NUR 185 EXAM 2 Latest 2023 with complete solution
STAGES OF BURNS
stage 1 emergent
stage 2 acute
stage 3 rehab
stage 1 emergent phase
-onset first 12-48 hrs
-hypovolemic shock
-hyperkalemia, oliguric
-cardiac dysrhythmia
-acute renal failure
stage 2 acute phase
-first 48-72 hrs
-circulatory overload
-hypokalemia
-polyuria
-chf
stage 3 rehab phase
-prevent infection
-return pt to normal state
-help pt cope with self esteem/appearance
stage 1 emergent phase interventions
-airway o2 ET tube
-LR
-foley/i&o
-ng tube
-analgesics
-vital signs
-tetanus toxoid
stage 2 acute phase interventions
-monitor fluid shifts
-monitor urine output
-treat burns
-prevent renal failure
-prevent hf
-prevent curling's/duodenal ulcers
-prevent contractures
1st degree burn
-superficial
-dry w/o vesicles
-sunburn
2nd degree partial thickness burn
-large moist vesicles
-very painful
3rd degree burn
, -dry w/leathery eschar
-charred vesicles
-no nerve endings/pain
-hot liquids, chemicals, electrical
4th degree burn
-destruction of entire skin
RACE
Rescue
Alarm
Contain fire
Extinguish/evacuate
PASS
Pull
Aim
Squeeze
Sweep
tb test
intradermal
3 types of fire extinguishers
A-paper, wood, plastic
B-flammable, combustible liquids
C-electrical equipment
air embolus
-air leaked in to pts vein
-break in iv line/air in line
air embolus nursing intervention
-turn to left side
-trendelenberg position
speed shock
-administering fluids faster than body can handle
ng tube feeding
-check residual before every feeding
smoke inhalation
-fumes damage cilia/mucosa of the respiratory tract
-decreased alveolar surfactant/atelectasis can occur
atelectasis
-can take several hrs for signs to appear
-increased risk with burns to face/neck/upper chest
smoke inhalation s/s
-cough
-hoarseness
-singed nasal hairs
-tachypnea
-nostril flaring
-agitation
-brassy cough
STAGES OF BURNS
stage 1 emergent
stage 2 acute
stage 3 rehab
stage 1 emergent phase
-onset first 12-48 hrs
-hypovolemic shock
-hyperkalemia, oliguric
-cardiac dysrhythmia
-acute renal failure
stage 2 acute phase
-first 48-72 hrs
-circulatory overload
-hypokalemia
-polyuria
-chf
stage 3 rehab phase
-prevent infection
-return pt to normal state
-help pt cope with self esteem/appearance
stage 1 emergent phase interventions
-airway o2 ET tube
-LR
-foley/i&o
-ng tube
-analgesics
-vital signs
-tetanus toxoid
stage 2 acute phase interventions
-monitor fluid shifts
-monitor urine output
-treat burns
-prevent renal failure
-prevent hf
-prevent curling's/duodenal ulcers
-prevent contractures
1st degree burn
-superficial
-dry w/o vesicles
-sunburn
2nd degree partial thickness burn
-large moist vesicles
-very painful
3rd degree burn
, -dry w/leathery eschar
-charred vesicles
-no nerve endings/pain
-hot liquids, chemicals, electrical
4th degree burn
-destruction of entire skin
RACE
Rescue
Alarm
Contain fire
Extinguish/evacuate
PASS
Pull
Aim
Squeeze
Sweep
tb test
intradermal
3 types of fire extinguishers
A-paper, wood, plastic
B-flammable, combustible liquids
C-electrical equipment
air embolus
-air leaked in to pts vein
-break in iv line/air in line
air embolus nursing intervention
-turn to left side
-trendelenberg position
speed shock
-administering fluids faster than body can handle
ng tube feeding
-check residual before every feeding
smoke inhalation
-fumes damage cilia/mucosa of the respiratory tract
-decreased alveolar surfactant/atelectasis can occur
atelectasis
-can take several hrs for signs to appear
-increased risk with burns to face/neck/upper chest
smoke inhalation s/s
-cough
-hoarseness
-singed nasal hairs
-tachypnea
-nostril flaring
-agitation
-brassy cough
