Nursing Process III Exam 4 Questions With 100% Correct Answers 2024

Nursing Process III Exam 4 Questions With 100% Correct Answers 2024 1st degree burn: superficial Epidermis Pink and painful (still has nerves) No scarring Blanching is present Heals in a few days 2nd degree burn: partial thickness Epidermis and dermis Superficial: blisters that are shiny and moist Deep: pale, waxy, moist or dry blisters Painful Scarring, contractures, impairment possible Heals in 2-6 weeks 3rd degree burn: full thickness - Epidermis, dermis and hypodermis, may extend to subcutaneous fat, connective tissue, muscle/bone - Prolonged contact with source of burn - May look black, yellow, red, wet - No pain or limited pain due to the nerve fibers being destroyed - Skin will not heal, needs skin grafting - Eschar: dead tissue, leathery, must be removed by debridement 3 stages of 3rd degree burns: emergent, acute and rehabilitative Emergent phase: onset of injury to the restoration of capillary permeability (24-48hours after a burn) - First aid - Fluid resuscitation - Rule of 9’s to determine extent - Decrease edema - Foley to monitor output - Assessment by the ABA guidelines Acute phase: capillary permeability stabilized to wound closure (48-72 hours after burn and until wounds have healed) - Start of diuresis through closure of the wound, remember urinary output - Decrease in perfusion to the stomach/intestines → paralytic ileus - Wound care - Nutrition therapy - Infection prevention - Pain management - Respiratory issues, may need intubation if complications occur Rehabilitation stage: burn healed and the patient is functioning mentally and physically, begins with wound closure and ends with highest level of health restoration - Prevention of contractures/scars - Successful resumptom of work, family roles - ROM exercise to increase mobility Goals: - Psychosocial - ADL’s - PT/OT - Cosmetic considerations Extent of Burns - Expressed as percentage of total body surface area (TBSA) - Rule of 9's is the rapid method - Lund and Browder method > Determines surface area measurements by age - Compartment syndrome > In the extremities: tight skin such as eschar acting like a band around the skin cutting off blood circulation Types of Burns Thermal: most common Superficial heat (dry or moist) Children and older adults are most often affected Example: steam, liquid, fire Chemical Burn caused by a toxic substance, tissue protein destruction leads to necrosis Can be alkalotic or acidotic, or organic substance like bleach, gas, paint thinner Radiation Sunburns (UV) and cancer treatment (radiation therapy) Nuclear/ multisystem involvement Electric Electrical current that passes through the body causing damage within Severity depends on the type, duration of the current, and amount of voltage Severe or very high voltage may → cardiac arrest Potential complication: cardiac arrest, dysrhythmias, fracture of bones Release of myoglobin and hemoglobin in to the blood which can clog the kidneys What is an inhalation injury? - Caused by inhaling smoke which can cause flame injury or carbon monoxide poisoning - Damage is to the respiratory system, happens mostly in a closed area - Signs: hair singed ar