Burn Injury Severity and Nursing Care

<p>Coagulation necrosis of cells occurs (A)</p> Signup and view all the answers

<p>They are lost from the intravascular space (D)</p> Signup and view all the answers

<p>Hypovolemic shock (D)</p> Signup and view all the answers

<p>Zone of hyperemia (B)</p> Signup and view all the answers

<p>Hemodynamic instability (B)</p> Signup and view all the answers

<p>Decreased cardiac output (D)</p> Signup and view all the answers

<p>Elevation of the extremity (B)</p> Signup and view all the answers

<p>Fasciotomy (D)</p> Signup and view all the answers

<p>Increased heart workload (B)</p> Signup and view all the answers

<p>Hypovolemic shock (B)</p> Signup and view all the answers

<p>Hyperkalemia (C)</p> Signup and view all the answers

<p>4 hours post injury (A)</p> Signup and view all the answers

<p>Hypokalemia or potassium depletion (C)</p> Signup and view all the answers

<p>Maintenance of adequate tissue oxygenation (D)</p> Signup and view all the answers

<p>Maintaining proper patient positioning (D)</p> Signup and view all the answers

<p>Vital signs and urine output (D)</p> Signup and view all the answers

<p>Monitor core body temperature frequently (C)</p> Signup and view all the answers

<p>Using a numeric pain intensity scale (B)</p> Signup and view all the answers

<p>Symptoms of deficiency or excess of specific serum electrolytes (D)</p> Signup and view all the answers

<p>Work quickly to minimize heat loss (D)</p> Signup and view all the answers

<p>Control of pain using pharmacological measures (C)</p> Signup and view all the answers

<p>Occult blood in the stool (C)</p> Signup and view all the answers

<p>Establish an airway (C)</p> Signup and view all the answers

<p>Fluid resuscitation (B)</p> Signup and view all the answers

<p>For accurate monitoring of urine output (B)</p> Signup and view all the answers

<p>Abdominal compartment syndrome (C)</p> Signup and view all the answers

<p>Perform warming techniques (B)</p> Signup and view all the answers

<p>Stabilizing airway, breathing, and circulation (D)</p> Signup and view all the answers

<p>4 ml of RL * wt * % TBSA (C)</p> Signup and view all the answers

<p>Loss of plasma or water shifts (C)</p> Signup and view all the answers

<p>Burns of the extremities (C)</p> Signup and view all the answers

<p>It causes acute tubular necrosis (B)</p> Signup and view all the answers

<p>Thrombocytopenia (D)</p> Signup and view all the answers

<p>Hypothermia on admission (D)</p> Signup and view all the answers

<p>Paralytic ileus (D)</p> Signup and view all the answers

<p>Increased risk for sepsis (B)</p> Signup and view all the answers

<p>Elevated hematocrit (A)</p> Signup and view all the answers

<p>Pain management (C)</p> Signup and view all the answers

<p>Early positioning/mobility (A)</p> Signup and view all the answers

<p>To remove devitalized tissue (C)</p> Signup and view all the answers

<p>Hypertrophic scarring (C)</p> Signup and view all the answers

<p>Multidisciplinary care (D)</p> Signup and view all the answers

<p>Nutritional intake (D)</p> Signup and view all the answers

<p>High calorie, high protein diet (A)</p> Signup and view all the answers

<p>Returning patients to the highest level of function (C)</p> Signup and view all the answers

Most burn injuries can be avoided through preventative measures.

Factors like patient age, burn depth, extent of burn, inhalation injury, other injuries, location, and comorbidities affect burn severity.

Burn injuries affect tissue in three zones: coagulation (center), stasis (surrounding), and hyperemia (outer).

A burn exceeding one-third of total body surface area (TBSA).

Methods like the Rule of Nines, Lund & Browder, and Palmer are used to estimate the extent of burn surface area.

Burn injuries cause tissue damage through heat transfer (chemical or thermal), and cellular destruction (coagulation, denaturation, ionization).

Major burns trigger a systemic inflammatory response, leading to hemodynamic instability (fluid shifts), potentially causing hypovolemic shock.

Young children and older adults have higher risk of complications and death from burn injuries compared to other age groups.

An early stage of hypovolemic shock caused by intravascular fluid loss from burns.

Low blood volume due to fluid loss.

Surgical incision through eschar (dead tissue) to relieve pressure and restore blood flow.

Surgical incision through the fascia (connective tissue layer) to relieve pressure and constricted muscle.

Elevated potassium levels in the blood, often following significant cell damage from burns.

Localized swelling due to fluid build-up in tissues.

Amount of blood pumped by the heart per minute, decreases in burn shock.

The opposition to blood flow in the blood vessels that increases to compensate for fluid loss.

In the initial stages of a burn, the hematocrit (percentage of red blood cells in blood) might be higher than usual. This is due to the destruction of some red blood cells caused by the burn injury.

Burns can disrupt the normal clotting process in the body. This can include a decrease in platelets (thrombocytopenia) leading to potential bleeding issues.

Burns often cause an extended time for blood to clot (prolonged clotting time) and an increased prothrombin time, which reflects the liver function's ability to produce clotting factors.

Inhalation of smoke or heat during a burn can cause damage to the respiratory system. Signs include: burns on face/neck, singed nasal hair, hoarseness, stridor, soot in sputum, dyspnea, tachypnea, and low oxygen levels.

Burns can reduce blood flow to the kidneys. Adequate fluids can restore blood flow. Muscle damage releases myoglobin, which can strain the kidneys.

If blood flow to the kidneys is severely compromised, hemoglobin and myoglobin can block the renal tubules, leading to acute tubular necrosis and potential kidney failure.

Burns significantly increase the risk of sepsis due to the compromised skin barrier, allowing bacteria to enter the body more easily.

Patients with burns may experience low body temperature (hypothermia) in the initial hours after the injury, which is associated with increased mortality and complications.

A type of gastric or duodenal erosion caused by severe physiological stress, often seen in burn patients.

A life-threatening condition that occurs when pressure builds up within the abdominal cavity, compressing organs and restricting blood flow.

Removing the patient from the source of injury to stop the burning process.

Airway, breathing, and circulation (ABC) are the top priorities in the emergency department.

Administering intravenous fluids to replace lost volume and maintain blood pressure in burn patients.

Monitors urine output, an essential indicator of fluid status and kidney function in burn patients.

Decompresses the stomach, preventing vomiting and aspiration, especially in patients with large burns.

Low body temperature due to heat loss, which can worsen burn outcomes.

To maintain adequate tissue oxygenation by providing 100% humidified oxygen and monitoring arterial blood gases, among other interventions.

Maintaining a patent airway through proper positioning, providing humidified oxygen, and encouraging coughing and deep breathing.

Increased capillary permeability and evaporative losses from the burn wound lead to fluid loss and reduced blood volume.

Monitoring vital signs, hemodynamics, and urine output, regulating IV fluids, and observing for electrolyte imbalances.

Loss of skin microcirculation and open wounds contribute to heat loss and hypothermia.

Use a pain intensity scale to determine the severity of their pain.

To manage the burn injury effectively, starting 48 to 72 hours after the initial injury.

To control pain associated with chemical or physical injury.

The phase following immediate resuscitation, focusing on wound care, infection prevention, and restoring fluid balance.

Removal of dead or infected tissue from a burn wound to promote healing and prepare for grafting.

Surgical procedure where healthy skin from another part of the body is transferred to the burn wound to aid healing.

Increased metabolic rate following a burn injury, leading to higher calorie and protein needs.

Long-term recovery phase focusing on restoring function, minimizing scarring, and addressing psychological needs.

Problems like nerve damage, wound breakdown, contractures, and pain that can occur during rehabilitation.

Nerve damage caused by severe burns, often affecting sensation and movement.

Thick, raised scars often forming after deep burns, potentially limiting movement and function.