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Burns
| Question | Answer |
|---|---|
| Fluid resuscitation in client being treated for burns. Which one would indicate the success of the fluid resuscitation? -heart rate is rapid -urinary output is 0.5 mL/kg/hour -breathing is unlabored and skin is clammy -client is conscious | urinary output is 0.5 mL/kg/hour (Successful fluid resuscitation is gauged by a urinary output of 0.5 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.) |
| The nurse in the ER receives a patient who sustained a severe burn injury. What is the priority action by the nurse in this situation? -establish a patent airway -insert an indwelling catheter -replace fluids -administer pain medication | establish a patent airway (Nursing assessment in the emergent phase of burn injury focuses on the major priorities for any trauma patient; the burn wound is a secondary consideration to stabilization of airway, breathing, and circulation.) |
| Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: -hyperkalemia -hypernatremia -hypocalcemia -hypoglycemia | hyperkalemia (Hyperkalemia results from massive cell destruction. Hypokalemia may occur later with fluid shifts and inadequate potassium replacement.) |
| A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? | 27% (The TBSA would be 27%. 18% for the anterior trunk and 9% for the left arm.) |
| Specific potential complications are common to specific types of burns. Which burns can impair ventilation? -face, neck, chest -perineal -hands, major joints -all options are correct | face, neck, chest (Burns of the face, neck, or chest have the potential to impair ventilation.) |
| Monitoring fluid resuscitation in client treated for burns. Which one would indicate success of fluid resuscitation? -HR rapid and regular -urinary output is 0.3 to 0.5 mL/kg/hour -breathing is unlabored, skin is clammy -client is alert and conscious | urinary output is 0.3 to 0.5 mL/kg/hour (Successful fluid resuscitation is gauged by a urinary output of 0.3 to 0.5 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client’s heart rate, breathing, or mental status.) |
| Which of the following is a true statement regarding the purposes of skin grafts? -increases evaporative fluid loss -increases potential for infection -reduces scarring and contractures -prolongs recovery | reduces scarring and contractures |
| classification of burn? Tx: eschar may slough, grafting necessary, scarring and loss of contour and function | third degree (full thickness) |
| classification of burn? causes: prolonged exposure or high voltage electrical injury; skin involvement: deep tissue, muscle and bone | fourth degree (full thickness that includes fat, fascia, muscle, and/or bone) |
| classification of burn? S/Sx: shock, myoglobinuria (red pigment in urine) and possible hemolysis (blood cell destruction) | fourth degree (full thickness that includes fat, fascia, muscle, and/or bone) |
| classification of burn? wound appearance: charred | fourth degree (full thickness that includes fat, fascia, muscle, and/or bone) |
| classification of burn? amputations likely; grafting of no benefit, given depth and severity of wound(s) | fourth degree (full thickness that includes fat, fascia, muscle, and/or bone) |
| most common method used to estimate the extent of burns in adults | rule of nines |
| type of burn? superficial injuries present themselves as contact points on physical exam; deep tissue injuries may not be visible initially but in most circumstances should be assumed on presentation so that timely intervention may be initiated | electrical burns |
| type of burn? may see airway affected (inhalation injury), burns to face (soot around face, mouth); stridor, hoarse/raspy voice, singed nasal hairs | thermal burns |
| type of burn? cancer treatment, prolonged environmental exposure, tanning beds (UV lights) | radiation burns |
| BIG thing to remember for frostbite! | controlled rewarming |
| classification of burn? causes: sunburn, low-intensity flash, superficial scald | first degree burn (superficial) |
| skin involvement with first degree burn (superficial)? | epidermis |
| classification of burn? Tx: complete recovery within a few days, oral pain meds, cool compresses, skin lubricants (e.g., ointments, emollients); topical antimicrobial agents not indicated | first degree (superficial) |
| classification of burn? causes: scalds, flash flame, contact; skin involvement: epidermis, portion of dermis | second degree (partial thickness) |
| classification of burn? Tx: cool water, meds (silvadene, medihoney), vaseline drsg, non-stick drsg; may require grafting | second degree (partial thickness) |
| classification of burn? causes: flame, prolonged exposure to hot liquids, electric current, chemical, contact; skin involvement: epidermis, dermis, and sometimes SQ tissue----may involve connective tissue, and muscle | third degree (full thickness) |
| classification of burn? Tx: eschar may slough, grafting necessary, scarring and loss of contour and function; wet-to-dry drsg, wound vac, escharotomy, debridement | third degree (full thickness) |
| degree of burn? full thickness that includes fat, fascia, muscle, and/or bone | fourth degree |
| what do you immediately do for chemical burns? | flush skin with running water unless the chemical is a powder (ie lye, white phosphorus); powder should be brushed off skin |
| fluid resuscitation formula for thermal or chemical burn | 2mL LR x kg x TBSA (always round up!) |
| fluid resuscitation formula for electrical burn | 4mL LR x kg x TBSA (always round up!) |
| fluid resuscitation...pt should receive total amount of fluid within what time frame? first half of fluids should be given within first __ hours? | 24-hours; 8 |
| emergent phase time frame? | 24-48 hours |
| phase of burn injury? hyperkalemia, increased H&H, check ABGs, decreased urine output, decreased GI motility (can lead to bowel obstruction, ileus) | emergent phase |
| If no GI issues...give tube feeding or TPN? | tube feeding (keep GI tract moving) |
| phase of burn injury? 48-72 hours after injury; at risk for hypokalemia, fluid overload, hemodilution | acute (or intermediate) phase |
| phase of burn injury? focus is on wound healing, psychosocial support, self-image, lifestyle, and restoring maximal functional abilities so the patient can have the best quality life, both personally and socially | rehabilitation |
| T or F? Breathing must be assessed and patent airway established immediately during the initial minutes of emergency burn care. | true |
| Formulas are only a guide for burn care fluid resuscitation. How often must the patient’ s response to fluid therapy (heart rate, blood pressure, and urine output) be evaluated? -Every hour -Every 2 hours -Every 3 hours -Every 4 hours | every hour |
| two age groups that have increased morbidity and mortality from burn injuries? | young children, older adults |
| burns that exceed ___ of TBSA are considered major burn injuries and produce both a local and a systemic inflammatory response | 1/3 |
| _______ is the immediate consequence of ensuing fluid loss and results in decreased perfusion and oxygen delivery | hypovolemia |
| two pulmonary complications that occur secondary to inhalation injuries | acute resp. failure and ARDS |
| PU: Full-thickness burns to anterior chest. The leathery skin is tight, making it difficult to breathe. Tx management? -ETT insertion -tracheostomy -escharotomy -ventilator assisted breathing | escharotomy |
| PU: Significant electrical burns from workplace accident. What occurrence makes it difficult to assess internal burn damage in electrical burns? -deep tissue cooling -cont'ing inflammatory process -protein cell coagulation -all options are correct | deep tissue cooling (b/c deep tissues cool more slowly than those at the surface, it is difficult initially to determine extent of internal damage) |
| PU: Which client(s) would be a candidate for TPN? Select all that apply. -child w/short bowel syndrome -young adult with gastroenteritis -middle-aged man w/acute pancreatitis -woman w/superficial burns -man w/two-thirds of his colon removed | -child w/short bowel syndrome -middle-aged man w/acute pancreatitis -man w/two-thirds of his colon removed |
| PU: Client burned in house fire. Burns cover face and left forearm. Extent of burns does client most likely have, measured as a percentage? | 18% (face is 9% and forearm 9%) |
| PU: Home health client recovering following a long course of in-pt Tx for burn injuries. Nurse action? -assess for S/Sx of electrolyte imbalances -give fluids as prescribed -assess for risk for injury recurrence -assess client's psychosocial state | assess client's psychosocial state (recovery can be psychologically challenging) |
| PU: Older adult pt lives alone, serum albumin level 2.50 g/dL. What does this level indicate? -a severe protein deficiency -low levels of serum protein -an acceptable amount of protein -an extremely high measurement of protein | a severe protein deficiency (normal level ~3.5-5.5) |
| PU: Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation? -myoglobin in urine -increase in antidiuretic hormone -elevation of BG levels -hypernatremia | myoglobin in urine (myoglobin from muscle tissue destruction is transported to kidneys for excretion and can cause tubular necrosis and acute renal failure) |
| PU: Factory worker sustained flash burn to Rt arm. Flames extinguished. Next step is "cool the burn". How? -ice to site of burn for 5-10 mins -wrap affected extremity in ice -oil-based substance to burn -wrap cool towels around area intermittently | wrap cool towels around area intermittently |
| PU: Which type of debridement involves use of surgical scissors, scalpels, and forceps to separate and remove eschar? -mechanical -surgical -natural -chemical | mechanical |
| PU: Potential cause of superficial partial-thickness burn? -sunburn -scald -flash flame -electrical current | sunburn |
| PU: Chemical burn to arms from white phosphorus. Priority action? -douse area w/large amounts of water -brush off all traces of chemical from skin -covering burned area to prevent further spread -apply ice to burned area | brush off all traces of chemical from skin |
| PU: Planning care for a pt w/a major thermal burn. What urinary output indicates optimal fluid replacement? -10ml/hr -30ml/hr -80ml/hr -100ml/hr | 30ml/hr (30-50 ml/hr ideal) |
| rule of nines: what percentage(s) with what areas of body? | -head 9% -anterior 18% -posterior 18% -each arm 9% -each leg 18% -peri area 1% |
| ***Who is a GENIUS when it comes to knowing burns?*** | You are, superstar!!! |
Created by:
nurse savage
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