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Burns Info
| Question | Answer |
|---|---|
| What type of shock results from massive tissue destruction? | Hypovolemic |
| What are three types of fluid and electrolyte imbalances occur with massive tissue damage? | Hyponatremia, hyperkalemia, protein shifts |
| What are the signs circulatory failure with burns? | Decreased preload, decreased blood pressure, tachycardia, dark/burgendy urine |
| What are the four types of burns? | Thermal, chemical, electrical, smoke inhalation |
| What are the signs of an upper respiratory inhalation injury? | Edema, hoarsness, dysphagia, copius black tinged secreations, stridor, retractions, obstruction |
| Up to how many hours may there not be any signs of smoke inhalation? | 48 hours |
| When would you suspect if a client has an inhalation injury? | The client has been trapped and has facial burns, singed facial/nose hair, dyspnea, coal colored sputum, hoarsness, changes in mental status |
| What will the plan of care include for the client with inhalation injury? | Bronchodiators, humidified oxygen, pulmonary toilet, carboxy hgb blood level monitoring |
| What are the two possible causes of a superficial partial thickness burn? | Superficial sunburn and quick heat flash |
| What are some causes for deep partial thickness burns? | flame, flash, scald, contact burns, chemical, tar |
| What does a third and fourth degree/ full thickness burn look like? | dry, waxy, white, leathery, or hard skin; visible thromboed vessels; insensitivity to pain, possible involvement of muscles, tendons, and bones |
| What classification of burns is an electrical burn? | Full-Thickness Burn |
| What are care measures in the pre-hospital/ER Care? | ABCC-spine, stop the burning, cool with h20, remove restrictive objects, cover the wounds, irrigate chemical burns |
| The emergent phase begins with what and ends with what? | Begins with fluid shifts, and ends with diuresis |
| What is a goal of the emergent phase? | prevent hypovolemic shock and/or maintain vital organ function |
| What are the priorities in the emergent phase? | continue w/ first aide, prevent shock, prevent resp. distress, assess/treat of other injuries and wounds |
| What is the nursing management of the airway during the emergent phase? | alert for signs of smoke inhalation, intubate w/in 2 hours for facial/neck burns, bronchoscopy w/in 6-12 hours of facial/neck burns, 100%O2, high fowlers, bronchodilators, escharotomy PRN |
| What is included in the fluid rescusitation nursing management during the emergent phase? | Assess fluid needs, minimum of 2 large bore IV catheters, transfuse PRN, Parkland Formula, Foley, monitor effects of fluid replacement |
| What is the IV fluid of choice in fluid rescusitation in the emergent phase? | LR |
Created by:
agarnham
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