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