BURNS- CHP. 25 EXAM # 3
A BURN WITH ERYTHEMA, BLANCHING ON APPLICATION OF PRESSURE, AND NO VESICLES OR BLISTERS.
1ST DEGREE BURN
A BURN CHARACTERIZED BY DRY, WAXY, LEATHERY SKIN THAT IS INSENSITIVE TO PAIN.
3RD OR 4TH DEGREE BURN.
A NURSE ASSESSES FOUR PATIENTS WITH BURN INJURIES. WHICH PATIENT DOES THE NURSE SUSPECT TO HAVE A FIRST-DEGREE BURN?
A FIRST DEGREE BURN IS A SUPERFICIAL OR PARTIAL-THICKNESS BURN. IT IS CHARACTERIZED BY REDNESS, PAIN, AND MODERATE TO SEVERE TENDERNESS OF THE BURN SITE.
A NURSE IS PROVIDING CARE TO A PATIENT WITH PARTIAL-THICKNESS BURN. WHICH CLINICAL MANIFESTATION DOES THE NURSE ANTICIPATE?
DAMAGE TO EPIDERMIS AND DERMIS INVOLVING VARIOUS DEPTHS. BURNS MAY BE SUPERFICIAL OR DEEP THICKNESS. PARTIAL-THICKNESS BURNS INVOLVE DAMAGE TO THE EPIDERMIS AND DERMIS AT VARYING DEPTHS.
INFECTION BECAUSE OF POOR SUPPLY TO THE CARTILAGE IS FOUND IN PATIENTS WITH WHAT TYPE OF BURNS?
EAR AND NOSE BURNS
A NURSE IS TEACHING A GROUP OF PARENTS HOW TO REDUCE THE RISK FOR INJURY RELATED TO BURNS. WHICH STATEMENT BY A PARTICIPANT INDICATES EFFECTIVE LEARNING?
I SHOULD HOLD REGULAR HOME FIRE EXIT DRILLS REGULAR HOME EXIT DRILLS ENSURE THE FAMILY KNOWS THE PRIMARY ESCAPE ROUTES IN CASE OF ANY FLAME ACCIDENTS AT HOME. FRAYED WIRES LACK PROTECTIVE INSULATION, AND CONTACT MAY RESULT IN ELECTRICAL INJURIES. GASOLINE AND KEROSENE SHOULD NEVER BE USED TO START A FIRE. OUTDOOR ACTIVITIES SHOULD BE AVOIDED DURING ELECTRICAL STORMS.
A NURSE IS PROVIDING CARE TO A PATIENT WHO SUFFERED BURNS TO THE PERINEUM. FOR WHAT IS THE PATIENT AT RISK OF DEVELOPING?
INFECTION FROM URINE CONTAMINATION. THE PERINEUM IS THE PART OF THE BODY OCCUPIED BY UROGENITAL PASSAGES AND THE RECTUM. A PATIENT WITH BURNS TO THE BUTTOCKS OR PERINEUM IS AT INCREASED RISK FOR INFECTION FROM URINE OR FECES CONTAMINATION.
THE AMBULANCE REPORTS TRANSPORTING A PATIENT TO THE EMERGENCY DEPARTMENT WHO HAS EXPERIENCED A FULL-THICKNESS THERMAL BURN FROM A GRILL. WHAT MANIFESTATIONS WILL THE NURSE SUSPECT?
NO PAIN, WAXY WHITE SKIN, AND NO BLANCHING WITH PRESSURE WITH FULL THICKNESS BURNS, THE NERVES AND VASCULARATURE IN THE DERMIS ARE DESTROYED SO THERE IS NO PAIN, THE TISSUE IS DRY AND WAXY LOOKING OR MAY BE CHARRED, THERE IS NO BLANCHING WITH PRESSURE.
A PATIENT WITH BURNS TO THE FACE AND NECK IS AT RISK FOR DEVELOPING AN INFECTION
OF THE RESPIRATORY TRACT.
SEVERE PAIN, BLISTERS, AND BLANCHING OCCUR WITH
PARTIAL THICKNESS (DEEP, SECOND-DEGREE) BURNS.
BLANCHING WITH PRESSURE IS OBSERVED IN PARTIAL-THICKNESS BURNS, BECAUSE VARYING DEGREES OF BOTH THE EPIDERMIS AND DERMIS ARE INVOLVED, AND SKIN ELEMENTS OF REGENERATION ARE VIABLE. WOUNDS APPEAR MOTTLED WHITE, PINK TO CHERRY-RED IN PARTIAL THICKNESS BURNS.
PARTIAL THICKNESS BURNS
PAIN, MINIMAL EDEMA, BLANCHING, AND REDNESS OCCUR WITH
PARTIAL-THICKNESS ( SUPERFICIAL, FIRST DEGREE ) BURNS
MOIST BLEBS, BLISTERS, AND HYPERSENSITIVITY TO TOUCH ARE OBSERVED IN
SECOND-DEGREE BURNS
FULL-THICKNESS BURNS, IN WHICH THERE IS LACK OF BLANCHING ON APPLICATION OF PRESSURE IS A :
THIRD AND FOURTH-DEGREE BURN ( FULL THICKNESS)
A PATIENT IS BROUGHT TO THE EMERGENCY DEPARTMENT (ED) WITH SEVERE BURNS ON THE LEGS AND FEET. WHICH FACTORS LEAD THE NURSE TO BELIEVE THE PATIENT MAY HAVE FULL-THICKNESS BURNS?
TOUCH SENSATION IS IMPAIRED LACK OF BLANCHING WITH PRESSURE IS OBSERVED WOUNDS APPEAR WAXY WHITE, DARK BROWN, OR CHARRED. TOUCH SENSATION IS IMPAIRED DUE TO IMPAIRED NERVE ENDINGS IN FULL-THICKNESS BURNS. LACK OF BLANCHING WITH PRESSURE IS OBSERVED, BECAUSE ALL SKIN ELEMENTS ARE DESTROYED. WOUNDS APPEAR WAXY WHITE, DARK BROWN, OR CHARRED IN FULL-THICKNESS BURNS, BECAUSE ALL SKIN ELEMENTS AND LOCAL NERVE ENDINGS ARE DESTROYED, AND COAGULATION NECROSIS IS PRESENT.
A PATIENT PRESENTS IN THE EMERGENCY DEPARTMENT WITHA BRIGHT RED BURNED AREA WITH MOIST, RED , SHINY VESICLES AND BLISTER FORMATION. THE PATIENT REPORTS SEVERE PAIN WHEN THE SITE IS EXPOSED TO AIR. WHICH TYPE OF BURN WILL THE NURSE DOCUMENT IN THE PATIENT'S MEDICAL RECORD?
A SECOND-DEGREE BURN. A SECOND DEGREE BURN MANIFESTS AS A BRIGHT RED BURNED AREA WITH MOIST, RED, SHINY VESICLES AND BLISTER FORMATION. THE PATIENT REPORTS SEVERE PAIN WHEN THE SITE IS EXPOSED TO AIR.
A PATIENT ARRIVES IN THE BURN UNIT WITH ERYTHEMA, PAIN, AND MILD SWELLING FOLLOWING A BURN INJURY WHILE COOKING. BASED ON THE WOUND OBSERVATION AND THE PATIENT'S SYMPTOMS, THE NURSE SHOULD DOCUMENT THE DEPTH OF THE BURN AS WHAT?
FIRST DEGREE BURNS WHICH ARE PAINFUL, ERYTHEMATOUS, AND ASSOCIATED WITH MILD SWELLING ARE FIRST-DEGREE BURNS. SECOND -DEGREE BURNS ARE ASSOCIATED WITH VESICLES THAT APPEAR SHINY THIRD AND FOURTH DEGREE BURNS ARE WHITE, WAXY, AND ARE INSENSITIVE TO PAIN DUE TO NERVE DESTRUCTION.
COAGULATION NECROSIS, DAMAGE TO ALL SKIN ELEMENTS, AND THE DESTRUCTION OF NERVE ENDINGS ARE OBSERVED IN
FULL -THICKNESS BURN INJURIES
A BURN OF THE LAYERS OF SUBCUTANEOUS FAT, MUSCLE, OR DEEPER STRUCTURES IS A :
FULL THICKNESS BURN
A PATIENT WITH A HAND BURN , DEPICTED IN THE IMAGE IS ADMITTED TO THE BURN TRAUMA CENTER. THE HAND SHOWS DRY, LEATHERY ESCHAR WITH WHITE WAXY AND CHARRED SKIN, WHICH IS INDICATIVE OF A
FULL-THICKNESS BURN. FULL THICKNESS AND PARTIAL THICKNESS ELECTRICAL BURNS ARE CHARACTERIZED BY HEAT COAGULATION OF THE BLOOD SUPPLY AND CONTACT AREA.
WHEN ASSESSING A PATIENT SUFFERING FROM INHALATION BURNS ON THE FACE AND CHEST, WHAT FINDINGS SHOULD A NURSE ANTICIPATE?
INCREASING HOARSENESS DARKENED ORAL OR NASAL MEMBRANES PRODUCTIVE COUGH WITH BLACK SPUTUM IN INHALATION BURNS: EITHER THE RESPIRATORY TRACT IS EXPOSED TO INTENSE FUMES OR HEAT, OR THE PATIENT INHALES NOXIOUS CHEMICALS OR SMOKE. INCREASING HOARSENESS IS SEEN DUE TO IRRITATION OF THE UPPER AIRWAY DURING INHALATION AND THE LARYNGEAL EDEMA CAUSED BY INHALATION INJURY. SOME OTHER SIGNS INCLUDE: DARKENED ORAL OR NASAL MEMBRANES AND PRODUCTIVE COUGH WITH BLACK SPUTUM, WHICH ARE EVIDENT DUE TO CHARRING OF THE MEMBRANES OF THE RESPIRATORY TRACT. LOCATION OF CONTACT POINTS IS DONE IN CASE OF ELECTRICAL BURNS, IN THIS CASE THE SKIN MAY APPEAR LEATHERY WHITE AND CHARRED.
BURNS TO THE HANDS AND FEET PUT THE PATIENT AT RISK FOR INFECTION OF THE :
VASCULAR AND NERVE SUPPLIES