Burns NUR 221 Test 3
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| 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.
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| Hallmarks of superficial burns…. | Painful, no edema, redness, blanched with pressure
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| Hallmarks of Partial thickness burns… | blistered, moist, painful
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| Hallmarks of full thickness burns: | dry, discolored, no pain
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| Treat burn patients with falls and electrical injuries as… | potential cervical spine injuries
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| Patients with potential cervical spine injuries will have there neck braces removed when? | After X-ray confirms absence of spine injury
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| A client went to the beach and was sunburned. Which is a proper classification of this burn? | A sunburn is a superficial burn.
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| A full-thickness burn is identified by: | the destruction of the entire dermis
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| With partial degree (2nd-degree) burns, skin regeneration begins to take place: | in 2-4 weeks
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| Plasma seeps into the surrounding tissues after a burn. The greatest amount leaks out in: | 24-36 hours
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| As fluid is reabsorbed after injury, renal funtion retains a diuresis for up to: | 2 weeks
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| Fluid shifts during the 1st week of the acute phase of a burn injury that cause massive cell destruction result in: | hyperkalemia
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| Plasma leakage produces edema, which increases: | the hematocrit level
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| Normal hematocrit: | males- 42-54%, females 38-46%
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| The leading cause of death in fire victims is believed to be | carbon monoxide intoxication
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| A serious GI disturbance frequently seen with a major burn is: | paralytic ileus
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| A child tips a pot of boiling water onto his bare legs. The mother should: | immerse child's legs in cool water
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| As 1st priority of care, a patient with a burn injury will need: | an airway established
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| Eyes that have been irritated or burned with a chemical should be flushed w/ cool, clean water: | immediately
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| A nurse knows that a burn injury of 25% of total body surface area is classified as: | moderate
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| Electrolyte changes in the 1st 48 hours of a major burn include: | base bicarbonite deficit
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| The Evans formula for replacing fluid lost during the 1st 24-48 hours recommends the administration of: | colloids, electrolytes, glucose
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| One parameter of adequate fluid replacement is an hourly urinary output in the range of: | 30-50 mL
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| During the fluid remobilization phase, the nurse knows to expect the following: | hemodilution, increased urinary output, sodium deficit
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| What would the nurse NOT expect during fluid remobilization? | metabolic alkalosis
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| Fluid and electrolyte changes in the emergent phase of burn injury include__________, ____________, and ___________ | base bicarbonite deficit, elevated hematocrit, sodium deficit
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| Fluid remobilization usually begins: | after 48 hours, when fluid is being reabsorbed from interstitial tissue
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| Wound cleansing and debridement usually begin when eschar begins to separate at: | 1.5 to 2 weeks
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| Leukopenia within 48 hours is a side effect associated with topical antibacterial agent: | sulfadiazene, silver (Silvadene)
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| 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")
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| An example of a permanent burn wound covering that is used to support an autograph is: | Alloderm
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| The most likely prescribed anlagesic for acute burn pain is: | morphine sulfate
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| The recommended route for administering low-dose narcotics is: | intravenous
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| The backbone of nutritional support during burn injury is | High protein, high calorie (up to 5,000 calories/day)
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| Early indicatators of late-stage septic shock include: | decreased pulse pressure, pale, cool skin, renal failure.
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| Early indicators of late-stage septic shock DO NOT include: | a full, bounding pulse
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| The 2 age groups most at risk for burn injury are: | the very young and elderly.
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| The majority of burns occur… | at home, in the kitchen
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| Burn injuries are classified according to ____________, and_____________ | depth of injury, extent of injured body surface area
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| List 2 pulonary complications that occur secondary to inhalation injuries | acute respiratory failure, acute respiratory distress syndrome (ARDS)
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| The leading cause of death in thermally injured patients is | sepsis
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| The 1st priority of on the scene care for a person with burn injury is to | prevent injury to the rescuer
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| List 4 collaberative problems for a patient in the emergent phase of burn injury: | acute respiratory failure, distributive shock, acute renal failure, compartment syndrome
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| List 3 disorders of wound healing: | hypertrophic scarring, keloid formation, contractures
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| 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)
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| 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.
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| 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.
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| The most frequent thermal injury is: | scald injuries
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| debridement | removal of foreign material and devitalized tissue until surrounding healthy tissue is exposed
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| eschar | devitalized tissue resulting from a burn
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| Advise parents to set water heater no higher than: | 120 F
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| Factors in determining depth of burn: | How injury occurred, causative agent, temp of agent, duration of contact w/ agent, thickness of skin
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| In the palm method, the size of the patient's palm is approx ____% of TBSA | 1%
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| In the rule of nines, which body parts are represented as 9%? | Each arm and the head
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| Which is the most precise method for determining burn injury and more appropriate for children? | Lund and Browder Method
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| 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.
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| 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
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| Critical components of care a thermal burn injury are: | Prompt administration of IV fluids and and monitoring of urine output
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| In a patient receiving fluid resuscitation, what urine output is expected? | 75-100 mL/hour
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| Burns are caused by a transfer of_____________ to __________ energy from a | heat source, to the body
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| Examples of thermal burns: | Sunburn, House fire, electrical
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| Burns that do not exceed 25% TBSA produce a primarily_____________ | local response
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| Major burn injuries________________, and may produce both_____________ and______________ | exceed 25% TBSA, local response, a systemic response
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| Chemical burns are generally initially treated by… | rinsing off with running water
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| During burn shock, serum sodium levels___________in response to fluid resuscitation | vary
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| An escharotomy may be performed to | relieve the constricting effect of burned tissue
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| During burn shock,_____________ is common | Hyponatremia (sodium depletion)
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| Immediately after burn injury,________________ results from massive cell destruction | hyperkalemia (excessive potassium)
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| Later in burn injury,____________ may occur with fluid shifts and inadequate potassium replacement | hypokalemia (potassium depletion)
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| With a true electrical injury, there is a___________ and a (an)______________ | entrance wound, exit wound
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| 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!)
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| Systemic edema is usually maximal after___________ hours, and completely resolved in _____ days | 24-48 hours post-burn, 7-10 days
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| In burns covering less than 25% of TBSA edema is | in burned and surrounding areas
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| In burns over 25% TBSA, edema is | generalized
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| Edema in burn wounds can be reduced by____________ | avoiding unnecessary overresuscitation
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| Burn shock is a combination of which 2 types? | distributive and hypovolemic shock
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| Fluid shifts and shock result in _______________ and___________________ tissue | hypoperfusion, organ hypofunction
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| The most common cause of inhalation injury is__________ | carbon monoxide
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| 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!)
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| Upper airway injury results from… | direct heat or edema
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| Upper airway injury is treated by_____________ | early nasotracheal or endotracheal intubation
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| Inhalation below the glottis results from inhaling the products of | incomplete combustion or noxious gases (carbon monoxide biggest culprit)
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| Inhalation injury below the glottis is usually not a _____________ issue | airway issue (glottis doesn’t close)
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| The cardinal sign of inhalation below the glottis is: | expectoration of carbon particles in the sputum.
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| What is the leading cause of morbidity and mortality in patients with thermal injuries? | Sepsis
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| Serious burn injury diminishes………. | resistance to infection
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| Immunosuppression places the patient with burn injury at high risk for__________ | sepsis
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| 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.
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| The emergent/resuscitative phase of burn injury involves… | onset of injury to completion of fluid resuscitation
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| 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!
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| 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
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| 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
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| In patients with scattered burns, the__________method is used. | palm
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| Electrical burns can cause… | seizures
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| Trauma causes the release of potassium into extracellular fluid resulting in: | hyperkalemia
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| Sodium traps in edema fluid and shifts into cells as poatassium is released resulting in: | hyponatremia
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| The recommended route for giving pain meds is: | IV (necessary due to altered tissue perfusion from burn injury)
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| Patients with electrical burns should have an | EKG
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| 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
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| 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
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| If a patient has contact lenses… | they must be removed immediately
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| Survival of the patient with burn injury depends on… | adequate fluid resuscitation
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| 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.
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| "Which of the following is NOT considered a characteristic of a deep partial thickness burn? | No edema
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| "What are characteristics of a deep partial thickness burn? | broken epidermis, edema, a mottled, red base, and a weeping surface
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| 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.
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| "Which of the following phases of burn care encompasses the beginning of diuresis to near completion of wound closure? | Acute.
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| What are local responses to burns? | acute inflammation, Intravascular coagulation, cellular enzymes and vasoactive substances, actiation of compliment, altered vascular permeability
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| 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
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| 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!
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| Occult blood in stools, regurgitation of "coffee ground" material from the stomach, or bloody vomitus may be a signs of: | Curling's ulcer
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| Curling's Ulcer | an acute peptic ulcer of the duodenum resulting as a complication from severe burns. Give Zantac or nexium to reduce acid.
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| 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
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| Early signs of sepsis may include: | increased temperature, increased pulse rate, widened pulse pressure, and flushed dry skin in unburned areas
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