NUR 202 Exam 3 Review_Complex Health Concepts_Graded A | NUR202 Exam 3 Review_2022/2023

NUR 202 Exam 3 Review_Complex Health Concepts Exam 3 prep Burns: The tissue destruction caused by a burn injury leads to local and systemic problems that affect fluid and electrolyte balance and lead to protein losses, sepsis, and changes in metabolic, endocrine, respiratory, cardiac, hematologic, and immune functioning. The extent of problems is related to age, general health, extent of injury, depth of injury, and the specific body area injured. Even after healing, the burn injury may cause late complications such as contracture formation and scarring. Thus, care priorities are the prevention of infection and closure of the burn wound. A lack of or delay in wound healing is a key factor for all systemic problems and a major cause of disability and death among patients who are burned. CHARACTERISTIC SUPERFICIAL SUPERFICIAL PARTIAL- THICKNESS DEEP PARTIAL- THICKNESS FULL- THICKNESS DEEP FULL- THICKNESS Color Pink to red Pink to red Red to white Black, brown, yellow, white, red Black Edema Mild Mild to moderate Moderate Severe Absent Pain Yes Yes Yes Yes and no Absent Blisters No Yes Rare No No Eschar No No Yes, soft and dry Yes, hard and inelastic Yes, hard and inelastic Healing time 3-6 days About 2 wk. 2-6 wk. Weeks to months Weeks to months Grafts required No No Can be used if healing is prolonged Yes Yes CHARACTERISTIC SUPERFICIAL SUPERFICIAL PARTIAL- THICKNESS DEEP PARTIAL- THICKNESS FULL- THICKNESS DEEP FULL- THICKNESS Example Sunburn, flash burns Scalds, flames, brief contact with hot objects Scalds; flames; prolonged contact with hot objects, tar, grease, chemicals Scalds; flames; prolonged contact with hot objects, tar, grease, chemicals, electricity Flames, electricity, grease, tar, chemicals • Assess for airway patency. • Administer oxygen as needed. • Cover the patient with a blanket. • Keep the patient on NPO status. • Elevate the extremities if no fractures are obvious. • Obtain vital signs. • Initiate an IV line and begin fluid replacement. • Administer tetanus toxoid for prophylaxis. • Perform a head-to-toe assessment. Specific Management Flame Burns • Smother the flames. • Remove smoldering clothing and all metal objects. Chemical Burns • If dry chemicals are present on skin or clothing, DO NOT WET THEM. • Brush off any dry chemicals present on the skin or clothing. • Remove the patient's clothing. • Ascertain the type of chemical causing the burn. • Do not attempt to neutralize the chemical unless it has been positively identified and the appropriate neutralizing agent is available. Electrical Burns • At the scene, separate the patient from the electrical current. • Smother any flames that are present. • Initiate cardiopulmonary resuscitation. • Obtain an electrocardiogram (ECG). Radiation Burns • Remove the patient from the radiation source. • If the patient has been exposed to radiation from an unsealed source, remove his or her clothing (using tongs or lead protective gloves). • If the patient has radioactive particles on the skin, send him or her to the nearest designated radiation decontamination center. • Help the patient bathe or shower. The resuscitation phase is the first phase of a burn injury. It begins at the onset of injury and continues for about 24 to 48 hours. During this phase, the injury is evaluated and the immediate problems of fluid imbalance (loss), edema, and reduced blood flow are assessed. The priorities for management during this period are to (1) secure the airway, (2) support circulation and organ perfusion by fluid replacement (parklands 4ml × Kg × % body burned) ½ the first 8hr and ½ over the next 16hrs If pt comes in with IV fluids started by EMS, the nurse should minus that amount already received from the first 8hrs) (3) keep the patient comfortable with analgesics, (4) prevent infection through careful wound care, (5) maintain body temperature, and (6) provide emotional support. Patient will be placed in reverse isolation to protect them from infections Everyone should have gown, gloves, mask. Sterile sheets on bed, Pt will be swollen due to the fluids shifting in third spacing. Explain to family that this is a normal process in burns and that once fluid is replaced the body will return to normal. Always assess pulse, motor sensory Diet: High protein-beans, meats peanut butter, nuts If pt has soot in nares or oral cavity you should suspect inhalation injury. Pt will be at risk for compromised airway will show signs of drooling, become progressively hoarse, develop brassy cough, wheeze, stridor, crowing, increased restlessness nonrebreather mask should be applied if patient has burns to facial area place a sterile gauze before putting mask on pt. Priority for burn pts FLUIDS, INFECTION, PAIN Skin cancer Any skin cancer occurs as a result of failure of cellular regulation over cell division. Overexposure to sunlight is the major cause of skin cancer, although other factors also are associated. Because sun damage is an age-related skin finding, screening for suspicious lesions is an important part of physical assessment of the older adult. The most common skin cancers are actinic or solar keratosis, squamous cell carcinoma, basal cell carcinoma, and melanoma.