2500 - Unit 7
escharotomy
A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area?
Lactated Ringer's solution
A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first?
Fluid resuscitation
A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client
hemodilution
A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client?
rule of nines
A system that assigns percentages to sections of the body, allowing calculation of the amount of skin surface involved in the burn area.
inflammation
Begins immediately when burn occurs; swelling
local
Burns less than 20% TBSA produce primarily a ______ response
local and systemic
Burns more than 20% may produce a _________ response and are considered major burns
• Occurs 48-72 hours post injury. • Fluid reenters the vascular space from the interstitial space. • Hemodilution• Increased urinary output • Monitor Na+ levels • Monitor K+ levels • Metabolic acidosis/alkalosis monitoring
During the Acute or Intermediate Phase: what should the nurse do as interventions for Fluid and Electrolyte Shifts
Acute/Intermediate Phase
From beginning of diuresis to wound closure
rehabilitation phase
From wound closure to return to optimal physical and psychosocial adjustment
Every 1 hour
How often must the patient' s response to fluid therapy (urine output, heart rate, and blood pressure) be evaluated?
A urine output consistently above 40 ml/hour
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?
Emergent/Resuscitative Phase
Onset of injury to completion of fluid resuscitation
true
T/F: Edema that could occlude the upperairway may occur up to 2 days after the burn
false
T/F: burn patients have a lowered metabolism
true
T/F: most burns occur at home
Tdap
Tetanus, Diphtheria, Pertussis Vaccine
natural debridement
The dead tissue separates from the underlying viable tissue spontaneously.
total body surface area
What does TBSA stand for?
Cardiac dysrhythmias
Which of the following is a common complication of an electrical burn injury?
Parkland (Baxter) Formula
commonly used formula for fluid resuscitation
third degree burn
full thickness; affect the epidermis, dermis, and sometimes subcutaneous skin grafting is necessary examples include flames, prolonged hot liquids, electric currents, chemicals, etc.
4,000-6,000 calories
how many extra calories does a burn patient require
surgical debridement
is the removal of devitalized tissue by using a scalpel, scissors, or other sharp instrument.
thermal, radiation, chemical, electrical, smoke/inhalation
list some of the causes of burns
remodeling
may last for years; replace with scar tissue
second degree burn
partial or deep thickness; affects the epidermis and portions of the dermis examples include scalds, flash falmes, etc. usually heal in 21 days with minimal scarring blistered, mottled red
mechanical debridement
removes dead tissue by applying a mechanical force such as whirlpool, scrubbing or wet to moist dressing
first degree burn
superficial, epidermal layer examples include sunburns, superficial scalds, low intensity, etc.
hydrotherapy
therapy using water
palm method
used to estimate extent of burn injury. Palm of patient's hand approximates 1% TBSA.
chemical debridement
using special compounds to dissolve tissue
• Impaired gas exchange • Ineffective airway clearance • Fluid volume deficit • Hypothermia • Acute Pain • Anxiety
what are possible nursing diagnoses for a burn patient
genitals
what body parts are worth 1% with the rule of nines for adults
anterior trunk, posterior trunk, r leg, l leg
what body parts are worth 18% with the rule of nines for adults
entire head, r arm, l arm
what body parts are worth 9% with the rule of nines for adults
- prirotize your safety first - extinguish flames or remove source - cool the burn - remove restrictive objects - cover the wound - irrigate chemical burns
what emergency interventions should be taken at the burn scene
altered thermoregulation, immunodepression, hypermetabolism
what other physiologic changes occur for a pt with systemic burns
cardiac depression, edema, hypovolemia
what physiologic changes occur in the cardiovascular system for a pt with systemic burns
impaired motility and absorption, vasoconstriction, loss of mucosal barrier with bacterial translocation, increased pH
what physiologic changes occur in the gastrointestinal system for a pt with systemic burns
vasoconstriction
what physiologic changes occur in the kidneys for a pt with systemic burns
vasocontriction, edema
what physiologic changes occur in the pulmonary system for a pt with systemic burns
24-36 hours
when does the greatest fluid volume leak occur
Hemodilution
an increase in blood plasma, resulting in a dilution of the blood's cellular contents
proliferation
begins 2-3 days post burn; fibroblasts begin to heal
Lund and Browder method
A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool?
Paralytic ileus
The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn?
fourth degree burn
deep tissue and bone affected charred may be caused by high voltage electrical or prolonged exposure to something
Biobrane Dressing
dressing for partial thickness burn
