question

Tissue injury or necrosis caused by transfer of energy from a heat source to the body Categories:

answer

thermal, radiation, electrical, chemical

question

Tissue destruction results from:

answer

Coagulation Protein denaturation Ionization of cellular contents

question

Critical systems affected include

answer

Respiratory Integumentary Cardiovascular Renal GI Neurologic

question

Severity is determined by burn depth First degree

answer

SUPERFICIAL partial thickness (sunburn) Injury to the epidermis Leaves skin pink or red, but NO blisters Dry Painful (relieved by cooling) Slight edema No scarring and skin grafts are not required

question

Second degree

answer

DEEP partial thickness destruction of epidermis and upper layers of dermis Injury to deeper portions of the dermis Painful (sensitive to touch and cold air) Appeared RED or WHITE, WEEPS FLUID, Blisters present Hair follicles intact (i.e. hair does not pull out easily) Very edematous Blanching followed by capillary refill Heals without surgical interventions, usually does not scar

question

Third degree

answer

Full thickness and deep full thickness; involves total destruction of dermis and epidermis Skin CANNOT regenerate Requires skin grafting Underlying tissue (fat, fascia, tendon, bone) may be involved Wound appears dry and leathery as eschar develops PAINLESS

question

Severity is determined by extent of surface area burned. Rule of nines:

answer

Head and neck 9% Upper extremities 9% each Lower extremities 18% each Front trunk 18% Back trunk 18% perineal area 1%

question

Head and neck

answer

9%

question

Upper extremities each

answer

9%

question

Lower extremities

answer

18% each

question

Front trunk

answer

18%

question

back trunk

answer

18%

question

Perineal area

answer

1%

question

Lund and broder method:

answer

estimates the percentage of the body surface area burned, percentages are assigned to specific body parts based on client's age, critical body areas are face, hands feet, and perineum

question

Three stage of burn care Stage 1: resuscitative/emergent phase

answer

-begins at the time of injury and concludes with the restoration of capillary permeability, which typically reverses 48 to 72 hours following the injury -is characterized by fluid shift from intravascular to interstitial and shock; focus of care is to preserve vital organ functioning -expect to administer large volumes of fluid in this phase based on the client's weight and extent of injury -fluid replacement formulas are calculated from the time of injury and not from the time or arrival at the hospital

question

Stage II: acute phase

answer

Occurs from beginning of diuresis (48-72 hours after injury) to near completion of wound closure Is characterized by fluid shift from interstitial to intravascular Focus is on INFECTION control, wound care and closure, pain management, nutritional support, and physical therapy

question

Stage III: rehabilitation phase

answer

occurs from major wound closure to return to optimal level of physical and pscyhosocial adjustment (approx 5 years) is characterized by grafting and rehabilitation specific to the client's needs

question

Nursing assessment

answer

absence of bowel sounds indicating paralytic ileus Radically decreased urinary output in first 72 hours after injury, with increased specific gravity Radically increased urinary output (diuresis) 72 hours to 2 weeks after initial after initial injury

question

Absence of bowel sounds indicating

answer

paralytic ileus

question

Signs of inadequate hydration

answer

restlessness disorientation decreased urinary volume and urinary sodium and increased urine specific gravity

question

Signs of inhalation burn

answer

Red or burned face Singed facial and nasal hairs circumoral burns Conjunctivitis Sooty nasal mucous or bloody sputum Hoarseness Asymmetry of chest movements with respirations and use of accessory muscles indicative of pneumonia Rales, wheezing, and rhonchi denoting smoke inhalation Impaired speech and drooling indicating laryngeal edema

question

Hint ABCs of assessment

answer

Airway Breathing Circulation

question

Physiologic responses to burns

answer

Increased HR Thirst Increased release of glycogen stored Increased blood sugar level Skin vasoconstricted Extremities pale, cool Capillary refill slow Decreased urine output Increased specific gravity Respirations rapid Slow or no gastric motility Decreased bowel sounds Abdominal distention N/V Beginning ulceration of GI mucosa Increased catecholamine secretion Increased metabolic rate and caloric needs increased secretion of aldosterone Fluid retention Generalized edema Weight gain Hemoccult positive stools

question

Nursing plans and interventions

answer

****Emergent phase****: efforts are directed toward stabilization with ongoing assessment =Assist with admission care: -extinguish source of burn (burning may continue with clothing attached to skin) Thermal: remove clothing, cool burns by immersion in tepid water, apply dry sterile dressings Chemical: flush with water or NS Electrical: separate client from electrical source =Provide an open airway; intubation may be necessary if laryngeal edema is a risk =Determine baseline data: vital signs, blood gases, weight =Determine depth and extent of burn =Administer tetanus toxoid =Initiate fluid and electrolyte therapy: ringer's lactate solution with electrolytes and colloids adjusted according to lab results find fluid resuscitation formula used

question

Nursing plans and interventions contd

answer

Insert NG tube to prevent vomiting, abdominal distention, and gastric aspiration Administer IV pain meds as prescribed Monitor hydration status: record urinary output hourly (30-100ml/hr is normal range) Maintain IV fluids titrated to keep urine output at 30-100 ml/hr Accurately record I and O Weigh daily Observe for signs of inadequate hydration: restlessness, disorientation, hypothermia, decreased UO Monitor respiratory functioning: provide care for the intubated client; suction endotracheal or nasotracheal tube; monitor ABGs; observe for cyanosis, disorientation; administer oxygen; encourage use of incentive spirometer, coughing, and deep breathing Elevate HOB to 30* or more for burns of the face and head

question

Provide woundcare

answer

use strict aseptic technique Perform debridement and dressing changes according to client's condition Change dressings in minimum time (very painful); premedicate client; maintain sterile technique Maintain room temperature above 90*, humidified and free of drafts Monitor body temp frequently; have hyperthermia blanket available

question

Assess for paralytic ileus

answer

absence of bowel sounds N/V Abdominal distention

question

Assist with management of pain

answer

administer analgesics intravenously teach distraction and relaxation techniques teach use of guided imagery

question

Assess for circulatory compromise in burns that constrict body parts Prepare client for escharotomy

answer

Provide proper nutrition: maintain NPO status until bowel sounds are heard, and then advance to clear liquids as prescribed Provide a diet high in protein, carbs, fats, and vitamins Monitor caloric intake

question

***Acute phase***: characterized by fluid shift from interstitial to intravascular (diuresis begins); occurs from 72 hours to 2 weeks after initial injury to near completion of wound closure

answer

Provide infection control, including the following: Maintain protective isolation of entire burn unit Cover hair AT ALL times Wear masks during dressing changes Use STERILE technique for hydrotherapy, dressing change, and debridement Administer IV antibiotics if indicated Be sure any live plants and flowers are REMOVED; they are prohibited Splint and position client to prevent contractures. avoid use of pillows in cases of neck burns.****

question

Hint Massive volumes of IV fluids are given It is not uncommon to give over 1000ml/hr during various phases of burn care

answer

hemodynamic monitoring must be closely observed o be sure the client is supported with fluids but is NOT overloaded

question

Hint Infection is a LIFE THREATENING RISK for

answer

those with burns

question

Acute phase contd

answer

Perform ROM exercises; they are painful -Administer pain med immediately prior to performing ROM exercises -Perform active OM exercises for 3-5 mins frequently during the day -Mobilize ASAP using splints designed for the client

question

Acute phase Provide fluid therapy; may use COLLOIDS to keep fluid in vascular space

answer

Monitor serum chemistries at all times keep an IV site available; a saline lock is helpful Maintain strict I and O Encourage oral intake of fluids

question

Acute phase Provide adequate nutrition

answer

Provide high calorie (up to 5000cal/day), high protein, high carb diet Give nutritional supplements via NG tube feeding at night if caloric intake in inadequate Keep accurate calorie counts Administer all meds with either MILK or JUICE May require TPN Weigh daily

question

Acute phase Provide burn and wound care

answer

Clean wound per agency routine (daily or up to 3x/day) in hydrotherapy or shower Apply silver sulfadiazine (silvadene) or mafenide acetate (sulfamylon) or other antimicrobial agents to burn areas prescribed Cover with dressing (closed method) or leave open (open method), according to agency policy or physician's prescription Prepare client for grafting when eschar has been removed Prepare client for autografts (use of client's own skin for grafting) Use heat lamp to donor site following graft to allow area to reepithelialize

question

Rehabilitation phase: characterized by the ABSENCE of

answer

infection risk Ongoing discharge planning occurs Client may return home when the danger of infection has been eliminated High protein fluids with vitamin supplements are recommended Pressure dressings such as Jobst garments may be worn continuously to prevent hypertrophic scarring and contractures

question

Hint Preexisting conditions that might influence burn recovery are

answer

age, chronic illness (DM, cardiac problems) physical disabilities, disease meds used routinely and rug or alcohol abuse

question

Mafenide acetate (sulfamylon)

answer

indications: treatment of burns; usually used with open method of wound care Adverse reactions: painful; causes mild acidosis Nursing implications: administer pain meds prior to dressing change Penetrates wound rapidly

question

Silver sulfadizaine (silvadene)

answer

Indications: treatment of burns; usually used with open method of wound care; used to avoid acid base complications; keeps eschar soft, making debridement easier Adverse reactions: penetrates wound slowly Nursing implications: administer pain med prior to dressing change

question

List four categories of burns

answer

Thermal, radiation, chemical, electrical

question

Describe fluid management in the emergent, acute, and rehab phase of burned client

answer

Emergent: replacement of fluids titrated to UO Acute: patent infusion site is maintained in case supplemental IV fluids are needed; saline lock helpful; colloids may be used Rehab: no extra fluids needed, but high protein drinks recommended

question

Outline admission care of burned client

answer

Provide patent airway bc intubation may be necessary Determine baseline data Initiate fluid and electolyte therapy pain med determine depth and extent of burn administer tetanus toxoid insert NG tube

question

Nutritional status is a major concern when caring for a burned client. List 3 specific dietary interventions used with burned clients.

answer

High calorie, high protein, high carb diet; meds with juice or milk****; no 'free' water; tube feeding at night. Maintain accurate, daily calorie counts. weight client daily

question

Describe the method of extinguishing each of the following burns: thermal, chemical, and electrical

answer

Thermal: remove clothing, immerse in tepid water Chemical: flush with water or saline Electrical: separate client from electrical source

question

4 signs of inhalation burn

answer

Singed nasal hairs, circumoral burns; sooty or bloody sputum, hoarseness, and pulmonary signs, including asymmetry of respirations, rales, or wheezing

question

Why is the burned client allowed no 'free' water?

answer

Water may interfere with electrolyte balance. Clients need to ingest food products with highest biologic value

Exit HESI: Burns – Flashcards

Unlock all answers in this set

Haven't found what you were looking for?

Search for samples, answers to your questions and flashcards