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NURS 361 - Advanced Acute Care Nursing Practice I Final > Burns > Flashcards

Burns Flashcards

1
Q

List four different types of burns.

A

Thermal
Electrical
Chemical
Radiation

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2
Q

Type of burn associated with steam, scald, contact with heat, fire

A

thermal burn

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3
Q

Type of burn associated with lightning, electricity (high or low voltage)

A

electrical burn

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4
Q

Type of burn associated with acids and alkalines, tar, or asphalt

A

chemical burns

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5
Q

Type of burn associated with exposure to industrial equipment

A

radiation burn

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6
Q

What depth of injury if a sunburn, minor steam burn?

A

Superficial (epidermal burn)

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7
Q

What are the various depths of a partial thickness burn?

A

Superficial: sunburn, minor steam burn
Moderate: wet and weepy, very painful
Deep: no blisters, minimal fluid leakage

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8
Q

What are the characteristics of a full thickness burn?

A

Destruction of all layers of skin down to and including subcutaneous tissue
Pale white or charred in color and leathery
Painless and insensitive to palpation

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9
Q

What is the zone of coagulation?

A
  • the site of greatest heat transfer​
  • irreversible skin death occurs
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10
Q

What is the zone of stasis?

A
  • characterized by pronounced inflammatory reaction​
  • potentially salvageable area but it can be converted by infectionor inadequate resuscitation to full-thickness injury​
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11
Q

What is the zone of hyperemia?

A
  • outermost area; minimal cell involvement​
  • where early spontaneous recovery occurs
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12
Q

What percentage of burn produces a primarily local response?

A

Burns that do not exceed 20% TBSA produce a primarily local response

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13
Q

What percentage of burns results in both local and systemic responses and is considered a major burn?

A

Those that exceed 20%

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14
Q

What is involved in a systemic response to burns?

A
  • Systemic responses include release of cytokines and other mediators into the systemic circulation
  • Fluid shifts and shock result in tissue hypoperfusion and organ hypofunction
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15
Q

What are some of the effects of major burns?

A
  • Fluid and electrolyte shifts
  • Cardiovascular effects
  • Pulmonary injury
  • Upper airway
  • Renal and GI alterations
  • Immunologic alterations
  • Effect on thermoregulation
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16
Q

What effects can major burns have on the respiratory system?

A
  • Upper airway
  • Inhalation below the glottis
  • Carbon monoxide poisoning
  • Restrictive defects
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17
Q

What are the phases of burn management?

A

Emergent or Immediate Resuscitative
* From onset of injury to completion of fluid resuscitation
Acute
* From beginning of diuresis to near completion of wound closure
Rehabilitation
* From major wound closure to return to individual’s optimal level of physical and psychosocial adjustment

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18
Q

When does the emergent or immediate resuscitative occur?

A

From onset of injury to completion of fluid resuscitation

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19
Q

When does the acute phase of burn management occur?

A

From beginning of diuresis to near completion of wound closure

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20
Q

When does the rehabilitation phase of burn management occur?

A

From major wound closure to return to individual’s optimal level of physical and psychosocial adjustment

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21
Q

What is involved with airway management in burn management?

A

Intubation for inhalation injuries

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22
Q

What is the Parkland formula for circulatory management?

A

4 mL RL X kg X BSA burn = 24hrfluidresuscitation​
half is given in first 8hrs​
half is given in last 16hrs(all within 24hrs)​

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23
Q

What is the objective for renal management in burn management?

A

keep u/o > 0.5 mL/kg/hr

24
Q

What is important to watch for in GI management during burn management?

A
  • paralytic ileus (common)
  • Curling’s ulcer (acute gastric erosion resulting as a complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis of the gastric mucosa)
25
Q

What is involved in wound care for burns?

A

Washing of wounds​
Debridement- natural, mechanical, chemical, surgical
Blister management- leave intact unless impairing ROM​
Dressings: Silver-Flamazine,Acticoat,AquacelAG​
Skin grafting – see options in Table 59-7

26
Q

What is involved in pain management during burn management?

A

Burn pain is thought to have both nociceptive and neuropathic pain
for** partial thickness** burns​
morphine orfentanylinfusion with boluses for dressing changes​
Consider anxiety and sleep deprivation roles on pain
Consider nonpharmacologic measures

27
Q

What are signs of compartment syndrome?

A
  • Circumferential burns​
  • Tight compartment​
  • Pain with passive ROM​
  • Paralysis​
  • Decreased sensation (vibration)​
  • Paresthesia​
  • Decreased pulses​
28
Q

What is the treatment for compartment syndrome?

A

escharotomies

29
Q

What are short-term complications of burns?

A
  • Shock- hypovolemic, neurogenic​
  • Renal failure(acute tubular necrosis and AKI)
  • Respiratory distress, failure​
  • Hypothermia​
  • Pneumonia​
  • Inflammation - SIRS​
  • Infection - sepsis​
  • Tissue damage​
  • Multiple organ failure
30
Q

What are long-term complications of burns?

A
  • Scarring​
  • Contractures​
  • Weakness​
  • Thermoregulation​
  • Itching​
  • Pain​
  • Body image disturbances​
  • Psychological concerns
31
Q

What are some tools to estimate the extent of body surface area injured?

A
  • Rule of Nines
  • Lund and Browder Method
  • Palmer Method
32
Q

What is the Rule of Nines?

A

A system that assigns percentages in mutliples of nine to major body surfaces to estimate the total body surface area injured by burn

33
Q

What is the Lund and Browder model?

A

A more precise method of estimating the extent of a burn; it recognizes that the percentage of TBSA of various anatomic parts, especially the head and legs, changes with growth. Accounts for changes that occur with age as well.

34
Q

What is the Palmer method?

A

A method of estimating the extent of burns for scattered burns. The size of a patient’s palm is about 1% of TBSA.

35
Q

What immunologic changes occur with burns?

A

**Diminished resistance to infection due to alterations in the immune cells; sepsis continues to be the leading case of morbidity and mortality in patients with thermal injuries

36
Q

What are priorities during the emergent or immediate resuscitative phase of burn care?

A
  • Primary survey: A, B, C, D, E
  • Prevention of shock
  • Prevention of respiratory distress
  • Detection and treatment of concomitant injuries
  • Wound assessment and inital care
37
Q

What are priorities during the acute phase of burn care?

A
  • Wound care and closure
  • Prevention or treatment of complications, including infection
  • Nutritional support
38
Q

What are priorities during the rehabilitation phase of burn care?

A
  • Prevention of scars and contractures
  • Physical, occupational, and vocational rehabilitation
  • Functional and cosmetic reconstruction
  • Psychosocial counselling
39
Q

What are key nursing diagnoses associated with nursing burn care?

A
  • Impaired gas exchange
  • Impaired skin integrity
  • Interrupted family processes
  • Ineffective airway clearance
  • Fluid volume deficit
  • Hypothermia
  • Pain
  • Anxiety
  • Collaborative problems: acute respiratory failure, distributive shock, acute renal failure, compartment syndrome, paralytic ileus, Curling’s ulcer
  • Risk for infection
  • Impaired mobility
  • Disturbed body image
  • Imbalanced nutrition
  • Impaired coping
  • Decreased perfusion
40
Q

What are some disorders of wound healing?

A
  • Scars
  • Keloids
  • Failure to heal
  • Contractures
41
Q

In the rule of nine, what percentage is the anterior and posterior head?

A

9% (4.5% each)

42
Q

In the rule of nine, what percentage is the anterior trunk?

A

18%

43
Q

In the rule of nine, what percentage is the posterior trunk?

A

18%

44
Q

In the rule of nine, what percentage is the genital area?

A

1%

45
Q

In the rule of nine, what percentage is the anterior and posterior arm?

A

9% (4.5% each side) for each arm

46
Q

In the rule of nine, what percentage is the anterior and posterior legs?

A

18% (9% each side) per leg

47
Q

What is the shortest of the three phases in burn management?

A

emergent or immediate resuscitative phase

48
Q

What is involved in nutritional support for burn patients?

A
  • Adequate protein intake to promote wound healing
  • Base targets on pre-burn status
49
Q

Which groups are at greatest risk for burn injuries?
A. Middle Adults
B. Older Adults
C. Children
D. Teenagers
E. Young Adults

A

B. Older Adults
C. Children

50
Q

Severe electrical contact injuries are often caused by low-voltage lines in which form?
A. Alternating current
B. Direct current
C. Current source
D. Reflex arc

A

A. Alternating current

51
Q

Description of superficial burns

A
  • Involves epidermis only
  • May be caused by the sun or brief exposure to hot liquids
  • Erythema, pain, minimal edema
  • No blisters, dry skin
  • Heals in 3 to 7 days via sloughing of the epidermal layer, no scarring
52
Q

Description of superficial, partial-thickness burn

A
  • Involves the epidermis and th epapillary layer of the dermis (superficial layer)
  • May be caused by hot liquids, brief contact with hot objects, or flash flame
  • Erythema, brisk cap refill, blisters, moistness
  • Moderate edema, very painful
  • Heals in 10-14 days via re-epithelialization
  • No scarring; potential for hypo-or hyperpigmentation
53
Q

Description of deep, partial-thickness burn

A
  • Involves the epidermis and the reticular layer of the dermis (deep layer)
  • May be caused by flame, hot liquids, radiation, tar, or other hot objects and materials
  • Erythematous or pale, sluggish or absent cap refill
  • Moist or dry, no blisters
  • Significant edema and altered sensation
  • Heals in 21 days or longer
  • Potential for scarring and hypo- or hyperpigmentation
  • May require skin grafting for optimal function or appearance
54
Q

Description of full-thickness burn

A
  • Involves the epidermis, dermis, and subcutaneous layer
  • May be caused by flame, electricity, or chemicals
  • Dry, leathery, white
  • Absent capillary refill
  • Generally requires skin grafting
  • Heals via contraction and granulation tissue formation
  • Autografting is required for healing
  • Scarring and hypo or hyperpigmentation
55
Q

Description of subdermal burn

A
  • Involves the epidermis, dermis, subcutaneous layer, and muscle, tendon, or bone
  • May be caused by electricity, prolonged contact with flame, or a hot object or material
  • Charred, dry appearance
  • Requires skin grafting, flap, or amputation
56
Q

What is burn shock?

A

Combination of distributive and hypovolemic shock; can rapidly lead to cardiovascular collapse

NURS 361 - Advanced Acute Care Nursing Practice I Final (13 decks)

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