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NCLEX burns review
Terms in this set (100)
where do most burns occur?
in the home
why does plasma seep out into the tissue with burns?
increased capillary permeability
what to worry about with burns?
when does the majority of shock occur?
within the first 24 horus
what pulse change occurs with burns?
increased HR! (think: fluid volume deficit)
what happens to cardiac output with burns?
decreases (less volume in the body to pump out)
what happens to urinary output with burns?
(kidney's either aren't being perfused adequately or they are trying to hold onto fluids)
how long does it take to cause permanent kidney damage with low perfusion?
what is secreted after a burn?
epinephrine, ADH, and aldosterone
-causes vasoconstriction so blood is shunted to vital organs
-retain water & sodium, blood volume goes up!
what do you not want systolic BP to drop below?
-will not have adequate organ perfusion
rule of nines: head & neck
rule of nines: trunk
rule of nines: arms
(4.5 front, 4.5 back)
rule of nines: leg
(9 front, 9 back)
rule of nines: genital area
can the rule of nines be done multiples times to estimate total body surface area affected?
first and second degree burns
partial thickness burns
third and fourth degree burns
full thickness burns
what areas are of the most concern with burns?
head, neck, face, or chest
burns are also considered more severe on:
hands, feet, joints, or eyes
why would someone with heart, lung, or kidney disease be at a bigger risk for complications of burns?
can't handle the fluid shifts required
why would pre-existing diabetes or peripheral vascular disease cause problems with burns?
may not heal well from leg or foot burn
higher mortality rate from burns is expected in:
very young and very old
-skin is thin & less subcutaneous fat = burn can go deeper and cause more complications
how to stop the burning process:
wrap client in a blanket!
-cool water for no more than 10 mins
-remove jewelry (swelling & metal gets hot)
-remove non-adherant clothing & cover burns with a clean dry cloth
(will require debreidment)
why cover burn clients in a blanket?
-stops burning process
-hold in body heat & keep out germs!
what is the #1 cause of death with burns?
what are inhalation injuries caused by:
inhaling carbon monoxide or hydrogen cyanide
client is hypoxic with suspected carbon monoxide poisoning:
100% oxygen asap (try to get to some hemoglobin)
how to treat hydrogen cyanide?
-antidote may be given at hospital
When you see a client with burns to the neck/face/chest you had better think what?
AIRWAY! HCP might intubate prophylactically
more death with upper or lower body burns?
one of the most important aspects of burn management is:
-will need at least 2 large bore IV's
what is used for fluid replacement in burn clients?
crystalloids (LR) and colloids (albumin)
fluid replacement therapy for the first 24 hours is based on what?
the time the injury occurred
what is fluid replacement based on?
clients weight & TBSA affected?
total fluid replacement for first 24 hours =
(2-4 mL of LR) X (body weight in kg) X (% of TBSA burned)
how much fluid is given in first 8 hours?
1/2 total volume
how much fluid is given in 2nd 8 hours?
1/4 total volume
how much fluid is given in 3rd 8 hours?
1/4 total volume
what does albumin do?
holds onto fluid in the vascular spaces
-increases vascular volume, kidney perfusion, blood pressure, and cardiac output
what happens to the workload of the heart when we give albumin?
it increases --> caution! can stress the heart too much
what is a measurement you should take hourly while giving albumin?
CVP (ensures you are not overloading the client)
when giving a narcotic, what is the most important assessment you must make?
what type of pain meds are preferred with burns?
IV! (drug of choice: opioids)
what immunization should you give a burn client to provide immediate protection?
tetanus (immune globulin - passive immunity)
why are broad spectrum antiobiotics avoided in burn clients?
could cause super infections / sepsis
when giving -mycin drugs , what do you worry about?
-increase in BUN or creatinine
-hearing changes / loss / ringing in ears
(can cause ototoxicity and nephrotoxicity)
When are broad spectrum antibiotics used?
when waiting for the wound cultures to return
-make sure you have already collected cultures before you start them though
if there is reduced blood flow to the burned area, the delivery of antibiotics can be:
-topical medications may be used instead to deliver a uniform amount of silver to wound
how long can topical dressings be left in place?
common topical drugs used with burns:
can cause acid base problems and stings!
if it rubs off, reapply:
keep these dressings wet! can cause electrolyte problems
SAFETY! check for allergies because many burn antimicrobial creams contain:
how to apply topical agents to a burn"
apply thin layer using sterile gloves
-client at high risk for infection due to presence of open wounds (asepsis is critical)
-light gauze dressing may or may not be applies to cover the burn area
enzymatic debreidment agents may be used to remove necrotic, dead tissue:
where not to use enzymatic debreidment:
-don't use on face
-don't use if pregnant
-don't use over large nerves
-don't use if area is opened to a body cavity (can eat good tissue)
what is most important thing to remember before sending a client to debreidment?
what could happen to a client if immersion hydrotherapy (whirlpool) is used?
patient's own skin
what happens to the donor site now?
-dressing until bleeding stops, then left open to air
if the client is well nourished, the surgeon can re-harvest from the same donor site every:
if the graft becomes blue or cool, what could this mean?
if you are changing a dressing and the when you unroll it the graft is hanging, what do you do?
cover graft with sterile saline dressing and over site with a dry dressing
-THEN notify HCP
why would a healthcare provider take a TB syringe and aspirate blood from under the graft or prescribe you to roll Q-tips over the graft with gentle pressure from the middle out?
to prevent air, blood, or exudate from accumulating under the graft
-will prevent it from adhering!
client will need _______ calorie intake:
what are 2 things needed in the diet to promote healing?
protein & vitamin C
what lab work would you use to ensure proper nutrition and positive nitrogen balance?
(most sensitive to all nutritional value)
2. skin color
3. skin temperature
4. capillary refill
what is the problem with a circumferential burn?
goes all around --> should be checking circulation
-complication: compartment syndrome
what helps circulation by reducing edema?
elevation of burned extremity
what procedures will help to relieve pressure if a vascular check in an extremity is decreased?
difference between escharotomy and fasciotomy?
fasciotomy cuts much deeper into the tissue and cuts through fascia of the muscle?
is it possible to not see urine return when inserting a catheter in a burned client?
-kidneys are trying to hold onto what little fluid remains or kidneys are not being perfused adequately
what is normal after electrical burns but would still cause reason to worry?
red or brown urine
what does red/brown urine mean?
myoglobin was released from damaged muscles
--> could clog kidney's and cause renal failure
what drug may be ordered to flush out the kidney's?
-report when urine is clear
after 48 hours, the client will begin to diurese because:
fluid is going back into the vascular space
what to worry about now? fluid volume excess!
what happens with burns:
what should you prevent in GI system:
stress ulcer (Curling's ulcer)
blood in stool and coffee ground emesis
what to prescribe to prevent stress ulcer:
why is it important for the burned client to be NPO and have an NG tube hooked to suction?
could develop paralytic ileus
decreased vascular volume
decreased GI motility
can all lead to:
when will the NG tube be removed?
hear bowel sounds (peristalsis has returned)
when you start GI feedings, what should you measure to ensure it is flowing through GI tract correctly?
*return residual back to client
what to worry about if client has burns on hands/fingers/toes?
how to prevent chin-to-chest contractures?
hyperextend the neck (head is back, no pillows)
how to prevent hand contractures
-wrap each finger separately
-use splints to prevent contractures
#1 complication of perineal burn:
-must be removed or tissue cannot regenerate
-bacteria likes to grow here
if a client has a chemical burn, you should remove the client and begin:
-15 to 30 minutes (cool water or sterile saline)
if powder chemical, what is first step?
brush it off, then flush
what to do if chemical burn in eye?
remove contact lenses!
special about electrical burn:
2 wounds (entrance and exit)
-exit wound is usually worse
what is the first thing to do in an electrical burn?
continuous heart monitoring for 24 hours
-may also be placed on C-spine board because they generally occur in high places
what arrythmia is client at high risk for with electrical injury?
what is common with electrical injury?
-circulatory system is destroyed or damaged
other complications of electrical wounds/ injuries:
*think: anywhere with a vessel, there will be a nerve
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