patho bby
central area
what is zone of coagulation; due to the characteristic coagulation necrosis of cells that occur
Intravascular fluid leak occurs in the first ____-___ hrs. after the burn injury, peaking at ___-__ hrs. after the initial burn injury.
what is 24,36,6,8
when is rule of 9s calculated
what is at initial assessment & 48 hour mark
if silver does not work
what is mafenide
A nurse in a provider's office is assessing a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn?
a. superficial thickness
b. superficial partial thickness
c. deep partial thickness
d. full thickness
what is A; damage to top layer of skin
zone of stasis, will undergo necrosis within __-___ hrs, with persistent ischemia
what is 24, 48
deeper burn → continue to form edema up to ___ hrs post injury
what is 18
used to determine damage to respiratory tract from inhalation injury
if expected to be NPO longer than 5 days
what is TPN
A nurse is caring for a client who has sustained burns over 35% of TBSA. The client's voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following?
a. pulmonary edema
b. bacterial pneumonia
c. inhalation injury
d. carbon monoxide poisoning
what is C; wheezing & hoarseness indicate inhalation injury w impending loss of the airways; these require immediate reporting to the provider
partial thickness burns involve the entire epidermis & varying portions of the dermis; healing time depends on the depth of the dermal injury, ranging from 2-3 weeks; hair follicles & skin appendages remain intact; the wound bed is moist due to serous leakage from the peripheral microcirculation
what is 2nd degree burns
cardiovascular changes w severe burns
what is cardiac depression, edema, & hypovolemia
special consideration for electrical burns
what is obtain baseline ECG & continuous cardiac monitoring
closely resemble human plasma
what is LR
A nurse is assessing a client who sustained deep partial-thickness & full-thickness burns over 40% of the body 24 hr ago. Which of the following findings are common during this phase? SATA.
a. temperature 36.1 C (97 F)
b. bradycardia
c. hyperkalemia
d. hyponatremia
e. decreased hematocrit
what is A, C, D
- A: decreased temp can occur in the first few hours following a burn, bc the body's ability to regulate temp is compromised
- B: tachycardia occurs
- C: hyperkalemia occurs during the initial phase following a burn as a result of leakage of fluid from the intracellular space
- D: hyponatremia occurs during the initial phase of a burn as a result in sodium retention in the interstitial space
- E: Hct increases
full-thickness involving total destruction of the epidermis, dermis, 7 sometimes damage to the underlying tissue
what is 3rd degree burns
GI symptoms
what is bladder pressure, increasing serum lactate, & feeding intolerance
diagnose CO poisoning
what is carboxy-hemoglobin level
prophylaxis
what is tetanus
A nurse is preparing to administer fentanyl to a client who sustained deep partial-thickness and full-thickness burns over 60% of the body 24 hr ago. The nurse should plan to use which of the following routes to administer the medication?
a. subcutaneous
b. oral
c. IV
d. transdermal
what is C; for rapid administration & fast pain relief during the resuscitation phase
skin organelles such as hair follicles & sweat glands may be affected
what is 3rd degree burns
blisters, sensitive to air currents, pain
what is 2nd degree burn
get this bc they act like an idiot & you need to see what kind of idiot they are
what is blood alcohol level
decreased heart rate & blocks harmful catecholamine effects
what is propranolol
A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? SATA.
a. limit visitors in the client's room
b. encourage fresh vegetables in the diet
c. ↑ protein intake
d. instruct the client to consume 2,000 calories/day
e. restrict fresh flowers in the room
what is A, C, E;
- A: to ↓ risk of infection
- C: promotes wound healing & prevents tissue breakdown
- D: 5,000 calories/day bc caloric needs double or triple beginning 4 to 12 days following the burn
- E: these ↑ risk of infection so yes restrict is correct