HESI – Burns

List the four categories of burns
1. Thermal
2. Radiation
3. Chemical
4. Electrical
Burn depth is a measure of severity. Describe the characteristics of superficial partial thickness, deep partial thickness, and full thickness burns
*Superficial partial thickness (FIRST DEGREE): pink to red skin (sunburn), slight edema, and pain relieved by cooling
*Deep partial thickness (SECOND DEGREE): destruction of epidermis and upper layers of dermis, white or red, very edematous, sensitive to touch and cold air, hair does not pull out easily
*Full thickness (THIRD DEGREE): total destruction of dermis and epidermis, reddened areas do not blanch with pressure, not painful, inelastic, waxy white skin to brown, leathery skin
Describe fluid management in the emergent phase, acute phase, and rehabilitation phase of the burned client
*Stage I (emergent): replacement of fluids is titrated to urine output
*Stage II (acute): patient infusion site is maintained in case supplemental IV fluids are needed, saline lock is helpful, colloids may be used
*Stage III (rehabilitation): no extra fluids are needed, but high-protein drinks are recommended
Describe pain management of the burned client
*Administer pain medication, especially prior to dressing wound
*Teach distraction and relaxation techniques
*Teach use of guided imagery
Outline admission care of the burned client
*Provide a patent airway because intubation may be necessary
*Determine baseline data
*Initiate fluid and electrolyte therapy
*Administer pain medication
*Determine depth and extent of burn
*Administer tetanus toxiod
*Insert NG tube
Nutritional status is a major concern when caring for a burned client. List three specified dietary interventions used with burned clients
1. High-calorie, high-protein, high-carbohydrate diet
2. Medication with juice or milk
3. No “free” water
4. Tube feeding at night
5. Maintain accurate, daily calorie counts and weigh the client daily
Describe the method of extinguishing each of the following burns: thermal, chemical, and electrical
*Thermal: remove clothing, immerse in tepid water
*Chemical: flush with water or saline
*Electrical: separate client from electrical source
List four signs of an inhalation burn
1. Hoarseness
2. Singed nasal hairs, circumoral burns
3. Sooty or bloody sputum
4. Pulmonary signs, including asymmetry of respirations, rales or wheezing
Why is the burned client allowed no “free” water?
Water may interfere with electrolyte balance; client needs to ingest food products with highest biological value
Describe an autograft
Use of client’s own skin for grafting