MSN Exam for Burn Management and Care 3

EXPLANATION

✔Correct answer:

“I’ll be fully recovered when I’ve reached the highest level of functioning that I’m capable of achieving.” This statement reflects a correct understanding of the primary goal of burn rehabilitation: to help the patient achieve their maximum functional and psychological recovery following a burn injury. The rehabilitation phase begins once the wounds are largely healed and focuses on helping the patient regain independence, mobility, and coping strategies to adapt to any long-term physical or emotional challenges. Full recovery does not always mean returning to a pre-injury state but rather optimizing the patient's quality of life and functional abilities within their new circumstances.

Burn rehabilitation often involves physical therapy to restore range of motion and strength, occupational therapy to support daily activities, emotional support to cope with body image changes, and sometimes vocational training to return to work. The process is patient-centered, recognizing that "full recovery" is individualized and based on each patient’s capacity and goals.

Imagine recovery after a burn as learning to play a new tune on a piano that has a few broken keys. You may not be able to play the original song perfectly, but with practice and adaptation, you can still create beautiful music in a different way.

Nurses play a critical role in educating and supporting burn patients during their rehabilitation journey.

• Educate the patient about the importance of physical therapy to prevent contractures and maintain mobility.
• Encourage participation in occupational therapy to regain skills for daily living and work-related tasks.
• Provide emotional support and connect the patient with resources for addressing psychosocial concerns, such as support groups for burn survivors.
• Teach the patient about proper skin care to manage scarring, including the use of pressure garments and moisturizers.
• Help the patient set realistic, achievable goals for recovery, emphasizing progress over perfection.

✘Incorrect answer options:

“I will never completely recover from this burn injury.” While burn injuries can lead to long-term physical and emotional challenges, this statement reflects pessimism and does not align with the goals of burn rehabilitation, which aim to maximize recovery and functionality. Nurses should help the patient develop a positive outlook and focus on achievable goals.

“I’ll be considered fully recovered once all of my wounds have closed.” Wound closure is an important milestone but is only the beginning of the rehabilitation process. Recovery also involves addressing mobility, scarring, psychosocial issues, and reintegration into daily life. Wound closure alone does not signify complete recovery.

“My recovery will be complete when I can do everything I did before I was injured.” While some patients may return to their pre-injury level of functioning, this is not always realistic, especially in cases of severe burns with permanent physical or emotional impacts. Recovery is focused on helping the patient achieve their personal best rather than an idealized or pre-injury state.

EXPLANATION

✔Correct answer:

Assisting the patient to rest in a position of maximal comfort. While comfort is important for a patient’s recovery, resting in a position of maximal comfort is the least effective strategy for preventing contractures. In burn patients, the "position of comfort" typically involves flexion of joints and muscle groups, which promotes the development of contractures. Contractures are permanent tightening of the skin, muscles, tendons, and other tissues, limiting joint mobility and function. To prevent contractures, patients should instead be positioned in a functional alignment that stretches the affected areas, even if it is initially uncomfortable.

For example, in burns involving the upper torso, functional positioning might include maintaining the shoulders in abduction, elbows extended, and the neck in a neutral or slightly extended position. These positions counteract the natural tendency of burned tissues to contract and scar into a flexed position.

Imagine a rubber band left unused in a coiled position—it tightens and becomes stuck. To keep the rubber band functional, it needs to be stretched periodically. Similarly, burned tissues need to be stretched and aligned to prevent stiffening and shortening.

Nurses play a key role in positioning, therapy, and educating patients about the importance of contracture prevention.

• Encourage range-of-motion (ROM) exercises and physical therapy to maintain joint flexibility and prevent contracture formation.
• Position the patient to prevent flexion contractures, even if this is less comfortable, such as avoiding pillows under the head to maintain neck extension.
• Use splints or other devices as prescribed to maintain proper alignment of affected areas.
• Incorporate functional activities (e.g., chewing gum, blowing up balloons) that maintain oral and respiratory muscle mobility for burns near the face or neck.
• Educate the patient and caregivers on the importance of consistent positioning and stretching to improve long-term outcomes.

✘Incorrect answer options:

Regularly changing the position of the bed or the television, or both. This intervention is aimed at encouraging the patient to change their body position frequently, which helps to prevent stiffness and contractures. For example, placing the television in a position that encourages neck movement can help maintain flexibility. This is an effective strategy for contracture prevention.

Encouraging the patient to engage in activities such as chewing gum and blowing up balloons. For burns involving the neck or facial area, these activities are beneficial in maintaining oral and facial muscle mobility, preventing tightening of the skin and muscles, and promoting lung expansion. This is an effective strategy.

Discouraging the use of pillows during sleep or positioning the head in hyperextension. Avoiding pillows under the head helps to maintain neck extension, which is especially important for preventing contractures in patients with burns to the neck or upper chest. Proper positioning of the neck and shoulders is critical for contracture prevention, making this an effective intervention.

EXPLANATION

✔Correct answer:

Changing gloves between wound care procedures on different areas of the patient’s body. Autocontamination occurs when microorganisms from one area of a patient’s body are transferred to another area, often through improper handling during wound care or other procedures. In burn patients, large areas of damaged skin serve as portals of entry for pathogens, and strict infection control practices are critical to minimize this risk. The most essential intervention to prevent autocontamination is changing gloves between wound care procedures on different areas of the patient’s body. This practice prevents the transfer of bacteria from colonized or infected wounds to non-infected or cleaner areas.

For example, if a nurse performs wound care on an area of the patient that is heavily colonized or infected and then touches another, less-affected area without changing gloves, this facilitates autocontamination. By ensuring glove changes and adherence to aseptic techniques, the nurse reduces the risk of spreading harmful microorganisms across different parts of the patient’s body.

Think of wound care like working with different paints on a canvas. If you use the same brush without cleaning it between colors, the colors mix and contaminate each other. Changing gloves between wound sites is like using a clean brush each time, keeping everything separate and clean.

To prevent infection through autocontamination, nurses must implement consistent and thorough infection control measures.

• Change gloves and other personal protective equipment (PPE) when moving between different wound sites on the same patient.
• Use aseptic techniques when performing wound care, including cleaning wounds with appropriate solutions and using sterile dressings.
• Inspect wounds regularly for signs of infection, such as redness, swelling, increased exudate, or foul odor.
• Educate the patient and family about the importance of not touching or scratching wounds, which can also spread bacteria.
• Ensure the patient’s environment remains clean and free of potential contaminants.

✘Incorrect answer options:

Avoiding the sharing of equipment, such as blood pressure cuffs, between different patients. This measure prevents cross-contamination between patients, not autocontamination. While important for overall infection control, it is not specific to preventing the spread of infection between different areas on the same patient.

Employing the closed method of burn wound management. The closed method involves covering burn wounds with dressings, which can help protect wounds and reduce the risk of infection. However, this strategy alone does not address the risk of autocontamination, as improper glove use or aseptic technique can still lead to contamination.

Practicing thorough and consistent hand hygiene. Hand hygiene is critical for preventing both cross-contamination and autocontamination, but it is a general measure. While hand hygiene is foundational, changing gloves between wound care procedures is the most specific and direct intervention for preventing autocontamination during wound care.

EXPLANATION

✔Correct answer:

Crystalloid solutions. During the emergent phase of burn care (the first 24-48 hours post-burn), crystalloid solutions, such as Lactated Ringer's (LR), are the fluid of choice for initial resuscitation. Crystalloid solutions are used because they effectively restore intravascular volume, replace fluid lost due to capillary leak, and maintain adequate perfusion of vital organs. Lactated Ringer's is particularly preferred because it closely mimics the electrolyte composition of plasma and helps buffer metabolic acidosis, a common issue in burn patients.

Significant burns cause increased capillary permeability, leading to a massive fluid shift from the intravascular space into the interstitial space. This results in hypovolemia, decreased perfusion, and a risk for burn shock. Fluid resuscitation during the emergent phase is critical to maintain circulation and prevent shock. Crystalloids are isotonic solutions that expand the intravascular space, helping to restore circulating volume until the capillary leak resolves.

Imagine a leaking garden hose that needs water to keep flowing. Adding a clear, lightweight liquid (like crystalloid solution) is practical and effective to maintain flow, as it moves easily through the hose and replenishes what's leaking out.

Administering the correct fluid volume is essential to prevent complications such as overhydration or inadequate perfusion.

• Use the Parkland formula to calculate fluid requirements: 4 mL × body weight in kg × % total body surface area (TBSA) burned.
• Administer half of the calculated volume in the first 8 hours, with the remaining half given over the next 16 hours.
• Monitor urine output as a key indicator of effective resuscitation (goal: 30-50 mL/hour in adults).
• Assess for signs of fluid overload (e.g., pulmonary edema) and hypovolemia (e.g., tachycardia, hypotension).
• Monitor electrolyte levels, as sodium and potassium imbalances are common during the emergent phase.

✘Incorrect answer options:

Colloid solutions. Colloid solutions (e.g., albumin) are not typically used during the emergent phase of burn care. These solutions are more expensive and may worsen edema because they draw additional fluid into the already-compromised interstitial space due to capillary leak. Colloids are generally reserved for the later phases of burn care, once capillary permeability stabilizes (e.g., after 24-48 hours).

Fresh frozen plasma (FFP). FFP is used to replace clotting factors in patients with coagulation disorders but is not indicated for initial fluid resuscitation in burn patients. While burn injuries can cause coagulation abnormalities, addressing fluid resuscitation to prevent hypovolemic shock takes priority in the emergent phase.

Packed red blood cells (PRBCs). PRBCs are used to treat anemia or hemorrhagic shock but are not indicated in the immediate resuscitation of burn patients unless there is significant blood loss, which is uncommon in burns. Burn injuries typically involve fluid and plasma loss rather than whole blood loss.

EXPLANATION

✔Correct answer:

Superficial partial-thickness burn. The described burn injury—characterized by pink coloration, blisters, and extreme pain—is most consistent with a superficial partial-thickness burn. This type of burn affects the epidermis and the upper portion of the dermis (the papillary layer). The blisters form due to fluid accumulation between the epidermis and dermis, and the exposed nerve endings in the dermis make these burns extremely painful.

Superficial partial-thickness burns typically heal within 10-14 days with minimal to no scarring if proper care is provided. The pink color indicates good blood supply to the dermis, which promotes healing. These burns are often caused by scalds, brief contact with hot objects, or sunburns.

Think of the skin like a two-layer cake with frosting. A superficial partial-thickness burn damages the frosting (epidermis) and lightly scrapes the top layer of the cake (upper dermis), causing fluid (blisters) to form. The exposed cake layer (dermis) makes the burn very tender to touch (pain).

Management focuses on promoting healing, preventing infection, and relieving pain.

• Clean the wound gently with sterile solutions to remove debris and prevent infection.
• Apply topical antimicrobial agents, such as silver sulfadiazine, as prescribed to reduce the risk of infection.
• Cover the burn with a sterile, non-adherent dressing to protect the area and promote healing.
• Administer analgesics to manage pain and discomfort.
• Educate the patient on proper wound care and the importance of avoiding blister rupture to reduce infection risk.

✘Incorrect answer options:

Superficial burn. Superficial burns (first-degree burns) affect only the epidermis. They are characterized by redness (erythema), mild swelling, and pain, but do not exhibit blisters. An example is a mild sunburn. The presence of blisters in this case rules out a superficial burn.

Deep partial-thickness burn. Deep partial-thickness burns extend deeper into the dermis (involving the reticular layer) and are typically more red or white in color, with a mottled appearance. These burns are often less painful than superficial partial-thickness burns because more nerve endings are destroyed. The description of extreme pain and pink coloration suggests the burn does not reach this depth.

Full-thickness burn. Full-thickness burns (third-degree burns) involve the complete destruction of the epidermis, dermis, and sometimes underlying structures such as fat, muscle, or bone. These burns are typically painless due to destruction of nerve endings and appear white, leathery, or charred. The pink color, presence of blisters, and extreme pain indicate that this burn is not full-thickness.

EXPLANATION

✔Correct answer:

Heart rate and rhythm. Electrical injuries pose a significant risk to the cardiovascular system, as the electrical current can disrupt the heart’s conduction pathways. This can result in dysrhythmias, including ventricular fibrillation, asystole, or other life-threatening arrhythmias. The priority assessment is to monitor heart rate and rhythm closely to identify and manage any abnormalities that may arise. Electrical currents can also lead to delayed cardiac complications, making continuous monitoring essential.

When an electrical current passes through the body, it can travel along the path of least resistance, often through the cardiovascular and nervous systems. Electrical injuries can depolarize cardiac cells, interfering with the normal conduction system. Even if the patient initially appears stable, delayed arrhythmias may occur, especially within the first 24-48 hours. Thus, heart rate and rhythm must be monitored as a priority to detect and treat any arrhythmias promptly.

Imagine the heart as an electrical circuit. When struck by an electrical surge, the circuit (the heart’s conduction system) can become disrupted, causing irregular or complete loss of function. Monitoring the circuit’s performance (heart rate and rhythm) ensures that any issues are quickly identified and repaired.

Assessing and monitoring the cardiovascular system is critical to prevent or manage complications associated with electrical injuries.

• Connect the patient to continuous cardiac monitoring to detect arrhythmias such as ventricular fibrillation, atrial fibrillation, or heart block.
• Obtain a 12-lead electrocardiogram (ECG) as soon as possible to evaluate baseline cardiac function and any acute changes.
• Monitor for signs of myocardial damage, such as chest pain, hypotension, or ST-segment changes on the ECG.
• Assess for other systemic signs of electrical injury, including peripheral pulses, as electrical currents can cause vascular damage and compartment syndrome.
• Prepare for advanced cardiac life support (ACLS) interventions if life-threatening arrhythmias develop.

✘Incorrect answer options:

Current range of motion in all extremities. While range-of-motion assessments are important in electrical injuries to identify musculoskeletal damage (e.g., fractures caused by intense muscle contractions), they are not the priority. The cardiovascular system is the most immediately at risk in electrical injuries, so assessing heart rate and rhythm is more critical.

Respiratory rate and pulse oximetry reading. Assessing respiratory status is important, particularly if the electrical injury involves the chest or respiratory muscles. However, electrical injuries more commonly affect the cardiovascular system, and disruptions to the heart's rhythm can result in respiratory compromise secondarily. Monitoring heart rate and rhythm is therefore the priority.

Orientation to time, place, and person. Neurological assessment is relevant in electrical injuries because of the potential for central nervous system damage (e.g., seizures, altered mental status). However, in the acute phase, cardiac monitoring takes precedence, as arrhythmias are more immediately life-threatening than neurological changes.

EXPLANATION

✔Correct answer:

Frequent monitoring of fluid and electrolyte balance. Total parenteral nutrition (TPN) is a form of intravenous nutritional support that bypasses the gastrointestinal system and delivers nutrients directly into the bloodstream. Because TPN solutions are highly concentrated and contain glucose, electrolytes, and other nutrients, they can significantly alter a patient’s fluid and electrolyte balance. Monitoring is critical to prevent complications such as hyperglycemia, hypoglycemia, fluid overload, electrolyte imbalances (e.g., hyperkalemia or hypokalemia, hypernatremia or hyponatremia), and metabolic abnormalities.

Key assessments for fluid and electrolyte balance include:

• Daily weights: Rapid weight changes may indicate fluid retention or dehydration.
• Serum electrolyte levels: Imbalances in potassium, sodium, calcium, magnesium, or phosphate are common in patients receiving TPN and can lead to serious complications (e.g., cardiac arrhythmias, muscle weakness).
• Blood glucose levels: TPN contains a high glucose concentration, which may cause hyperglycemia. Conversely, sudden cessation of TPN can cause hypoglycemia.
• Intake and output (I&O): Monitoring I&O helps assess fluid status and detect fluid overload or dehydration.

Think of the body as a balanced aquarium. TPN is like adding highly concentrated nutrients to the water. If you add too much or too quickly, it can throw off the water chemistry, harming the fish (organs). Careful monitoring ensures the aquarium stays balanced and healthy.

Nurses must prioritize frequent assessment of fluid and electrolyte status in patients receiving TPN to prevent complications.

• Monitor serum electrolyte levels, glucose, and albumin as prescribed and report abnormalities promptly.
• Check blood glucose levels every 4-6 hours during initiation or changes in TPN and administer insulin if prescribed.
• Assess for signs of fluid overload, such as edema, hypertension, or crackles in the lungs, and for dehydration, such as dry mucous membranes or tachycardia.
• Record daily weights to monitor fluid status and ensure appropriate nutritional support.
• Maintain strict intake and output records to detect changes in fluid balance.

✘Incorrect answer options:

Evaluation of the peripheral IV insertion site. TPN is typically administered via a central venous catheter (CVC) or a peripherally inserted central catheter (PICC) because TPN solutions are highly concentrated and can irritate peripheral veins. Evaluating the IV site is important for detecting catheter-related complications, such as infection or thrombosis, but it is not the most critical assessment. The risk of metabolic complications related to fluid and electrolyte imbalance is more immediate and severe.

Confirmation of nasogastric or orogastric tube placement in the stomach. This intervention is relevant for patients receiving enteral nutrition, not TPN. TPN bypasses the gastrointestinal system entirely and is delivered intravenously. Therefore, confirming NG or orogastric tube placement is unnecessary in this context.

Auscultation and assessment of bowel sounds. Bowel sounds are important to assess for gastrointestinal function, especially in patients transitioning to oral or enteral nutrition. However, since TPN bypasses the gastrointestinal tract, this assessment is not a primary concern during TPN therapy. Instead, fluid and electrolyte monitoring is essential to prevent metabolic complications.

EXPLANATION

✔Correct answer:

Preparing for endotracheal intubation. In a burn patient with initial wheezing that has now ceased, the absence of wheezing is a life-threatening sign of complete or near-complete airway obstruction due to progressive airway edema. This occurs as a result of thermal injury, inhalation of smoke or chemicals, or the body’s inflammatory response. The nurse’s next priority action is to prepare for endotracheal intubation to secure the airway before complete obstruction occurs, as delayed action can result in respiratory failure and make intubation extremely difficult or impossible.

Inhalation injuries often cause upper airway edema due to inflammation and fluid leakage into the airway tissues. Early symptoms like wheezing indicate narrowing of the airway, while the cessation of wheezing suggests that the airway has become so swollen that air is no longer able to pass through. Immediate airway management, including intubation, is necessary to maintain oxygenation and ventilation.

Imagine a narrowing tunnel where the walls are swelling inward. Initially, you hear cars struggling to pass through (wheezing). When the cars stop moving completely (silence), it means the tunnel is fully blocked, and urgent action is needed to clear the obstruction.

Securing the airway is the immediate priority, as airway edema can progress rapidly. After intubation, ongoing monitoring and interventions are essential.

• Notify the healthcare provider or rapid response team immediately for emergency airway management.
• Prepare necessary equipment for intubation, including an endotracheal tube, laryngoscope, bag-valve-mask, and suction device.
• Administer supplemental oxygen via a non-rebreather mask or bag-valve-mask while preparing for intubation.
• Monitor for other signs of airway compromise, such as stridor, use of accessory muscles, or decreased oxygen saturation.
• Position the patient appropriately (e.g., head elevated) to facilitate breathing while awaiting intubation.

✘Incorrect answer options:

Documenting the change in assessment findings. While documentation is important, it should never take precedence over immediate intervention in a life-threatening situation. Addressing airway compromise is the priority.

Loosening any dressings present on the patient's chest. This intervention is relevant in cases where circumferential burns or restrictive dressings impair chest wall movement and ventilation. However, in this scenario, the issue is airway edema, not restricted chest expansion. Therefore, loosening dressings will not address the cause of the airway obstruction.

Elevating the head of the bed. Elevating the head of the bed can improve lung expansion and ease breathing, but it is not sufficient when airway obstruction is imminent. While useful as a supportive measure, preparing for intubation is the life-saving action required in this situation.

EXPLANATION

✔Correct answer:

Immediately notify the emergency response team. The absence of breath sounds following an inhalation injury in a patient who was previously wheezing is a medical emergency that indicates a potential complete airway obstruction or impending respiratory failure. This condition may result from airway edema caused by thermal injury, chemical exposure, or the inflammatory response to the inhalation injury. Prompt intervention is critical to prevent complete respiratory arrest.

Inhalation injuries can cause damage to the upper airway (thermal injury) and lower airway (chemical exposure or smoke inhalation). In the first 24 hours post-injury, progressive edema of the airway structures can occur, narrowing the airways and leading to obstruction. Initially, patients may wheeze as air struggles to pass through narrowed airways, but the transition to silent chest (absent breath sounds) indicates that airflow has stopped due to critical narrowing or blockage. This is a sign of impending respiratory collapse, requiring immediate escalation of care and potential airway intervention (e.g., intubation).

Imagine a hosepipe that is initially partially clogged, allowing water to flow through with difficulty, creating a hissing noise (wheezing). If the clog becomes complete, the water stops flowing entirely, and the hissing sound disappears (silent chest). This silent state indicates a total obstruction, which in the airway is a life-threatening emergency.

Immediate action is critical to prevent airway compromise and respiratory arrest.

• Call for the emergency response team or a rapid response team (RRT) immediately to secure the airway (intubation or tracheostomy may be necessary).
• Provide supplemental oxygen if not already in place, but note that this alone is insufficient if airway obstruction is present.
• Prepare the patient for potential intubation by ensuring equipment (e.g., endotracheal tube, bag-valve-mask, suction) is readily available.
• Monitor vital signs closely, particularly oxygen saturation, respiratory rate, and heart rate.
• Ensure the patient is positioned appropriately to maximize breathing effort while waiting for advanced airway management.

✘Incorrect answer options:

Elevate the head of the bed. Elevating the head of the bed is a standard intervention to promote lung expansion and reduce the work of breathing. However, in this situation, it is not sufficient because the absence of breath sounds suggests critical airway obstruction, which requires advanced airway management. Time should not be wasted on this step.

Loosen any dressings present on the patient's chest. Loosening chest dressings may be beneficial if restrictive dressings or eschar are causing respiratory compromise, such as in circumferential burns of the chest. However, this is not relevant to the scenario described, which involves an inhalation injury and absent breath sounds rather than mechanical restriction of the chest wall.

Simply document the change in assessment findings. Documentation is essential but should never take precedence over immediate action in a life-threatening situation. Delaying intervention in this scenario could result in complete airway obstruction and respiratory arrest.

EXPLANATION

✔Correct answer:

Keeping the hip at zero degrees of flexion with the leg flat. Maintaining the hip at zero degrees of flexion (a neutral position with the leg flat) is critical for preventing contractures in burn patients, particularly around the hip. Burns can lead to scar tissue formation and tightening of the skin, which increases the risk of joint contractures. A contracture is the permanent tightening or shortening of muscles, tendons, or ligaments, which restricts range of motion. Keeping the hip in a neutral position helps to counteract this risk by stretching the surrounding tissues and preventing them from shortening as they heal.

After a burn injury, the body undergoes a healing process that includes inflammation, proliferation of new tissue, and scar formation. If the affected area is allowed to remain in a flexed position for prolonged periods, the surrounding muscles and connective tissues adapt to this shortened state, leading to contracture. Maintaining a neutral position (zero degrees flexion) reduces this risk by keeping the tissues in their normal lengthened state, preserving joint mobility.

Think of the hip joint as a door hinge. If the door (hip) is left partially open (flexed) for a long time, rust (scar tissue) can build up, making it hard to open or close fully later. Keeping the door straight and flat (neutral position) prevents rust buildup and allows the hinge to function normally.

It is essential for nurses to implement and encourage proper positioning early during the healing process to minimize complications such as contractures.

• Ensure the affected leg is kept flat (neutral position) using appropriate positioning aids, such as pillows or splints, if necessary.
• Encourage range-of-motion (ROM) exercises to maintain joint mobility and flexibility once it is safe to do so.
• Collaborate with physical and occupational therapists for rehabilitation and individualized exercise plans.
• Monitor the patient for signs of discomfort or improper positioning, and adjust as needed to promote compliance with therapy.
• Educate the patient and family about the importance of maintaining proper positioning to prevent long-term complications.

✘Incorrect answer options:

Maintaining the hip in 30 degrees of flexion: Prolonged flexion of the hip promotes shortening of the anterior muscles and tissues, increasing the risk of contracture. This position is contraindicated in burn patients around the hip area.

Flexing the knee at a 30-degree angle: Flexion of the knee is not the primary focus for preventing contractures of the hip joint. While knee positioning is important, the hip must remain in a neutral position to avoid contracture formation around that joint.

Abducting the leg with a foam wedge: While abduction may be helpful in some cases (e.g., post-hip surgery), it is not the priority in this scenario. The main goal for burn patients around the hip is to prevent flexion contractures, which is best achieved by maintaining a neutral, flat position.

EXPLANATION

✔Correct answer:

Full-thickness burn. The burn described—white, leathery texture, absence of blisters, minimal pain, and no bleeding—is consistent with a full-thickness burn (third-degree burn). Full-thickness burns involve the complete destruction of the epidermis and dermis, and often extend into the subcutaneous tissue. The leathery appearance (eschar) and white coloration result from coagulation of proteins and destruction of blood vessels within the skin.

Minimal pain is a hallmark of full-thickness burns because the nerve endings in the dermis are destroyed, leaving the affected area insensate. These burns do not heal on their own and typically require interventions such as skin grafting for wound closure.

Imagine a piece of wood burned until it becomes charred and hardened. The surface loses its flexibility and sensitivity, just like the leathery and insensate characteristics of a full-thickness burn.

Full-thickness burns require intensive care to prevent complications such as infection, fluid loss, and delayed wound healing.

• Cover the burn with a sterile, dry dressing to prevent infection and reduce further damage.
• Monitor for signs of infection (e.g., increased redness, foul odor, fever) and systemic complications such as sepsis.
• Provide pain management for surrounding areas, as partial-thickness burns may coexist with full-thickness burns and remain painful.
• Anticipate the need for debridement and skin grafting, as full-thickness burns will not regenerate new skin.
• Collaborate with a burn care team for long-term rehabilitation and functional recovery.

✘Incorrect answer options:

Partial-thickness superficial burn. Superficial partial-thickness burns (second-degree burns) involve damage to the epidermis and the upper layer of the dermis. They are characterized by pink or red color, blisters, moist appearance, and significant pain due to intact nerve endings. The described white, leathery appearance and minimal pain indicate a deeper, more severe injury than a superficial partial-thickness burn.

Partial-thickness deep burn. Deep partial-thickness burns extend deeper into the dermis, involving the reticular layer. These burns may appear red or white and have a mottled texture. They are often less painful than superficial partial-thickness burns due to partial nerve damage. However, they retain blistering, moisture, and some degree of pain, which are absent in the described case.

Superficial burn. Superficial burns (first-degree burns) affect only the epidermis and are characterized by redness, pain, and no blisters. They heal quickly without scarring. The described burn’s white and leathery texture, combined with minimal pain, is far more severe than a superficial burn.

EXPLANATION

✔Correct answer:

Impaired Gas Exchange related to airway edema. The highest priority in the first 24 hours following burn injury is ensuring a patent airway and adequate gas exchange. The anterior neck and chest burns present a high risk of airway compromise due to airway edema and potential involvement of the upper respiratory tract. Swelling in the neck area can obstruct the airway, and burns on the chest may limit lung expansion. Without prompt intervention, impaired gas exchange could lead to hypoxemia, respiratory failure, and death.

Burns, particularly chemical burns, can cause direct damage to the airway and lungs if inhaled or applied to the neck and chest. The inflammatory response causes swelling of the airway tissues and increased secretions. Circumferential chest burns may also impair lung expansion by restricting chest wall movement. Both conditions threaten gas exchange and require immediate nursing and medical attention.

Think of the airway as a tunnel. After a burn, swelling is like construction barriers closing in on the tunnel, making it harder for traffic (air) to flow through. If the barriers aren't managed, the tunnel could close entirely, halting air movement.

The focus is on monitoring respiratory status and intervening immediately to prevent airway compromise.

• Assess airway patency frequently, noting signs of airway compromise, such as hoarseness, stridor, use of accessory muscles, or dyspnea.
• Monitor oxygenation using pulse oximetry and arterial blood gas (ABG) analysis.
• Administer humidified oxygen to improve oxygen delivery and reduce airway irritation.
• Prepare for endotracheal intubation or tracheostomy if airway obstruction is suspected.
• Collaborate with the healthcare team for a bronchoscopy if inhalation injury is suspected.

✘Incorrect answer options:

Risk for Infection related to impaired skin integrity. Infection is a serious risk in burn patients due to the loss of the skin’s protective barrier, but it typically becomes a concern after the initial 24 hours, during the intermediate phase of burn care. Ensuring adequate oxygenation takes precedence during the emergent phase.

Deficient Fluid Volume related to fluid shifts and increased capillary permeability. Fluid loss and hypovolemia are major concerns during the emergent phase of burn care. However, airway compromise is a more immediate threat to survival. Fluid resuscitation can be addressed once the airway is secured.

Acute Pain related to tissue damage and nerve injury. Pain is an important concern in burn care, but managing life-threatening conditions such as airway compromise and hypovolemia takes precedence. Pain control becomes a higher priority once the patient is stabilized.

EXPLANATION

✔Correct answer:

Impaired Adjustment. While all the listed options are relevant to a patient recovering from a full-thickness burn, Impaired Adjustment takes the highest priority in the post-discharge context. A full-thickness burn often results in significant physical and psychological trauma. The patient has endured a month-long hospitalization, likely involving painful procedures, wound care, and significant changes in body image and functional abilities. Returning home marks a major transition, requiring the patient to adapt to a new reality that may include ongoing pain, limited mobility, scarring, and emotional distress. This adjustment process can be incredibly challenging and significantly impact the patient's overall well-being and recovery. Prioritizing impaired adjustment allows the nurse to address the patient's psychosocial needs, promote coping mechanisms, and facilitate a smoother transition to home life.

Full-thickness burns destroy all layers of the skin and often involve underlying tissues. This extensive damage leads to significant pain, fluid shifts, and metabolic stress during the acute phase. However, the long-term consequences extend beyond physical healing. Scarring, contractures, and altered body image can lead to emotional distress, anxiety, depression, and difficulty reintegrating into social and occupational roles. The patient may struggle with self-esteem, social interactions, and adapting to functional limitations.

Imagine returning home after a major life event, such as a natural disaster that destroyed your house. You might still have some physical injuries, but the bigger challenge is adjusting to living in temporary housing, dealing with insurance, and coping with the emotional trauma of the experience. Similarly, a burn patient faces the challenge of adjusting to a changed life after a traumatic injury.

Addressing impaired adjustment in a burn patient requires a comprehensive and interdisciplinary approach:

• Psychosocial Support: Provide empathetic listening, emotional support, and encouragement. Assess for signs of anxiety, depression, and post-traumatic stress disorder (PTSD).
• Referral to Mental Health Professionals: Refer the patient to a psychologist, psychiatrist, or support group specializing in burn recovery. These professionals can provide counseling, cognitive behavioral therapy (CBT), and other interventions to address emotional distress and promote coping skills.
• Body Image Counseling: Offer resources and support to help the patient cope with changes in body image and self-esteem. This may include information on reconstructive surgery, scar management, and support groups for individuals with similar experiences.
• Occupational and Physical Therapy: Continue occupational and physical therapy to maximize functional abilities and independence. This can help the patient regain skills needed for daily living and return to work or other activities.
• Family and Social Support: Encourage the patient to maintain connections with family and friends. Provide education and support to family members to help them understand the patient's needs and provide appropriate support.

✘Incorrect answer options:

Acute Pain. While pain management remains important post-discharge, the patient's wounds are described as "minimally open," suggesting that acute pain is likely less severe than during the acute phase of the burn. Impaired adjustment encompasses the broader psychological and social challenges of recovery, making it a higher priority. Chronic pain management would be a more appropriate diagnosis if pain was a primary issue.

Deficient Diversional Activity. While engaging in diversional activities is beneficial for overall well-being, it is not the highest priority in this context. The patient's primary needs revolve around adjusting to a significantly changed life, managing emotional distress, and regaining functional abilities.

Imbalanced Nutrition: Less than Body Requirements. Nutritional needs are crucial during the acute phase of burn recovery. While maintaining adequate nutrition remains important post-discharge, it is less of an immediate priority compared to the psychosocial challenges of adjustment, especially with ongoing home care support. The home care team will likely monitor and address nutritional needs.

EXPLANATION

✔Correct answer:

“Your appearance will likely be different from before the injury.” This response is the most honest and therapeutic. Full-thickness burns, especially facial burns, often result in permanent scarring and changes in appearance. While reconstructive surgery and other interventions can significantly improve outcomes, it's crucial to acknowledge the reality that the patient's appearance will likely be different from before the injury. This honest acknowledgment validates the patient's concerns and opens the door for further discussion about coping mechanisms, available resources, and realistic expectations for recovery. It avoids giving false hope while acknowledging the emotional impact of the changes.

Facial burns can damage multiple layers of skin, subcutaneous tissue, and even underlying structures. The healing process involves the formation of scar tissue, which has different characteristics than normal skin. Scar tissue is often thicker, less elastic, and may have a different color or texture. Depending on the severity and location of the burn, scarring can lead to contractures, disfigurement, and functional limitations.

Imagine a piece of fabric that has been torn and then sewn back together. Even with careful stitching, the repaired area will likely look different from the original fabric. There might be visible seams or puckering. Similarly, burned skin, even after healing, will have a different appearance due to the formation of scar tissue.

Supporting a burn patient with concerns about their appearance requires a sensitive and holistic approach:

• Active Listening and Empathy: Listen attentively to the patient's concerns and acknowledge their feelings. Validate their emotions and create a safe space for them to express their fears and anxieties.
• Realistic Expectations: Provide honest and realistic information about the healing process, potential outcomes, and available treatment options, including reconstructive surgery, scar management techniques (pressure dressings, silicone sheeting), and cosmetic procedures.
• Psychosocial Support: Offer emotional support and encourage the patient to seek counseling or join support groups for burn survivors. These resources can help them cope with body image issues, self-esteem concerns, and the emotional impact of their injuries.
• Referral to Specialists: Refer the patient to appropriate specialists, such as plastic surgeons, dermatologists, and mental health professionals, who can provide specialized care and support.
• Promoting Self-Care: Encourage the patient to engage in self-care activities that promote physical and emotional well-being, such as exercise, healthy eating, and relaxation techniques.

✘Incorrect answer options:

“Reconstructive surgery can restore your appearance to its pre-injury state.” This statement offers false hope. While reconstructive surgery can significantly improve appearance and function, it rarely restores the pre-injury state completely, especially with severe burns.

“We can eliminate the scarring through the application of pressure dressings.” Pressure dressings can help minimize scarring but cannot completely eliminate it, especially in full-thickness burns. This response is misleading.

“It’s best not to focus on your appearance at this stage of recovery.” This response dismisses the patient's valid concerns. Focusing on appearance is a normal part of the recovery process, and it's important to address these concerns therapeutically. Dismissing them can invalidate the patient's feelings and hinder their emotional recovery.

EXPLANATION

✔Correct answer:

Frequent monitoring for signs of airway compromise such as hoarseness, stridor, and dyspnea. In a patient with severe burns to the upper torso, the most immediate and primary concern is airway compromise, especially if the injury suggests the potential for inhalation injury or thermal damage to the upper airway. Signs such as hoarseness, stridor, and dyspnea indicate swelling or obstruction of the airway, which can progress rapidly and lead to respiratory failure. This is particularly concerning in burns involving the face, neck, or upper chest, where airway edema can develop due to inhalation of hot gases, smoke, or chemical toxins.

Inhalation injury damages the mucosa of the upper airway (nasopharynx, oropharynx, larynx) and leads to inflammation and edema, which can obstruct the airway. Smoke inhalation and exposure to toxic gases (e.g., carbon monoxide, cyanide) can worsen the situation by impairing oxygen exchange in the lungs. Early identification and proactive airway management (e.g., intubation) are critical because delayed intervention could make securing the airway much more difficult once edema progresses.

Imagine a road where debris (edema) is starting to block traffic (airflow). Early signs like slowed traffic (hoarseness or stridor) warn of worsening blockage. If the debris isn't cleared quickly, the road could become completely impassable (airway obstruction).

Addressing airway compromise takes precedence over all other concerns in this scenario.

• Assess for early signs of airway injury, including hoarseness, stridor, use of accessory muscles, or visible burns around the mouth and nose.
• Monitor for singed nasal hairs, soot in the oropharynx, and carbonaceous sputum, which indicate inhalation injury.
• Prepare for emergent intubation if signs of airway compromise are present, as airway swelling may rapidly progress.
• Administer high-flow oxygen via a non-rebreather mask or bag-valve-mask if oxygenation is impaired.
• Collaborate with respiratory therapy and anticipate the need for bronchoscopy to assess the extent of airway injury.

✘Incorrect answer options:

Debriding and applying dressings to the wounds. While wound care is essential in managing burns, it is not the most immediate concern in the acute phase of burn treatment. Addressing airway compromise takes precedence over wound care to ensure the patient’s survival.

Administering prophylactic antibiotics. Prophylactic antibiotics are generally not recommended in burn care unless there is evidence of infection. Burns disrupt the skin barrier and increase the risk of infection, but antibiotics are typically initiated based on clinical signs of infection rather than prophylactically. Airway management is a more immediate concern.

Establishing a patent intravenous (IV) line for fluid resuscitation. While fluid resuscitation is critically important in managing burns, airway compromise takes priority. Without a patent airway, fluid resuscitation will not save the patient. Once the airway is secure, IV access can be established to address the risk of hypovolemic shock.

EXPLANATION

✔Correct answer:

Place the patient in an upright position. The patient is exhibiting signs of pulmonary complications, such as crackles, tachypnea (respiratory rate of 40 breaths per minute), and hemoptysis (blood-tinged sputum), which suggest the possibility of pulmonary edema or inhalation injury. The priority intervention is to improve oxygenation by placing the patient in an upright position to maximize lung expansion and facilitate breathing. Upright positioning helps reduce pressure on the diaphragm, improves ventilation-perfusion matching, and enhances the patient's ability to clear secretions.

Pulmonary edema in burn patients can result from fluid resuscitation (volume overload), inhalation injury causing damage to the alveoli, or systemic inflammatory responses increasing capillary permeability. These changes lead to fluid accumulation in the alveolar spaces, impaired gas exchange, and respiratory distress. The upright position improves ventilation and oxygenation while allowing gravity to aid in draining excess fluid.

Imagine your lungs as sponges soaking up air and water. When they’re overloaded with water (fluid in the lungs, as seen in pulmonary edema), it becomes harder for the sponge to absorb air and do its job. By lying flat, the water pools and presses down on the sponge, making it even harder to work. Sitting upright allows gravity to pull the water down, freeing up more space for the sponge to expand and absorb air, improving the efficiency of breathing. This is why positioning is so crucial in managing pulmonary complications.

After positioning the patient upright, additional interventions and monitoring should be performed to address respiratory status and prevent further complications.

• Provide supplemental oxygen via a non-rebreather mask or nasal cannula to improve oxygenation.
• Monitor arterial blood gases (ABGs) to assess for hypoxemia or respiratory acidosis.
• Prepare for advanced interventions, such as endotracheal intubation, if the patient’s respiratory distress worsens.
• Collaborate with the healthcare team to evaluate for fluid overload and adjust IV fluids if needed.
• Conduct frequent lung assessments to monitor for changes, such as worsening crackles or decreased oxygen saturation.

✘Incorrect answer options:

Administer digoxin. Digoxin is used to improve cardiac output in patients with heart failure or certain arrhythmias. While pulmonary edema can be associated with cardiac issues, the primary focus here is respiratory support, not cardiac medication. Pulmonary complications from burns are more likely caused by fluid shifts, inhalation injury, or systemic inflammation.

Perform chest physiotherapy. Chest physiotherapy is helpful in clearing secretions, but it is not appropriate in the acute setting of suspected pulmonary edema or inhalation injury. Aggressive physiotherapy could worsen respiratory distress in a fragile respiratory system. The focus should first be on optimizing oxygenation.

Monitor urine output. Monitoring urine output is important in burn patients to assess the effectiveness of fluid resuscitation and kidney perfusion, but it does not directly address the patient’s respiratory distress. The priority intervention in this scenario is to optimize breathing and oxygenation.

EXPLANATION

✔Correct answer:

Initiate intravenous fluid resuscitation. The patient’s presentation—low blood pressure (70/40 mmHg), tachycardia (140 bpm), tachypnea (25 bpm), pallor, and weak or absent pedal pulses—is consistent with hypovolemic shock, a critical condition caused by significant fluid loss in burn injuries. The initial action in managing hypovolemic shock is to restore circulating volume through intravenous (IV) fluid resuscitation. This intervention addresses the underlying cause of the shock: inadequate intravascular volume due to fluid shifts and plasma loss from the damaged capillaries.

For burn patients, the Parkland formula is often used to guide fluid resuscitation in the emergent phase:

• 4 mL of Lactated Ringer’s solution × patient’s weight in kg × % total body surface area (TBSA) burned.
• Half of the total calculated volume is administered in the first 8 hours post-burn, and the remaining half over the next 16 hours.

Restoring volume improves perfusion to vital organs, such as the brain, heart, and kidneys, and prevents progression to multi-organ failure.

Thermal burns cause significant increases in capillary permeability, leading to fluid and protein leakage into the interstitial space. This results in hypovolemia, decreased cardiac output, and poor tissue perfusion. Without prompt fluid resuscitation, these changes can lead to cellular ischemia, lactic acidosis, and death.

Imagine your body is like a tree, and the blood is the water flowing through its roots, trunk, and branches. After a burn injury, it’s as if a large part of the tree’s bark (the skin) is damaged, causing water (fluid) to leak out and the tree to wither. Without enough water flowing through the trunk (blood vessels), the branches (organs) begin to dry out and fail. Fluid resuscitation is like pouring water back into the roots, helping the tree regain its strength, restore its flow, and keep its branches alive. Without this immediate replenishment, the tree (body) cannot survive.

Prompt fluid resuscitation is the most critical intervention in the emergent phase for burn patients in hypovolemic shock.

• Begin IV fluid resuscitation immediately, using isotonic crystalloids such as Lactated Ringer’s solution.
• Monitor vital signs (blood pressure, heart rate, respiratory rate) to assess the effectiveness of fluid replacement.
• Assess urine output (goal: 30-50 mL/hour in adults) as a key indicator of adequate perfusion and resuscitation.
• Monitor for signs of fluid overload, such as crackles in the lungs, and adjust fluids as necessary.
• Reassess perfusion regularly, including skin color, temperature, and pulse strength.

✘Incorrect answer options:

Assess peripheral pulses using a Doppler ultrasound device. While assessing pulses is important for evaluating perfusion in burn patients, it is not the priority when the patient is already showing clear signs of hypovolemic shock. Fluid resuscitation must take precedence to improve perfusion to vital organs before other assessments are performed.

Obtain a complete blood count (CBC) laboratory analysis. A CBC can provide valuable information, such as hematocrit and white blood cell count, to assess for hemoconcentration or infection. However, this is a secondary intervention. Immediate action to stabilize the patient’s hemodynamic status through fluid resuscitation is more critical.

Obtain an electrocardiogram (ECG) tracing. An ECG may be indicated if the patient has pre-existing cardiac conditions or if electrolyte abnormalities are suspected. However, the priority is restoring intravascular volume, as hypovolemia must be corrected to improve cardiac output and perfusion. Obtaining an ECG does not address the root cause of hypovolemic shock.

EXPLANATION

✔Correct answer:

"Tagamet is used prophylactically to prevent the development of stress ulcers in the stomach." Cimetidine (Tagamet) is a histamine-2 (H2) receptor antagonist. In the context of burn management, it is primarily used for stress ulcer prophylaxis. Severe physiological stress, such as that experienced by burn patients, can lead to increased gastric acid production and decreased mucosal blood flow. This combination creates a high risk for the development of stress ulcers, also known as Curling's ulcers, in the stomach and duodenum. Cimetidine works by blocking H2 receptors in the stomach's parietal cells, which reduces gastric acid secretion. This helps to maintain a more neutral gastric pH, thus preventing the formation of ulcers and subsequent complications such as gastrointestinal bleeding.

Severe burns trigger a significant systemic stress response, leading to various physiological changes. One of these changes is increased gastric acid secretion due to increased levels of histamine. Simultaneously, blood flow to the gastrointestinal mucosa may be reduced due to fluid shifts and vasoconstriction, making the mucosa more vulnerable to damage from the increased acid. This combination of increased acid and decreased mucosal protection creates an ideal environment for ulcer development. Cimetidine mitigates this risk by reducing acid production.

Imagine the stomach lining as a protective shield against stomach acid. During severe stress (like a major burn), the acid production increases significantly, like a powerful acid being poured onto the shield. If the shield is weakened (due to reduced blood flow), the acid can eat through it, causing an ulcer. Cimetidine acts like a buffer, neutralizing some of the acid and protecting the shield from damage.

When administering cimetidine or other H2 receptor antagonists to burn patients, nurses should consider the following:

• Monitoring for Side Effects: While generally well-tolerated, cimetidine can cause side effects such as headache, dizziness, and diarrhea. In rare cases, it can cause more serious side effects like confusion or thrombocytopenia.
• Drug Interactions: Cimetidine can interact with several other medications, so it's essential to review the patient's medication list for potential interactions.
• Alternative Medications: Proton pump inhibitors (PPIs) like pantoprazole or omeprazole are often preferred over H2 receptor antagonists for stress ulcer prophylaxis due to their more potent acid suppression and less frequent dosing.
• Assessment for GI Bleeding: Monitor the patient for signs of gastrointestinal bleeding, such as hematemesis (vomiting blood), melena (black, tarry stools), or occult blood in the stool.
• Patient Education: Explain to the patient the purpose of the medication and the importance of preventing stress ulcers.

✘Incorrect answer options:

"Tagamet is administered to stimulate intestinal motility." Cimetidine does not directly stimulate intestinal motility. Medications like metoclopramide or erythromycin are used for this purpose.

"Tagamet is given to aid in the prevention of hypovolemic shock." Cimetidine does not directly prevent hypovolemic shock. Fluid resuscitation with crystalloids and colloids is the primary intervention for preventing and treating hypovolemic shock in burn patients.

"This medication helps to prevent potential kidney damage." Cimetidine is not primarily used to prevent kidney damage. While some medications can have nephroprotective effects, cimetidine's main action is on gastric acid secretion.

EXPLANATION

✔Correct answer:

Education on how to perform dressing changes correctly. Proper wound care is critical for preventing infection, promoting healing, and minimizing complications after a full-thickness burn injury. The patient must understand how to perform dressing changes at home to maintain a clean wound environment and reduce the risk of infection. Full-thickness burns involve damage to all layers of the skin, which compromises the body’s natural barrier against pathogens. As such, thorough discharge education on aseptic technique, dressing application, and signs of infection (e.g., increased redness, warmth, swelling, or foul odor) is the most immediate and crucial information the patient needs to manage their ongoing recovery.

In addition to wound care, patients should also be educated about the importance of proper hydration, nutrition, and adherence to follow-up care, as these factors significantly influence wound healing. Dressing care is a direct and immediate priority that impacts the patient’s recovery and prevents potential complications that could lead to rehospitalization.

Imagine a fresh burn wound as a vulnerable seed planted in a garden. Without proper care—such as watering (moist environment), sunlight (nutrition), and weeding (preventing infection)—the seed cannot grow into a healthy plant. Similarly, wound care is the foundation of healing after a burn.

Nurses must prioritize wound care education during discharge to ensure the patient and their caregivers feel confident managing care at home.

• Teach the patient step-by-step instructions on how to clean the wound and apply dressings using aseptic technique.
• Explain how to recognize signs of infection (e.g., fever, wound drainage, redness) and stress the importance of seeking medical attention promptly if these occur.
• Review the use of prescribed topical agents (e.g., silver sulfadiazine) or medications for wound care and pain management.
• Encourage adherence to follow-up appointments with the burn care team for ongoing evaluation and adjustment of the care plan.
• Provide written instructions and resources (e.g., videos, local wound care services) to reinforce the teaching.

✘Incorrect answer options:

Instructions on how to maintain home smoke detectors. While important for preventing future burn injuries, this is a long-term safety measure and not as critical to the patient’s immediate post-discharge care as proper wound care. Smoke detector education can be addressed during follow-up appointments or included as part of broader education.

Information about joining a community reintegration program. Community reintegration programs can provide emotional and social support for burn survivors and help them adapt to physical and psychological changes. However, this is a secondary priority compared to wound care, as it focuses on long-term adjustment rather than immediate recovery.

Discussion of available options for scar revision procedures. Scar management, including revision procedures, is typically addressed months after the burn injury, once healing is complete. Although this discussion is important, it is not an immediate concern upon discharge. The focus at this stage should be on wound healing and infection prevention.

EXPLANATION

✔Correct answer:

36%. Using the Rule of Nines, the total body surface area (TBSA) affected by burns is calculated by dividing the body into regions that approximate multiples of 9%. This method is widely used to estimate the extent of burns, particularly in adults. The affected areas in Ms. Rodriguez’s case are as follows:

1. Left arm: Each arm is 9% TBSA (4.5% for the anterior surface and 4.5% for the posterior surface). Since only the left arm is affected, and only the anterior portion is mentioned, this contributes 4.5% to the TBSA calculation.
2. Left anterior leg: Each leg is 18% TBSA (9% for the anterior surface and 9% for the posterior surface). Since only the anterior surface of the left leg is burned, this contributes 9% to the TBSA calculation.
3. Anterior trunk: The entire trunk is 36% TBSA (18% for the anterior surface and 18% for the posterior surface). Since only the anterior surface is involved, this contributes 18% to the TBSA calculation.

Adding these values together:

• 4.5% (left anterior arm)
• 9% (left anterior leg)
• 18% (anterior trunk)

= 36% TBSA burned.

Think of the Rule of Nines as dividing the body into "puzzle pieces" with specific percentages. By combining the burned pieces (e.g., a 9% arm piece, a 9% leg piece, and an 18% trunk piece), you can calculate the percentage of the "puzzle" that is burned.

Accurate TBSA calculation is crucial for guiding fluid resuscitation, wound care, and overall treatment in burn patients.

• Use the TBSA percentage to initiate fluid resuscitation using formulas such as the Parkland formula (e.g., 4 mL × body weight in kg × % TBSA burned).
• Monitor for signs of hypovolemia and ensure adequate urine output (30-50 mL/hour) as an indicator of effective resuscitation.
• Provide pain management, as burns of this extent can cause significant pain.
• Assess for complications such as infection, electrolyte imbalances, and respiratory distress (especially in extensive burns).
• Collaborate with a burn specialist or team to manage wound care and long-term rehabilitation.

✘Incorrect answer options:

27%: This underestimates the TBSA. While the anterior leg (9%) and anterior trunk (18%) total 27%, it does not include the additional 4.5% from the anterior surface of the left arm.

45%: This overestimates the TBSA. Including both the anterior and posterior trunk or both surfaces of the left leg and arm would lead to this value, but the question specifies only the anterior trunk, leg, and arm.

18%: This significantly underestimates the TBSA. The anterior trunk alone contributes 18%, without accounting for the additional burned areas on the anterior left arm and left leg.

EXPLANATION

✔Correct answer:

Document the finding in the patient's chart. A blood glucose level of 140 mg/dL in a burn patient is a common finding and does not require immediate intervention. Following a major burn injury, the body enters a hypermetabolic state in response to the stress of the injury. This response is characterized by the release of stress hormones, such as cortisol, epinephrine, and glucagon, which stimulate gluconeogenesis and glycogenolysis, leading to stress-induced hyperglycemia. In critically ill burn patients, mild to moderate hyperglycemia (e.g., 140 mg/dL) is expected and should be documented as part of the patient’s physiological response to the burn injury.

It is important to monitor glucose levels regularly to ensure they remain within an acceptable range and to detect any signs of uncontrolled hyperglycemia, which could increase the risk of complications such as infections, delayed wound healing, or sepsis. However, in this case, the glucose level of 140 mg/dL does not require rechecking, a family history evaluation, or altering intravenous fluids unless persistent hyperglycemia or clinical changes occur.

Think of a burn patient’s body as a car engine running on overdrive to recover. This increased activity burns more fuel (glucose), so the body releases extra fuel into the bloodstream. Documenting this finding ensures the healthcare team stays aware of the patient’s “fuel level” without overreacting unless the level becomes dangerously high.

While this finding is within the expected range, nurses should remain vigilant and monitor for trends or signs of complications.

• Monitor blood glucose levels regularly as prescribed, particularly in patients receiving enteral or parenteral nutrition or those with pre-existing diabetes.
• Document the glucose level and communicate findings to the healthcare team if levels consistently exceed 180 mg/dL, which may require insulin therapy or other interventions.
• Assess for signs of hyperglycemia, such as polyuria, polydipsia, or altered mental status, and evaluate the patient’s overall clinical picture.
• Continue administering prescribed IV fluids, as these are essential for fluid resuscitation and maintaining perfusion in burn patients.
• Collaborate with a dietitian or pharmacist to ensure that the patient’s nutritional and metabolic needs are being met.

✘Incorrect answer options:

Obtain a detailed family history related to diabetes mellitus. Stress-induced hyperglycemia is not necessarily indicative of diabetes mellitus. While a family history of diabetes may be relevant in the long term, this is not a priority in the acute phase of burn care when the hyperglycemia is most likely a response to the burn injury.

Recheck the blood glucose level to confirm the result. A blood glucose level of 140 mg/dL is consistent with the hypermetabolic and stress response of burn injuries and does not warrant immediate rechecking unless clinical signs suggest a significant problem or the result is unexpectedly high (e.g., above 180-200 mg/dL).

Discontinue any intravenous fluids containing dextrose. IV fluids containing dextrose are sometimes used during the emergent and acute phases of burn treatment to meet increased energy demands. Discontinuing these fluids could lead to hypoglycemia or disrupt the fluid resuscitation protocol. Any changes to fluid therapy should only be made after consulting the burn team or physician and based on the patient’s overall condition.

EXPLANATION

✔Correct answer:

Impaired Gas Exchange related to airway edema or swelling. The highest priority nursing diagnosis during the initial 24 hours post-burn is Impaired Gas Exchange, especially in a patient with burns to the anterior neck and chest. These injuries pose a significant risk of airway compromise due to inhalation injury, airway edema, or restricted chest expansion. Burns to the anterior neck can cause significant swelling, potentially leading to airway obstruction. Furthermore, chemical burns may exacerbate the risk of inhalation injury, which can result in upper airway edema, bronchoconstriction, or damage to the respiratory tract.

Inhalation injuries or burns near the neck and chest can lead to rapid airway swelling, which may obstruct airflow. Additionally, circumferential chest burns can impair thoracic movement, limiting lung expansion and oxygenation. Without prompt intervention, this can progress to hypoxemia and respiratory failure. As airway compromise can be life-threatening, this diagnosis takes priority over others.

Imagine a garden hose with swelling inside that gradually blocks the flow of water. Similarly, airway edema acts as internal swelling that can block airflow, making breathing difficult or impossible. Ensuring the hose remains open (airway patency) is the most urgent concern.

To address impaired gas exchange, nurses must focus on protecting the airway and monitoring respiratory function.

• Perform frequent assessments for early signs of airway compromise, such as hoarseness, stridor, or difficulty breathing.
• Administer humidified oxygen to support oxygenation and reduce airway irritation.
• Prepare for potential intubation or tracheostomy if signs of airway obstruction develop.
• Monitor arterial blood gases (ABGs) to assess oxygenation and ventilation status.
• Anticipate bronchoscopy if inhalation injury is suspected to evaluate airway damage and clear debris.

✘Incorrect answer options:

Risk for Infection related to impaired skin integrity. Infection is a critical concern in burn patients due to the loss of the skin’s protective barrier, but it is not the immediate priority during the first 24 hours. The acute focus is on stabilizing the airway, circulation, and breathing. Infection typically becomes a greater concern during the intermediate phase of burn care (after the first 24-48 hours).

Deficient Fluid Volume related to fluid shifts and increased capillary permeability. Fluid loss due to increased capillary permeability and fluid shifts is an important concern in the emergent phase of burn care. However, fluid volume status is managed through fluid resuscitation (e.g., Lactated Ringer's via the Parkland formula). While fluid resuscitation is critical, it is secondary to securing the airway and maintaining adequate gas exchange.

Acute Pain related to tissue damage and nerve injury. Pain management is an essential part of burn care, but it is not the highest priority in the emergent phase. Pain can be addressed once the patient’s airway and hemodynamic stability are ensured.

EXPLANATION

✔Correct answer:

Neck in hyperextension, using a rolled towel under the shoulders. Contracture prevention is a key nursing priority in burn patients, especially for areas like the neck, where scarring can cause skin shortening and limit range of motion. For burns on the posterior neck, the most effective position to prevent contractures is placing the neck in hyperextension, supported by a rolled towel under the shoulders. Hyperextension stretches the posterior neck tissues and counteracts the natural tendency of burned skin to contract during healing. If the neck is not maintained in hyperextension, the patient risks developing a flexion contracture, which can lead to impaired function and deformity.

Imagine a rubber band that has been heated and damaged. If you leave it curled up, it hardens in that position. But if you stretch it out while it cools, it stays flexible and usable. Similarly, positioning the neck in hyperextension stretches the healing tissue, preventing it from "curling up" into a contracture.

Maintaining the correct position and encouraging active participation in physical therapy are critical to long-term functional outcomes.

• Educate the patient about the importance of maintaining the hyperextended position as much as possible, even during rest.
• Place a rolled towel or similar support under the shoulders to maintain the neck in hyperextension.
• Encourage range-of-motion (ROM) exercises for the neck to preserve flexibility and function.
• Monitor for patient discomfort and provide pain management as needed to ensure compliance with positioning.
• Collaborate with physical and occupational therapists for additional strategies to prevent contractures.

✘Incorrect answer options:

Head turned to one side, supported with a pillow. Turning the head to one side can increase the risk of contracture by causing uneven stretching of the neck tissues. Additionally, the use of a pillow under the head can encourage flexion, which should be avoided in this scenario.

Head flexed forward, with chin resting on the chest. This position promotes flexion contractures and is contraindicated for burns on the posterior neck. Flexion causes the healing tissues on the posterior neck to shorten and tighten, leading to deformity.

Neck in a neutral position, no pillows under the head. While keeping the neck in a neutral position is better than allowing flexion, it does not adequately stretch the tissues on the posterior neck. Hyperextension is required to prevent contractures and preserve full neck range of motion.

EXPLANATION

✔Correct answer:

Prepare for a sepsis evaluation, including obtaining appropriate cultures. The combination of diarrhea, hypothermia, and a low white blood cell count (leukopenia) in a patient with open burn wounds strongly suggests sepsis. Open burn wounds disrupt the skin's protective barrier, making the patient highly susceptible to infection. Diarrhea can be a sign of gastrointestinal involvement in sepsis or a side effect of broad-spectrum antibiotics, which are often used in burn care and can disrupt normal gut flora. Hypothermia, rather than fever, can be an early indicator of sepsis, especially in immunocompromised patients or those with significant burns. Leukopenia further supports the suspicion of sepsis, as the body's immune system is overwhelmed, leading to a decrease in circulating white blood cells. Therefore, the priority nursing intervention is to prepare for a sepsis evaluation, which includes obtaining blood, urine, and wound cultures to identify the causative organism and guide appropriate antibiotic therapy. Early recognition and aggressive management of sepsis are crucial to improve patient outcomes.

Burn injuries compromise the skin's integrity, creating a portal of entry for pathogens. The systemic inflammatory response syndrome (SIRS) triggered by burns, coupled with impaired immune function, predisposes patients to infections. Sepsis develops when the body's response to infection becomes dysregulated, leading to organ dysfunction. In burn patients, sepsis can manifest with atypical signs such as hypothermia, rather than the typical fever, and leukopenia, rather than leukocytosis (elevated white blood cell count). Diarrhea can be a consequence of the inflammatory process or antibiotic-associated diarrhea due to disruption of the normal gut flora.

Imagine the body's defenses as a castle wall. A burn injury is like a breach in the wall, allowing invaders (bacteria) to enter. Sepsis is like the invaders overrunning the castle, causing chaos and damage throughout. Diarrhea might be like a disruption in the castle's supply lines, and hypothermia and low white blood cell counts are signs that the castle's defenders are struggling to fight back effectively. The priority is to identify the type of invaders (get cultures) so the correct reinforcements (antibiotics) can be sent in.

In addition to preparing for a sepsis evaluation, the following nursing interventions are crucial:

• Initiate Broad-Spectrum Antibiotics: After obtaining cultures, initiate broad-spectrum antibiotics as prescribed by the physician. These antibiotics will be adjusted based on the culture results.
• Fluid Resuscitation: Continue or adjust fluid resuscitation as needed to support hemodynamic stability. Sepsis can lead to vasodilation and further fluid shifts, requiring careful monitoring and fluid management.
• Temperature Management: Implement measures to address hypothermia, such as warming blankets, adjusting the room temperature, and administering warmed intravenous fluids.
• Monitor Vital Signs and Laboratory Values: Closely monitor vital signs, including temperature, heart rate, blood pressure, and respiratory rate. Monitor laboratory values such as white blood cell count, electrolytes, and blood glucose.
• Wound Care: Maintain meticulous wound care to prevent further infection. This includes regular dressing changes and monitoring for signs of wound infection.

✘Incorrect answer options:

Continue routine monitoring of the patient's condition. While ongoing monitoring is essential, the patient's current presentation requires immediate action beyond routine monitoring. The signs and symptoms strongly suggest sepsis, which is a life-threatening condition requiring prompt intervention.

Adjust the ambient room temperature to a warmer setting. While addressing hypothermia is important, it is not the priority. The underlying cause of the hypothermia, which is likely sepsis, must be addressed first. Simply warming the patient without treating the infection will not resolve the problem.

Increase the current rate of intravenous fluid administration. While fluid resuscitation is important in burn patients and those with sepsis, it is not the priority in this situation. Obtaining cultures and initiating antibiotics are crucial for addressing the underlying infection. Increasing fluids without addressing the infection may not improve the patient's condition and could potentially worsen it if capillary leak is present.

EXPLANATION

✔Correct answer:

Auscultating breath sounds over the trachea and mainstem bronchi. Drooling and difficulty swallowing in a burn patient are highly concerning signs of potential airway compromise. These symptoms suggest possible edema or inflammation in the upper airway, which can rapidly lead to airway obstruction. The priority action is to directly assess the patient's respiratory status by auscultating breath sounds over the trachea and mainstem bronchi. This allows the nurse to identify any stridor (a high-pitched, harsh sound indicative of upper airway obstruction), wheezing, or diminished breath sounds, which are critical indicators of impending respiratory distress. Early detection of these abnormal breath sounds enables prompt intervention to secure the airway and prevent respiratory failure.

Burns, especially those involving the face, neck, or inhalation injuries, can cause significant edema and inflammation of the upper airway. This edema can narrow the airway lumen, leading to difficulty swallowing (dysphagia) and drooling (due to an inability to manage secretions). If the edema progresses, it can completely obstruct the airway, resulting in respiratory arrest. Auscultation of breath sounds helps detect early signs of airway narrowing and guides appropriate interventions.

Imagine the airway as a straw. When it's clear, air flows easily. However, if the straw is pinched or partially blocked (like by swelling in the airway), it becomes difficult to blow or suck air through it. Auscultating breath sounds is like listening to the sound of air moving through the straw; a whistling sound (stridor) indicates a significant blockage.

When assessing a burn patient with potential airway compromise, several key interventions and considerations are crucial:

• Continuous Monitoring: Closely monitor the patient's respiratory rate, oxygen saturation (SpO2), and work of breathing. Look for signs of respiratory distress such as nasal flaring, use of accessory muscles, and intercostal retractions.
• Airway Management: Be prepared to assist with or perform endotracheal intubation if the patient's airway becomes compromised. Have emergency airway equipment readily available.
• Humidified Oxygen: Administer humidified oxygen to help loosen secretions and reduce airway irritation.
• Positioning: Elevate the head of the bed to promote lung expansion and reduce edema in the upper airway.
• Fluid Management: Careful fluid resuscitation is essential in burn patients, but over-resuscitation can exacerbate edema. Monitor for signs of fluid overload.

✘Incorrect answer options:

Assessing the patient's level of consciousness and pupillary reactions. While assessing the level of consciousness and pupillary reactions is important for a comprehensive neurological assessment, it is not the priority action in this situation. The immediate threat is airway compromise, so assessing respiratory status takes precedence. Changes in level of consciousness or pupillary reactions may be secondary to hypoxia but are not the primary concern at this moment.

Determining the last time the patient consumed food or liquids. Knowing the patient's oral intake history is relevant for nutritional management and aspiration risk, but it does not address the immediate threat of airway obstruction. The priority is to assess the patency of the airway and the patient's respiratory status.

Measuring abdominal girth and auscultating bowel sounds. Measuring abdominal girth and auscultating bowel sounds are important for assessing abdominal complications in burn patients (e.g., ileus, abdominal compartment syndrome), but they are not directly related to the immediate concern of airway compromise indicated by drooling and difficulty swallowing. These assessments can be performed after addressing the airway.