NU 374 > Burns > Flashcards

Burns Flashcards

(52 cards)

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1
Q

__ hampers the ability to shiver

A

small muscle

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2
Q

infants < 6 months old rely on ___ temperature controls

A

metabolic temp controls

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3
Q

temperature regulation for burns

A
  • monitor core temperature
  • external protection ie blankets, warm room
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4
Q

first degree burn

A
  • Involves the epidermal layer only
  • Self-replacing 3-6 days after skin sloughs off
  • Skin intact; No blisters; erythema; blanches; Desquamation within 1 week of injury
    mild pain for several days
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5
Q

second degree burn (partial thickness)

A
  • Extends into dermal layer
    Self-healing with scarring in approx. 14-21 days
  • Wet appearance; shiny skin, weepy; intact and partially open blisters; wound blanches; sensitive to temperature, air, and touch
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6
Q

deep 2nd (almost full thickness)

A
  • Deep 2nd burns resemble full-thickness but structures such as sweat glands and hair follicles are intact
    Self-healing with significant scarring in > 21 days
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7
Q

third degree (full-thickness)

A
  • Extends to the subcutaneous layer destroying nerve endings, sweat glands, and hair follicles
  • Periphery of wound has 1st or 2nd degree characteristics
    Color varies (velvet red, white, black, brown)
    Thrombosed vessels can be seen
    Dry leathery appearance
    Degree of pain is dependent on depth (appears with healing)
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8
Q

fourth degree (deep full-thickness)

A
  • Injures underlying structures including muscle, fascia, and bone with exposure of ligaments, tendons, and bone
  • Color varies with charring in deepest areas
    Impaired ROM
    Dull dry appearance
    Insensitive to pain
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9
Q

minor burn

A

Partial thickness <10%
Full thickness <2%

treat outpatient prn

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10
Q

moderate burn

A

Partial thickness 10-20%
Full thickness 3-10%
Hot liquids

treat in hospital with burn center expertise

Topical treatments
Autografting may be required

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11
Q

major burn

A

Partial thickness >20%
Full thickness >10%
Burns involving face, eyes, ears, hands, feet, and perineum
Electrical burns, flame burns, inhalation injuries, pre-existing conditions

treat in specialized burn center
- Surgical excision and grafting
Amputation if no circulation to area

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12
Q

key points of moderate and major burns

A
  • Most dramatic fluid shift in first 8-12 hrs.
  • Fluid replacement is calculated from burn injury time not ER arrival
  • Hypotonic IVF=high risk of hyponatremia, cerebral edema and seizures
  • Increases in cyanosis, deep tissue pain, cap refill and decreased pulses with a circumferential burn=immediate MD call
  • Elevate burned extremities
  • Frequent monitoring and linen changes
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13
Q

nursing assessment: history

A

brief: inhalation injury
detailed: if non-life threatening

A thorough health history is important. It can help determine the seriousness of the injury. Depending on the severity of the burns, it may not be possible to get all of the data at once.

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14
Q

nursing assessment: detailed history

A

Description of incident (Date, time, cause)
r/o smoke inhalation or associated fall
Document treatment received thus far
Child’s recent health status
allergies
Current meds
Recent or chronic illness
Immunization history (esp. most recent tetanus)
Evaluate for abuse vs. accidental injury

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15
Q

physical assessment: primary survey

A
  • Airway- is it patent? Maintainable?
  • inhalation injury suspicion
  • Skin color
  • Respiratory-effort? Symmetry? Breath sounds?
  • Cardiovascular- pulse strength? Perfusion? Heart rate? Edema? (grade)
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16
Q

physical assessment: secondary survey

A

Determine burn depth

Estimate TBSA (rapid estimation with chart or child’s hand)

Any other traumatic injuries? (cervical, internal)
- Perform head to toe exam to rule out associated injuries
- Knowing the mechanism of injury helps predict the type of associated trauma
- Do not be overwhelmed by the appearance of the burn

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17
Q

Suspect inhalation injury if:

A
  • Burns around mouth, nose, or eyes
  • Black colored sputum
  • Hoarseness or stridor
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18
Q

pediatric airway anatomy

A

Relatively small airway

Less edema is needed to develop obstruction
- Larynx more anterior than in adult
- Glottis more angulated and more anterior
- Narrowest point is cricoid, not glottis
- Insert NGT for decompression which will help to eliminate swallowed air

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19
Q

breathing assessment

A

Normal use of abdominal muscles when breathing
Ensure bilateral breath sounds
Obtain CXR for tube placement
Secure tubes

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20
Q

care of burn patient: introduction

A
  • ABC’s first
  • Proper wound management critical in all phases of care
  • Survival and functional outcome both depend on successful burn wound healing
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21
Q

care of burn patient: circulation

Study These Flashcards
A

Initiate fluid resuscitation immediately
Establish early IV access:
- Percutaneous Cutdown
Femoral IO

prehospital/during primary triage at hospital:
- 5 years old and younger: use LR @ 125ml/hr.
- 6 – 14 years old: use LR @ 250ml/hr.
- Fluid for child <10kg: use D5LR

22
Q

care of burn patient: disability

Study These Flashcards
A

Assess level of consciousness
Hypoglycemia
Hypoxia

23
Q

care of burn patient: expose, examine and environmental control

Study These Flashcards
A

Remove all clothing including diaper
Assess for associated or pre-existing injuries
Cover with clean, dry linens
Conserve body heat

24
Q

secondary survey: history

Study These Flashcards
A

Events leading to injury
Past medical history
Immunization history
Allergies
Consider potential for abuse

25
secondary survey: calculate TBSA burn
Bigger head Front and Back totals Smaller legs Palmer method (Infant hand – 1%)
26
secondary survey: fluid resuscitation
½ of total in the 1st 8 hours post injury The other 1/2 over the next 16 hours
27
fluid resuscitation formular
children > 14 yr or > 40kg: 2mL/kg x patients weight in kg x TBSA, divide by 2 (run based on burn time) children < 14 yr or < 40kg: 3mL/kg x patients weight in kg x TBSA, divide by 2 (run based on burn time) electrical burns: 4mL/kg x patients weight in kg x TBSA, divide by 2 (run based on burn time)
28
fluid resuscitation formulas are ____. the nurse should ___ to maintain ____.
Fluid resuscitation formulas are ESTIMATES only!! - Titrate IVF ↑ or ↓ by 1/3 to maintain U/O of 1ml/kg/hr.
29
escharotomy
Circumferential extremity or torso burns Rarely done prior to transfer Consult with the burn center
30
pain management of burns can reduce:
Sleep deprivation Anxiety tantrums Pruritus Post-traumatic stress Regression Contractures (from scars and disuse) Graft loss (movement)
31
pain management of burns
Narcotics-morphine (IV or PO) Anesthetics-propofol or ketamine Antihistamines-diphenhydramine Relaxation Distraction Medical play Guided imagery Family participation
32
child abuse
Pattern not compatible with history given Story changes Younger sibling is blamed for injury Caregiver absent at time of injury Delay in seeking treatment Child appears passive Other injuries
33
transfer criteria
Partial and Full-thickness burns to: - face - hands - feet - genitalia - perineum Inhalation injury Chemical injury Electrical injury
34
average hot water heater setting
140°
35
boiling water temperature
212°
36
temperature of cooking oil when frying
350-450°
37
flash point of cooking oils temperature
500-700°
38
temperature for burn injury in 10 sec
130°
39
burn injury in 5 seconds
140°
40
temperature for instantaneous full thickness burn
160°
41
prevention of burns
Stop drop and roll Plug outlets Water heater temperature Back burner cooking Cabinet locks No smoking How not to start a fire…..
42
fire escape plan
- working smoke detectors - two ways out - practice at least 1x/month - have a meeting place - count heads
43
broselow tape is used if
use if age or weight is unknown to detect TBSA
44
rule of nines
Rule of nines in 2nd and 3rd degree burns Calculate percent of each area burned and not the entire area Note: If one surface of an upper extremity is burned = 4 ½ percent TBSA rather than 9% as indicated on the lower extremities.
45
rule of nines: infant
46
patients palmar surface (hand and fingers) TBSA %
1% TBSA
47
oliguria
- Usually due to inadequate resuscitation - Associated with elevation of SVR and reduction of cardiac output - Diuretics are contraindicated - Requires increased hourly fluid administration
48
hourly urine output
- large sized pre-teens and adolescents: 0.5mL/kg/hr (30-50mL/hr) - infants and children: 1mL/kg/hr If expected UOP increased/decreased for 2 consecutive hours: - Decrease / increase fluid infusion by 1/3
49
monitoring resuscitation
Assess mental status frequently Anxiety and restlessness may reflect hypoxia Urinary output most reliable guide - Indwelling bladder catheter - Dependent upon normal renal function
50
limited glycogen stores when under age __
1 year old - monitor blood glucose
51
pediatric patients are more susceptible to (fluid ___)
fluid overload
52
resuscitation and LR
- Mimics intravascular fluid - Treats hypovolemia - Replaces intracellular sodium deficits - For moderate and severe burns - Infuse via large bore IV, Central line, or IO route
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