Burn Flashcards
Fluid resuscitation with the Parkland (Baxter) formula
recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours.
The clinical appearance of superficial partial-thickness
includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours
Reliable clues to the occurrence of inhalation injury is
the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, altered mental status, and “cherry red” skin color.
Electrical injury
puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer’s at 2-4 mL/kg/%TBSA, a rate sufficient to maintain urinary output at 75 to 100 mL/hr. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin.
An 82-year-old patient is moving into an independent living facility. What is the best advice the nurse can give to the family to help prevent this patient from being accidently burned in her new home?
Install tap water anti-scald devices prevent accidental scald burns that more easily occur in older people as their skin becomes drier and the dermis thinner
what are the expected finding in 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
what is accomplished In the emergent phase treatment ?
the immediate, life-threatening problems from the burn, hypovolemic shock and edema, are treated and resolved.Toward the end of the emergent phase, fluid loss and edema formation end
The nurse knows that the patient is moving out of the emergent phase of burn injury when what happens?
fluid loss and edema formation end, Interstitial fluid returns to the vascular space and diuresis occurs, Urinary output is the most commonly used parameter to assess the adequacy of fluid resuscitation
, When the fluid balance has been restored, dilution causes the hematocrit levels to drop, sodium levels increase, potassium decrease
When teaching the patient about the use of range-of-motion (ROM), what explanations should the nurse give to the patient?
Active and passive ROM maintains function of body parts and reassures the patient that movement is still possible,
Contractures are prevented with ROM as well as splints
During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progressed from the emergent phase?
Monitoring for complications (e.g., wound infection, pneumonia, contractures) is needed in the acute phase. Fluid replacement occurs in the emergent phase.
A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage?
Tachycardia
The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient?
In the rehabilitation phase, the patient will work toward resuming a functional role in society, but frequently there are body image concerns and grieving for the loss of the way they looked and functioned before the burn, so continued counseling helps the patient in this phase as well.
what are the priorities in major burn?
ABC, fluid resuscitation( IV LR two big IV), Foley with urimeter to monitor hydration , keep them warm, don’t use ice
ketamine
used for pain control in children
Hydrotherapy
makes debridement process easy and it should not be too long because sodium may drop
