Integumentary system

Question 1

Types of burns

Answer 1

Partial-thickness burns - 1st degree and 2nd degree

Full thickness burns - 3rd degree and 4th degree

Question 2

To determine adequacy of fluid resuscitation, the nurse must assess

Answer 2

Vital signs (especially heart rate)
Urine output
Adequacy of capillary refill
Sensorium status

Question 3

Emergency care

Answer 3

MINOR BURNS
* Stop the burning process
* Remove burned clothing and jewelry
* Apply cool water to burn or run it under cool water
*Cover with a clean cloth if risk of damage or contamination

MAJOR BURNS
* Stop the burning process
* Place victim in horizontal position
* Roll victim in a blanket or similar object, covering the head
* Remove burned clothing/jewelry
* Assess for adequate airway and breathing.
* Keep victim warm
* Begin intravenous and oxygen therapy

Question 4

Nursing management with acute phase of burns

Answer 4

• Treatment of burn shock
• Management of pulmonary status
• Monitor vital signs
• Monitor urinary output - should be 0.1 - 2 ml/kg/hr weighing less than 30 kg and 30 - 50 ml/hr for children weighing more
• Monitor respiratory status - rate, rhythm, work of breathing

*Monitor laboratory data

• Monitor objective signs of hydration - LOC, capillary refill, mucous membranes, skin turgor

*Nurse client attached to cardiopulmonary monitor

Question 5

The types of fluid resuscitation formulas

Answer 5

Parkland formula = 4 ml x body weight (kg) x percentage of total BSA burned

Galveston or Shirners Burn Hospital formula = 5000 ml/m2 burned area + 2000 ml/m2 of total bsa

Question 6

Nursing management with management phase of burns

Answer 6

• Comfort management
• Care of the burn wound
• Prevention of complications
• Psychological support of the child and family
• Caring for the caregiver