Burns

A 23-year-old male client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge?

• how to maintain at home smoke-detectors

• joining a community reintegration program

• learning to perform dressing changes

• options available for scar removal

Answer explanation

Teaching the patient and his family to perform dressing changes is critical for the goal of progression towards independence. Proper management of burn injury through proper dressing changes helps prevent wound deterioration. Encouragement of the patient and his family members in participating in dressing changes and wound care helps prepare for the patient’s eventual discharge and home care needs. All other choices (below) are important during the rehabilitation stage but dressing changes is a priority.

• Option A: Teach on the importance of installing and maintaining smoke detectors on every level of the home and changing batteries periodically to help prevent fires.

• Option B: Surviving a burn injury has a tremendous psychological impact on the patient and family. The nurse plays a key role in helping the patient adapt. Providing referrals to social services and counseling helps the patient during his rehabilitation phase.

• Option D: Discussion about burn reconstruction treatment after the scars have healed or matured is usually discussed after the first few years after injury. This option is often used to “improve both the function and the cosmetic appearance of burn scars”.

A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first?

• start IV fluids

• check pulses using a doppler

• obtain CBC

• obtain ECG

Answer explanation

Hypovolemic shock is a common cause of death in the emergent phase of clients with serious injuries. Administration of fluids can treat this problem. For burns classified as severe (> 20% TBSA), fluid resuscitation should be initiated to maintain urine output > 0.5 mL/kg/hour.

• Option C: Following a severe burn injury, significant hematologic changes occur that are reflected in complete blood count (CBC) measurements. A CBC will be taken to ascertain if a cardiac or bleeding problem is causing these vital signs. However, these are not actions that the nurse would take immediately.

• Option B: Checking pulses would indicate perfusion to the periphery but this is not an immediate nursing action. Carefully check pulses in any extremity with circumferential burns. These burns can act as tourniquets as burn-associated edema begins, leading to compartment syndrome.

• Option D: In patients with extensive burns, it is sometimes a challenge to monitor the ECG, because the lack of natural skin and application of protective ointments prevent the adherence of the ECG discs.

A 40-year-old male client who was burned was admitted under your care. Assessment reveals he has crackles, respiratory rate of 40/min, and is coughing up blood-tinged sputum. What action will the nurse take first?

• administer digoxin

• perform chest physiotherapy

• monitor urine output

• place the patient in high-fowler's

Answer explanation

Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out.

• Option A: Digoxin may be given later to increase cardiac contractility to prevent backup of fluid into the lungs. However, digoxin has the potential to cause bradyarrhythmias.

• Option B: Chest physiotherapy will not get rid of the fluid and is not a priority among the choices. Chest physiotherapy is only applicable during the post-burn management of the patient.

• Option C: Monitoring urine output is important. However, it is not an immediate intervention. Use the patient’s urine output and physiologic response to determine if the volume is adequate for resuscitation.

How will the nurse position a patient with a burn wound to the posterior neck to prevent contractures?

• Have the patient turn his head from side to side.

• Keep the patient in a supine position without the use of pillows

• Keep the patient in a semi-fowler's position with their arms elevated

• place a towel roll under the patient's neck or shoulder

Answer explanation

Deformities and contractures can often be prevented by proper positioning. Maintaining proper body alignment when the patient is in bed is vital. The function that would be disrupted by a contracture to the posterior neck is flexion. Moving the head from side to side prevents such a loss of flexion. This movement is what would prevent contractures from occurring.

• Option B: The client should not only be in a supine position but there should be a movement to avoid contractures. Splinting and proper positioning will also help achieve the prevention of contractures. As a matter of importance, movement should be incorporated into the patient’s daily routine from their inception to the hospital.

• Option C: The burns are in the client’s posterior neck. Performing active or passive range of motion (ROM) exercises, depending on the patient’s level of consciousness is crucial in the prevention of these complications.

• Option D: Placing a towel roll under the neck might not help prevent contractures. Immobilization is only allowed when a part of the body has just been grafted. Even then, the area must be kept in an antideformity position.

On assessment, the nurse notes that the patient has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse’s next action?

• document the findings

• loosen any dressings on the chest

• raise the head of the bed

• prepare for intubation

Answer explanation

Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose the effective movement of air. When this occurs, wheezing is no longer heard and neither are breath sounds. The client requires the establishment of an emergency airway. The swelling usually precludes intubation.

Ten hours after the patient with 50% burns is admitted, her blood glucose level is 142 mg/dL. What is the nurse’s best action?

• document the findings

• obtain a family history

• repeat the glucose measurement

• stop IV fluids containing dextrose

Answer explanation

Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma.

A 32-year-old patient, who is on an anticoagulant medication due to a history of deep vein thrombosis, arrives at the emergency department after accidentally spilling a pot of boiling water mixed with hot oil on their right arm while attempting to deep-fry food at home. The patient is in significant pain and reports that the burn occurred approximately 30 minutes ago. Upon assessment, the nurse observes a large burned area on the patient's right arm with a mix of pink and mottled red areas, blisters, and signs of active bleeding from the blistered areas. The burned area is very painful to touch and the client is visibly anxious. Based on the assessment findings and the patient's medical history, how will the nurse categorize this burn injury?

• full-thickness

• superficial

• partial thickness deep

• full thickness deep

Answer explanation

Deep partial-thickness burns are pink or red in color, swollen, painful, with blisters that may ooze a clear fluid. Deep partial-thickness (second-degree) involves the deeper dermis. Healing occurs in 3 to 8 weeks with scarring present.

• Option A: Third-degree involves the full thickness of skin and subcutaneous structures. It appears white or black/brown. With pressure, no blanching occurs. The burn is leathery and dry. There is minimal to no pain because of decreased sensation.

• Option B: The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color that is red; without blisters and pain present. Superficial (first-degree) involves the epidermis of the skin only. It appears pink to red, there are no blisters, and it is dry. It is moderately painful. Superficial burns heal without scarring within 5 to 10 days.

• Option D: Blisters are not seen with full-thickness burns and are rarely seen with deep partial-thickness burns. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.

The patient has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are present, and there is just a “small amount of pain.” How will the nurse categorize this injury?

• full thickness

• partal-thickness

• superficial

• deep partial-thickness

Answer explanation

The characteristics of the wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; pain minimal; outer layer firm and inelastic. The burn is leathery and dry. There is minimal to no pain because of decreased sensation. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.

The client has experienced an electrical injury of the lower extremities. Which are the priority assessment data to obtain from this client?

• current range of motion in all extremities

• heart rate & rhythm

• respiratory rate & pulse ox reading

• orientation to time, place, and person

Answer explanation

Electric current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate, rhythm, and ECG changes. It is also important to obtain the patient’s cardiac history, including any history of prior arrhythmias.

• Option A: Range of motion is also important. However, the priority is to make sure that the heart rate and rhythm are adequate to support perfusion to the brain and other vital organs.

• Option C: The airway is not at any particular risk with this injury. Therefore, respiratory rate and pulse oximetry are not priority assessments. Any patient that was in contact with a high voltage source should have continuous cardiac monitoring during evaluation.

• Option D: These patients are specifically at risk for cardiac damage if the path of the current traversed the heart. One may also consider CT imaging of the head if the patient has altered mental status or associated head trauma from a fall or being thrown in a blast.

The patient who is burned is drooling and having difficulty swallowing. Which action will the nurse take first?

• assess LOC and pupil reaction

• determine the last time food or liquid was consumed

• auscultate breath sounds over the trachea

• measure abdominal girth and auscultate bowel sounds

Answer explanation

Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his airway because of this injury. The absence of breath sounds over the trachea and mainstem bronchi indicates impending airway obstruction and demands immediate intubation.