Skin Flashcards
Key interventions for burn patients
- Airway acsess,
- Administer O2,
- Cover patient w blanket,
- Keep pt NPO,
- Elevate extremities if no fractures obvious,
- Vitals,
- Start IV,
- Tetanus prophylaxis
patient is in the resuscitation phase of a burn who is hoarse, has a brassy cough, or difficulty swallowing or produced audible breath sound on exhalation. nursing priority?
Immediately apply oxygen and notify rapid response team
Burn patient has pulmonary edema. Nursing priority?
- Elevate the head of bed at least 45 degrees
- Apply oxygen
- Notify Rapid response team
Which burn classification?
Pink to red Mild edema Yes pain No blisters No eschar 3-6 days to heal No graft EX: sunburn
superficial
Which burn classification?
Pink to red MIld to moderate edema Yes Pain Yes Blisters No eschar 2 weeks to heal EX: Scalds, flames, touching hot objects briefly
superficial partial thickness burns
Which burn classification?
Red to white Yes Pain Moderate Edema Rare blisters 2-6 weeks to heal EX: Scalds, flames, touching hot objects for longer, chemicals, grease
Deep partial thickness
Which burn classification?
Black, brown, yellow, white or red Can have pain Severe edema No blisters Yes eschar Weeks to months to heal EX: Scalds, flames, touching hot objects for longer, chemicals, grease, electricity
Full thickness
Which burn classification?
BLACK No Pain No edema No blisters Weeks to months to heal Yes eschar EX: flames, electr
Deep full thickness
What is the actual parkland formula? What phase is it used for?
Volume of LR = 4 mL x %TBSA burned x weight in kg
With parkland formula how much do you give in the first 8 hours?
Half of the formula
With parkland formula how much do we give in the next 16 hours?
half of the formula
With parkland formula how much do we give in the next 8 hours after the first 8 hours?
25% of original formula
Rule of nines. What %?
Head and neck
9% (4.5% for front and 4.5% for back)
Rule of nines What %?
Each arm
9% ((4.5% for front and 4.5% for back)
Rule of nines What %?
anterior trunk
18%
Rule of nines What %?
posterior trunk
18%
Rule of nines What %?
Each leg
18% (9% for front and 9% for back)
Rule of nines What %?
perineum
1 %
intubation has not been performed in a patient whose upper airways were exposed to heat or toxic gases, nursing priority?
- continually assess the upper airway for edema and obstruction
- Medications like Albumin and Hypertonic solution (pulls from cell to body)
what does PaO2 (60-80) look like with burns?
slightly decreased
what does
PaCO2 (35-45) look like with burns?
PaCO2
Slightly increased from inhalation
pH with burns?
low, metabolic acidosis
normal protein? 6.4-8.3
Low, protein lost in wound
Albumin? 3.5-5.0
Low, protein lost in wound
Skin graft type?:
Temporary
Human (cadaver)
Body rejects in 2 weeks
Homograft
or allograft
Skin graft type?:
Temporary
Another species such as a pig
Body rejects in 5-7 days
Heterograft (xenograft)
Skin graft type?:
Examples: Integra, Epicel, Dermagraft, Alloderm Cultured epithelial autograft Varying percentage of rejection rates Evolving research Expensive
Artificial, synthetic skin
Skin graft type?:
from self
Permanent
Split thickness grafts
Mesh or sheet form
Autograft
key interventions for preventing pressure ulcers?
- Protect bony prominences
- Watch BNC etc
- Turn q2 h
- Float heels
- Keep Dry
Which skin cancer?
firm, nodular lesion topped with a crust or a central area of ulceration
Squamous cell carcinoma
Which skin cancer?
PEARLY papule with a central crater and rolled waxy borders. Telangiectasis and pigment flecks visible on close inspection
Basal Cell Carcinoma
Which skin cancer?
Irregularly shaped pigmented papule or plaque - variegated colors with red, white and blue tones
Melanoma
Which skin cancer?
small papule with dry, rough, adherent yellow or brown scale. Base may be erythematous. Associated with yellow, wrinkled, weather beaten skin. Thick indurated ones are more likely to be independent.
Actinic keratosis
