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NCLEX > Burns > Flashcards

Burns Flashcards

1
Q

When does a majority of the initial fluid shift out of the vessels occur?

A

1st 24 hrs

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2
Q

Does the pulse increase or decrease as the fluid leaves the vasculature?

A

increases (b/c fluid vol deficit)

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3
Q

How long does it take for kidneys to sustain damage from inadequate perfusion?

A

20 min

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4
Q

Why is epinephrine secreted?

A

vasoconstriction to shunt blood to vital organs

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5
Q

What 2 hormones will make the make blood volume go up? How do they do it?

A

ADH –> Retain water only

Aldosterone –> Retain Na and water

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6
Q

Describe the Rule of 9’s (aka Consensus Formula)

A 
Head and neck --> 9%
Trunk front --> 18%
Trunk back --> 18%
Each arm --> 9%
Each leg --> 18%
Genital --> 1%
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7
Q

Describe the Parkland Formula (formula and admin guide)

A

(4 ml of LR) x (kg) x (% TBSA burned) = total fluid needed in 1st 24 hrs

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

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8
Q

If client is restless, what 3 things could this be caused from? Which is the nurses PRIORITY?

A

Inadequate fluid replacement
Pain
Hypoxia (This is PRIORITY!!!)

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9
Q

What is the best indicator for fluid volume status in burn pts?

A

UOP

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10
Q

More deaths occur with (upper or lower) body burns?

A

Upper

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11
Q

If client receiving fluids rapidly, what measurement could be taken hourly to ensure not overloading the client?

A

CVP (right atrial pressure)

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12
Q

What occurs if heart can’t keep up with the amount of fluid as fluid volume is increased?

A

Heart is over-stressed, fluid backs up into the lungs

assess for crackles

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13
Q

What are 2 important immunizations for burn pts?
Are they active or passive immunity?
How quickly do they provide protection?

A

Tetanus toxoid

  • Active immunity
  • 2-4 wks b/c body must make own antibodies

Immune globulin

  • Passive immunity
  • Immediate protection b/c getting someone else’s antibodies
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14
Q

4 things to look for with circulatory checks?

A

1) pulse
2) color
3) temp
4) cap refill

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15
Q

How often check UOP

A

Hourly

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16
Q

When does the pt begin to diuresis? Why?

What happens to UOP?

A

48 hrs after burn
Capillaries have healed
UOP increases

17
Q

What electrolyte imbalance do we watch for in burn pts?

A

Hyperkalemia

cells lyse and K+ spills into vascular space

18
Q

Why NPO and NG tube with suction?

A

Could develop paralytic ileus

19
Q

What are 3 reasons a burn pt could have a paralytic ileus?

A
  • decreased vascular volume
  • decreased GI motility
  • hyperkalemia
20
Q

How many calories should a burn pt consume?

A

5000 - 6000

21
Q

What labs are good indicators of nutrition and nitrogen balance?

A
  • Prealbumin (most sensitive current indicator of nutritional status)
  • Total protein
  • Albumin
22
Q

Classify burn:

Damage only to epidermis

A

Superficial thickness

aka First Degree

23
Q

Classify burn:

Damage to entire epidermis and varying depths of the dermis

A

Partial-thickness

aka Second Degree

24
Q

Classify burn:

Damage to entire dermis and sometimes fat

A

Full-thickness

aka Third Degree

25
Q

What is the #1 complication with a perineal burn?

A

infection

26
Q

What type of isolation is used with the burn pt?

A

protective

27
Q

What should we remember when using enzymatic debridement agents to remove necrotic tissue?

A

Don’t use:

  • on face
  • if pregnant
  • over large nerves
  • if area is opened to a body cavity
28
Q

What to remember with mafenide acetate (Sulfamylon)

A

Can cause acid/base problems
Stings
If rubs off, apply more

29
Q

What to remember with silver nitrate

A

Keep dressings wet

Can cause electrolyte problems

30
Q

What to remember with povidone-iodine (Betadine)

A

Stings and stains

May cause allergies and acid/base problems

31
Q

What should we worry about with aminoglycoside antibiotics (-mycin)? What labs do we watch closely?

A

Nephro- and ototoxicity

BUN and creatinine to assess kidney function

32
Q

Where does autograft skin come from?

A

The pt

33
Q

How often can new skin be harvested from the same donor site?

A

Every 12 - 14 days

34
Q

How long do you flush chemical/electrical burns?

A

15 - 30 min

35
Q

What arrythmia is electrical burn pt at risk for?

A

V-fib

NCLEX (13 decks)

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