BURNS
Antiacids, H2 receptor antagonists (Tagemet)
When treating a curling's ulcer, which is related to diminied blood flow to the gastric mucosa, what should you give?
Assess area first
When trying to rescue a patient from the scene of a fire, what is the first thing that a person should do?
Insert an indwelling catheter to be sure urine output of 30mL/per hour
When you have a burn, what's the best way to monitor the patient's getting adequate urine output?
The return of distal pulses
Which of the following would be the anticipated therapeutic outcome of an escharotomy procedure performed for a circumferential arm burn?
Urine output
A Client is receiving IV fluids, who has sustained full-thickness burn injuries of the back and legs. The nurse knows the most reliable indicator for determining fluid resuscitation:
100% oxygen via a tight-fitting, nonrebreather face mask
A client arrives at the ER after a burn injury that occured at the home, and an inhalation injury is suspected. What should the nurse anticipate that would be prescribed?
carboxyhemoglobin, and tissue hypoxia occurs.
When oxygen molecules are displaced and carbon monoxide binds to hemoglobin, (they don't get any oxygen) it's called:
Monitor pulses, CMST and bleeding of affected extremity
When patient has had an escharotomy, what should the nurse monitor?
Forth Degree burn
This type of burn is a deep full thickness burn and is also known as:
increase circulation and decrease edema
A nurse elevates a circumferential burn on a patient, what is the purpose for this?
Superficial burn
A nurse in a provider's office is collecting data from a client who has severe sunburn. Which of the following is the proper classification of this burn?
Hyperkalemia and Hyponatremia
A nurse is caring for a client who has admitted 24 hr ago with full thickness burns to 50% of his body. Which of the following are expected findings for this client?
Inhalation injury
A nurse is caring for a client who sustained burns to 35% if his total body surface area. Of the burns, 20% are full-thickness. The burns are on the client's arms, face, neck, and shoulders. The client's voice seems hoarse, and he is wheezing with a brassy cough. What does this indicate to the nurse?
inadequate chest wall expansion and pulmonary insufficiency
A patient is admitted to the ICU for a circumferential thorax burn, what complications could the patient most like have when they can't breath?
infection
A patient with 3rd degree burn has redness, swelling, pain and 101.3F, and also purulent drainage, What do these symptoms indicate?
BP decreases <90/60, heart rate increases
A patient with burns comes into the ER, what is a sign that the patient has dehydration, (fluid resuscitation)?
WBC more than 10, hgb increase, hct increase, BUN increase
A patient's lab come back, how does the nurse know that the patient might have an infection?
Third degree burn
This type of burn is a full thickness burn and is also known as:
It's a depletion of fluid and electrolytes
Burns are traumatic injuries that result in tissue loss or damage, what else do they do?
Give Oral analgesics, aspirin and Vicodin
For a superficial burn, what type of medication should you be giving a patient?
Give morphine IV routinely, (30 mins before wound care)
For patient's with severe burns, what type of medication should the nurse be administrating?
9% (4.5% anterior and 4.5% posterior)
Head and neck burn injuries are how much percent?
By increasing capillary permeability and damaging celluar proteins
How does a burn destroy cells?
Children under 4 and clients over 65 years old
In what type of patients with burns is the mortality rate higher?
Full thickness burn
This type of burn is deep red, black, white and/or leathery, it requires the removal of dead of eschar (dead tissue), what is it?
Second Degree burn
This type of burn is partial thickness superficial burn, and is also known as:
Wound covering donated from a human cadaver
Patient is having an allograft homograft, what is this?
The burn has probably caused larygeal edema, which has occluded the airway
Patient was admitted after receiving flame burns to face and chest, the nurse notes a hoarse cough and that the client is expectorating sputum w black flecks. The client's eyelashes and eyebrows are singed, and the eyelids are swollen. The client suddenly becomes restless, and his color becomes dusky, the nurse interprets this date indicating which of the following?
CMP, or BMP, and CBC
To check the patient's electrolyte imbalance, what type of labs would the nurse predict that the Doctor might order?
Partial thickness superficial burn
The S&S for this type of burn is edema and large blisters and is very painful, what is it called?
prevent fluid, electrolyte and acid base imbalance
The way to manage a burn injury once the patient is in the hospital is to do what?
First Degree burn
This burn is a superficial thickness burn and is also known as:
Deep Full thickness burn
This type of burn involves the injury to the muscle and bone, and it's eschar is hard and inelastic, why type of burn is it?
Do not use multiple outlet plugs and dont run a cord under a rug
Ways to prevent fire/burns around the house are;
A cherry red mouth
What are the signs and symptoms of carboxyhemoglobin?
Dyspnea, decrease in O2 sat., abnormal lung sounds
What are the signs and symptoms respiratory distress (NANDA: ineffective breathing pattern)?
to cleanse crust that collects bacteria
What does hydrotherapy do for wound care on burns?
Prevents contractures, prevents tissue from scaring
What does physical therapy do for burns?
It's a colorless, odorless and tasteless gas
What is Carbon Monoxide?
compartment syndrome, causes severe pain
What is a fasciotomy?
Do not leave portable heaters on when sleeping
What is one of the most important ways to prevent a fire around the house?
Blood pressure drops causing decrease in blood to kidneys with chance of renal failure
What is the pathophysiology of burns?
18% (9% each, 4.5% anterior, 4.5% posterior)
What is the percentage of burn for the arms?
36% (18% each, 9% anterior, 9% posterior)
What is the percentage of burn for the legs?
1%
What is the percentage of burn for the perineum?
Prevent hypovolemic shock and preserve vital organ functioning
What is the primary goal for a patient with a burn injury coming into the ER?
Wash with copious amounts of water
What should a patient do if they get a chemical burn?
18%
What's the percent of burn for anterior trunk?
18%
What's the percent of burn for posterior trunk?
Vitamin C, protein, increase carbs and calories
What's the proper nutrition for wound healing?
Compartment syndrome, which stops circulation
When a patient comes in for circumferential burns of the extremities which produce a tourniquet-like effect, what type of complications can it lead to?
Pulmonary complications or air obstruction
When a patient comes into the ER with burns of the head, neck and chest, what type of complication can this be associated with?
stridor (blockage of airway), hoarse voice and trouble breathing
When a patient has just inhaled smoke, the signs and symptoms to be aware of are:
Superficial thickness burn
When a patient is experiencing a type of burn with severe erythema (redness), no blisters, is painful, but pain could be eased by cooling the area and is usually caused by sun, steam, is called:
Always check the patient's airway
When a patient is taken to the ER, besides checking the oropharynx for blisters and erythema, what is the most important thing you should always check on a patient?
Symptoms of shock and acute renal failure develop
When are patient is severely burned and is unconscious, what is one of the Pathophysiology of burns that is occuring?
Check mucous membranes and assess skin turgor
When assessing a patient that is dehydrated, what should you check on them?
check capillary refill, distal pulses, CMST, and pain
When assessing a patient with burns, to make sure they're getting proper circulation, what should a nurse check?
Third spacing
When fluid is where it's not suppose to be, or rapid shift of fluid from intravascular (vessels) to interstitial area is?
Intravenous
a nurse is caring for a client who is to receive fentanyl (sublimaze) for pain. The client was admitted to the hospital 24 hours ago with deep partial-thickness and full-thickness burns over 70% of his body. Which of the following routes should be used for medication administration?