The family of a client who has been burned asks at what point the client will no longer be at greater risk for infection. What is the nurse’s best response?
Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open.
The client with a new burn injury asks the nurse why he is receiving intravenous cimetidine (Tagamet). What is the nurse’s best response?
Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement, prevent hypovolemic shock, or prevent kidney damage.
The client who is burned is drooling and having difficulty swallowing. Which action will the nurse take first?
Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his airway because of this injury. The absence of breath sounds over the trachea and mainstem bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important to assess oxygenation to the brain. Ascertaining time of last food intake is important in case intubation is necessary (the nurse would be more alert for the signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.
The nurse should teach the community that a minor burn injury could be caused by what common occurrence?
Minor burns are common occurrences. The use of space heaters can cause a fire if clothing, bedding and other flammable objects are near them. Chimneys should be swept each year to prevent creosote build-up and resultant fire. Burn injuries do not commonly occur from microwave cooking, but rather when taking food from this oven. Lastly, sunscreen agents are recommended to prevent sunburn.
The nurse is conducting a home safety class. It is most important for the nurse to include which information in the teaching plan?
Everyone should use smoke detectors and carbon monoxide detectors in their home environment (just not in a garage). Recommendations are that each bedroom has a separate smoke detector. Space heaters can be a cause of fire if clothing, bedding, and other flammable objects are nearby.
The client with facial burns asks the nurse if he will ever look the same. Which response is best for the nurse to provide?
Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. Pressure dressings prevent further scarring. They cannot remove scars. The client and family should be taught the expected cosmetic outcomes.
The client with open burn wounds begins to have diarrhea. The client is found to have a below-normal temperature, with a white blood cell count of 4000/mm3. Which is the nurse’s best action?
These findings are associated with systemic gram-negative infection and sepsis. To verify that sepsis is occurring, cultures of the wound and blood must be taken to determine the appropriate antibiotic to be started. Continuing just to monitor the situation can lead to septic shock. Increasing the temperature in the room may make the client more comfortable, but the priority is finding out if the client has sepsis and treating it before it becomes a shock situation. Increasing the rate of intravenous fluids may be done to replace fluid losses with diarrhea, but is not the priority action.
The nurse uses topical gentamicin sulfate (Garamycin) on a client’s burn injury. Which laboratory value will the nurse monitor?
Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Topical gentamicin will not affect the red blood cell count or sodium or magnesium level.
The client with a full-thickness burn is being discharged to home after a month in the hospital. His wounds are minimally opened and he will be receiving home care. Which nursing diagnosis has the highest priority?
Recovery from a burn injury requires a lot of work on the part of the client and significant others. The client is seldom restored to his or her preburn level of functioning. Adjustments to changes in appearance, family structure, employment opportunities, role, and functional limitations are only a few of the numerous life-changing alterations that must be made or overcome by the client. By the rehabilitation phase, acute pain from the injury or its treatment is no longer a problem.
The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired outcome of the procedure, which nursing action will be carried out first?
All steps are part of the nonsurgical wound care for clients with burn injuries. The first step in this process is removing exudates and necrotic tissue.
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