Peniz
What is the severity of burns determined by?
Why do you have to warm slowly with bath water if someone has frostbite?
Really cold and peripherally shut down. If you stick them in something warm and all of these nerve cells are stimulated they are going to have incredible pain and also vasoconstriction. All of the fluid comes and you get edema and tissue that has lots of volume in it and the tissue is already damaged. This extra volume and pressure will damage those tissues more. Gradually warm them (painful regardless but less so).
The nurse is planning care for a client with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which of the following interventions would the nurse expect to include in this client’s care? (Select all that apply.)
An escharotomy (a scalpel or electrocautery incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion. Pain control is essential in the care of a client with a burn injury.
What depth of burn shows skin redness with no blisters at the time of injury?
Superficial partial thickness: skin redness, pain, no blisters at time of burn, skin blanches
Which coincides with Pre-Hospital Care?
Remove restrictive clothing
Create at least 3 IV access sites
Fluid Resuscitation
Vital Sings
Remove restrictive clothing
A nurse is caring for a client who has second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which of the following recommendations?
One half of the total 24-hour fluid requirement should be administered in the first 8 hours.
Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first eight hours, one quarter of total fluid requirement should be administered in the second eight hours, and one quarter of total fluid requirement should be administered in the third 8 hours.
Hypercalcemia
Hyponatermia
Hypokalemia
Hyperkalemia
Hypokalemia can occur with constant loss of potassium from burn wound, with vomiting, diarrhea, prolonged GI suction, prolonged IV therapy (without potassium supplement).
What kind of burn is this: Smoke, carbon monoxide, above/below glottis?
Inhalation
The nurse is caring for a client with partial- and full-thickness burns to 65% of the body and is planning nutritional interventions for this client. Which of the following dietary choices should the nurse implement?
High-calorie and high-protein foods
A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Failure to supply adequate calories and protein leads to malnutrition and delayed healing. Calorie-containing nutritional supplements, protein powder, supplemental vitamins, and iron supplements can be administered to aid in increasing caloric intake.
Immunological changes as a result of burns. (immune system).
The nurse is admitting a client to the emergency department who has first- and second-degree burns after being involved in a house fire. Which of the following assessment findings would alert the nurse to the presence of an inhalation injury? (Select all that apply.)
Reliable clues to the occurrence of inhalation injury are the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, and “cherry red” skin colour.
Singed nasal hair
Generalized pallor
Painful swallowing
History of being involved in a large fire
Reliable clues to the occurrence of inhalation injury are the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, and “cherry red” skin colour.
Tell me about complications with the renal system.
(hint - muscles)
What kind of diet are burn management patients put on?
High protein, high carbohydrate, high caloric diet
What causes edema with burns?
The nurse is admitting a client who has first- and second-degree burns covering the face, neck, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, which of the following percentages of body area have been affected?
22.5%
Using the rule of nines, the face and neck together encompass 4.5% of the body area; the right upper arm encompasses 9% of the body area; and the entire anterior trunk encompasses 18% of the body area. Since the client has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore, adding the three areas together, the nurse would correctly calculate the extent of this client’s burns to cover approximately 22.5% of the total body surface area.
What kind of burn is this? Sunburn.
Radiation
What depth of burn shoes blisters, severe pain, and edema?
Deep partial thickness: fluid filled vesicles (blisters)contain albumin, shiny wet surface, severe pain, edema
The nurse is caring for a client with superficial partial-thickness burns of the face sustained within the last 12 hours. Which of the following symptoms should the nurse expect to find?
Reddening of the skin
The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.
What are signs and symptoms of carbon monoxide poisoning? (select all that apply).
bright red tongue
wheezing
dizziness
headache
bright red tongue
dizziness
headache
The nurse is admitting a client who fell through the ice on a pond near his farm and has signs and symptoms of severe hypothermia. Which of the following interventions should the nurse should anticipate?
Active core rewarming
Active core rewarming involves the application of heat directly to the core and is indicated for severe hypothermia. Immersion in a hot bath and rehydration and massage are not appropriate interventions in the treatment of severe hypothermia. Passive rewarming is used in mild hypothermia.
When someone is burnt with hot water, heat, and contact with hot objects what do we want to also rule out socially wise?
Abuse.
The nurse is caring for a client with an electrical burn injury. Which of the following health care provider orders should the nurse question?
Lactated Ringer’s at 25 mL/hour
Electrical injury puts the client at risk for myoglobinuria, which can lead to acute tubular necrosis. Treatment consists of infusing lactated Ringer’s at a rate sufficient to maintain urinary output at 75–100 mL/hour. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin. An infusion rate of 25 mL/hour is not sufficient to maintain adequate urine output in prevention and treatment of acute tubular necrosis.
What are the four phases of burn management?
Pre-hospital care
Emergent (resuscitative)
Acute (wound healing)
Rehabilitative (restorative)
What kind of burn is this: most damage is beneath the skin.
Electrical.
What depth of burn can show exposed bone and appear waxy?
Full thickness: surface dry, hard, may appear white waxy or leathery with deep red thrombosed vessels, or black charred muscles, tendons, and bone exposed, with notable absence of pain, no visible hair or pores, tissue does not blanch.