Burns, Integumentary, Pre-op, Intra-op, Post-op
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| Burn (definition) | Occurs when there is injury to the tissues of the body caused by heat, chemicals, electric current, or radiation
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| Thermal burns | caused by flamed, flash, scald, or contact with hot objects (most common type)
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| Chemical burns | result from tissue injury and destruction from acids, alkalis, and organic compounds
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| Smoke and Inhalation Injury | result from inhalation of hot air or noxious chemicals and can cause damage to the tissues of the respiratory tract
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| Electrical burns | A result of intense heat generated from an electric current. Direct damage to nerves and vessels, causing tissue anoxia and death.
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| Cold Thermal Injury (frostbite) | results in the formation of ice crystals in the tissues and cells
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| How is severity of a burn determined? | depth of the burn
extent of the burn
location of the burn
Pt risk factors
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| Partial-thickness skin destruction includes | First degree and second degree burns
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| First-Degree | superficial epidermal damage with hyperemia
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| Second-Degree | epidermis and dermis involved to varying depth: mild to moderate edema and blisters
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| Full-Thickness skin destruction includes | Third and Fourth degree burns
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| Third and Fourth-Degree | all skin elements and local nerve endings destroyed. Necrosis present. Surgical intervention required for healing
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| The severity of the burn injury is related to the __________ of the burn wound. | Location
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| Lund-Browder chart | considered more accurate because the pt's age, in proportion to relative body-area size, is taken into account
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| Rule of Nines | considered adequate for initial assessment of an adult burn patient.
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| Cardiovascular complications of burn injury | Dysrhythmias and hypovolemic shock
Ischemia, paresthesias, necrosis, gangrene
Increase in blood viscosity
Microcirculation is impaired
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| Respiratory complications of burn injury | upper airway burns cause edema formation and obstruction of the airway
inhalation injury
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| Urinary complications of burn injury | Acute Tubular Necrosis
blood flow to kidneys decreased, causing renal ischemia
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| Early endotracheal intubation in the burn pt | elimates the necessity for emergency tracheostomy after respiratory problems have become apparent
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| Fluid therapy for the burn pt | establish IV access that can accommodate large volumes of fluid.
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| Debridement | necrotic skin is removed
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| Open method of wound care | pt's burn is covered with a topical antimicrobial and has no dressing over the wound
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| Multiple dressing change method of wound care | sterile gauze dressing are saturated with or laid over a topical antimicrobial
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| Drug therapy for burn pts | analgesics and sedatives
tetanus immunization
antimicrobial agents
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| _________ takes PRIORITY over nutritional needs | Fluid replacement
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| What nutritional needs do burn pts have? | high calorie, high protein, supplemental vitamins, iron supplements
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| Emergent phase | the period of time required to resolve the immediate, life-threatening problems resulting from the burn injury
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| Acute phase | begins with mobilization of ECF and subsequent diuresis. Ends when the burned area is completely covered by skin grafts or when the wounds are healed.
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| From the onset of the burn event until the pt is stabilized, nursing and collaborative management predominately consists of airway management, fluid therapy, and wound care. | true
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| Skin health promotion includes | avoiding environmental hazards, adequate rest/exercise, proper hygiene/nutrition, use of self-examination techniques
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| Environmental hazard: sun exposure | premature aging, precancerous and cancerous lesions. Tanning is skin's response to injury. Some medications enhance the sun's effect
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| Environmental hazard: radiation | excessive radiation can cause edema, erythema, and hypo/hyperpigmentation
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| Adequate rest | sleep is restorative. NREM: body tissue restoration and repair and renewal of epithelial cells occurs
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| Exercise | increases circulation and dilates blood vessels.
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| _______ and __________ protect from bacterial overgrowth | Perspiration, skin acidity
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| Most soaps _________ skin surface | neutralize
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| Nutrition | well-balanced diet can produce healthy skin, hair, and nails. Important for skin support: vit A, B, C, K, protein, unsaturated fatty acids
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| Macule | flat, nonpalpable change in skin color, smaller than 1 cm
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| papule | Palpable, circumscribed, solid elevation in skin, smaller than 1 cm
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| Wheal | irregularly shaped, elevated area or superficial localized edema, varies in size
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| Vesicle | circumscribed elevation of skin filled with serous fluid, smaller than 1 cm
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| Pustule | Circumscribed elevation of skin similar to vesicle but filled with pus; varies in size
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| 5 characteristics of malignant skin lesions | A = asymmetry
B = Border irregularity
C = Color variation
D = Diameter > 6 mm
E = elevation
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| Malignant melanoma | a tumor occuring in melanocytes. Can spread to any organ. Most deadly skin disease.
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| Normal bacteria on the skin | staph aureus and strep b
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| Predisposing factors for infections | moisture, obesity, skin disease, systemic corticosteroids, antibiotics, chronic diseases
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| Bacterial infections of the skin | Impetigo, Furuncle, Folliculitis, Carbuncle
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| Cellulitis is characterized by | erythema, tenderness, edema
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| Viral infections of the skin | Herpes simplex (types 1/2), Herpes Zoster (shingles), Warts/plantar warts
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| Silver is | a natural antibiotic
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| Fungal infections of the skin | Candidiasis, tinea Corporis (ringworm), tinea curis (jock itch), tinea pedis (athlete's foot), tinea unguium (nails)
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| Scabies | mites under the skin
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| symptoms of scabies | severe itching at night
usually not on face, on hands, wrists, genitals, axillary folds
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| treatment of scabies | launder all clothes, antibiotics if 2ndary infection, anti-itch creams
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| Begbugs | were nearly eradicated in the US 50 years ago, resistant strains of "super" bedbugs are infesting mattresses at an alarming rate.
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| Urticaria | erythema and edema from histamine response. Treat by removing the source, implementing antihistamine therapy, systemic corticosteroids, and applying cool compresses
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| Rashes from drug reactions can occur _______ days after medication. | 1-14 days
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| Lesions from contact dermatitis can appear ______ after contact with allergen | 2-7 days
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| benign conditions of the skin | acne, nevi, psoiasis, seborrheic keratoses, acrochordons, lipoma, vitiligo, lentigo
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| What are the uses of wet dressings? | to remove scales and crusts off lesions
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| What are the different types of baths? | saline, water, sodium bicarb, oatmeal
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| Surgery (definition) | the art and science of treating disease, injuries, and deformities by operation and instrumentation
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| Surgery involves... | the pt, surgeon, anesthesia care provider, and nurse
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| Purposes of surgery | Diagnosis, cure, palliation, prevention, exploration, and cosmetic improvement
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| Diagnosis: | determination of the presence and/or extent of pathology
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| Cure: | elimination or repair of pathology
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| Palliation: | alleviation of symptoms without cure
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| Prevention: | examples include removal of a mole before it becomes malignant or removal of the colon in a pt with familial polyposis to prevent cancer
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| Exploration: | surgical examination to determine the nature or extent of a disease
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| Cosmetic Improvement | examples include repairing a burn scar or changing breast shape
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| Elective surgery | carefully planned surgery
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| Emergency surgery | unexpected, urgent intervention
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| Inpatient surgery | pt is admitted to the hospital on the day of surgery. Usually pts who are in the hospital before surgery due to medical conditions
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| Ambulatory surgery is also called what? | same-day or outpatient surgery
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| What are the benefits of ambulatory surgery? | more convenient, involves fewer laboratory tests, fewer pre/post op meds, less psychological stress, less susceptibility to hospital-acquired infections, do not require an overnight hospital stay
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| Who prefers ambulatory surgery? | Physicians, third party payers, and pts
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| What kind of anesthetic is used in ambulatory surgery? | general, regional, or local anesthetic
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| What is the nurse's role in surgery? | prepare pt for surgery, care for pt during surgery, facilitate pt recovery following surgery
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| What are the primary purposes of the pt interview? | to obtain health information, to determine pt's expectation about surgery/anesthesia, to provide and clarify information about the surgical experience, to assess pt's emotional state/ readiness for surgery
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| Goal of assessment of the preop pt | to gather data in order to identify risk factors and plan care to ensure pt safety throughout the surgical experience
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| The most common psychologic factors in surgery are | anxiety, fear, and hope
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| Anxiety | Comes from facing the unknown
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| Anxiety | extremely high levels diminish cognition, decision making, and coping abilities
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| Anxiety | can arise from lack of knowledge, fear of the potential outcome, or unrealistic expectations of surgery
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| Anxiety | can arise when surgical interventions are in conflict with the pt's religious and cultural beliefs
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| Most prevalent fear | potential for death or permanent disability resulting from surgery
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| Hope | May be the pt's strongest method of coping
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| Why should a medication history be taken? | drugs and herbal products may interact with anesthetics
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| Why should a medication hx be taken? | Recreational drug use may affect the type and amount of anesthesia required.
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| Allergies | the pt with a hx of any allergic responsiveness is at a greater risk of developing hypersensitivity reactions to drugs administered during anesthesia.
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| What type of allergy should the nurse screen for? | Latex allergies
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