“Intelligence is like a river:

the deeper it is,

the less noise it makes.”
-- Milwaukee Journal Sentine
An adult’s shirt catches on fire and is now in flames.
He panics and runs into his neighbor’s yard.
Which of the following intervention is appropriate?
Select all that apply.
____ 1. Dousing the flames with water.
____ 2. Removing his burned clothing.
____ 3. Removing his jewelry.
____ 4. Rolling him on the ground.

1, 3, 4
A 78-year-old man is admitted with severe
flame burns resulting from smoking in bed.
The nurse can expect his room environment
to include

a. Strict isolation techniques and policies.

b. A semi-private room.
c. Liberal unrestricted visiting.
d. Equipment shared between the client and
the other burn client in the unit.

A
A 23-year-old factory worker was burned
severely in an industrial accident. He has 2 nd
degree burns on his right leg and arm and
on his back. He has 3rd degree burns on his
left arm.
The triage nurse, using the rule of nines,
estimates the extent of the client’s burns as
___%.

54%
A client has suffered a chemical burn.
The best initial action is to:

a. Roll the client in a blanket.

b. Secure lead-lined gloves and move the client
away from the chemical.
c. Flush the area with copious amounts
of water or normal saline.
d. If the chemical is an acid, neutralize with a base.

c.
Deep partial-thickness burns involves the

a. epidermis only
b. entire epidermis and the upper portion
of the dermis
c. epidermis and the entire dermal layer
d. epidermis, the dermis, and the muscle

c
Visual inspection of a full-thickness burn
would reveal:

a. A swollen reddened area that blanches

when pressure is applied
b. Blisters of varying sizes with a
cherry-red base
c. Moist skin surface with a mottled,
reddened are
d. Dry skin surface with a pearly-white or
charred appearance

d
Burns
- Refers to injuries that result
from direct contact with or
exposure to any thermal,
chemical, electrical or
radiation source.
- Destruction of the layers skin or other body parts
causing loss of intracellular fluid and electrolytes.
- Involves painful treatment and long period

of rehabilitation
CAUSES:

• CHEMICAL
• ELECTRICAL
• MECHANICAL
• RADIATION
• THERMAL
Smoke inhalation
-Occurs when smoke
(particular products of fire, gases & superheated air)
 causes respiratory tissue damage
Classification of Burns
Burn injuries – described according to the
a. DEPTH of the injury
b. extent of surface area injured
Classification according to DEPTH
 Superficial-Partial Thickness
“1st degree burn”
 Epidermis (upper dermis)
 Reddened; blanches with pressure
 Dry or with minimal or no edema
 Possible blisters
 (may be) painful

 Soothed by cooling
 No scarring;
 Peeling
 Recovery in a week
Classification according to DEPTH
 Deep Partial Thickness
“2nd degree burn”
 Epidermis & entire dermis
 Blistered; mottled red base

 Edema
 Painful
 Sensitive to cold air
 Depigmentation contractures
 Recovery in 2-4 weeks
Classification according to DEPTH
 Full-Thickness
“3rd degree burn”
 Epidermis; entire dermis & subcutaneous tissue
 Dry, pale white, leathery or charred

 Edema
 Painless
 Shock; Hematuria
 Hemolysis
 Needs grafting
 Scarring and contractures
Deep Full-Thickness
“4th degree burn”
• extend through muscle, bone and internal tissues
 BURN DEPTH
I. Partial thickness
a. Superficial partial
thickness burn
- 1st degree
- epidermis, upper dermis
b. Deep partial
thickness burn
- 2nd degree
- epidermis, dermis
II. Full thickness burn
3rd degree – (FT) skin and SQ tissue
4th degree – (DFT) skin, SQ tissue, muscle, bones
 Classification according to
EXTENT of
BODY SURFACED AREA INJURED

Burn Assessment (TBSA)

> Rule of Nines

> Lund and Browder Chart
> Palm Method
Rule
of
Nines
 Lund and Browder Chart

- More precise method of

estimating the extent
of burn injury

- “percentage of
surface area of
various anatomic parts
(head and legs)
changes with growth”

- “TBSA changes with age”

Palm Method
- Indicated for scattered burns
- client’s palm is approximately 1% of the TBSA
The nurse is planning care for an adult man
who is admitted with severe flame burns.
Nursing care planning is based on the knowledge
that the first 24-48 hours post-burn are characterized by:

a. An increase in the total volume of intravascular plasma.

b. Excessive renal perfusion with diuresis.
c. Fluid shift from interstitial spaces to plasma.
d. Fluid shift from plasma to interstitial spaces.

d.
 Stages of Burn Injury
I. Shock Phase
 1st 24 - 48 hours
 Shifting of fluid, Na, CHON
from IVC to interstitial spaces
 Hypovolemia/shock
 Release of Catecholamines
 Hyponatremia
 Hyperkalemia
 Decreased urine output
 Hemoconcentration
 Metabolic Acidosis
A nurse is providing care for a severely burned client
during the shock phase of the burn injury.
Which assessment findings would indicate that the client
is receiving adequate fluid volume replacement?

a. Urine output 20 ml/h, CVP 3, weak pulses,

K+ level of 5.3
b. Urine output 50 ml/h, BP 100/60,
oriented to person and place.
c. Weak thready pulses, BP 70/40,
pulse 130, Hct 52%.
d. Restlessness, confusion, urine output 15 ml/h,
rapidly increasing weight.
b
The nurse is caring for an adult who was admitted
following severe burns sustained in a house fire.
The nurse understands that an acceptable range for
hourly urine output during the first 2 days post-burn is:

a. 20 ml
b. 30-50 ml
c. 100-150 ml
d. 150-200 ml

b.
 Stages of Burn Injury
II. Diuretic Phase
 48 to 72 hrs after injury
 Capillaries regain integrity
 Fluid returns to IVS
 Increased blood volume
 Increased urine output
 Hypervolemia
 Hemodilution
 Diuresis
 Hypokalemia
 Hyponatremia
 Stages of Burn Injury

III. Recovery
Phase

 Convalescent phase
 5th day onwards
 starts when diuresis is completed and
wound healing and coverage begin
During the first 24 hours post burn,
there is a shift of fluid from the intravascular
compartment to the burn site.
The nurse should expect a decreased:

a. Specific gravity of urine

b. Hematocrit
c. Serum potassium
d. Urinary output

d
During the stage of diuresis there is resorption
of fluid into the intravascular and increased urinary
output. Which electrolyte imbalance is most
frequently associated with this stage?

1.Hypernatremia, hyperkalemia, carbonic acid deficit

2.Hyponatremia, hyperkalemia, bicarbonate excess
3.Hyponatremia, hypokalemia, bicarbonate deficit
4.Hypernatremia, hypokalemia, carbonate acid excess

c.
Mr. W. H. is a 30-year-old man with
three children, D., A., and S.

While barbecuing at an outdoor pool party,

he sustains second and third degree burns
of the anterior portion of both arms,
the upper half of his anterior trunk,
and the anterior and posterior positions
of his left legs.
Immediate care of burns at the scene of the
accident includes stopping the burning
process. This can be done by:

a. immersing the burned in ice water

b. applying Vaseline to the burned areas
c. flushing the burned area with solution
of tannic acid
d. covering the burned area with moist,
sterile dressings

d.
second and third degree burns of the anterior
portion of both arms, the upper half of his
anterior trunk, and the anterior and posterior
positions of his left legs.

Mr. H. is brought to the emergency room.

Based on the rule of nines, which percentage
is the best estimate of the extent of Mr. H’s
burns?
a. 27 c. 36
b. 45 d. 54
c.
What is the priority of care in the
emergency room during the initial
management of the burn client?

a. Obtaining a medical history

b. Caring for the burn would
c. Providing for fluid needs
d. Administering tetanus antitoxin
as prescribed

c.
 Management
of Burns
PHASES OF BURN CARE

I. EMERGENT / RESUSCITATIVE PHASE

II. ACUTE / INTERMEDIATE PHASE

III.REHABILITATION
A 25-year-old electrical worker has come in
contact with a live power line. He is unconscious and
is lying across the power line. The best initial action is to:

a. Move the person away from the power line using

a wooden pole.
b. Cover the person with a blanket.
c. Grab the person and pull him away from the power lines.
d. Flush the wound with copious amounts of water.

a
 I. Emergent / Resuscitative Phase

- from onset of injury to completion of fluid resuscitation

- first 24 – 48 hours

- “on the scene care”

- first priority -“PREVENT INJURY TO THE RESCUER”

- request for - “FIRE & EMERGENCY MEDICAL SERVISES”
I. Emergent Phase

R - RESCUE
A - ALARM
C - CONTAIN
E - EXTINGUISH / EVACUATE
 I. Emergent Phase

Major concern:

“life-threatening airway & breathing problems”

 I. Emergent Phase
PRIORITIES

FIRST AID
“ABC” of trauma care

• AIRWAY
• BREATHING
• CIRCULATION
 I. Emergent Phase
A. “AIRWAY MANAGEMENT”

1.O2 administration

2.Coughing / suctioning

3.Bronchodilators & mucolytics

4.Endotracheal intubation &

mechanical ventilation
 I. Emergent Phase

B. PREVENTION
OF SHOCK

1.Insert large bore IV catheter (gauge 16-18)

in non-burned area
2. IV fluid administration – large amount
3. CVP insertion
4. Catheterization
 fluid
resuscitation

-Adequacy of fluid resuscitation is determined by:

“URINE OUTPUT” – renal perfusion index

GOAL: a. UO – 30 to 50 ml/hr (0.5 to 1.0 ml/kg/hr)

b. SBP - > 100mmhg
c. PR - < 110 beats/min
 I. Emergent Phase
B. PREVENTION OF SHOCK
GUIDELINES & FORMULAS
FOR FLUID REPLACEMENT THERAPY

CONCESUS FORMULA
- Lactated Ringer’s Solution (other balanced saline solution)
- 2 – 4 ml x kg body weight x % TBSA burned
- half to be given in first 8 hours
- remaining half to be given over the next 16 hours
Weight – 50kg, TBSA burned – 36%
The physician has ordered 3, 600 milliliters of
intravenous fluid to be given during the first 8
hours at a rate of 450 ml/hr. The nurse should
recognize that the :

a. Amount is within the normal range for

a burned client
b. Physician’s orders should be questioned
as soon as possible
c. Physician probably means 45 ml/hr
d. Maximum amount of intravenous fluid for
a 24-hour period is 4, 000 milliliters
4ml x 50kg x 36% = 7200 ÷ 2 = 3600ml
a. 450ml x 8 hours = 3600ml
 GUIDELINES & FORMULAS
FOR FLUID REPLACEMENT THERAPY

a. EVANS FORMULA
b. BROOKE ARMY FORMULA
c. PARKLAND / BAXTER FORMULA
d. HYPERTONIC SALINE SOLUTION
An adult was burned in a house fire 16 hours ago.
She suffered second-and third-degree burns over 65%
of her body. She is receiving lactated Ringer’s at 200ml/h.
Which intervention is a priority at this time?

a. Monitoring hourly urine output.

b. Assessing for signs and symptoms of infection.
c. Performing range of motion q 1-2 h.
d. Meeting the high caloric needs of the client.

a.
 Formulas are only a guide.
Client’s response, evidenced by
HR, BP & UO,
is the primary determinant of
actual fluid therapy and
must be assessed at least hourly.

Client outcomes are improved by

optimal fluid resuscitation
Mr. H. becomes confused and shouts whenever
anyone enters the room. His CVP reading is 18
centimeters, and he has a 2.2-kiligram (5-pound)
weight gain and a urine output of 100 ml/hr.
The nurse should recognize these as signs of

a. The diuretic stage

b. Hypovolemia
c. Circulatory overload
d. Septic shock

c
 I. Emergent Phase

C. CERVICAL
IMMOBILIZATION

D. CARDIAC
MONITORING

E. DETECTION & TREATMENT OF

CONCOMITANT INJURIES
- “secondary head-to-toe survey”
F. WOUND ASSESSMENT & INITIAL CARE
I. Emergent
Phase
“INITIAL CARE”
 EXTINGUISH the flames
 COOL the burn (not cold)

 REMOVE restrictive clothing prn

 COVER the wound - no ointment/lotions

 IRRIGATE - chemical burn

 I. Emergent Phase

 Insert NGT:
- RISK FOR ASPIRATION
- no food or fluid by mouth

 Pain relief: morphine, fentanyl

 Tetanus Prophylaxis, topical antibiotics
 Address psychological needs:
- patient and family
I. Emergent Phase
Airway
Breathing
Circulation

Disability
Exposure
Fluid Resuscitation
The nurse is caring for a man admitted with
severe burns sustained when his clothing
caught acute burn phase, the nurse explains
to the man that his nursing care plan is directed
toward all of the following except:
1.Strict aseptic technique.
2.Proper alignment of all joints.
3.Maintenance of fluid and electrolyte balance.
4.Frequent and routine administration of narcotics.

D – narcotics- given only after careful assessment

in this phase due to the danger of
Shock and Respiratory Depression
II. ACUTE / INTERMEDIATE PHASE

- Begins 48 – 72 hours
after burn injury
- beginning of diuresis
to near completion of
wound closure

PRIORITIES
1. PREVENTION & TREATMENT
OF COMPLICATIONS
2. PAIN MANAGEMENT
3. WOUND CARE AND CLOSURE
4. NUTRITIONAL SUPPORT
II. ACUTE / INTERMEDIATE PHASE

1. PREVENTION & TREATMENT

OF COMPLICATIONS
a. Continued assessment and maintenance of
respiratory & circulatory status, F & E balance,
and GI function
Aspergillus infection of Burn wound
 PREVENTION & TREATMENT
OF COMPLICATIONS

b. Infection
Control

- Standard precaution

- Isolation technique
Medications
 Topical Antibacterials
 Silver sulfadiazine (Silvadene)
 Mafenide acetate (Sulfamylon)
 Silver nitrate
 The physician has prescribed mafenide acetate
(Sulfamylon) for the burn site every 12 hours.
In anticipating Mr. H’s needs, the nurse should
recognize that:

a. There is a great deal of pain associated with the

application of the preparation
b. A thick layer (1/4 inch) of Sulfamylon should be
applied to the burn area for maximum effect
c. The application of Sulfamylon is most effective
when covered with pressure dressings
d. The medication is antibacterial, so it is not
necessary to use sterile techniques

a.
A client with severe burns is receiving IV Zantac.
Which statement best explains the reason for
administration of this medication in this situation?
a. The client was treated for gastritis several years ago.
b. The medication will reduce hypoxemia in burn clients.
c. The medication is an H 2 receptor antagonist and will
decrease acid secretion.
d. The medication will aid in removal of
pulmonary secretions.

c
 Medications
 Antiulcer: Magnesium/Aluminum
Cimetidine; Ranitidine
Sucralfate
 Anti-anxiety: Lorazepam
 Antibiotic: Gentamicin
 Anti-infectives: Neomycin

 Colloid: Albumin 5%
 Vitamins
II. ACUTE / INTERMEDIATE PHASE

2. PAIN MANAGEMENT

- analgesic of choice – MORPHINE SULFATE

-FENTANYL
-OXYCODONE
(oxycontin)

- NSAIDS
3. WOUND CARE AND CLOSURE

•Hydrotherapy
•Shower
•Shower carts

- Water temperature – 37.8C (100F)

- Room temperature – 26.6 – 29.4C (80 – 85F)

Hydrotherapy
-limited to 20 -30 minutes – prevent chilling and
additional metabolic stress
Wound Debridement

 Natural

 Mechanical

 Surgical
A client has undergone a skin graft.
Which finding most likely indicates that
complications with the recipient site may exist?

a. Small amounts of blood beneath the graft.

b. Small amounts of serum beneath the graft.
c. A meshed pattern in the graft.
d. Continuous bleeding beneath the graft.

Ans. d
A client with a skin graft has undergone a full
thickness skin graft from her right upper thigh to
her upper chest area. The most appropriate nursing
action in caring for her donor site is to:
a. Keep the fine mesh gauze dressing on her chest
soaked with normal saline.
b. Completely immobilize her right upper thigh area.
c. Maintain the compression bandage on her
right upper thigh for several days.
d. Remove the nylon fabric adhered to the donor site
no later than two to three days after grafting has
taken place.

c
An adult has undergone a skin graft from his
left buttock to his right upper thigh.
When caring for the recipient site,
the nurse can expect to:

a. Apply silver sulfadiazine to promote rapid healing.

b. Assess for bleeding and large amounts
of fluid accumulation beneath the graft.
c. Encourage the client to ambulate and
do leg lifts on return from OR.
d. Encourage the client to take frequent
soaking baths to relieve his soreness and discomfort.

b.
II. ACUTE / INTERMEDIATE PHASE

4. NUTRITIONAL SUPPORT
III. Rehabilitative Phase Priorities
 Prevention of scars and contractures
 Physical, occupational and vocal rehab
 Functional and cosmetic reconstruction
 Psychosocial counseling
P. L. 28 years old, is admitted to the hospital
with partial-thickness burns of the face and neck.

He sustained the burns while putting out of fire

that involved all industrial substances.
In an initial nursing assessment of Mr. L.,
which nursing action would be the most important?

a. Determining how he felt about his facial injuries

b. Assessing for changes in the circumference of his neck
c. Observing for signs of increased intracranial pressure
d. Weighing him after his clothes are removed

Ans. b
Which finding would be the most significant
in determining whether airway obstruction may
occur in Mr. L?

a. A PO2 of 73 mmHg
b. A cough that produces whitish sputum
c. Complaints of neck pain
d. Singed nasal hair

Ans. d
The nurse should expect which procedures
to be performed within two hours after
the burn injury?
a. Tracheostomy
b. Escharotomy
c. Intubation
d. Chest tube insertion

Ans. B
Escharotomy – a linear excision made through
the eschar to release constriction
of underlying tissue
 Biologic Dressings
 Homografts (allografts)
 Living or deceased skin
 Stored in skin banks
 Revascularizes in 48 hrs.
 Can be left in place
for several weeks

 Heterografts (xenografts)
 From animals (usu. Pigs)
 Does not revascularize

 Amnion (amniotic membrane)

 Least expensive
 Does not revascularize