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HGTC 221 Burns 1

Burns NUR 221 Test 3

True or False? There is no pain with Full thickness Burns. False. With full thickness burns, there is bound to be areas of partial thickness burns in periphery, which are incredibly painful. Full thickness burns themselves are painless.
Hallmarks of superficial burns…. Painful, no edema, redness, blanched with pressure
Hallmarks of Partial thickness burns… blistered, moist, painful
Hallmarks of full thickness burns: dry, discolored, no pain
Treat burn patients with falls and electrical injuries as… potential cervical spine injuries
Patients with potential cervical spine injuries will have there neck braces removed when? After X-ray confirms absence of spine injury
A client went to the beach and was sunburned. Which is a proper classification of this burn? A sunburn is a superficial burn.
A full-thickness burn is identified by: the destruction of the entire dermis
With partial degree (2nd-degree) burns, skin regeneration begins to take place: in 2-4 weeks
Plasma seeps into the surrounding tissues after a burn. The greatest amount leaks out in: 24-36 hours
As fluid is reabsorbed after injury, renal funtion retains a diuresis for up to: 2 weeks
Fluid shifts during the 1st week of the acute phase of a burn injury that cause massive cell destruction result in: hyperkalemia
Plasma leakage produces edema, which increases: the hematocrit level
Normal hematocrit: males- 42-54%, females 38-46%
The leading cause of death in fire victims is believed to be carbon monoxide intoxication
A serious GI disturbance frequently seen with a major burn is: paralytic ileus
A child tips a pot of boiling water onto his bare legs. The mother should: immerse child's legs in cool water
As 1st priority of care, a patient with a burn injury will need: an airway established
Eyes that have been irritated or burned with a chemical should be flushed w/ cool, clean water: immediately
A nurse knows that a burn injury of 25% of total body surface area is classified as: moderate
Electrolyte changes in the 1st 48 hours of a major burn include: base bicarbonite deficit
The Evans formula for replacing fluid lost during the 1st 24-48 hours recommends the administration of: colloids, electrolytes, glucose
One parameter of adequate fluid replacement is an hourly urinary output in the range of: 30-50 mL
During the fluid remobilization phase, the nurse knows to expect the following: hemodilution, increased urinary output, sodium deficit
What would the nurse NOT expect during fluid remobilization? metabolic alkalosis
Fluid and electrolyte changes in the emergent phase of burn injury include__________, ____________, and ___________ base bicarbonite deficit, elevated hematocrit, sodium deficit
Fluid remobilization usually begins: after 48 hours, when fluid is being reabsorbed from interstitial tissue
Wound cleansing and debridement usually begin when eschar begins to separate at: 1.5 to 2 weeks
Leukopenia within 48 hours is a side effect associated with topical antibacterial agent: sulfadiazene, silver (Silvadene)
Biologic dressings that use skin from living or recently deceased humans are known as: homografts (think of that homo with the skin suit from "Silence of the Lambs")
An example of a permanent burn wound covering that is used to support an autograph is: Alloderm
The most likely prescribed anlagesic for acute burn pain is: morphine sulfate
The recommended route for administering low-dose narcotics is: intravenous
The backbone of nutritional support during burn injury is High protein, high calorie (up to 5,000 calories/day)
Early indicatators of late-stage septic shock include: decreased pulse pressure, pale, cool skin, renal failure.
Early indicators of late-stage septic shock DO NOT include: a full, bounding pulse
The 2 age groups most at risk for burn injury are: the very young and elderly.
The majority of burns occur… at home, in the kitchen
Burn injuries are classified according to ____________, and_____________ depth of injury, extent of injured body surface area
List 2 pulonary complications that occur secondary to inhalation injuries acute respiratory failure, acute respiratory distress syndrome (ARDS)
The leading cause of death in thermally injured patients is sepsis
The 1st priority of on the scene care for a person with burn injury is to prevent injury to the rescuer
List 4 collaberative problems for a patient in the emergent phase of burn injury: acute respiratory failure, distributive shock, acute renal failure, compartment syndrome
List 3 disorders of wound healing: hypertrophic scarring, keloid formation, contractures
An ER client has a blood pressure of 96/62 and has full thickness burns on the chest and neck. The nurse's immediate response is to: Call the physician and prepare to intubate the client (clients w/ burns to the face are at increased risk for inhalation injury. The edema that results can be sudden and occlude airway almost immediately)
The nurse is caring for a client with full thickness burns on 50% of his body. The spouse asks why he looks so puffy. The nurse's best response is: The burn causes his fluids to shift into his tissues and that is causing the puffiness.
The nurse assesses that a client is at risk for developing DIC. Which lab finding should be reported to the physician immediately? Fibrinogen level 110mg/dL. (Normal adult level is 140-400 mg/dL) A decreased level indicates an excessive use of fibrinogen during clotting process.
The most frequent thermal injury is: scald injuries
debridement removal of foreign material and devitalized tissue until surrounding healthy tissue is exposed
eschar devitalized tissue resulting from a burn
Advise parents to set water heater no higher than: 120 F
Factors in determining depth of burn: How injury occurred, causative agent, temp of agent, duration of contact w/ agent, thickness of skin
In the palm method, the size of the patient's palm is approx ____% of TBSA 1%
In the rule of nines, which body parts are represented as 9%? Each arm and the head
Which is the most precise method for determining burn injury and more appropriate for children? Lund and Browder Method
After an electrical burn, a cardiac monitor should be used for how long? For at least 24 hours or until patient is stable. Cardiac dysrhythmias are common after this type of injury.
In the Lund and Browder method, assessments should be made when? Initial evaluation on arrival of patient, and is revised on 2nd and 3rd postburn days, because demarcation usually is not clear until then
Critical components of care a thermal burn injury are: Prompt administration of IV fluids and and monitoring of urine output
In a patient receiving fluid resuscitation, what urine output is expected? 75-100 mL/hour
Burns are caused by a transfer of_____________ to __________ energy from a heat source, to the body
Examples of thermal burns: Sunburn, House fire, electrical
Burns that do not exceed 25% TBSA produce a primarily_____________ local response
Major burn injuries________________, and may produce both_____________ and______________ exceed 25% TBSA, local response, a systemic response
Chemical burns are generally initially treated by… rinsing off with running water
During burn shock, serum sodium levels___________in response to fluid resuscitation vary
An escharotomy may be performed to relieve the constricting effect of burned tissue
During burn shock,_____________ is common Hyponatremia (sodium depletion)
Immediately after burn injury,________________ results from massive cell destruction hyperkalemia (excessive potassium)
Later in burn injury,____________ may occur with fluid shifts and inadequate potassium replacement hypokalemia (potassium depletion)
With a true electrical injury, there is a___________ and a (an)______________ entrance wound, exit wound
The systemic response in a major burn injury is cause by the release of _______________ and___________into the systemic circulation cytokines, other mediators (these put patient at risk for distributive shock!)
Systemic edema is usually maximal after___________ hours, and completely resolved in _____ days 24-48 hours post-burn, 7-10 days
In burns covering less than 25% of TBSA edema is in burned and surrounding areas
In burns over 25% TBSA, edema is generalized
Edema in burn wounds can be reduced by____________ avoiding unnecessary overresuscitation
Burn shock is a combination of which 2 types? distributive and hypovolemic shock
Fluid shifts and shock result in _______________ and___________________ tissue hypoperfusion, organ hypofunction
The most common cause of inhalation injury is__________ carbon monoxide
What is essential in accelerating the removal of carbon monoxide from the hemoglobin molecule? Administering 100% oxygen (carbon monoxide competes with oxygen on hemoglobin molecule!)
Upper airway injury results from… direct heat or edema
Upper airway injury is treated by_____________ early nasotracheal or endotracheal intubation
Inhalation below the glottis results from inhaling the products of incomplete combustion or noxious gases (carbon monoxide biggest culprit)
Inhalation injury below the glottis is usually not a _____________ issue airway issue (glottis doesn’t close)
The cardinal sign of inhalation below the glottis is: expectoration of carbon particles in the sputum.
What is the leading cause of morbidity and mortality in patients with thermal injuries? Sepsis
Serious burn injury diminishes………. resistance to infection
Immunosuppression places the patient with burn injury at high risk for__________ sepsis
Any patient with possible airway injuries must be observed for at least __________ for respiratory complications because_____________ 24 hours, airway obstruction may occur very rapidly or develop in hours. Decreased lung compliance, decreased arterial oxygen levels, and respiratory acidosis may occur over the 1st 5 days after a burn.
The emergent/resuscitative phase of burn injury involves… onset of injury to completion of fluid resuscitation
Priorities in the emergent/resuscitative phase of burn injury are.. Prevent injury to rescuer, stop injury, ABCs, Start oxygen and large bore Ivs, Remove restrictive objects and cover wound, Do assessment and obtain history, Treat all pats w/ falls and electrical injuries as potential cervical spine injury!
When inserting large bore Ivs during emergent phase, what are some guidelines? At least 2, 18s, Acs if possible, must be away from burn and not distal to burn
The four major goals relating to burns: "Prevention, Institution of lifesaving measures for the severely burned person, Prevention of disability and disfigurement through early, specialized, individualized treatment, Rehabilitation through reconstructive surgery and rehabilitative programs
In patients with scattered burns, the__________method is used. palm
Electrical burns can cause… seizures
Trauma causes the release of potassium into extracellular fluid resulting in: hyperkalemia
Sodium traps in edema fluid and shifts into cells as poatassium is released resulting in: hyponatremia
The recommended route for giving pain meds is: IV (necessary due to altered tissue perfusion from burn injury)
Patients with electrical burns should have an EKG
True or False? A blood pressure cuff can be placed around a patient's burned extremity? True. The cuff must be of the correct size and with accommodations made for the bulky dressings
Nausea and vomiting typically occur due to.. paralytic ileus- therefore patient must be placed in a position to prevent aspiration and no fluid is given by mouth
If a patient has contact lenses… they must be removed immediately
Survival of the patient with burn injury depends on… adequate fluid resuscitation
Signs of possible inhalation injury and risk of respiratory dysfunction Erythma or blistering of lips or buccal mucosa, singed nostrils, burns of face, neck, or chest, increasing hoarseness, soot in sputum or tracheal tissue in respiratory secretions.
"Which of the following is NOT considered a characteristic of a deep partial thickness burn? No edema
"What are characteristics of a deep partial thickness burn? broken epidermis, edema, a mottled, red base, and a weeping surface
True or False? Electrical burns can cause significant internal damage? True. The devastating effects of electric burns can cause lifelong neurovascular problems. Entry and exit wounds exist with a true electric burn.
"Which of the following phases of burn care encompasses the beginning of diuresis to near completion of wound closure? Acute.
What are local responses to burns? acute inflammation, Intravascular coagulation, cellular enzymes and vasoactive substances, actiation of compliment, altered vascular permeability
Anasarca also known as "extreme generalized edema" is a medical condition characterised by widespread swelling of the skin due to effusion of fluid into the extracellular space. Seen in burns over 25% TBSA
What is an immediate nursing intervention in anticipation of post burn edema? Remove patient's jewelry on affected extremities (rings, watches, earrings). DOCUMENT where items are kept and /or who they were given to due to liability issues!
Occult blood in stools, regurgitation of "coffee ground" material from the stomach, or bloody vomitus may be a signs of: Curling's ulcer
Curling's Ulcer an acute peptic ulcer of the duodenum resulting as a complication from severe burns. Give Zantac or nexium to reduce acid.
What nursing interventions help with contractures? Maintain positions of joints in alignment, perform gentle ROM exercises, Consult ot and PT for exercises and positioning recommendations
Early signs of sepsis may include: increased temperature, increased pulse rate, widened pulse pressure, and flushed dry skin in unburned areas
Created by: Laurie2000