BURNS: COMPLICATIONS

Question 1

BURN COMPLICATION (3)

Answer 1

1. Airway Injury
2. Fluid and Electrolyte Imbalances
3. Wound Infections​

Question 2

AIRWAY INJURY (10)

Answer 2

Airway Injury

1. ◯◯ Thermal injuries to the airway may result from steam or chemical inhalation, aspiration of
2. scalding liquid, and explosion while breathing. If the injury took place in an enclosed space,
3. carbon monoxide poisoning should be suspected.
4. ◯◯ Clinical manifestations may be delayed for 24 to 48 hr.
5. ◯◯ Clinical manifestations include progressive hoarseness, brassy cough, difficulty swallowing,
6. drooling, increased secretions, adventitious breath sounds, and expiratory sounds that include
7. audible wheezes, crowing, and stridor.
8. ◯◯ Nursing Actions – Maintain airway and ventilation, and provide oxygen as prescribed.
9. ◯◯ Client Education – Educate the client and family about airway management, such as deep
10. breathing, coughing, and elevating the head of the bed.

Question 3

Fluid and Electrolyte Imbalances

◯◯ Nursing Actions (3)

CLIENT EDUCATION

Educate the client and family about signs and symptoms of electrolyte imbalances and the need to alert the provider immediately.

Answer 3

1. Assess fluid volume status. Weigh daily and maintain strict I&O.
2. ■■ Monitor laboratory results and compare to previous data.
3. ■■ Administer IV fluids and electrolytes.

Question 4

WOUND INFECTION

NURSING ACTION (6)

Client Education – Educate the client and family on the importance of infection control.

Answer 4

Nursing Actions

1. ■■ Assess for discoloration, edema, odor, and drainage.
2. ■■ Assess for fluctuations in temperature and heart rate.
3. ■■ Obtain wound culture.
4. ■■ Administer antibiotics as prescribed.
5. ■■ Monitor laboratory results, observing for anemia and infection.
6. ■■ Maintain surgical aseptic technique with dressing changes.