exam 3 Flashcards
(71 cards)
1
Q
minor burns information
A
- treated at the scene and followed up at local ED
- Full-thickness burn < 2% TBSA
OR - partial-thickness burn < 10% TBSA
2
Q
moderate burns info
A
- treated at scene, transported to burn center or specialized facility
- FTB 2-10%
OR
-PTB 15-25%
3
Q
Major burns info
A
- require emergency treatment at closest facility, then transfer to burn center immediately
4
Q
Major burn criteria
A
- FTB > 10%
- PTB > 25%
- > 60 yo
- has chronic cardiac, pulmonary, or endocrine condition
- presence of electrical burn
- presence of inhalation injury or other complicated injury
- burns to eyes, ears, face, hands, feet, or perineum
5
Q
superficial thickness burn
A
- damage to epidermis
- pink to red, no blisters, mild edema, no eschar
- painful/tender, sensitive to heat, heals in 3 to 6 days, no scarring
6
Q
superficial partial thickness burn
A
- damage to entire epidermis and some parts of dermis
- pink to red, blisters, mild to moderate edema, no eschar
- painful, heals within 2 to 3 weeks, no scaring but minor pigment changes
7
Q
Deep partial thickness description
A
- damage to entire epidermis and deep into dermis
- red to white, blisters rare, moderate edema, eschar soft and dry
- painful and sensitive to touch, heals in 2 to 6 wks, scarring likely, possible grafting
8
Q
full-thickness burn description
A
- damage to entire epi and dermis, can extend into subcutaneous, nerve damage
- red, black, brown, yellow or white; no blisters; severe edema; eschar hard and inelastic
- sensation minimal or absent, heals within weeks to months, scarring, grafting
9
Q
deep full thickness burn description
A
- damage to all layers, extends to muscle, tendons, and bones
- black, no blisters, no edema, eschar hard and inelastic
- no pain, heals within weeks to months, scarring and grafting
10
Q
s/s inhalation damage
A
singed nasal hair, eyebrows, eyelashes
sooty sputum
hoarseness
wheezing
edema of nasal septum
smoky smealling breath
11
Q
indications of impending loss of airway
A
- hoarseness
brassy cough
drooling
difficulty swallowing
audible wheezing
crowing
stridor
12
Q
CO inhalation s/s
A
h/a, weakness, confusion, erythmea, upper airway edema followed by sloughing of respiratory tract mucosa
13
Q
older adults are at higher risk of what when burned?
A
- damage to subcutaneous tissue, muscle, connective tissue, and bone (b/c of thinner skin)
- complications from burns b/c of chronic illnesses
14
Q
Resuscitation phase of burns
A
initial fluid shift, occurs in first 12 hrs continues for 24 to 36 hrs
- priorities include: securing airway, support circulation and organ perfusion by fluid replacement, manage pain, prevent infection, maintain body temp, provide emotional support
15
Q
Labs for resuscitation phase
A
- glucose: elevated
- BUN: Elevated
- Hct and Hgb: elevated
- Na: decreased b/c third spacing
- K: increased due to cell destruction
- Cl: increased
- plasma lactate: elevated
- carboxyhemoglobin: >10 = smoke inhalation
- ABGs - metabolic acidosis
- protein blood albumin decreased
16
Q
Fluid remobilization phase of burns
A
starts at 24 hr, diuretic stage begins 48 to 72 hr after injury
17
Q
labs for fluid remobilization phase
A
- Hgb and Hct: decreased
- Na: decreased
- K: decreased
- WBC: increase, then decrease
- glucose: elevated
- ABGs: slight hypoxemia and metabolic acidosis
- protein and albumin: low
18
Q
acute phase of burn
A
- begins 36 to 48 hr after injury
- ends when wound closes
- priorities: assess and maintain CV, resp, GI systems, wound care, pain control, psychosocial interventions
19
Q
rehabilitative phase of burn
A
- when most of burn area has healed
- ends when client achieves highest level of functioning possible
- can last for years
20
Q
nursing care to stop the burning process
A
- remove clothing or jewelry that may conduct heat
- apply cool water soaks to run cool water over the injury
- flush chemical burns w/ a large volume of water
- cover the burn with a clean cloth to prevent contamination and hypothermia
- perform ABCDE
- provide warmth
21
Q
nursing care for minor burns
A
- provide analgesics
- cleanse with mild soap and tepid water; avoid friction
- use antimicrobial ointment
- apply nonadherent, hydrocolloid dressing if clothing is irritating burn
- avoid greasy lotions or butters
- determine need for tetanus shot
22
Q
s/s of resuscitation phase for moderate and major burns
A
- tachycardia
- increased respiratory rate
- decreased GI motility
- increased blood glucose
23
Q
respiratory system and moderate/major burns nursing
A
- assess respiratory rate and depth
- monitor chest expansion
- upper airway edema may become pronounced 8 - 12 hr after beginning fluid resusitation
- provide humidified supplemental o2
- support airway and ventilation (may need mechanical vent and paralytic meds if PaO2 is < 60 mmHG)
- monitor and maintain chest tubes
- suction q1h or as needed
- perform chest PT and have client cough, breathe deeply, and use incentive spirometer
24
Q
CV system and moderate/major burns nursing
A
- monitor central and peripheral pulses
- capillary refill
- pulse ox
- BP
- ECG changes or presence of edema
25
fluid replacement and moderate/major burns nursing
- initiate IV access w/ large-bore needle; if large are aburn use of central venous catheter or intraosseous catheter
- fluid resuscitation must meet individual client's needs
- administer HALF of total 24-hr IV fluid volume within FIRST 8 HRS from time burn occurred and remaining half over next 16 hours
- infuse 0.9% NaCl or lactated ringers
- infuse albumin or synthetic plasma expanders after first 24 hr of burn recovery
- monitor VS
- assess fluid overload
- weigh client daily
- ensure output of 30 mL/hr
- prepare to administer blood products
- monitor for manifestations of shock
- IF urine output is below request prescription to increase fluid replacement DO NOT ADMINISTER DIURETICS
26
comfort management and moderate/major burns nursing
- avoid routes other than IV during resuscitation phase
- use IV opioid analgesics or anesthetics
- monitor for respiratory depression when administering opioid analgesics
- use PCA
- administer meds before dressing changes
- instruct client to pat rather than scratching to relieve itching
27
thermoregulation and moderate/major burns nursing
- for decreased temp: use warm, inspired air, warm room, warming blankets, and warmers for infusing liquids
- low-grade fever - occurs later after first few hrs following injury can remain increased for several weeks
28
system and moderate/major burns nursing
- may need NG tube insertion
- monitor stool, vomitus, and gastric secretions for blood
- asses for hypomotility and for tolerance of feedings
29
urinary system and moderate/major burns nursing
- insert an indwelling catheter
- monitor I&O
- monitor for red-tinged urine as indication of damage tor ed blood cells of muscles
- gycosuria expected
30
infection prevention and moderate/major burns nursing
- maintain a protective environment
- restrict plants and flowers
- restrict consumption of fruits and veggies
- limit visitors
- monitor for s/s of infection
- use client- dedicated equipment
- administer tetanus toxoid
- administer antibiotics and monitor for peak and trough levels
- STRICT ASEPSIS WITH WOUND CARE
31
normal hct
41 to 50% - men
36 to 48% women
32
normal hbg
14 - 18 men
12 - 16 women
33
normal respiration rate
12-20 breaths/min
34
rule of 9
groin - 1%
entire right arm: 9%
entire left arm: 9%
head and neck: 9%
entire left leg: 18%
entire right leg: 18%
entire trunk: 36% - {chest and upper back 9% each; abdomen and lower back 9% each}
35
nutritional support and mod/severe burns
- increase protein and carb intake
- increase caloric intake
36
what % of body loss needs additional calorie intake?
10
37
caloric intake and mod/severe burns
- double or triple 4 - 12 days after burn
- 5k calories/day
38
burn medications
- silver nitrate 0.5%
- silver sulfadiazine 1%
- mafenide acetate
- polymyxin B-bacitracin
- Gentamicin topical
- mannitol
39
gentamicin topical info
- anti-infective agent
- advantages: bactericidal
- disadvantages: nephrotoxic, ototoxic
40
polymyxin B-bacitracin info
- apply every 2-8 hrs to keep burn moist
- advantages: bacteriostatic against gram-positive; painless and easy to apply
- disadvantages: hypersensitivity can develop
41
Mafenide acetate info
- apply twice per day
- advantages: penetrates eschar and goes into underlying tissues; bacteriostatic against gram neg and pos bacteria
- disadvantages: painful to apply and remove; can cause metabolic acidosis
42
silver sulfadiazine 1% info
- apply a thin layer with a clean glove
- advantages: usually pain free; effective against gram (+/-) and yeast
- disadvantages: can cause transient neutropenia, sulfa allergy contraindicated, penetrates eschar minimally, can cause blue-green or gray discoloration, decreases granulocyte formation
43
silver nitrate 0.5% info
- apply with a gauze dressing
- advantages: reduces fluid evap, bacteriostatic, inexpensive
- disadvantages: does not penetrate eschar, stains clothing, and linen, depletes sodium and potassium
44
mechanical debridement
use scissors and forceps to cut away the dead tissue
45
hydrotherapy debridement
- use mild soap or detergent to wash gently, rinse with room temp water
- encourage client to exercise joints
46
chemical debridement
- apply topic enzyme to break down and remove dead tissue
47
nursing actions for wound grafting
- maintain immobilization of graft sites
- elevate extremities
- give analgesics
- perform ROM exercises
48
s/s of infection of graft
- green subcut fat
- subeschar hemorrhage
- degeneration of granulation
- hyperventilation
- unstable body temp
- discoloration of unburned skin surrounding graft
49
autograft
from another area of client's body
50
sheet graft
sheet of skin for covering the wound
51
artificial skin graft
- synthetic product for faster healing of partial and full thickness burns
52
mesh graft
stretch over large areas of a burn
53
how to avoid contractures for burns
- keep neutral position w/ limited flexion
- compression dressing for up to 24 months to increase mobility and reduce scarring
- assist w/ active or passive ROM at least 3 times per day
54
compartment syndrome
develop as edema increases and skin has lost elasticity due to damage
55
POAG (primary open angle glaucoma)
- gradual rise in IOP b/c aqueous humor outflow is decreased in canal of schlemm and trabecular meshwork
56
PACG
- IOP rises suddenly
57
POAG s/s
- h/a
- mild eye pain
- loss of peripheral vision
- decreased accommodation
- halos around lights
- elevated IOP (>21 mHg; usually 22 to 32)
58
PACG s/s
- rapid onset of elevated IOP (>30 mmHg)
- decreased or blurred vision
- colored halo around lights
- pupils nonreactive to light
- severe pain and nausea
- photophobia
59
normal IOP
10 to 21 mm Hg
60
glaucoma checks
- before 40: q2-4 years
- 40-54: 1-3 years
- 55 to 64: 1-2 years
- 65+ 6-12 months
61
meds for glaucoma
- cholinergic agents
- adrenergic agents
- timolol
- carbonic anhydrase inhibitors (-amide)
- prostaglandin analogs
- systemic osmotics (mannitol and oral glycerin)
62
mannitol info
- used for PACG to quickly decrease IOP
- emergency treatment
- IV
63
timolol info
- first-line drug therapy; decrease IOP by reducing aqueous humor production
- CAUTION: asthma, COPD, DM
64
carbonic anhydrase inhibitors (-amide) info
- decrease IOP reducing aqueous humor production
- NO allergic sulfa
65
risk factors for glaucoma
- age
- infection
- tumors
- DM
- genetics
- eye trauma
- severe myopia
- retinal detachment
- hypertension
66
how to administer glaucoma meds
- use every 12 hrs
- one drop in each eye twice daily
- wait 5-10 minutes between eye drops if more than one is prescribed
- avoid touching tip of bottle to eyee
- always wash hands before and after use
- apply pressure using punctal occlusion technique after eye drop is instilled
67
punctal occlusion technique
placing pressure on inner corner of the eye
68
client ed for glaucoma surgery
- wear sunglassess when outside or in brightly lit area
- avoid IOP increasing activities
- don't lie on operative side and report severe pain or nausea
- limit activities
- report n/v with pain
- best vision is not expected until 4-6 wks after surgery
- report if any changes in vision occur
69
activities that will increase IOP
- sneezing
- coughing
- straining
- head hyperflexion
- restrictive clothing
- sexual intercourse
- bending over at waist
70
activities to limit with glaucoma surgery
- tilting head back to wash hair
- cooking and housekeeping
- rapid, jerky movements
- driving and operating machinery
- playing sports
71
prostaglandin analogs info
- incrase outflow of uveosclera by dilating blood vessels; drains humor at more rapid rate
- check for corneal abrasions
- can darken iris color with long-term use
