Chapter 57 Management of Patients With Burn Injury
1. When assessing a client with partial-thickness burns over 60% of the body, which
finding should the nurse report immediately?
Hoarseness of the voice
Hoarseness is indicative of 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 urine output is adequate.
2. All of the following are antimicrobials commonly used to treat burns except:
Tetracycline
Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution
are the three major antimicrobials used to treat burns.
3. Which is the primary reason for placing a client in a horizontal position while
smothering flames are present?
To keep fire and smoke from airway
The primary reason the client is placed in a horizontal position while smothering flames is to
prevent the fire, hot air, and smoke from rising toward the head and entering the
respiratory passages. Stop, drop, and roll method is a quick efficient means to distinguish
flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to
the head.
, 4. Which is the primary nursing intervention in the care of a client with burns exceeding
20% of total body surface area?
Fluid resuscitation
Fluid resuscitation requirements are paramount in the management of clients having burns
that exceed
20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the
time the burn injury occurred to restore the intravascular volume and prevent hypovolemic
shock and renal failure. Infection prevention is a care consideration with all burns.
Endotracheal tube placement may be necessary if respiratory factors indicate the need.
Intake and output records are maintained to determine the success of fluid resuscitation
efforts.
5. The spouse of a victim, who was struck by lightning, asks the nurse why the areas
involved seems so small but the damage is extensive. Which is the best explanation
from the nurse?
Electrical burns usually follow an internal path.
Electrical current follows the path of less resistance. Becausethe skin is the most resistant
organ, the current follows nerves, blood vessels, and muscles, causing organ damage along
the way. Lightning is high-voltage electricity. Presence of water acts as a conductor of
electrical current.
6. Which type of burn injury involves destruction of the epidermis and upper layers of
the dermis and injury to the deeper portions of the dermis?
,Deep partial-thickness
A deep partial-thickness burn involves destruction of the epidermis and upper layers of the
dermis and injury to deeper portions of the dermis. In a superficial partial-thickness burn,
the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary
refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total
destruction of epidermis and dermis and, in some cases, destruction of underlying tissue,
muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs
with prolonged flame contact or high voltage injury that destroys all layers of the skin and
damages tendons and muscles.
A patient is being cared for in a burn unit after suffering partial-thickness burns. The patient’s
laboratory work reveals a positive wound culture for gram-negative bacteria. The health
care provider orders silver sulfadiazine (Silvadene) to be applied to the patient’s burns. The
nurse provides information to the patient about the medication. Which of the following
statements made by the patient indicates an understanding about this treatment? Select
all that apply.
“This medication is an antibacterial.”
“This medication will be applied directly to the wound.” “This medication will help my burn
heal.”
This medication is an antibacterial, which has a broad spectrum of activity against gram-
negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to
the wound. This medication will not stain the patient’s skin, but it will help heal the patient’s
burned areas.
, During the acute phase of burn injury, the nurse knows to assess for signs of potassium
shifting during what time frame?
Beginning on day 4 or day 5
Beginning on the fourth or fifth post-burn day, potassium ions shift from the extracellular
fluid into cells, leading to a potassium deficit.
A patient will be receiving biologic dressings. The nurse understands that biologic dressings,
which use skin from living or recently deceased humans, are known by what name?
Homografts
Homografts (or allografts) and xenografts (or heterografts) are also referred to as biologic
dressings and are intended to be temporary wound coverage. Homografts are skin
obtained from recently deceased or living humans other than the patient. Xenografts
consist of skin taken from animals (usually pigs). An autograft uses the client’s own skin, which
is transplanted from one part of the body to another.
A child tips a pot of boiling water onto his bare legs. The mother should: Immerse the child's
legs in cool water.
1. When assessing a client with partial-thickness burns over 60% of the body, which
finding should the nurse report immediately?
Hoarseness of the voice
Hoarseness is indicative of 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 urine output is adequate.
2. All of the following are antimicrobials commonly used to treat burns except:
Tetracycline
Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution
are the three major antimicrobials used to treat burns.
3. Which is the primary reason for placing a client in a horizontal position while
smothering flames are present?
To keep fire and smoke from airway
The primary reason the client is placed in a horizontal position while smothering flames is to
prevent the fire, hot air, and smoke from rising toward the head and entering the
respiratory passages. Stop, drop, and roll method is a quick efficient means to distinguish
flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to
the head.
, 4. Which is the primary nursing intervention in the care of a client with burns exceeding
20% of total body surface area?
Fluid resuscitation
Fluid resuscitation requirements are paramount in the management of clients having burns
that exceed
20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the
time the burn injury occurred to restore the intravascular volume and prevent hypovolemic
shock and renal failure. Infection prevention is a care consideration with all burns.
Endotracheal tube placement may be necessary if respiratory factors indicate the need.
Intake and output records are maintained to determine the success of fluid resuscitation
efforts.
5. The spouse of a victim, who was struck by lightning, asks the nurse why the areas
involved seems so small but the damage is extensive. Which is the best explanation
from the nurse?
Electrical burns usually follow an internal path.
Electrical current follows the path of less resistance. Becausethe skin is the most resistant
organ, the current follows nerves, blood vessels, and muscles, causing organ damage along
the way. Lightning is high-voltage electricity. Presence of water acts as a conductor of
electrical current.
6. Which type of burn injury involves destruction of the epidermis and upper layers of
the dermis and injury to the deeper portions of the dermis?
,Deep partial-thickness
A deep partial-thickness burn involves destruction of the epidermis and upper layers of the
dermis and injury to deeper portions of the dermis. In a superficial partial-thickness burn,
the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary
refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total
destruction of epidermis and dermis and, in some cases, destruction of underlying tissue,
muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs
with prolonged flame contact or high voltage injury that destroys all layers of the skin and
damages tendons and muscles.
A patient is being cared for in a burn unit after suffering partial-thickness burns. The patient’s
laboratory work reveals a positive wound culture for gram-negative bacteria. The health
care provider orders silver sulfadiazine (Silvadene) to be applied to the patient’s burns. The
nurse provides information to the patient about the medication. Which of the following
statements made by the patient indicates an understanding about this treatment? Select
all that apply.
“This medication is an antibacterial.”
“This medication will be applied directly to the wound.” “This medication will help my burn
heal.”
This medication is an antibacterial, which has a broad spectrum of activity against gram-
negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to
the wound. This medication will not stain the patient’s skin, but it will help heal the patient’s
burned areas.
, During the acute phase of burn injury, the nurse knows to assess for signs of potassium
shifting during what time frame?
Beginning on day 4 or day 5
Beginning on the fourth or fifth post-burn day, potassium ions shift from the extracellular
fluid into cells, leading to a potassium deficit.
A patient will be receiving biologic dressings. The nurse understands that biologic dressings,
which use skin from living or recently deceased humans, are known by what name?
Homografts
Homografts (or allografts) and xenografts (or heterografts) are also referred to as biologic
dressings and are intended to be temporary wound coverage. Homografts are skin
obtained from recently deceased or living humans other than the patient. Xenografts
consist of skin taken from animals (usually pigs). An autograft uses the client’s own skin, which
is transplanted from one part of the body to another.
A child tips a pot of boiling water onto his bare legs. The mother should: Immerse the child's
legs in cool water.
