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45 Cards in this Set
- Front
- Back
Mild to severe burn. Pink to red color is noted. No Blisters. Skin blanches. Burn is painful and eased by cooling. Discomfort lasts about 48 hours.similar to 1st degree.
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Superficial Thickness Burn
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Large Blisters cover an extensive area. Edema is present. Mottled base with a wet, shiny surface. Gfafts may be used. Similar to 2nd degree.
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Partial thickness superficial burn
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Burn leaves a deep red, black,white, yellow or brown area. Edema present. Fat is exposed. Requires removal of eschar and split or full thickness skin grafting. Healing takes weeks to months.Similar to 3rd degree.
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Full thickness burn
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Burn involves injury to the muscle and bone. Injury appears black. Edema and pain are absent. No blisters. Eschar is hard and inelastic. Grafts are required. Healing takes weeks to months. Similar to 4th degree.
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Deep full thickness burn
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Head percentile of burn
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4.5% anterior and 4.5 % posterior
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Trunk
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18% anterior and 18 % posterior
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Arms
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9% each = 18%
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Legs
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18% each 9%anterior and 9%posterior
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Perineum
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1%
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A skin ulcer characterized by redness and intact skin
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Stage 1 Ulcer
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A skin ulcer characterized by non-intact skin with partial skin thickness loss. It may appear as an abrasion, shallow crater or a blister.
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Stage 2 Ulcer
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Full thickness Ulcer
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Stage 3 Ulcer
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Full thickness ulcer with necrosis with damage to bone, muscle or supportive tissue.
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Stage 4 Ulcer
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Tx. for Psoriasis
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Corticosteroid therapy with a warm moist dressing and an occlusive outer wrap for 12 hours.
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Edema in a burn patient of over 25% is characterized by:
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Hypoproteinemia and increased permeability.
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A client experiences a burn injury to the right arm, left arm, right leg and anterior thorax. What percentage is he burned?
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54%
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What is the tx. for frostbite?
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Rapid and Continuous rewarming of the toes until flushing returns
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Which client is least likely to develope Psoriasis?
1) Black african american male 2) a woman in menopause 3)Emotional distress 4) Genetic predisposition |
Black African American
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What finding would the nurse note in a client with Scabies?
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Multiple Straight or wavy thread like lines. (The baby mites find their way to the skin and lay their eggs).
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How much Lactated Ringers solution via I.V according to the Parkland Baxter Formula would be given to a client who was burned at 7 a.m, weighed 98# (90kg., and was burned by 83% and will be receiving I.V by 3 p.m?
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29,880 ml.
4 ml.x 90kg.x83 = 29.880 divided by 2 = 14,940 ml. |
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Alkalis, such as lye causes a
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Liquefaction necrosis
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Thick, leathery eschar forms from exposure to...
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acids or heat
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Hard, cherry red skin forms from exposure to...
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Thermal injury
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What happens in the emergent phase (48-72 hours) after a burn? What does the body exude?
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Elevated hematocrit levels (first 24-36 hours), high pulse, decreased blood pressure, decreased urine output.
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Where would petechiae be best noted in the dark skinned client?
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The oral mucosa and conjunctiva
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Where would palor be best noted in the dark skinned client?
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Palms of hands and soles of feet
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Where would jaundice best be noted in the dark skinned client?
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The sclera of the eye
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Erythema is
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Diffuse redness of the skin
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How would you assess for erythema in a dark skinned client?
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Feel for an increased temp around the wound edges
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Sign noted in Pemphigus Vulgaris where finger nail pressure to the skin causes some to slough off...
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Nikolsky's sign
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The fiber in the skin responsible for toughness and resiliancy.
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Collagen
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Overgrowth of the outer skin layer resulting in callus formation.
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Hyperkeratosis
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Loss of pigmentation from decreased melanocyte activity.
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Vitiligo
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Areas of blotchy brown macules across the cheeks and forehead from overproduction of melanin caused by hormones.
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Melasma
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lesions which resemble a net.
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reticular
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Occurs with increasing age and has no significance. Noted by bright ruby colored round lesions scattered throughout the trunk and thighs.
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Cherry Angiomas
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Type of angioma which commonly occurs in people with liver disease and vitamin B deficiency.
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Spider Angiomas
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Caused by excess keratin formation in the skin
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Psoriasis
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A disorder of the nail bed caused by a fungal infection. Causes separation from the nail plate.
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Paronchia
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Ecchymosis
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Bruise
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Ecchymosis and Petechiae
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Purpura
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Full Thickness burn includes:
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Dermis, Epidermis and Epithelial layer of s.q fat
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When is edema usually seen in a burn patient?
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In between 18-24 hours.
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A c;ient has an inhalation injury and is unusually combative. What is the cause?
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Hypoxia
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What would the nurse include in the plan of care for a pt. with a circumforencial burn injury?
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Check peripheral pulses every hour
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