NCLEX-PN Burns

NCLEX-PN Burns Leave the first rating Students also studied Terms in this set (92) Science MedicineEmergency Medicine Save NCLEX-PN Psychiatric Nursing 58 terms RCoburn1Preview NCLEX-PN Acid Base Balance 35 terms RCoburn1Preview ***HURST REVIEW NCLEX-RN Readi...125 terms BaiileytaylorPreview NCLEX 107 term RCo Where do most burns occur?home Safety ConsiderationsSet water heat no higher that 120 F Why does plasma seep out into the tissue?increased capillary permeability (leaking) When does the majority of plasma seeping occur? 24 hrs worry about shock Why does pulse increase?-anytime someone is in FVD, the pulse will INCREASE Why does cardiac output decreases?less volume to pump out Why does the urine output decrease after a burn? kidneys are either trying to hold onto fluid or they aren't being perfused adequately Why is epinephrine secreted?Makes you vasoconstrict, and shunts blood to the vital organs if systolic BP drops below 90 will not have adequate organ perfusionDangerous Why are ADH and aldosterone secreted?Aldosterone- water & sodium are retained ADH- water is retained Therefore, blood volume will go up

Stop the burning processWrap pt in blanket to stop burning process Since flames are gone, does that mean burning process has stopped? no What else could have been done to stop burning process? cool water No more than 10 mins Blanket will help hold bodyheat & keep out germs Remove jewelry bc swelling & metal gets hot Remove non-adherent clothing & cover burns w clean/dry cloth Inhalation injury#1 cause of death injuries caused by inhaling carbon monoxide or hydrogen cyanide Carbon monoxide poisoningNormally oxygen binds w hemoglobin Carbon monoxide travels much faster than oxygen gets to hemoglobin 1st and binds oxygen can't bind now hypoxic tx with 100% O2 Hydrogen cyanidetx 100% O2 antidote given at hospital Someone is burned in a _______ _____, they will have inhaled more carbon monoxide &/or hydrogen cyanide so risk for complications is increased closed space When you see a client with burns to the neck/face/chest you had better think what?

AIRWAY

What might the primary healthcare provider do prophylactically?intubate trach Testing StrategyLeast invasive 1st indicators of inhalation injurySigned nose hair Singed facial hair Soot on face Coughing up secretions with dark specks Difficulty of swallowing Wheezing Blisters found on the oral/pharyngeal mucosa Hoarseness Substernal/Intercostal retractions and Stridor Do you think there is more death with upper or lower body burns?upper Systemic Antibiotic Therapybroad spectrum antibiotics are avoided bc their usage could lead to super infections or secondary infections & even sepsis broad spectrum antibioticswill be used until the wound cultures have returned

Always make sure that the cultures have been collected before you start the antibiotics When giving Mycin drugs, We worry.....when the BUN or creatinine levels increase or if their is a complaints of any hearing loss.Mycin drugs can lead toototoxicity (irreversible hearing loss) and/or nephrotoxicity.Check BUN and creatinine, if they are increasing assume they are nephrotoxic If there is reduced blood flow to burned area, the delivery of antibiotics to the tissues could be reduced Silver impregnated dressings provided broad antimicrobial effects to the burn by delivering a uniform amt of silver to wound Dressings can be left in place3 to 14 days Common topical drugs used with burnsmafenide acetate (Sulfamylon)-can cause acid base problems & stings silver nitrate-keep wet/can cause electrolyte problems antimicrobial ointments-antibacterial coverage & promote moist wound Why should these antibiotic drugs be alternated? bacteria will build resistance or tolerance How do you apply topical agents to a burn?apply a THIN layer of the mediation using STERILE gloves the client is at high risk for infection due to the presence of open wounds, so SEPSIS is critical A light gauze dressing may or may not be applied to cover burn area Enzymatic debridement agents may be used to remove necrotic/dead tissue sutilains (Travase) collagenase (Santyl) Don't use on face Don't use if pregnant Don't use over lg nerves Don't use if area is opened to body cavity Hydrotherapy is also used todebride What's the most important thing to remember before sending pt to hydrotherapy?pain management What could happen to this pt if immersion hydrotherapy(whirlpool) is used?cross contamination An autograft uses the pt'sown skin ______ ______ is taken from a healthy donor site & placed over the burned area intact skin

The donor site now an open wound, so a dressing may applied until the bleeding stops Then the donor site can be leftopen to air If the client is well nourished, the surgeon can re-harvest from the same donor site every 12-14 days If the skin graft should become blue or cool, what does this mean?poor circulation The primary HCP may take a tuberculin syringe & aspirate blood or exudate from under the graft They may also prescribe cotton-tipped applicators over the graft w steady, gentle pressure from center of the graft out to edges If air, blood, or exudate is accumulating under graft, the new graft will not adhere leading to total or partial loss of the graft Do you think the pt will need more or less calories? more Meeting daily caloric requirements is critical and should start within 1-2 days postburn Caloric needs should be regularly calculated by dietitian & readjusted as pt's condition changes What two things are needed in the diet to promote healing?protein vitamin C Name the lab work you would check to ensure proper nutrition & a positive nitrogen balance?pre albumin Circulatory checkpulse skin color skin temp cap refill A pt has a circumferential burn on their arm. What does circumferential mean? What should you be checking?all way around circulation Elevation of the extremity may help improve circulation by reducing the edema if client's vascular check in an extremity is decreased, what procedures will help to relieve pressure?Escharotomy Fasciotomy they relieve pressure & restores circulation