NCLEX-Style Practice Questions: Burns

NCLEX-Style Practice Questions: Burns

Leave the first rating Terms in this set (17) Science MedicineEmergency Medicine Save What is a burn? Types of burns? Burns: Tissue injury or necrosis caused by transfer of energy from a heat source to the body

Types of burns include: thermal burns, radiation

burns, electrical burns, and chemical burns

Tissue destruction results from: coagulation,

protein denaturation, ionization of cellular contents First degree burnsSuperficial partial-thickness (e.g. sunburn), injury to the epidermis, leaves skin pink or red, but no blisters. Dry, painful, slight edema, no scarring and skin grafts are not required.Second degree burnsDeep partial-thickness destruction of epidermis and upper layers of dermis Injury to deeper portions of the dermis Painful (sensitive to touch and cold air) Appears red or white, weeps fluid, blisters present. .Hair follicles intact (i.e., hair does not pull out easily) Very edematous Blanching followed by capillary refill Heals without surgical intervention, usually does not scar

Third degree burnsa.Full-thickness and deep full-thickness; involves total destruction of dermis and epidermis b.Skin cannot regenerate c.Requires skin grafting d.Underlying tissue (fat, fascia, tendon, bone) may be involved e.Wound appears dry and leathery as eschar develops f.Painless Rule of ninesSeverity is determined by the extent of the surface area burned: Rule of nines: head and neck 9%, upper extremities 9% each, lower extremities 18% each, front trunk 18%, back trunk 18%, perineal area 1% for adults

Stages of burn care: Stage 1

(resuscitative/emergent phase)

• Begins at the time of injury and concludes with

the restoration of capillary permeability, which typically reverses 48 to 72 hours following the injury

• Is characterized by fluid shift from intravascular

to interstitial and shock; focus of care is to preserve vital organ functioning

• Expect to administer large volumes of fluid in this

phase based on the client's weight and extent of injury

• Fluid replacement formulas are calculated from

the time of injury and not from the time of arrival at the hospital

Stages of burn care: Stage II (Acute

phase)

• Occurs from beginning of diuresis (48 to 72

hours after injury) to near completion of wound closure

• Is characterized by fluid shift from interstitial to

intravascular

• Focus is on infection control, wound care and

closure, pain management, nutritional support, and physical therapy

Stages of burn care: Stage III: Rehabilitation phase

• Occurs from major wound closure to return of

optimal level of physical and psychosocial adjustment (approximately 5 years)

• Is characterized by grafting and rehabilitation

specific to client's needs

BURNS: Nursing Assessment A. Absence of bowel sounds indicating paralytic

ileus

• Radically decreased urinary output in the first 72

hours after the injury with increased specific gravity

• Radically increased urinary output (diuresis) 72

hours to 2 weeks after initial injury

• Signs of inadequate hydration (restlessness,

disorientation, decreased urinary volume and urinary sodium, and increased urine specific gravity)

• Signs of inhalation burn (red or burned face,

singed facial and nasal hairs, circumoral burns, conjunctivitis, sooty nasal mucous or bloody sputum, hoarseness, Asymmetry of chest movements with respirations and use of accessory muscles indicative of pneumonia,.Rales, wheezing, and rhonchi denoting smoke inhalation, Impaired speech and drooling indicating laryngeal edema)

• Description of physiology responses to burns
• Preexisting conditions or illnesses that may

influence recovery Prioritization of careAIRWAY, BREATHING, CIRCULATION

Nursing Interventions: Emergent

phase Efforts are directed towards stabilization with ongoing assessment Extinguish source of burn (remove clothing, flush with water/NS, etc.), Provide open airway (intubation may be necessary), Determine baseline data (weight, vitals, blood gases), Determine depth and extent of burn, Administer tetanus toxoid, Initiate fluid and electrolyte therapy (Massive volumes of IV fluids are given. It is not uncommon to give over 1000 mL/hr during various phases of burn care. Hemodynamic monitoring must be closely observed to be sure the client is supported with fluids but is not overloaded. ) Insert NG, Administer IV pain medication, Monitor hydration status (intake, output, weigh), respiratory care (encourage incentive spirometer, coughing, deep breathing, elevate HOB), Provide wound care (strict aseptic technique, debridement, premedicate client before dressing changes Burn management continued Maintain room temp above 90 degrees, humidified monitor body temp, have hyperthermia blankets avaliable assess for paralytic ileus (bowel sounds, nausea, vomiting, abdominal distention) Assess for circulatory compromise in burns that construct body parts (escharotomy prep if indicated) Provide proper nutrition (high protein, high carb, high fat, high vitamins) Burn care topical medications Apply silver sulfadiazine (Silvadene) or mafenide acetate (Sulfamylon) or other antimicrobial agents to burn area as prescribed