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