Exam #2 Nurs 260

Front 1

Epidermis

Back 1

tough, outer layer

has melanocyte and kerantinocyte cellsuu

Front 2

dermis

Back 2

• two layers; upper and lower
  

contains:

• hair follicles
  
• sweat glands
  
• sebaceous glands
  
• blood vessels
  
• nerve endings
  

Front 3

function of the skin

Back 3

• sensation
  
• protection
  
• thermoregulation
  
• secretion: for lubrication
  
• metabolism and biochemistry
  
• prevent fluid loss
• synthesis

Front 4

which vitamin is synthesized on the skin?

Back 4

vitamin D

Front 5

what does vitamin D help with metabolizing?

Back 5

calcium and phosphate

Front 6

What effects can aging have on the skin?

Back 6

↓ elasticity

↓ fluids

more comorbidities

Front 7

types of burns

Back 7

superficial

partial thickness

full thickness

Front 8

superficial thickness burns

Back 8

• 1st degree
  
• only epidermis involved
  
• redness with mild edema, pain, and increased sensitivity to heat
  
• dead skin peels after 2-3 days
  
• heals in 3-5 days with no scarring
  

Front 9

superficial partial thickness burns

Back 9

• 2nd degree
  
• heat injury to upper 1/3rd of dermis
  
• red, moist, painful, blanch when pressure is applied
  
• blisters form r/t plasma leakage from damaged vessels
  
• heals in 10-21 days
  
• no scarring-minor pigment changes may occur
  

Front 10

deep partial thickness burns

Back 10

• 2nd degree
  
• extends deeper into the dermis
  
• some blistering may take place, but not always
  
• wound is dry and red with areas of whiteness in deeper parts
  
• moderate edema develops
  
• heals in 3-6 weeks w/o surgery-usually develops scarring
  
• skin grafting can reduce healing time
  

Front 11

full thickness burn

Back 11

• 3rd degree
  
• destroys entire epidermis and dermis
  
• skin cannot regenerate
  
• all dermal structures destroyed
  
• extensive burn may involve fat, fascia, tendon, and bone (4th degree)
  
• color can be white, yellow, brown, black
  
• eschar develops
  

Front 12

if all dermis structures are destroyed, what will the patient have the inability to do?

Back 12

• grow hair
  
• produce sweat
  
• secrete oil
  
• feel sensations

Front 13

where do 3rd degree burns occur most often?

why?

Back 13

• face
  
• feet
  
• hands
  

• due to lack of fat
  

Front 14

why would a 3rd degree burn not be painful?

Back 14

lack of nerve endings

Front 15

where would a 3rd degree burn be painful?

Back 15

at the wound margins; nerve endings are still there

Front 16

what would be required to close a 3rd degree burn wound?

Back 16

skin graft

Front 17

escharotomy

Back 17

removal of eschar in wound to promote healing

Front 18

fasciotomy

Back 18

incision usually made into the fascia

usually done opposite of wound to relieve pressure and promote circulation

Front 19

what conditions would complicate performing an escharotomy or fasciotomy?

Back 19

diabetes

elderly patients

patients on blood thinners

Front 20

what type of burn can compromise a patient's ability to breathe?

Back 20

circumferential burns

Front 21

what is a circumferential burn?

Back 21

"Circumferential deep full thickness burns of an extremity or around the chest or abdomen should be carefully monitored. Edema and swelling in the tissue deep to the burn cause the unyielding overlying burnt skin ('eschar') to act like a tourniquet."

Front 22

criteria for a minor burn

Back 22

• deep - partial thickness <15%
  
• full thickness <2%
  
• no eyes, ears, face, hands, and perineum
  
• no electrical or inhalation
  
• must be <60 yrs. old
  

Front 23

facility for a minor burn

Back 23

ER/outpatient

Front 24

criteria for a moderate burn

Back 24

• Deep - partial thickness 15-25%
  
• deep/full thickness 2-10%
  
• no hands, feet, face, eyes, ears, or perineum
  
• no electrical or inhalation
  
• must be <60 yrs. old

Front 25

facility for a moderate burn

Back 25

hospital or maybe burn unit

Front 26

criteria for a major burn

Back 26

partial thickness >25%

full thickness >10%

true electrical injuries

includes hands, face, eyes, ears, feet, perineum

inhalation, fracture, or other trauma

other comorbidities

Front 27

facility for a major burn

Back 27

burn unit

Front 28

what type of burn is most frequent in toddlers?

Back 28

hot water scalds :(

Front 29

most common burn with older children?

Back 29

flame-related burns

Front 30

how many documented cases of child abuse include burns?

Back 30

10-20%

Front 31

what accounts for 10% of house fires?

Back 31

children playing with lighters or matches

Front 32

way to assess the extent of a burn?

does not apply to children

Back 32

rule of nines

Front 33

types of burns

Back 33

thermal

electrical

chemical

radiation

Front 34

Thermal burn

Back 34

also called heat burn

due to

• flame (dry heat)
  
• scalding (moist heat-liquids or steam)
• contact with hot surfaces or materials

Front 35

electrical burns

Back 35

• internal injury is worse than external
• entrance and exit wounds
• damage along the path of electrical current

Front 36

How does electrical burns affect body systems?

Back 36

• cardiac dysrhythmias or arrest
  
• respiratory abnormalities
  
• cataract formation
  
• vascular damage: in the pathway of the electrical current
  
• renal damage: may see dark, frothy urine consistent with protein and blood in urine
  

Front 37

what type of electrical burns are see in children and why?

Back 37

burns of the mouth: due to children biting or sucking on electrical cords

Front 38

the amount of damage of chemical burns depends on what?

Back 38

• concentration of agent
• quantity of agent
• length of exposure
• mechanism of action
• depth of penetration

Front 39

what chemical binds with calcium and magnesium in the body?

Back 39

hydrofluoric acid

Front 40

what is a MSDS?

Back 40

material safety data sheet

"a document that contains information on the potential health effects of exposure to chemicals, or other potentially dangerous substances, and on safe working procedures when handling chemical products."

Front 41

how do we treat chemical burns?

Back 41

• brush off any dry chemicals
  
• remove all clothing and jewelry
• determine type of chemical
• flush with copious amounts of water (with rare exception)
• do not neutralize unless you're sure of the chemical and the appropriate agent

Front 42

how do we treat radiation burns?

Back 42

• protect yourself!
• remove from the radiation source
• if exposed to an unsealed source, remove client's clothing using tongs or lead protective gloves
• send to nearest designated radiation decontamination center
• help client bathe or shower

Front 43

emergent phase of a burn injury

Back 43

most acute phase; most chance to die

lasts for approx. 48 hrs

severity of symptoms depend on severity of burn

may see:

oliguria

hypoproteinemia: protein in 3rd spacing or urine

hyperkalemia

hyponatremia

↑ HCT r/t hemoconcentration

metabolic acidosis

Front 44

most burns result in what type of acid/base imbalance?

Back 44

metabolic acidosis

Front 45

what type of shock develops quickly after a major burn injury?

Back 45

hypovolemic shock r/t massive fluid loss

↓ circulating volume

↓

↓ venous return

↓

↓ stroke volume

↓

↓ CO

↓

↓ cellular O2 supply

↓

impaired tissue perfusion

↓

impaired cellular metabolism

Front 46

which diagnostic test determines acid-base balance?

Back 46

ABG's

Front 47

when does the diuretic phase begin?

Back 47

approximately 48 hours after onset of injury

or whenever diuresis starts

Front 48

what occurs during the diuretic phase?

Back 48

• restoration of capillary integrity
• ↑ intravascular volume
• ↑ blood volume
  
• ↑ renal function and diuresis
  

Front 49

nursing assessments for acute and intermediate phase

Back 49

• AIRWAY
• hemodynamics
• EKG
• labs
• skin integrity
• peripheral pulses
• gastric: removal of acids by NG tube
• pain
• psychosocial responses
• watching for potential comlplications

Front 50

nursing interventions for acute and intermediate phase

Back 50

• AIRWAY MAINTENANCE
• restoring fluid balance
• preventing infection (aseptic practice)
• nutrition

1. TPN or possible G tube once bowel sounds are assessed
   
2. high calories
   

• promotion of skin integrity
• relieving pain
• promoting mobility
• coping strategies
• acting on potential complications

Front 51

what else should we be doing as we do our interventions?

Back 51

teaching as we go along so the patient understands everything we are doing to them

we need to assess if our patient understands what we are teaching

Front 52

nursing interventions in rehab phase

Back 52

• prevention of hypertrophic scarring
  
• promoting activity tolerance
  
• improving body image
  
• improving contractures
  
• teaching self care
  
• not done until wounds are completely covered over

Front 53

Speaking of eschar....here's a really bad joke

A snail slides into a car dealership to buy a car. The snail looks around and finally decides which car he will buy. He then proceeds to tell the salesman that he wants a custom paint job. He tells the salesman "I want you to paint a giant S on each side of the car, including the hood, the trunk, and the roof."

The salesman says "sure we can do that, but why on earth would you want an S on each side of your car?"

Back 53

The snail smiles and says "because when I drive down the street, I want everyone to look my way and say, "wow! look at that S car go!" 😁 😂

Front 54

what is the most important thing to assess with hyponatremia?

Back 54

changes in LOC

Front 55

what type of issues are monitored with ↑ or ↓ K+?

Back 55

cardiac issues

Front 56

major buffer system in extracellular fluids

Back 56

carbonic acid to sodium bicarbonate

Front 57

ratio that must be maintained to stay in acid base balance

Back 57

1 part carbonic acid to 20 parts sodium bicarbonate

Front 58

respiratory regulation

Back 58

regulates acid base balance by eliminating or retaining CO2

Front 59

causes of respiratory acidosis

Back 59

• respiratory arrest
  
• lung disease (COPD, emphysema, etc.)
  
• post abdominal surgery
  
• inflamed airways r/t pneumonia, asthma
  
• smoke inhalation, burns
  

Front 60

acute manifestations of respiratory acidosis

Back 60

• mental cloudiness
  
• changes in LOC
• dizziness
• muscular twitching
• unconsciousness

Front 61

chronic manifestations of respiratory acidosis

Back 61

weakness

dull headache

Front 62

causes of respiratory alkalosis

Back 62

• hyperventilation
  
• impaired lung expansion
  
• pain
  
• intubation
  

Front 63

clinical manifestations of respiratory alkalosis

Back 63

• lightheadedness
• inability to concentrate
• hyperventilation syndrome
• tinnitus
• sweating
• dry mouth
• convulsions
• loss of conciousness

Front 64

if patient has metabolic acidosis, the respiratory system compensates by:

Back 64

hyperventilating

Front 65

if the patient had metabolic alkalosis, the respiratory system responds by:

Back 65

hypoventilating

Front 66

carbon monoxide poisoning

Back 66

• one of the leading causes of death assoc. with fires
  
• in the presence of CO2, Hgb prefers to bind with CO instead of O2 → results in ↓ O2 to tissues
  
• pulse oximeter reading will not be accurate: get ABG's, auscultate, assess s/s hypoxia
  

Front 67

s/s of carbon monoxide poisoning

Back 67

bright red lips and tongue

carboxyhemoglobinemia: skin turns red

dyspnea

headache

tachypnea

confusion

impaired judgement

cyanosis

respiratory depression

Front 68

treatment for CO poisoning

Back 68

100% O2 via nonrebreather mask

intubation

hyperbaric O2 therapy

Front 69

ultimate regulator of acid base balance

Back 69

the kidneys

Front 70

renal tubules response to alkalosis

Back 70

↑ amount of bicarb excretion

Front 71

renal tubules response to acidosis

Back 71

reabsorption of bicarb and excretion of acid

Front 72

changes in renal function with a burn injury

Back 72

• ↓ decreased renal blood flow
  
• cellular debris
  
• hypovolemia leased to renal artery constriction
  
• hematuria and/or myoglobinuria can lead to tubular damage
  
• uric acid can form from proteins released by damaged cells-can also cause tubular damage
  
• renal failure can be caused by either ↓ renal blood flow or pre-existing renal disease
  

Front 73

causes of metabolic acidosis

Back 73

• burns
  
• diabetes
  
• renal failure
  
• lactic acidosis
  
• diarrhea
  

Front 74

clinical manifestations of metabolic acidosis

Back 74

• headache
  
• confusion
  
• drowsiness
  
• ↑ RR
  
• N/V
  
• death
  

Front 75

causes of metabolic alkalosis

Back 75

• vomiting
  
• NG suctioning
  
• steroid administration
  
• XS administration of bicarb
  

Front 76

clinical manifestations of metabolic alkalosis

Back 76

• dizziness
  
• tingling of fingers and toes
  
• depressed respirations
  

Front 77

hyperkalemia due to damaged cells cause what to be seen on EKG?

Back 77

• tall, tented T waves
  
• increased PR interval
  
• ST depression
  
• loss of P wave
  
• widening of QRS
  
• Vfib
  

Front 78

what happens to the GI system with a burn?

Back 78

↓ GI motility

paralytic ileus caused by ↓ blood flow and sympathetic stimulation

at risk for Curling's ulcer

Front 79

five primary objectives for management of the burn patient

Back 79

1. preserve body function
2. prevent infection
3. restore skin integrity
4. provide comfort and support
5. restore a normal living pattern to the patient

Front 80

emergent or resuscitative phase of burn care

Back 80

from injury until physiologically stable

(about 36-48 hours)

Front 81

acute or diuretic phase of burn care

Back 81

lasts until all full thickness burns covered with skin

Front 82

rehabilitation phase of burn care

Back 82

return to highest possible level of functioning

Front 83

treatment of the burn patient

primary survey

Back 83

A= Airway

B= Breathing

C= Circulation

D= Disability, neurological deficit

E= Exposure and evaluation

F= Fluid resuscitation

Front 84

most important factor of airway treatment

Back 84

• assess airway
  
• listen for changes in cough, voice
  
• have intubation equipment ready
  

Front 85

important aspects of neuro assessments

Back 85

• need to know baseline mental status
  
• assess other causes of mental status deficits
  
• cervical collar and immobilization until spine is cleared
  

Front 86

Fluid resuscitation formula for 1st 24 hours

Back 86

TBSA x Kg x 4mL lactated ringers

Front 87

when is fluid resuscitation calculated?

Back 87

from the time of injury, NOT from arrival time at the hospital

Front 88

objectives of fluid therapy

Back 88

1. compensate for water and Na+ lost to traumatized areas and interstitial spaces
2. reestablish sodium balance
3. restore circulating volume
4. provide adequate perfusion
5. correct acidosis
6. improve or maintain renal function

Front 89

goals for fluid resuscitation

Back 89

keep urine output 30-50mL/hr for adults and older kids, Na+ at 140meq/L

for kids <30kg = urine output of 1mL/hr/kg

Front 90

what fluid is used after 1st 24 hours?

Back 90

colloids

Front 91

single most efficient indicator for fluid resuscitation adequacy?

Back 91

urine output during 1st 24 hours (at least 30mL/hr)

Front 92

cushing's ulcer (stress ulcer)

Back 92

an acute gastritis erosion resulting as a complication from severe burns when reduced plasma volume leads to ischemia and cell necrosis (sloughing) of the gastric mucosa

Front 93

what is the drug of choice for pain and anxiety for adults and children?

Back 93

morphine: allows body to relax and promote circulation

Front 94

nutritional goals for burn patient

Back 94

increased calories

increased protein

needs vary according to the size of the burn

TPN or may need G tube

feed GI system when bowel sounds are heard

Front 95

what do we worry about before we worry about the wound itself?

Back 95

ventilatory and hemodynamic stability

Front 96

objectives of wound treatment

Back 96

• prevention of infection
• removal of devitalized tissue
• closure of the wound

Front 97

preventative efforts regarding infection

Back 97

• application of antimicrobial agents
• meticulous wound care - aseptic technique
• vigilant surveillance - temp changes, ↑ WBCs

Front 98

sulfamylon

Back 98

• soft white cream
  
• readily penetrates eschar - good for full thickness burns
  
• agent of choice when burn wound becomes infected
  
• application may be painful - pretreat with pain meds
  
• prolonged use can cause metabolic acidosis
  

Front 99

silvadene

Back 99

• soft white cream
• application is cool and soothing
• cross-reactivity may occur for patients allergic to sulfa drugs
• limited penetration of eschar - works better when eschar is removed
• forms a loose yellow film that must be debrided daily
• can cause transient leukopenia
• antimicrobial, anti fungal
• applied w/ sterile gloves
• can cause skin to turn black

Front 100

silver nitrate

Back 100

• painless on application
• very limited penetration of eschar
• must be maintained in contact with wound through use of continuous wet dressings
• do not use on face
• can cause major electrolyte imbalance and black discoloration of wound

Front 101

petroleum/mineral oil based

Back 101

• neosporin/polysporin
  
• limited penetration of eschar
  
• used mostly on grafts
  
• good for gram + and gram -
  

Front 102

non surgical treatment of wounds

Back 102

• removes exudates and necrotic tissue
• rigorous cleaning of the area
• stimulates granulation and revascularization
• good time to do ROM's
• warm room before treatment

Front 103

debridement

Back 103

• removal of eschar and other cellular debris
• mechanical debridement includes hydrotherapy and use of friction/gauze
• enzymatic debridement includes autolysis and use of enzyme agents

Front 104

tangential excision

Back 104

remove successive thin layers of eschar to a level of tissue viability

Front 105

fascial excision

Back 105

• excision of burn wound to level of fascia
  
• less blood loss
  
• use for large full thickness burns
  
• best to do when patient is edematous: easier to separate the fascia
  

Front 106

meshed autograft

Back 106

• allows for graft to be expanded
  
• allows for coverage of large areas when there are limited donor sites available
  
• the wider the mesh ratio, the greater the time required for the graft to close → more prone to infection and hypertrophic scarring
  
• never used on face
  

Front 107

sheet autograft

Back 107

excellent cosmetic appearance

requires more donor sites

used on face and hands if possible

difficult to apply on irregular surfaces

Front 108

sign of graft rejection

Back 108

curling edges

sloughing

could be from infection

Front 109

CEA cultured epidermal autograft

Back 109

skin cells from patient grown in a lab

very costly

smooth, seamless surface, but thin

18-25 days to grow

Front 110

biological and synthetic dressings

Back 110

can cover partial thickness wounds to promote healing or serve as temporary wound covers after burn excision when no autografts are available

Front 111

allograft

Back 111

cadaver skin

becomes vascularized and creates a favorable environment

body will begin to reject in 7 days - normal

Front 112

xenoderm

Back 112

pig skin

does NOT become vascularized, but does create a favorable subgraft environment

body begins to reject in 7 days

Front 113

biobane

Back 113

synthetic skin cover of collagen designed to accelerate healing

will turn opaque as healing occurs

change q 7-10 days

manmade silicon film with nylon fabric

great for depp partial thickness burns

less pain, ↑ flexibility, ↓ r/f infection

Front 114

complications of burns

Back 114

infection

keloid formation

contracture formation

Front 115

keloid formation

Back 115

also called hypertrophic scar

abnormal fibrous proliferations of the dermis

most common in darker skinned people

treatment os surgical removal with possible steroid injections or low-dosed radiotherapy

hard to counteract

Front 116

contractures

Back 116

fibrosis of connective tissue in skin, fascia, muscle or a joint capsule that prevents normal mobility

Front 117

how to prevent contractures

Back 117

abduct limbs away from body

splay fingers and toes if on hands and feet

maintain patient in neutral position with minimal flexion

use splints if necessary

range of motion 3 times a day

if possible, if the burn is on hands, have pt. perform active ROM q hr while awake

Front 118

pressure therapy

Back 118

used for the prevention of hypertrophic scar development and contractures

pressured delivered by

• scar massage
• ace wrapping
• pressure garments

garments should be worn 23 hours a day for 12-24 months