1
Q
Thermal Burns
A
most common type of burn injury
•are caused by flames, scalds, and heat
2
Q
Radiation Burns
A
Are caused by exposure to ultraviolet light (sun exposure), x-rays,or a radioactive source, therapeutic treatment for cancer
Sun exposure is the most common burn, specifically two wavelength of light UVA and UVB that is more dangerous.
3
Q
Chemical Burns
A
Are caused by contact with strong acids, alkalis or organic compounds.
Cleaning agents used in the home
(drain cleaner, bleach) and agents used in the industrial setting (caustic soda, sulfuric acid)
4
Q
Classification of burns
A
Superficial
partial thickness
full thickness
5
Q
3 layers of skin
A
- Epidermis: thin like sheet of paper; barrier
- Dermis: 30-45% thicker than epidermis-nerves and blood vessels
- Subcutaneous: fat, lymph, muscles and bones
6
Q
Superficial burn (1st degree)
A
Ultraviolet light ( sun burn), flash flame
Dry, No vesicles
Minimal or No edema
Blanch with pressure & refills when pressure is removed
Increased erythema
Burn is painful
heals in 3-7 days.
7
Q
Superficial partial thickness (2nd degree)
A
Due to contact with hot liquids or solids, flash flame to clothing, direct flame, chemicals, ultraviolet
Large moist vesicles that increase in size
Blanches with pressure/refills when pressure removed
Mottled with dull, white, tan, pink or cherry red areas
Very painful
- Blistering and destruction of the epidermis.
- Slight damage to underlying dermis.
- Generally heal w/o intervention
8
Q
full thickness burn (3rd degree)
A
Contact with hot liquids or solids, flame, chemicals, electrical contact
Dry leather eschar
Charred vessels visible under eschar
Vesicles rare but thin walled vesicles do not grow in size MAY be present
No blanching with pressure
White, charred, dark tan, black red
Little or no pain hair easily pulls out
9
Q
deep full thickness 4th degree
A
- muscles, tendons, bone
- black, no edema
- no blisters, eschar is hard and inelastic
10
Q
True or false: A burn can have different degrees at once
A
True; different levels over different parts of the body
11
Q
Electrical Burns
A
- black eschar at the entrance and exit; follows the vascular system and causes clots along the pathway
- risk for arrhythmias, delayed and immediate
- cardiac monitoring for 24 hours
- the closer the burn to an airway, the higher risk
12
Q
Chemical burns do not need
A
heat
-some you can’t use water to rinse bc they are activated by water
13
Q
Emergent phase patient care
A
Most at risk for hypovolemic shock
- prevent shock–greatest initial threat
- prevent respiratory distress (provide 02)
- pain management; IV narcotics
- Fluid Resuscitation
- Tetanus
- -before you treat pain; get the fluids going
14
Q
•Stage 2 Intermediate or Acute (Diuretic) Phase
A
- Begins 48 - 72 after burn injury
- Greatest concern – circulatory overload—- it may result from the fluid shift back from the interstitial spaces into the capillaries.
the acute phase begins when the kidney excrete large volumes of urine
15
Q
burn wound care
A
- prevent infection (patients own bacteria)
- prevent cross contamination
- assists body’s healing process
- Cleanse, Debride, Coverage
- Topical creams (water based)
- biological dressings/grafts
- prevent contractures with positioning, ROM exercises, ambulation, pressure dressings
16
Q
debridement removes
A
dead tissue-prepare wound for grafting
17
Q
Topical Antibacterial Agents for Burn Wounds need to be
A
water based
creams not ointments
18
Q
__________ due to an increase in capillary permeability may be the greatest threat
A
volume shifts
19
Q
Burn shock is most likely to occur within the first ________ immediately following the injury; consequently, the patient must be monitored closely during this time period for s/s.
A
48 hours
20
Q
A method to determine the % or size of burns, the ___________ uses a diagram
A
rule of nines -head is 9%, each arm is 9%, chest is 18%, back is 18%, groin is 1%, each leg is 18% --not accurate for all ages; a rough estimate
21
Q
A method to determine the % or size of burns, the _________ is the most accurate and is used for all pediatric patients
A
Berkow method
-requires time to calculate and requires a table for all ages
22
Q
__________ is a topical antimicrobial agent for burn therapy;
A
silvadene
it is the most popular and has a wide range of effectiveness; easy to use and relatively painless; pt say “cooling effect”
-now known that using this to treat large burns doesn’t increase survival rates significantly
23
Q
The #1 goal during the emergent/resuscitative phase of burns is control of _______ and ________!!
A
ABCs and shock
–>any change in hemodynamic status, decrease in BP, oxygen, deep breathing, turning
24
Q
Nutrition after burns requires a tremendous number of __________;
A
calories
high cal, fat, protein, carb diet with supplements
-metabolism is high due to the healing process
25
Nursing care after excision and grafting
- immobilize the graft
- elevate to decrease edema
- check for bleeding and signs of neruovascular impair (inc pain, numbness, tingling)
- maintain bulky pressure dressings (applied in OR and in place 2-3 days)
- application of sterile saline or antibiotic soln q4hrs
- after autograft, observe donor site (left open to air, keep pressure off site, heat lamp)
- assess for infection (donor and graft site)-red, swelling, drainage
- manage pain
26
The best cover when closing the burn wound is the
patient's own skin
- few donor sites
- meshed skin: run donor skin through machine that makes small slits that allow for expansion; healing occurs as spaces btwn mesh fill in with new epithelial skin growth
27
Heterograft / Xenograft
tissue from another species, such as a pig or a cow, used as a temporary graft
28
Homograft / Allograft
the transfer of tissue between tow genetically dissimilar individuals of another person who is not an identical twin (often a cadaver)
29
S/S of burn shock
cool dry skin, dry mucous membranes, poor skin turgor, decreased urine output, edema,diaphoresis, weakness, dizziness, change of LOC, decreased BP and pulse, tachycardia, dysrhythmia, abnormal labs
---> Tx with aggressive fluid replacement therapy!!!
30
debridement
is the removal of dead tissue:
31
circumferential
eschar extends around the extremities or chest and can restrict edema, inward pressure to tissue
32
Eschar
is dead tissue and remnants that must be removed before the wound can heal!
33
The drug of choice for pain relief of burns is continuous drips of _____________!
morphine sulfate
-control CO and prevent further sympathetic responses (change in HR, rhythm, BP)
34
The purpose of fluid therapy in the first 24-48 hours is to prevent ____________!
hypovolemic shock
35
Medical Management
* Evolves through three phases
* Emergent phase
* Acute phase
* Rehabilitation phase
36
Nonthermal burns
result from electricity, chemicals, and radiation
37
Medical Management
| •Emergent phase
* Stop the burning process
* “stop, drop, and roll”
* Establish airway
* Control bleeding
* Remove all nonadherent clothing and jewelry
* Cover victim
* Transport to hospital
* Monitor vital signs
* In case of Chemical burn
* Rinse with water or appropriate solvent
* In case of Electical burn
* Monitor for cardiac arrest
* Entry and exit point
38
•Primary Assessment
* Assess ABCs
* Assess for life threatening injuries
* Airway remains priority
* Suspect inhalation injury if;
* Occurred in closed or confined area
* Singed facial hair
* Black-tinged sputum
* Soot in throat
* Hoarseness
* Neck and/or face burns
* Stridor -- life-threatening sign
39
•Once in hospital
* Establish airway
* Begin fluid resuscitation
* Insert a Foley catheter
* Insert an NG tube
* Treat pain
* Administer analgesics IV
* Maintain airway, fluid status, monitor vital signs
* Provide tetanus immunization prophylaxis as needed
* Primary Goal in first 72hours
* Maintain respiratory integrity, prevent hypovolemic shock and renal failure
40
•Carbon Monoxide (CO) Poisoning
* CO displaces oxygen from hemoglobin
* DO NOT rely on pulse oximetry
* Cannot distinguish between oxyhemoglobin and carboxyhemoglobin
* S/S
* Headache
* Nausea
* Vomiting
* Unsteady gait
* Treatment
* Administer 100% oxygen
41
Medical Management
| •Acute phase
* Maintain airway
* Maintain fluid status
* Treat pain
* Monitor fluid output
* Monitor vital signs
42
Rehabilitation Phase
* Starts on admission
* “Officially” begins when 20% or less of TBSA remains burned
* Promote independence
* Promote function
* Promote mobility
* Prevent contractures
43
The nurse is caring for several clients who have burns over different parts of the body. The client who has burns over which part of the body is most at risk of life-threatening complications?
1. Lower torso
2. Upper part of the body
3. Hands and feet
4. Perineum
2. Persons with burns of the upper part of the body frequently have respiratory involvement. Airway problems increase the mortality rate.
44
The nurse is caring for several clients who have burns. Which of the following persons with burns has the poorest prognosis?
1. A 20-year-old with second- and third-degree burns over 60% of the body
2. An 80-year-old with second- and third-degree burns over 50% of the body
3. A 35-year-old with second- and third-degree burns over 60% of the body
4. A 2-year-old with second- and third-degree burns over 30% of the body
2. The very old and the very young are at the highest risk and have the highest mortality rate. The very old are half-dehydrated before the burn occurred and have greater difficulty with the fluid shifts. The very young have a greater percentage of their body weight that is supposed to be water. They have more difficulty with the fluid shifts that occur following a burn.
45
Which of the following clients should have his clothing removed immediately?
1. A 32-year-old man who was burned while working on high-tension wires
2. A 14-year-old boy who suffered severe smoke inhalation during a fire at school
3. A 78-year-old man who was burned during a fire that started when the client fell asleep while smoking
4. A 19-year-old student who spilled chemicals on himself in the chemistry lab at school
4. Clothing should be removed from persons with chemical burns so that they will not be further contaminated.
A flame burn should be smothered, and if necessary, the area should be soaked with water, but the clothing should not be removed until the person is in the emergency room. A person who suffered from smoke inhalation does not have an immediate need to remove clothing. A person who received an electrical burn does not have an immediate need to remove clothing.
46
A 28-year-old man received severe burns of the chest, abdomen, back, legs, and hands when
the house caught fire. In the emergency room, a nasogastric tube was inserted, and the client was ordered NPO. What is the primary reason for the nurse to keep this client NPO?
1. To prevent the deadly complication of aspiration
2. To make the client more comfortable
3. To help prevent paralytic ileus
4. To help prevent excessive fluid loss
3. Burn victims are very prone to paralytic ileus. The client will remain NPO until bowel sounds have returned.
47
The nurse is ordered to insert an indwelling catheter in a severely burned client for which reason?
1. To prevent contamination of burned areas
2. To measure hourly urine output
3. To prevent urinary tract infection
4. To detect internal injuries quickly
2. Measurement of urine output is a high priority. Fluid replacement is based on output. The goal is to prevent the client from going into shock by maintaining a urine output of 50 to 100 mL/hr.
48
A severely burned man had his last tetanus shot when he started work at his job two years ago. What should the nurse expect to administer now?
1. Tetanus toxoid booster
2. Tetanus antitoxin
3. Hyperimmune human tetanus globulin
4. DPT booster
1. Tetanus toxoid is given when the client has had prior tetanus inoculations. Hyperimmune tetanus globulin is given when the person has not had prior tetanus immunization. DTP is not given past the age of 6 years. Tetanus antitoxin is given when a person has not been immunized and considerable time has elapsed from the time of the injury. Tetanus antitoxin helps to fight a tetanus infection that is developing. Tetanus toxoid and immune globulin help to prevent tetanus infection from developing.
49
A severely burned client is to be admitted from the emergency department. What type of room should the nurse prepare for the client?
1. A semi-private room with a noninfectious
client
2. A room with a postoperative client
3. An isolation room
4. A private room with a private bath
3. Burn victims should be placed in isolation because they are very susceptible to infection.
50
The nurse is planning care for a newly burned client. What is the priority nursing observation to be made during the first 48 hours after the burn?
1. Hourly blood pressure
2. Assessment of skin color and capillary refill
3. Hourly urine measurement
4. Frequent assessment for pain
3. Fluid replacement is based on hourly measurement of urine output. The other observations are important and should be done, but they are not the highest priority.
51
Cimetidine (Tagamet) is ordered IV every six hours for a person with severe burns. What is the primary reason for administering Tagamet to this client?
1. To prevent infection
2. To restore electrolyte balance
3. To promote renal function
4. To prevent Curling's ulcers
4. Curling's (stress) ulcers occur frequently in burn victims. Tagamet is a histamine blocker that reduces gastric acid and helps to prevent the development of ulcers.
52
A client who was severely burned goes to the Hubbard tank daily. Tanking sessions are limited to a half hour for which reason?
1. A longer period of time is too tiring.
2. Eschar becomes difficult to remove with longer
soaking.
3. Prolonged soaking causes electrolyte dilution.
4. The water becomes too cool and may cause
chilling.
3. The water in the Hubbard tank is hypotonic, and sodium loss occurs through the open wounds. The bath may be painful and fatiguing for the client. The primary reason is the physiological problem of sodium loss.
53
Silver nitrate dressings are applied to burns on an adult. What should be included in the nursing care plan?
1. Change the dressings every two hours.
2. Keep the dressings wet.
3. Carefully monitor fluid intake.
4. Observe for black discoloration.
2. Silver nitrate dressings must always be kept wet, or the silver nitrate is not effective. Silver nitrate does cause black discoloration, but this is incidental and not a major nursing consideration.
54
The nurse is caring for a client who is having silver nitrate dressings. Which lab values should the nurse monitor?
1. Blood urea nitrogen (BUN)
2. Blood gases
3. Complete blood count (CBC)
4. Serum electrolytes
4. Silver nitrate can cause depletion of potassium, sodium, and chloride; therefore, serum electrolytes are essential.
55
A young man has extensive burns on the front and back of the chest. His treatment includes the use of Sulfamylon to the burned areas. How should the nurse apply this medication?
1. With a sterile, gloved hand
2. With a sterile applicator
3. With sterile 4 × 4's
4. By aerosol spray
1. A sterile, gloved hand is the preferred way to apply topical antimicrobials.
56
An electrician was wearing a glove that had a hole in it when he grabbed a "hot" wire. His coworkers came to him immediately and called the rescue squad. When the industrial nurse reached him, the electric current had been shut off. What action should the nurse take initially?
1. Dress the entrance and exit wounds
2. Check respirations and pulse rate
3. Remove clothing from the burned area
4. Roll him in a blanket
2. Electric burns cause cardiac arrhythmia's. Checking respiration's and the pulse rate is the highest priority.
There is no need to remove clothing or roll a victim of an electric burn in a blanket because there are no flames. Dressing wounds is of lesser priority than assessing cardiac and respiratory functioning.
57
Autograft
from same patient, permanent
58
debridement -mechanical
hydrotherapy or simple washing (ex hubbard tank); wet-dry dressing removes eschar
59
debridement -enzymatic/chemical
applying collagenase to digest necrotic tissue
60
vesiculation
blistering
61
autograft
surgical transplantation of any tissue from one part of the body to another location in the same patient
62
a synthetic graft
substitute the autograft is permanent, whereas the other types are temporary
63
pedicle method
the tissue is left partially attached to the donor site and the other portion of the tissue is attached to the burn site
64
the freestanding method
the tissue is completely removed from the donor site and is attached to the burn site
65
What occurs within the first 12 hours
The greatest fluid loss
66
curling's ulcer
a duodenal ulcer that develops 8 to 14 days after severe burns on the surface of the body; the first sign is usually vomiting of bright red blood
acute phase
67
what is a life-threatening sign in emergent phase
stridor
68
patients with moderate to severe burns are treated using the following steps
1 establish airway
2 initiate fluid therapy
3 insert a foley catheter to determine hourly urinary output
4 insert a ng tube to prevent aspiration
5 administer analgesics iv in small, frequent doses for pain control
6 maintain airway and fluid status and monitor vital signs
69
tissue hypoxia
carbon monoxide (CO) binds to hemoglobin with greater affinity than does oxygen
70
signs of respiratory difficulty include
a hoarse voice or a productive cough
other physical findings are singed nasal hairs,
agitation, tachypnea, flaring nostrils or intercostal refractions,
brassy cough, grunting or guttural respiratory sounds,
erythema or edema of the oropharynx or nasopharynx,
sooty sputum
71
what occurs approximately 48 to 72 hours into a burn
fluids begin to shift back to the vascular compartment.
| fluid return denotes the end of the hypovolemic stage and the beginning of the diuretic stage
72
what shifts from the vascular compartment to the interstitial compartment
the proteins, plasma and electrolytes
73
what damages the cilia and the mucosa of the respiratory tract
the fumes of a fire
74
most deaths from burns result directly from
burn shock
75
advantages to the open method are (wound care)
1 the wound can be observed more easily
2 movement in bed is less restricted
3 circulation of the boy part is not restricted
4 exercises can be done more easily to prevent contractures
76
patients with moderate to severe burns are treated using the following steps
1 establish airway
2 initiate fluid therapy
3 insert a foley catheter to determine hourly urinary output
4 insert a ng tube to prevent aspiration
5 administer analgesics iv in small, frequent doses for pain control
6 maintain airway and fluid status and monitor vital signs
77
the open or exposure method may be used for
burns of the (wound care) face, neck, ears and perineum
78
advantages of the closed method (wound care)
(1) it is protects the burn area from injury
| (2) it prevents contamination of the area by the health care provider
79
disadvantages to the open method are (wound care)
1 pain
2 chilling
3 contamination of wound by the health care provider
4 unattractive appearance which causes emotional distress
5 the need for protective isolation precautions for the immunocompromised patient
Integumentary
flashcards
Decks in class (8)
# Cards
-
Care of the Patient with an Integumentary Disorder (adult health)43
-
Integumentary Disorders (Saunders NCLEX-PN®6
-
Integumentary skin & disease( A&P)26
-
Foundations: Health Promotion and Care of the Older Adult41
-
Surgical wound Care (Foundations)36
-
Burns79
-
Agents Used in the Treatment of Skin Conditions18
-
Chapter 22: Surgery and Nutrition Support12
