CBRN Review 3

While examining a pink burn wound, the nurse should press on the wound to assess: 

• pain. 

• infection. 

• fluctuance. 

• blanching. 

• blanching. 

Comments: Assessing for blanching is a fundamental part of burn wound assessment, as it is an indicator of adequate perfusion for wound healing. Presence of blanching indicates a partial thickness burn, as opposed to full thickness. Fluctuance is rare in the burn wound, as cellulitis is more common in this population. Burn nurses use validated pain assessment tools to assess pain in the burn patient. Infection is assessed as redness, warmth, and drainage from the wound.

When caring for a patient with necrotizing fasciitis, who has undergone complete debridement of necrotic tissues, the nurse recognizes the PRIORITY treatment is: 

• Antibiotics 

• Pain medication 

• Hyperbaric oxygen 

• Topical steroids 

• Antibiotics 

Comments: The key components in management of necrotizing fasciitis include radical surgical intervention and antibiotic therapy. Although hyperbaric therapy, pain medication and topical steroids can be beneficial treatments, none of those treatments should delay surgery or antibiotic therapy.  

In order to optimize wound healing in the burn patient, the nurse understands that the patient needs: 

• Vitamin E supplementation. 

• To restrict free water intake. 

• Vitamin C supplementation. 

• To reduce intake of fats. 

• Vitamin C supplementation. 

Comments: Vitamin C is essential for wound healing as it aids in collagen formation. Deficiencies in vitamin C are directly related to delays in wound healing. Vitamin E, fat intake, and free water intake do not have this direct impact on wound healing. 

A patient underwent surgical debridement with placement of a xenograft. Several days later during a dressing change, it is noted that the graft looks pale. The nurse understands: 

• color in the graft will appear later. 

• this is an expected finding. 

• the wound bed has become infected. 

• this represents graft failure. 

• this is an expected finding. 

Comments: Xenografts do not vascularize to their color will always appear pale even when they adhere to the wound bed. If a graft fails, it will not adhere to the wound bed. An infected graft will be malodorous with discharge. 

A burn nurse is applying a self adherent compressive wrap to a hand burn. The wrap is correctly applied when: 

• It is stretched no more than 25% of the strip. 

• It covers fingertips and web spaces. 

• It is wrapped proximal to distal. 

• The dressing is two layers thick. 

• It is stretched no more than 25% of the strip. 

Comments: Self adherent compressive wraps (such as Coban) are an effective compressive dressing option for hands when the tissue is too fragile yet for a glove. Correct application is prudent to avoid potential injury. When applying, the individual strips should only be stretched up to 25% to prevent the tourniquet effect of the dressing as it tightens around fingers and the hand. Fingertips should be left exposed to observe capillary refill.  

An adult patient presents to the burn unit following an apartment fire and the burn nurse prepares to draw labs. Which of the following symptoms would indicate to the nurse that the patient’s carboxyhemoglobin level is likely above 60%? 

• Cyanosis and tachypnea 

• Weak pulse and irregular respirations 

• Severe headache and blurred vision 

• Nausea and increased heart rate 

• Weak pulse and irregular respirations 

Comments: Patients exhibit symptoms such as weak pulse and irregular respirations, such as Cheyne-Stokes, with carboxyhemoglobin levels above 60%. Severe headache and blurred vision are symptoms associated with levels between 30%-40%. Nausea and increased heart rate is seen in levels between 40%-50%. Oxygenation is not typically affected. 

A patient with a 60% TBSA burn returns to the intensive care unit from the surgical suite following skin grafting with the following vital signs: 

HR 120 beats/min 
RR 16 breaths/min 
BP 112/66 mmHg 
Temp 35.1 (axillary) 
Pulse oximetry 98% (FiO2 40% ventilated) 
Estimated blood loss is 200 mL. 

What is the FIRST action of the burn nurse? 

• Administer pain medication as ordered. 

• Administer a fluid bolus of lactated Ringers solution. 

• Obtain a complete blood count. 

• Initiate passive rewarming measures. 

• Initiate passive rewarming measures. 

Comments: Alterations in skin integrity impact the ability of the burn patient to thermoregulate, and hypothermia is commonly experienced during and after surgery due to prolonged exposure. Hypothermia is further exacerbated by the reduced ability of the postoperative patient to generate heat due to general anesthesia. Hypothermia causes coagulopathies which can result in larger blood losses leading to hemodynamic instability, and increases the already extreme metabolic demand of the burn patient. Pain is expected after a grafting procedure, but does not take precedence over thermoregulation. A CBC and fluid bolus are not indicated at this time, as the reported EBL was 200ml and the BP is within normal limits.

A 6 year-old male patient presents to the hospital after spilling boiling hot soup into their lap. The child has 5% TBSA full thickness burns to his thighs, perineum and penis. Which intervention will MOST likely be indicated? 

• Bladder irrigation 

• Fluid resuscitation 

• Indwelling catheter 

• Fluid restriction 

• Indwelling catheter 

Comments: Partial-thickness burns of the genitalia do not require urinary catheter placement unless indicated for other reasons (such as monitoring of resuscitation). Full-thickness burns of the penis may require insertion of a urinary catheter in case of severe swelling to maintain the patency of the urethra. Scrotal swelling, though often significant, does not require specific treatment other than reassurance. 

A 25-year-old patient who was struck by lightning 24 hours ago now has dark urine. Apart from high-volume fluid administration, the nurse should also anticipate orders for: 

• sodium bicarbonate. 

• continuous renal replacement therapy. 

• spironolactone (Aldactone) 

• fresh frozen plasma. 

• sodium bicarbonate. 

Comments: A treatment goal for rhabdomyolysis is to flush the kidneys with high volume. Increasing the urine output to 150 mL/hr helps to “push” the myoglobinuria through the kidneys and decrease the risk of acute kidney injury. Administration of sodium bicarbonate is a treatment to alkalinize the urine when myoglobin is present. Continuous renal replacement therapy (CCRT) is indicated in instances of acute renal failure but is initiated later in the progression of the acute injury and would not be anticipated early on prior to other interventions. Although loop diuretics may be utilized in some instances, Spironolactone is a potassium-sparing diuretic and is not indicated in this situations. 

Following a month long inpatient stay, a patient is accepted for transfer to a skilled nursing facility. To facilitate transfer, enteral feeds and IV medications are discontinued. Before transport, the patient becomes anxious and agitated with increases in heart rate and blood pressure, and has a seizure. What is the MOST likely cause for the change in patient condition? 

• Acute withdrawal from benzodiazepines 

• Undiagnosed seizure disorder 

• Hypoglycemia 

• Acute withdrawal from opioids

• Acute withdrawal from benzodiazepines 

Comments: Acute benzodiazepines withdrawal is signaled by symptoms of sympathetic stimulation (hypertension and tachycardia), agitation, and anxiety. In more severe instances of acute withdrawal, seizures may occur. 

An adult is extricated from a trailer fire. EMS reports the patient was confused on scene, reported shortness of breath, and had soot in their mouth and nose. The patient became obtunded and was intubated with the following ventilator settings: 

Pressure Control 12 
RR 20 breaths/min 
PEEP 8 cm H2O 
FiO2 100% 

Vital signs: 

HR: 140 beats/minute (frequent premature ventricular contractions) 
BP: 75/30 mm Hg (MAP 45) 
RR: 20 breaths/minute 
Sp02: 92% on ventilator

The burn nurse recognizes that this patient is experiencing signs and symptoms of: 

• Carbon monoxide poisoning 

• Hydrogen cyanide toxicity 

• Acute respiratory distress syndrome 

• Flash pulmonary edema 

• Hydrogen cyanide toxicity 

Comments: This patient was extricated from a house fire which carries the risk of hydrogen cyanide toxicity. They developed confusion, dyspnea, had soot in the airway, became obtunded, tachycardic with PVC's, hypotensive, and experienced respiratory arrest. Carbon monoxide poisoning is a risk to this patient, but the signs and symptoms are not correct. The described signs and symptoms do not accurately describe acute respiratory distress disorder or flash pulmonary edema. 

After sustaining an axilla burn, a child is seen for a 6-month follow up appointment. During the assessment, it is noted that the child has a large area of hypertrophic scarring and is only able to raise the arm to 120 degrees of shoulder flexion. Which of the following is the MOST appropriate intervention for this patient? 

• Alternating between active and passive range of motion exercises 

• Surgical intervention 

• Application of compression garments 

• Outpatient physical therapy 

• Surgical intervention 

Comments: When hypertrophic scarring occurs, the most effective way to restore function and help prevent new scar formation is through surgery. Scar ablation, Z-plasty, and excision and grafting are optimal in releasing the contractures.  

During the procurement of a donor site for an autograft, the infiltration of dilute epinephrine solution is routinely performed to: 

• Increase heart rate 

• Cleanse the wound bed 

• Promote perfusion 

• Reduce bleeding 

• Reduce bleeding 

Comments: Blood loss during burn surgery is a major concern. Tangential excision and grafting of burn wounds result in significant intraoperative blood loss, and infiltration of a dilute epinephrine solution (tumescence) is routinely performed to reduce such bleeding.

The burn nurse understands patients who undergo negative-pressure wound therapy are likely to experience a(n): 

• increase in bleeding. 

• reduction in early mobility. 

• increase in hypertrophic scar formation. 

• reduction in neuropathic pain. 

• reduction in neuropathic pain. 

Comments: Negative-pressure wound therapy reduces neuropathic pain by 54%. There is no evidence at this time to suggest negative-pressure wound therapy reduces scar formation or increases bleeding risk. Negative pressure wound therapy allows for early mobility

A 60 year-old welder with a past medical history of diabetes and hypertension sustained a 30% flame burn, including a circumferential burn to the right lower extremity. The next day, the patient reports new numbness and tingling to the right leg and delayed capillary refill is noted to right toes. The burn nurse is MOST concerned about which potential complication? 

• Compartment syndrome 

• Soft tissue infection 

• Peripheral neuropathy 

• Fracture 

• Compartment syndrome 

Comments: It is imperative to monitor circumferential burns closely. This occurs when the tissue under the wound becomes edematous to the point that the tissue pressure exceeds the perfusing pressure of the vasculature. This will lead to the clinical signs described by the 5 P's of pain, pallor, paresthesia, pulselessness, and paralysis. While soft tissue infection, fracture, and peripheral neuropathy are possible for this patient they are unlikely given the acute onset of the symptoms and known mechanism of injury. 

While working in their yard on home oxygen, a patient sustains a burn injury. The patient presents to a community hospital with singed nasal hairs, strong voice, and no cough. The outside hospital is asking for advice on how to treat the patient. What advice is the best choice? 

• Intubate patient 

• Administer oxygen to patient via face mask 

• Observe patient 

• Transfer patient to burn center 

• Observe patient 

Comments: Airway obstruction may occur following burns of the oropharynx, face, or neck as the tissues of the upper airway become edematous. Therefore, observation is warranted if there is any suspicion of inhalation injury. 

A patient with a partial thickness burn is being discharged. In order to reduce pain associated with dressing changes, the nurse applies: 

• A wet to dry dressing. 

• A silver-based silicone dressing. 

• A petroleum-based gauze. 

• A silver sulfadiazine cream with gauze overlay. 

• A silver-based silicone dressing. 

Comments: A silver-based silicone dressing can stay in place for several days as long as it remains clean and dry. This can greatly reduce the number of dressing changes required and therefore optimize pain management for the burn patient. Petroleum-based gauze, silver sulfadiazine cream with gauze, and wet to dry dressings must all be changed at least daily.  

When caring for a burn patient, which intervention focuses on pulmonary improvement while reducing the risk of ventilator-associated pneumonia? 

• Frequent pulmonary toilet  

• Administering oral steroid agents 

• Maintaining the head of bed less than 30 degrees 

• Obtaining routine sputum cultures 

• Frequent pulmonary toilet 

Comments: Prevention of the pulmonary component of multisystem failure is focused on interventions. Many of these interventions will be managed by the bedside nurse, such as suctioning and oral hygiene which are components of pulmonary toilet measures. 

A patient presents with a small dark leathery burn to the hand that was sustained while etching glass. The burn nurse anticipates monitoring which lab value? 

• Potassium 

• White blood cells 

• Arterial blood gas 

• Calcium 

• Calcium 

Comments: Hydrofluoric Acid is a corrosive agent used in glass etching and can penetrate the tissues, causing a liquefactive necrosis. The fluoride ion rapidly binds to free calcium in the blood and can cause hypocalcemia and cardiac arrhythmias. While the other lab values may be considered, calcium is of greatest concern with hydrofluoric acid exposure.

A patient admitted 10 hours ago with a 15% TBSA burn to bilateral upper extremities, neck and face is consistently reporting 9/10 pain with no relief after multiple administrations of pain medication. The patient is pacing in the room, diaphoretic, febrile at 38.1 C (100.6 F) orally, has had several loose bowel movements, and is yawning regularly. The burn nurse recognizes the patient is showing signs of: 

• C. difficile infection 

• Anxiety disorder 

• Opioid withdrawal 

• Sepsis 

• Opioid withdrawal 

Comments: Pacing, diaphoresis, fever, diarrhea, and yawning are all signs on opioid withdrawal. This in combination with the timing of the admission, the patient is most likely experiencing opioid withdrawal. While a fever is one sign of sepsis, this patient is not showing any other signs of sepsis and it is early into the recovery it unlikely their symptoms are caused by sepsis. It is unlikely this patient is experiencing a c. difficile infection within the short time of admission and no antibiotics have been administered 

A patient grafted 3 weeks ago is experiencing severe pruritis at their donor site. Which of the following might exacerbate this symptom? 

• Massage with mineral oil 

• Administration of PO Zyrtec 

• Application of scented body lotion 

• Application of compression garment 

• Application of scented body lotion 

Comments: This patient may be experiencing contact dermatitis secondary to newly epithelized skin. The scented body lotion may further irritate the healing area and increase the patient's pruritis. Zyrtec is an antihistamine and would not exacerbate this symptom. Compression and massage will help with the itching. 

The burn nurse recognizes that a burn patient can be managed in the outpatient setting when which of the following criteria have been met? 

• Independence in activities of daily living, has appropriate transportation, and has access to dressing supplies 

• Antibiotic course has been completed, performs active range of motion, and screens negative for post-traumatic stress disorder 

• Resolution of pruritus, involvement in support group, and has adequate mobility 

• Adequate pain control, nutritional goals have been achieved, and absence of wound infection 

• Adequate pain control, nutritional goals have been achieved, and absence of wound infection 

Comments: A burn patient can be considered a candidate for outpatient management when pain is well controlled, nutrition is provided enterally, and there is no active wound infection.

After sustaining a 20% TBSA full-thickness burn 4 days ago, a patient is preparing for an excision and debridement procedure. The nurse anticipates the patient will MOST LIKELY return from the procedure after placement of: 

• dressings. 

• an artificial dermis. 

• an autograft. 

• Allograft. 

• Allograft. 

Comments: Allografts are used to induce vascularization, decrease contamination, and promote mobility in full-thickness burns. Full-thickness skin grafts are most often used on smaller areas for functional or cosmetic purposes. An artificial dermis is used in conjunction with split-thickness autografts, while escharotomies are generally performed within the first 24 hours following an injury.

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