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NCLEX > Burns > Flashcards

Burns Flashcards

1
Q

why does plasma seep out into the tissue?
when does most of this occur?
when does the pulse increase?

A

increased capillary permeability (leaky)
in the first 24 hrs
anytime you’re in a fluid volume deficit, the pulse will increase

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2
Q

why does the CO decrease?

why does the urine decrease?

A

less volume to pump out

kidneys are either trying to hold on to fluid or they arent being perfused adequately.

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3
Q

why is epinephrine secreted?

why are ADH and aldosterone secreted?

A
  • makes you vasoconstrict, and shunt blood to the vital organs.
  • retain sodium and water with aldosterone and retain water with ADH, therefore the blood volume goes up.
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4
Q

what is the most common airway injury?

why?

A

carbon monoxide poisoning.

-normally, oxygen binds with hemoglobin. carbon monoxide travels much faster then oxygen. therefore, it gets to hemoglobin first and binds. oxygen cant bind now because carbon monoxide is already there

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5
Q

when you see a client with burns to the neck/face/chest you had better think what?

what may the physician do prophylactically?

A

airway

Et tube

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6
Q 
Rule of nine, what percentage is the..
head and neck
arm
trunk 
genital
leg
A 
head and neck -9
arm-9 each
trunk- 18 front 18 back
genital- 1 
leg- 18 each
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7
Q

treatment for pt with burns greater than 20-25 TBSA.

A
  • fluid replacement
  • should know what time the burn occurred because fluid therapy (for the 1st 24 hrs) is based on the time is injury occurred, not when the treatment was started.
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8
Q

Common rule : calculate what is need for the first ______ and give ____ of the volume calculated during the first ___ hrs.

A

24 hours
half
8 hours
(parkland formula)

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9
Q

Parkland formula

A

(4ml of LR)x(body weight in kg)x(%of TBSA burned) = total fluid replacement for the first 24 hrs after burns.

1st 8hrs= 1/2 of total volume
2nd 8hrs= 1/4 of total volume
3rd 8hrs= 1/4 of total volume

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10
Q

if the client is restless, it could suggest 3 problems: inadequate fluid replacement, pain , or hypoxia

Nurse’s priority?

A

hypoxia

pain never killed anyone

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11
Q

a client was wrapped in a blanket to stop the burning process. since the flames are gone does that mean the burning has stopped?

what else could have been done to stop the burning process?

the blanket helped by … holding in the ____ and kept out ____.

A

NO

Cool water not ICE water because they will vasoconstrict

body heat
infection

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12
Q 
Albumin:
you know that albumin holds onto \_\_\_ in the \_\_\_ space. 
vascular volume?
kidney perfusion?
BP?
CO?
A 
fluid, vascular
UP
UP
UP 
UP
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13
Q
  • will albumin help correct a fluid volume deficit?
  • why?
  • when you start giving a client albumin, you know the vascular volume will ___.
  • therefore, what will happen to the workload of the heart>
A

yes!
because we are putting more fluid in the vascular space
UP
UP

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14
Q 
If you have stress the heart TOO much:
-the client could be thrown into \_\_\_\_.
-if this occurs, what will happen to CO?
-lung sounds?
-
A

fluid volume excess
DOWN
wet

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15
Q

in a client who is receiving fluid rapidly, what is a measurement you could take hourly to ensure you’re not overloading the client?

A

CVP

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16
Q

what immunization should be given with burn pt?

A

-tetanus toxoid (active immunity)
(takes 2-4 to develop their own immunity)

-immune globin (immediate protection)
(passive immunity)

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17
Q

if a pt has a circumferential burn on their arm, what should you be checking?

A

circulatory check:

  1. pulse
  2. skin color
  3. skin temp.
  4. capillary refill
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18
Q

eschartomy

A

relieves the pressure and restores the circulation, cut through the eschar.

19
Q

fasciotomy

A

relieves the pressure and restores the circulation: but the cuts is much deeper into the tissue: it cuts through the fascia of the muscle.

20
Q

what drug might you order to flush out the kidneys?

A

mannitol
IV med. that can crystalize within a solution especially if it gets cold.
-use IV line filter
-observe solution for clarity before giving.
-DO NOT refridgerate

21
Q

the patient serum potassium level is 5.8.
where do we find most of the K?
-with a burn, what happen to the cell
-so what happens to the number of K in the serum(vascular space)
-electrolyte imbalance? hypo or hyper kalemia?

A

inside the cell
cell rupture
goes UP
Hyperkalemia

22
Q

why do you think magnesium carbonate, pantoprazole, or famotidine(pepcid) are ordered?

A

to prevent a stress ulcer (curling ulcer)

23
Q

why do you think the physician wants the client to be NPO and have an NG tube hooked to suction?

A

because they could develop paralytic ileus (GI tract slows way down or stops!)

24
Q

why would they develop paralytic ileus?

A
  • decreased vascular volume
  • decreased GI motility
  • hyperkalemia
25
Q

when you start GI feeding, what should you measure to ensure that the supplement is moving through the GI tract>

A

residual

26
Q

what is some lab work you could check to ensure proper nutrition and positive nitrogen balance?

A

prealbumin, total protein, albumin

27
Q

superficial thickness

A

formerly called first degree burn; damage only to epidermis

28
Q

partical- thickness

A

formerly called second- degree burn; damage to entire epidermis and varying depths of the dermis

29
Q

full thickness

A

formerly called third degree burn; damage to entire dermis and sometimes fat

30
Q

if they have burns on their hands, what are some specific measures that may be taken?

A
  • wrap each finger separately

- use splint to prevent contractures

31
Q

what is eschar?
does it have to be removed?
if its not removed, can new tissue regenerate?
what like to grow on eschar?

A

dead tissue
yes
no
bacteria

32
Q

Always make sure ____ before you start the antibiotic.

A

that the cultures have been collected

33
Q

when giving mycin drugs…. we worry when_____.

A

BUN and creatinine increases or if the client complains of any hearing loss.

34
Q

mycin drugs can lead to ___.

A

ototoxicity (irreversible hearing loss)

nephrotoxicity

35
Q

autograft

A

uses the clients own skin. good skin is taken from a healthy donor site and placed over the burned area.

36
Q

if the client is well nourished, the surgeon can reharvest from the same donor site every ___.

A

12 to 14 days

37
Q

if the skin graft becomes blue or cool what would this mean?

A

poor circulation

38
Q

sometimes the physician will order for you to roll sterile qtips over the graft with steady, gentle pressure from the center of the graft out to the edges. why?

A

to get exudate out from under the graft

39
Q

what if the graft come off, what would you do?

A

wet sterile saline dressing!

40
Q

chemical burn. what would you do first

A

remove the client from the chemical and begin to flush

41
Q

how long would you flush for a chemical burn?

A

15-30 mins

42
Q

electrical burn—2 wounds. what are they?
what is the first thing you do for an electrical injury?
how long?

A

entry and exit
cardiac monitor
24 hrs

43
Q

what arrhythmia is electrical burn pt at risk for?

A

vfib

44
Q

with electrical burns, ___ and __ can build up and cause renal damage

A

myogloin and hemoglobin

NCLEX (14 decks)

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