NURSING 480 STUDY GUIDE AND ANSWERED FINAL EXAM (GUARANTEED SUCCESS)

NUR 480 STUDY GUIDE AND ANSWERED FINAL EXAM Rule of 9's ● Head: front and back each is 4.5% ● Torso: chest and abdomen 9% each ● Back: upper and lower 9% each ● Arms: front and back 4.5% each, 9% total for one arm ● Groin: 1% ● Legs: front and back 9% each, 18% total for one leg ● Burns ● Body tissue injuries by thermal, chemical, electrical or radioactive agents ● Results in destruction of skin layers, and underlying tissues ● Loss of temperature regulation, sweat and sebaceous gland function and sensory function ● Health Promotion/Disease Prevention ○ Fire extinguishers, smoke alarms, emergency numbers, never re-enter a burning building, exit plan for fires, “stop, drop, & roll”, store matches & lighters out of reach, reduce water heater setting to below 120oF, annual inspection & cleaning of fireplace, cover electrical outlets, wear gloves with chemicals, avoid tanning beds, avoid smoking in bed, matches/lighters out of reach for children, don’t leave hot objects on the edge of counter, never add flammable substances (gasoline, lighter fluid, kerosene) to an open flame ● Severity depends on: ○ Percentage of total body area ○ Depth of burn ○ Location of burn ○ Patient’s age ○ Causative agent ○ Presence of other injuries ○ And involvement of the respiratory system and the overall health of the patient ● Extent of body surface ○ Rule of Nine: quick, multiples of 9 ○ Lund and Browder Method: more exact, percentages for anatomical parts ○ Palmer method: quick, scattered burns, patient’s palm size is 1% of total body surface area (TBSA) ● Depth of Burn and Manifestations Class Degree Layer Appearance Example Pain healing superficial 1st epidermis Pink-red, tender, mild edema sunburn Yes 3-6 days Superficial partial 2nd Epidermis Part of dermis Pink-red, blisters, mild- moderate edema Flame Burn scalds Yes 3 weeks Deep partial 3rd Epidermis Deep dermis Red-white, moderate edema, soft/dry eschar scarring/grafting Grease Tar Chemical Electrical burns Yes 2-6 weeks Full thickness 3rd Epidermis Deep dermis Extended to subcutaneous tissue Nerve damage Red-tan, black, brown, white, severe edema, hard inelastic eschar Grease Tar Chemical Electrical burns Yes or no Weeks- months Deep full 4th All layers, muscles, tendons, and bones Black with no edema, eschar hard inelastic Electrical burns flames No Weeks- months ● Assessment ○ Risk factors for death from burns ■ Older than 60 ■ Burn involves more than 40% of total body surface area ■ Inhalation injury ● Lab Tests ○ CBC ○ Electrolytes ○ BUN ○ Carboxyhemoglobin ○ ABGs ○ Glucose ○ Liver function tests (LFT) ○ Urinalysis ○ Clotting studies ● Phases of Burn Care ○ Emergent: Resuscitative ( 1st 24-48 hours) ○ Acute: wound healing (begins when fluid resuscitation is done and ends when wound is covered by tissue) ○ Rehabilitative: restorative (begins when most of burn area is healed and ends when client achieves highest level of functioning possible ● Nursing Interventions ○ Moderate to Major burns ■ IV fluid replacement using Parkland Formula (amount of fluid for 1st 24 hours from burn) ● 4 ml/kg/% burn ● Give ½ fluids in 1st 8 hours ● Give 2nd ½ over remaining 16 hours ● Deduct any fluid given prehospital from amount to be infused in 1st 8 hours ■ Monitor respiratory, cardiovascular, GI, and urinary systems ■ Give warm blankets for hypothermia ■ Pain management ■ Infection prevention ■ Nutritional support ■ Restoration of mobility to prevent contractures ■ Psych support ● Medications: Topical Agents: Antimicrobial Creams ○ Silver nitrate: bacteriostatic, apply with gauze dressing, painful, stains, doesn’t penetrate eschar ○ Silver sulfadiazine: apply thin layer with clean glove, usually pain free, effective against gram - & +, AE: neutropenia, sulfa allergy contraindicated, gray/blue discoloration, penetrates eschar minimally ○ mafenide: penetrates eschar, painful to apply/remove, bacteriostatic against gram - & +, AE: metabolic acidosis ○ bacitracin: bas-i-tray-sin bacteriostatic, painless, against gram + organisms; keep burn moist ○ Gentamicin: bactericidal aminoglycoside, anti-infective; AE: nephrotoxicity, ototoxic ● Collaborative Care ○ Consults ○ escharotomy/fasciotomy ○ Wound care ■ Hyperbaric O2 therapy ○ Skin coverings to promote healing ● Complications ○ Airway injury can be delayed for 24-48 hours ■ Support airway with ventilation and O2 ○ Fluid and electrolyte imbalances ○ Wound infections ■ Increase risk of sepsis: use sterile techniques with dressing changes ○ Scarring and contractures ■ Deep burns can limit movement of bones and joints, scar tissue can form causing shortening and tightening of the skin, muscles, and tendons which can cause contractures ● Assist with active/passive ROM at least 3 times daily ● Position neutrally with limited flexion ● Encourage splints and ambulation asap ● Compression dressing for up to 24 months to increase mobility and reduce scarring ● Electrolyte Imbalances ○ Hyperkalemia : potassium level greater than 5.5: tired and weak, feeling of numbness or tingling, nausea, vomiting, trouble breathing, chest pain, irregular heartbeats, bradycardia, and asystole. Caused by renal failure, dehydration, diabetes, ACE inhibitors, and RBs ○ Hypokalemia: low potassium less than 3.5: weakness, fatigue, constipation, muscle cramping, palpitations, ventricular arrhythmias. Caused by Bartter, Gietlman, Liddle or Cushings syndrome, high dose PCN, diuretics, and long term laxative use. ○ Hypocalcemia: low calcium less than 8.0: Chvostek’s and Trousseau’s Signs, numbness and tingling sensations in the perioral area or in the fingers and toes, muscle cramps, particular in the back and lower extremities; may progress to carpopedal spasm (tetany), wheezing; may develop from bronchospasm, dysphagia, and voice changes (due to laryngospasm). Caused by hypoparathyroidism, renal failure, GI illness, nutritional deficit, radiocontrast estrogen, loop diuretics, bisphosphonates antibiotics and antiepileptic drugs. ○ Hypercalcemia: high calcium greater than 10.0: headaches, fatigue, excessive thirst, excessive urination, nausea, abdominal pain, decreased appetite, constipation, vomiting, abnormal heart rhythms, depression, memory loss, irritability, confusion and coma. Caused by hyperparathyroidism, lung disease, cancer, diuretics, lithium, calcium supplements and antacids.