MSN Exam for Burn Management and Care 4

EXPLANATION

✔Correct answer:

Immediately loosen the neck dressing. The most appropriate initial nursing intervention is to immediately loosen the neck dressing to address the potential cause of Mr. Thompson's respiratory distress. A tight neck dressing may be compressing the trachea or surrounding soft tissue, compromising the patient’s airway and causing difficulty breathing. Loosening the dressing promptly alleviates this compression and allows Nurse Miller to reassess the patient’s respiratory status. Since airway and breathing are the highest priorities in any situation (as per the ABCs of emergency care), this intervention is critical and must be performed before initiating other measures.

Surgical dressings applied to the neck area may cause swelling or tightness that restricts airflow through the trachea, leading to respiratory distress. This is especially concerning because the neck region contains vital structures such as the trachea, carotid arteries, and jugular veins. Obstruction of the airway can result in hypoxia and respiratory failure if not addressed immediately.

Imagine wearing a scarf that’s too tight around your neck. If it starts to choke you, loosening it immediately would allow you to breathe freely again. Similarly, a tight neck dressing can act like that choking scarf, and loosening it quickly restores airflow.

In cases of respiratory distress caused by a tight dressing, the nurse should prioritize actions that alleviate the obstruction and support breathing.

• Immediately loosen or adjust the dressing to relieve any pressure on the trachea or airway.
• Reassess the patient’s respiratory status, including respiratory rate, oxygen saturation, and ease of breathing, after loosening the dressing.
• Provide supplemental oxygen as needed if respiratory distress persists despite loosening the dressing.
• Notify the physician or healthcare provider promptly to evaluate the cause of the distress and the appropriateness of the current dressing.
• Monitor the patient closely for worsening symptoms, such as stridor, cyanosis, or declining oxygen levels, which may indicate further airway compromise.
• Document the intervention and the patient’s response in the medical record.

✘Incorrect answer options:

Administer supplemental oxygen: While supplemental oxygen is often indicated for respiratory distress, it is not the first priority in this case. The underlying cause of the distress—airway compression due to a tight neck dressing—must be addressed immediately before administering oxygen. Simply providing oxygen without relieving the compression will not resolve the obstruction.

Immediately notify the emergency response team: Notifying the emergency response team is necessary if the patient’s condition deteriorates or respiratory distress does not improve after initial interventions. However, the first action must be to relieve the airway compression by loosening the dressing, as this can quickly resolve the issue and may prevent the need for emergency escalation.

Simply document the observation in the patient’s chart: While documentation is important, it is not an intervention and does not address the immediate problem. Respiratory distress requires prompt action to prevent airway compromise, making documentation a secondary priority after the patient’s safety is ensured.

EXPLANATION

✔Correct answer:

Debridement of loose, nonviable tissue from the burn wound. The initial step in wound care for a burn injury is debridement of loose, nonviable (necrotic) tissue. This is because necrotic tissue acts as a medium for bacterial growth and delays the wound healing process. Removing this tissue reduces the risk of infection, prepares the wound bed for application of topical antimicrobial agents or dressings, and promotes proper granulation and epithelialization. Debridement is a key priority to ensure that subsequent interventions, such as applying medications or dressings, are effective.

Burn injuries result in the formation of devitalized tissue (eschar) due to thermal damage. This tissue impairs healing by blocking the migration of epithelial cells and fostering bacterial colonization. Removing the eschar and necrotic tissue improves the wound environment, allowing for better penetration of topical agents and facilitating the body's natural healing processes.

Imagine trying to grow a garden (new skin) but leaving a layer of weeds and dead leaves (necrotic tissue) covering the soil. Removing the weeds and dead material clears the way for seeds (healthy cells) to grow and thrive.

Debridement should be performed carefully and with proper precautions to avoid additional harm to the patient.

• Use sterile instruments and maintain strict aseptic technique during the debridement process to minimize infection risk.
• Assess the patient’s pain level before debridement, and administer prescribed analgesics or sedatives to ensure comfort during the procedure.
• Perform wound irrigation with normal saline or an appropriate wound-cleansing solution to remove debris and bacteria.
• Monitor the wound for signs of infection (e.g., erythema, purulent discharge, increased warmth) and document findings in the patient’s chart.
• Educate the patient and family about the importance of ongoing wound care, including the role of debridement, in the healing process.

✘Incorrect answer options:

Application of silver sulfadiazine (Silvadene) ointment to the wound: While silver sulfadiazine is a commonly used topical antimicrobial agent for burn wounds, it should not be applied before debridement. Necrotic tissue can block the penetration of topical agents, making them less effective. Debridement must be performed first to ensure the wound bed is clean and prepared for medication application.

Covering the wound area with an elastic compression wrap: Compression wraps are typically used during later phases of burn care to reduce edema, minimize scarring, or improve circulation. They are not an initial priority in the acute phase of wound care, especially when necrotic tissue is still present.

Placement of a synthetic dressing over the affected area: Synthetic dressings are beneficial for covering and protecting the wound after cleaning and debridement, but they should not be applied over necrotic tissue. The primary focus at this stage is preparing the wound bed by removing any nonviable tissue.

EXPLANATION

✔Correct answer:

"It's understandable to experience feelings of sadness or depression during this recovery process." This statement by Mr. Thompson demonstrates an accurate understanding of the potential psychosocial impact of a severe burn injury. Burn injuries are life-altering events that not only affect physical health but also have profound emotional, psychological, and social consequences. Feelings of sadness, depression, anxiety, anger, and even post-traumatic stress disorder (PTSD) are common among burn survivors. Recognizing and accepting these emotional challenges is a critical first step in developing healthy coping mechanisms and accessing mental health support when needed. This statement suggests that Mr. Thompson is aware of the emotional toll his recovery may take, which is essential for realistic goal-setting and adaptation.

Patients with severe burns often face significant changes in body image, physical abilities, and social interactions. The healing process can be lengthy and painful, with complications such as scarring, disfigurement, and reduced mobility. Additionally, burn survivors may experience grief over the loss of their pre-injury lifestyle, including changes in work, relationships, and independence. Emotional support, counseling, and access to peer support groups can help patients navigate these challenges.

Recovering from a severe burn injury is like climbing a mountain after a storm has swept away the trail. The journey is slow and challenging, and it's normal to feel frustration, sadness, or even doubt about reaching the top. However, acknowledging these emotions allows you to prepare for the climb, gather the right tools (coping mechanisms and support), and adjust your pace to make steady progress toward healing and a new perspective.

Nurses play a vital role in addressing the emotional and psychosocial needs of burn survivors.

• Assess the patient’s emotional state regularly and provide opportunities for open communication about their feelings.
• Educate the patient and their family about the common emotional responses to severe burns, including sadness, anger, anxiety, and grief.
• Encourage the patient to participate in counseling or therapy to develop coping mechanisms and address any symptoms of depression or PTSD.
• Facilitate access to burn survivor support groups, where patients can connect with others who have faced similar challenges.
• Involve a multidisciplinary team, including mental health professionals, social workers, and physical therapists, to provide holistic care.
• Help the patient set realistic expectations for recovery and emphasize that emotional healing is as important as physical recovery.

✘Incorrect answer options:

"I fully expect to resume my regular work schedule as soon as I am discharged.": This statement reflects unrealistic expectations. Recovery from extensive burn injuries often involves prolonged physical and emotional rehabilitation, and patients may need to make adjustments to their work or daily routines. Setting unattainable goals can lead to frustration or disappointment.

"I know I won't have any feelings of anger or resentment about what has happened.": This statement is inaccurate because feelings of anger, resentment, and frustration are common emotional responses to traumatic events such as burn injuries. Acknowledging these emotions is a critical part of the healing process, and denying them may hinder emotional recovery.

"Once I'm back home, everything will go back to the way it was before the accident.": This statement reflects a lack of understanding about the long-term impact of burn injuries. Burn survivors often face lasting physical and emotional challenges, and recovery typically involves adapting to a "new normal." Expecting life to immediately return to its pre-injury state can lead to unmet expectations and emotional distress.

EXPLANATION

✔Correct answer:

"My primary goal is to achieve the highest possible level of function within my new limitations." This statement demonstrates a realistic understanding of the rehabilitation process following a full-thickness burn injury. Recovery after such injuries is a long and multifaceted process that involves physical, emotional, and social adaptations. Full-thickness burns often result in scarring, contractures, and potential functional limitations despite advanced medical and rehabilitative interventions. Setting a goal to achieve the highest possible level of function acknowledges the potential for limitations while focusing on maximizing independence and quality of life. This mindset is essential for maintaining motivation during a challenging rehabilitation process.

Rehabilitation for full-thickness burns emphasizes optimizing mobility, preventing complications such as contractures, managing scars, addressing psychological and emotional needs, and facilitating reintegration into daily life. Patients often work with a multidisciplinary team, including physical therapists, occupational therapists, and mental health professionals, to regain function and adapt to any residual impairments.

Think of the rehabilitation process like rebuilding a damaged house after a fire. The goal isn’t necessarily to make the house exactly the same as before but to restore it to the best possible condition so it can be lived in comfortably again.

Nurses play a critical role in supporting burn patients during the rehabilitation phase.

• Encourage realistic goal-setting that focuses on maximizing function and independence while acknowledging potential limitations.
• Promote adherence to physical and occupational therapy programs to prevent contractures and maintain mobility.
• Provide education on scar management techniques, such as pressure garments and silicone sheets, to minimize the impact of scarring.
• Assess for signs of depression, anxiety, or PTSD and refer the patient to mental health services as needed.
• Foster a supportive environment by involving the patient’s family and providing resources, such as burn survivor support groups.

✘Incorrect answer options:

"I will be completely recovered once all of my wounds have fully healed.": This statement reflects a misunderstanding of the long-term challenges associated with full-thickness burns. Even after wounds heal, issues such as scarring, mobility limitations, and emotional recovery persist and require ongoing management.

"I expect to be able to resume all of my previous activities without any limitations.": While optimism is important, this statement is unrealistic for many burn patients with full-thickness injuries, who often face permanent physical limitations or need to adapt their activities.

"It's impossible to ever fully recover from a major burn injury like this.": This statement demonstrates hopelessness and is not accurate. While complete restoration of pre-burn function may not always be possible, burn survivors can achieve meaningful recovery, independence, and a high quality of life through rehabilitation and adaptive strategies.

EXPLANATION

✔Correct answer:

Changing gloves between wound care procedures on different anatomical locations of Ms. Ramirez’s body. Changing gloves between wound care procedures on different anatomical locations is the most important intervention in preventing autocontamination (self-contamination) in burn patients. Autocontamination occurs when microorganisms are transferred from one part of the patient’s body to another, particularly from an infected wound or colonized area to a non-infected site. Burn wounds are highly susceptible to infection due to the loss of the skin’s protective barrier. By changing gloves between treating different anatomical locations, Nurse Garcia prevents cross-contamination between wound sites and minimizes the risk of introducing bacteria to non-infected areas.

Burn wounds provide an ideal environment for bacterial growth due to tissue necrosis and protein-rich exudates. Autocontamination is a significant concern during the acute phase, as burn wounds can be colonized with pathogens from the patient’s own skin or gastrointestinal flora. Effective infection control measures, such as changing gloves between wound sites, are critical to breaking this cycle.

Imagine cleaning two spills with the same sponge—using the same sponge spreads the mess from one area to another. Changing gloves is like switching to a clean sponge for each spill, preventing cross-contamination.

Nurses must prioritize interventions that prevent the spread of microorganisms between wound sites.

• Change gloves and use sterile instruments between treating different wound areas to minimize autocontamination.
• Use aseptic technique and sterile supplies during all wound care procedures.
• Dispose of soiled dressings properly to prevent contamination of the care environment.
• Monitor for signs of infection in each wound site, such as increased redness, purulent drainage, or a foul odor.
• Educate the patient about the importance of not touching or scratching their wounds to avoid spreading bacteria.
• Collaborate with the interdisciplinary team to ensure adherence to infection control protocols.

✘Incorrect answer options:

Strictly avoiding the sharing of equipment, such as blood pressure cuffs, between different patients: While this measure is critical to preventing cross-contamination between patients, it does not address autocontamination, which refers specifically to the transfer of microorganisms within the same patient.

Utilizing the closed method of burn wound management: The closed method (covering the burn wound with dressings) helps prevent external contamination but does not directly address autocontamination. Cross-contamination between wound sites can still occur if infection control measures, like changing gloves, are not followed.

Consistently performing meticulous hand hygiene: Although hand hygiene is essential in overall infection prevention, it is primarily aimed at reducing the introduction of external pathogens rather than preventing the spread of microorganisms within the same patient (autocontamination). Changing gloves between wound sites more directly addresses autocontamination.

EXPLANATION

✔Correct answer:

Boiling water spills during cooking. Boiling water spills during cooking are a common cause of minor burn injuries in the household. These burns, often classified as scald burns, occur when hot liquids or steam come into contact with the skin, causing thermal injury. Scald burns are particularly common in kitchen settings due to accidental spills of boiling water, soups, or hot beverages. Nurse Lee should emphasize safety measures such as careful handling of hot liquids, using pot holders, and ensuring pots and pans are placed on back burners with handles turned inward to reduce the risk of accidental tipping.

Scald burns are one of the most frequent types of burns, especially among children and elderly individuals, due to their thinner skin and increased vulnerability. Community education focused on preventing these injuries can significantly reduce burn incidence.

Think of boiling water as a loaded bucket of paint. If spilled, it quickly spreads and stains (burns) everything it touches. Being cautious while handling it can prevent accidents.

Nurses can play a vital role in promoting burn prevention through education and awareness.

• Teach individuals to use back burners and turn pot handles away from the edge of the stove to prevent accidental tipping.
• Encourage the use of child safety gates in the kitchen to keep young children away from cooking areas.
• Advocate for the use of kettle cords with safety locks or cordless kettles to reduce tipping hazards.
• Advise on the importance of using protective mitts or potholders when handling hot cookware.
• Educate about the need to cool burns immediately with lukewarm (not ice-cold) water and seek medical attention for severe burns.

✘Incorrect answer options:

Wearing sunscreen during outdoor activities: Wearing sunscreen is a preventive measure, not a cause of burns. In fact, sunscreen protects against sunburns caused by UV radiation, reducing the risk of skin damage.

Using a microwave to warm food: While microwave use can lead to burns (e.g., from steam or hot food spills), it is not as common or significant a cause of household burns as boiling water spills. Education on safe microwave use (e.g., avoiding superheated liquids) is still important but secondary in this context.

Drinking cold beverages on a hot day: Drinking cold beverages does not cause burns. It is, in fact, a recommended practice for staying hydrated and cool, particularly in hot weather.

EXPLANATION

✔Correct answer:

“Because the graft is my own skin, there is no chance it won’t ‘take.’” This statement indicates a need for further teaching. While autografts (using the patient's own skin) have a higher success rate than allografts (using skin from a cadaver), there is still a possibility that the graft may not "take." Factors such as infection, poor blood supply to the recipient site, hematoma formation under the graft, or improper wound care can compromise graft survival. It's crucial for the patient to understand that graft failure is a potential complication, even with autografts.

Skin grafting involves transferring a section of skin from a donor site to a recipient site. For the graft to "take," it must establish a new blood supply through a process called neovascularization. Several factors can interfere with this process: infection can damage the new blood vessels; poor blood supply at the recipient site can prevent adequate oxygen and nutrients from reaching the graft; a hematoma (blood clot) under the graft can create a barrier preventing contact with the recipient bed; and improper wound care can disrupt the healing process.

Imagine transplanting a small plant from one pot to another. Even if you're using a cutting from the same plant (like an autograft), the transplant might not be successful. If the new pot's soil is dry (poor blood supply), if there's a disease in the soil (infection), or if the plant isn't properly cared for after transplanting, it might not survive.

When educating patients about skin grafting, nurses should include the following:

• Graft Survival: Explain the factors that can affect graft survival, including infection, blood supply, hematoma formation, and wound care. Emphasize the importance of following post-operative instructions to maximize the chances of graft success.
• Donor Site Care: Explain that the donor site, where the skin was taken from, will also require care and will be a source of pain. Discuss pain management strategies and wound care instructions for the donor site.
• Scarring: Inform the patient that both the graft site and the donor site will likely result in some degree of scarring. Discuss scar management techniques, such as pressure dressings, silicone sheeting, and massage, that can help minimize scarring.
• Infection Prevention: Emphasize the importance of preventing infection by practicing good hygiene, keeping the wound clean and dry, and recognizing signs of infection (redness, swelling, purulent drainage, fever).
• Post-Operative Restrictions: Explain any post-operative restrictions on movement or activity that are necessary to promote graft healing.

✘Incorrect answer options:

“For the first few days after surgery, the donor sites will be painful.” This statement is accurate. The donor site is essentially a partial-thickness wound and will be a source of pain post-operatively.

“I will have some scarring in the area where the skin is removed for grafting.” This statement is also accurate. Scarring is expected at both the donor and recipient sites.

“I am still at risk for infection after the procedure.” This statement is correct. Any surgical procedure, including skin grafting, carries a risk of infection. Proper wound care and hygiene are crucial to minimize this risk.

EXPLANATION

✔Correct answer:

A myocardial infarction (MI) one year prior. A history of a myocardial infarction (MI) within the past year should prompt Nurse Hernandez to consider a modification of the standard fluid resuscitation protocol. Burn patients require aggressive fluid resuscitation during the emergent phase (the first 24-48 hours) to prevent hypovolemic shock due to fluid shifts caused by increased capillary permeability. However, patients with a history of cardiovascular disease, such as an MI, are at increased risk for fluid overload and heart failure during resuscitation. The heart may not tolerate the increased intravascular volume, leading to complications such as pulmonary edema or worsening cardiac function. These patients may require closer hemodynamic monitoring and adjustments to the fluid resuscitation protocol to avoid overloading the heart while still ensuring adequate tissue perfusion.

The Parkland Formula is often used for fluid resuscitation in burn patients, but patients with cardiac conditions may require lower fluid volumes, more gradual fluid administration, or invasive monitoring (e.g., central venous pressure or pulmonary artery catheter) to prevent fluid-related complications. Burn injuries also increase the metabolic demands on the heart, further straining its ability to function if the patient has pre-existing cardiac damage.

Think of the heart as a pump. A heart that’s previously been damaged by an MI is like a pump that’s worn out—it can’t handle being overloaded with too much water (fluid). Carefully controlling how much water flows in prevents the pump from failing.

When caring for a burn patient with a history of cardiovascular disease, close monitoring and adjustments to the fluid resuscitation plan are critical.

• Collaborate with the healthcare provider to adjust the fluid resuscitation protocol, considering the patient’s cardiac history.
• Monitor for signs of fluid overload, such as dyspnea, crackles on lung auscultation, jugular vein distention, and peripheral edema.
• Use invasive hemodynamic monitoring (e.g., central venous pressure or pulmonary artery catheter) if indicated to assess fluid status and guide resuscitation.
• Assess urine output closely, aiming for the target range (30-50 mL/hour in adults) to ensure adequate perfusion without overhydration.
• Monitor vital signs frequently, particularly blood pressure, heart rate, and oxygen saturation, to detect early signs of cardiac decompensation.
• Administer diuretics as prescribed if signs of fluid overload occur, balancing this with the need to maintain perfusion to vital organs.

✘Incorrect answer options:

A history of seasonal asthma: Seasonal asthma, unless severe or poorly controlled, does not typically impact fluid resuscitation. While asthma may complicate airway management in burn patients with inhalation injuries, it is not directly relevant to fluid resuscitation protocols.

A diagnosis of Hepatitis B ten years prior: A history of resolved or managed Hepatitis B infection does not usually affect fluid resuscitation. Hepatic dysfunction could influence fluid management if present, but there is no indication in this scenario that Mr. Silva has ongoing liver damage.

A history of kidney stones within the past six months: While a history of kidney stones may indicate a need to monitor renal function and hydration status closely, it does not typically warrant modification of fluid resuscitation protocols unless there is evidence of acute or chronic kidney dysfunction. Elevated creatinine or reduced urine output would be more indicative of renal impairment requiring adjustments.

EXPLANATION

✔Correct answer:

Document the absence of bowel sounds in the patient's chart. The absence of bowel sounds in all four abdominal quadrants 12 hours after a burn injury is likely due to paralytic ileus, a common complication in the early stages of severe burns. Paralytic ileus occurs as a result of the body's systemic response to the burn, which includes reduced blood flow to the gastrointestinal (GI) tract, sympathetic nervous system activation, and the release of inflammatory mediators. Documenting this finding is the appropriate nursing intervention, as it ensures accurate communication with the healthcare team. Additionally, further monitoring and follow-up are required to determine if this condition persists or worsens.

Severe burn injuries trigger a stress response that redirects blood flow away from nonessential organs, such as the GI tract, to prioritize perfusion of vital organs like the brain and heart. This leads to decreased peristalsis and bowel motility, resulting in a temporary loss of bowel sounds and paralytic ileus.

Think of the GI system as a conveyor belt that moves food. After a severe burn injury, the body temporarily "shuts off the power" to the conveyor belt to conserve energy and resources for critical areas like the heart and brain. This shutdown stops movement in the GI tract, leading to absent bowel sounds.

In addition to documenting the absence of bowel sounds, nurses should take other actions to monitor and address paralytic ileus.

• Document the findings accurately, including the timing and location of the assessment.
• Monitor for other signs of paralytic ileus, such as abdominal distention, nausea, vomiting, or inability to pass gas.
• Notify the healthcare provider if the absence of bowel sounds persists or if the patient develops additional symptoms.
• Maintain the patient on nothing by mouth (NPO) status as prescribed to prevent complications such as vomiting or aspiration.
• Collaborate with the healthcare provider regarding the need for imaging studies or interventions such as nasogastric (NG) tube placement if indicated.
• Assess fluid and electrolyte balance closely, as patients with paralytic ileus are at risk of imbalances due to decreased GI function and losses through the burn injury.

✘Incorrect answer options:

Administer a prescribed laxative medication: Laxatives are not appropriate in cases of paralytic ileus because the underlying issue is the lack of peristalsis (bowel movement), not a functional obstruction or stool impaction. Administering a laxative in this situation could worsen discomfort or cause complications.

Increase the rate of the patient's intravenous fluid infusion: While fluid resuscitation is critical in burn patients during the initial phase, increasing the IV fluid rate solely based on absent bowel sounds is not an appropriate intervention. The patient's fluid status should be managed based on burn resuscitation protocols (e.g., Parkland formula) and clinical markers such as urine output, blood pressure, and heart rate.

Reposition the patient onto their right lateral side: Repositioning may help in cases of mild gas retention or partial bowel obstruction, but it does not resolve paralytic ileus caused by systemic stress and reduced GI perfusion. While frequent repositioning is beneficial for preventing pressure injuries in burn patients, it is not directly indicated for absent bowel sounds.

EXPLANATION

✔Correct answer:

Serum potassium of 7.5 mmol/L (mEq/L). A serum potassium level of 7.5 mmol/L (mEq/L) is critically elevated (hyperkalemia) and must be reported immediately, as it poses a serious risk to the patient’s cardiac function. Hyperkalemia is a common complication during the first 24-48 hours after a severe burn injury due to massive cellular destruction. Burns cause significant release of intracellular potassium into the bloodstream as cells are damaged. High potassium levels can lead to life-threatening cardiac dysrhythmias, such as ventricular fibrillation or asystole, if not addressed promptly.

In burn injuries, widespread cell destruction leads to the release of intracellular potassium. The inflammatory response and fluid shifts associated with burns exacerbate this electrolyte imbalance. Hyperkalemia affects cardiac electrical activity by altering the resting membrane potential, increasing the risk of arrhythmias. Symptoms such as muscle weakness, paresthesia, and changes on an ECG (e.g., peaked T waves, widened QRS complex) may also occur.

Imagine your heart as an electrical circuit. Excess potassium acts like a power surge, disrupting the circuit and causing it to malfunction. Immediate action is needed to prevent the circuit (heart) from short-circuiting.

Nurse Thompson should take immediate action to address hyperkalemia and prevent complications.

• Notify the physician immediately about the critical potassium level.
• Monitor the patient’s cardiac status using continuous ECG monitoring to detect any dysrhythmias.
• Prepare to administer interventions such as:
  • Calcium gluconate to stabilize cardiac membranes.
  • Insulin with dextrose to drive potassium back into cells.
  • Sodium bicarbonate if metabolic acidosis is present.
  • Diuretics or dialysis to remove excess potassium if indicated.
• Monitor serum potassium levels frequently to evaluate the effectiveness of treatment.
• Educate the patient and family about the importance of electrolyte monitoring and management during burn recovery.

✘Incorrect answer options:

Arterial pH of 7.32: An arterial pH of 7.32 indicates mild acidosis, which is expected during the emergent phase of burn care due to hypovolemia and tissue hypoxia. While acidosis requires monitoring and eventual correction, it is not as immediately life-threatening as hyperkalemia.

Hematocrit of 52%: An elevated hematocrit level is expected within the first 24 hours post-burn due to hemoconcentration resulting from fluid shifts and plasma loss. This finding should be monitored, but it is not immediately critical unless accompanied by signs of hypovolemia or inadequate fluid resuscitation.

Serum sodium of 131 mmol/L (mEq/L): A sodium level of 131 mmol/L indicates mild hyponatremia, which is also a common finding in the emergent phase of burn care due to sodium losses in burn exudate and fluid shifts. While hyponatremia requires correction, it is not as urgent as hyperkalemia.

EXPLANATION

✔Correct answer:

Administering morphine sulfate 4 mg intravenously. Intravenous (IV) administration of opioids like morphine sulfate is the preferred route for managing acute, severe pain in burn patients. The IV route provides the most rapid and predictable onset of analgesia, which is crucial in controlling the intense pain associated with burn injuries. Morphine sulfate is a potent opioid analgesic that effectively binds to opioid receptors in the central nervous system, reducing the perception of pain. Titrating the dose based on the patient's pain level allows for optimal pain control.

Burn injuries damage nerve endings and trigger the release of inflammatory mediators, leading to intense pain. The pain can be both nociceptive (due to tissue damage) and neuropathic (due to nerve damage). Effective pain management is essential not only for patient comfort but also for promoting healing, reducing stress, and facilitating participation in necessary procedures like wound care and physical therapy. IV opioids provide rapid and effective pain relief by directly affecting the central nervous system's pain pathways.

Imagine a fire alarm (pain signal) going off loudly. IV morphine is like quickly cutting the wire to the alarm at the main control panel (central nervous system), immediately silencing it. Other routes of administration are like trying to muffle the alarm with a pillow (slower and less effective).

Effective pain management in burn patients requires a multimodal approach:

• Assessment: Regularly assess the patient's pain using a validated pain scale (e.g., numeric rating scale, visual analog scale). Consider both pain at rest and pain with movement or procedures.
• Titration: Titrate opioid doses based on the patient's individual response and pain level. Frequent reassessment is essential to ensure adequate pain control and minimize side effects.
• Other Analgesics: Consider using adjunctive analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen, if appropriate, to provide multimodal pain relief. However, NSAIDs should be used cautiously due to their potential effects on platelet function and renal function, which may be compromised in burn patients.
• Non-Pharmacological Measures: Incorporate non-pharmacological pain management techniques, such as relaxation techniques, guided imagery, and distraction, to complement pharmacological interventions.
• Monitoring for Side Effects: Closely monitor for opioid-related side effects, such as respiratory depression, sedation, nausea, vomiting, and constipation. Implement appropriate interventions to manage these side effects.

✘Incorrect answer options:

Administering hydromorphone (Dilaudid) 4 mg intramuscularly. While hydromorphone is a potent opioid, the intramuscular (IM) route is not the preferred route for acute pain management in burn patients. The IM route has a slower and less predictable absorption rate compared to the IV route. In burn patients, altered peripheral perfusion can further impair absorption from IM injections.

Applying ice directly to the burned area. Applying ice directly to a burn wound is contraindicated. It can cause further tissue damage due to vasoconstriction and potential frostbite. Cooling can be used in the immediate minutes after a minor burn, but never directly on the wound and not for major burns.

Minimizing tactile stimulation of the affected area. While minimizing unnecessary touch or pressure on the burn wound is important to reduce pain and prevent further tissue damage, it does not address the patient's underlying pain. This is a supportive measure, not a primary pain management intervention. Adequate analgesia is still needed even when minimizing stimulation.

EXPLANATION

✔Correct answer:

Decreased Tissue Perfusion. The priority nursing diagnosis for Mr. Lee during the immediate post-burn period is Decreased Tissue Perfusion, particularly in the affected limbs. The chemical burns, along with the significant edema observed, can compromise blood flow to surrounding tissues due to increased capillary permeability and localized swelling. This can lead to tissue ischemia, necrosis, or even compartment syndrome if not promptly addressed. Additionally, the absence of pain in the affected areas may indicate nerve damage, a characteristic of deeper burns, which further elevates the need for vigilant monitoring of perfusion.

After a burn injury, the body responds with an inflammatory cascade that increases capillary permeability, resulting in significant fluid and protein leakage into the interstitial spaces. This leads to edema and intravascular hypovolemia, which compromises circulation to the affected tissues. Decreased tissue perfusion can exacerbate cellular hypoxia, delaying healing and increasing the risk of infection and further complications.

Imagine a swollen hose (edematous tissue) that pinches itself off, reducing the flow of water (blood) to the plants (tissues) it’s supposed to nourish. Without intervention, the plants will wilt and die (tissue ischemia and necrosis).

Nurse David must focus on interventions to assess and improve tissue perfusion and prevent complications.

• Perform frequent neurovascular checks, including assessing pulses, capillary refill, skin temperature, color, and sensation in the affected limbs.
• Monitor for early signs of compartment syndrome, such as increased pain (if sensation is intact), worsening edema, tightness, and diminished pulses, and report these findings promptly.
• Elevate the affected extremities to reduce edema and improve venous return, while ensuring the elevation does not impede arterial circulation.
• Maintain adequate fluid resuscitation according to burn guidelines (e.g., the Parkland Formula) to support overall perfusion and prevent hypovolemic shock.
• Collaborate with the healthcare team to prepare for potential escharotomy or fasciotomy if perfusion issues persist or worsen due to circumferential burns or severe swelling.
• Document findings thoroughly to track changes in perfusion status and treatment effectiveness.

✘Incorrect answer options:

Disturbed Body Image: While burns, particularly those involving visible areas, can lead to body image disturbances, this is not the immediate priority in the first 24 hours. Physical stabilization, including addressing perfusion and preventing tissue ischemia, takes precedence during the emergent phase.

Risk for Disuse Syndrome: This diagnosis refers to the potential for complications due to immobility, such as muscle atrophy or joint stiffness. While it is a valid consideration for long-term care, it is not a priority during the emergent phase, where the focus is on stabilizing tissue perfusion and preventing further damage.

Risk for Ineffective Breathing Pattern: This diagnosis would be appropriate for burns involving the chest or airway, where inhalation injury or chest wall restriction might impair respiratory function. However, since the burns are localized to the legs and arms, there is no evidence to suggest impaired breathing in this scenario.

EXPLANATION

✔Correct answer:

“The risk of infection is substantially reduced when the burn wounds achieve closure.” The risk of infection in burn patients is highest while the wounds remain open because the damaged skin barrier—the body’s primary defense against pathogens—is compromised. Infection risk is substantially reduced once the burn wounds achieve closure through re-epithelialization or grafting, as the new skin provides a protective barrier against microbial invasion. Until then, the open wounds are highly susceptible to bacterial colonization, sepsis, and other complications, even with meticulous wound care.

Burn injuries disrupt the skin's integrity, leading to loss of the first line of defense against environmental pathogens. This, combined with immune system suppression often seen in burn patients, increases the likelihood of infection. Burn wounds provide an ideal environment for bacterial growth due to their nutrient-rich nature and the prolonged inflammatory phase during healing. Once epithelialization is complete or the wound is covered with a skin graft, the protective barrier is restored, significantly lowering the risk of infection.

Imagine the skin as a roof protecting a house. If the roof is damaged (burn injury), rain (pathogens) can easily get in and cause problems (infection). Once the roof is repaired (wound closure), the house is again protected from the elements, reducing the risk of damage.

Nurses play a crucial role in infection prevention and promoting wound healing in burn patients.

• Maintain strict aseptic technique during wound care and dressing changes to minimize the risk of introducing infections.
• Administer prescribed antibiotics or antimicrobial agents as indicated, but educate the family that antibiotics alone do not eliminate infection risk in open wounds.
• Monitor for signs of infection, such as increased wound drainage, erythema, fever, or a foul odor, and report these findings promptly.
• Educate the patient and family about the importance of nutrition, particularly protein intake, to promote wound healing and strengthen the immune response.
• Encourage adherence to physical therapy and rehabilitation to maintain mobility and prevent complications associated with prolonged immobility.

✘Incorrect answer options:

“The risk of infection will significantly decrease once he completes the prescribed course of antibiotics.” Antibiotics help treat existing infections or may be used prophylactically in burn patients, but they do not eliminate the underlying risk of infection as long as the wounds remain open. The completion of antibiotics is not the definitive point at which infection risk is reduced.

“The risk diminishes considerably once his albumin levels return to the normal range.” While albumin levels are important for overall healing and immune function, their normalization does not directly correlate with a reduced risk of infection. Open wounds remain the primary risk factor for infection in burn patients, regardless of albumin levels.

“The risk decreases once the fluid remobilization phase begins.” The fluid remobilization phase, which occurs after the initial 24-48 hours post-burn, marks a shift in fluid dynamics but does not directly impact infection risk. Open wounds still pose a significant infection risk during this phase.

EXPLANATION

✔Correct answer:

"This mask should help minimize the severity of my facial scarring." Ms. Rodriguez’s statement reflects an accurate understanding of the purpose of wearing a facial pressure garment. Pressure garments are commonly used in burn care to minimize hypertrophic scarring and improve the appearance and elasticity of healed skin. By applying constant, even pressure to the affected areas, these garments help flatten and remodel collagen deposits during the scar maturation phase. This process reduces the thickness and irregularity of scars, preventing raised or disfiguring scars that are common after burns. Facial pressure garments are a key component of rehabilitation and scar management, particularly for areas prone to cosmetic and functional concerns, such as the face.

After a burn injury, the skin heals by producing new collagen. However, in severe burns, this process can become disorganized, resulting in excessive collagen deposition and hypertrophic scarring. Pressure therapy helps regulate collagen synthesis and alignment, promoting a smoother and less visible scar.

Think of collagen as clay being molded into shape after a burn injury. The pressure garment acts like a sculptor’s hands, applying steady pressure to smooth and shape the clay (collagen) into a more even and natural form.

Nurses play a vital role in educating patients about the use of pressure garments and ensuring proper compliance.

• Explain to the patient that pressure garments should be worn for 23 hours per day (removing only for cleaning and bathing) for maximum effectiveness.
• Emphasize the importance of using the garment for the duration recommended by the healthcare team, often for 6-12 months or longer, depending on the severity of the burns.
• Ensure the garment fits properly and does not cause discomfort or restrict circulation.
• Instruct the patient on proper care of the pressure garment, including cleaning and maintenance, to prevent skin irritation or infection.
• Provide emotional support and reassurance, as wearing facial pressure garments can affect self-esteem and body image.
• Monitor the skin under the garment for any signs of breakdown, irritation, or infection, and address these promptly.

✘Incorrect answer options:

"Wearing this mask will protect my new skin from harmful sun exposure.": While protecting new skin from sun exposure is critical for burn patients, this is not the primary purpose of pressure garments. Sunscreen or other protective measures, such as wide-brimmed hats, are more appropriate for sun protection.

"This treatment will help prevent infection in my burn wounds.": Pressure garments are not used for infection prevention. Infection control is managed through proper wound care, antibiotics, and aseptic techniques. Pressure garments are typically applied after the wounds have healed.

"Using this mask will completely prevent any permanent scarring.": While pressure garments significantly reduce the severity of scarring, they cannot guarantee the complete prevention of permanent scars. Some level of scarring may persist depending on the depth and severity of the burn injury.

EXPLANATION

✔Correct answer:

Install a functioning smoke detector in every bedroom of the home. Smoke detectors are critical for early fire detection and significantly reduce the risk of death and injury in the event of a house fire. Emphasizing the need for functioning smoke detectors in every bedroom ensures that all occupants, including those who may be asleep, are alerted promptly to a potential fire hazard. Smoke detectors should also be installed in hallways outside of sleeping areas and on every level of the home, per fire safety guidelines. Testing smoke detectors regularly and replacing batteries as needed are essential components of home safety.

Fires in residential settings are a major cause of injury and death, and prompt detection can make the difference between life and death. Having smoke detectors in bedrooms provides a layer of protection because many fires occur during sleeping hours when individuals are less likely to be aware of fire hazards.

Think of smoke detectors as "alarm clocks for danger." Just like an alarm clock wakes you up for your day, smoke detectors wake you up and alert you to fire risks, giving you time to act and protect yourself.

When educating the community about home safety, it is essential for nurses to provide clear, actionable steps and emphasize the importance of routine maintenance for fire safety devices.

• Teach the community about the proper placement of smoke detectors (in every bedroom, outside sleeping areas, and on every home level).
• Instruct on testing smoke detectors monthly and replacing batteries at least once a year, or when the device signals a low battery.
• Encourage families to establish and practice a fire escape plan that includes at least two exits from each room.
• Explain the importance of replacing smoke detectors every 10 years or as recommended by the manufacturer.
• Provide information on accessing local resources or programs that provide free or low-cost smoke detectors for those in need.

✘Incorrect answer options:

Ensure chimneys are professionally cleaned every two years: While cleaning chimneys regularly is important for preventing fire hazards, such as creosote buildup, the frequency should ideally be annual, not every two years, per fire safety recommendations. Additionally, this point is less critical compared to ensuring functional smoke detectors in every bedroom.

Utilize space heaters as the primary heating source in place of gas heaters: This is not a safe practice. Space heaters pose significant fire hazards if not used properly, and they should not be relied upon as a primary heating source. It is important to educate individuals on the safe use of heating equipment and the need for proper ventilation with gas heaters.

Place carbon monoxide detectors exclusively within the garage area: This statement is incorrect because carbon monoxide (CO) detectors should not be placed only in the garage. CO detectors are crucial in all living areas where fuel-burning appliances are used, such as near bedrooms and on every home level. Exclusively placing CO detectors in the garage neglects other areas of potential CO exposure, such as near gas stoves or furnaces.

EXPLANATION

✔Correct answer:

Critically low urine output of 10 mL per hour. During the emergent (resuscitative) phase of burn care, which typically occurs within the first 24-48 hours after a burn injury, fluid shifts from the intravascular space to the interstitial tissues due to increased capillary permeability. This fluid shift leads to hypovolemia (burn shock) and reduced perfusion to vital organs, including the kidneys, often resulting in oliguria (critically low urine output, <30 mL/hour). A urine output of 10 mL/hour is a classic finding in the emergent phase and reflects inadequate renal perfusion, necessitating urgent fluid resuscitation to restore intravascular volume and support organ function.

After a severe burn, the inflammatory response causes capillaries to leak fluid, proteins, and electrolytes into the interstitial space, leading to hypovolemia, reduced cardiac output, and decreased renal perfusion. Without sufficient circulating blood volume, the kidneys cannot produce adequate urine, resulting in oliguria or anuria. Urine output is a key indicator of the effectiveness of fluid resuscitation during this critical phase.

Imagine a garden hose that is barely trickling water because the tank it draws from (intravascular fluid) is almost empty. The trickle (low urine output) shows that the tank needs to be refilled quickly (fluid resuscitation) to restore normal flow.

Nurses must closely monitor fluid status and initiate interventions promptly during the emergent phase of burn care.

• Measure urine output hourly using a Foley catheter to evaluate renal perfusion and fluid resuscitation effectiveness.
• Administer IV fluids according to the Parkland Formula or other burn resuscitation protocols to restore intravascular volume.
• Monitor for other signs of hypovolemia, such as tachycardia, hypotension, or altered mental status.
• Assess for electrolyte imbalances, particularly hyperkalemia and hyponatremia, which commonly occur during the emergent phase.
• Collaborate with the healthcare team to adjust fluid therapy based on urine output, blood pressure, and central venous pressure.

✘Incorrect answer options:

Elevated blood pressure reading of 170/100 mm Hg: Hypertension is not expected in the emergent phase of burn care. Hypotension, not hypertension, is more common due to hypovolemia from massive fluid shifts. Elevated blood pressure may be observed later if there is fluid overload or other complications, but it is not typical during the emergent phase.

Presence of foul-smelling discharge emanating from the burn wound: Foul-smelling discharge indicates infection, which is more likely to occur during the acute phase of burn care, once the risk of infection increases due to prolonged wound exposure. The emergent phase primarily focuses on fluid resuscitation and stabilization, and wound infections are less likely to be present at this early stage.

Reports of pain localized at the site of the burn injury: While burn pain is common, full-thickness burns typically destroy nerve endings, resulting in little or no sensation in the injured area. Pain is more prominent in areas of partial-thickness burns where nerve endings remain intact. Therefore, localized pain is not as expected in deep full-thickness burns.

EXPLANATION

✔Correct answer:

Switching gloves between cleaning different areas of the patient’s burn wounds. Autocontamination refers to the transfer of microorganisms from one area of the patient's body to another, often from infected to noninfected wounds or tissue. To prevent this, switching gloves between cleaning different areas of the patient's burn wounds is the most critical intervention. By changing gloves, Nurse Sophie reduces the risk of spreading bacteria or pathogens from one burn site to another, especially if one area is colonized or infected. This practice ensures that each wound is treated as a separate site, minimizing the potential for cross-contamination and subsequent infection.

Burn wounds compromise the skin’s natural barrier, creating an environment where bacteria can easily colonize. If bacteria from an infected wound are transferred to another site on the same patient, it can delay healing, increase tissue damage, and elevate the risk of systemic infection or sepsis. Changing gloves between wound sites is a simple but highly effective measure to break this chain of infection.

Think of cleaning different wounds like painting multiple walls with different colors. Using the same brush for all walls will mix the colors (bacteria) and ruin the result. Switching gloves is like using a clean brush for each wall to avoid mixing paint.

Preventing autocontamination is a key priority in burn wound care. Nurses must adopt strict infection control practices to protect the patient.

• Use separate sterile equipment and supplies for each wound area during dressing changes and wound care.
• Change gloves and wash hands between cleaning different areas of the patient’s wounds to prevent cross-contamination.
• Adhere to strict aseptic technique during dressing changes, ensuring that sterile fields are maintained at all times.
• Educate the patient and caregivers on the importance of avoiding touching or scratching their wounds to reduce the risk of spreading bacteria.
• Collaborate with the interdisciplinary team to monitor for early signs of infection, such as changes in wound drainage, erythema, or increased patient temperature.

✘Incorrect answer options:

Ensuring no equipment, like blood pressure cuffs, is shared between patients: This practice is critical for preventing cross-contamination between patients, not autocontamination within the same patient. Proper infection control measures to prevent cross-contamination are important but do not directly address the prevention of infection between different areas of a patient’s own wounds.

Applying the closed method for managing burn wounds: The closed method, which involves covering burn wounds with dressings, helps protect the wounds from external contamination but does not specifically prevent autocontamination. Autocontamination occurs when pathogens are transferred between different sites on the same patient, which is not directly addressed by the closed method.

Maintaining proper and thorough hand hygiene consistently: While hand hygiene is essential to overall infection control and reduces the risk of introducing external pathogens, it does not specifically prevent autocontamination between a patient’s own wound sites. Changing gloves between wound sites addresses this risk more directly.

EXPLANATION

✔Correct answer:

Independently performing his morning hygiene and grooming. Independently performing morning hygiene and grooming signifies a crucial step towards acceptance of a changed body image. By actively engaging in self-care activities, Mr. Davis demonstrates a willingness to interact with and care for his altered body. This behavior suggests a move away from avoidance and denial towards acknowledging and adapting to his current physical state. It represents a positive shift in self-perception and a growing sense of control over his recovery process.

Burn injuries, particularly those resulting in significant scarring or disfigurement, can profoundly impact a patient's body image and self-esteem. The psychological response can range from shock and denial to anger, depression, and anxiety. Acceptance of the altered appearance is a gradual process that involves acknowledging the changes, adapting to new physical limitations, and developing a positive self-image despite the visible differences. Engaging in self-care activities is a tangible way for patients to reconnect with their bodies and begin the process of acceptance.

Imagine someone who has lost a limb. Initially, they might avoid looking at the affected area or allowing others to see it. However, as they begin to adjust, they might start practicing using a prosthetic limb or learning new ways to perform daily tasks. This active engagement with their changed body is a sign of acceptance and adaptation. Similarly, Mr. Davis performing his own hygiene is a sign that he is beginning to accept his altered appearance.

Supporting body image adaptation in burn patients involves several key nursing interventions:

• Encourage Self-Care: Promote independence in self-care activities as tolerated. Provide assistance and support as needed but encourage the patient to take the lead in their own care.
• Therapeutic Communication: Engage in open and empathetic communication about the patient's feelings and concerns related to their appearance. Validate their emotions and provide reassurance.
• Referral to Support Groups: Connect the patient with burn support groups or other resources that can provide peer support and opportunities to share experiences with others who have undergone similar challenges.
• Body Image Counseling: Refer the patient to a mental health professional specializing in body image issues. Counseling can help the patient develop coping strategies, improve self-esteem, and address any underlying emotional distress.
• Collaboration with Interdisciplinary Team: Work collaboratively with other members of the interdisciplinary team, including occupational therapists, physical therapists, and plastic surgeons, to address the patient's physical and psychosocial needs comprehensively.

✘Incorrect answer options:

Permitting family members to manage his dressing changes. While allowing family involvement can be helpful for support, it does not directly indicate acceptance of his own body image. It could suggest reliance on others or discomfort with viewing his own wounds.

Engaging in conversations about potential future reconstructive surgeries. Discussing reconstructive surgery demonstrates a focus on improving appearance, but it doesn't necessarily signify acceptance of the current altered body image. It could reflect a desire to return to the pre-injury state rather than adapting to the present.

Consistently adhering to the prescribed pressure dressing regimen. Adherence to the pressure dressing regimen is important for scar management and wound healing, but it primarily reflects compliance with medical recommendations, not necessarily acceptance of the altered body image.

EXPLANATION

✔Correct answer:

The presence of a brassy, or “barking,” cough. A brassy, or "barking," cough is a hallmark sign of an inhalation injury. This type of injury often occurs in burn patients who have been exposed to smoke, hot gases, or chemicals during a fire. The brassy cough suggests irritation or swelling of the airway, which may be caused by thermal damage, inhalation of toxic fumes, or soot particles. This symptom is an urgent concern because it may indicate impending airway obstruction or edema, requiring immediate intervention to secure the airway.

Inhalation injuries often result in inflammation and edema of the upper and lower respiratory tract. This can lead to airway narrowing, increased secretions, and a characteristic brassy or hoarse cough. In severe cases, the injury may progress to airway obstruction, hypoxia, or respiratory failure. These patients require close monitoring for signs of respiratory distress, such as stridor, wheezing, or changes in oxygen saturation.

Imagine inhaling smoke during a fire as breathing in hot air that irritates the throat and airway, like touching your hand to a hot stove. The throat swells and becomes irritated, leading to a cough (the "barking" sound), signaling the airway is struggling to stay open.

Early identification and intervention for inhalation injuries are critical to preventing airway compromise.

• Monitor the patient’s respiratory status closely, including oxygen saturation, respiratory rate, and effort.
• Assess for other signs of inhalation injury, such as soot around the mouth or nose, singed nasal hairs, hoarseness, or stridor.
• Prepare for airway management interventions, such as intubation, if there are signs of airway compromise or worsening respiratory distress.
• Administer humidified oxygen as prescribed to support oxygenation and reduce airway irritation.
• Collaborate with the healthcare team to obtain diagnostic studies, such as bronchoscopy or arterial blood gas analysis, to confirm and assess the extent of the injury.
• Provide education to the patient and family about the potential risks of inhalation injury and the importance of reporting respiratory changes promptly.

✘Incorrect answer options:

A decrease in the patient’s blood pressure: While hypotension may occur in burn patients, especially during the hypovolemic stage of burn shock, it is not specific to inhalation injury. Hypotension is more closely related to fluid loss and systemic responses rather than airway or respiratory involvement.

Reports of nausea: Nausea can occur in burn patients due to pain, stress, or systemic effects, but it is not indicative of inhalation injury. Nausea is not specific to respiratory system involvement.

Reports of a headache: A headache in burn patients may suggest carbon monoxide poisoning, a separate condition often associated with smoke inhalation. While carbon monoxide poisoning can occur alongside inhalation injury, a headache alone is not diagnostic of an inhalation injury and does not provide direct evidence of airway compromise.

EXPLANATION

✔Correct answer:

A urine output of 50 mL per hour. The most reliable indicator of effective fluid resuscitation in a burn patient is adequate urine output, as it reflects improved renal perfusion and effective circulatory volume. A urine output of 50 mL per hour falls within the expected range for an adult (approximately 30-50 mL/hour), indicating that the kidneys are adequately perfused and the patient is maintaining proper fluid balance. In burn patients, fluid resuscitation is essential to counteract hypovolemia caused by fluid shifts from the intravascular to interstitial spaces (burn shock). Adequate urine output confirms that the resuscitation efforts are successfully restoring vascular volume and maintaining vital organ perfusion.

In the early post-burn period, large fluid shifts occur due to increased capillary permeability, resulting in hypovolemia, reduced cardiac output, and impaired organ perfusion. Fluid resuscitation restores circulating volume, stabilizes hemodynamics, and prevents organ failure. The kidneys, being highly vascularized, are sensitive to changes in perfusion and serve as an excellent indicator of fluid status.

Imagine a garden hose (vascular system) that’s been kinked, reducing water flow (blood and fluid). Once the kink is fixed (fluid resuscitation), the water flows freely again and hydrates the plants (organs), demonstrated by the plants thriving (adequate urine output).

Monitoring urine output is a critical part of evaluating fluid resuscitation in burn patients.

• Use a urinary catheter to accurately measure hourly urine output during the resuscitation phase.
• Maintain a target urine output of 30-50 mL/hour for adults or 0.5-1.0 mL/kg/hour, as per burn resuscitation guidelines.
• Monitor for signs of over-resuscitation, such as excessive urine output, pulmonary edema, or worsening peripheral edema.
• Use formulas like the Parkland Formula to calculate initial fluid resuscitation needs and adjust based on ongoing assessments.
• Regularly assess other clinical markers of fluid balance, such as blood pressure, heart rate, central venous pressure (CVP), and mental status.

✘Incorrect answer options:

A hematocrit level of 60%: A hematocrit level of 60% is abnormally high and suggests hemoconcentration, which occurs when there is insufficient fluid in the intravascular space. This finding indicates inadequate fluid resuscitation rather than effective hydration. With appropriate fluid therapy, the hematocrit should normalize as plasma volume is restored.

A heart rate of 130 beats per minute: Tachycardia (heart rate >100 bpm) is a sign of hypovolemia or inadequate fluid resuscitation. Effective resuscitation should stabilize the heart rate to within normal limits (60-100 bpm). Persistent tachycardia may also indicate pain, anxiety, or other complications requiring intervention.

An increase in peripheral edema: While some degree of peripheral edema is expected due to capillary leakage during the early phases of a burn injury, excessive or increasing edema may indicate fluid overload or inappropriate resuscitation. Effective fluid resuscitation minimizes edema by ensuring proper vascular filling without overhydration.

EXPLANATION

✔Correct answer:

The development of a wound infection. The findings of a fever (temperature of 100°F or 37.8°C), an elevated white blood cell (WBC) count of 15,000/mm³, and a white, malodorous discharge from the wound are strong indicators of a wound infection. These symptoms suggest the body's immune response to the presence of pathogens in the wound. The malodorous discharge and the elevated WBC count specifically point to an infection, as these are classic signs of a local infection progressing to systemic involvement. In burn patients, infection is a common and potentially serious complication due to the loss of the skin barrier and the nutrient-rich wound environment that supports bacterial growth.

After a burn injury, the skin's integrity is compromised, allowing microorganisms to invade the underlying tissues. Burn wounds are particularly susceptible to infection because of the necrotic tissue present, which serves as an ideal medium for bacterial colonization. As pathogens proliferate, the immune system responds by increasing WBC production and releasing inflammatory mediators, resulting in systemic signs such as fever and leukocytosis. The malodorous discharge is indicative of bacterial overgrowth and tissue breakdown.

Imagine a burn wound as an unguarded open gate in a garden. Without a barrier, pests (bacteria) invade and begin destroying the plants (tissues), leading to foul smells (discharge) and the garden's natural defense system (immune response) fighting back with reinforcements (WBCs and fever).

Nurses should take prompt action to manage wound infections and prevent complications such as sepsis.

• Perform a thorough wound assessment, including observing for signs of infection (e.g., increased redness, swelling, warmth, purulent discharge, and foul odor).
• Obtain a wound culture to identify the specific microorganism and guide appropriate antibiotic therapy.
• Administer prescribed antibiotics and monitor the patient for any adverse reactions to medications.
• Perform meticulous wound care using aseptic technique to prevent further contamination.
• Monitor vital signs regularly to detect systemic infection or early signs of sepsis.
• Educate the patient and family about proper wound hygiene and the importance of reporting changes in wound appearance or systemic symptoms.

✘Incorrect answer options:

The typical acute phase response to the initial injury: While the acute phase of a burn injury involves inflammatory responses such as mild fever and WBC elevation, the presence of malodorous discharge and the combination of findings strongly indicate infection rather than a normal inflammatory response.

The process of autodigestion of collagen within the wound: Autodigestion of collagen occurs in burn wounds as part of the natural enzymatic breakdown of damaged tissues. However, this process does not produce systemic signs such as fever, leukocytosis, or malodorous discharge.

The normal formation of granulation tissue within the burn wound: Granulation tissue forms during the proliferative phase of healing and is characterized by a healthy, red, moist appearance. It does not produce malodorous discharge, fever, or leukocytosis. These findings are indicative of infection rather than normal healing.

EXPLANATION

✔Correct answer:

Perform hand hygiene each time before entering the patient’s room. The most critical directive for ensuring patient safety and proper infection control is to emphasize hand hygiene before entering the patient’s room. Open burn wounds are highly susceptible to infection because the skin, which serves as a protective barrier, is compromised. Proper hand hygiene is the single most effective way to prevent the transmission of pathogens and healthcare-associated infections. By strictly adhering to hand hygiene protocols, the risk of cross-contamination and subsequent wound infections is significantly reduced.

Burn wounds create an ideal environment for bacterial colonization due to exposed tissue, protein-rich exudates, and compromised local immune responses. Without proper hand hygiene, healthcare workers can inadvertently transfer pathogens to the wound, leading to localized infection or systemic complications like sepsis.

Think of hands as delivery vehicles. Without cleaning them (hand hygiene), you risk delivering harmful germs to a vulnerable location (the burn wound). Clean hands are like sanitized delivery trucks ensuring no contamination occurs.

Nurses must consistently reinforce hand hygiene practices among all staff to protect burn patients from infection.

• Ensure all healthcare workers wash their hands with soap and water or use an alcohol-based hand sanitizer before and after patient contact, wound care, or handling medical equipment.
• Place visible reminders and hand hygiene stations outside the patient’s room to encourage compliance.
• Provide education on the importance of hand hygiene in preventing healthcare-associated infections (HAIs).
• Monitor adherence to hand hygiene practices and address lapses immediately to maintain high standards of infection control.
• Encourage the patient and family to also perform hand hygiene before touching the wound or dressing.

✘Incorrect answer options:

Administer the ordered tetanus toxoid injection: While it is important to administer a tetanus toxoid injection to prevent tetanus in burn patients, this task is typically within the LPN's scope of practice and is not as immediately critical for infection control as hand hygiene. Tetanus prevention addresses a specific pathogen (Clostridium tetani) but does not prevent the broad range of pathogens that can cause infections in burn wounds.

Evaluate the wounds for any signs of infection: Wound evaluation for signs of infection (e.g., redness, swelling, purulent drainage) is essential, but this is a responsibility that typically falls under the RN's scope of practice. While an LPN may assist in assessing and reporting observations, ensuring proper hand hygiene is a more fundamental and universal directive to prevent infections in the first place.

Encourage the patient to practice deep breathing and coughing: Deep breathing and coughing exercises help prevent respiratory complications, such as atelectasis or pneumonia, but they are not directly related to infection control for the open burn wound. Although this intervention is important, hand hygiene remains the top priority for preventing burn wound infections.

EXPLANATION

✔Correct answer:

An elevation in the client's serum creatinine level. An elevation in the client’s serum creatinine level suggests an adverse reaction to topical gentamicin sulfate. Gentamicin is an aminoglycoside antibiotic that carries a significant risk of nephrotoxicity (kidney damage), even when used topically on large burn wounds. This occurs because the drug can be absorbed systemically through damaged skin, particularly when applied to large surface areas. Elevated serum creatinine is an early indicator of renal impairment, reflecting a reduced ability of the kidneys to filter waste products. Early identification of nephrotoxicity is crucial to prevent progression to acute kidney injury (AKI).

Aminoglycosides, such as gentamicin, are concentrated in the renal proximal tubules, where they disrupt cellular function, leading to tubular necrosis and reduced renal clearance. Systemic absorption of gentamicin through damaged or burned skin increases the risk of this adverse effect, making it critical to monitor kidney function during its use.

Think of the kidneys as a coffee filter. If gentamicin causes damage, it’s like tearing a hole in the filter, allowing debris to pass through (reduced filtering ability), which can be detected by elevated creatinine levels.

Nurses must closely monitor renal function and address nephrotoxicity when caring for patients using gentamicin.

• Monitor serum creatinine and blood urea nitrogen (BUN) levels regularly to assess renal function.
• Assess urine output hourly, ensuring it meets the target of at least 30 mL/hour for adults, which indicates adequate kidney perfusion.
• Observe for other signs of nephrotoxicity, such as decreased urine output, swelling, or electrolyte imbalances (e.g., hyperkalemia).
• Collaborate with the healthcare provider to adjust or discontinue gentamicin if signs of nephrotoxicity appear.
• Encourage adequate hydration to support renal clearance, unless contraindicated by the patient’s condition.
• Educate the patient about potential adverse effects and the importance of reporting symptoms like reduced urination or swelling.

✘Incorrect answer options:

Exacerbated wound pain beginning 30 to 40 minutes post-application: Increased wound pain is not a typical adverse reaction to gentamicin. Pain may result from wound sensitivity, dressing changes, or improper wound care techniques but does not indicate nephrotoxicity or other systemic effects of gentamicin.

Observation of small, pale pink papules within the wound bed: The presence of pale pink papules in the wound bed may indicate granulation tissue formation, which is a normal and expected part of the wound healing process. This finding is unrelated to adverse reactions to gentamicin.

A documented decrease in the client’s white blood cell count: A decrease in white blood cell (WBC) count could indicate bone marrow suppression, which is not a common adverse effect of gentamicin. Instead, gentamicin is more commonly associated with nephrotoxicity and, less frequently, ototoxicity.

EXPLANATION

✔Correct answer:

Providing a high-protein, high-calorie diet with frequent small meals. The most effective nursing intervention to support Ms. Sanchez's recovery is to provide a high-protein, high-calorie diet with frequent small meals. Burn patients have significantly increased metabolic demands due to the hypermetabolic state triggered by the injury. This state is characterized by increased energy expenditure, protein catabolism, and nutrient loss through burn exudates. Protein is especially critical for wound healing, collagen synthesis, and preventing muscle breakdown, while additional calories are necessary to meet the energy demands of the healing process. Frequent small meals ensure adequate nutrient intake, especially if the patient experiences early satiety or gastrointestinal discomfort.

After a burn injury, the body’s metabolism increases dramatically to support the repair of damaged tissue. The body may require up to 2-3 times more calories and protein than normal, depending on the extent of the burns. Without sufficient nutrition, healing is delayed, immune function is impaired, and the patient is at higher risk of complications such as infection and weight loss.

Think of the body as a construction site after damage from a storm. The workers (healing cells) need extra supplies like bricks (protein) and fuel (calories) to repair the damage. Without enough materials and energy, the repair process slows down or stops.

Ensuring optimal nutrition in burn patients requires careful planning and monitoring.

• Collaborate with a dietitian to calculate the patient’s caloric and protein needs based on their weight, age, and total body surface area (TBSA) affected by burns.
• Encourage high-protein foods such as lean meats, eggs, dairy products, legumes, and protein supplements.
• Include calorie-dense foods like nuts, avocados, and whole grains to meet increased energy demands.
• Provide small, frequent meals to improve nutrient intake, particularly if the patient has a reduced appetite or gastrointestinal discomfort.
• Monitor for signs of malnutrition, such as unintentional weight loss, delayed wound healing, or decreased muscle mass.
• Consider enteral feeding (via nasogastric or gastrostomy tube) if oral intake is insufficient to meet the patient’s needs.

✘Incorrect answer options:

Encouraging a low-fat, low-calorie diet to prevent weight gain: A low-fat, low-calorie diet is contraindicated for burn patients. These patients require a calorie surplus to meet their heightened energy demands and support the healing process. Restricting calories or fats can lead to delayed wound healing and further complications.

Limiting fluid intake to avoid edema in the healing areas: Fluid restriction is not appropriate in burn care unless the patient has specific conditions such as heart failure or renal impairment. Adequate hydration is essential for maintaining perfusion to tissues, supporting wound healing, and preventing complications like dehydration.

Recommending intermittent fasting to promote metabolic efficiency: Intermittent fasting is not appropriate for burn patients. Extended fasting periods can exacerbate catabolism (muscle breakdown) and impair the healing process. Burn patients require continuous nutrient intake to meet their metabolic demands and maintain an anabolic state for tissue repair.

EXPLANATION

✔Correct answer:

Serum Creatinine levels. Gentamicin sulfate (Garamycin) is an aminoglycoside antibiotic commonly used in burn wound care to prevent or treat bacterial infections. However, aminoglycosides are nephrotoxic and can cause acute kidney injury, particularly with prolonged use or in patients with pre-existing renal impairment. Monitoring serum creatinine levels is essential because creatinine is a reliable marker of renal function. An increase in creatinine levels can indicate nephrotoxicity, necessitating adjustment or discontinuation of the medication. Early detection of renal dysfunction helps prevent long-term kidney damage.

Aminoglycosides accumulate in the renal proximal tubular cells, disrupting normal cellular function and causing apoptosis or necrosis. This process leads to impaired filtration and kidney damage, manifesting as elevated serum creatinine and reduced glomerular filtration rate (GFR).

Think of the kidneys as water filters. Using gentamicin is like running slightly gritty water through the filters. Over time, the grit (nephrotoxicity) can clog or damage the filters (kidneys), making them less efficient. Monitoring creatinine levels is like checking how well the filters are working.

Nurses must be vigilant in monitoring renal function and minimizing the risks of gentamicin therapy.

• Assess baseline and periodic serum creatinine and blood urea nitrogen (BUN) levels during gentamicin therapy.
• Evaluate urine output and report any significant decrease, as this could indicate renal impairment.
• Educate the patient about signs of nephrotoxicity, such as reduced urine output, swelling, or changes in urine color.
• Ensure adequate hydration to help minimize the risk of nephrotoxicity.
• Collaborate with the healthcare provider to adjust the dose or frequency of gentamicin administration based on renal function.

✘Incorrect answer options:

Red blood cell count: Gentamicin does not directly affect red blood cell (RBC) production or cause anemia. Monitoring RBC levels is not a priority when administering gentamicin.

Serum Sodium levels: Gentamicin is not known to directly affect sodium levels. Electrolyte imbalances, such as hyponatremia, are not typical adverse effects of gentamicin.

Serum Magnesium levels: While gentamicin can sometimes cause hypomagnesemia, this is not as common or as critical as its nephrotoxic effects. Monitoring magnesium levels may be necessary in certain high-risk patients but is not the primary concern.