N420 Exam 3 Burns
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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
- lg blisters
- edema present
- 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)
- moderate edema
- severe pain
- *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
- no sensation
- months to heal
Normal intra-abdominal pressure.
about 5mm Hg (higher w/ obesity)
Bladder pressure of ________ indicates increasing abdominal pressure, resulting in ________.
- 20-25 mmHg
- 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?
- foul-smelling drainage
- increased WBC
- fluid accumulation
Carbon monoxide levels between 11%-10% result in what s/s?
- decreased visual activity
- decreased cerebral fxn
- slight breathlessness
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
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