Ch. 32: Burns Part 2 Flashcards Preview

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Flashcards in Ch. 32: Burns Part 2 Deck (30):
1

What are 5 steps for nursing actions of wound care?

1. Pre-medicate as prescribed
2. Remove previous dressings
3. Assess for odors, draining, or discharge
4. Cleanse wound as prescribed
5. Assist with debridement

2

What medication may we give to pre-medicate?

1. Analgesics
2. Hydroxyzine or diphenhydramine for pruritis

3

In assist with debridement, what needs to be done?

Provide hydrotherapy to cleanse the wound--use once or twice a day for up to 20 min

*use mild soap/detergent to gently wash burns, then rinse with room temp water
*encourage active ROM during hydrotherapy
*Monitor for cold stress and hypothermia

4

What are the 3 types of biological skin coverings?

Allograft
Xenograft
Synthetic skin coverings

5

Biological skin coverings may be used to promote healing of _____. What does it require?

Large burns; requires repeated surgical application

6

Biological: skin from human cadavers that is used for partial and full thickness burn wounds

Allograft

7

Biological: Obtained from animals, such as pigs, for partial thickness burn wounds

Xenograft

8

Biological: Used for partial thickness burn wounds

Synthetic skin covering

9

Permanent skin coverings may be the treatment of choice for burns covering _______

Large areas of the body

10

What are the 2 types of permanent skin coverings?

Autograft (3 types of autografts)
Artificial skin

11

What is an autograft?

Clients skin

12

Permeant skin covering: What are the 3 types of autografts?

Sheet graft
Mesh graft
Cultured epithelium

13

Permanent skin covering-Autografts

Sheet of skin used to cover the wound

Sheet graft

14

Permanent skin covering-Autograft

Sheet of skin placed in a mesher so skin graft has small slits in it; allows grafts to cover larger areas of burn wound

Mesh graft

15

Permanent skin covering-Autograft

Epithelial cells cultured for use when grafting sites are limited

Cultured epithelium

16

Permanent skin covering:Synthetic product that is used for partial and full thickness burn wounds. Healing slower or faster?

Artificial skin; healing is faster

17

Skin coverings: Should graft site be movable?

No, maintain immobilization of the graft site

18

Skin coverings: Should we elevate extremity or let it relax in normal body alignment?

Elevate it

19

What are some signs of infection to a skin graft?

-Discoloration of unburned skin surrounding burn wound
-Green color to SQ fat
-Degeneration of granulation tissue
-Development of subeschar hemorrhage
-Hyperventilation
-Unstable body temp

20

What should we instruct the client about their skin covering?

Keep extremity ELEVATED
Report signs of infection

21

Complications: Inhalation injury- Direct thermal injury

Occurs with burns to ____.
Can be delayed ____ hrs.
Findings?
Nursing actions?

Face and lips
24-48 hours

Wheezing, increased secretions, hoarseness, wet crackles in lungs, singed nasal hairs, laryngeal edema, carbonaceous secretion

Maintain airway and ventilation; proved 100% o2 if prescribed

22

Complications: Inhalation injury-Carbon monoxide injury

Occurs?
Findings?
Nursing actions?

Incident took place in an enclosed area

Findings: Mucosal erythema and edema, followed by sloughing of the mucosa

Maintain airway and ventilation; provide 100% o2 if prescribed

23

Complications: Shock/systemic sepsis

What do we administer?
What do we monitor?
What do we assess?

Administer: IV crystalloid solutions for first 24 hours, followed by colloid solutions

Monitor: I&O, Labs, VS

Assess: Sensorium *confusion*; Cap refil

24

Complications: Pulmonary problems

How do maintain airway?
Adminster?

Maintain airway via intubation, sometimes tracheostomy

Administer oxygen as prescried

25

Complications: Wound infection

Assess for?
Obtain?
Administer?
Monitor?
What type of technique when changing dressings?

Assess: discoloration, edema, odor, drainage, flucutations in temp and HR

Obtain: CULTURE

Administer: Antibiotics as prescribed

Monitor: Labs

Technique: SURGICAL ASEPTIC

26

A nurse is caring for a client who has a superficial partial thickness burn. Which of the following is an appropriate action for the nurse to take?
A. Administer IV of 0.9% sodium chloride
B. Apply cool, wet compresses to affected area
C. Clean affected area using a soft-bristle brush
D. Administer morphine sulfate

B

27

A nurse is caring for a client who has major burns and suspected septic shock. Which of the following findings are consistent with septic shock? (select all that apply)
A. Increased body temp
B. Altered sensorium
C. Decreased cap refill
D. Decreased urine output
E. Increased bowel sounds

A, B, D

28

A nurse is caring for a client who has a major burn and is experiencing severe pain. Which of the following is an appropriate nursing intervention to manage this client's pain?
A. Morphine sulfate IV continuous
B. Meperidine IM as needed
C. Acetaminophen PO every 4 hours
D. Hydrocodone PO every 6 hours

A

29

A nurse is caring for a client who has a skin graft. Which of the following clinical manifestations indicate infection? (select all that apply)
A. Green color to SQ fat
B. Unstable body temp
C. Generation of granulation tissue
D. Subeschar hemorrhage
E. Change in skin color around affected area

A. B, D, E

30

A nurse is caring for a client who has a moderate burn. Which of the following is an appropriate action for the nurse to take?
A. Maintain immobilization of the affected area
B. Expose affected area to air
C.Initiate high-protein, high-calorie diet
D. Implement contact isolation

C