Question

An industrial nurse responds to an emergency in the plant where a worker is burned. Which is the correct sequence of nursing actions? A. Eliminate the source of the burn, ensure airway patency, observe for and treat associated injuries, treat burn shock. B. Eliminate the source of the burn, ensue airway patency, cool the burn wound, apply topical antibiotic cream. C. Ensure airway patency, insert a nasogastric tube, insert a bladder catheter, stare IV fluid infusion. D. Treat burn shock, ensure airway patency, start IV antibiotics and put the client in reverse isolation.

Short answer

The correct sequence of nursing actions is A: Eliminate the source of the burn, ensure airway patency, observe for and treat associated injuries, treat burn shock.

Step-by-step solution

Assess the Immediate Danger

First, quickly assess the situation to eliminate any immediate threat to you or the patient. This includes eliminating the source of the burn to prevent further injury.

Ensure Airway Patency

The next step is to ensure that the airway is open and clear. This is critical in all emergencies because a blocked airway can rapidly lead to asphyxiation.

Observe and Treat Associated Injuries

After ensuring the airway is intact, evaluate the patient for other associated injuries that might have been sustained during the accident.

Treat Burn Shock

If the patient is showing signs of burn shock, which can include a rapid pulse, low blood pressure, and shallow breathing, these symptoms should be treated promptly.

Select the Correct Option

After evaluating the steps, it is clear that the correct sequence is provided in option A: Eliminate the source of the burn, ensure airway patency, observe for and treat associated injuries, treat burn shock.

Key concepts

Emergency Nursing

In the high-stakes scenario of a burn incident within an industrial setting, emergency nursing plays a pivotal role. The initial actions taken by the nurse are crucial for the patient’s recovery and survival. Emergency nursing in the context of burns begins with a rapid assessment of the scene to eliminate ongoing hazards to both the patient and the responder. Immediate removal from the source of the burn is essential to halt further damage to the patient's tissue.

This field requires a composed demeanor, critical thinking, and adherence to emergency protocols. The nurse must rapidly evaluate the severity of the burns, the potential for associated traumas, and the signs of burn shock. Knowledge of emergency procedures, such as the 'stop, drop, and roll' technique or the use of fire blankets, can be lifesaving. Additionally, emergency nurses prioritize patient care actions, perform triage, and coordinate with other healthcare professionals to manage the patient's condition effectively.

Airway Management

A clear and patent airway is the cornerstone of initial treatment in burn victims and a primary focus of airway management. When the respiratory tract is compromised due to injury or edema from the heat and smoke, immediate action is necessary to prevent asphyxiation.

Emergency nurses are trained to look for signs of airway obstruction, such as burns around the mouth, singed nasal hairs, hoarseness, and difficulty breathing. The nurse may use a head-tilt or jaw-lift maneuver to open the airway. In more severe cases, advanced airway management techniques, such as intubation, may be required. Continuous monitoring of the airway is imperative until the patient is stable or transferred to specialized care.

Burn Treatment

Once immediate risks are mitigated and the airway secured, attention turns to the burn treatment itself. Cooling the burn wound can be a beneficial initial step as it helps to reduce pain, swelling and stop the burning process. However, it's crucial to avoid overcooling, which can lead to hypothermia, particularly in large burns or in young children.

Caring for the Burn Site

• Gently remove any jewelry or clothing that is not adhered to the burn, as swelling can make later removal more difficult.
• Use lukewarm water instead of ice water to avoid further tissue damage.
• Cover the burn with a clean, dry cloth to reduce the risk of infection.

The application of topical antibiotics and sterile dressings aids in infection prevention, which is a major concern with burn wounds. It is essential to follow the latest guidelines and protocols regarding the use of creams and dressings, as the improper application can exacerbate the injury.

Burn Shock Management

Burn shock, characterized by a reduced blood volume leading to cell oxygen deprivation and organ failure, presents a significant risk to severe burn patients. Management starts with the estimation of the total body surface area (TBSA) burned to guide fluid resuscitation. The Parkland formula is commonly used to calculate the amount of fluids required in the first 24 hours.

Rapid intravenous (IV) fluid administration is critical to counteract the effects of capillary leak and evaporation from open wounds. Electrolyte balance is carefully monitored and maintained, as imbalances can be life-threatening. If needed, vasopressors may be administered to maintain blood pressure. Throughout all stages of burn shock management, the nurse assesses the patient's vital signs, urinary output, and consciousness level to gauge the effectiveness of interventions and the patient's progress toward stabilization.