Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Test 5 Burns
Burn
| Question | Answer |
|---|---|
| What is Phlebitis? | Inflammation of the Veins |
| If a patient is experiencing Phlebitis while receiving an IV. What is the next priority action? | Take out the IV |
| What are the common Symptoms of Phlebitis? | -Pain, tenderness and Swelling -The incision will be Red and itchy -The vein will feel hard and cord like -Bulging or visible veins -The skin will be warm to touch over the vein -IV Must come out |
| What happens when "Infiltration" occurs? | The catheter tip slips out of the Vein and begins to leak into the tissues |
| What are the signs and symptoms of Infiltration? | Mounded site area is (BIG) Skin feels Cool to touch Area may look Pale and Blanching Swelling No Blood Return |
| If a patient is experiencing Infiltration while receiving an IV. What is the next priority action? | Stop the infusion immediately and remove the catheter. |
| Pressure Garments for burn patients are to be worn for how long? | 23 Hrs. a day, for 1 Year |
| What is Extravasation? | The leakage of fluid or medication from a blood vessel into the surrounding tissues |
| Signs and Symptoms of Extravasation include: | Pain, Burning, or Stinging (at the IV site) Swelling Skin Changes (Redness, Blanching-pale, or Mottling-bluish grey) Blistering (Indicates Tissue Damage) Coldness at the site Absent pulse Restricted range of motion |
| What is a Flare Reaction? | A localized, non-painful, allergic response Immediate redness when IV push Cause by local histamine release May Subside in 30-90 min |
| What is a Escharotomy? | Its a procedure that involves making an incision through the eschar- the tough, leathery, non-elastic dead tissue that forms after a deep burn. This relieves pressure on the underlying tissues and improve circulation |
| Why do we administer Lactated Ringers? | It is an "ISOTONIC" crystalloid solution that closely mimics the body's natural extracellular fluid. |
| What is the Primary Function of Administering Lactated Ringers? | Fluid Replacement This restores the circulating blood volume, which is essential for maintaining blood pressure and organ perfusion. |
| Why is it important to move the patient that has burns? What are we trying to prevent? | Contractures Are permanent tightening or shortening of tissue, which results in severe functional limitations and disfigurement. |
| What is the #1 thing that a health care provider should do to prevent the spread of infections? | Wash their hands |
| How do you Treat wounds? | Use a sterile field Prevent cross contamination Separate the cleaning method by doing one section at a time |
| The Number on cause of burns in children is: | SCALD |
| What does superficial mean? | The wound is not deep, and it only appears on the surface of the skin |
| What is Partial Thickness Burn? | 2nd Degree Burn Skin may appear White or Red Healing is slow may take up to 3 weeks Skin may need grafting depending on scaring |
| What is Full thickness Burn? | 3rd and 4th degree burn Change in coloration of skin Skin is leathery, will need escharotomy Grafting is needed Commonly Red, white, brown, or black if its chard |
| What are some signs and symptoms of inhalation during closed face fires? | Soot on face/ clothes singing eyebrows/lashes Drooling Black Sputum (Carbonaceous) Sore throat- Cherry red, Coughing, and hoarse Intubation May need a trach May start to wheeze End point = Stridor |
| During an Inhalation injury you must Auscultate: | Over the Right and Left main stem Bronchos |
| When things Start to burn it omits carbon dioxide. What are some percentages of severity? | 0-10%-normal (Smokers) 20-40%-Mild 40-60%-Severe 60%-Lethal (Death) |
| If a person come in complaining about headache and dizziness they may have been exposed to what? | Carbon Monoxide |
| What is a Fasciotomy? | Primarily used for severe burns to relieve acute pressure and restore circulation |
| What is Silver Sulfadiazine cream for? | To prevent infection by controlling bacteria on the wound surface of severe burns |
| Never Remove clothes on a burn patient. However, you may remove clothes if: | The burn is due to boiling hot water. |
| You should never put what on a burn? | ICE |
| What medications are typically used for pain management with burn patients? | • Opioids for Pain • Narcotics • IV analgesics |
| What is the biggest concern when it comes to a patient that has encountered an electrical burn? | CARDIAC After shock you must complete EKG and Labs to make sure that the patient has no heart damage |
| What are some Vascular Changes resulting from burn injuries? | After damage, leakage occurs Blood flow decreases or ceases due to occluding blood vessels Blood vessel thrombosis may occur causing necrosis |
| What is Fluid Shift? | The burned area surrounding blood vessels clamp down (vasoconstriction) and cause leakage. This results in Severe edema (Michelin Man) swelling occurs all over the body |
| Why do fluid imbalance occur after burns? | •Occurs as a result of the massive fluid shift and cell damage following a significant burn injury •Immediately after the injury they go into Hyperkalemic state because calcium leaves the body |
| Why would a burn patient experience Hyponatremia? | They are Hemo Concentrated, because they are dehydrated |
| How would you know that your patient is dehydrated? What Lab would you run? | BUN |
| Fluid Remobilization usually occurs after how long? | 24-36 hours Your dilation should start to fix itself, everything should return to normal |
| During Fluid Remobilization what occurs during the diuretic phase? | The fluids shift sending the patient into Hypokalemia, because of diluting the patient with the fluids |
| What is a Curling Ulcer/ Peptic Ulcer? | Ulcers that form in the stomach or duodenum resulting from stress due to a major burn. Typically happens with in 8-12 hours |
| Why would a Burn patient be prone to getting a Peptic ulcer? | Sympathetic nervous system “Flight or Fight” kicks in during emergent stages. This is why the patient would get a curling ulcer. It causes reduced GI motility and paralytic ileus |
| How do you monitor and treat a patient with a Curling Ulcer? | • Auscultate the abdomen to assess bowel sounds which may be reduced • Monitor for n/v and abdominal distention • Clients with burns who are intubated generally require an NG tube inserted to prevent aspiration and removal of gastric secretions |
| What should you do during the Phases of Burn Injuries (Emergent) stage 24-48hrs of (ADMISSION) | • Upon Admission, you will issue a Tetanus Shot • Secure the Airway • Support circulation by fluid replacement • Keep comfortable with analgesics • Prevent infection through wound care • Maintain Body temperature |
| What are some clinical manifestations that you should be aware of ? | If patient lungs sound bad, it may be pulmonary. • They may go into shock if their pressure drops • Everyone should get a EKG/5lead at the baseline of admission • Monitor oxygenation (Pulse Ox) . • Capillary Refill for the need of escharotomy |
| Remember” Kidneys are always the first to take a hit. (Its related to decreased renal blood flow). What should you do if you Can’t keep the patient pressure up? | •You want to make sure that the patient has enough urinary “Output”. You are looking for signs and symptoms of perfusion: •“Critical Thinking” Perfusion: What kind of Urine do the patient have? What’s there LOC? •Measure BUN, Creatine and NA levels |
| SKIN ASSESSMENT? | •Assess the skin to determine the size and depth of burn injury •The size of the injury is first estimated in comparison to the total body surface area (TBSA). •Use the rule of nines for clients whose weights are in normal proportion to their heights |
| “Remember” in the first 24 hours the patient will not have enough Fluids. Fluids will be the primary mission. What is some information you should know when it comes to fluids? | • NEVER GIVE A DIURETIC • LACTATED RINGERS IS ISOTONIC (Just like normal saline) • Crystalloid (hypertonic saline) adjust to maintain urine output at 30 mL/hr. • Crystalloid only (lactated ringers) |
| Nursing Care plan in the Emergent Phase. | • Decrease Cardiac Output • Deficient Fluid Volume (Because the patient is leaking) • Ineffective Tissue Perfusion • Ineffective breathing pattern |
| What are some steps for Dressing the Burn Wound. (Remember this cream) | • After burn wounds are cleaned and debrided, topical antibiotics are reapplied to prevent infection • Standard wound dressings are multiple layers of gauze applied over the topical agents on the burn wound • silver sulfadiazine cream |
| What will be infection Signs? | • Vitals: This will show signs of infections • Drainage: Coming out of the wound. (Pseudomonas is a green color infection that happens with burns) • Altered level of consciousness • Gi dysfunction such as diarrhea, vomiting |
| What is an ointment that can help with the spread of MRSA infections? | • Mupirocin (Bactroban)- Antibiotic Ointment that is giving in the nose to help with MRSA. A lot of people have it in their nose |
| During the Acute Phase why is it important to Move the patient? | •Preserve Joint Mobility (Prevent Contractures) •Prevent Pressure Ulcers Risk: Burn wounds that cross joints (especially full-thickness burns) tighten and shrink during healing, leading to severe joint restriction (contractures). |
| NEED TO KNOW! – You CANNOT meet the Metabolic Demand. Why? | • They have issues with their stomach (ileus) • They have an NG Tube • “The Caloric need for a patient with a major burn injury are indeed Astronomical. |
| What are the different types of Grafts? | • Autograft: Tissue harvested from the patient's own body • Allograft: Tissue harvested from a genetically different member of the same species (Cadaver) • Xenograft: Tissue harvested from a different species (pig skin). |
| What are some Discharge Instructions a patient should follow? | • Wound Treatment: Infection Prevention • When Do you call for HELP! • When is the next doctor appointment? • How would they Bath? “Reminder” Pressure garments are worn 23 hours a day |
| What medication should you NOT give? | No Aspirin |
| With Circumferential Burns on chest or legs, what should you do? | • There is no circulation, you have to check for pulses and perfusion of blood in the body which is circulatory S&S |
| What are the signs and symptoms of Infiltration? | • Mounded • Skin at site feel cool to touch • Area may look pale and blanching • Swelling • No blood return Remember: Must Take IV OUT!! Immediately |
| Management & Complications: for Extravasation? | • Stop the infusion • Do not flush • Gently aspirate • Remove the catheter Note: If the IV meets resistance you must get rid of it |
| How long should a patient wear their Pressure garment? | Are to be worn 23 hours a day for 1 year |
| Warmers and Heat lamps can be used to: | Help keep the patient’s body temperature controlled. |
| Sensory Question: If a patient asks, will they ever look the same? The answer is: | NO. You will never look the same. |
| Parkland Formula: | Total Fluid (mL)= 4mL x Weight (kg) x % TBSA (second degree burn) Administration Rule: Half of the calculated volume is given in the first 8 hours post-burn, and the remaining half is given over the next 16 hours. |
| High Risk areas for Burns? | Hands, Feet, & Perineurium |
| What size needle for an IV is Preferrable? | 22 Gauge |
| If a patient is going through Extravasation, What should you never do? | Never Elevate the Arm |
| Superficial (1st Degree Burn) Signs and symptoms | Redness Mild swelling No Blistering Skin Blanches with pressure |
| Superficial Partial Thickness (2nd Degree) signs and symptoms | Bright red to pink Moist and Shiny Large weeping blisters Very painful |
| Deep partial thickness (2nd Degree) Signs and Symptoms | Waxy white, yellow or mottled red Small blisters that are flat Does not blanch Some pain Often requires skin grafting |
| Full thickness (3rd Degree) Signs and symptoms | Leathery, rigid eschar (hard, dry, elastic) White, tan, black (charred), or deep red Painless Requires grafting |
| Deep full Thickness (4th degree) signs and symptoms | Extends all layers to the bone Black, Charred Painless Requires extensive surgery including fasciotomies, amputations, and complex reconstruction. Healing is minimal without surgical intervention |
Created by:
LorrenIsrael