Ch. 32: Burns Part 2

Question 1

What are 5 steps for nursing actions of wound care?

Answer 1

1. Pre-medicate as prescribed
2. Remove previous dressings
3. Assess for odors, draining, or discharge
4. Cleanse wound as prescribed
5. Assist with debridement

Question 2

What medication may we give to pre-medicate?

Answer 2

1. Analgesics

2. Hydroxyzine or diphenhydramine for pruritis

Question 3

In assist with debridement, what needs to be done?

Answer 3

Provide hydrotherapy to cleanse the wound–use once or twice a day for up to 20 min

• use mild soap/detergent to gently wash burns, then rinse with room temp water
• encourage active ROM during hydrotherapy
• Monitor for cold stress and hypothermia

Question 4

What are the 3 types of biological skin coverings?

Answer 4

Allograft
Xenograft
Synthetic skin coverings

Question 5

Biological skin coverings may be used to promote healing of _____. What does it require?

Answer 5

Large burns; requires repeated surgical application

Question 6

Biological: skin from human cadavers that is used for partial and full thickness burn wounds

Answer 6

Allograft

Question 7

Biological: Obtained from animals, such as pigs, for partial thickness burn wounds

Answer 7

Xenograft

Question 8

Biological: Used for partial thickness burn wounds

Answer 8

Synthetic skin covering

Question 9

Permanent skin coverings may be the treatment of choice for burns covering _______

Answer 9

Large areas of the body

Question 10

What are the 2 types of permanent skin coverings?

Answer 10

Autograft (3 types of autografts)

Artificial skin

Question 11

What is an autograft?

Answer 11

Clients skin

Question 12

Permeant skin covering: What are the 3 types of autografts?

Answer 12

Sheet graft
Mesh graft
Cultured epithelium

Question 13

Permanent skin covering-Autografts

Sheet of skin used to cover the wound

Answer 13

Sheet graft

Question 14

Permanent skin covering-Autograft

Sheet of skin placed in a mesher so skin graft has small slits in it; allows grafts to cover larger areas of burn wound

Answer 14

Mesh graft

Question 15

Permanent skin covering-Autograft

Epithelial cells cultured for use when grafting sites are limited

Answer 15

Cultured epithelium

Question 16

Permanent skin covering:Synthetic product that is used for partial and full thickness burn wounds. Healing slower or faster?

Answer 16

Artificial skin; healing is faster

Question 17

Skin coverings: Should graft site be movable?

Answer 17

No, maintain immobilization of the graft site

Question 18

Skin coverings: Should we elevate extremity or let it relax in normal body alignment?

Answer 18

Elevate it

Question 19

What are some signs of infection to a skin graft?

Answer 19

• Discoloration of unburned skin surrounding burn wound
• Green color to SQ fat
• Degeneration of granulation tissue
• Development of subeschar hemorrhage
• Hyperventilation
• Unstable body temp

Question 20

What should we instruct the client about their skin covering?

Answer 20

Keep extremity ELEVATED

Report signs of infection

Question 21

Complications: Inhalation injury- Direct thermal injury

Occurs with burns to ____.
Can be delayed ____ hrs.
Findings?
Nursing actions?

Answer 21

Face and lips
24-48 hours

Wheezing, increased secretions, hoarseness, wet crackles in lungs, singed nasal hairs, laryngeal edema, carbonaceous secretion

Maintain airway and ventilation; proved 100% o2 if prescribed

Question 22

Complications: Inhalation injury-Carbon monoxide injury

Occurs?
Findings?
Nursing actions?

Answer 22

Incident took place in an enclosed area

Findings: Mucosal erythema and edema, followed by sloughing of the mucosa

Maintain airway and ventilation; provide 100% o2 if prescribed

Question 23

Complications: Shock/systemic sepsis

What do we administer?
What do we monitor?
What do we assess?

Answer 23

Administer: IV crystalloid solutions for first 24 hours, followed by colloid solutions

Monitor: I&O, Labs, VS

Assess: Sensorium confusion; Cap refil

Question 24

Complications: Pulmonary problems

How do maintain airway?
Adminster?

Answer 24

Maintain airway via intubation, sometimes tracheostomy

Administer oxygen as prescried

Question 25

Complications: Wound infection

Assess for?
Obtain?
Administer?
Monitor?
What type of technique when changing dressings?

Answer 25

Assess: discoloration, edema, odor, drainage, flucutations in temp and HR

Obtain: CULTURE

Administer: Antibiotics as prescribed

Monitor: Labs

Technique: SURGICAL ASEPTIC

Question 26

A nurse is caring for a client who has a superficial partial thickness burn. Which of the following is an appropriate action for the nurse to take?
A. Administer IV of 0.9% sodium chloride
B. Apply cool, wet compresses to affected area
C. Clean affected area using a soft-bristle brush
D. Administer morphine sulfate

Answer 26

B

Question 27

A nurse is caring for a client who has major burns and suspected septic shock. Which of the following findings are consistent with septic shock? (select all that apply)
A. Increased body temp
B. Altered sensorium
C. Decreased cap refill 
D. Decreased urine output
E. Increased bowel sounds

Answer 27

A, B, D

Question 28

A nurse is caring for a client who has a major burn and is experiencing severe pain. Which of the following is an appropriate nursing intervention to manage this client's pain?
A. Morphine sulfate IV continuous
B. Meperidine IM as needed
C. Acetaminophen PO every 4 hours
D. Hydrocodone PO every 6 hours

Answer 28

A

Question 29

A nurse is caring for a client who has a skin graft. Which of the following clinical manifestations indicate infection? (select all that apply)
A. Green color to SQ fat
B. Unstable body temp
C. Generation of granulation tissue
D. Subeschar hemorrhage
E. Change in skin color around affected area

Answer 29

A. B, D, E

Question 30

A nurse is caring for a client who has a moderate burn. Which of the following is an appropriate action for the nurse to take?
A. Maintain immobilization of the affected area
B. Expose affected area to air
C.Initiate high-protein, high-calorie diet
D. Implement contact isolation

Answer 30

C