NUR 2790 / NUR2790 Professional Nursing III / PN 3 Final Exam Review | Rated A Complete Guide | Latest 2021 / 2022 | Rasmussen College

NUR 2790 / NUR2790 Professional Nursing III / PN 3 Final Exam Review | Rated A Complete Guide | Latest 2021 / 2022 | Rasmussen College 1. Superficial burn (1st degree) - burn involving only epidermis, causes redness and swelling but NO blisters, NO eschar, painful, NO skin grafts - *36 days of healing* - Sunburn - Flash Burns 2. Superficial partial thickness (2nd degree) - epidermis and upper dermis blisters, inflammation, pain, mild to moderate edema, NO eschar, NO skin grafts - *heal in 721 days* - Scalds - Flames - Brief contact with hot objects 3. Deep partial thickness (2nd degree) - Epidermis and part of dermis - Blister formation - Red and white, bloody blisters, moist, painful, less blanching, Eschar SOFT and DRY, moderate edema, painful - *26 weeks of healing* - Scalds - Flames - Prolonged contact with hot objects - Tar, Grease, Chemicals 4. full thickness burn (3rd degree) - a burn in which all the layers of the skin are damaged. There are usually areas that are charred black or areas that are dry and white. Pain, BLACK BROWN YELLOW WHITE RED, severe edema, No blistering, ESCHAR hard and inelastic skin grafts required - *weeks to months of healing* - Scalds - Flames - Prolonged contact with hot objects - Tar, Grease, Chemicals, electricity 5. Deep full thickness burn (4th degree) - rare burn that extends into underlying muscle and bone. - Black in color, absent edema, NO blistering, eschar hard and inelastic, skin grafts required - *weeks to months of healing* - flames - electricity - grease - tar - chemicals 6. Burn treatment includes - Debridement (removal) of burned skin - Antibiotics - Temporary covering - Skin grafts - fluid replacement (LR) 7. Burn Labs - Laboratory Tests: - CBC, serum electrolytes, BUN, ABGs, fasting blood glucose, liver enzymes, urinalysis, and clotting studies. - Initial fluid shift (first 24 hr after injury) o Hct and Hgb elevated due to loss of fluid volume and fluid shifts into interstitial space (third spacing) o Sodium decreased due to third spacing (hyponatremia) o Potassium increased due to cell destruction (hyperkalemia) - Fluid mobilization (48 to 72 hr after injury) o Hgb and Hct decreased due to fluid shift from interstitial space back into vascular fluid o Sodium remains decreased due to renal and wound loss o Potassium decreased due to renal loss and movement back into cells (hypokalemia) - WBC count initial increase then decrease with left shift - Blood glucose elevated due to stress response - ABGs slight hypoxemia and metabolic acidosis - Total protein and albumin low due to fluid loss 8. Emergent/Resuscitative Phase - First 24 to 48 hr after the burn occurs - fluid imbalance evaluated immediately (loss) - edema - reduced blood flow - ABC assessment - PRIORITIES: - secure airway - support circulation and organ perfusion by fluid replacement - keep PT comfortable with analgesics - prevent infection through wound care - maintain body temps - provide emotional support - HYPOVOLEMIC SHOCK is common cause of death elec and fluid deficit - AIRWAY = brassy cough, drooling, dysphagia, wheezing and stridor 9. Acute Phase of Burn Injury - Begins about 36 to 48 hr after injury; lasts until wound closure is completed - *Care directed toward:* - Continued assessment and maintenance of CV, respiratory systems - Continued assessment and maintenance of GI and nutritional status - Burn wound care - Pain control - Psychosocial interventions - RISK FOR SEPSIS infection, patient develop pneumonia resulting in respiratory failure and can require ventilation - PRIORITY: o assess ABC (respiratory and cardiovascular system to maintain systems and prevent complications) 10. Rehabilitation phase of burns - begins when burn injury has healed and ends when highest level of function achieved - occupational, ADLs, and selfcare therapy (includes family member) - involves both physical and psychological therapy and care - pressure garments are worn: minimizes and reduces scarring (compliance a real issue)