Chapter 26

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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


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