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Patient Centered Care 3 > Tissue Integrity > Flashcards

Tissue Integrity Flashcards

1
Q

What does carbon monoxide poisoning cause?

A

Tissue hypoxia

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2
Q

What are some signs of smoke inhalation?

A
  1. Loss of ciliary action and severe mucosal edema
  2. Congestion results in atelectasis
  3. Black tinged sputum and coughing up mucopurulent material
  4. Soot around the nose and mouth
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3
Q

What are some upper airway injury signs?

A

Inflammation and edema causing airway obstruction

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4
Q

What are some external factors from burns that show problems with the lungs?

A
  1. burns of the neck and thorax result in edema (Obstructed airway can’t breathe= Faciotic)
  2. Extrinsic edema compresses the trachea and occlude the airway causing decreased tidal volume
  3. The effects of the fluid shifts can result in decreased lung compliance, pulmonary edema, and s/s of adult respiratory distress syndrome
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5
Q

What respiratory issues can indicate a pulmonary injury?

A
  1. Progressively hoarse
  2. Develop a brassy cough
  3. Drool or have difficulty swallowing
  4. Wheezes, crowing, and strider
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6
Q

What are the effects of burns on the cardiovascular system?

A
  1. hypovolemic shock
  2. cardiac arrest
  3. Vascular compromise
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7
Q

What happens when there is hypovolemic shock?

A

decreased volume causes fluid shifts

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8
Q

What is 3rd spacing?

A

When fluid shifts from intracellular and intravascular compartments to the interstitium.

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9
Q

When does burn shock typically occur?

A

within the first 24-36 hour of the injury

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10
Q

What happens during burn shock?

A
  1. Blood pressure rises
  2. Cardiac output increases
  3. Urinary output improves
  4. Diuresis continues from several days to 2 weeks postburn
  5. During this phase, the extra cardiac workload may predispose older clients or clients with cardiac disease to go into fluid volume overload
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11
Q

What kind of effect do burns on 40% of an individual’s TBSA have on the cardiovascular system?

A

Significant myocardial dysfunction, with a decrease in myocardial contractibility and cardiac output

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12
Q

What happens to the integumentary system with burns?

A
  1. Loss of water secondary to evaporation
  2. Infection secondary to loss of skin integrity, which allows pathogens to enter the body
  3. Difficulty maintain body temperature due to heat loss from open wounds
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13
Q

What happens to the GI system with burns?

A
  1. Decreased peristalsis- paralytic ileus/obstruction
  2. Gastric distention
  3. Increase the chance of aspiration
  4. Possible secondary ileus secondary to burn trauma
  5. An ileus leads to gastric distention
  6. Nausea/vomiting and hematemesis (Bloody vomit)
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14
Q

What happens to the urinary system during burns?

A
  1. Serum creatinine and blood urea nitrogen increase
  2. Urine may be dark brown color due to underlying muscle damage or the presence of large amounts of dead or damaged erythrocytes after a major burn
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15
Q

What happens to the immune system during burns?

A
  1. the immune system is impaired
  2. This increases the patient’s risks for infection
  3. This period of vulnerability is transient and may last from 1-4 weeks
  4. During this time opportunistic infections may be fatal despite aggressive antimicrobial therapy
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16
Q

What are the signs of hypovolemic shock?

A
  1. altered mental state- restlessness, and disorientation may be present
  2. Tachycardia
  3. Dyspnea due to blood loss and lack of red blood cells
  4. Cool clammy skin due to blood loss
  5. Hypotension
  6. Decreased urinary output due to low fluid volume
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17
Q

How should a nurse treat hypovolemic shock?

A
  1. Elevate the lower extremities 8-12 inches
  2. Do not elevate in presence of head, spine, chest, abdominal, or lower extremity injuries
  3. Maintain body temperature
  4. Provide rapid transport
  5. IV therapy
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18
Q

What are the 4 types of shock?

A
  1. Cardiogenic
  2. hypovolemic
  3. Distributive
  4. Obstructive
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19
Q

What are the degrees of burns?

A
  1. Superficial= 1st degree
  2. Partial-thickness= 2nd degree
  3. Full-thickness= 3rd degree
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20
Q

What are the characteristics of a superficial burn?

A
  1. An example is a sunburn that is red/pink with no blisters.
  2. pink to red color with mild edema
  3. pain
  4. no blisters or eschar
  5. no graft required
  6. heals in 3-5 days
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21
Q

What makes superficial burns hurt?

A

air touching the skin

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22
Q

What can help to reduce the pain?

A

Use a tub of tepid, not cold, water

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23
Q

If a larger area is burned and causes a superficial burn, what may a patient experience?

A

Chills, headache, nausea, and vomiting

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24
Q

How long does it take for superficial burns to heal?

A

3-6 days with dryness and peeling of the outer layer of the skin and no scar formation

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25
Q

How should superficial burns be treated?

A

Mild analgesics and application of water-soluble lotions

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26
Q

Describe second-degree superficial partial-thickness burn

A
  1. Pink-red-white color, edema pain blisters

2. Heal in less than 2 weeks

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27
Q

What should a nurse remember when caring for a patient with a second-degree burn?

A

LEAVE BLISTERS INTACT: It protects from infection, helps it get smaller, and gets reabsorbed.

28
Q

How long does it take someone to heal from a deep partial-thickness burn?

A

2-6 weeks to heal

29
Q

What is present in a deep partial-thickness burn?

A

Eschar which is crust and it is constrictive

30
Q

Are full-thickness burns painful? Explain.

A

No, because the nerve endings were burned off

31
Q

Describe a full-thickness burn

A
  1. Dry, pearly white, charred surface
  2. wound is black, brown, yellow, white, or red in color
  3. severe edema
  4. pain in outer areas
  5. eschar is present
  6. takes weeks to months to heal
  7. skin grafting
32
Q

How does someone get burns from dry heat?

A
  1. open flames

2. Most often occur in house fires or explosions

33
Q

How does someone get burns from moist heat?

A
  1. scalding injuries

2. hot liquids or steam

34
Q

If someone asks if they will look the same after a severe burn?

A

Tell them honestly that they will not look the same.

35
Q

What are contact burns from?

A

Hot metals, tar, or grease contact to the skin often leads to full-thickness injuries.

36
Q

What is a Hubbard tank and why would it be used for burns?

A
  1. A Hubbard tank used for full immersion hydrotherapy.

2. It works by promoting debridement of the wounds in burns.

37
Q

What do full-thickness burns require in order to heal?

A

Skin grafting

38
Q

What should you know about someone who gets hit by lightning?

A
  1. electrical burn
  2. place them on an EKG
  3. golfers get hit a lot because of metal sticks
39
Q

Describe the rule of nines for an adult

A
  1. 4.5 front and back of the head
  2. 9% on both arms
  3. 18% on both legs
  4. 18% front and 18% back of the torso
  5. 1% groin
  6. 1% on the palmar surface of the hands
40
Q

Describe the rule of nines for a child

A
  1. 18% head
  2. 18% front and 18% back of the torso
  3. 9% both arms
  4. 14% both legs
41
Q

Describe the rule of nines for an infant

A

the same for a child

42
Q

What is the process of wound healing for burns?

A
  1. inflammation
  2. Proliferation
  3. Remodeling
43
Q

What can happen when full-thickness burns heal?

A

When they heal they can have wound contractions. The neck can contract. This makes the individual look like a turtle. We do not want this.

44
Q

What do neutrophils do during the inflammation phase of burn healing?

A

they infiltrate the wound and peak in about 24 hours- after 24 hours do another CBC to see how they are doing.

45
Q

When does the proliferation phase of burn healing begin?

A

2-3 days postburn

46
Q

What is a hypertrophic scar

A

an overgrowth of dermal tissue that remains within the boundaries of the wound

47
Q

What is a keloid scar?

A

A scar that extends beyond the boundaries of the original wound

48
Q

Which population is at the most risk for hypertrophic and keloid scars?

A

Darker-skinned people

49
Q

What are the nursing interventions for minor burns?

A
  1. To promote wound healing
  2. To eliminate discomfort
  3. maintain mobility
  4. Prevent infection
  5. debridement to remove necrotic material from the wound
  6. Twice-daily wound cleansing with an application of a topical ointment
  7. ROM exercises for affected joints to prevent contractions
  8. weekly clinical appointments until the wound heals completely
50
Q

What are the three stages of interventions for severe burns?

A

Emergent
resuscitative/acute
Rehabilitative

51
Q

What are the interventions during the emergent/resuscitative stage?

A
  1. estimate the extent of the burn
  2. Institute first aid measures
  3. Implement fluid resuscitation therapies
  4. Assess the patient for shock and evidence of respiratory distress
  5. IV lines are inserted
52
Q

What is the Parkland formula?

A

Volume of Ringer’s Lactate= 4 mL x % BSA x weight

50% of fluids get used during the first 8 hours. 50% of the fluids get used during the next 16 hours

53
Q

What should be repeatedly checked while giving fluids?

A

Look at hourly urine outputs

54
Q

A patient is burned over 55% of BSA and weighs 75 kg. How much fluid resuscitation will this patient receive in the first 8 hours? How many mL/per hour?

A

4 mL x 55 x 75= 16500

16500/2= 82500 during the first 8 hours

1025 mL/hour

55
Q

What are the steps to prehospital management burns?

A
  1. eliminate the heat source
  2. stabilize the client
  3. Identify type of burn
  4. Prevent heat loss- cover up
  5. Reduce wound contamination
  6. Prepare for transport
  7. Support vital functions
  8. Room temp NS on sheet. DO NOT PUT DRY SHEET ON THEM
56
Q

What airway and ventilatory management interventions are used for emergency and acute care?

A
  1. elevate HOB 30 degrees
  2. Suction frequently
  3. Use intubation if necessary
  4. Humidify room air or O2
  5. Administer meds to dilate constricted bronchial passages
  6. Assess with arterial line
  7. Monitor carboxyhemoglobin levels
  8. pain medications if not in shock
57
Q

What is important to remember with the administration of pain meds?

A

Hypotension, constipation, and respiratory depression

58
Q

What is a CVP?

A

Central venous pressure tells volume status= decreased number dry; increased # wet

59
Q

What is a PAP?

A

Pulp artery pressure

60
Q

In the first 12-36 hours within the burn injury what can the patient develop and what should a nurse look for?

A

Cap leak syndrome/ movement of fluid

Watch for tachycardia and hypotension

61
Q

What interventions are used during the acute stage?

A
  1. fluid resuscitation
  2. Ventilatory management
  3. Surgeries
  4. Hydrotherapy- Hubbard Tank
  5. Nutrition
  6. Physical therapy- no contractures
  7. Wound Care
  8. Medications
  9. Psychosocial support
62
Q

What nutrition should be given to patients with burns?

A
  1. Milk
  2. Fruit
  3. Green veggies
  4. Chicken breast
  5. High calories; high carbs
  6. high proteins
  7. check albumin levels
  8. possible TPN
63
Q

When does a patient officially recover?

A

When they reach the highest level of functioning

64
Q

What happens to potassium when burn shock starts and resolves?

A

Hyperkalemia during burn shock.

Hypokalemia when burn shock is resolved.

65
Q

What meds are typically used for burns?

A
  1. analgesics- Opioids IV should be used during the emergent phase because it is more rapidly absorbed
  2. antianxiety meds
  3. anti-inflammatory meds
  4. Antimicrobials
  5. Tetanus prophylaxis
  6. antacids
66
Q

What type of ointments should be used with burn patients?

A

Ointments to eat up eschar that end in “ase”

Patient Centered Care 3 (19 decks)

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