Burns - Med Surg - HESI NCLEX RN Review Flashcards

Terms Definitions
Describe Burns.
Tissue injury or necrosis caused by transfer of energy from a heat source to the body.
What are the 4 categories of burns?
Tissue destruction from burns results from what?
Protein denaturation
Ionization of cellular contents
What are the critical systems of the body that are affected by burns?
Describe the severity of a 1st Degree Burn.
Superficial partial-thickness burns (sunburn)
Leaves skin pink/red
Painful (relieved by cooling)
Slight edema
Describe the severity of a second degree burn?
Deep partial-thickness destruction of epidermis and upper layers of dermis

Injury to deeper portions of the dermis

Painful (sensitive to touch and cold air)

Appears red or white, weeps fluid, blisters

Hair follicles remain intact

Very edematous

Blanching followed by capillary refill

Heals without surgical intervention, usually does not scar
Describe the severity of a third degree burn?
Full-thickness involves total destruction of dermis and epidermis

Skin cannot regenerate

Requires skin grafting

Underlying tissue (fat, fascia, tendon, bone) may be involved.

Wound appears dry and leathery as eschar develops

How do you determine the extent of a surface area burn?
Use Rule of Nines
Lund and Browder chart
What are the % of the Rule of Nines?
head and neck 9%
upper extremities 9 % each
lower extremities 18% each
front/back trunk 18% each
1% perineal area
There are three stages of burn care. Name them.
Stage I - Emergent Phase
Stage II - Acute Phase
Stage III - Rehabilitation Phase
Describe Stage I or the Emergent Care Phase.
Begins at the time of injury and concludes with the restoration of capillary permeability, which typically reverses 48 to 72 hours following an injury.

Characterized by fluid shift from intravascular to interstitial and shock. Focus on care is to preserve vital organ functioning.

Expect to administer large volumes of fluid in this face.
Describe Stage II or the Acute Care Phase
Occurs from beginning of diuresis to the near completion of wound closure

Characterized by fluid shift from interstitial to intravascular
Describe Stage III or the Rehabilitation Phase
Occurs from major wound closure to return to optimal level of physical and psychosocial adjustment (about 5 years)

Characterized by grafting and rehabilitation specific to the client's needs.
What are things you will assess for?
Absence of bowel sounds

Radically decreased UO in 1st 72 hours with increased specific gravity

Radically increased UO 72 hours to 2 weeks after initial injury

Signs of inadequate hydration

Signs of inhalation burn

Description of physiological responses to burns

Preexisting conditions/illness which could influence recovery
Why would you want to listen to bowel sounds?
Paralytic Ileus
What are the signs of inadequate hydration when you assess a burn patient?


Decreased urine output, urinary sodium, and increased specific gravity
What are signs of an inhalation burn?
Singed nasal hairs
Circumoral burns


Sooty or bloody sputum


Asymmetry of chest movements with respirations and use of accessory muscles indicate pneumonia

Rales, wheezing, and rhonchi denoting smoke inhalation
Nursing interventions with burns are directed towards...
Stabilization with ongoing assessment

Provide admission care

Monitor hydration status

Monitor respiratory functioning

Provide wound care

Assess for paralytic eleus

Assist with pain management

Assess for circulatory compromise in burns that constrict body parts.
Thermal burns. How to you remove the source of the burn?
Remove clothing

Cool burns by immersion in tepid water

Apply dry sterile dressing
Chemical burns. How do you remove the source of the burn?
Flush with water or saline
Electric burn. How do you remove the source of the burn?
Separate client from electrical source
After removal of the source of the burn what are steps you want to do?
Provide an open airway (intubation, esp if laryngeal edema)

Determine baseline data: VS, blood gases, weight

Determine depth and extent of burn

Administer tetanus toxoid

Start F& E therapy

Insert NG to prevent vomiting, abdominal distention, or gastric aspiration

Administer IV pain medication as prescribed
Why do you give tetanus toxoid?
Tetanus Toxoid is used to prevent tetanus (also known as lockjaw).

Tetanus is a serious illness that causes convulsions (seizures) and severe muscle spasms that can be strong enough to cause bone fractures of the spine.
What are the measures do you take when monitoring fluid hydration?
Record UO (30-100 mL/hour)

Increase IV fluids to keep UO normal flow

Weigh patient

S/S inadequate hydration: restlessness, disorientation, hypothermia, decreased UO
What are the measures do you take when monitoring respiratory functioning?
Provide care for intubation


Monitor ABGs

Observe for cyanosis, disorientation

Administer O2

Encourage use of incentive spirometer, coughing, and deep breathing
What are the measures do you take when providing wound care?
Use aspeptic technique

Debridement and dressings changes according to client's condition.

Change dressings in minimum time, premedicate (painful!)

Maintain room temperature above 90 'F, humidified, free of drafts

Monitor body temperature frequently; have hyperthermia blankets available
HES HINT: Infection and Burns
Infection is a life-threatening risk for those with burns.
What do you look for in paralytic ileus?
No bowel sounds

Nausea and vomiting

Abdominal distention
Assisting with pain management in burn patient. What are interventions you would take?
Analgesics IV

Teach distraction/relaxation techniques

Teach use of guided imagery
How do you know that the patient is in the acute phase of burn injury?
Fluid shifts from interstitial to intravascular space (diuresis begins)

Occurs from 72 hours to two weeks after initial injury to near completion of wound closure
What are the nursing interventions you want to provide during the acute phase of a burn?
Infection control

Splint client to prevent contractures. Avoid use of pillows with neck burns.

Perform ROM. It is very painful, though.

Provide fluid therapy; colloids to keep fluid in vascular space.

Provide adequate nutrition.
Infection control and burns
Maintain protective isolation of entire burn unit

Cover hair at all times

Wear masks during dressing changes

Use sterile technique for hydrotherapy, dressing change, and debridement

Live plants and flowers are prohibited
Acute Phase of Burns: Performing ROM. What do you do?
Give pain meds before you start ROM.

Perform ROM 3-5 minutes frequently during the day.

Mobilize as soon as possible using splints for the client.

Encourage active ROM when up and about.
Acute Phase of Burns: Provide fluid therapy for patients
Use colloids to keep fluid in the intravascular space

Monitor serum chemistries at all times

Keep an IV site available; a heparin lock is helpful

Maintain strict I&O

Encourage oral intake of fluids
Acute Phase of Burns: adequate nutrition
High-calorie (up to 5000 calories/day)



Give supplements via NG tube feeding at night if caloric intake is inadequate

Keep accurate calorie counts

Administer all medications with either milk or juice

Weigh daily
Acute Phase of Burns: Provide burn/wound care
Cleansing per your agency routine (daily or up to TID)

Wet to dry dressing changes two or three times daily to remove eschar

Apply silver sulfadiazine (Silvadene) ormafenite acetate (Sulfamylon) to burn

Closed/Open Method - according to your agency policy

Prepare client for grafting when eschar has been removed

Prepare client for autograpfts (usng own skin)

Use heat lamp to donor site following graft to allow the area to reepithelize
HESI HINT: Pre-existing conditions
Preexisting conditions that might influence burn recovery are age, chronic illness (diabetes, cardiac problems, etc), physical disabilities, disease, medications used routinely, and drug/alcohol abuse.
Mafenie acetate (Sulfamylon)

Is a topical anitmicrobial agent

What is it indicated for?

What is the nx implication?
Treatment of burns

Usually used in OPEN method of wound care

Pain meds PRIOR to dressing changes

Penetrates wound rapidly
Silver Sulfadiazine (Silvadene)

Is a topical anitmicrobial agent

What is it indicated for?

What is the nx implication?
Treatment of burns

Usually used in OPEN method of wound care

Used to avoid acid-base complications

Keeps eschar soft, making debridement easier
Rehabilization phase is characterized by...
absence of infection risk

ongoing discharge planning

May return home when the danger of infection has been eliminated

High-protein fluids with vitamin supplement

Pressure dressings such as Jobst garments may be worn continuously to prevent hypertrophic scaring and contractures
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