Exam 4 NR 464 With Complete Solutions
phases of burn management
emergent
Emergent Phase: time required to resolve immediate problems
phases of burn management
acute
Acute: Begins with mobilization of extracellular fluid and
diuresis.
Ends when burned area covered by skin grafts, or when wounds
are healed.
Weeks to months
phases of burn management
rehab
Rehab: Goals for this period are to (1) assist the patient in
resuming a functional role in society, and (2) rehabilitate from
functional and cosmetic reconstructive surgery. Rehabilitation-
focused activities that have been taking place during the earlier
emergent and acute phases now begin in earnest once the
patient’s wounds have healed.
When an adult male is lighting a barbecue grill with
lighter fluid, his shirt bursts into flames. To
extinguish the flames most effectively, with as little
further damage as possible, it is best to:
,A. Remove the burning clothes.
B. Slap the flames with the hands.
C. Log-roll the person in the grass.
D. Pour cold liquid over the flames.
C
pre hospital care small thermal burn
cover with clean, cool, tap water damp towel
pre hospital care large thermal burns
ABCS!
do not immerse in cool water or pack with ice
remove burned clothing
wrap in clean dry sheet, or blanket
increased capillary permeability burns
•Can begin as early as 20 minutes post burn.
-result of fluid shift: intravascular volume depletion (decrease
BP and increase Pulse)
-third spacing
priority concern with burn
hypovolemic shock
edema
, Na and K burns
Na+ shifts to the interstitial spaces and remains until edema
formation ceases.
K+ shift develops because injured cells and hemolyzed RBCs
release K+ into extracellular spaces.
nursing care burn shock
Ongoing nursing assessment of the ABCs, vital signs, cardiac
rhythm, oxygenation, and level of consciousness are priorities in
the emergent phase of burn care.
burn shock shivering
may occur as a result of chilling that is caused by heat loss,
anxiety, or pain.
burn shock myoglobin and hgb
are released into the bloodstream and occlude renal tubules.
Adequate fluid replacement can counteract myoglobin and
hemoglobin obstruction of the tubules.
pain full thick and deep partial thick burns
areas of full-thickness and deep partial-thickness burns are
initially anesthetic because the nerve endings are destroyed.
burn shock and elevated Hct
commonly caused by hemoconcentration resulting from fluid
loss. After fluid balance has been restored, lowered hematocrit
levels are found secondary to dilution
burn shock and thrombosis
phases of burn management
emergent
Emergent Phase: time required to resolve immediate problems
phases of burn management
acute
Acute: Begins with mobilization of extracellular fluid and
diuresis.
Ends when burned area covered by skin grafts, or when wounds
are healed.
Weeks to months
phases of burn management
rehab
Rehab: Goals for this period are to (1) assist the patient in
resuming a functional role in society, and (2) rehabilitate from
functional and cosmetic reconstructive surgery. Rehabilitation-
focused activities that have been taking place during the earlier
emergent and acute phases now begin in earnest once the
patient’s wounds have healed.
When an adult male is lighting a barbecue grill with
lighter fluid, his shirt bursts into flames. To
extinguish the flames most effectively, with as little
further damage as possible, it is best to:
,A. Remove the burning clothes.
B. Slap the flames with the hands.
C. Log-roll the person in the grass.
D. Pour cold liquid over the flames.
C
pre hospital care small thermal burn
cover with clean, cool, tap water damp towel
pre hospital care large thermal burns
ABCS!
do not immerse in cool water or pack with ice
remove burned clothing
wrap in clean dry sheet, or blanket
increased capillary permeability burns
•Can begin as early as 20 minutes post burn.
-result of fluid shift: intravascular volume depletion (decrease
BP and increase Pulse)
-third spacing
priority concern with burn
hypovolemic shock
edema
, Na and K burns
Na+ shifts to the interstitial spaces and remains until edema
formation ceases.
K+ shift develops because injured cells and hemolyzed RBCs
release K+ into extracellular spaces.
nursing care burn shock
Ongoing nursing assessment of the ABCs, vital signs, cardiac
rhythm, oxygenation, and level of consciousness are priorities in
the emergent phase of burn care.
burn shock shivering
may occur as a result of chilling that is caused by heat loss,
anxiety, or pain.
burn shock myoglobin and hgb
are released into the bloodstream and occlude renal tubules.
Adequate fluid replacement can counteract myoglobin and
hemoglobin obstruction of the tubules.
pain full thick and deep partial thick burns
areas of full-thickness and deep partial-thickness burns are
initially anesthetic because the nerve endings are destroyed.
burn shock and elevated Hct
commonly caused by hemoconcentration resulting from fluid
loss. After fluid balance has been restored, lowered hematocrit
levels are found secondary to dilution
burn shock and thrombosis
