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45 Cards in this Set

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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.
Superficial Thickness Burn
Large Blisters cover an extensive area. Edema is present. Mottled base with a wet, shiny surface. Gfafts may be used. Similar to 2nd degree.
Partial thickness superficial burn
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.
Full thickness burn
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.
Deep full thickness burn
Head percentile of burn
4.5% anterior and 4.5 % posterior
Trunk
18% anterior and 18 % posterior
Arms
9% each = 18%
Legs
18% each 9%anterior and 9%posterior
Perineum
1%
A skin ulcer characterized by redness and intact skin
Stage 1 Ulcer
A skin ulcer characterized by non-intact skin with partial skin thickness loss. It may appear as an abrasion, shallow crater or a blister.
Stage 2 Ulcer
Full thickness Ulcer
Stage 3 Ulcer
Full thickness ulcer with necrosis with damage to bone, muscle or supportive tissue.
Stage 4 Ulcer
Tx. for Psoriasis
Corticosteroid therapy with a warm moist dressing and an occlusive outer wrap for 12 hours.
Edema in a burn patient of over 25% is characterized by:
Hypoproteinemia and increased permeability.
A client experiences a burn injury to the right arm, left arm, right leg and anterior thorax. What percentage is he burned?
54%
What is the tx. for frostbite?
Rapid and Continuous rewarming of the toes until flushing returns
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
What finding would the nurse note in a client with Scabies?
Multiple Straight or wavy thread like lines. (The baby mites find their way to the skin and lay their eggs).
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?
29,880 ml.
4 ml.x 90kg.x83 = 29.880 divided by 2 = 14,940 ml.
Alkalis, such as lye causes a
Liquefaction necrosis
Thick, leathery eschar forms from exposure to...
acids or heat
Hard, cherry red skin forms from exposure to...
Thermal injury
What happens in the emergent phase (48-72 hours) after a burn? What does the body exude?
Elevated hematocrit levels (first 24-36 hours), high pulse, decreased blood pressure, decreased urine output.
Where would petechiae be best noted in the dark skinned client?
The oral mucosa and conjunctiva
Where would palor be best noted in the dark skinned client?
Palms of hands and soles of feet
Where would jaundice best be noted in the dark skinned client?
The sclera of the eye
Erythema is
Diffuse redness of the skin
How would you assess for erythema in a dark skinned client?
Feel for an increased temp around the wound edges
Sign noted in Pemphigus Vulgaris where finger nail pressure to the skin causes some to slough off...
Nikolsky's sign
The fiber in the skin responsible for toughness and resiliancy.
Collagen
Overgrowth of the outer skin layer resulting in callus formation.
Hyperkeratosis
Loss of pigmentation from decreased melanocyte activity.
Vitiligo
Areas of blotchy brown macules across the cheeks and forehead from overproduction of melanin caused by hormones.
Melasma
lesions which resemble a net.
reticular
Occurs with increasing age and has no significance. Noted by bright ruby colored round lesions scattered throughout the trunk and thighs.
Cherry Angiomas
Type of angioma which commonly occurs in people with liver disease and vitamin B deficiency.
Spider Angiomas
Caused by excess keratin formation in the skin
Psoriasis
A disorder of the nail bed caused by a fungal infection. Causes separation from the nail plate.
Paronchia
Ecchymosis
Bruise
Ecchymosis and Petechiae
Purpura
Full Thickness burn includes:
Dermis, Epidermis and Epithelial layer of s.q fat
When is edema usually seen in a burn patient?
In between 18-24 hours.
A c;ient has an inhalation injury and is unusually combative. What is the cause?
Hypoxia
What would the nurse include in the plan of care for a pt. with a circumforencial burn injury?
Check peripheral pulses every hour