4092 10 burns Flashcards
In addition to destruction of body tissue, a burn injury results in the loss of: _____ regulation
temperature
Metabolism ____ to maintain body heat as a result of burn injury and tissue damage
increases
Quick method to approximate the extent of burn by dividing the body into multiples of nine. The total of the sum is equal to the total body surface area (TBSA). This determines the measurement and the extent of the burn
Rule of Nines
A more exact method estimating the extent of burn by the percentage of surface area of anatomic parts, particularly the head and legs of the client injured. Dividing body into smaller parts and providing a TBSA for each body part, an estimate of TBSA can be determined
Lund and Browder Method
Quick method to approximate scattered burns using the palm of the client’s hand. The palm of the client’s hand (excluding the fingers) is equal to 0.5% TBSA. This method can be used for all age groups.
Palmer Method
One factor in how severe a wound is, is the involvement of the ___ blank system
respiratory (did they breath in smoke)
Three Phases of Burn Care: Emergent
First 24 to 48 hr after the burn occurs
Three Phases of Burn Care: Acute phase begins when
fluid resuscitation is finished
Three Phases of Burn Care: Acute phase ends when
the wound is covered by tissue
Three Phases of Burn Care: Rehabilitative phase begins when
most of the burn area is healed
Three Phases of Burn Care: Rehabilitative phase ends when
reconstructive and corrective procedures are complete (may last for years)
Reduce setting on water heater to below
140° F (60° C).
Risk for Death from Burns: Burn involves greater than ___ TBSA
40% TBSA
Superficial burn
damage to epidermis
Superficial partial thickness
damage to the entire epidermis and some parts of the dermis
Deep partial thickness
damage to entire epidermis and deep into the dermis
Full thickness
damage to the entire epidermis and dermis, and may extend into the subcutaneous tissue. Nerve damage also occurs
Deep full thickness
damage to all layers of skin and extends to muscle, tendons and bones
Example of Superficial burn
sun burn
Example of Superficial partial thickness
Flame or burn scalds
Burn Appearance: Pink to red, tender, no blisters, mild edema, and no eschar
Superficial
Burn Appearance: Pink to red, blisters, mild to moderate edema, and no eschar
Superficial partial thickness
Burn Appearance: Red to white, with moderate edema, free of blisters, and soft and dry eschar
Deep partial thickness
Burn Appearance: Red to tan, black, brown, or white. Free from blisters, severe edema, and hard and inelastic eschar
Full thickness
Burn Appearance: Black, no edema
Deep full thickness
Possible grafting involved
Deep partial thickness
Grafting required
Full thickness and Deep full thickness
Clinical manifestations may not be evident for ____ and are seen as wheezing, hoarseness, and increased respiratory secretions
24 to 48 hr
Carbon monoxide inhalation findings:
e_____
upper airway ____
s____
errythemia (red skin)
upper airway edema
sloughing of respiratory tract
H_____ and s____ may result when injury to at least 20% to 30% TBSA occurs
Hypovolemia and shock
Initial fluid shift (first 24 hr after injury): H and H will be
increased (because they lost fluid)
Initial fluid shift (first 24 hr after injury): Sodium and Potassium
Hyponatremia
Hyperkalemia
Minor Burns: Stop the burning process: Remove ____ or ____ that might conduct heat
clothing or jewelry
Minor Burns: Stop the burning process: Apply cool water soaks or run cool water over injury; do not use
ice
Minor Burns: Stop the burning process: chemical burns
Flush chemical burns with large volume of water
Minor Burns: Stop the burning process: to prevent contamination and hypothermia
Cover the burn with clean cloth
Minor Burns: Stop the burning process: Provide w____
warmth
Minor Burns: Cleanse with mild soap and tepid water, avoid excess
friction
Minor Burns: Apply dressing (n_____, h_____) if the burn area is irritated by clothing
nonadherent, hydrocolloid
Minor Burns: Check immunization status for t____ and determine need for immunization
tetanus
Moderate and Major Burns: first priority
Maintain airway
Moderate and Major Burns: A ______ tube may be indicated for clients at risk for aspiration.
nasogastric
Moderate and Major Burns: Assist client to _______ every hour
cough and deep breathe
Moderate and Major Burns: Keep head of bed
elevated at all times (airway priority)
Moderate and Major Burns: Initiate intravenous access using
large-bore needle
Moderate and Major Burns: Initiate intravenous access using a large-bore needle. If a large area of the body is burned,
a central venous catheter is inserted
Moderate and Major Burns: ____ ____ replacement is needed during the emergent phase to maintain tissue perfusion and prevent hypovolemic (burn) shock
Rapid fluid
Moderate and Major Burns: AFTER the first 24 hours, the IV fluids given would be
Colloid solutions, such as albumin (DURING the 1st 24 hours its NS or LR)
Follow _____ precautions when performing wound care.
standard
A client with large burns could need up to ____ calories per day
5,000
Avoid pain medication that’s given
IM or SQ
When performing wound care follow ___ precautions
standard
When do you assist with ambulation?
as soon as they’re stable
In addition to retaining water and protein, Biologic Skin Coverings also cover nerve endings which means the help with
pain
Allograft vs Autograft
Allo is from any human, Auto specifically means its from your own body
Mesh graft
A skin graft that can be stretched to cover a bigger area
Graft: the extremity should be kept
elevated
The skin will regrow as long as
there is some part of the dermis left
No matter what, even if nerve endings are destroyed all burns
all burns are painful
superficial thickness wounds are the least
damaging because it only involves the epidermis.
superficial thickness wound example
sun burn
in a partial thickness wound, it affects
the epidermis and part of the dermis (think partial = part)
You can have 2 kinds of partial thickness wounds
superficial and deep
superficial partial thickness ___ when pressured
blanch
superficial partial thickness: they develop blisters because
there’s plasma leaking out
superficial partial thickness usually don’t
scar
Deep partial compared to superficial partial
are LESS painful because nerves are gone
Deep partial: healing can be sped up with
grafting
Full thickness burn is when
the epi and entire dermis is gone
lethary eschar
Full thickness burn
Full thickness burn: the eschar must be
removed
Full thickness burn: the eschar can have a constricting affect so you may need
fasciotomy
Deep full thickness
not only is dermis gone, but it extends into other tissue
