Chapter 26
Fluid resuscitation of burn patient how to assess:
-admin one bore free IV line -parkland formula to figure out fluid amount -assess IV hourly, vital signs, urine output, and assess for fluid overload
Deep partial thickness wound
-deeper into the skin with fewer healthy cells -rare blisters -soft and dry eschar -red and dry with white areas in deeper parts (dry because fewer blood vessels are patent) -blanches slowly or not at all -moderate edema -less pain than superficial because nerve endings are destroyed -heal 3-6 weeks with a scar -skin grafting can reduce healing time
superficial partial thickness wound
-entire epidermis and upper 3rd of the dermis -red and moist -blanch when pressure is applied -leakage of large amounts of plasma -blister formation -increased pain sensation -nerve endings are exposed -heal 10-21 days with no scar but minor pigment changes
Rule of 9's (parkland formula)
-head 9% -9% each arm & leg (4.5 front and 4.5 back) -18% chest/stomach -18% back
The health care provider has ordered a blood transfusion for a female patient with serious electrical burns. What hematocrit level reflects the need for transfusion when symptoms of hypoxia are present?
18%
What is the initial bolus dose of morphine through patient-controlled analgesia (PCA)?
5-10mg
Which of the following skin grafts are obtained from human cadavers?
Allograft
How long must a patient with burns wear pressure garments after undergoing biological dressing?
Atleast 23 hours a day
smoke poisoning
Cyanide binds to cell energy making components inhibiting cell metabolism and function
Which part of the skin varies in depth in the human body?
Dermal appendages
Why do blisters not form in deep partial-thickness wounds?
Due to the thick dead tissue layer which sticks to the underlying dermis
What type of burn injury may require the nurse to remove smoldering clothing and metal objects that are close to the patient's body?
Flame injury
circumferential wound
Full thickness wound: completely surrounds extremity blood flow and breathing may be decreased due to tight eschar
Which type of burn injuries includes a fasciotomy as part of the treatment plan?
Full-Thickness wound
Which method must be employed during hydrotherapy for the debridement of a wound in the patient with acid burns
Nonviable tissue must be removed by forceps
pulmonary fluid overload
Occurs even when lung tissues have not been damaged directly Histamine, other inflammatory mediators cause capillaries to leak fluid into pulmonary tissue space
Which type of burns result in a reduction in the activation of vitamin D when exposed to sunlight?
Partial-thickness burns
The nurse is encouraging ROM exercises for the client who states, "This hurts terrible; i don't want to do this" identify the appropriate nursing response
ROM helps promote mobility let me check when you were last given pain meds which techniques for pain management have you used in the past that were helpful?
Which physiologic outcome describes the goal of topical sulfadiazine in the care of a patient with a burn injury?
Reduction of bacterial growth in the wound and prevention of sepsis
Which statement is true regarding the layers of skin?
The dermis consists of appendages such as sweat glands and oil glands.
Resuscitation phase:
The first phase of a burn injury -secure airway -support organ circulation and oxygen perfusion -pt analgesics -prevent infection thru wound care -maintain body temp -emotional support
Which description of minor burn wound care defines open technique?
The medication is applied on the burn without the dressing
Which physiological action of carbon-monoxide manifests as "cherry red" coloration of skin in a patient with carbon-monoxide poisoning?
Vasodilating effect
When managing the care of a patient with a major full-thickness burn, when would the nurse begin to see fluid shifts resulting in edema?
Within 12 hours
What develops from hemodilution?
anemia
Carbon monoxide poisoning
co2 binds to hemoglobin which impairs oxygen unloading PaO2 is normal, vasodilation occurs pt appears red
Deep full thickness wound
damage to muscle, bone, and tissue -flame, electrical, or chemical s/s: black and depressed, no sensation need early excision & skin graft
s/s of fluid shift
decreased BV, BP drop, Edema, excessive weight gain within first 12 hours
s/s of full thickness wound
decreased sensation, promote blood supply to decrease healing time
Which assessment finding does the nurse interpret as demonstrating a clients fluid resuscitation adequacy
decreased urine specific gravity
Which type of burn injury can convert to a deeper injury due to tissue hypoxia?
deep-partial thickness wound
Which type of burn injury is caused by an open flame?
dry heat
What is the pressrun weight?
dry weight pt weight prior to edema
what type of burn can we not initially assess
electrical burns
Which type of injury is called a "grand masquerader" of burns?
electrical injury
Superficial thickness wounds define- s/s- what occurs?
epidermis is the only part of the skin that is injury; caused by prolonged exposure to low-intensity hear or short exposure to high-intensity s/s: redness with mild edema, increased sensitivity to heat Desquamation: peeling of dead skin after 2-3 days (heal within 3-6 days)
Parkland Formula
fluid replacement requirements for first 24 hours in burn pt 1/2 the volume in first 8 hours the second half over 16 hours
What is the characteristic of a burn caused by brief contact with a hot plate?
heals in about two weeks
Causes of fluid shift
hypovolemia, metabolic acidosis, hyperkalemia (direct cell injury), hyponatremia
escharotomies
incision through the eschar
fasciotomies
incision through the eschar and fascia
thermal heat injury
inhaled from steam can injury lower RT, rapid swelling and airway obstruction
The client asks about ways to prevent carbon monoxide poisoning which teaching will the nurse provide
it is important to have carbon monoxide detectors in your home because it is an odorless gas
metabolic acidosis due to
loss of bicarbonate in urine, increase rate of metabolism due to vascular injuries
Vascular injuries
macrophage detect injury and release chemicals that cause blood constriction fluid shift occurs after initial vasoconstriction, BV near burn dilate and release fluid in third space (third spacing or capillary leak syndrome occurs)
A patient sustains severe burn injuries from contact with a hot liquid. Which type of burn injury would the nurse anticipate?
moist heat injury
Respiratory assessment -direct airway injury:
mouth, nose, pharynx, black particles of carbon in nose - pt may become hourse, brassy, cough, drool or hard to swallow, audible wheeze or stridor ** upper airway injury **
Hemoconcentration
occurs from increase in blood osmolarity, increase H & H, due to vascular dehydration and increase blood viscosity, decrease BF, increase tissue hypoxia
Which nursing interventions decrease the risk for cross contamination in the client with a severe burn injury?
place client in isolation ensure that no plants or flowers are in the pt room teach family members not to bring fresh fruits and vegetables to the client
Which condition can be prevented by maintaining quite environment for better sleep?
psychosis
Which physiological change will result in loss of function from contracture formation in a 65-year-old patient with burn injuries who is admitted to the hospital?
slower healing time
Hyponatremia from fluid shift pathophysiology:
sodium retained in response to stress increases aldosterone, your body holds onto sodium in the interstitial space (third space)
Which burn injury is characterized by desquamation?
superficial-thickness wound
Full thickness wound
the dermis, epidermis, and subcutaneous tissue are penetrated; muscle and bone may be involved -Hard, dry leather eschar must slough before it can heal, severe edema under eschar
Partial thickness wound
tissue integrity is lost within epidermis and parts of dermis
when is a transfusion needed?
when hematocrit drops less than 20-25% s/s of hypoxia present
