N420 Exam 3 Burns
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N420 Exam 3 Burns
Burn that damages only the epidermis.
Burn that destroys the epidermis and a small portion of underlying dermis.
Superficial partial-thickness burn
Characteristics of a superficial partial-thickness burn.
pink & MOIST (wet & shiny, weeping)
hair follicles intact
blanches with pressure
*will heal 10-21 days w/o scarring (Saunders p.567)
Characteristics of a deep partial-thickness burn.
red & DRY w/ white areas in deeper parts
no blisters (dead tissue sticks to dermis)
*heals 3-6 wks; scars; poss skin graft needed
SIX priority nursing axns with burn pts.
1. Assess airway
2. Administer O2
3. Vital signs
4. IV fluid replacement
5. Elevate extremities (if no fractures)
6. Keep pt warm & NPO
*then perform full assessment;
tetanus toxoid may be prescribed for prophylaxis
Full-thickness burn characteristics.
destroys epidermis & dermis
grafting may be required
DRY, hard, leathery eschar
WAXY white, deep red, yellow, brown or black
little or no sensation
*healing weeks to months
Deep full thickness burn characteristics.
injury beyond skin into tissues, muscle, bone, & tendons
months to heal
Normal intra-abdominal pressure.
about 5mm Hg (higher w/ obesity)
Bladder pressure of ________ indicates increasing abdominal pressure, resulting in ________.
inadequate organ perfusion (need to decompress abdomen)
Why would an escharotomy need to be performed on a burn pt?
As fluid is replaced, edema worsens.
Burned tissue acts like a tourniquet - similar to compartment syndrome.
Pts with large burn wounds are at risk for what?
abdominal compartment syndrome
If burns exceed ____% TBSA, a NG tube should be inserted & connected to low suction. Why?
to decompress the abdomen & prevent vomiting
For a pt with frostbit, how should you rewarm the affected part?
rapidly & continuously with a warm water bath or towels at 104-107.6 degrees F
What is the most reliable and most sensitive noninvasive assessment parameter for CO & tissue perfusion?
What med route should you avoid in a burn pt?
IM or SQ
(absorption thru soft tissue is unreliable when hypovolemia & lg fluid shifts occur)
How should you remove exudate from a graft?
roll a cotton-tipped applicator over the graft
What to monitor for after a graft?
Carbon monoxide levels between 11%-10% result in what s/s?
decreased visual activity
decreased cerebral fxn
Carbon monoxide levels between 21%-40% result in what s/s?
dizziness, tinnitus, vertigo, confusion
pale to reddish-purple skin
Carbon monoxide levels between 41%-60% result in what s/s?
seizure & coma
When fluid resuscitation is adequate, what should the heart rate be?
less than 120 beats/min