nines, which percentageis the best estimate of the extent of Mr. H’s burns?

a. 27 c. 36

b. 45 d. 54

c.

second and third degree burns of the anteriorportion of both arms, the upper half of hisanterior trunk, and the anterior and posteriorpositions of his left legs.

What is the priority of care in theemergency room during the initialmanagement of the burn client?

a. Obtaining a medical history b. Caring for the burn would c. Providing for fluid needsd. Administering tetanus antitoxin as prescribed

c.

Management of Burns

I. EMERGENT / RESUSCITATIVE PHASE

II. ACUTE / INTERMEDIATE PHASE

III.REHABILITATION

PHASES OF BURN CARE

A 25-year-old electrical worker has come in contact with a live power line. He is unconscious andis lying across the power line. The best initial action is to:

a. Move the person away from the power line using a wooden pole.b. Cover the person with a blanket.c. Grab the person and pull him away from the power lines.d. Flush the wound with copious amounts of water.

a

I. Emergent / Resuscitative Phase

- first priority -“PREVENT INJURY TO THE RESCUER”- request for - “FIRE & EMERGENCY MEDICAL SERVISES”

- from onset of injury to completion of fluid resuscitation

- first 24 – 48 hours

- “on the scene care”

R -A -C -E -

I. Emergent Phase

RESCUE

ALARM

CONTAIN

EXTINGUISH / EVACUATE

I. Emergent Phase

Major concern:

“life-threatening airway & breathing problems”

I. Emergent Phase

PRIORITIES

FIRST AID

“ABC” of trauma care

• AIRWAY• BREATHING• CIRCULATION

1.O2 administration

2.Coughing / suctioning

3.Bronchodilators & mucolytics

4.Endotracheal intubation & mechanical ventilation

I. Emergent Phase

A. “AIRWAY MANAGEMENT”

I. Emergent Phase

B. PREVENTION OF SHOCK

1.Insert large bore IV catheter (gauge 16-18) in non-burned area2. IV fluid administration – large amount3. CVP insertion 4. Catheterization

-Adequacy of fluid resuscitation is determined by:“URINE OUTPUT” – renal perfusion index

GOAL: a. UO – 30 to 50 ml/hr (0.5 to 1.0 ml/kg/hr) b. SBP - > 100mmhg c. PR - < 110 beats/min

fluid resuscitation

B. PREVENTION OF SHOCK

GUIDELINES & FORMULASFOR FLUID REPLACEMENT THERAPY

CONCESUS FORMULA- Lactated Ringer’s Solution (other balanced saline solution)- 2 – 4 ml x kg body weight x % TBSA burned- half to be given in first 8 hours- remaining half to be given over the next 16 hours

I. Emergent Phase

The physician has ordered 3, 600 milliliters of intravenous fluid to be given during the first 8 hours at a rate of 450 ml/hr. The nurse should recognize that the :

a. Amount is within the normal range for a burned client b. Physician’s orders should be questioned as soon as possible c. Physician probably means 45 ml/hrd. Maximum amount of intravenous fluid for a 24-hour period is 4, 000 milliliters

a.

Weight – 50kg, TBSA burned – 36%

4ml x 50kg x 36% = 7200 ÷ 2 = 3600ml450ml x 8 hours = 3600ml

GUIDELINES & FORMULASFOR FLUID REPLACEMENT THERAPY

a. EVANS FORMULAb. BROOKE ARMY FORMULAc. PARKLAND / BAXTER FORMULAd. HYPERTONIC SALINE SOLUTION

An adult was burned in a house fire 16 hours ago. She suffered second-and third-degree burns over 65%of her body. She is receiving lactated Ringer’s at 200ml/h. Which intervention is a priority at this time?

a. Monitoring hourly urine output.b. Assessing for signs and symptoms of infection.c. Performing range of motion q 1-2 h.d. Meeting the high caloric needs of the client.

a.

Formulas are only a guide. Client’s response, evidenced by HR, BP & UO, is the primary determinant of actual fluid therapy and must be assessed at least hourly.

Client outcomes are improved by optimal fluid resuscitation

Mr. H. becomes confused and shouts wheneveranyone enters the room. His CVP reading is 18 centimeters, and he has a 2.2-kiligram (5-pound)weight gain and a urine output of 100 ml/hr. The nurse should recognize these as signs of

a. The diuretic stage b. Hypovolemia c. Circulatory overload d. Septic shock

c

I. Emergent Phase

E. DETECTION & TREATMENT OF CONCOMITANT INJURIES - “secondary head-to-toe survey”F. WOUND ASSESSMENT & INITIAL CARE

C. CERVICAL IMMOBILIZATION

D. CARDIAC MONITORING

EXTINGUISH the flamesCOOL the burn (not cold)REMOVE restrictive clothing prnCOVER the wound - no ointment/lotions IRRIGATE - chemical burn

I. EmergentPhase

“INITIAL CARE”

Insert NGT:

- RISK FOR ASPIRATION - no food or fluid by mouth

Pain relief: morphine, fentanyl Tetanus Prophylaxis, topical antibiotics Address psychological needs: - patient and family

I. Emergent Phase

I. Emergent Phase

AirwayBreathingCirculation

DisabilityExposureFluid Resuscitation

The nurse is caring for a man admitted withsevere burns sustained when his clothingcaught acute burn phase, the nurse explainsto the man that his nursing care plan is directedtoward all of the following except:

1.Strict aseptic technique.2.Proper alignment of all joints.3.Maintenance of fluid and electrolyte balance.4.Frequent and routine administration of narcotics.

D – narcotics- given only after careful assessment in this phase due to the danger of Shock and Respiratory Depression


- Begins 48 – 72 hours after burn injury- beginning of diuresis to near completion of wound closure

PRIORITIES

1. PREVENTION & TREATMENT OF COMPLICATIONS2. PAIN MANAGEMENT3. WOUND CARE AND CLOSURE4. NUTRITIONAL SUPPORT

1. PREVENTION & TREATMENT OF COMPLICATIONSa. Continued assessment and maintenance of respiratory & circulatory status, F & E balance, and GI function


Aspergillus infection of Burn wound

PREVENTION & TREATMENT OF COMPLICATIONS

b. Infection Control

- Standard precaution

- Isolation technique

Topical Antibacterials Silver sulfadiazine (Silvadene) Mafenide acetate (Sulfamylon) Silver nitrate

Medications

The physician has prescribed mafenide acetate (Sulfamylon) for the burn site every 12 hours. In anticipating Mr. H’s needs, the nurse should recognize that:

a. There is a great deal of pain associated with the application of the preparation

b. A thick layer (1/4 inch) of Sulfamylon should be applied to the burn area for maximum effectc. The application of Sulfamylon is most effective when covered with pressure dressings d. The medication is antibacterial, so it is not necessary to use sterile techniques

a.

A client with severe burns is receiving IV Zantac. Which statement best explains the reason for administration of this medication in this situation?

a. The client was treated for gastritis several years ago.b. The medication will reduce hypoxemia in burn clients.c. The medication is an H 2 receptor antagonist and will

decrease acid secretion.d. The medication will aid in removal of pulmonary secretions.

c

Antiulcer: Magnesium/Aluminum Cimetidine; Ranitidine Sucralfate Anti-anxiety: Lorazepam Antibiotic: Gentamicin Anti-infectives: Neomycin Colloid: Albumin 5% Vitamins

Medications


2. PAIN MANAGEMENT

- analgesic of choice – MORPHINE SULFATE

-FENTANYL-OXYCODONE (oxycontin)

- NSAIDS

3. WOUND CARE AND CLOSURE

- Water temperature – 37.8C (100F)- Room temperature – 26.6 – 29.4C (80 – 85F)

Hydrotherapy-limited to 20 -30 minutes – prevent chilling and additional metabolic stress

•Hydrotherapy•Shower•Shower carts

Wound Debridement

Natural

Mechanical

Surgical

A client has undergone a skin graft. Which finding most likely indicates that complications with the recipient site may exist?

a. Small amounts of blood beneath the graft.b. Small amounts of serum beneath the graft.c. A meshed pattern in the graft.d. Continuous bleeding beneath the graft.

Ans. d

A client with a skin graft has undergone a full thickness skin graft from her right upper thigh toher upper chest area. The most appropriate nursing action in caring for her donor site is to:

a. Keep the fine mesh gauze dressing on her chest soaked with normal saline.b. Completely immobilize her right upper thigh area.c. Maintain the compression bandage on her right upper thigh for several days.d. Remove the nylon fabric adhered to the donor site no later than two to three days after grafting has taken place.

c

An adult has undergone a skin graft from his left buttock to his right upper thigh.When caring for the recipient site,the nurse can expect to:

a. Apply silver sulfadiazine to promote rapid healing.b. Assess for bleeding and large amounts of fluid accumulation beneath the graft.c. Encourage the client to ambulate and do leg lifts on return from OR.d. Encourage the client to take frequent soaking baths to relieve his soreness and discomfort.

b.


4. NUTRITIONAL SUPPORT

III. Rehabilitative Phase Priorities Prevention of scars and contractures Physical, occupational and vocal rehab Functional and cosmetic reconstruction Psychosocial counseling

P. L. 28 years old, is admitted to the hospitalwith partial-thickness burns of the face and neck.

He sustained the burns while putting out of firethat involved all industrial substances.

In an initial nursing assessment of Mr. L., which nursing action would be the most important?

a. Determining how he felt about his facial injuries b. Assessing for changes in the circumference of his neck c. Observing for signs of increased intracranial pressure d. Weighing him after his clothes are removed

Ans. b

Which finding would be the most significantin determining whether airway obstruction mayoccur in Mr. L?

a. A PO2 of 73 mmHg b. A cough that produces whitish sputum c. Complaints of neck pain d. Singed nasal hair

Ans. d

The nurse should expect which procedures to be performed within two hours afterthe burn injury?

a. Tracheostomyb. Escharotomy c. Intubation d. Chest tube insertion

Ans. BEscharotomy – a linear excision made through the eschar to release constriction of underlying tissue

Biologic Dressings Homografts (allografts)

Living or deceased skin Stored in skin banks Revascularizes in 48 hrs. Can be left in place for several weeks

Heterografts (xenografts) From animals (usu. Pigs) Does not revascularize

Amnion (amniotic membrane) Least expensive Does not revascularize

burns with qand a

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