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NCLEX > Burns > Flashcards

Burns Flashcards

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1
Q

Why does plasma seep out into the tissues after a burn?

A

Increase capillary permeability

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2
Q

When does the majority of 3rd spacing occur?

A

1st 24 hours

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3
Q

Why might a burn pt go into shock?

A

Fluid volume deficit from 3rd spacing

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4
Q

What happens to the HR during fluid volume deficit?

A

Increases to shunt blood to vital organs

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5
Q

Why is epinephrine secreted?

A

Vasoconstricts and shunts blood to vital organs

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6
Q

What is the most common airway injury with burns?

A

Carbon monoxide poisoning

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7
Q

Why might a sat probe read 100% and red in color with carbon monoxide poisoning?

A

Carbon monoxide is bound to the hgb

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8
Q

How to treat hypoxia

A

100% O2

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9
Q

What do you do prophylactically when someone is burned to the neck/face/chest?

A

Intubate due to risk of airway injury

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10
Q

Rule of Nines

A 
Head: 9%
Chest: 18%
Back: 18%
Each arm: 9%
Each leg: 18%
Genitals: 1%
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11
Q

How to calculate fluid replacement

A

From the time of the burn, calculate the total amount needed for the first 24 hours. Give half of the total volume during the first 8 hours. 2nd 8 hours: 1/4. 3rd 8 hours: 1/4.

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12
Q

Parkland Formula

A

(4mL of LR) * (weight in kg) * (%TBSA) = Fluid volume for 1st 24 hours

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13
Q

Nurse’s priority in burn pt

A

Hypoxia, not pain

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14
Q

How do you determine if the pt’s fluid volume is adequate?

A

UOP 0.4mL/kg/hr (30-50mL/hr)

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15
Q

Why not use ice for burns?

A

Vasoconstriction inhibits blood flow to extremities, use cool water

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16
Q

How does a blanket help with burns

A

Holds in body heat and keeps out germs

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17
Q

How to treat burns after stopping burning process

A

Remove jewelry and non-adherent clothing, cover wound with a clean dry cloth

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18
Q

A client’s respirations are shallow. What are they retaining?

A

CO2 (resp acid)

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19
Q

Albumin

A

Holds onto fluid in the vascular space. Increases volume, BP, kidney perfusion, CO

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20
Q

What happens to CO during fluid volume excess?

A

Decreases, workload on heart is too much and it’s too stressed

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21
Q

In a client who is receiving fluids rapidly, what should you measure hourly to make sure they’re not overloaded?

A

CVP, not UOP

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22
Q

Why not use IM pain meds in burn pts

A

You must have adequate perfusion to the muscle

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23
Q

Tetanus toxoid booster

A

Active immunity (takes 2-4 weeks to develop immunity)

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24
Q

Immune globulin

A

Immediate protection, passive immunity

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25
Q

What shot will burn pts get if they haven’t had a recent tetanus shot?

A

Immune globulin

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26
Q

Eschar

A

Dry, dark scab falling away of dead skin

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27
Q

What is included in a circulatory check?

A

Pulse, color, temp of skin, capillary refill

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28
Q

Escharotomy

A

Relieves the pressure and restores the circulation, cuts through eschar

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29
Q

Fasciotomy

A

Relieves the pressure and restores the circulation, but the cut is much deeper into the tissue. It cuts through the fascia of the muscle

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30
Q

Skin turgor

A

Checks hydration, NOT circulation

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31
Q

Sensation

A

Neurovascular check, NOT circulation

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32
Q

Why might urine not return when inserting a catheter?

A

Kidneys are retaining the fluid or aren’t being perfused adequately

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33
Q

What would you do if the urine was brown or red?

A

Call doc. It’s normal, but the doc will want to flush out kidneys

34
Q

What drug is ordered to flush out the kidneys?

A

Mannitol

35
Q

Mannitol is what type of fluid?

A

Hypertonic diuretic

36
Q

How to care for mannitol

A

Inline filter, observe for crystals, do not refridgerate

37
Q

Diuretics are not usually given to burn pts except mannitol, why?

A

We don’t want to decrease CO, the goal with mannitol is to save the kidneys

38
Q

If there is no urine output, what do you worry about?

A

Kidney failure

39
Q

Why should the pt begin to diaries after 48 hrs?

A

Fluid is going back into the vascular space. Now worry about fluid volume excess

40
Q

Where do you find K

A

Inside the cell

41
Q

Why is serum K increased in burn pts?

A

Cells burst and release the K into the cell

42
Q

Why is mag carbonate, pantoprazole, or famotidine ordered?

A

To prevent a curling’s stress ulcer

43
Q

Why does the doc want the burn pt to be NPO and have an NG tube hooked to suction?

A

They could develop a paralytic ileus (nothings moving in the intestines, it builds up and they could aspirate)

44
Q

Why could they develop a paralytic ileus?

A

Decreased vascular volume, GI motility, hyperkalemia

45
Q

If a client doesn’t have bowel sounds, what happens to abdominal girth?

A

Increases

46
Q

When will the NG tube be removed?

A

When bowel sounds return

47
Q

What maximizes nutrition in the pt?

A

Protein and vitamin C

48
Q

When you start GI feeds, what is measured to ensure it’s moving through the intestines?

A

Gastric residuals

49
Q

What lab work do you check to ensure proper nutrition and a positive nitrogen balance?

A

Prealbumin, total protein, or albumin

50
Q

What might the pt with partial and full thickness burns develop?

A

Contractures

51
Q

First degree burn, damage only to epidermis

A

Superficial thickness

52
Q

Second degree burn, damage to entire epidermis and varying depths of dermis

A

Partial thickness

53
Q

Third degree burn, damage to entire dermis and sometimes fat

A

Full thickness

54
Q

How to care for burns on hands

A

Wrap fingers individually, use splints to prevent contractures

55
Q

How to care for neck

A

Hyperextend neck, no pillows, could cause chin to chest contracture

56
Q

1 complication of perineal burn

A

Infection

57
Q

Do you remove eschar?

A

Yes, new tissue can’t generate if you don’t. Also, bacteria grows in it

58
Q

What isolation with burn pts

A

Protective/reverse

59
Q

What enzymatic debridement agents can be used to remove necrotic, dead tissue?

A

Sutilains, collagenase. Enzymatic drugs eat dead tissue.

-Don’t use on face, if pregnant, over large nerves, open body vacity

60
Q

Hydrotherapy

A

Used to debride, give pain meds prior

61
Q

Major complication of hydrotherapy

A

Cross contamination

62
Q

Why are antibiotics alternated

A

So bacteria won’t build resistance or tolerance

63
Q

Why are broad spectrum antibiotics used

A

To prevent super infections or secondary infections, or until cultures come back

64
Q

What do you worry about with mycin drugs?

A

If the pts BUN or creatinine increases or if the pt complains of hearing loss. These drugs can lead to ototoxicity and/or nephrotoxicity

65
Q

Purpose of grafts

A

Removes burned dead tissue until healthy tissue is seen

66
Q

Autograft

A

Uses pts own skin. The donor site is an open wound, a dressing is applied until bleeding stops, then it can be left open to air

67
Q

When can the surgeon reharvest from the same donor site?

A

If the client is well nourished, every 12-14 days

68
Q

If the graft becomes blue or cool what does this mean?

A

Poor circulation

69
Q

Why are sterile q-tips ordered to roll with gentle pressure from the center of the graft out to the edges?

A

To attach it to where it needs to be

70
Q

What do you do if the graft comes loose?

A

Cover with sterile dressing

71
Q

How to handle a chemical burn?

A

FIRST remove the client from the chemical and begin flushing, don’t wait for order

72
Q

2 wounds of electrical burns

A

Entrance and exit, entrance is usually smaller. When it finds an exit, it usually blows out that area. Deal with the injuries you see, but don’t forget about the damage you can’t see (heart)

73
Q

What is the first thing you do for an electrical injury?

A

Continuous heart monitor for first 24 hours

74
Q

What arrhythmia is the client with an electrical burn at risk for?

A

V fib for first 24 hours

75
Q

Why might kidney damage occur with electrical burns?

A

Myoglobin is released with muscle injury, and hemoglobin can build up causing kidney damage

76
Q

Why might the electrical burn pt be placed on a spine board with a c-collar?

A

Electrical injuries occur in high places. Muscle contractions can cause fractures, and the force of the electricity can actually throw the victim forcefully

77
Q

Why are amputation common with electrical burns?

A

Circulatory system is destroyed, extremities aren’t perfused

78
Q

Complications of electrical wounds

A

Cataracts, gait problems, any type of neuro deficit. Anywhere there’s a vessel, there’s a nerve too, so they get damaged too.

79
Q

Silver sulfadiazine

A

Soothing. Apply directly, if it rubs off, apply more. Can lowers WBC and cause a rash.

80
Q

Mafenide acetate

A

Can cause acid base problems and stings. Apply more if rubbed off

81
Q

Silver nitrate

A

Keep dressings wet, can cause electrolyte problems

82
Q

Povidone-iodine

A

Stings and stains. May cause allergies and acid-base problems.

NCLEX (14 decks)

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