Burn/Derm ATI
a nurse is caring for a patient with herpes zoster. What action should nurse take?
admin acyclovir
vitamins that help with wound healing(4)
-A -B12 -C -K
small pox lesions appear similar to those of varicella zoster virus
extra fact
s/s stage 4 pressure ulcer
full thickness skin loss with exposed or palpable bone or muscle
s/s of a stage 3 pressure ulcer
full thickness skin loss with necrotic SQ tissue
a nurse identifies a pressure ulcer after a pt had a long, extensive recovery following a surgical procedure. When completing an incident report about the pressure ulcer, what else should the nurse do?
include any relevant statements the pt made about the ulcer
A nurse is in ER for pt with partial thickness burn to both lower legs, chest, face, and both forearms. Priority action
inspect mouth for s/s inhalation injury
good protein source for a vegan
lentils, nuts, legumes
priority information for nurse to know when assessing severity of a burn injury
location of burn d/t the possibility of an airway problem
a nurse in ER is caring for a pt who has deep partial and full thickness burns to his chest, abdomen, and upper arms. Priority intervention
maintain airway
assess which body area for herpes simplex
mouth
a nurse is caring for a pt who has herpes zoster, what should the nurse expect for an assessment
painful lesions following a nerve pathway.
s/s of a stage 2 pressure ulcer
partial thickness skin loss and a superficial ulcer
RF for developing pressure ulcers - pt scenarios(3)
-protein calorie malnutrition -R-side HF and 4+ edema to lower extremities -postoperative delirium
expected findings for a kid with partial thickness burn on R forearm(3)
-sensitive to touch -wound blanches with pressure -blisters
possible trx methods for psoriasis(3)
-tar preparations(reduce infl.) -corticosteroids -UV light therapy
order of findings r/t herpes zoster(6)
1. Paresthesia 2. redness/swelling 3.vesicles 4. weeping blisters 5. crusted lesions 6. postherpatic neuralgia
s/s stage 1 pressure ulcer
reddened intact skin and blood filled blisters
action on the nurse for a patient on bed rest
reposition every 2 hrs
herpes zoster, aka
shingles
basal cell carcinoma description
small, waxy nodule with rolled, translucent, pearly(shiny) borders
how to provide emotional support to a pt with major burns
talk with pt during wound care
how to treat a stage 1 pressure ulcer
transparent dressing
Pt has psoriasis and is getting phototherapy. Teaching?(3)
trx might be interrupted if areas of redness or tenderness develop -trx are given 2-3X/week till psoriasis clears(not consecutive days) -wear dark glasses during and after trx
trx options for basal cell carcinoma(4)
-cryosurgery -electrosurgery -radiation Therapy -micrographic surgery
pt has large lower leg pressure ulcer. What food is very high in protein to help for wound healing(4)
-grilled salmon -chicken -eggs -beef
what dressings can be used for ulcers stages 2-4
-hydrogel and alginate dressing
lab values to expect with an extensive burn injury pt(4)
-hyperkalemia -metabolic acidosis -hypovolemia -elevated Hgb d/t hemoconcentration caused by hypovolemia
a nurse is caring for a pt with a stage 3 pressure ulcer. What lab values might affect wound healing
-low serum albumin(<3.5)
a nurse is making teaching plan for pt with herpes zoster. What information should be included in plan(2)
-may have pain in affected area for weeks after the lesions have resolved -may have pain/itching on the spot before the vesicles appear
actions to do for a pt with psoriasis(4)
-occlusive dressings are helpful, but on for no longer than 8hrs -salicyclic acid effective to soften thick lesions -gentle friction during bath helps assist removal scales -identify effective stress reduction techniques(condition is aggravated by stress)
RF for developing wound dehiscence (3)
-poor nutrition status -obesity -wound infection
5200mL LR for first 24hrs burn pt. How much should pt get in first 8hrs - mL/hr
325mL/hr. Half the total amount should be given in the first 8 hrs. From there, divide half by 8hrs to get mL/hr
a nurse in an emergency department is caring for a pt who has burn on front and back of both legs and arms. what is %
54% -each arm is 9%(one side is 4.5%) -each leg is 18%(one side is 9%)
pt has pressure ulcers and needs to be moved. How to do this to maintain their skin integrity?
use a transfer device to lift the pt up in bed
A nurse is caring for a pt with a full thickness burn over 75% of his body. How to monitor the CV system?
via pulmonary artery pressure. This can also assess development of pulmonary edema which is associated with fluid status
instruction for pt with psoriasis and using a topical corticosteroid
warp plastic around the site to increase medications effectiveness(use thin layer)
how to maintain skin integrity for pt with UC
wipe perianal area with warm water and apply a barrier cream
a nurse is planning an educational program about basal cell carcinoma. What information should the nurse provide
basal cell carcinoma has a low incidence of metastasis. Very localized
zoster virus, aka
chicken pox
Pt has burns to face, eyes, and ears. What finding does nurse need to report to Dr.
difficulty swallowing
a nurse is monitoring a pt with extensive burn injury and is getting IV fluid resuscitation. Identify which value decrease as a sign of adequate fluid replacement
HR