Med-Surg Burn study guide

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What are the signs of a full thickness burn?
Loss of sensation
3rd and 4th degree burns
May not feel pain (Bad)
Extensive burn
How do you measure burns emergently?
Quick assessment technique, compare palm with size of burn wound. Palm is 1% of persons total body surface area.
What is the rule of 9s?
Total is around 100%
9% for upper back
9% for lower back/butt
9% for chest
9% for abdomen
9% for both back arms
9% for both front arms
9% for front and back of head
1% for groin area
9% left leg back
9% left leg front
9% right leg back
9% right leg front
What do you consider with chemical burns?
-Protect yourself from further burns in caring for client.
-Chemical burns liquify tissues.
-Worry about what is on them will get on you.
-Can damage you
-Wash area then treat
How do you assess for possible inhalation injury?
Big risk for impaired gas exchange
-(Look for soot around nasal passages)
-Intubated before airway is compromised
-Hypovolemic shock and infection
-Talking and speech changes
-Life-threatening complications
What makes electrical burns different?
-Cardiac dysrythmias.
-CNS complications.
-Follow internal path from enter to exit of arch.
-Disrupts electrical impulse.
-Not just what you touch, goes through body, causes damage all the way through.
How do you assess electrical burns?
EKG
Watch for signs of stress ulcers
Black tarry stools, vomiting blood
Why do you never apply ice to a burn?
Hinder blood flow
-Further damaging cells
When does a patient with a burn need fluid resuscitation?
When burn is greater than 20% of total body surface area
-Lose fluid quickly, dehydrates
-This replaces lost fluids
What are nursing considerations when applying antimicrobial agents to burns?
Only apply to clean skin
Why are autographs preferred when possible?
-Uses clients own skin-Less likely to reject
-Skin grafting is For deep partial thickness and full thickness burns
-Full thickness looks like regular skin
What are disadvantages of autographs?
Pressure garments
Need sunscreen
Which burns need grafts?
Full thickness and partial thickness burns
What are the complications of an acute burn event during treatment?
Infection, stress ulcers, and dehydration
What is natural debridement?
Sloughs on its own
What is the complication of surgical debridement?
Bleeding
What are pressure garments used for?
Tight fitting custom garments that minimize scarring and over growth of skin
Worn for 23 hours/day