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Rule of Nines
body regions
| Question | Answer |
|---|---|
| Major Burn Injuries | Greater than 25% TBSA Exception: Children under 10, adults over 40 = greater than 20% Greater than 10% TBSA full thickness Involve face, eyes, ears, hands, feet, perenium Electrical burns inhalation injury or major trauma preexisting disease |
| Moderate Burn Injuries | 15%-25% TBSA partial thickness Exception: Children under 10, adults over 40 = 10%-20% Less than 10% TBSA, full thickness Burns with no concurrent injury Burns in patients with no preexisting disease |
| Minor Burn Injuries | Less than 15% TBSA Exception: less than 10% Less than 2% TBSA, full thickness burns in patients with no preexisting disease |
| Medical Management of Burn Phases | 1. Emergent - stop the burning process, NO ICE, rinse all chemicals off skin 2. Provide open airway - 3. Control bleeding 4. remove nonadherent clothing and jewelry 5. Cover victim with clean cloth or sheet 6. Transport to hospital |
| Electrical burns result in... | cardiac arrest, requiring CPR or cardiac monitoring |
| Primary priority in ALL BURNS | OPEN AIRWAY |
| S/S of inhalation injury | singed facial hair, black-tinged sputum, soot in throat, hoarseness, neck or face burns. STRIDOR is LIFE THREATENING |
| During Emergent Phase, patient should be monitored | q 30min to 1 hr |
| Moderate to Severe burns treated with | 1. est airway& admin O2 2. Ringer's lactate. Amt dep %age of TBSA Weigh pt to ind fluid loss. 3. Foley Cath nn 30-50mL/h Out 4. NG prevent aspiration 5. Analgesics 6. maintain airway, fluids, monitor vitals 7. tetanus shot unless w/in 5 years ago |
| Primary goals of Emergent Phase burn treatment (hrs 1-72 post burn) | Maintain respiratory integrity prevent hypovolemic shock (which can lead to death) |
| Acute Phase (72h after burn) can last 10 days to several months | MAIN PURPOSE - Treat wound; prevent and manage complications metabolism increases fluid shifts back into circulation, therefore output increases and edema decreases |
| complications of burns | infection - #1 cause of death after first 72 hours heart failure, renal failure, contractures, paralytic ileus, Curling's ulcer - first sign usually vomiting bright red blood |
| Burn Care Nursing Interventions | ***Prioritize airway, breathing, circulation 1. respiratory pattern 2. vital signs 3. circulation 4. intake & output 5. ambulation 6. bowel sounds 7. inspection of wounds 8. mental status |
| assessment for infection | increasing erythema, odor, green or yellow exudate |
| Monitor closely during acute phase | elevated creatine, BUN, electrolyte levels, serum potassium levels may rise sharply, DAILY NUTRITIONAL STATUS - increase protein, vitamins, calories, SKIN GRAFTS REQUIRE ADEQUATE NUTRITION |
Created by:
Perfectlysusan
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