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Critical Care Nursing > Burns > Flashcards

Burns Flashcards

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1
Q

What are the 2 most common burns?

A

Flame and scald

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2
Q

How are burns classified?

A

By the depth of the injury and the extent of the TBSA that is burned

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3
Q

What factors are considered when determining the depth of a burn?

A
  • how injury occurred
  • causative agent
  • temperature of burning agent
  • duration of contact
  • thickness of skin in burned area
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4
Q

How are burns described?

A
  • superficial
  • superficial-partial thickness
  • deep-partial thickness
  • full thickness
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5
Q

Superficial burns only damage what?

A

the epidermis

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6
Q

Superficial Burns

A
  • red and dry
  • slight swelling
  • NO blister
  • painful like sunburn
  • no scarring
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7
Q

How long does it typically take superficial burns to heal?

A

7 days with usually no scarring

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8
Q

Superficial Partial-Thickness burns affect how much of the skin?

A

the epidermis is destroyed and small portion of underlying dermis

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9
Q

Superficial Partial-Thickness burns

A
  • blistered
  • exposed dermis is red and moist
  • hair follicles are intact
  • no scarring
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10
Q

How long does it take Superficial Partial-Thickness burns to heal?

A

14-21 days

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11
Q

Deep Partial-Thickness burn affects how much?

A

Extends into the reticular layer of the dermis and is hard to distinguish from full-thickness

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12
Q

Deep Partial-Thickness Burn

A
  • red or white
  • mottled
  • moist or fairly dry
  • severe pain
  • permanent scarring
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13
Q

How long does it take Deep Partial-Thickness burns to heal?

A

3-8 weeks

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14
Q

How much will a Full-Thickness burn affect?

A

involves total destruction of dermis and continues into the subcutaneous fat
Can also involve muscle and bone

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15
Q

How do Full-Thickness burns heal?

A

By contraction or epithelial migration

Will require surgery

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16
Q

Full-Thickness Burns

A
  • charred/leathery skin
  • hair follicles/sweat glands are destroyed
  • no longer experiences pain
  • significant scarring
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17
Q

A deep partial-thickness burn can convert to a full-thickness burn in how long?

A

24 hours

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18
Q

How can the nurse prevent a deep-partial thickness burn from converting to full-thickness burn?

A

Immediate assessment and management

-application of cool tap water for a minimum of 5 minutes

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19
Q

Why should the use of ice water be avoided for large burn injuries?

A

It can result in hypothermia and increased mortality

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20
Q

Why is tap water good for burn injuries?

A
  • reduction of pain

- reduction of tissue necrosis and need for skin grafting

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21
Q

What are the 3 distinct zones seen as a Bulls Eye pattern in burns?

A
  • zone of coagulation (center)
  • zone of stasis
  • zone of hyperemia
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22
Q

When is fluid volume loss at its greatest?

A

first 6-8 hours

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23
Q

When does capillary integrity return towards normal?

A

36-48 hours after the burn

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24
Q

What are the special care areas that are automatically considered major burns?

A

eyes, ears, face, hands, feet, perineum, joints

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25
Q

Burns of 60% TBSA can cause what?

A
  • depressed myocardial contractility
  • hemoconcentration
  • massive edema formation
  • hypovolemic shock
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26
Q

What is the onset of Burn Shock?

A

Fluid loss continues and vascular volume decreases, the CO and BP drop

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27
Q

Burn Shock is characterized by what?

A
  • capillary leak
  • third spacing
  • severe hypovolemia
  • decreased CO
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28
Q

What is the preferred IV fluid for burn resuscitation?

A

Lactated Ringer’s b/c sodium and potassium concentration are similar to normal intravascular levels

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29
Q

Lactate Ringers solution can also be converted to Bicarbonate by the liver to correct what seen w/ Burn Shock?

A

Metabolic ACIDOSIS

30
Q

If Fluid Resuscitation is delayed, large burn wound victims are at risk for what?

A

Abdominal Compartment Syndrome

31
Q

Abdominal Compartment Syndrome

A

fluid shifts into the abdominal cavity causing increased abdominal distention that interferes w/ pulmonary ventilation

32
Q

The volume loss into the peritoneal space w/ Abdominal Compartment Syndrome results in what?

A
  • decreasing CO
  • hypotension
  • decreasing urine output
33
Q

Escharotomy

A

surgical incision into the eschar to relieve the constricting effect of the burned tissue

34
Q

Severe lactic acidosis is associated w/ what?

A

high early mortality

35
Q

Consequences of inhalation injury

A
  • upper airway edema
  • bronchospasm
  • small airway occlusion
  • increased dead space
  • tracheobronchitis
  • pneumonia
36
Q

What are the 2 categories of pulmonary injuries?

A

upper airway injury

inhalation injury below glottis

37
Q

Upper airway injury result from what?

A

direct heat and edema

38
Q

S/S of Upper Airway injury

A
  • mechanical obstruction
  • bronchospasms
  • edema
39
Q

Treatment for Upper Airway injury

A

Short course of endotracheal intubation

40
Q

Inhalation injury below the glottis results from what?

A

inhaling noxious gases or steam

41
Q

S/S of Inhalation Injury

A
  • hypersecretion
  • severe mucosal edema
  • possible bronchospasm
  • atelectasis
  • expectoration of carbon particles
42
Q

What is the most common cause of inhalation injury?

A

Carbon Monoxide

43
Q

What is Standard care for Carbon Monoxide poisoning?

A

100% oxygen for 6 hours until HbCO level is below 10% and patient is asymptomatic

44
Q

Any patient w/ possible inhalation injury must be observed for how long?

A

24 hours

45
Q

S/S of Possible Pulmonary Damage

A
  • burns of face/neck
  • singed nasal hair
  • hoarseness, voice change, dry cough, stridor
  • sooty or bloody sputum
  • labored breathing or tachypnea
  • erythema and blistering of oral/pharyngeal mucosa
46
Q

What are the 2 potential GI complications that may occur w/ burns?

A

paralytic ileus and curling ulcer

47
Q

What are the 3 phases of burn care?

A
  • emergent/resuscitative
  • acute intermediate
  • rehabilitation
48
Q

What steps are important to remember?

A 
CABD
circulation 
airway
breathing 
disability
49
Q

Nursing Management for Circulation

A
  • monitor Apical pulse/BP frequently
  • tachycardia/slight hypotension are expected
  • urinary catheter is placed
  • strict I/O’s
  • daily weights
  • large bore IV
  • maybe endotracheal intubation
50
Q

Immediate interventions for establishing airway are?

A

100% humidified oxygen

51
Q

What can occur because of high-voltage electrical injuries?

A
  • spinal cord injury

- cardiac arrhythmias

52
Q

How long should a person have cardiac monitoring after an electrical injury?

A

24 hours after cessation of arrhythmia

53
Q

What may indicate cerebral hypoxia?

A
  • restlessness
  • confusion
  • difficulty answering questions
  • decreasing LOC
54
Q

If the burn exceeds 20% TBSA what type of tube should be inserted?

A

NG tube to low suction to decompress abdomen and prevent vomiting

55
Q

Why must a BP cuff be removed between readings?

A

It may act as a tourniquet as the extremity swells

56
Q

What color urine indicated muscle damage?

A

burgundy colored/pigmented

57
Q

When does the Acute/Intermediate phase of burn care begin?

A

48-72 hours after burn injury

58
Q

What is the most frequent clinically related complication that occurs in patients w/ fire/flame injuries?

A

Pneumonia

59
Q

What are the 2 goals of Debridement?

A
  • to remove tissue contaminated by bacteria and foreign bodies
  • to remove devitalized tissue or burn eschar in prep for grafting/healing
60
Q

Why are autografts the ideal covering for burn wounds?

A

They are the patient’s own skin and will not be rejected

61
Q

Purposes of wound covering are?

A
  • decrease risk of infection
  • prevent further loss of protein, fluid, and electrolytes
  • minimize heat loss
62
Q

Homograft

A

donor skin from a cadaver

63
Q

What are commonly used after grafting to immobilize the graft?

A

Occlusive dressing

64
Q

What type of dressing may be used to protect grafts?

A

Synthetic dressing

65
Q

Hyperalgesia

A

enhanced intensity of pain

66
Q

4 Types of Pain w/ Burn patients

A
  • rest pain/constant background/dull pain
  • breakthrough pain/intermittent;short duration;rapid onset
  • procedural
  • psychogenic pain;anticipatory pain
67
Q

Rest pain is best handled by what type of medication?

A

Regularly scheduled long-acting opioids

68
Q

Procedural pain requires what?

A

premedication w/ analgesic meds before painful procedures

69
Q

What is the analgesic of choice for Burn Pain?

A

Morphine sulfate

70
Q

Other Medications for Burns

A
  • ketamine
  • fentanyl
  • PCA pump
  • oxycodone
71
Q

What type of diet will burn patients be on?

A

High protein and calorie rich diet

72
Q

Promoting Mobility in burn patients

A
  • deep breathing
  • turning
  • proper positioning
  • low air loss/rotation beds
  • elastic pressure bandages for lower extremities

Critical Care Nursing (14 decks)

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