Burns Injuries/ Tissue Integrity
3rd degree burn
A Full-thickness burn is also referred to as:
gastric (curling's) ulcers
A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client?
Replace lost fluids and electrolytes
A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to:
epidermis and a portion of deeper dermis
A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:
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?
2nd degree burn
A partial-thickness burn is also referred to as:
Superficial
A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?
sterile water only
A patient has been prescribed Acticoat as a burn wound treatment. The nurse knows that Acticoat should be moisted with:
neutral position
A patient who receives autografts should keep the grafted extremity in which position?
the epidermis
A superficial burn only damages:
Mederma
A topical gel that can be used to reduce scarring:
Allograft
Another term used for a homograft is:
Heterograft
Another term used for a xenograft is:
Deep burn necrosis
Another term used for- 4th Degree burn:
Mafenide
Antimicrobial agent for gram-positive and gram-negative organisms that can DIFFUSE through eschar and avascular tissue
2mL/kg/%TBSA (lactated ringers)
Emergent phase fluid resuscitation formula for Chemical and Electical burns:
4mL/kg/%TBSA 1/2 total in first 8hrs Other 1/2 over 16 hrs
Emergent phase fluid resuscitation formula for thermal burns:
1. Establish airway/supply oxygen 2. Insert Large bore IV's 3. Cover the wound with clean/dry cloth or glaze. 4. Continuous irrigation of checkical injury must begin immediately.
Emergent/Resuscitative phase(On- the-scene) care steps:
-ABCDE -Prevent shock -Prevent respirratory distress -Detect and treat other injuries -Wound assessment and initial care.
Emergent/Resuscitative phase(On- the-scene) priorities:
Anxiety
Benzodiazepines may be used in conjunction with Opioids to help treat:
Homograft
Biologic dressing where skin is obtained from recently deceased or living humans other than the patient
distally to proximally
Circumferential dressings should always be applied:
Liquid blood component is lost into EXTRAVASCULAR space.
During the emergent/resuscitative phase of burn injury, hemoconcentration is due to which of the following?
excision and grafting
Early __________ and __________ of the burn wound is one of the most important factors in ameliorating hypermetabolism by removing eschar, thereby lessening the effects of inflammatory mediators
least resistance
Electrical current follows the path of:
Age, depth, surface area, inhalation, location, comorbidities,and presence of other injuries.
Factors that determine the severity of the burn injury include:
monthly
Fire detector alarms should be checked every:
Once a year
Fire detector batteries should be changed:
sunburn, low-intensity flash, superficial scald
First degree (superficial) burn causes:
Tingling, hyperesthesia, peeling, itching.
First degree burn Clinical manifestations:
Red, blanches, minimal edema, possible blisters
First degree burn wound appearance:
Can recover in days, oral pain meds, cool compresses, topical ointments/lubricants
First degree treatment:
Pulmonary system
Following a burn injury, the nurse determines which area is the priority for nursing assessment?
2-4 weeks
For deep partial-thickness burn injuries, recovery is expected in:
Hyperkalemia
Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is:
epidermis, dermis
In a superficial partial-thickness burn, the ____________ is destroyed and a small portion of the ________ is injured
numbness and decreased sensation to the area.
In relation to pain, full-thickness burn victims will experience:
Antimicrobials
Topical therapy that protects against bacteria and promotes a moisst environment.
hypertrophic/keloid scarring and contractures
Two complications in Rehabilitation phase related to partial and full-thickness burns.
Enzymatic
Type of debridement that encompasses the use of topical enzymes to the burn wound:
Mechanical
Type of debridement that involves the use of surgical tools to separate and remove the eschar:
Surgical
Type of debridement that uses the use of forceps and scissors during dressing changes or wound cleaning:
75-100 mL/h
Urinary output with fluid resuscitation formula in Electrical injuries:
0.5 to 1 mL/kg/h in adults
Urinary output with fluid resuscitation formula in thermal and chemical injuries:
hoarseness of the voice
When assessing a client with partial-thickness burns over 60% of the body, what finding should the nurse report immediately?
1
When using the Palmer method to estimate the extent of the burn injury, the nurse determines the palm is equal to which percentage of total body surface area?
Cardiac dysrhythmias.
Which complication is common for victims of electrical burns?
To keep fire and smoke from the airway
Which is the primary reason for placing a client in a horizontal position while smothering flames are present?
Silver Nitrate Solution
Which of the following topical burn preparations act as wick for sodium and potassium?
Sulfadiazine silver
Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application?
mafenide (sulfamylon)
Which topical antibiotic is ordered to prevent infection in clients with partial-thickness and full-thickness burns?
Natural
Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues?
Elderly and young children
Who are at higher risk for burns?
Thin skin, causes the burn to penetrate the skin deeper, causing further complications.
Why are the elderly and young children at higher risk for mortality and morbidity?
-use mild soap and water with washcloth -clip or shave hair around the burn area -Monitor for hypothermia ** water temp= 100F ** room temp= 80-85F
Wound cleaning:
Oxandrolone
an anabolic steroid that is commonly given to patients with burns because it improves protein synthesis and metabolism.
-onsistant application of emollients to keep skin pliable -apply pressire garments as prescribed -gentle massage
Nursing interventions for hypertophic/keloid scarring:
as soon as possible
Nutrition should be provided as __________________, upon arrival to the burn center
50%
Nutritional support with optimized protein intake can decrease the protein losses by approximately:
Early excision of necrotic tissue
One of the most important medical interventions for patients with burns that have positively affected mortality is:
Procedural pain
Pain caused by the discomfort that occurs with procedures such as daily wound treatments, invasive line insertion, and PT/OT:
-Opioids (morphine) -Nonsteroidal anti-inflammatory drugs -Anxiolytics -Anesthetic agents
Pharmacologic treatment for the management of burn pain includes the use of:
-Acute Respiratory Failure -ARDS -Heart Failure -Pulmonary Edema -Sepsis -Delirium
Potential complications associated with burn injuries in the Acute/Intermediate phase:
Face: 9% Anterior: 18% Posterior: 18% Arm: 9% each Leg: 18% each Pelvis: 1%
Rule of nines:
Hypertrophic scars
Scars that form within the boundaries of the initial wound and push outward on the perimeter of the wound. They are common in areas over joints and in the younger population. The scar becomes red (due to its hypervascularity), raised, and hard.
Biobrane
Skin substitute that has a nylon-silicone membrane coated with a protein:
Background pain
Term that describes the continuous level of discomfort experienced even when the patient is inactive or not undergoing any procedures.
Breakthrough pain
Term used for pain that is described as acute, intense, and episodic:
hypovolemia
The nurse receives a client following a serious thermal burn. What complication will the nurse take action to prevent first?
2-5 days
The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery?
the highest level of function possible within the context of their injuries
The ultimate goal of the rehabilitation phase is to return patients to:
Paralytic ileum, Curlings ulcer, and translocation of bacteria.
Three of the most common GI alterations in burn-injured patients are:
immediately after the burn has occurred, and can last for years.
Rehabilitation phase begins:
Electrical burn
myoglobinuria is a concern associated with which type of burn?
Long-acting, patient-controlled analgesic agents that will provide uniform long-term relief by using small escalating doses.
The goal of treatment for background pain is to provide:
Palmer method
The method used for scattered burns, using the patients hand as measurement:
inflammatory process
What physiologic process furthers a burn injury?
tachycardia, slight hypotension, tachypnea and anxiety
What signs and symptoms are expected soon after a burn injury?
Intestinal tract
What site is the source of most microbes leading to bacterial infection?
Superficial and Partial-thickness (1st and 2nd degree)
What stages of burn are the most painful?
Short-acting analgesics
What treatment is used for breakthrough pain?
Full-thickness
What type of burn requires skin grafting?
Pat the areas, do not scratch.
When a patient is healing from a burn-injury, itching becomes a normal part of healing. How should the nurse educate the patient in terms of relief?
Scalds, flash flame, contact
2nd Degree (Partial Thickness) burn causes:
Recovers in 2-3 weeks. some scarring and depigmentation, may require grafting.
2nd Degree (Partial Thickness) burn recovery time and treatment:
Epidermis and a portion of dermis.
2nd Degree (Partial Thickness) burn skin involvement:
-pain -sensitive to air currents -hypersensitivity.
2nd Degree (Partial Thickness) burn symptoms:
Blistered, mottled, red base, weeping surface, edema
2nd Degree (Partial Thickness) burn wound appearance:
-Dry -Pale white, red, brown, leathery or charred Visible coagulated vessels -Edema
3rd Degree (Full Thickness) burn appearance:
-flame -prolonged exposure to hot -liquids -electricity -chemicals -contact.
3rd Degree (Full Thickness) burn causes:
Epidermis, dermis, and sometimes subq tissue. May involve connective tissue and bone
3rd Degree (Full Thickness) burn involvement:
- Insensate skin - Shock - Myoglobinuria - Possible contact points (entrance or exit wounds in electrical burns)
3rd Degree (Full Thickness) burn symptoms:
-Eschar sloughing -Grafting is NECESSARY - Scarring -Loss of contour and function.
3rd Degree (Full Thickness) burn wound coarse of treatment:
Amputation -Grafting will be of no benefit given the depth and severity of the wound.
4th Degree burns that include fat, fascia, muscle, and/or bone will likely receive which surgical intervention:
5 days
Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which time frame?
From beginning of diuresis to near completion of wound closure
Acute/Intermediate phase duration:
-Restoring normal fluid balance -Infection prevention -Nutrition (hypermetabolism) -Wound care -Pain control -Positioning/mobility -Coping mechanisms
Acute/Intermediate phase priorities:
48-72 hours of burn injury
Acute/Intermediate phase typically begins within:
Establish a patent airway and administer humidified 100% oxygen
As the first priority of care, a patient with a burn injury will initially need:
activity or movement of the affected area.
Breakthrough pain is generally related to:
Silver-impregnated dressings
Broad antimicrobial agent that can be left in place for several days.
capillary leak (third-spacing), severe hypovolemia, and decreased cardiac output.
Burn shock is characterized by:
Full-thickness
Burn that involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone.
Provide adequate nutrition and calories to decrease catabolism. -High Protein -High Carbs/Calorie
The most important intervention in the nutritional support of a client with a burn injury is to:
Xenograft
Graft that consist of skin taken from animals (usually pigs):
Autograft
Graft that uses the client's own skin, which is transplanted from one part of the body to another:
1.5-2 g/kg/day
How much protein should a burn victim consume per day?
infection and slowed healing rate
Hypermetabolism can affect morbidity and mortality by increasing the risk of:
1. Nutrition ASAP 2. Early excision and grafting of burn wound. 3. Maintain environmental temp to decrease energy expidenture. 4. Insulin therapy (hyperglycemia and aids in muscle protein synthesis. 5. Oxandrolone (anabolic steriod) 6. Propanolol ( decreases heart rate and blocks harmful catecholamine effects)
Hypermetabolism nursing interventions:
Keloid scars
Irregularly formed scars that extend beyond the margins of the original wound. They are large, nodular, and ropelike, often causing itching and tenderness. They are more common in dark-pigmented skin
-Relaxation techniques -Distraction -Guided imagery -Hypnosis -Therapeutic touch -Humor -Music therapy -Virtual reality techniques
Nonpharmacologic therapies for burn victims are:
7-10 days, 6-12 months
Normal scarring in burn patients begins __-__ days post injury and progresses over the next __ to ___ months.
**COMPRESSION** -Elastic bandage wraps -Elasticized tubular bandages -Customized compression garment -Silicone sheet inserts for small areas -Gentle massage with moisturizer -Burn reconstruction
Prevention and treatment of scars:
Myoglobinuria
Red pigment in urine and possible hemolysis (blood cell destruction)
Emergent/Resuscitative phase(On- the-scene)
The emergent/resuscitative phase duration:
Silver Sulfadiazine
Water soluble, bacterial agent used to slow the growth of gram + and gram - organisms. 1%
Decreased peristalsis and bowel sounds.
What are the manifestations of paralytic ileus?
Morphine
What is the analgesic of choice for burn pain?
application of cool water
What is the best first-aid measure that can be used to cool a burn?
it compromises wound healing and immunocompetence.
What is the effect of protein catabolism in a client with severe burns?
Sepsis
What is the leading cause of morbidity and mortality in patients with burn injuries?
Carbohydrates
What is the most important energy source for patients who are severely burned?
-outermost zone -minimal injury -can fully recover
Zone of Hyperemia:
center area of the wound, non-viable necrosis of cells
Zone of coagulation:
-surrounding area of the zone of coagulation -injured cells are still viable -necrosis will occur in 24-48 hours
Zone of stasis:
