Burns Flashcards
Which type of burn has partial thickness and has large, moist vesicles that increase in size.Color is mottled with dull, white, tan, pink or cherry red areas.
A. First Degree Burn
B. Second Degree Burn
C. Third Degree Burn
B. Second Degree Burn
Which type of burn has little or no pain, no blanching with pressure and is dry with leathery eschar?
A. First Degree Burn
B. Second Degree Burn
C. Third Degree Burn
C. Third Degree Burn
What information should be included in a nursing assessment of a burn?
- depth of the burn (superficial, partial, full)
- causative agent (ie. ultraviolet light, direct flame, chemicals)
- temperature and duration of contact
- skin thickness
A burn exceeding what percentage of total body surface area results in massive evaporative water losses and fluid loss into the interstitial spaces? A. 15% B. 5% C. 10% D. 20%
D. 20%
What causes thermal burns?
Flames, scalds, and thermal energy (heat)
What are the three phases of pathophysiology and care of burns and what time frames do they cover?
Emergent phase: onset - stabilization (approx 12 hrs)
Acute phase: starts 48-72 hrs after burn and lasts from 10 days - months.
Rehabilitation phase: begins at admission. May last years.
**NOTE: phases may overlap
What is the greatest concern during the emergent phase of a burn?
Hypovolemic shock. Because fluid shifts from the capillaries into the interstitial spaces causing cells to become dehydrated.
What is the greatest concern during the acute phase of a burn? (aka diuretic phase)
Circulatory overload. Because fluid shifts back from the interstitial spaces into the capilaries.
What is the greatest risk during the rehabilitation phase?
Infection because skin is damaged.
What factors determine the classification of severity of a burn?
- Percentage of the TBSA burned
- Victim’s age
- Specific location of the burn
- Cause of the burn
- Other diseases present
- Depth of hte burn
- Injuries sustained during the burn.
If a patient has an electrical burn on their hands, what is the severity of the burn?
Major Burn
If a 25 yo has a burn covering 10% TBSA, what is the severity of the burn?
Minor Burn
If a 50 yo has a burn covering 15% TBSA with full thickness, what is the severity of the burn?
Major Burn
If a 40 yo has burns covering 20% TBSA with partial thickness, what is the severity of the burn?
Moderate Burn
If a patient has burns covering 18% TBSA and has black-tinged sputum and hoarseness, what is the severity of his/her burn?
Major Burn
If a diabetic patient has burns covering 15% of their body with partial thickness, what is the severity of their burn?
Major Burn
What are the signs and symptoms of inhalation injury?
singed facial hair black-tinged sputum soot in the throat hoarseness neck or facial burns Stridor (life-threatening sign)
What method should be used to determine if a patient has CO poisoning?
A. pulse oximetry
B. peak flow meter
C. carboxyhemoglobin test from blood sample
D. pulmonary function test
C. carboxyhemoglobin test from blood sample
What are early signs of CO poisoning and how is it teated?
HA, N/V, unsteady gait
Administering 100% oxygen
Why is it important to remove all nonadherent clothing and jewelry after an open airway is established and bleeding is controlled, during the emergent phase in a burn victim?
Because excessive swelling occurs.
What is the open or exposure method of burn wound care and what areas of the body is this method used for?
The area is cleaned and exposed to air. This encourages the formation of a hard crust followed by tissue regeneration.
Used for burns of the face, neck, ears and perineum.
What are the advantages of the open method of burn wound care?
- The wound can be observed more easily
- movement in bed is less restricted
- circulation of the body part is not restricted
- exercises can be done more easily
What are the disadvantages of the open method of burn wound care?
- pain
- chilling
- contamination of wound by the health care provider
- unattractive appearance, which causes emotional distress
- the need for protective isolation precautions for the immunocompromised patient
What is the closed method of burn wound care and what are the advantages of this method?
Clean the burn, apply the prescribed medication and dress the wound as ordered.
Advantages:
1. it protects the burn area from injury
2. it prevents contamination of hte area by the health care provider.
