Burn Flashcards
Electrical Burns
a) what is iceberg effect?
b) Pts at risk for?
a) severity of injury difficult to assess
because most damage occurs beneath skin
b) Dysrhythmias or cardiac arrest
Severe metabolic acidosis
Acute kidney injury
Smoke Inhalation Injury
a) What gas is poisoning?
b) how poisoning gas leads to death and what this called?
c) how to treat?
a) Carbon Monoxide (CO)
b) inhaled CO causes Hypoxia
Metabolic asphyxiation
c) 100% humidified oxygen
CO poisoning may occur with no burn injury to skin
Smoke Inhalation Injury
Upper airway injury
s/s
May have massive swelling with rapid onset
Eschar + edema may compromise breathing
Swelling from facial/neck burns can be lethal(cause death)
Severely narrowed airway
Smoke Inhalation Injury
Lower airway injury
s/s?
Injury to trachea, bronchioles, alveoli
Pulmonary edema may not appear till 12-24 hrs post burn
acute respiratory distress syndrome (ARDS)
Lower airway injury
Reliable clues:
Facial burns
Singed nasal hair
Hoarseness, painful swallowing
Darkened oral / nasal membranes
Carbonaceous sputum
Hx of fire in enclosed space
Clothing burns around chest / neck
Superficial partial-thickness burn?
a) involves?
b) s/s?
c) heal?
d) which classification is sunburn?
a) epidermis
b) Pink/red + very painful
c) heal < 1 week
d) superficial thickness burn
Deep partial-thickness burn
a) involves?
b) s/s?
c) heal?
a) dermis
b) moist / blister forming
intact nerve ending
red,shiny,wet
Extremely painful
c) 2-3 weeks
Full-thickness burn
a) all skin elements, nerve endings, fat, muscle, bone
b) Dry / leathery appearance
White to charred
Will require excision and grafting
a) all skin elements, nerve endings, fat, muscle, bone
b) Dry / leathery appearance
White to charred
Will require excision and grafting
Emergent Phase
a) most immediate problems occur?
b) Primary concerns?
life-threatening
a)up to 72hr post injury
b)Hypovolemic shock
Edema
Fluid shift
a) shift from where to where?
b) s/s?
c) what is the best guide to monitor?
d) Electrolyte shifts
a) sodium is moving
from blood to interstitial spaces “leaky capillaries”
b) tachycardia
hypovolemia
edema
c) urinary output
80 kg pt with 20% TBSA burns
4 ml x 20 x 80 = 6400 ml total 1st 24 hrs
d) K+ shift develops 1st (hyperkalemia)
Nursing care
a) First, what to need to assess?
b) When wound care occur?
c) Keep arm and hand what position?
a) ET intubation or not
Administer O2
b) AFTER the airway is secured, circulation is adequate and fluids replaced
c) Extended position
a) pt who has extensive burns on her face, what it the first action?
b) which nutrients promotes wound healing?
a) characteristics if the cough and sputum
burns to face is at risk for pulmonary injury and the development of a brassy cough can indicate an impending loss of airway
b) vitamin C
a) what is hydrotherapy?
b) acute phase pt.what plan?
c) prescription for silver sulfadiazine cream. what lab to watch out?
a) on a special shower table with warm water
use soft washcloths or gauze to scrub
leave small blisters intact but open a large one
b) initiate ROM
to prevent contracture
c) leukopenia
The nurse is planning care for the patient in the acute phase of a burn injury. What nursing action is important for the nurse to perform after the progression from the emergent to the acute phase?
Begin IV fluid replacement.
Monitor for signs of complications.
Assess and manage pain and anxiety.
Discuss possible reconstructive surgery.
Monitor for signs of complications.
Rationale:
Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase. Assessing and managing pain and anxiety occurs in the emergent and the acute phases. Discussing possible reconstructive surgeries is done in the rehabilitation phase.
A patient arrives in the emergency department after sustaining a full-thickness thermal burn to both arms while putting lighter fluid on a grill. What manifestations should the nurse expect?
Severe pain, blisters, and blanching with pressure
Pain, minimal edema, and blanching with pressure
Redness, evidence of inhalation injury, and charred skin
No pain, waxy white skin, and no blanching with pressure
No pain, waxy white skin, and no blanching with pressure
Rationale:
With full-thickness burns, the nerves and vasculature in the dermis are destroyed so there is no pain, the tissue is dry and waxy-looking or may be charred, and there is no blanching with pressure. Severe pain, blisters, and blanching occur with partial-thickness (deep, second-degree) burns. Pain, minimal edema, blanching, and redness occur with partial-thickness (superficial, first-degree) burns.
