EXAM I Flashcards
autograft
a graft derived from one part of a patient’s body and used on another part of that same patient’s body
A of ABCDEs
airway
B of ABCDEs
gas exchange or breathing
C of ABCDEs
circulatory and cardiac status
D & E of ABCDEs
disability (D) including neurologic deficit, and expose and examine (E) while maintaining a warm environment
If the victim has severe respiratory distress and/or airway edema, the rescuers must insert an
endotracheal tube and initiate mechanical ventilation
If the burn exceeds 20% to 25% TBSA ______ is inserted?
a nasogastric tube is inserted and connected to low intermittent suction.
To help guide the treatment plan, the following are essential:
documentation of body temperature, body weight, and preburn weight; history of allergies, tetanus immunization, past medical and surgical history, and current illnesses; and a list of current medications.
The acute/intermediate phase of burn care follows the __________ phase
emergent/resuscitative phase
The acute/intermediate phase begins ____________ hours after the burn injury.
48 to 72 hours after the burn injury.
Airway obstruction caused by upper airway edema can take as long as ________ to develop
48 hours
Causative agents of burn infections may include _____,_________,_________
bacteria, fungi, or viruses.
Circumferential dressings should always be applied _________________ in order to promote return of excess fluid to the central circulation
distally to proximally
Natural debridement is accomplished when
nonliving tissue sloughs away from uninjured tissue.
What uses surgical tools to separate and remove the eschar?
Mechanical debridement
Enzymatic debridement
encompasses the use of topical enzymes to the burn wound.
What uses forceps and scissors during dressing changes?
Surgical debridemen
Three of the most common GI alterations in burn-injured patients are:
paralytic ileus (absence of intestinal peristalsis)**
Curling’s ulcer, and translocation of bacteria.
Decreased peristalsis and bowel sounds are manifestations of paralytic ileus.
total destruction of dermis
full-thickness burn
epidermis is destroyed & small portion of the underlying dermis is injured.
superficial partial-thickness burn
sun burn
superficial partial-thickness burn
extends into the reticular layer of the dermis
deep partial-thickness burn
It is red or white, mottled, and can be moist or fairly dry.
deep partial-thickness burn
scalds and flash flames
deep partial-thickness burn
obtained from recently deceased or living humans other than the patient
Homografts
obtained from animals, principally pigs or cows
xenograft or heterograft
Burns of the _______ ________ _______ have the potential to impair ventilation.
face, neck, or chest
BUN levels of 28 mg/dL can indicate
possible renal failure
Lactated Ringer’s solution replaces
lost sodium and corrects metabolic acidosis
burns involving the ________ may affect dexterity and mobility
hands
After managing respiratory what is your next priority
prevent irreversible shock by replacing lost fluids &electrolytes.
report loss of pulse/sensation or presence of pain to the physician immediately and to prepare to assist with _________
an escharotomy.
reassess &revise the estimate of burn depth because
early appearance of burn injury may change
Indicators of possible pulmonary damage include:
singed nasal hair, hoarseness, voice change, stridor, burns of the face or neck, sooty or bloody sputum, and tachypnea.
nutritional support with burn injury is to
decrease catabolism.
what helps skin healing & prevents hypertrophied tissue from forming
continuous-compression wraps
During the initial assessment of burn victim, look for evidence of inhalation injury.
Once oxygen saturation and respirations are determined, -___________ is evaluated.
pain intensity
Immediately after burn injury___________results from massive cell destruction.
hyperkalemia (excessive K+)
_________may occur later with fluid shifts and inadequate potassium replacement
HYPOkalemia
main concern of superficial partial-thickness burn
pain management
Is sodium level of 140 mEq/L expected during the fluid remobilization phase of a major burn
NO
A urine output of less than 30 ml/hour in a client with burns indicates
a deficient fluid volume.
Debridement is the
removal of necrotic tissue.
An escharotomy is an incision into the eschar to
relieve pressure on the affected area
Acticoat antimicrobial barrier dressings can be left in place for
up to 5 days
Silver nitrate solution is
hypotonic and acts as a wick for sodium and potassium
A disadvantage of surgical debridement is
bleeding
Cardiac dysrhythmias are common for victims of
electrical burns
The nurse is applying an occlusive dressing to a burned foot. What position should the foot be placed in after application of the dressing?
adduction
With use of silver sulfadiazine (Silvadene), the nurse should watch for
leukopenia 2 to 3 days after initiation of therapy. (Leukopenia usually resolves within 2 to 3 days.)
the client with a burn is prone to develop
gastric (Curling’s) ulcers.
Anemia develops because of
the heat destroying the erythrocytes.
The greatest volume of fluid loss occurs in the first ___to____hours after the burn, peaking by ___to___ hours.
24 to 36
6 to 8
Skin grafting is essential for
deep partial-thickness burns
Sodium deficit, potassium excess, and decreased urinary output occur in ______ phase
EMERGENT
Rehabilitation begins immediately after
the burn has occurred and often extends for years after injury
Which phase has a duration From onset of injury to completion of fluid resuscitation
Emergent/resuscitative
Which phase has a duration From beginning of diuresis to near completion of wound closure
Acute/intermediate
Which phase has a duration From major wound closure to return to individual’s optimal level of physical and psychosocial adjustment
Rehabilition
Decreased peristalsis and bowel sounds are manifestations of
Paralytic ileus
Paralytic ileus and dilated bowel can lead to increased abdominal pressure, which can further increase ischemia
A number of factors have been instrumental in reducing mortality from fire, including
smoke alarms, carbon monoxide detectors, safer appliances for heating and cooking, flame-resistant materials, child-resistant lighters, and sprinkler systems
First-degree burns are superficial injuries that involve
only the outermost layer of skin
Second-degree burns involve the
entire epidermis and varying portions of the dermis
blister formation
Second-degree burns
Third-degree (full-thickness) burns involve
total destruction of the epidermis and dermis and, in some cases, destruction of underlying tissue.
Fourth-degree burns (deep burn necrosis) are those injuries that extend into
deep tissue, muscle, or bone
cellular death occurs in which zone
inner
(see full question) Which of the following is the key sign of onset of ARDS?
Stridor
Hypoxemia
Hypoxemia
scalds and flash flames are a _____________ burn
deep partial-thickness burn
electrical current or prolonged exposure to hot liquids cause a ________ burn
Full-thickness burns
Following a burn injury, which of the following areas is the priority for nursing assessment?
a) Cardiovascular system b) Pain c) Pulmonary system d) Nutrition
Pulmonary system
Explanation:
Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs
Cushing syndrome can be caused by which condition that we learned about in chapter 60?
hirsutism: the condition of having excessive hair growth
Which skin layer is the outermost layer of stratified epithelial cells
epidermis
Which layer is composed predominantly of keratinocytes
epidermis
The epidermis layer is almost completely replaced every
3-4 weeks
Production of melanin is controlled by ________ secreted from the _______?
a hormone secreted from the hypothalamus
What is the true skin?
DERMIS
What makes up the largest portion of the skin?
DERMIS
provides strength and structure to the skin
DERMIS
the innermost layer of the skin
subcutaneous
The subcutaneous tissues and the amount of fat deposited are important factors in body
temperature regulation.
what is the growth phase
anagen
how long does the anagen phase last on the scalp
6 years, whereas the
telogen or resting phase lasts approximately 4 months
Hair quantity and distribution can be affected by
endocrine conditions.
fingernails grow _____ daily
0.1 mm
finger nail renewal is
170 days
toenail renewal is
12-18 months
Sweat glands are found in the skin over most of the body surface, but they are most heavily concentrated in
the palms of the hands and soles of the feet.
Only the _____ ______ _____ ______ are devoid of sweat glands.
glans penis, the margins of the lips, the external ear, and the nail bed
The eccrine sweat glands are found
in all areas of the skin.
_______ is released from eccrine glands
sweat
The rate of sweat secretion is under the control of
the sympathetic nervous system.
Which is larger: apocrine or eccrine?
apocrine
The apocrine sweat glands are located in
in the axillae, anal region, scrotum, and labia majora.
Apocrine glands produce
milky sweat (that is sometimes broken down by bacteria to produce the characteristic underarm odor.)
which glad becomes active at puberty
apocrine
In women, they enlarge and recede with each menstrual cycle.
what is the outer layer of the epidermis
The stratum corneum
During immersion in water, the skin can accumulate water up to
three or four times its normal weight
What is the transfer of heat to another object of lower temperature situated at a distance.
radiation
What s the transfer of heat from the body to a cooler object in contact with it.
conduction
What consists of movement of warm air molecules away from the body
convection
The total blood circulated through the skin is approximately _______/min
450 mL
Blood flow through skin vessels is controlled primarily by
the sympathetic nervous system
Sweating does not occur until the core body temperature exceeds
37°C (98.6°F)
Vitamin D is essential for preventing
osteoporosis and rickets,
(people need 5 to 30 minutes of sun exposure twice a week)
what meds increase the damage that results from sun exposure
antihistamine, antibiotic, and diuretic agents
bright red “moles” are AKA
cherry angiomias
Lentigines are
freckles
Spider angiomas is a_________ lesion
vascular
Xerosis is
dryness
yellowish waxy deposits on upper and lower eyelids is
Xanthelasma
what techniques commonly used in examining the skin
Inspection and palpation
Secondary lesions result from
changes in primary lesions
resulting from external causes, such as scratching, trauma, infections, or changes caused by wound healing
MACULE:
characteristic?
size?
ex?
flat,
PAPULE:
characteristic?
size?
ex?
elevated, less than 0.5 cm, wart, psoriasis
PLAQUE
size?
ex?
> 0.5 cm,
EX:Psoriasis, actinic keratosis
NODULE:
characteristic?
size?
ex?
0.5–2 cm; circumscribed, Lipoma, squamous cell carcinoma, poorly absorbed injection, dermatofibroma
TUMOR:
size:
characteristic
1–2 cm;
tumors do not always have sharp borders, Larger lipoma, carcinoma
VESICLE
size
ex
less tham 0.5mm bulla, Circumscribed, elevated, palpable mass containing serous fluid
BULLA
> 0.5 cm,
Pemphigus, contact dermatitis, large burn blisters, poison ivy, bullous impet
PUSTULE
characterisitc
ex
Pus-filled vesicle or bulla
Acne, impetigo, furuncles, carbuncles
Chapped lips is an ex of
fissure
Dandruff, psoriasis, dry skin, pityriasis rose
are examples of
scales
impetigo, herpes, eczema are examples of
crust
Hypertrophied scar tissue secondary to excessive collagen formation during healing; elevated, irregular, red Greater incidence among African Americans
keloid
Thin, dry, transparent appearance of epidermis; loss of surface markings; secondary to loss of collagen and elastin; underlying vessels may be visible
atrophy
Thickening and roughening of the skin or accentuated skin markings that may be secondary to repeated rubbing, irritation, scratching Contact dermatitis
LICHENIFICATION
Skin moisture, temperature, and texture are assessed primarily by
palpation
Edema is indicated when the skin appears
tense and shiny,
when a finger gently pressed into the skin leaves an indentation or “pit.”
Beau’s lines in the nails may reflect
retarded growth of the nail matrix because of severe illness or, more commonly, local trauma.
Pitted surface of the nails is a definite indication of
psoriasis
Spoon-shape nails can indicate
a severe iron deficiency anemia.
Clubbing
can occur from?
manifested by?
can occur from hypoxia,
is manifested by a straightening of the normal angle
PETECHIA
description
size
secondary to
PETECHIA (PL. PETECHIAE)
Round red or purple macule
Small (1–2 mm)
Secondary to blood extravasation
Oily hair is usually caused by increased secretion from the
sebaceous glands close to the scalp
The most common cause of hair loss is
male pattern baldness
(i.e., androgenic alopecia)
Androgen is necessary for male pattern baldness to develop.
_________ signs may be the first manifestation of human immunodeficiency virus (HIV)
cutaneous signs
appearing in more than 90% of HIV-infected (Low CD4 count
Biopsies are performed on ____ _____ ____ _____ to rule out ________ and to establish _______
skin nodules, plaques, blisters, and other lesions
to rule out malignancy and to establish an exact diagnosis.
The Tzanck smear is a test used to examine cells from blistering skin conditions, such as
herpes zoster, varicella, herpes simplex, and all forms of pemphigus
The nurse is caring for a patient with dark skin who is having gastrointestinal bleeding. How can the nurse determine from skin color change that shock may be present?
The skin is ashen gray and dull.
What is the application of extreme cold to destroy tissue
Cryosurgery
Patch test reactions include
*Blisters
• Pain
• Ulceration
Pallor is the absence of or a decrease in normal skin color and vascularity and is best observed in ______
the conjunctivae or around the mouth.
Skin scrapings are used to diagnose
spores and hyphae
Cherry red nail beds, lips, and oral mucosa in a dark-skinned person are signs of
carbon monoxide poisoning.
The production of melanin is controlled by a hormone secreted from the
hypothalamus
What is the primary function of sebum?
Prevents drying and cracking of the skin and hair
______ are small red or purple macules, usually 1 to 2 mm in size, associated with bleeding tendencies
Petechiae
Possible carbon monoxide poisoning in a dark skinned individual..
Cherry red color to the nail beds, lips, and oral mucosa
Production of melanin is controlled by a hormone secreted by which of the following?
Hypothalamus
Shock due to decreased perfusion and vasoconstriction is indicated in black skin as
ashen gray, dull appearance.
a skin lesion that is elevated, round, and filled with serum is a
vesicle
Photochemotherapy involves a combination of psoralen methoxsalen and type A ultraviolet light. The psoralen methoxsalen is taken 1 to 2 hours before exposure to ultraviolet A. What problem is this used to treat?
psoriasis
what kind of lesion is a spider angioma?
vascular
A patient diagnosed with Addison’s disease would be expected to have which of the following skin pigmentations?
a) Gray b) Bronze c) Yellow d) Orange-green
bronza
To detect cyanosis in persons with dark skin, the nurse should assess which of the following areas?
oral mucosa
Pitted surface of the nails is a definite indication of
psoriasis
Solar lentigo refers to
liver spots
Which type of heat loss is caused by a cool breeze that blows across the body surface?
convection
which hair growth is the most rapid
beard.
followed by hair on the scalp, axillae, thighs, and then eyebrows.
Which layer of the skin is made of primarily adipose tissue?
subcutaneous
The dermis is made up of
blood, lymph vessels, nerves, sweat and sebaceous glands, and hair roots
The epidermis contains ___ ___ ___ cells
Merkel cells, Langerhan cells, and melanocytes
Blood vessels and sweat glands are found in the
dermis
Petechiae are associated with which of the following disorders?
thrombocytopenia
evaporation, called insensible perspiration, amounts to approximately _____ daily in an average-sized adult
600 mL
Petechiae are associated with
bleeding tendencies or emboli to the skin
Spider angioma is associated with
liver disease, pregnancy, and vitamin B deficiency.
Telangiectasia is associated with
venous pressure states.
