Study Guide Exam #2 Flashcards
Superficial
1st degree burn. Damage to epidermis. Example: Sunburn.
Heals 3-6 days. No scarring.
Superficial partial thickness
2nd degree burn. Damage to the entire epidermis and some parts of the dermis.
Example: Flame or burn scalds.
Painful. Heals 10-21 days. No scarring.
Deep partial thickness
Damage to entire epidermis and deep into the dermis.
Examples: flame and burns, grease, tar, or chemical burns, exposure to hot objects for prolonged time.
Painful 3-6 weeks. Scarring likely. Possible grafting.
xenograft
pigskin
xenograft
pigskin. For partial thickness burns.
explain how to treat a chemical burn. What are the complications of chemical burns.
Can be liquid or dry.
Liquids must be removed with copious amounts of water.
Dry chemicals must be brushed off.
amnion
Obtained from human placenta. Requires frequent changes.
explain how to treat a chemical burn. What are the complications of chemical burns.
Can be liquid or dry.
Liquids must be removed with copious amounts of water.
Dry chemicals must be brushed off.
Complications:Deep tissue damage,Heart attack, Death - rare, Systemic reaction, Scarring, Blindness, Seizures, Gastrointestinal tract damage
explain and be able to use the rule of nines for estimating burns.
Method to approximate the extent of burns by divings the body parts into multiples of 9. Total sum = total body surface area TBSA.
discuss circumferential burns, including priorities of care.
A deep full thickness burn that is a problem around the chest or abdomen. Oedema and swelling in the tissue deep to the burn cause the unyielding overlying burnt skin (‘eschar’) to act like a tourniquet. In a limb this will result in interference with distal blood flow.
list the priorities of emergent burn care.
ABC’s
how does the nurse evaluate the effectiveness of fluid replacement in the burn patient
- Monitor fluid volume status. With daily and maintain I&O
- Monitor labs to compare data
- Administer IV fluids and electrolytes (not potassium)
how are pain meds administered in the burn patient
Topically
list the tissues involved in a full thickness burn
epidermis, dermis, and subcutaneous layer.
what type of diet is necessary for the burn client who is beginning to take oral feeds and why
The client might need 5,000 calories a day to prevent hypoglycemia. Increased protein will be needed to prevent tissue breakdown and promote healing.
explain the pathophysiology of curling’s ulcer. how is it treated
Stress ulcers: An ulcer in the duodenum in clients who have severe burns on the surface of the body.
hypovolemia due to fluid shifts into the tissue –> diminished blood flow to the gastric mucosa –> paralysis of the GI tract –> increased susceptibility to hydrochloride acid –> erosion of the gastric mucosa with non-inflammatory ulcerations.
which tissues are usually affected in the client who has sustained electrical burns
Electrical burns can cause severe damage in organs, tissue destruction with subsequent need for amputation of a lim, and cardiac and/or respiratory arrest.
what med is used to treat a burn client with a pseudomonas infection
Silver nitrate 0.5%
burns of which part of the body pose the greatest risk for life threatening complications
The chest, neck, and face pose a risk to the respiratory system. Airway is #1.
why do patients with major burns need to be kept npo initially
Because of decreased GI motility. They will be in a hyper metabolic and hyper catabolic state.
why is a urinary catheter usually ordered for the burn client in the emergent/acute phase of a burn injury
Output needs to be monitored from Parkland Formula.
list the priorities of burn care and explain why you chose the order
- ABC’s #1.
- Fluid and Electrolyte
- Prevent infection
list 5 nursing interventions when caring for a client with major burns over 50% of the body
- Monitor airways and ventilation
- Assist client to cough and deep breath
- Suction hourly as needed
- Keep HOB elevated at all times
- Maintain cardiac output
