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NUR 206
Test 5-Burns
| Question | Answer |
|---|---|
| 1st degree burn | Superficial |
| 2nd degree burn | Partial thickness |
| 3rd degree burn | Full thickness |
| Escharotomy | incisions placed on burned skin to relieve pressure and prevent Compartment Syndrome. |
| Allograft | use of cadaver skin |
| Autograft | use of one's own skin-only one that is permanent |
| The best protection against infection is: | HANDWASHING!!!! |
| #1 instance of child abuse | Scalding |
| Functions of the skin | -Barrier to infection -Protection from external injury -Temp. control -Sensory organ -Control of bodily fluids -Determines identity |
| #1 cause of death from fires: | Inhalation Injury |
| Inhalation Injury | -soot on face/clothes -singing of lashes/eyebrows -hoarse -carbonation sputum(black sputum) -lacrimate (eyes watering) -wheezing -stridor -sore throat |
| When are you most likely to be trached after a fire? | When there is an inhalation injury. |
| What are the types of 2nd degree burns? | Superficial Partial Thickness (shallow) Deep partial Thickness (deep) |
| Superficial Partial Thickness (shallow)-2nd degree burn | entire epidermis and part of the dermis homogenous pink painful blisters blanches (skin turns white or pale) hair is usually intact does not scar, may pigment differently |
| Deep partial Thickness (deep)-2nd degree burn | -involves the epidermis and the thick, bottom layer of the dermis. -fluid-filled vesicles, red, shiny, wet, very painful -molted, red and white -does not blanch -heals >3weeks -usually scars -need to excise |
| Full Thickness-3rd degree burn | -destruction of all skin layers -red, white, brown, black -skin is in-elastic and leathery -can be painful, not always -heals only from the periphery -always excise and graft |
| High risk burns that will get you admitted to the burn unit: | face, eyes, ears, hands, feet, genitalia, or perineum or those that involve skin overlying major joints. |
| Electrical burns are high risk for: | Cardiac issues |
| What is a Curling's ulcer and when does it occur and how do you treat it? | -A peptic ulcer -Occur within 24 hours after burn -Due to reduced GI blood flow and mucosal damage -Treat clients with H2 blockers, mucoprotectants, and early enteral nutrition -Watch for sudden drop in hemoglobin |
| Types of burns: | Thermal-Exposure to flame or hot object. Chemical-exposure to acid, alkali, or organic substances. Electrical-conversion of electrical energy to heat. Extent of the injury depends on the type of current, pathway of flow, tissue resistance and duration f contact. Radiation-from radiant energy being transferred t the body causing a production of cellular toxins |
| Vascular changes resulting from burn injuries | -Circulatory disruption occurs at the burn site immediately after a burn injury. -Blood flow decreases or cease due to occluded blood vessels. -Damaged macrophages within the tissues release chemicals that cause constriction of vessel. -Blood vessel thrombosis may occur causing necrosis. |
| What is a macrophage? | A type of white blood that ingests (takes in) foreign material. Macrophages are key players in the immune response to foreign invaders such as infectious microorganisms. |
| When does fluid shift happen in burn patients? | -Occurs after initial vasoconstriction, then dilation -Blood vessels dilate and leak fluid into the interstitial space -Known as third spacing or capillary leak syndrome -Causes decreased blood volume and blood pressure -Occurs within the first 12 hours after the burn and can continue to up to 36 hours |
| What fluid imbalances occurs with burn victims? | -Hypovolemia -Metabolic acidosis -Hyperkalemia -Hyponatremia -Hemoconcentration (elevated blood osmolarity, hematocrit/hemoglobin) due to dehydration |
| Fluid Remobilization | -Occurs after 24 hours -Capillary leakage stops -Diuretic stage where edema fluid shifts from the interstitial spaces into the vascular space -Blood volume increases leading to increased renal blood flow and diuresis. -Body weight returns to normal -See Hypokalemia |
| What are the phases of burn injury | Emergent (24-48 hrs) Acute Rehabilitative |
| What are the immediate problem of the Emergent Phase of burn injury? | fluid loss, edema, reduced blood flow (fluid and electrolyte shifts) |
| Clinical manifestation in the Emergent Phase | -Cardiovascular begin immediately which can include shock -Obtain a baseline EKG -Monitor for edema, measure central and peripheral pulses, blood pressure, capillary refill and pulse oximetry -Changes in renal function (related to decreased renal blood flow) -Urine is usually highly concentrated and has a high specific gravity -Urine output is decreased during the first 24 hours -Fluid resuscitation is provided at the rate needed to maintain adult urine output at 30 to 50mL/hr |
| What is a common cause of death in the Emergent stage? | Shock |
| Additional clinical manifestations during the Emergent Phase | Sympathetic stimulation causes reduced GI motility and paralytic ileus Auscultate the abdomen to assess bowel sounds which may be reduced Monitor for n/v and abdominal distention Clients with burns of 25% TBSA or who are intubated generally require a NG tube inserted to prevent aspiration and removal of gastric secretions |
| When is the Rehabilitative phase started? | At admission |
| What lab values should a nurse be aware of for a burn victim? | Na-hypo and hypernatremia K-hyper and hypokalemia WBC-10,000-20,000 |
| What are signs of infection? | -septic shock -odor -partial thickness injury to full thickness injury -ulceration of health skin -grafts slough off -altered LOC -change in VS -Oliguria-low urine output less that 30mL/hr -diarrhea/vomiting -excess drainage |
| Nursing diagnosis in the Emergent phase | -Decreased CO -Deficient fluid volume r/t active fluid volume loss -Ineffective Tissue perfusion -Ineffective breathing pattern |
| Nursing diagnosis in the Acute Phase | -Impaired skin integrity -Risk for infection -Imbalanced nutrition -Impaired physical mobility -Disturbed body image |
| What is fluid used for burn victims? | Lactated Ringer (isotonic) |
| Acute Phase of Burn Injury | -Lasts until wound closure is complete -Care is directed toward continued assessment and maintenance of the cardiovascular and respiratory system -Pneumonia is a concern -Infection (Topical antibiotics – Silvadene) -Tetanus toxoid (tetanus vaccine is given) -Weight daily without dressings or splints and compare to pre-burn weight -A 2% loss of body weight indicates a mild deficit -A 10% or greater weight loss requires modification of calorie intake -Monitor for signs of infection |
| Rehabilitative Phase of Burn injury | -Begins at time of admission -Technically begins with wound closure and ends when the client returns to the highest possible level of functioning. -Provide psychosocial/emotional support. -Assess home environment, financial resources, medical equipment, prosthetic rehab. -Health teaching should include symptoms of infection, drugs regimens, f/u appointments, comfort measures to reduce pruritus. |
| Diet for burn victims | -Initially NPO -Begin oral fluids after bowel sounds return -Do not give ice chips or free water(can lead to electrolyte imbalance) -High protein, high calorie |
| What medication should you not give to burn victims? | Aspirin |
| Goals for Burn patients: | -Prevent complications (contractures) -emotional support -Analgesics (except Aspirin) -turn q2hr to prevent contractures -Hourly VS -respiratory function assessed -strict surgical asepsis -anti-infective methods used |
| In what phase are skin grafts done? | Acute Phase |
| How is a debridement done? | -forceps and curved scissor -hydrotherapy (application of water for treatment) -Only loose eschar removed -blisters are left alone to serve as a protector – controversial |
| Post care of skin grafts | -Maintain dressing -Use aseptic technique -Graft should look pink if it has taken after 5 days -Skeletal traction may be used to prevent contractures |
| How long should burn patients wear compression garments? | 23hrs a day for 1 year |
| Greatest number of burn injuries in adults are associated to: | Smoking and cooking |
| Children are prone to burn injuries from: | -accidentally scalding themselves -playing with matches or lighters |
| Treatment of Major Burns | Never try to remove clothes stuck to burns! Wait until the patient is in the hospital setting. |
| What is Compartment syndrome? | -The structures, tissues and blood vessels become squashed because of the increased amount of fluid within the tissues. -This means that the blood supply becomes compromised. |
| When does compartment syndrome happen in burn patients? | -Edema happens 8-12 hrs after the burn. -The body reacts to the extreme burn by the movement of fluid from the plasma to the interstitial space. -the interstitial spaces are full of fluid which results in hyperkalemia. |
| Heterograft or xenograft- | comes from a donor animal -usually a pig |
| Which skin graft is permanent? | Autograft |
| Renal Changes associated with burns | -In burns of 15-20% of the body surface, there is decreased urinary output which must be avoided or reversed. -UTIs are frequent. |
| Parkland Formulation | This is the formula used to calculate the amount of fluid required by a patient who has been burned. 4 x Pt wt in kg x TBSA/2 Amount is given over the 1st 8 hours, them again over 16hrs |
| What gauge should be used for elderly patients? | #22 |
| Infiltration | -When IV fluids leak into the surrounding tissue. -Cool, wet, painful swelling |
| Extravasation | When IV fluid leaks into the surrounding tissue; eating the tissue causing tissue death (necrosis) and scarring (eschar). You may need a skin graft depending on the severity. |
| Phlebitis | inflammation of veins causing pain, discomfort and swelling. The vein is hot, hard, sore and can become infected (purulent material can leak). Can happen when D5LR w/K is used. |
| Normal IV assessment | Clean, dry, intact w/no redness or swelling at the site. done q2hrs |
| High risk IV assessment | done q1hr |
| What ointment should not be used for burn patients allergic to sulfur? | Silvadene |
| Fluid and Electrolyte Imbalance problems associated with burns | -Edema appears around wound as a result of damage to capillaries -Loss of fluid at the burn area -Causes confusion, disorientation and decreased LOC |
| Pulmonary Changes associates with burns | -Most life threatening -Caused from inhalation injury -Pulmonary edema -Beware of Cough -Watch for increasing hoarseness, stridor and falling 02 saturation. |
| GI Changes associated with burns | -Acute gastric dilation -Paralytic ileus -Curling’s ulcer that produces coffee ground aspirate |
| Bloodwork that can be ordered: | -CBC (Complete Blood Count) -BUN (Blood Urea Nitrogen) -ABG (Arterial Blood Gasses) -UA (Urinalysis) -Total protein/albumin (gives info about nutritional status and body’s ability to maintain circulatory fluid) |
Created by:
shondell1971
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