CBRN Review 1

A burn therapist has created an individualized plan of serial casting for a patient with hand burns. Which nursing consideration applies?

• Ensure the cast is firmly fitted against the patient's hand 

• Assess exposed skin during dressing changes 

• Advise against serial casting for any burn injury 

• Advise against serial casting when an open wound is present 

Assess exposed skin during dressing changes

The burn nurse should regularly assess any exposed skin with serial casting during dressing changes and as needed. Serial cast applications are a recommended therapy for burn patients, and can be used if an open wound is present but cannot be used if there is a sign of cellulitis or infection. The cast should never fit firmly on the patient as this may cause pressure injuries and decreases circulation.

A patient returns from the operating room after excision and grafting of the back and buttocks. The patient is stable and post-operative orders state to restart their enteral nutrition. The goal rate is 100 ml/hr. At which rate should the nurse begin the infusion?

• Hold enteral feeding until the patient is out of bed to chair. 

• Start at 25 ml/hr, titrating up to 100ml/hour over 4 hours as tolerated. 

• Start at 100 ml/hr. 

• Start at 50 ml/hr for 2 hours and then increase to 100 ml/hr as tolerated. 

Start at 100 ml/hr. 

Studies have shown that after patients have been to the OR for excision and grafting, they tolerate enteral nutrition starting at goal rate immediately. Titrating the rate up is not necessary.

In a burn patient diagnosed with an acute kidney injury more than 30 days after their 75% TBSA burn injury, which of following are the MOST likely contributing factors:

• Hypovolemia and hypoxia 

• Multiple antibiotics and diuretics 

• Pain and sedation infusions 

• Electrolyte disturbances and hyper-metabolism

Multiple antibiotics and diuretics

Multiple antibiotics and diuretics are often unavoidable in large burn injury to treat sepsis. These medications can cause renal toxicity. Hypovolemia and hypoxia may lead to AKI more commonly during the early phase of a burn injury. Pain and sedation infusions may need to be used throughout the recovery period but are not the most likely causes of AKI in this scenario. Electrolyte disturbances and hyper-metabolism when managed properly do not primarily contribute to AKI.

The nurse is assessing a burn patient who is nauseated and vomiting while receiving enteral feeding. The nurse notes new onset abdominal distention and firmness, and elevated gastric residual volumes. The findings MOST likely suggest:

• gastrointestinal bleeding. 

• opioid intolerance. 

• urinary bladder retention. 

• development of an ileus. 

Development of an ileus.

Changes in the abdominal assessment, including new onset abdominal distention and firmness along with elevated gastric residual volumes, are early indicators of an ileus.

When, in the hospital course, should physical or occupational therapy intervention be initiated?

• Following surgical debridement 

• Within 48 hours of admission 

• Within 24 hours of admission 

• Following skin grafting

Within 24 hours of admission

A thorough patient history and assessment including the events leading up to the injury, pre-injury functional status, TBSA involvement, associated injuries, evaluation of range of motion, strength, and sensation of patient, activities of daily living capability, followed by a detailed treatment plan should be documented upon admission or within 24 hours of admission. While ongoing assessments and adjustments to the plan of care should occur as the clinical condition changes or post-operatively, the initial assessment should occur within 24 hours of admission.

When caring for a pregnant patient who has sustained a burn, the nurse recognizes that the MOST predictive factor for mortality of the obstetric patient is:

• Circumferential burn to the abdomen 

• Gestational age of the fetus 

• Total body surface area burned 

• Smoke inhalation 

Total body surface area burned 

The odds of mortality increase by about 1% per percentage of total body surface area burned. Therefore, the larger the burn size, the higher the risk of mortality. The second most predictive indicator is smoke inhalation due to the resulting hypoxia. Circumferential burns to the abdomen do not indicate mortality, but pregnant women are more likely to suffer from abdominal compartment syndrome and should be monitored. Gestational age of the fetus relates to the mortality of the fetus.

In order to meet the nutritional needs in a patient with a 30% TBSA burn injury, it is important to:

• Meet pre burn injury total caloric demands 

• Double the pre burn injury total caloric intake 

• Allow the patient to monitor food intake 

• Optimize nutritional support through enteral feeding

Optimize nutritional support through enteral feeding

Burn injuries create nutritional challenges for the burn patient through massive metabolic injury. It is important to optimize nutritional support through enteral feeding as the primary line of administration. Overfeeding is counterproductive in improving patient outcomes through exceeding the limit of glucose oxidation and fat-based calories. It is important to measure caloric needs post burn injury to ensure appropriate nutritional support is met. While the patient may be able to eat orally, it is important for the burn nurse to carefully monitor intake to ensure protein-caloric intake needs are met.

72 hours post resuscitation, a 3 year-old burn patient’s morning chemistry results reveal the following:

Sodium - 130
Potassium - 4.2
Chloride - 103
Carbon dioxide - 25
BUN - 6
Creatinine - 0.3
Glucose - 90
Phosphorus - 1.2
Magnesium - 2.0

Currently infusing via the intravenous route is: D5 1/2NS + 10 KCL @ 30ml/hr. The nurse should anticipate the following order:

• Adjustment to D5 NS + KCl

• Decreasing the rate of maintenance fluids. 

• Increasing the rate of maintenance fluids. 

• Adjustment to lactated Ringer's solution. 

Adjustment to D5 NS + KCl

Hyponatremia is a common post-resuscitation complication in pediatric patients due to young children’s inability to reabsorb sodium. Administering medications in 5% dextrose or 1/2 normal saline may lead to hyponatremia thus, hypotonic fluids should be avoided in the post-resuscitative phase for the pediatric patient population. Increasing or decreasing the rate will not mitigate, and may worsen, the risk of hyponatremia. Pediatric patients are also at risk of hypoglycemia secondary to decreased/diminished glycogen stores and therefore usually require a glucose source when administering maintenance fluids. Therefore, changing to a maintenance fluid that is not hypotonic (i.e. 1/2 NS to NS) while keeping a sugar source (in the form of 5% dextrose) we can best mitigate both hyponatremia and hypoglycemia.

A burn nurse is performing wound care on an intubated patient receiving ketamine (Ketalar). Which of the following is performed prior to initiation of wound care?

• Put the patient in restraints. 

• Play high-tempo music. 

• Cover the patient's eyes.

• Ensure NPO status for at least 8 hours. 

• Cover the patient's eyes. 

Comments: Ketamine is commonly used in the burn population as adjunct pain management. Due to its dissociative properties, the nurse provides a calm environment with decreased stimulation during its administration. This includes covering the eyes, as ketamine often causes patients to leave their eyes open during duration of action. Playing high-tempo music is not indicated, as it would increase the level of patient stimulation. NPO status is contraindicated in the burn patient, as nutrition delivery is vital for wound healing. Putting the patient in restraints is not required for ketamine administration.

A patient presents for follow-up in the clinic after sustaining a face and ear burn injury from a firework explosion 2 months ago. The patient complains of new onset hearing loss. The nurse anticipates:

• removing all head dressings 

• an order for a CT scan 

• assessment of the inner ear 

• a consult to audiology

• a consult to audiology 

Comments: Significant blast injuries are associated with tympanic membrane (TM) rupture. Resulting TM scarring may reduce auditory acuity. Several ototoxic medications (especially aminoglycosides and furosemide) are routinely used during critical care of the severely burned patient. A CT scan maybe ordered by the consulting provider. Specialists can assess the ear more thoroughly than the nursing assessment would reveal.

An adult patient was admitted 5 days ago after sustaining 25% TBSA burns from a house fire. The patient presents as follows: 

BP 72/44 mmHg (MAP 53) 
HR 134 beats/min 
RR 22 breaths/min 
SpO2 96% on high flow oxygen 
Temp 39.4 C (102.9 F) 

An IV fluid bolus is ordered STAT and administered. Which of the following assessment findings is MOST concerning when vital signs are repeated? 

• SpO2 92% on high flow 

• RR 26 breaths/min 

• HR 120 beats/min 

• BP 70/40 mmHg (MAP 50) 

• BP 70/40 mmHg (MAP 50) 

Comments: After the fluid bolus is administered, the BP remains lower than normal. The patient admitted 5 days ago is demonstrating signs of sepsis. Septic shock in burn is a change in patient condition that may indicate the concern for infection, and therefore needs to be treated with antibiotics while clinicians search for the cause of infection. While there is a need for clinical interpretation, the cause of infection is important to discover and treat._ 

A child is brought in following an accident in the home. The child presents with a wound on the hand surrounded by several abrasions. The nurse recognizes this is MOST likely which type of injury?

• Chemical 

• Scald 

• Friction 

• Electrical

• Friction 

Comments: While scald injuries are the most common type of burn in children, friction burns can occur as a consequence of a moving treadmill and almost always involve the upper extremity. Friction burns can be easily identified by the surrounding abrasions. 

Which of the following is an indication for early enteral nutrition in a burn patient? 

• Electrolyte disturbances 

• Dehydration 

• Diarrhea 

• Hypermetabolism 

• Hypermetabolism 

Comments: Hypermetabolism is associated with burn patients due to the metabolic response to the injury and trauma. It is a sign of acute stress response and increased energy expenditure. Diarrhea, dehydration and electrolyte disturbances are complications associated with rapid enteral nutrition from the high osmolar solution of the feedings.

When caring for an acute patient receiving narcotics for pain, and whom remains immobilized following multiple surgeries, the burn nurse should consistently assess for the development of which gastrointestinal complication?

• Paralytic ileus

• Abdominal compartment syndrome 

• Pancreatitis 

• Acalculous cholecystitis 

• Paralytic ileus 

Comments: Narcotics, prolonged immobilization, and surgery can all lead to a decrease in gastrointestinal motility. It is critical to assess for bowel sounds, as well as abdominal pain, cramping, and oral intake tolerance to prevent progression of GI symptoms to a paralytic ileus

The burn nurse is admitting a patient with erythematous thin-walled blistering skin, and pink moist denuded wounds over the face, arms, hands, and chest, for approximately 33% TBSA involvement. The patient is also complaining of pain, eye and vaginal irritation, and some difficulty swallowing. The burn nurse recognizes these symptoms are most likely related to:

• Toxic Epidermal Necrolysis (TEN) 

• Secondary infection 

• Alkalotic chemical burn 

• Stevens-Johnson Syndrome (SJS) 

• Toxic Epidermal Necrolysis (TEN) 

Comments: TEN, by definition, involves >30% TBSA, and complications of the systemic mucous membrane separation is more common in TEN patients effecting many systems within the body. Although SJS presents with similar symptoms with >30% TBSA involvement this patient is experiencing TEN.  

An adult patient sustained a low-voltage electrical injury. The burn nurse anticipates an order for continuous cardiac monitoring because electrically injured patients MOST often experience: 

• Atrial fibrillation 

• Sinus bradycardia 

• Ventricular fibrillation 

• Atrioventricular blocks 

• Atrial fibrillation 

Comments: Atrial fibrillation is the most common dysrhythmia experienced by electrical burn-injured patients. Ventricular fibrillation is the most common cause of death at the scene; therefore, these patients usually do not make it to a burn unit. 

The burn nurse is caring for an adult female with suspected toxic epidermal necrolysis (TEN). The patient first noticed lesions on her torso 2 days ago and now has new lesions on bilateral arms. The patient has been seen by ophthalmology for complaints of eye irritation. A feeding tube was placed this morning due to oral lesions and an inability to take nutrition by mouth. Which system not yet addressed are you MOST concerned about for this patient? 

• Gynecological   

• Cardiology 

• Renal 

• Psychology 

• Gynecological 

Comments: Vaginal involvement in TENS is common and causes severe pain, potential obstruction, and long term disfunction if left untreated. Mucosal surfaces are at highest risk in patients with TENS. Hearing loss, dental issues, and renal impairment are not commonly involved in TENS.  

A patient is admitted following an full-thickness burn to the forearm and wrist. During a neurovascular assessment, the nurse notes that the patient's hand is cold to the touch, has sluggish capillary refill, and no longer has a palpable radial pulse. Which step should the burn nurse take NEXT? 

• Obtain an order for more frequent neurovascular assessments and utilize a doppler 

• Notify the provider and prepare for an escharotomy 

• Elevate the extremity and continue to monitor 

• Place a heat pack on the affected hand and decrease the rate of maintenance fluids 

• Notify the provider and prepare for an escharotomy 

Comments: Loss of palpable pulses is one of the late signs of compartment syndrome and requires an escharotomy to relieve the pressure on the extremity. Elevation and heat are contraindicated in this scenario. Because the patient is already in the later stage of compartment syndrome, transfer and more frequent neurovascular assessments are unnecessary at this time. 

During the initial phase of burn injury, what is the PRIMARY concern regarding a patient's airway? 

• swelling of the upper airway 

• bronchospasm 

• sloughing of the oropharynx 

• swelling of the lower airway 

• swelling of the upper airway 

Comments: Airway concerns in burn patients can lead to death within minutes. Upper airway swelling can lead to total obstruction of the airway. Airway edema can occur with mucosal injury and fluid shifts with a large volume resuscitation. 

A previously healthy 87kg patient presents to the burn unit with 25% TBSA partial thickness and full thickness burns. In the first 8 hours of fluid resuscitation, how much lactated Ringer's solution would the burn nurse expect to infuse? 

• 8,900 ml 

• 2,175 ml 

• 1,087 ml 

• 6,780 ml 

• 2,175 ml 

Comments: The Consensus Formula recommends 2 ml of Lactated Ringer's solution per kg/% TBSA burned during the first 24 hours after the burn. This formula advocates giving half of the fluid in the first 8 hours after burn and the other half in the subsequent 16 hours. 

A patient with burns to the hands, face, and chest is brought to the burn unit after a house explosion. The patient is very agitated, tachycardic and noted to have dry mucous membranes. When the nurse asks how the fire started the answers are inconsistent with the burn pattern. The nurse must treat the burn injuries as: 

• Electrical and contact 

• Chemical and contact 

• Thermal and chemical   

• Thermal and electrical 

• Thermal and chemical 

Comments: The patient is exhibiting signs and symptoms of being in a fire associated with a methamphetamine lab explosion with tachycardia, agitation, and dehydration and unclear about how the fire started. During the primary survey, if no contact points are identified to indicate an electrical injury, this can be ruled out. Some of the injuries may be caused by contact with flying debris, but this would not be the main cause of the burn injuries.  

A patient with 40% TBSA burns is 32 weeks pregnant and is receiving DVT prophylaxis. The provider orders weekly doppler exams due to pregnancy-induced: 

• hypertension 

• peripheral edema 

• peripheral neuropathy 

• hypercoagulation 

• hypercoagulation 

Comments: Pregnancy induces a hypercoagulable state that is only made worse by sustaining a significant burn injury. Prevention includes DVT prophylaxis and weekly screening doppler studies to rule out DVT. Burn patients often develop peripheral edema, and burn neuropathic pain. Doppler imaging is not indicated for treatment for these conditions. Pregnancy induced hypertension would be managed per AHA and ACOG guidelines and does not involve doppler studies of extremities.

A burn patient with an 18% TBSA injury, with a known history of diabetes mellitus II, hypertension and alcohol use disorder is agitated and pacing. Vital signs are: 
 
BP 172/88 mmHg 
HR 110 beats/min 
RR 21 breaths/min 
SpO2 93% (room air) 
Pain 2/10 

  

Which PRIORITY intervention should the nurse perform? 

• Assess the patient’s lung sounds 

• Administer lorazepam (Ativan) 

• Administer metoprolol (Toprol XL) 

• Assess the patient's blood glucose. 

• Administer lorazepam (Ativan) 

Comments: Irritability, hyperactivity, tachycardia are all signs of alcohol withdrawal. The patient should be scored on a withdraw scale and treated according to the protocol.  

What is the therapeutic use of NSAIDs in the treatment of frostbite? 

• Improving blood flow to the affected areas 

• Inducing somnolence 

• Reducing complications of fever 

• Providing anti-inflammatory activity 

• Providing anti-inflammatory activity 

Comments: Ibuprofen inhibits cyclooxygenase enzymes (COX) that converts arachidonic acid to prostaglandin H2, which ultimately converts to other prostaglandins involved in inflammation.