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NCLEX study- BURNS
Terms in this set (47)
most burns occur where?
how hot should you keep hot water heater with kids and elderly?
why does plasma seep out of the tissue?
increased capillary permiability
they have been damaged from the heat
vascular volume is going down
high risk for shock
why is the first 24 hours so important?
FVD- increased risk of shock
FVD- pulse will __
FVD- Cardiac output will __
takes about __ mins of poor kidney perfussion to cause damage
heat causes vessels to __, making blood pressure go up/down initially.
__ will be secreted in body to cause vasoconsrtiction
why are adh and aldosterone secreted?
will make blood volume go up
most common airway injury
carbon monoxide poisoning
TX for hypoxia
if someone is burned in a closed space they are more at risk for
carbon monoxide poisoning
rule of nines
a trunk 18
p trunk 18
fluid replacement starts within first __ when INJURY OCCURRED
Parkland formula: calculate total fluid needed and give half of that in the first __ hours
Worry about __ FIRST
PAIN NEVER KILLED ANYONE
how to determine fluid replacement adequacy in burn pts-
urine output!! Minimum 0.3 ml/kg in adult
1 ml/kg in kids
A client weighing 235 lbs. has a 30% total body surface area burn. The primary healthcare provider's
order is: Titrate IV fluids to maintain urinary output at 0.5 ml/kg/hr. What is the desired output?
Record your answer as a whole number.
235/2.2 ---don't round answer
106.818181 kg x 0.5ml/kg/hr= 53.409
A client was wrapped in a blanket to stop the burning process. Since the flames are
gone does that mean the burning process has stopped?
no- COOL water (NOT ICE WATER- causes vasoconstriction)
blanket will help keep in body heat and keep out burns
remove jewelry because of swelling and it may be hot
cover burns with clean, dry clothing
signs of airway burns
singed nose hair
soot on face
secretions that are black
blisters in oral mucosa
holds on to fluid in vascular space
increases vascular volume
increase kidney perfusion
increase cardiac output
will help FVD
increase workload on the heart- be careful not to stress the heart too much. Could be thrown into FVO (CO will decrease, wet lung sounds)-check CVP to make sure they aren't hydrated too fast!! You have to have a central line.
Give the ____________ amount of narcotics necessary to relieve someone's pain.
Why are IV pain meds preferred over IM with burns?
they don't have good muscle perfussion
Immune globulin means
it contains antibodies
gives immunity NOW
if someone has circumferential burn, check:
what will relieve this pressure?
releases pressure and restores circulation
how often to check urine output?
Why may they not have immediate output?
kidneys are trying to hold on to fluid
they may not have adequate perfussion
what if urine is brown or red?
normal, but we're still worried
myoglobin is being released- these may clog the kidneys and cause failure. MANNITOL can be given to flush the kidneys to save them. EXCEPTION TO THE RULE.
The client's serum K+ level is 5.8
Where do we find most of our K+? _________________ the cell
when the cells rupture, the K+ goes out into the vascular space so they will have __
Why would they have NG tube connected to suction?
they could get a paralytic illius because:
*decrease in vascular volume (gut is last to get perfussed to)
*normal stress response
These pts will need what in diet?
When can NG tube be removed?
when you can hear bowel sounds
What is some lab work you could check to ensure proper nutrition and a positive nitrogen balance? __________________, total protein, or albumin.
-and this is the most sensitive!
we are in positive nitrogen balance
someone starving is in negative
partial thickness and full thickness burns: contractures
use splints to prevent
burns on neck- hyper extend their neck!
#1 complication with perineal burn: INFECTION
remove dead tissue so new tissue can regenerate
bacteria grows in eschar
specif measures with dressing changes on hands
wrap each finger separately so it won't grow together
what type of isolation for burn patients?
Why should these antibiotic
drugs be alternated?
bacteria will build up resistance
broad spectrum avoided to prevent secondary infections
TAKE CULTURES when
any time drugs end in -mycin, worry about
nephrotoxicity (BUN creatinine going up and UOP going down)
if donor site becomes blue, what does this mean?
if the graft is hanging off, what do you do?
put sterile saline dressing over graft immediately and call the MD
flush with water for at least 15 mins!
remove contact lenses
brush powder off skin if it's powder
entrance and exit
exit wound will be bad too
FIRST THING!- put on heart monitor for at least 24 hours
high risk for V-fib!!
myoglobin and HGB can build up and cause kidney damage
spine board and c-collar because these tend to occur in high places
can cause muscle contractions that can cause bone fractures
amputations common because circulation can be destroyed
THIS SET IS OFTEN IN FOLDERS WITH...
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