Heating & Cooling
This systemic response to cold is a complication that can occur during therapeutic hypothermia and requires the patient to receive sedation.
What is shivering?
Rationale: When shivering occurs during therapeutic hypothermia, it works against the treatment, which is why sedation is needed.
Conditions such as paralysis, stroke, or other neurologic disease may cause loss of sensation in a body area and put the patient at risk for this.
What is a pressure injury?
Increasing these 3 things in the diet is recommended to prevent tissue breakdown and promote healing.
What are calories, carbs, and protein?
Rationale: Burn patients need significantly increased calories, carbs, and protein because their bodies enter a hypermetabolic and hypercatabolic state after injuy.
Patients with this classification of burn will present with a burn wound that blanches with pressure, blisters and will be very sensitive to touch.
What is a partial-thickness burn?
This is the highest-priority initial nursing assessment for a patient with burns.
What is airway?
Rationale: The patient with burns is at risk for respiratory obstruction.Using the airway, breathing, circulation approach to client care is the first action the nurse should take to ensure that the patient has a patent airway.
This treatment is indicated for comatose patients after ROSC.
What is therapeutic hypothermia?
This assessment tool is helpful in determing a patient's pressure injury risk.
What is the Braden Scale?
Restoring and maintaining fluid balance is the highest priority during this phase of healing.
What is the resuscitation phase?
Rationale: During the resuscitation phase of burn recovery, the highest priority is to restore and maintain fluid balance to replace lost fluids and prevent hypovolemic shock.
In this procedure, a surgical incision is made in the eschar to release pressure and improve circulation in a part of the body that has a deep burn and is experiencing excessive swelling.
What is an escharotomy?
Rationale: Burn injuries that encircle a body part, such as an arm or the chest, can cause swelling and tightness in the affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue allows the skin to expand, reduces tightness and pressure, and improves circulation.
During this process, the affected area is gently washed with a mild antimicrobial soap or wound cleanser to remove dead skin and eschar (a type of dead tissue), followed by rinsing with warm saline or tap water.
What is hydrotherapy?
Malignant hyperthermia is attributed to a mutation in this gene.
What is RYR1?
This type of pressure injury can appear as intact skin with a dark purple or black colored blood filled blister.
What is a deep tissue injury?
The nurse's priority intervention during this phase of burn recovery is to apply dressings to the burn area to promote healing and prevent infection.
What is the acute phase?
Rationale: During the acute phase of burn recovery, preventing infection by applying appropriate dressings becomes top priority because the skin's protective barrier has been lost.
This classification of burn involves only the epidermal layer of the skin.
What are superficial burns?
These types of burns can cause cardiac arrest or arrhythmias due to electrical current affecting the heart conduction system.
What are electrical burns?
The priority goal of therapeutic hypothermia is to achieve _____ and _____ .
What is reduce metabolic demand and protect the brain?
This is the most serious complication of a pressure injury.
What is infection?
This phase of burn wound healing begins immediately following a burn injury, as platelets come into contact with the damaged tissue and start to aggregate.
What is the inflammation phase?
This classification of burns causes increased capillary permeability leading to fluid shifting out of the vascular space causing hypovolemia.
What are full-thickness burns?
This constitutes a significant segment of the nursing care plan throughout the entire course of burn treatment.
What is pain management?
If during surgery a patient begins to develop malignant hyperthermia, this is the priority action.
What is stop the triggering anesthetic agent?
Manifestations of this stage pressure ulcer can include full-thickness skin loss with necrotic adipose tissue.
What is a stage 3 pressure ulcer?
This phase of burn wound healing begins about 2 to 3 days postburn and lasts until complete re-epithelialization occurs by epithelial cell migration, surgical intervention, or a combination of the two.
What is the proliferation phase?
This population is more likely to sustain burns to a greater percentage of their TBSA, largely because their skin is so much thinner and therefore more delicate than that of individuals of a different age.
What is the older adult population?
This is life-threatening condition occurs within the first 24-48 hours after a major burn and is caused by massive fluid shifts, leading to decreased circulating blood volume and poor tissue perfusion.
What is burn shock?
Rationale: Burn shock is a form of hypovolemic shock that happens when severe burns increase capillary permeability. This causes fluid, proteins, and electrolytes to leak out of the bloodstream into surrounding tissues (third spacing).