The nurse should plan to begin rehabilitation efforts for the burn client:

Most burns result from preventable accidents. Thermal burns, which are the most common type,occur because of fires from motor vehicle crashes, accidents in residences, and arson or electrical malfunctions. Children may be burned when they play with matches or firecrackers or because of a kitchen accident. Chemical burns occur as a result of contact with, ingestion of, or inhalation of acids, alkalis, or vesicants (blistering gases). The percentage of burns actually caused by abuse is fairly small, but they are some of the most difficult to manage. Neglect or inadequate supervision of children is fairly common. Effective prevention and educational efforts such as smoke detectors, flame-retardant clothing, child-resistant cigarette lighters, and the Stop Drop and Roll program have decreased the number and severity of injuries.

Gender, Ethnic/Racial, and Life Span Considerations

Preschool children account for over two-thirds of all burn fatalities. Clinicians use a special chart (Lund-Browder Chart) for children that provides a picture and a graph to account for the difference in body surface area by age. Serious burn injuries occur most commonly in males, and in particular, young adult males ages 20 to 29 years of age, followed by children under 9 years of age. Individuals older than 50 years sustain the fewest number of serious burn injuries.

The younger child is the most common victim of burns that have been caused by liquids. Preschoolers, school-aged children, and teenagers are more frequently the victims of flame burns. Young children playing with lighters or matches are at risk, as are teenagers because of
carelessness or risk-taking behaviors around fires. Toddlers incur electrical burns from biting electrical cords or putting objects in outlets.

Most adults are victims of house fires or workrelated accidents that involve chemicals or electricity. The elderly are also prone to scald injuries because their skin tends to be extremely thin and sensitive to heat.

Because of the severe impact of this injury, the very young and the very old are less able to respond to therapy and have a higher incidence of mortality. In addition, when a child Burns 167 experiences a burn, multiple surgeries are required to release contractures that occur as normal growth pulls at the scar tissue of their healed burns. Adolescents are particularly prone to psychological difficulties because of sensitivity regarding body image issues. No specific gender and ethnic/racial considerations exist in burns.

Gerontologic Considerations

• Elderly people are at higher risk for burn injury because of reduced coordination, strength, and sensation and changes in vision.
• Predisposing factors and the health history in the older adult influence the complexity of care for the patient.
• Pulmonary function is limited in the older adult and therefore airway exchange, lung elasticity, and ventilation can be affected.
• This can be further affected by a history of smoking.
• Decreased cardiac function and coronary artery disease increase the risk of complications in elderly patients with burn injuries. Malnutrition and presence of diabetes mellitus orother endocrine disorders present nutritional challenges and require close monitoring.
• Varying degrees of orientation may present themselves on admission or through the course of care making assessment of pain and anxiety a challenge for the burn team.
• The skin of the elderly is thinner and less elastic, which affects the depth of injury and its ability to heal.

Primary Nursing Diagnosis

Ineffective airway clearance related to airway edema

OUTCOMES. Respiratory status: Gas exchange; Respiratory status: Ventilation; Symptom control behavior; Treatment behavior: Illness or injury; Comfort level
INTERVENTIONS. Airway management; Anxiety reduction; Oxygen therapy; Airway suctioning; Airway insertion and stabilization; Cough enhancement; Mechanical ventilation; Positioning; Respiratory monitoring

Medical Management

MINOR BURN CARE. Minor burn wounds are cared for by using the principles of comfort, cleanliness, and infection control. A gentle cleansing of the wound with soap and water 2 or 3 times a day, followed with a topical agent such as silver sulfadiazine or mafenide, prevents infection. Minor burns should heal in 7 to 10 days; however, if they take longer than 14 days, excision of the wound and a small graft may be needed. Oral analgesics may be prescribed to manage discomfort, and as do all burn patients, the patient needs to receive tetanus toxoid to prevent infection.

MAJOR BURN CARE. For patients with a major injury, effective treatment is provided by a multidisciplinary team with special training in burn care. In addition to the physician and nurse, the team includes specialists in physical and occupational therapy, respiratory therapy, social
work, nutrition, psychology, and child life for children. The course of recovery is divided into four phases: emergent-resuscitative, acute-wound coverage, convalescent-rehabilitative, and reorganization-reintegration.

The emergent-resuscitative phase lasts from 48 to 72 hours after injury or until diuresis takes place. In addition to managing airway, breathing, and circulation, the patient receives fluid resuscitation, maintenance of electrolytes, aggressive pain management, and early nutrition.Wounds are cleansed with chlorhexidine gluconate and care consists of silver sulfadiazine ormafenide and surgical management as needed. To prevent infection, continued care includes further débridement by washing the surface of the wounds with mild soap or aseptic solutions. Then the physician débrides devitalized tissue, and often the wound is covered with antibacterial agents such as silver sulfadiazine and occlusive cotton gauze.

The acute-wound coverage phase, which varies depending on the extent of injury, lasts until the wounds have been covered, through either the normal healing process or grafting. The risk for infection is high during this phase; the physician follows wound and blood cultures and prescribes antibiotics as needed. Wound management includes excision of devitalized tissue, surgical grafting of donor skin, or placement of synthetic membranes. Inpatient rehabilitation takes place during the convalescent-rehabilitative phase. Although principles of rehabilitation are included in the plan of care from the day of admission, during this time, home exercises and wound care are taught. In addition, pressure appliances to reduce scarring, or braces to prevent contractures, are fitted. The reorganization phase is the long period of time that it may take after the injury for physical and emotional healing to take place.

Nursing Management: Emergent/Resuscitative Phase

• Focus on the major priorities of any trauma patient; the burn wound is a secondary consideration, although aseptic management of the burn wounds and invasive lines continues.
• Assess circumstances surrounding the injury: time of injury, mechanism of burn, whether the burn occurred in a closed space, the possibility of inhalation of noxious chemicals, and any related trauma.
• Monitor vital signs frequently; monitor respiratory status closely; and evaluate apical, carotid, and femoral pulses particularly in areas of circumferential burn injury to an extremity.
• Start cardiac monitoring if indicated (eg, history of cardiac or respiratory problems, electrical injury).
• Check peripheral pulses on burned extremities hourly; use Doppler as needed.
• Monitor fluid intake (IV fluids) and output (urinary catheter) and measure hourly. Note amount of urine obtained when catheter is inserted (indicates preburn renal function and fluid status).
• Assess body temperature, body weight, history of preburn weight, allergies, tetanus immunization, past medicalsurgical problems, current illnesses, and use of medications.
• Arrange for patients with facial burns to be assessed for corneal injury.
• Continue to assess the extent of the burn; assess depth of wound, and identify areas of full and partialthickness injury.
• Assess neurologic status: consciousness, psychological status, pain and anxiety levels, and behavior.
• Assess patient’s and family’s understanding of injury and treatment. Assess patient’s support system and coping skills.

Promoting Gas Exchange and Airway Clearance

• Provide humidified oxygen, and monitor arterial blood gases (ABGs), pulse oximetry, and carboxyhemoglobin levels.
• Assess breath sounds and respiratory rate, rhythm, depth, and symmetry; monitor for hypoxia.
• Observe for signs of inhalation injury: blistering of lips or buccal mucosa; singed nostrils; burns of face, neck, or chest; increasing hoarseness; or soot in sputum or respiratory secretions.
• Report labored respirations, decreased depth of respirations, or signs of hypoxia to physician immediately; prepare to assist with intubation and escharotomies.
• Monitor mechanically ventilated patient closely.
• Institute aggressive pulmonary care measures: turning, coughing, deep breathing, periodic forceful inspiration using spirometry, and tracheal suctioning.
• Maintain proper positioning to promote removal of secretions and patent airway and to promote optimal chest expansion; use artificial airway as needed.

Restoring Fluid and Electrolyte Balance

• Monitor vital signs and urinary output (hourly), central venous pressure (CVP), pulmonary artery pressure, and cardiac output.
• Note and report signs of hypovolemia or fluid overload.
• Maintain IV lines and regular fluids at appropriate rates, as prescribed. Document intake, output, and daily weight.
• Elevate the head of bed and burned extremities.
• Monitor serum electrolyte levels (eg, sodium, potassium, calcium, phosphorus, bicarbonate); recognize developing electrolyte imbalances.
• Notify physician immediately of decreased urine output; blood pressure; central venous, pulmonary artery, or pulmonary artery wedge pressures; or increased pulse rate.

Maintaining Normal Body Temperature

• Provide warm environment: use heat shield, space blanket, heat lights, or blankets.
• Assess core body temperature frequently.
• Work quickly when wounds must be exposed to minimize heat loss from the wound.

Minimizing Pain and Anxiety

• Use a pain scale to assess pain level (ie, 1 to 10); differentiate between restlessness due to pain and restlessness due to hypoxia.
• Administer IV opioid analgesics as prescribed, and assess response to medication; observe for respiratory depression in patient who is not mechanically ventilated.
• Provide emotional support, reassurance, and simple explanations about procedures.
• Assess patient and family understanding of burn injury, coping strategies, family dynamics, and anxiety levels. Provide individualized responses to support patient and family coping; explain all procedures in clear, simple terms.
• Provide pain relief, and give antianxiety medications if patient remains highly anxious and agitated after psychological interventions.

Monitoring and Managing Potential Complications

• Acute respiratory failure: Assess for increasing dyspnea, stridor, changes in respiratory patterns; monitor pulse oximetry and ABG values to detect problematic oxygen saturation and increasing CO2; monitor chest xrays; assess for cerebral hypoxia (eg, restlessness, confusion); report deteriorating
• respiratory status immediately to physician; and assist as needed with intubation or escharotomy.
• Distributive shock: Monitor for early signs of shock (decreased urine output, cardiac output, pulmonary artery pressure, pulmonary capillary wedge pressure, blood pressure, or increasing pulse) or progressive edema. Administer fluid resuscitation as ordered in response to physical findings; continue monitoring fluid status.
• Acute renal failure: Monitor and report abnormal urine output and quality, blood urea nitrogen (BUN) and creatinine levels; assess for urine hemoglobin or myoglobin; administer increased fluids as prescribed.
• Compartment syndrome: Assess peripheral pulses hourly with Doppler; assess neurovascular status of extremities hourly (warmth, capillary refill, sensation, and movement); remove blood pressure cuff after each reading; elevate burned extremities; report any extremity pain, loss of peripheral pulses or sensation; prepare to assist with escharotomies.
• Paralytic ileus: Maintain nasogastric tube on low intermittent suction until bowel sounds resume; auscultate abdomen regularly for distention and bowel sounds.
• Curling’s ulcer: Assess gastric aspirate for blood and pH; assess stools for occult blood; administer antacids and histamine blockers (eg, ranitidine [Zantac]) as prescribed.

Nursing Management: Acute/ Intermediate Phase

The acute or intermediate phase begins 48 to 72 hours after the burn injury. Burn wound care and pain control are priorities at this stage.

• Focus on hemodynamic alterations, wound healing, pain and psychosocial responses, and early detection of complications.
• Measure vital signs frequently; respiratory and fluid status remains highest priority.
• Assess peripheral pulses frequently for first few days after the burn for restricted blood flow.
• Closely observe hourly fluid intake and urinary output, as well as blood pressure and cardiac rhythm; changes should be reported to the burn surgeon promptly.
• For patient with inhalation injury, regularly monitor level of consciousness, pulmonary function, and ability to ventilate; if patient is intubated and placed on a ventilator, frequent suctioning and assessment of the airway are priorities.

Restoring Normal Fluid Balance

• Monitor IV and oral fluid intake; use IV infusion pumps.
• Measure intake and output and daily weight.
• Report changes (eg, blood pressure, pulse rate) to physician.

Preventing Infection

• Provide a clean and safe environment; protect patient from sources of crosscontamination (eg, visitors, other patients, staff, equipment).
• Closely scrutinize wound to detect early signs of infection.

Monitor culture results and white blood cell counts.

• Practice clean technique for wound care procedures and aseptic technique for any invasive procedures. Use meticulous hand hygiene before and after contact with patient.
• Caution patient to avoid touching wounds or dressings; wash unburned areas and change linens regularly.

Maintaining Adequate Nutrition

• Initiate oral fluids slowly when bowel sounds resume; record tolerance—if vomiting and distention do not occur, fluids
• may be increased gradually and the patient may be advanced to a normal diet or to tube feedings.
• Collaborate with dietitian to plan a protein and calorie-rich diet acceptable to patient. Encourage family to bring nutritious and patient’s favorite foods. Provide nutritional and vitamin and mineral supplements if prescribed.
• Document caloric intake. Insert feeding tube if caloric goals cannot be met by oral feeding (for continuous or bolus feedings); note residual volumes.
• Weigh patient daily and graph weights.

Promoting Skin Integrity

• Assess wound status.
• Support patient during distressing and painful wound care.
• Coordinate complex aspects of wound care and dressing changes.
• Assess burn for size, color, odor, eschar, exudate, epithelial buds (small pearllike clusters of cells on the wound surface), bleeding, granulation tissue, the status of graft take, healing of the donor site, and the condition of the surrounding skin; report any significant changes to the physician.
• Inform all members of the health care team of latest wound care procedures in use for the patient.
• Assist, instruct, support, and encourage patient and family to take part in dressing changes and wound care.
• Early on, assess strengths of patient and family in preparing for discharge and home care.

Relieving Pain and Discomfort

• Frequently assess pain and discomfort; administer analgesic agents and anxiolytic medications, as prescribed, before the pain becomes severe. Assess and document the patient’s response to medication and any other interventions.
• Teach patient relaxation techniques. Give some control over wound care and analgesia. Provide frequent reassurance.
• Use guided imagery and distraction to alter patient’s perceptions and responses to pain; hypnosis, music therapy, and virtual reality are also useful.
• Assess the patient’s sleep patterns daily; administer sedatives, if prescribed.
• Work quickly to complete treatments and dressing changes.

Encourage patient to use analgesic medications before painful procedures.

• Promote comfort during healing phase with the following:
• oral antipruritic agents, a cool environment, frequent lubrication of the skin with water or a silicabased lotion, exercise and splinting to prevent skin contracture, and diversional activities.

Promoting Physical Mobility

• Prevent complications of immobility (atelectasis, pneumonia, edema, pressure ulcers, and contractures) by deep breathing, turning, and proper repositioning.
• Modify interventions to meet patient’s needs. Encourage early sitting and ambulation. When legs are involved, apply elastic pressure bandages before assisting patient to upright position.
• Make aggressive efforts to prevent contractures and hypertrophic scarring of the wound area after wound closure for a year or more.
• Initiate passive and active range-of-motion exercises from admission until after grafting, within prescribed limitations.
• Apply splints or functional devices to extremities for contracture control; monitor for signs of vascular insufficiency, nerve compression, and skin breakdown.

Strengthening Coping Strategies

• Assist patient to develop effective coping strategies: Set specific expectations for behavior, promote truthful communication to build trust, help patient practice coping strategies, and give positive reinforcement when appropriate.
• Demonstrate acceptance of patient. Enlist a noninvolved person for patient to vent feelings without fear of retaliation.
• Include patient in decisions regarding care. Encourage patient to assert individuality and preferences. Set realistic expectations for selfcare.

Supporting Patient and Family Processes

• Support and address the verbal and nonverbal concerns of the patient and family.
• Instruct family in ways to support patient.
• Make psychological or social work referrals as needed.
• Provide information about burn care and expected course of treatment.
• Initiate patient and family education during burn management. Assess and consider preferred learning styles; assess ability to grasp and cope with the information; determine barriers to learning when planning and executing teaching.
• Remain sensitive to the possibility of changing family dynamics.

Monitoring and Managing Potential Complications

• Heart failure: Assess for fluid overload, decreased cardiac output, oliguria, jugular vein distention, edema, or onset of S3 or S4 heart sounds.
• Pulmonary edema: Assess for increasing CVP, pulmonary artery and wedge pressures, and crackles; report promptly. Position comfortably with head elevated unless contraindicated. Administer medications and oxygen as prescribed and assess response.
• Sepsis: Assess for increased temperature, increased pulse, widened pulse pressure, and flushed, dry skin in unburned areas (early signs), and note trends in the data. Perform wound and blood cultures as prescribed. Give scheduled antibiotics on time.
• Acute respiratory failure and acute respiratory distress syndrome (ARDS): Monitor respiratory status for dyspnea, change in respiratory pattern, and onset of adventitious sounds. Assess for decrease in tidal volume and lung compliance in patients on mechanical ventilation. The hallmark of onset of ARDS is hypoxemia on 100% oxygen, decreased lung compliance, and significant shunting; notify physician of deteriorating respiratory status.
• Visceral damage (from electrical burns): Monitor electrocardiogram (ECG) and report dysrhythmias; pay attention to pain related to deep muscle ischemia and report. Early detection may minimize severity of this complication. Fasciotomies may be necessary to relieve swelling and ischemia in the muscles and fascia; monitor patient for excessive blood loss and hypovolemia after fasciotomy.

Nursing Process: Rehabilitation Phase

Rehabilitation should begin immediately after the burn has occurred. Wound healing, psychosocial support, and restoring maximum functional activity remain priorities. Maintaining fluid and electrolyte balance and improving nutrition status continue to be important.

• In early assessment, obtain information about patient’s educational level, occupation, leisure activities, cultural background, religion, and family interactions.
• Assess selfconcept, mental status, emotional response to the injury and hospitalization, level of intellectual functioning, previous hospitalizations, response to pain and pain relief measures, and sleep pattern.
• Perform ongoing assessments relative to rehabilitation goals, including range of motion of affected joints, functional abilities in ADLs, early signs of skin breakdown from splints or positioning devices, evidence of neuropathies (neurologic damage), activity tolerance, and quality or condition of healing skin.
• Document participation and selfcare abilities in ambulation, eating, wound cleaning, and applying pressure wraps.
• Maintain comprehensive and continuous assessment for early detection of complications, with specific assessments as needed for specific treatments, such as postoperative assessment of patient undergoing primary excision.

Nursing Diagnoses

• Activity intolerance related to pain on exercise, limited joint mobility, muscle wasting, and limited endurance
• Disturbed body image related to altered appearance and selfconcept
• Deficient knowledge of postdischarge home care and recovery needs

Collaborative Problems/Potential Complications

• Contractures
• Inadequate psychological adaptation to burn injury

• Goals include increased participation in ADLs; increased understanding of the injury, treatment, and planned followup care; adaptation and adjustment to alterations in body image, selfconcept, and lifestyle; and absence of complications.

Promoting Activity Tolerance

• Schedule care to allow periods of uninterrupted sleep. Administer hypnotic agents, as prescribed, to promote sleep.
• Communicate plan of care to family and other caregivers.
• Reduce metabolic stress by relieving pain, preventing chilling or fever, and promoting integrity of all body systems to help conserve energy. Monitor fatigue, pain, and fever to determine amount of activity to be encouraged daily.
• Incorporate physical therapy exercises to prevent muscular atrophy and maintain mobility required for daily activities.
• Support positive outlook, and increase tolerance for activity by scheduling diversion activities in periods of increasing duration.

Improving Body Image and Self-Concept

• Take time to listen to patient’s concerns and provide realistic support; refer patient to a support group to develop coping strategies to deal with losses.
• Assess patient’s psychosocial reactions; provide support and develop a plan to help the patient handle feelings.
• Promote a healthy body image and selfconcept by helping patient practice responses to people who stare or ask about the injury.
• Support patient through small gestures such as providing a birthday cake, combing patient’s hair before visitors, and sharing information on cosmetic resources to enhance appearance.
• Teach patient ways to direct attention away from a disfigured body to the self within.
• Coordinate communications of consultants, such as psychologists, social workers, vocational counselors, and teachers, during rehabilitation.

Monitoring and Managing Potential Complications

• Contractures: Provide early and aggressive physical and occupational therapy; support patient if surgery is needed to achieve full range of motion.
• Impaired psychological adaptation to the burn injury:
• Obtain psychological or psychiatric referral as soon as evidence of major coping problems appears.

Teaching Self-care

• Throughout the phases of burn care, make efforts to prepare patient and family for the care they will perform at home. Instruct them about measures and procedures.
• Provide verbal and written instructions about wound care, prevention of complications, pain management, and nutrition.
• Inform and review with patient specific exercises and use of elastic pressure garments and splints; provide written instructions.
• Teach patient and family to recognize abnormal signs and report them to the physician.
• Assist the patient and family in planning for the patient’s continued care by identifying and acquiring supplies and equipment that are needed at home.
• Encourage and support followup wound care.
• Refer patient with inadequate support system to home care resources for assistance with wound care and exercises.
• Evaluate patient status periodically for modification of home care instructions and/or planning for reconstructive surgery.

Evaluation

• Demonstrates activity tolerance required for desired daily activities
• Adapts to altered body image
• Demonstrates knowledge of required selfcare and followup care
• Exhibits no complications

Exam

MSN Exam for Burns (PM)*

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Question 1

During the acute phase of a burn, the nurse in-charge should assess which of the following?

A

Client’s lifestyle

B

Alcohol use

C

Tobacco use

D

Circulatory status

Question 1 Explanation: 

During the acute phase of a burn, the nurse should assess the client’s circulatory and respiratory status, vital signs, fluid intake and output, ability to move, bowel sounds, wounds, and mental status. Information about the client’s lifestyle and alcohol and tobacco use may be obtained later when the client’s condition has stabilized.

Question 2

When assessing a client with partial thickness burns over 60% of the body, which of the following should the nurse report immediately?  

A

Complaints of intense thirst

B

Moderate to severe pain

C

Urine output of 70 ml the 1st hour

D

Hoarseness of the voice

Question 2 Explanation: 

Hoarseness indicate injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client’s output is adequate.

Question 3

The burned client's family ask at what point the client will no longer be at increased risk for infection. What is the nurse’s best response?

A

“When fluid remobilization has started.”

B

“When the burn wounds are closed.”

C

“When IV fluids are discontinued.”

D

“When body weight is normal.”

Question 3 Explanation: 

Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at great risk for infection as long as any area of skin is open.

Question 4

Three days after a burn injury, the client develops a temperature of 100° F, white blood cell count of 15,000/mm3, and a white, foul-smelling discharge from the wound. The nurse recognizes that the client is most likely exhibiting symptoms of which condition?

A

Acute phase of the injury

B

Autodigestion of collagen

C

Granulation of burned tissue

D

Wound infection

Question 4 Explanation: 

Color change, purulent, foul-smelling drainage, increased white blood cell count, and fever could all indicate infection. These symptoms will not be seen in the acute phase of the injury. Autodigestion of collagen and granulation of tissue will not increase the body temperature or cause foul-smelling wound discharge.

Question 5

During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent?

A

Increased wound pain 30 to 40 minutes after drug application

B

Presence of small, pale pink bumps in the wound beds

C

Decreased white blood cell count

D

Increased serum creatinine level

Question 5 Explanation: 

Gentamicin does not stimulate pain in the wound. The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored.

Question 6

A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?

A

36%

B

9%

C

18%

D

27%

Question 7

The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized?

A

Full thickness

B

Partial-thickness deep

C

Partial-thickness superficial

D

Superficial

Question 7 Explanation: 

The characteristics of the wound 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).

Question 8

The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse’s best first action?

A

Administer oxygen.

B

Loosen the dressing.

C

Notify the emergency team.

D

Document the observation as the only action.

Question 8 Explanation: 

Respiratory difficulty can arise from external pressure. The first action in this situation would be to loosen the dressing and then reassess the client's respiratory status. DIF: Cognitive Level: Application or higher TOP: Nursing Process Step: Implementation/Intervention MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

Question 9

Following a full-thickness (third-degree) burn of his left arm, a male client is treated with artificial skin. The client understands postoperative care of artificial skin when he states that during the first 7 days after the procedure, he will restrict:

A

range of motion.

B

protein intake.

C

going outdoors.

D

fluid ingestion.

Question 9 Explanation: 

To prevent disruption of the artificial skin’s adherence to the wound bed, the client should restrict range of motion of the involved limb. Protein intake and fluid intake are important for healing and regeneration and shouldn’t be restricted. Going outdoors is acceptable as long as the left arm is protected from direct sunlight.

Question 10

A client with a solar burn of the chest, back, face, and arms is seen in urgent care. The nurse’s primary concern should be:  

A

fluid resuscitation

B

infection

C

body image

D

pain management

Question 10 Explanation: 

With a superficial partial thickness burn such as a solar burn (sunburn), the nurse’s main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has a lower priority than pain management.

Question 11

The family of a client who has been burned asks at what point the client will no longer be at greater risk for infection. What is the nurse’s best response?

A

“As soon as he finishes his antibiotic prescription.”

B

“As soon as his albumin level returns to normal.”

C

“When fluid remobilization has started.”

D

“When the burn wounds are closed.”

Question 11 Explanation: 

Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open.

Question 12

Which laboratory result, obtained on a client 24 hours post-burn injury, will the nurse report to the physician immediately?

A

Arterial pH, 7.32

B

Hematocrit, 52%

C

Serum potassium,7.5 mmol/L (mEq/L)

D

Serum sodium, 131 mmol/L (mEq/L)

Question 12 Explanation: 

The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in the potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal, but not to the same degree of severity, and would be expected in the emergent phase after a burn injury.

Question 13

A 30-year-old homemaker fell asleep while smoking a cigarette. She sustained severe burns of the face,neck, anterior chest, and both arms and hands. Using the rule of nines, which is the best estimate of total body-surface area burned?

A

18%

B

22%

C

31%

D

40%

Question 13 Explanation: 

Using the Rule of Nine in the estimation of total body surface burned, we allot the following: 9% – head; 9% – each upper extremity; 18%- front chest and abdomen; 18% – entire back; 18% – each lower extremity and 1% – perineum.

Question 14

The nurse should teach the community that a minor burn injury could be caused by what common occurrence?

A

Chimney sweeping every year

B

Cooking with a microwave oven

C

Use of sunscreen agents

D

Use of space heaters

Question 14 Explanation: 

Minor burns are common occurrences. The use of space heaters can cause a fire if clothing, bedding and other flammable objects are near them. Chimneys should be swept each year to prevent creosote build-up and resultant fire. Burn injuries do not commonly occur from microwave cooking, but rather when taking food from this oven. Lastly, sunscreen agents are recommended to prevent sunburn.

Question 15

The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired outcome of the procedure, which nursing action will be carried out first?

A

Applies silver sulfadiazine (Silvadene) ointment

B

Covers the area with an elastic wrap

C

Places a synthetic dressing over the area

D

Removes loose nonviable tissue

Question 15 Explanation: 

All steps are part of the nonsurgical wound care for clients with burn injuries. The first step in this process is removing exudates and necrotic tissue.

Question 16

Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery?

A

Changing gloves between wound care on different parts of the client's body.

B

Avoiding sharing equipment such as blood pressure cuffs between clients.

C

Using the closed method of burn wound management.

D

Using proper and consistent handwashing.

Question 16 Explanation: 

Autocontamination is the transfer of microorganisms from one area to another area of the same client’s body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on different parts of the client’s body can prevent autocontamination.

What is the rehabilitation phase of a burn?

What is the first priority with clients who have burns?

What is the nursing management of burns?

Which is a priority goal of nursing care for a client with a burn during the first 48 72 hours after skin grafting?