Burns 3

Question 1

describe kidney and urine function in resuscitation phase

Answer 1

• r/t decreased blood flow and cellular debris
• urine output is decreased (unconcentrated and high specific gravity)
• myoglobin released from damaged muscle and circulated to kidneys

Question 2

how do you assess kidney function in resuscitation phase

Answer 2

assess kidney function by measuring urine output hourly, compare with fluid intake

Question 3

what is the greatest problem r/t disruption in fluid and electrolyte balance

Answer 3

shock

Question 4

describe hypovolemic shock in burn pts

Answer 4

• common cause of death in the resuscitation phase in pts with serious injuries
• decreases C.O.

Question 5

what to monitor for cardiovascular assessment

Answer 5

-cardiac status: central and peripheral pulses, cap refill, pulse ox

Question 6

describe the skin assessment of burn pt

Answer 6

• assess skin and determine size and depth of burn injury
• TBSA (total body surface area): compare burn to this
• important for diagnosis, prognosis, calculating fluid and drugs
• inspect tissue integrity

Question 7

describe the rule of 9s

Answer 7

• body divided into rule of 9s
  head: 4.5% anterior and 4.5% posterior
  chest: 18% anterior and 18% posterior
  arm: 4.5% anterior and 4.5 posterior (for each extremity)
  leg: 9% anterior and 9% posterior (for each extremity)

Question 8

these provide precise measurement of amount of perfusion of the injured tissue

Answer 8

ICG (idocyanine green)

LDI (lase doppler imaging)** most common

Question 9

what is a priority nursing interventino

Answer 9

monitoring pts resp status

Question 10

GI assessment for rescuscitation

Answer 10

• decreased blood flow reduced GI motility and promotes development of paralytic ileus
• bowel sounds are decreased
• pt with 25% TBSA require NG

Question 11

these do NOT provide direct assessment data about the burn wound

Answer 11

-x ray and scans

Question 12

normal hemoglobin (M and W)

Answer 12

M: 14-18 g/dL
W: 12-16 g/dL

Question 13

normal hematocrit (M and W)

Answer 13

M: 42-52 %
W: 37-47 %

Question 14

normal urea nitrogen

Answer 14

10-20 mg/dL

Question 15

normal glucose

Answer 15

74-106 mg/dL

Question 16

normal sodium

Answer 16

136-145 mEq/L

Question 17

normal potassium

Answer 17

3.5 - 5.0 mEq/L

Question 18

normal chloride

Answer 18

98-106 mEq/L

Question 19

normal PaO2

Answer 19

80 -100 mmHg

Question 20

normal paCO2

Answer 20

35-45 mmHg

Question 21

normal COHb

Answer 21

0-10%

Question 22

normal total protein

Answer 22

6.4 - 8.3 g/dL

Question 23

normal albumin

Answer 23

3.5 - 5 g/dL

Question 24

what are the problems if the burn is > 25 % TBSA

Answer 24

1) potential for decreased oxygenation
2) potential for shock
3) pain (acute and chronic)
4) potential for ARDS

Question 25

when does upper airway edema become pronounced

Answer 25

8-12 hrs after fluid resuscitation begins

Question 26

what needs to be monitored profusely in resuscitation and what can improve it

Answer 26

gas exchange

positioning and deep breathing can improve breathing and gas exchange

Question 27

what may be needed if long term intubation is expected

Answer 27

tracheotomy

Question 28

describe titration

Answer 28

adjustment of IV fluid rate on basis of urine output plus serum electrolyte values

Question 29

how is hypovolemia prevented

Answer 29

• IV fluid and drug therapy to restore perfusion (fluid resuscitation)
• large bore central venous catheter, peripheral lines can be useful
• monitor pt response to determine blood perfusion and adequacy of resuscitation

Question 30

how to determine if blood perfusion and resuscitaiton treatment is adequate

Answer 30

urine output (noninvasive assessment)
want hourly urine output of 30 mL/hr