N420 Exam 3 Burns

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  1. Burn that damages only the epidermis.
    Superficial (first-degree)
  2. Burn that destroys the epidermis and a small portion of underlying dermis.
    Superficial partial-thickness burn
  3. Characteristics of a superficial partial-thickness burn.
    • painful
    • pink & MOIST (wet & shiny, weeping)
    • hair follicles intact
    • lg blisters
    • edema present
    • blanches with pressure
    • *will heal 10-21 days w/o scarring (Saunders p.567)
  4. Characteristics of a deep partial-thickness burn.
    • red & DRY w/ white areas in deeper parts
    • no blisters (dead tissue sticks to dermis)
    • moderate edema
    • severe pain
    • *heals 3-6 wks; scars; poss skin graft needed
  5. 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
  6. Full-thickness burn characteristics.
    • destroys epidermis & dermis
    • grafting may be required
    • DRY, hard, leathery eschar
    • WAXY white, deep red, yellow, brown or black
    • edema
    • little or no sensation
    • *healing weeks to months
  7. Deep full thickness burn characteristics.
    • injury beyond skin into tissues, muscle, bone, & tendons
    • black
    • no sensation
    • months to heal
  8. Normal intra-abdominal pressure.
    about 5mm Hg (higher w/ obesity)
  9. Bladder pressure of ________ indicates increasing abdominal pressure, resulting in ________.
    • 20-25 mmHg
    • inadequate organ perfusion (need to decompress abdomen)
  10. 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.
  11. Pts with large burn wounds are at risk for what?
    abdominal compartment syndrome
  12. If burns exceed ____% TBSA, a NG tube should be inserted & connected to low suction. Why?
    • 25
    • to decompress the abdomen & prevent vomiting
  13. 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
  14. What is the most reliable and most sensitive noninvasive assessment parameter for CO & tissue perfusion?
  15. 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)
  16. How should you remove exudate from a graft?
    roll a cotton-tipped applicator over the graft
  17. What to monitor for after a graft?
    • foul-smelling drainage
    • fever
    • increased WBC
    • hematoma
    • fluid accumulation
  18. Carbon monoxide levels between 11%-10% result in what s/s?
    • flushing
    • h/a
    • decreased visual activity
    • decreased cerebral fxn
    • slight breathlessness
  19. Carbon monoxide levels between 21%-40% result in what s/s?
    • N/V
    • dizziness, tinnitus, vertigo, confusion
    • drowsiness
    • pale to reddish-purple skin
    • tachycardia
  20. Carbon monoxide levels between 41%-60% result in what s/s?
    seizure & coma
  21. When fluid resuscitation is adequate, what should the heart rate be?
    less than 120 beats/min
Card Set:
N420 Exam 3 Burns
2014-12-07 02:40:27
N420 Burns
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