ED Burn Priority of Interventions

jerzy6546 · May 19, 2013

I think you're right.

sloths4life · May 19, 2013

That's comforting. I need a rationale, too. Mine is:

Patient's airway status always comes first no matter what

You shouldn't begin fluid resuscitation until you've determined the TBSA

Once you have determined TBSA you may insert the IV catheters and begin fluid resuscitation

Pain is of priority but you cannot deliver IV morphine without an IV insertion first, so pain meds are given AFTER placement of 18 gauge catheters

Then pain meds are delivered

Finally saline dressings are applied to wounds

Nursey86 · May 19, 2013

Hi! So I have this question and I've come up with an answer but I want your opinion on it!
The question is:
The ED nurse is caring for a patient admitted with extensive, deep partial-thickness and full-thickness burns. Which interventions should the nurse implement? List in order of priority.
1. Estimate the amount of burned area using the rule of nines
2. Insert two (2) 18-gauge catheters and begin fluid replacement
3. Apply sterile saline dressings to the burned area
4. Determine the patient's airway status
5. Administer morphine sulfate, a narcotic analgesic, IV.
I think the order is:
4. Determine the patient's airway status
1. Estimate the amount of burned area using the rule of nines
2. Insert two (2) 18-gauge catheters and begin fluid replacement
5. Administer morphine sulfate, a narcotic analgesic, IV.
3. Apply sterile saline dressings to the burned area

I would worry about airway 1st, then apply the sterile towels, then put in the 2 large IV'S so you can start LR right away because their fluid status is compromised. Then estimate the TBSA (you can adjust the fluid settings later) and then give the pain meds. Remember that full thickness burns do not hurt due to nerve damage, but the deep partials will hurt. That is how I would care for the patient in my practice as a burn nurse, but I feel that test questions always want you to follow the ABC rule, so 4,2, 1, 3, and 5 is how I would answer it on the exam. I hope I was semi-helpful!

sloths4life · May 19, 2013

Your rationale makes more sense than mine (especially considering that I am a baby nursing student- I just started)!! I forgot to look at the extent of the burns - full thickness burns damage all of the nerve endings, you are right. I know of the ABC rule but I don't know how to apply it. Since Breathing is 2nd, fluid inserting the catheters as the second step makes sense because fluid resuscitation will help hypoxia, right? Do these kinds of questions get easier? Because I struggle with priority questions so much!

Itchy.C · May 19, 2013

i feel 42135 is better,but still wait for the correct answer

Esme12, ASN, BSN, RN · May 19, 2013

Hi! So I have this question and I've come up with an answer but I want your opinion on it!
The question is:
The ED nurse is caring for a patient admitted with extensive, deep partial-thickness and full-thickness burns. Which interventions should the nurse implement? List in order of priority.
1. Estimate the amount of burned area using the rule of nines
2. Insert two (2) 18-gauge catheters and begin fluid replacement
3. Apply sterile saline dressings to the burned area
4. Determine the patient's airway status
5. Administer morphine sulfate, a narcotic analgesic, IV.
4, 2, 3, 5, 1

Airway management, fluid therapy, and wound care, Analgesics ordered to manage pain, classify burns.

What is going to kill the patient first. Airway......when a patient first arrives you are concerned if they can breathe. If they can't breath the rule of nines won't matter for anything other than the death certificate. Extensive burn patients require fluids...shock is the second biggest danger. They need large amounts of fluids not only to rehydrate but to flush the kidneys of myoglobin from the bombardment of CPK from the extensive muscle destruction caused by the burns. You need to address/cover burns to prevent further damage, give these poor people some thing for pain once you are sure they are breathing it will also assists with anxiety lung edema/after-load reduction/vasodilitation and accompanying pulmonary edema...then you may take the time to asses the percentage of burns

4, 2, 3, 5, 1...but that is in the real world.

nurseprnRN, BSN, RN · May 20, 2013

Airway always first (if they give you the choice in the list...sometimes they don't, and want you to prioritize the others)

Get the IV lines started stat because no matter what, you're going to need them, and you might need them a lot faster than you think.

Cover wounds to prevent further body heat losses, minimize chance of infection, and decrease pain-- remember, you need functioning skin for a lot of temp regulation, and this is going away with a big burn; nobody thinks of hypothermia in burns, but it's a big cause of problems with many body systems

Morphine, morphine, morphine

You can check the "Rule of Nines" once things get stabilized a bit

chare · May 20, 2013

4. Determine the patient's airway status

Correct. Determining the patient's airway status, and intervening as necessary is nearly always the first choice.

1. Estimate the amount of burned area using the rule of nines
2. Insert two (2) 18-gauge catheters and begin fluid replacement
5. Administer morphine sulfate, a narcotic analgesic, IV.

These are correct. All formulae used to determine fluid resuscitation in burn patients require an estimate of BSA involved in the burn injury. The two most commonly used in the emergency department are the Parkland and the modified Parkland formula. In both of these formulae, the patient receives 50% of the calculated 24 hour fluid requirement in the first 8 hours. This is 8 hours from the time of the burn, not presentation to the ED.

While your option was for IV analgesia, in actuality this patient would likely receive an IM or SC dose of either morphine or dilaudid.

3. Apply sterile saline dressings to the burned area

Correct. In fact, this is likely not an appropriate intervention. Saline dressings are applied for the cooling effect, and if used, are done so with burns of ≤10 total BSA. Doing so in a patient with "extensive" burns is going to hasten the onset of hypothermia.