Chapter 55 Nursing Care of Patients with Burns

Answers CHAPTER 55 NURSING CARE OF PATIENTS WITH BURNS AUDIO CASE STUDY Peyton and Burns 1. Superficial partial-thickness burns are bright red to pink, blanch to touch, are moist and glistening, and have serum-filled blisters. Deep partial-thickness burns may be pink to light red to white with blisters. They are soft and pliable, and blanching is present. Full-thickness burns are snowy white, gray, or brown. The texture is firm, leathery, and inelastic. 2. Partial-thickness burns are the most painful, because the nerve endings are intact. Full-thickness burns cause nerve destruction and so are not painful. Most burns have a mixture of severity, so pain is nearly always present. 3. Following a major burn, increased capillary permeability leads to the leakage of plasma and proteins into the tissue, resulting in the formation of edema and the loss of intravascular volume. There is also water loss by evaporation through the burned tissue that can be 4 to 15 times the normal amount. Increased metabolism leads to further water loss through the respiratory system. Intake and output as well as daily weights help monitor fluid status. 4. Burns raise the metabolic rate and require extra calories. The goals of nutritional support in burned patients are to (1) meet metabolic needs, (2) promote wound healing, (3) promote resistance to infection, and (4) reduce protein loss (severely burned patients can lose nearly one-half pound of skeletal muscle per day). VOCABULARY 1. (6) 2. (4) 3. (3) 4. (1) 5. (5) 6. (2) CRITICAL THINKING 1. The most likely cause of this change is the effect the electrical current had on the bones in the forearm. Remember that the bones offer the most resistance to electrical injury. This type of burn can develop worsening symptoms from the inside out. Mr. Patel is experiencing ischemia. His burn needs to be reevaluated by the health care provider (HCP). 2. Do further examination: Check his left arm, and use it as a basis for comparison for changes in the right. Check the size of the discoloration. Measure the circumference of the right forearm. Check his right brachial pulse. Also, recheck his right leg and foot for assessment changes. 3. Elevate his right arm, and make sure that the dressing is not binding. Contact the registered nurse or HCP immediately. An escharotomy may be necessary to relieve pressure. Further debridement may be necessary. REVIEW QUESTIONS—CONTENT REVIEW The correct answers are in boldface. 1. (2) is correct. A burn caused by a flame, as in a house fire, is most often associated with an inhalation injury. (1) is incorrect. An electrical burn is one of the most serious types of burn injury and can result in loss of limbs and internal injuries. (3) is incorrect. A scald is a burn from a hot liquid and is common in children under age 5 and people over age 65. (4) is incorrect. A contact burn results from contact with hot tar, hot metals, or hot grease; it produces a full-thickness injury on contact. 2. (3) is correct. Hot liquids cause a scald burn. (1) is incorrect. Radiation burns are caused by ultraviolet light or radiation therapy. (2) is incorrect. Contact burns are caused by hot tar, hot metals, or hot grease. (4) is incorrect. Chemical burns are caused by contact with chemicals, usually industrial. 1 2 Chapter 55 Answers REVIEW QUESTIONS—TEST PREPARATION The correct answers are in boldface. 3. (4) is correct. Stage 3 is rehabilitation, and exercises will be used to return the patient to optimum function. (1, 2, 3) are more appropriate for stages 1 and 2. 4. (3) is correct. Inhalation injury is a priority concern in a home fire. (1, 2, 4) are important once respiratory status is stabilized. 5. (2) is correct. Clothing must be removed because it can hold heat in and continue the burning process. (1, 4) are appropriate after clothing has been removed and the burning process stopped. (3) is incorrect. Ice is not appropriate and may cause additional tissue damage. 6. (1) is correct. Circulation is a concern with any burn, but especially with a circumferential burn. (2) is incorrect. Numbness and tingling are signs of circulatory impairment and are not normal. (3, 4) may be appropriate, but circulation is the first priority. 7. 100 mL 1 hour 1 hour 15 gtt 60 minutes 1 mL = 25 gtt per minute 8. (1) is correct. Acute renal insufficiency can occur as a result of hypovolemia and decreased cardiac output. Decreased urine output should be reported. (2) is incorrect. The licensed practical nurse/licensed vocational nurse can administer oral narcotics. (3) is incorrect. Respiratory rate is within normal limits; oxygenation is acceptable. (4) is incorrect. Metabolic demands are very high in patients with burns, and hyperglycemia is seen due to hypermetabolism; however, decreased urinary output is a higher priority. 9. (2) is correct. In the first 48 hours after a burn, fluid shifts lead to hypovolemia and, if untreated, hypovolemic shock; this blood pressure is alarmingly low and should be reported. (1) is incorrect. Loss of intravascular fluid causes an increase in hematocrit; this reading is still within normal limits. (3) is incorrect. Tachycardia may be related to fluid loss, hypermetabolism, or other hematologic changes; this pulse rate is not critical. (4) is incorrect. Hyperventilation as well as increased oxygen consumption due to hypermetabolism, fear, anxiety, or pain may occur; this respiratory rate is not critical.