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Flashcards in Burns Deck (79)
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Thermal Burns

most common type of burn injury
•are caused by flames, scalds, and heat


Radiation Burns

Are caused by exposure to ultraviolet light (sun exposure), x-rays,or a radioactive source, therapeutic treatment for cancer
Sun exposure is the most common burn, specifically two wavelength of light UVA and UVB that is more dangerous.


Chemical Burns

Are caused by contact with strong acids, alkalis or organic compounds.

Cleaning agents used in the home
(drain cleaner, bleach) and agents used in the industrial setting (caustic soda, sulfuric acid)


Classification of burns

partial thickness
full thickness


3 layers of skin

*Epidermis: thin like sheet of paper; barrier
*Dermis: 30-45% thicker than epidermis-nerves and blood vessels
*Subcutaneous: fat, lymph, muscles and bones


Superficial burn (1st degree)

Ultraviolet light ( sun burn), flash flame

Dry, No vesicles
Minimal or No edema
Blanch with pressure & refills when pressure is removed

Increased erythema

Burn is painful
heals in 3-7 days.


Superficial partial thickness (2nd degree)

Due to contact with hot liquids or solids, flash flame to clothing, direct flame, chemicals, ultraviolet

Large moist vesicles that increase in size
Blanches with pressure/refills when pressure removed

Mottled with dull, white, tan, pink or cherry red areas

Very painful

-Blistering and destruction of the epidermis.
-Slight damage to underlying dermis.
-Generally heal w/o intervention


full thickness burn (3rd degree)

Contact with hot liquids or solids, flame, chemicals, electrical contact

Dry leather eschar
Charred vessels visible under eschar
Vesicles rare but thin walled vesicles do not grow in size MAY be present
No blanching with pressure

White, charred, dark tan, black red

Little or no pain hair easily pulls out


deep full thickness 4th degree

-muscles, tendons, bone
-black, no edema
-no blisters, eschar is hard and inelastic


True or false: A burn can have different degrees at once

True; different levels over different parts of the body


Electrical Burns

-black eschar at the entrance and exit; follows the vascular system and causes clots along the pathway
-risk for arrhythmias, delayed and immediate
-cardiac monitoring for 24 hours
-the closer the burn to an airway, the higher risk


Chemical burns do not need

-some you can't use water to rinse bc they are activated by water


Emergent phase patient care

Most at risk for hypovolemic shock
1. prevent shock--greatest initial threat
2. prevent respiratory distress (provide 02)
3. pain management; IV narcotics
4. Fluid Resuscitation
5. Tetanus
--before you treat pain; get the fluids going


•Stage 2 Intermediate or Acute (Diuretic) Phase

•Begins 48 - 72 after burn injury
•Greatest concern – circulatory overload---- it may result from the fluid shift back from the interstitial spaces into the capillaries.

the acute phase begins when the kidney excrete large volumes of urine


burn wound care

-prevent infection (patients own bacteria)
-prevent cross contamination
-assists body's healing process
-Cleanse, Debride, Coverage
-Topical creams (water based)
-biological dressings/grafts
-prevent contractures with positioning, ROM exercises, ambulation, pressure dressings


debridement removes

dead tissue-prepare wound for grafting


Topical Antibacterial Agents for Burn Wounds need to be

water based
creams not ointments


__________ due to an increase in capillary permeability may be the greatest threat

volume shifts


Burn shock is most likely to occur within the first ________ immediately following the injury; consequently, the patient must be monitored closely during this time period for s/s.

48 hours


A method to determine the % or size of burns, the ___________ uses a diagram

rule of nines
-head is 9%,
each arm is 9%,
chest is 18%,
back is 18%,
groin is 1%,
each leg is 18%
--not accurate for all ages; a rough estimate


A method to determine the % or size of burns, the _________ is the most accurate and is used for all pediatric patients

Berkow method

-requires time to calculate and requires a table for all ages


__________ is a topical antimicrobial agent for burn therapy;


it is the most popular and has a wide range of effectiveness; easy to use and relatively painless; pt say "cooling effect"
-now known that using this to treat large burns doesn't increase survival rates significantly


The #1 goal during the emergent/resuscitative phase of burns is control of _______ and ________!!

ABCs and shock

-->any change in hemodynamic status, decrease in BP, oxygen, deep breathing, turning


Nutrition after burns requires a tremendous number of __________;


high cal, fat, protein, carb diet with supplements
-metabolism is high due to the healing process


Nursing care after excision and grafting

-immobilize the graft
-elevate to decrease edema
-check for bleeding and signs of neruovascular impair (inc pain, numbness, tingling)
-maintain bulky pressure dressings (applied in OR and in place 2-3 days)
-application of sterile saline or antibiotic soln q4hrs
-after autograft, observe donor site (left open to air, keep pressure off site, heat lamp)
-assess for infection (donor and graft site)-red, swelling, drainage
-manage pain


The best cover when closing the burn wound is the

patient's own skin

-few donor sites
-meshed skin: run donor skin through machine that makes small slits that allow for expansion; healing occurs as spaces btwn mesh fill in with new epithelial skin growth


Heterograft / Xenograft

tissue from another species, such as a pig or a cow, used as a temporary graft


Homograft / Allograft

the transfer of tissue between tow genetically dissimilar individuals of another person who is not an identical twin (often a cadaver)


S/S of burn shock

cool dry skin, dry mucous membranes, poor skin turgor, decreased urine output, edema,diaphoresis, weakness, dizziness, change of LOC, decreased BP and pulse, tachycardia, dysrhythmia, abnormal labs
---> Tx with aggressive fluid replacement therapy!!!



is the removal of dead tissue: