Burn Interventions
Burn Interventions
Measuring Burns
Burn Phases
NCLEX
100
Interventions for minor burns that can be done at home
What are:
> Eliminate the cause of the burn, immerse in cool water (NOT COLD), apply cool wet compress on large extremities you cannot immerse in cool water, apply a clean dressing over burn, apply aloe vera or burn creams, do not break blisters, NSAIDS
100
Parkland Formula for fluid resuscitation
What is:
> 4mL x body weight x TBSA
> Half is given within first 8 hours of onset of burns, other half is given in the next 16 hours
> Only partial thickness and full thickness burns, IV for over 20%, PO for less than 20%
100
Burn percentage of each body part adult and baby
What is:
100
SXS of inhalation injury
What are:
> Tachypneic, gasping, wheezing, hoarse voice, accessory muscle use, coughing, stridor
100
When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth?
a. First-degree skin destruction
b. Full-thickness skin destruction
c. Deep partial-thickness skin destruction
d. Superficial partial-thickness skin destruction
ANS: B
With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain
200
Potential Complication of burn dressing (think circulation)
What is:
> Issues with circulation, potential for acute compartment syndrome
200
Post Graft Education (1 major thing)
What is:
> Reminding the client/ staff that after a graft the body part MUST be elevated at all times
200
First degree and second degree burn characteristics and causes
What is: (First Degree)
> Only affects the epidermis
> SXS: Red, pink, painful, dry, no blisters, blanchable
> Examples: Sunburn, skin peels
What is: (Second Degree)
> Into dermis
> SXS: Pink, moist, blanchable, edema, blisters
> Examples: Severe sunburns, boiling water
200
SXS of carbon monoxide poisoning
What are:
> LOC changes, EKG changes, cherry red skin, head ache (1st symptom), drowsiness, death
200
A nurse is caring for a patient who has burns of the ears, head, neck, and right arm and hand. The nurse should place the patient in which position?
a. Place the right arm and hand flexed in a position of comfort.
b. Elevate the right arm and hand on pillows and extend the fingers.
c. Assist the patient to a supine position with a small pillow under the head.
d. Position the patient in a side-lying position with rolled towel under the neck.
ANS: B
The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the patient). The patient with burns of the ears should not use a pillow for the head because this will put pressure on the ears, and the pillow may stick to the ears. Patients with neck burns should not use a pillow because the head should be maintained in an extended position in order to avoid contractures.
300
Transfer criteria for burn centers
What is:
> Circumferential burns, face/neck burns, compromised airway, dominant hand burns, functional alterations, inhalation injuries, pediatric patients, chemical or electrical burns
300
Purpose of compression garments
What is:
> Scar reduction, controls collagen production, increases mobility, decreases venous statis
300
Deep partial thickness burns characteristics and treatment options
What is:
> Deep into dermis affecting nerves, hair follicles, and sweat glands
> SXS: Red (at least around the edges), white and yellow, not too moist, little blanching, waxy, moderate edema, soft fry eschar
> Will scar, potential for contractures, needs skin grafts, needs fluids
300
When does the acute phase begin
> 36 to 48hrs post injury
300
A patient arrives in the emergency department with facial and chest burns caused by a house fire. Which action should the nurse take first?
a. Auscultate the patient's lung sounds.
b. Determine the extent and depth of the burns.
c. Infuse the ordered lactated Ringer's solution.
d. Administer the ordered hydromorphone (Dilaudid).
ANS: A
A patient with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.
400
Interventions to regulate temperature in a patient with burns
What are:
> Warm IVF, burn dressings, burn blanket, bear hugger, room at 85 to 100 degrees
400
Ways to prevent infection in the acute phase
What are:
> Using sterile techniques, washing hands, neutropenic precautions, tetanus vaccine
400
Full thickness burns characteristics and treatment options
What is:
> Destruction of skin into fat layer
> SXS: Little to no pain, black, yellow, brown, white, waxy, hard inelastic dry eschar, severe edema
> TX: Needs grafting and fluids
400
When does the rehabilitative phase begin?
> Starts with wound closure and ends when highest level of function is achieved
400
A patient with severe burns has crystalloid fluid replacement ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30,000 mL. The initial rate of administration is 1875 mL/hr. After the first 8 hours, what rate should the nurse infuse the IV fluids?
938 mL/hour
500
Interventions to prevent contractures in the acute phase
What are:
> ROM active or passive 3x a day, no pillows, facial exercises if burn on face, turn every 2 hours, work with PT/OT, use abduction blocks
500
Emergent Phase: Airway Assessment and interventions
What is:
> Assessment needs to be completed immediately especially if burn is on neck, chest, face or upper back, is patient having difficulty swallowing?, respiratory pattern, burnt facial hair?, carbon monoxide poisoning?
> Interventions: High flow oxygen, intubation, cricothyrotomy, sit patient up, continuously assess patient
500
Fourth degree burn characteristics
What is:
> Damage extends to the bone
> SXS: black, charred, nerve endings destroyed so no pain, may need amputation, severe edema
500
Priorities of emergent burn phase and acute burn phase
What are:
> Airway support, circulation support (preventing/ treating shock, F/E shifts, renal issues), temperature control, pain control, emotional support
> Acute phase adds nutrition, wound care, infection, mobility
500
On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now?
a. Monitor urine output every 4 hours.
b. Continue to monitor the laboratory results.
c. Increase the rate of the ordered IV solution.
d. Type and crossmatch for a blood transfusion.
ANS: C
The patient's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Because the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase once the patient's fluid balance has been restored. On admission to a burn unit, the urine output would be monitored more often than every 4 hours; likely every1 hour.