Which of the following initial interventions is most appropriate for managing a superficial partial-thickness burn on a patient's forearm?

B) Gently cleanse the burn with mild soap and water

A) Apply a cold compress directly to the burn area

B) Gently cleanse the burn with mild soap and water

C) Leave the burn open to air for faster healing

D) Wrap the burn tightly with a gauze bandage

Which of the following is the most appropriate initial action for a nurse to take when managing a superficial partial-thickness burn?

B) Cleanse the burn with mild soap and water

A) Apply a cold compress directly to the burn

B) Cleanse the burn with mild soap and water

C) Cover the burn with a dry gauze dressing

D) Leave the burn exposed to air for faster healing

What is the primary reason for elevating a burn injury site, such as the patient's left forearm, during recovery?

D) To promote blister formation

Which observation made by the nurse indicates that the patient's burn is healing as expected?

B) The redness has faded considerably

A) The presence of discharge and odor

B) The redness has faded considerably

C) The patient reports increased pain

D) The sterile dressing is not intact

What is the primary goal of performing range of motion exercises for a patient with a healing superficial partial-thickness burn?

C) To enhance respiratory function

What is the primary reason for assessing the patient's vital signs during a follow-up visit after a burn injury?

C) To assess the patient's overall stability

A) To evaluate the patient's hydration status

B) To monitor for signs of infection

C) To assess the patient's overall stability

D) To determine if the patient is experiencing pain

What is the primary purpose of monitoring the patient's vital signs during a follow-up assessment for burn recovery?

C) To assess the patient's overall stability and recovery progress

A) To evaluate the effectiveness of pain management

B) To ensure the patient remains hydrated

C) To assess the patient's overall stability and recovery progress

D) To determine the need for additional dietary supplements

A nurse is reviewing a patient's lab results and notes a slight elevation in the white blood cell count. Which of the following actions should the nurse take first?

B) Document the finding and continue to monitor

A) Immediately notify the physician

B) Document the finding and continue to monitor

C) Administer antibiotics as a precaution

D) Stop the patient's current medication regimen

A patient with a burn injury has a slightly elevated white blood cell count of 11,500/mm³. What is the most appropriate action by the nurse?

D) Continue monitoring and educate the patient on signs of infection

A) Administer antibiotics immediately

B) Encourage increased fluid intake

C) Notify the healthcare provider urgently

D) Continue monitoring and educate the patient on signs of infection

burns with tbsa - Nursing Case Study

Pathophysiology

• Primary mechanism: Burns cause direct damage to skin cells, leading to the loss of the protective barrier. This disrupts fluid balance and increases the risk of infection.

• Secondary mechanism: The body responds with an inflammatory reaction, causing increased capillary permeability. This results in fluid and protein leakage into tissues, contributing to edema and hypovolemia.

• Key complication: Hypovolemia can lead to decreased blood flow to organs, potentially causing shock if not managed promptly.

Patient Profile

Demographics:

25-year-old female, chef

History:

• Key past medical history: No significant medical history

• Current medications: None

• Allergies: None

Current Presentation:

• Chief complaint: Mild burns on forearm

• Key symptoms: Redness, mild pain, and swelling on left forearm

• Vital signs: Temperature 98.6°F, Heart rate 78 bpm, Blood pressure 120/80 mmHg, Respiratory rate 16 breaths per minute, Oxygen saturation 98%

Section 1

Initial Assessment Findings:

Upon initial assessment, the nurse observes that the burn on the patient’s left forearm covers approximately 5% of the total body surface area (TBSA). The area is characterized by superficial partial-thickness burns, indicated by redness, mild blistering, and tenderness upon palpation. The patient rates her pain as a 4 on a scale of 0 to 10. Her skin remains intact, and there are no signs of infection such as increased warmth, pus, or unusual odor. The nurse notes that the swelling is localized, and there is no involvement of deeper structures such as muscles or tendons.

The nurse performs a thorough review of systems, confirming that all other body systems are functioning normally. Capillary refill time is less than 2 seconds, indicating adequate peripheral perfusion. The patient is alert and oriented, with no signs of distress or respiratory compromise. Her vital signs remain stable, with a heart rate of 78 beats per minute, blood pressure of 120/80 mmHg, and an oxygen saturation of 98% on room air. The patient is able to move her fingers freely, with no neurological deficits noted in the affected limb.

Building upon this assessment, the nurse proceeds to educate the patient on burn care management, including gentle cleansing of the burn site with mild soap and water, and the application of a topical antibiotic ointment to prevent infection. The nurse advises keeping the burn covered with a sterile, non-stick dressing to maintain a moist wound environment, promoting optimal healing. The patient is encouraged to elevate her arm to reduce swelling and is provided with instructions on signs of infection and when to seek further medical attention. As the patient exhibits a positive response to initial interventions, the plan includes monitoring for any changes in symptoms or the development of complications over the next 24 to 48 hours.

Section 2

As the patient continues her recovery over the next 24 hours, the nurse conducts regular assessments to monitor her response to the interventions. The patient reports that her pain level has decreased slightly to a 3 on a scale of 0 to 10, indicating effective pain management. Upon inspection, the burn site on the left forearm appears to be healing as expected, with reduced redness and slight retraction of the blistering. The nurse notes that the swelling has diminished due to the patient's adherence to the elevation advice. The topical antibiotic ointment is being applied correctly, and the sterile dressing remains intact with no signs of discharge or odor, confirming the absence of infection.

The patient's vital signs remain stable, with a heart rate of 76 beats per minute, blood pressure of 118/76 mmHg, and an oxygen saturation of 98% on room air. Capillary refill time is still less than 2 seconds, and the patient maintains full range of motion in her fingers, which she practices with gentle hand exercises as instructed. The nurse reinforces the importance of maintaining this regimen to prevent stiffness and enhance circulation.

However, during the latest assessment, the patient expresses slight anxiety about potential scarring. The nurse takes this opportunity to educate her on the natural healing process of burns, emphasizing that superficial partial-thickness burns typically heal well with minimal scarring. The nurse also discusses the use of sunscreen and protective clothing once the burn has healed to protect the area from sun damage. The patient is reassured by this information and expresses confidence in her recovery plan. The nurse schedules a follow-up visit to reassess the wound and address any further concerns as part of the ongoing monitoring process.

Section 3

The next morning, as the nurse enters the patient's room for the routine assessment, she greets the patient and sets about evaluating her condition. The patient reports a restful night with minimal disturbance, indicating that the prescribed pain management regimen continues to be effective. Upon inspection of the left forearm, the nurse observes further improvement at the burn site. The redness has faded considerably, and the blistering shows signs of progressive retraction, aligning with anticipated healing patterns for superficial partial-thickness burns. The sterile dressing remains intact, and there is still no evidence of discharge or odor, affirming the absence of infection. The patient confirms she has been diligent in performing her hand exercises, and the nurse notes that her range of motion remains unaffected, with good capillary refill and no signs of stiffness.

Vital signs are reassessed, revealing a heart rate of 74 beats per minute, blood pressure of 116/74 mmHg, and an oxygen saturation of 99% on room air, all indicating continued stability. The patient shares that she is feeling more relaxed about her recovery after the previous day's discussion about scarring, although she admits to a slight increase in anxiety due to an upcoming family event where she wants to appear her best. The nurse reassures her that the healing is progressing well and reiterates the importance of adhering to the care plan, including the use of sunscreen and protective clothing once healed, to ensure the best cosmetic outcome.

To support the patient's emotional well-being and address her anxiety, the nurse suggests incorporating relaxation techniques, such as deep breathing exercises, which could be beneficial in managing stress levels. The patient agrees to try these techniques and expresses gratitude for the continued support. The nurse documents the assessment findings and plans to follow up on both the physical recovery and the emotional aspects of the patient's healing journey, ensuring a holistic approach to care. This comprehensive monitoring will help guide any necessary adjustments to the care plan in future visits.

Section 4

Later in the afternoon, the nurse returns to conduct a follow-up assessment, aiming to ensure the patient's continued progress and address any new concerns. As she enters the room, the patient is in good spirits, having just finished a light lunch. The nurse begins by reviewing the patient's latest vital signs, which show a heart rate of 72 beats per minute, blood pressure of 114/76 mmHg, and an oxygen saturation of 98% on room air. These readings are consistent with the patient's stable condition and provide reassurance that her recovery is on track.

The nurse proceeds to inspect the burn site on the left forearm, noting that the redness has diminished further, and the blisters have almost completely retracted. The skin appears slightly pink and tender, which is typical for the healing stage of superficial partial-thickness burns. The sterile dressing remains clean and dry, with no signs of infection, and the patient reports only mild discomfort, which is well-managed with her current pain regimen. The nurse also observes that the patient's range of motion remains excellent, with no stiffness or swelling, indicating that her diligent hand exercises are effective.

During their conversation, the patient shares that she practiced the deep breathing exercises earlier and found them helpful in reducing her anxiety about the upcoming family event. Encouraged by this positive response, the nurse reinforces the importance of these techniques and suggests additional resources, such as guided imagery or meditation apps, to further support the patient's emotional well-being. With the patient's consent, the nurse plans to continue monitoring her progress and collaborate with the healthcare team to ensure that both her physical and emotional needs are met, laying the groundwork for a smooth and confident return to her daily activities.

Section 5

Later in the day, the nurse receives new diagnostic results from the laboratory, which were ordered during the patient's initial assessment. The lab results include a complete blood count (CBC) and electrolyte panel. The CBC shows a slight elevation in white blood cell count at 11,500/mm³, which is on the higher end of normal range but not yet indicative of an infection. The nurse considers this finding in the context of the patient's healing process and knows that mild elevation can be typical due to the inflammatory response from the burn injury. The electrolyte panel reveals all values within normal limits, suggesting that the patient is well-hydrated and her nutritional intake is adequate.

Recognizing the importance of these results, the nurse discusses them with the patient, explaining that the slightly elevated white blood cell count is not uncommon in the healing phase and will be monitored closely to ensure it does not increase further. The nurse emphasizes the importance of continuing to follow the prescribed wound care regimen and maintaining adequate hydration and nutrition to support healing. The nurse also reminds the patient to report any new symptoms such as increased redness, warmth, or drainage from the burn site, which could indicate an infection.

The nurse's focus then shifts to reinforcing the need for continued monitoring and education. She suggests scheduling a follow-up appointment to reassess the lab values and the burn's healing progress. The patient expresses understanding and is reassured by the nurse's clear communication and plan of care. The nurse's thorough explanation and continued support help to build the patient's confidence in her recovery journey, demonstrating a commitment to holistic care that addresses both physical and emotional aspects of healing.