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NUR 265 ADVANCED MED SURG > Unit 8 Chapter 23 Burns > Flashcards

Unit 8 Chapter 23 Burns Flashcards

1
Q

causes of burn

A

Dry heat: house fires; brief exposure; very high temperatures
* Moist heat: contact hot liquids * Contact burns: hot metal, tar or grease; full thickness injury
* * Chemical burns: direct contact or ingested; chemical disinfectants & gasoline toxic effects on kidneys & liver
* * Electrical burns: injuries called “Grand Masquerader”; once current penetrates skin heat is generated, damaging tissue
* * (EXAM 4: Radiation injuries: more serious in industrial settings)

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2
Q

Are burn patients immunosuppressed?
A. No
B. Yes

A

B. Yes
due to the burns, they lose the first barrier of infection. The skin.

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3
Q

What are the s/s of an infected wound?

A

Pus
Yellow crust
Purulent drainage
Increasing redness occurs around the wound.
Red Streak.
Tenderness
More Pain. …
More Swelling

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4
Q

with burns is hyperkalemia present?
A. no
B. yes

A

B. yes

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5
Q

Priority for clients with full thickness burns with jeans and blader vest wedding ring and bracelet?

A
  • remove clothes due to third spacing
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6
Q

House fire with exposed carbon dioxide, poisoining how would you expect the client to present?

A

RED CHERRY SKIN

PATIENTS EXPOSED TO FIRE ARE EXPOSED TO CARBON DIOXIDE POISOINING

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7
Q

Inhalation injuries = Decreased ability to oxygenate Assess for:

A
  • Facial burns/Singed nasal hairs * Change in voice, smoky smell to breath * Brassy Cough, Drooling, difficulty swallowing * Upper Airway edema * *Wheezes (partial obstruction) * Pulmonary edema
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8
Q

Burns in the face with house fire. What is a clinical finding of inhalation of smoke?
A. Asymatretic pupils
B. constricted pupis
C. bradycardia
D. Singed nasal hairs

A

D. Singed nasal hairs

ESTABLISH AIRWAY PRIORITY

  • Facial burns/Singed nasal hairs * Change in voice, smoky smell to breath * Brassy Cough, Drooling, difficulty swallowing * Upper Airway edema * *Wheezes (partial obstruction) * Pulmonary edema
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9
Q

Priority for clients who have been electrified by lighting. (Electrical burn) What is the nurse’s priority action?

A

PERFORM ECG

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10
Q

Should clients with burns take PO OR IV opioids or pain medication prior to dressing change?
A.PO (by mouth)
B. Intravenous IV

A

B. Intravenous IV

WHAT SHOULD BE AVOIDED?
PO
IM
SUBQ

  • IV pain meds to minimize pain & anxiety
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11
Q

RULE OF 9

A

ENTIRE LEFT ARM 9%
ENTIRE RIGHT ARM 9%
ENTIRE LEFT LEG 18%
ENTIRE RIGHT LEG 18%
ENTIRE HEAD 9%
ENTIRE FRONT CHEST 18%
ENTIRE BACK CHEST 18%
PERINEAL SPACE 1%

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12
Q

What is the parkland formula

A

4ml/kg/TBSA

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13
Q

An 18 yr old male weighing 82 kg burns his back, the back of his left leg, and his entire right arm in a house fire. Using the parkland formula how much fluid will he need in 24 hours?
A. 10,560ml
B. 11,808ml
C. 500ml
D. 5,904

A

B. 11,808ml

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14
Q

A 26 yr old female was burned while starting the grill while using gasoline to “speed things up.”She burned her face, her bilateral anterior arms, and her chest. She weighs 176lbs. Using the parkland formula how much fluid will he need in 8 hours?
A. 10,080ml
B. 5,040
C. 630ml
D. 315ml

A

B. 5,040

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15
Q

A 68 yr old man lights a cigarette while filling up his tank at Valero. He burn his face, his chest, and his bilateral arms. Running away, he managed to stop drop and roll which then spread the fire to his back. He weight 242lbs. Using the parkland formula how much fluid will he need in 8 hours?
A. 10,080ml
B. 5,040
C. 25740
D. 12870

A

D. 12870

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16
Q

A 46 yr old male is burned by a gasoline explosion while starting his lawn mower. He burns the anterior portion of both legs, his perineal area, his chest, and the anterior portion of both arms. He weighs 264lbs. What. is the total body surface area that is affected by the fire?
A. 10%
B. 46%
C. 25%
D. 12%

17
Q

A 52 yr old female burns half her chest, most of her back, and most of her left leg while retrieving her cat from a house fire. She weighs 143lbs. What. is the total body surface area that is affected by the fire?
A. 54%
B. 46%
C. 25%
D. 12%

18
Q

Do clients with burns need high-calorie meals
A. no
B.yes

19
Q

Nursing Managment for Burn Patients

A
  • Assessment of skin color, sensation, capillary refill, and peripheral pulses is essential.
  • Remove rings, watches, and other jewelry due to the swelling that often accompanies fluid resuscitation.
20
Q

Emergency Care for Burn Patient (6 steps)

A
    1. assess for airway patency
    1. administer O2
    1. obtain VS
    1. Initiate IV line & begin fluid replacement as prescribed.
    1. Elevate extremities if no fracture.
    1. Keep warm & place on NPO status.
21
Q

Complications of Burns

A
  • Hypovolemic shock: low bp high hr
    *Burn wound infection
  • Paralytic Ulcer
    *Pulmonary edema
  • Curling’s ulcer
    *Compartment syndrome
  • AKI
    *ARDS
  • Contractures - pressure garments
  • Other immobility related problems

^^GOAL TO PREVENT THIS FROM HAPPENING^^

22
Q

Rescitation phase of burn

A

24-48 hours; fluid loss & decrease blood flow * Perform thorough assessment & obtain details

  • Resp: top nursing priority, O2, intubation, CO poisoning
  • Prevent shock & complications: multiple IVs, fluid/electrolytes, tissue perfusion, fluid
    replacement (Parkland formula)
23
Q

Acute phase

A
  • Lasts when fluid shift resolves 36-48 hrs thru grafting or wound healing

Aseptic, sterile environment/ minimizing infection

CARE PLAN CONSULT
* Escharotomy or Fasciotomy: procedure to relieve seizure
* Pressure garments
* Protective isolation: Protecting client from us we cannot allow them to be infected

24
Q

What isolations are indicated for burn patients?
A. Droplet
B. Protective
C. Standard
D. Airborne

A

B. Protective

25
Where would you assess for infection for a burn patient? A. WBC 20,000 B. Patent report C. On the non burned edges D. On burned edges
**C. On the non burned edges**
26
Which of the following clients is a priority? A. The client with 18% of burns complains of pain 4/10 B. The clients tube feeding that has 20ml legs in the bag C. The clients who is receiving IV fluid rescusitation D. The burn client who has a purulent and swollen wound on non-burned edges.
D. The burn client has purulent and swollen wound on non-burned edges. **^SIGN OF INFECTION** **Burn patients are at risk for sepsis shock a code should be alarmed once you find this** s/s of infection wound Pus Yellow crust **Purulent drainage** **Increasing redness** occurs around the wound. Red Streak. **Tenderness** More Pain. ... More **Swelling**
27
Are Burn patients on TPN A. no B. yes
B. yes
28
What should nurses wear before dressing change for a burn client? A. N95 mask B. Lead Apron C. Gown D. Googles
C. Gown **Nurses MUST be donned with mask, gloves, gown**
29
Wound care and debridement
Burn wounds must be cleaned, remove exudate and necrotic tissue * Use of hydrotherapy daily * Collagenase used for rapid wound debridement * Early detection & Infection Control is essential Function: oxygenate the skin promote cleaning it is painful, Medicate client with 30 minutes prior to starting wound care debridement or dressing change**IV PAIN MEDS PREFERABLY**
30
Burn Care and Dressing Change
* Remove 30 minutes after medicated * Moisten with water for ease * Once the wound is clean, pat dry & apply prescribed topical medication * Wrap lightly * Hydrotherapy Daily **ALL DRESSING CHANGES ARE STERILE**
31
Compression Garments
**Compression Garments: prevent edema** * Can be elastic wraps or custom fit garments * Beneficial in preventing contractures, saving mobility, and reducing scarring Worn everyday Worn for 23 hours a day Worn for 12-24 months
32
Escharotomy
- skin is too tight, and the patient cannot breathe (relieve pressure due to third spacing). **ASSESS FOR PULSE** -post op - antibiotics needed and sterile technique
33
Fasciotomy
An incision is made through the fascia to release constriction of underlying muscle post op - antibiotics needed and sterile technique **ASSESS FOR PULSE**
34
Topical medications for Burn on Medsurg flor
* Silvadene * Sulfamylon * Collagenase for rapid wound debridement * Gentamicin * Broad Spectrum Antibiotics *
35
What vaccination should be provided to the burn client? A. Influenza B. Tetanus C. Mumps D. Varicella
B. Tetanus * Tetanus vaccination <10 years

NUR 265 ADVANCED MED SURG (53 decks)

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