NC of Patients with Burns

Burns are wounds caused by an energy transfer from a heat source to the body, heating the tissue enough to cause damage.

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Treatment involves the patient and family members. Referrals to support groups, counselors, and psychiatrists are important during the rehabilitation stage.

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A graft has been successful if there is good adherence of the graft to the wound with no evidence of necrosis or infection.

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The size of a burn wound is estimated based on parts of the body affected. A quick and common method is the Rule of Tens.

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At the time of the injury, after the burning has stopped, the burn wound itself is a higher priority than the ABCs (airway, breathing, circulation) of trauma resuscitation.

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A patient is brought to the emergency department after a house fire. The patient has extensive trunk and lower extremity burns and is diagnosed with a deep partial-thickness burn. What assessment findings does the nurse expect?

• Snowy white, painless lesions

• Blistered, pinkish-white, painful lesions

• Blackened, painful lesions

• Bright-red, moist lesions

Which of the following actions is appropriate initial treatment of a chemical burn?

• Lavage with water.

• Neutralize the chemical.

• Apply the prescribed topical agent.

• Wrap the patient in sterile sheets.

A patient is admitted to the emergency department with flame burns to the entire chest, abdomen, back, and upper extremities. Using the Rule of Nines, what approximate percentage of burns should the nurse document?

• 36%

• 45%

• 54%

• 64%

Which nursing interventions are appropriate for a patient with a circumferential burn to an extremity? Select all that apply.

• Apply compression bandages starting at the distal end of the extremity.

• Administer analgesics if numbness or tingling occur.

• Check neurovascular status hourly.

• Assist with escharotomy if indicated.

• Elevate the extremity.

How will the nurse know if interventions for impaired gas exchange related to smoke inhalation have been effective?

• Partial pressure of carbon dioxide (PaCO₂) is greater than 45 mm Hg.

• Oxygen saturation (SpO₂) is less than 90%.

• pH is 7.34.

• Partial pressure of oxygen (PaO₂) is 88 mm Hg.