Skin

Question 1

first degree burns

Answer 1

superficial burn through epidermis
dry skin and blanchable redness
cause redness, pain, swelling

Question 2

second degree burn

Answer 2

partial thickness burn- involves epidermis and dermis
big painful blisters, fluid filled vessel, skin, moist
blanchable

Question 3

third degree burn

Answer 3

full thickness burn- through epidermis and dermis
dry, waxy, leathery, charred black color, white, nonblanchable
no pain

Question 4

fourth degree burn

Answer 4

full thickness burn through epidermis, dermis, and subcutaneous tissue to the muscle and bone
no pain

Question 5

treatment for minor burns

Answer 5

3 C’s for 1st and 2nd degree
1. put cool water on it
2. cover with clean, dry cloth
3. remove clothing or jewlery around area

Question 6

Parkland formula

Answer 6

Purpose: LR, time starts at time of burn not time of eval
 To calculate the IV fluids needed for the first 24 hours after a burn
injury > 20% of TBSA

Formula:
 4 mL x Patient weight in kg x % of TBSA burned = 24hour volume of IV
fluid
 First 8 hours give half of the 24 total volume of fluid
 Second 8 hours give one-fourth of the total volume
 Third 8 hours give one-fourth of the total volume

Question 7

What kind of potassium problem do burn victims have

Answer 7

first 24 hrs have hyperkalemia

Question 8

what kind of sodium levels do burn victims have

Answer 8

hypernatremia

Question 9

What kind of precautions are burn victims on

Answer 9

neutropenic

Question 10

Rule’s of 9

Answer 10

head= front is 4.5%, back is 4.5%
arm= front is 4.5,% back is 4.5%
legs= front is 9% back is 9%
torso= front is 18%, back is 18%
peri area= 1%

*only include partial and full thickness burns

Question 11

Pt’s at risk for pressure injuries

Answer 11

bedridden, poor nutrition, diabetic neuropathy, liver failure- low albumin

Question 12

Stage 1 pressure ulcer

Answer 12

one layer of skin damage, epidermis intact, non blanchable, skin intact

Question 13

Stage 2 pressure ulcer

Answer 13

2 layers of damage, broken epidermis and dermis, red/pink wound, dry, shiny, open skin

Question 14

Stage 3 pressure ulcer

Answer 14

3 layers of damage, epidermis, dermis, and subcutaneous fat
major skin loss, looks like bubble wrap

Question 15

stage 4 pressure ulcer

Answer 15

4 layers of damage all the way to muscle, tendons and bones

Question 16

Unstageable

Answer 16

eschar- black dead tissue and sloughing- yellow stingy skin
needs to be debrided before staging

Question 17

Treatment for pressure injuries

Answer 17

assess and document
turn q2hr
protein and fluids 2-3L per day
monitor fluid output more than 30ml
Give albumin- necessary for healing 3.5-5 normal