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NCLEX > Burns > Flashcards

Burns Flashcards

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1
Q

Why does plasma seep out into the tissue

A

Increased capillary permeability

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2
Q

When does capillary permeability happen

A

first 24 hours

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3
Q

capillary permeability leads to

A

fluid volume deficit, shock, increased heart rate

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4
Q

why does cardiac output decrease in burns

A

less volume in vascular space

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5
Q

why does urine output decrease

A

kidneys holding on to fluid OR inadequate renal perfusion (only takes 20 minutes for acute tubular necrosis)

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6
Q

why is Epinephrine secreted

A

vasoconstriction to increase BP and shunt blood to vital organs

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7
Q

what other hormones are secreted

A

ADH (retain water) & Aldosterone (retain sodium and water)

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8
Q

what is the most common airway injury

A

Carbon monoxide

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9
Q

what are the S/S & Tx of carbon monoxide poisoning

A

S/S: cherry red color
Tx: 100% oxygen

burns that occur in close space increase the amount of CO that was inhaled

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10
Q

when you see a client with burns to face, chest, neck, facial hair, think what first

A

prophylactically intubation

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11
Q

Rule of 9s

A 
burned area: 
head/neck -9%
arm (each) -9%
leg (each) -18%
trunk (back) -18%
trunk (front) -18%
genital -9%
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12
Q

clients with burns over 20/30% of body

A

fluid replacement is the most important aspect of treatment.

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13
Q

when should fluid replacement therapy occur

A

first 24 hours after the time of injury

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14
Q

what is the parkland formula

A

(4ml of LR) X (body weight in kg) X (% of TBSA burned) = total fluid requirement for first 24 hours after burn

hrs 1-8: 1/2 the total volume
hrs 8-16: 1/4 the total volume
hrs 16-24: 1/4 the total volume

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15
Q

restlessness could indicate what

A

pain, hypoxia, inadequate fluid replacement

hypoxia takes prescience
in priority Qs refer to Maslow’s hierarchy

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16
Q

how do you determine client’s fluid volume is adequate

A

in Burns use Urine Output to determine fluid volume. In first 24 hours we are loading them with fluids because their vesicles are leaking (due to shock), so weight is not accurate.

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17
Q

what is normal urine output

A

0.5 ml/kg/hr -adults
1 ml/kg/hr -children

for adults minimum is 30-50 ml/hr

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18
Q

Emergency Management of burns

A

treat burn site with cool (not cold) water to stop burning process that still may be occurring.

wrap client in blanket to prevent heat loss and protect against germs

remove jewelry due to swelling of skin after burn and possibility that jewelry is still hot after burn

remove non-adhearent clothing to prevent swelling and cover burn site with clean dry cloth

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19
Q

signs of airway injury

A

singed facial hair, burnt hair, burnt nasal hair soot on face, coughing up black soot and sputum, blisters on lips/tongue/gums/oral pharyngeal mucosa

respiratory acidosis is possible due to shallow respirations

upper body burn is more dangerous due to airway restriction

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20
Q

medication management

A

Albumin increases vascular volume (Na & H2O)

hold fluid in vascular space, increase vascular volume, increase kidney perfusion, increase BP, increase cardiac output, corrects fluid volume deficit.

watch out for putting increased work load on heart and possibility of fluid volume excess

if fluid volume excess occurs, then CO will drop, lung sounds will be wet. Must take CVP measurements every hour to ensure client is not going into overload

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21
Q

Pain management

A

IV because it is fast acting and IMs won’t work due to poor muscle perfusion.

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22
Q

Immunizations

A

Booster shot (toxoid) is ACTIVE IMMUNITY -body must take ACTIVE role in making anti-bioties to agonist. Takes 2-4 weeks

IMMUNE GLOBULIN is IMMEDIATE protection, because the anti-bodies are supplied immediately to body in Immune Globulin. Lasts 3 Mo

23
Q

circumferential burn

A

burn is all the way around (arm, leg)

NURSING PRIORITY: check pulses

24
Q

Circulatory Check:

A

Pulse
Skin Color
Temperature
Capillary Refill

25
Q

Escharotomy

A

circulation is restored & pressure is relieved by cutting through eschar (dead tissue)

26
Q

Fasciotomy

A

relieves pressure & restores circulation by cutting deeper into tissue, through eschar and fascia

27
Q

if you insert a foley and no urine is produced what is the cause?

A

Kidneys are either preserving the fluid they have left OR they aren’t being perfused adequately.

output should be checked every hour

28
Q

what do you do if Urine is red or brown?

A

Call doctor. This is likely to happen, however it is still a concern.

Red -hemoglobin from RBC destruction
Brown -myoglbin from muscle tissue destruction

could clog kidneys and lead to renal failure

Manitol (osmotic diuretic) might be ordered to flush out kidneys.
one time EXCEPTION TO RULE: normally wont want to decrease the CO of a burn client, but to save kidney fxn diuretic is used

Manitol crystalized in solution if cold. Before administration observe for clarity, do not refrigerate, and use inline filter.

29
Q

if Urine Output is less than 30 ml/hr what do we worry about?

A

Kidney Failure

30
Q

Why will client begin to diurese after 48 hours

A

fluid is returning to vascular space. Now we worry about fluid volume excess.

UO should increase (depending on kidney fxn)

31
Q

burn clients are at risk for what electrolyte imbalance

A

hyperkalemia. Most of our potassium is found inside the cell, with a burn the cells lyse and K+ ions are in the vascular space.

32
Q

are antacids ordered for burn clients

A

to prevent curlings ulcer (stress ulcer in stomach with burn client).
Mylanta, Protonix, or Pepcid are ordered.

33
Q

Antacids:

A

Amphogel, milk of magnesium

34
Q

H2 Antagonist:

A

Zantac, Pepcid, Axid

35
Q

Proton Pump Inhibitor:

A

Protonix, Nexium

36
Q

why is client NPO and on NG tube suction?

A

likelihood of developing a paralytic illius, blood is shunted to vital organs away from intestines.

abdominal girth will increase

paralytic illus is caused by 1) low vascular volume (blood shunting) 2) normal stress response 3) Hyperkalemia (muscle weakness of intestines prevents movement -not as common)

37
Q

nutrition

A

hypermetabolic state requires more calories, PROTEIN & VITAMIN C

NG tube feedings must pull back for a residual volume, hold feedings if over 50 ml & give residual back to patient (if you don’t, if could mean fluid, lyte, acid/base imbalance).

NG tube is removed after osculating bowel sounds

38
Q

labs to ensure proper nutrition and positive nitrogen balance

A

PRE-ALBUMIN (quicker & more sensitive), total protein, & albumin.

39
Q

contractures

A

skin is being pulled and off sets muscle development

if client has partial and full-thickness burns (especially 3rd degree).

40
Q

classification of burns:

A

superficial thickness: formally called first degree burn; damage only to epidermis

partial thickness: formally called second degree burn; damage to entire epidermis and varying depths of the dermis

full-thickness: formally called third degree; damage to entire dermis, and sometimes fat.

41
Q

special measures

A

separately wrap each finger
use hand/finger splint to prevent contractures
hyper extend neck as it’s healing to prevent contractures, don’t use pillow, promote chin to chest

42
Q

perineal burn #1 complication

A

infection

43
Q

eschar

A

dead tissue. It must be removed to promote new tissue growth and prevent bacterial growth

44
Q

type of isolation

A

protective (reverse) isolation, protect them from us

45
Q

travase or collagenase

A

enzymatic drugs to eat dead tissue

1) dont use on face (scarring)
2) dont use if pregnant
3) dont use over large nerve
4) dont use if area is opened to a body cavity

46
Q

Hydrotherapy

A

used to debriefed. watch for cross contamination. medicate prior to Tx

47
Q

Common drug used with burns

A

Silvadene - soothing, apply directly, if rubs off apply more, can lower the WBC, can cause rash

Sulfamylon -can cause acid base problems, stings, if it rubs off apply more

Silver nitrate -keep these dressings wet; can cause electrolytes problems

Betadine -stings, stains, allergies, acid-base problems

drugs should be alternated to prevent bacterial resistance or tolerance

48
Q

why do we avoid broad spectrum antibiotics

A

to prevent super or secondary infections

broad spectrum may be used until the wound cultures come back

collect cultures BEFORE starting antibiotics

49
Q

Mycin drugs

A

worry when BUN or creatinine increases or andy change is hearing

can cause OTOTOXICITY & NEPHROTOXICITY

stop if any hearing changes occur. If BUN or creatinine increase, assume it is nephrotoxic

50
Q

grafts

A

site can be harvested every 13 to 14 days if well nourished

graft site is open wound, so cover until bleeding stops

if new skin graft is blue or cool then there is poor circulation

might need to use Q tip and do a spiral pattern to remove air & fluid under graft or else it will not adhere

51
Q

chemical burn

A

flush with water for 15 to 20 minutes (if chemical is powder then brush powder off first).

52
Q

electrical burn

A

there are 2 wounds; entrance and exit (exit will be much bigger)

53
Q

electrical injury precaution

A

heart monitor for 24 hours

watch for V fib

watch Kidney Damage with myoglobin & hemoglobin buildup in rentals

place client in C collar because they may have fallen or contracted their muscles forcefully

54
Q

why do amputations happen with electrical burns

A

electricity kills vascularity

cataracts, gait problems, and any neurological deficit (vessels and nerves get messed up)

NCLEX (6 decks)

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