NUR 445 Exam 4 Med Surg | Arizona College of Nursing

Exam 4 Med Surg

Burns
 Burn depth
o Superficial
 Epidermal layer of skin
 Mild erythema and hypersensitivity
 Looks like a “sunburn” and usually caused by
the sun
 Dry, no blister, blanch easily, pink/redish
 Heal quickly, usually need no intervention
 Usually, no scarring involved
 Resolves in 24-72 Hours
 Treatment
 Apply cool compression or run under cool
water
 Lotion 1-2X/day
o Aloe based, Frangrance free
 Take ibuprofen, Tylenol, aspirin for
pain/discomfort
 Drink plenty of fluids and rest
 DO NOT apply ice or submerge in ice water
o Bandage is not necessary

o Superficial/Partial Thickness
 Usually seen from scalding liquids & have blisters
 Epidermis and superficial, or minimal layers of the
dermis
 Blisters (closed/open or weeping), mild edema,
pink/reddish, blanches easily
o Usually heals 1-2 wks w/minimal to no
scarring
 Cap refill remains normal w/open blisters
 Will be painful d/t nerve endings exposed
 May require medical management and admission
 Treatment
 If blister is open wash w/mild soap & warm
water

,  Apply bacitracin and cover w/nonadherent
bandage
 Dependent extremities should be elevated to
prevent edema and encourage venous return
 Educate on s/s of infection
o Fever, pain, redness/swelling, purulent
drainage, red streaks from wound (see
PCP ASAP)
 CAN return to normal activities



o Deep/ Partial Thickness
 Epidermis and deep/bottom layers of the dermis
 Will have a WAXY appears, no
weeping/blisters, will have edema and may
have blanching, Mottled, pale center
 Light pink or cherry red
 Pain and decreased sensation
 Cap refill is decreased or absent
 Take longer than 2 wks to heal and at risk of
Infection

o Full Thickness Burn
 Epidermis, dermis and subQ/fatty tissue and
muscle/bone
 Hair, sweat glands, nerve endings all
destroyed
o No pain (causes misleading to needing
help)
 Will have NO blisters formation or blanching.
Will be very dry and feel like leather.
o Charred appearance
o Referred to as “eschar”
 Treatment
 Does not heal on its own
o Requires skin graft
Question:
The nurse correlates which clinical manifestation w/superficial
partial thickness burns?

, Blisters. They can appear wet, weeping blisters and pink in
color.

Types of burns
 Thermal Burns
o Flash, scald, contact w/hot objects or flames
 Caused by house, car or cooking accidents
o Contact/thermal burns associated w/ cooking & heating
incidents

 Electrical Burns
o Usually work related and related to gas and electrical
wires
 Breaker boxes/overhead powerlines
o Higher length of hospital stays, morbidities, number of
surgeries required.
o Can requires amputations w/extensive burns
o Also called the Grand Masquerader
 Extent of tissue damage is not always apparent on
the surface of the skin
o Special monitoring
 Assess for injury/cause, determine if they need a c-
collar to support airway
 Look at contact points
o Such as scalp d/t hair
 Cardiac monitor for at least 24-48 hours
 Baseline ECG
 Neuro assessment
 Regular basis to monitor for any changes in
LOC
 Fluid resuscitation
 Monitor their urine and look for myoglobinuria
o Indicates muscle damage
o Urine will look red/tea colored
 Important to maintain urine output of 1
mL/kg/hr for patients with electrical injuries.

 Chemical Burns
o Industrial/household setting

, o 3% of all burn center victims
o Bleach, gas, acids, alkaline, compounds, lime
o Special monitoring
 Use PPE when dealing with chemical burns
 Remove saturated clothing
 Brushing off skin IF powdered substance
 Continuous irrigation with copious amounts of water
 Until the patient reports a decrease in pain,
the patient's temperature cannot tolerate
further or transferred to burn center.
 Flush eyes continuously if in the eyes
 Until ophthalomolgist does full exam

 Radiation Burns
o Least common
o Associated w/treatment and sunburns (UV radiation)
o Nuclear or iodine

Question:
The nurse recognizes which etiology as consistent with a thermal
burn?
Scalding, flash, contact with hot objects or flames

Total Burn surface Percentage
 Adults are resuscitating at injuries of 20% or greater TBSA
o We determine percentage of burn to determine fluids and
treatment
 If underestimated, it can cause
o Shock and organ failure
 If overestimated, it can cause
o Pulmonary edema d/t excess fluids given
 Three most common methods are rule of palm, rule of nines,
lund & Browder classification
o Adult body gets broken down into 9% areas
o Determines amount of body burnt and in adults.