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Burns
| Question | Answer |
|---|---|
| Thermal burns are from... | flames, scalds, heat |
| Nonthermal burns are from... | electricity, chemical, radiation |
| What is plasma | its liquid compartment of blood |
| What kind of water is in the body | IntracellularExtracellular (intravascular) Extracellular (interstitial) |
| Stage I is what stage | Is hypovolemic stage - first 48 hours |
| Stage II is what stage | Is diuretic stage 48-72 hours |
| What not to give and not give first 24 hours after burn? | Give IV fluids. Do NOT give K+ |
| What happend durring Stage I? | Capilaries dilate -> increased capillar permeabiity -> Plasma to interstitial fluid shifting -> Edema-Blistering Hyperkalemia - Cardiac arrest BP low->hypovolemia-Ac.Ren.Fail |
| What happend durring Stage II? | Interstitial to plasma fulid shifting -> Increased blood volume -> Increased urine output - hypokalemia -> circul.overload - CHF |
| 12-48 hours post burn | greatest fluid loss proteins, plasma & electrolytes shift from the VASCULAR TO THE INTERSTITIAL SPACE. hyperkalemia falsely elevated hematocrithypotensionoliguria - low urine outputrapid, shallow respirations, restlessnesshypovolemic shock |
| 48-72 hours post burn | fluids shift back from the INTERSTITIAL TO THE VASCULAR COMPARTMENT increased blood volume- increased cardiac output increased urine outputhypokalemiafluid overloading |
| Normal K+ level | 3.5 - 5 |
| What is hematocrit | hematocrit says how your blood is concentrated (syrupe) |
| What determines rule of nines? | BSA burned - total volume of body surface |
| Factors affecting severity of burn injury | % of BSA burn,edage, location, cause, other diseases, depth injuries sustained |
| History of what nurse has to determine in past 5 years? | Tetanus booster |
| S&S of smoke inhalation | hoarse voicesinged nasal hairsbrassy caugherythema of the pharyngxsooty, black sputum |
| Rule of Nines | arm 9% eachhead 9%chest 18%back 18%leg 18% eachgroin 1% |
| First degree burn | Superficial - causes redness, minimal affectiong only the epidermis, painful, dry, without blisters |
| Second degree burn | Partial Thicknes - involves the epidermis and the dermis, appears red, blistered, maybe swollen and very painful (contact with hot liquids or solids, direct flame, chemicals) |
| Third degree burn | Full thickness - burns-destroy the epidermis, dermis, underlying bones, muscles, and tendons.The site appears white or charred. No sensation in the area since the nerve endings are destroyed. (flame, chemicals, electrical). |
| Child burn percentage | Head to neck 18%Leg (groin to toe) 14%Anterior trunk 18%Posterior trunk 18% |
| How many % of burn require hospitalization and rehabilitation and are classified as a major injuries? | 10% child15-20% adult |
| Burn dx tests | electrolites, CBC, serum chemistries, ABG, carboxyhemoglobin |
| Burn Emergent Phase | stop, drop, roll techniqueremove clothing and shoesdo not apply iceopen airway and control bleedingremove jewelrycover area with clean sheet |
| S&S of carbon monoxide poisoning | headache, nausea, vomiting, unsteady gait, |
| Treatment of carbon monoxide poisoning | give 100% oxygen |
| Burn med. mng | IV therapy (Ringers lactate)Insert foley cat. (to monitor output)Insert NGT (decompress to remove gas - paralytic ileus - means yor intestitnes dont work and u retain gas)Morphine sulfateTetanus prophylaxis |
| Burn acute phase | 10 days to monthsprevent infectionprevent other complications - HF, contractures, RF, paralytic ileus, Curling ulcer |
| What is Hypoximia, Hypoxia, Ischemia | lack of oxygen |
| Burn nursing interventions | complete ABCVSMIOBUN & creatit.High cal. protein & vit. diet/TPNprotective (reverse) isolationSTRICT surg. aseptic tech.hydrotherapyTemporary skin substitutes (TransCyte - prevents frequent, painful drsg changes) |
| Burn nursing interventions continued | Debride wound - prevent infectionAply topical ATB/drugsChange drsg. 2xDRemove Eschar (excherotomy) to increase prepheral circulationOpen/closed wound care methodproper posioning and ROMSpecial beds (bed cradle,Cirocolectic bed, Clinitron) |
| Burn nursing interventions continued 2. | Skin grafts to full thinkness burnsimobilie graft sitegive antacid or proton pump inhibor drugs (ulcer) |
| Burn medicatios (ATB) | mefenide (Sulfamylon) - is painful to applysilver sulfadiazine (Silvadene)silver nitrate - stains skin |
| Types of skin grafting | autograft - from same personhomograft/allograft - from another person/cadaverheterograft/xenograft - from another species (pig or cow) |
| Burn regabilitation phase | Begins at admissionPhysical therapySkin careExcercisesAmbulation |
| Burn prognosis | outcome depends on the siz, depth of burn, age of victim, body part ivoved and presence of other disease |
| Burns related nrsg diagnoses | Disturbed body image related to scarringDeficient self care related to pain or fatioquePost trauma syndrome related to the cause of the burnIneffective coping related to long term rehabilitationGrieving related to loss of wellness |
Created by:
Lidunka25
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