Term
| Signs of local infections |
|
Definition
*Conversion of a partial-thickness injury to a full-thickness injury
* Ulceration of healthy skin at the burn site.
* Erythematous, nodular lesions in uninvolved skin and vesicular lesions in healed skin
*Edema of healthy skin surronding the burn wound
*Excessive drainage
*Pale, boggy, dry, or crusted granulation tissue
*Wound breakdown after closure
*Odor |
|
|
Term
|
Definition
* Altered level of consciousness
* Changes in vital signs (tachycardia, tachypnea, temperature, instability, hypotension)
* Increased fluid requirements for maintenance of a normal urine output.
* Hemodynamic instability
* Oliguria
* GI dysfunction(diarrhea, vomiting, abd distention, paralytic ileus)
* Hyperglycemia
*Thrombocytopenia
* Change in total WBC count (above or below normal)
* Metabolic acidosis
*Hypoxemia |
|
|
Term
| Acute phase of burn injury- priority nursing intervention |
|
Definition
| Assess the cardiovascular and respiratory systems to maintain these systems and to identify or prevent complication. |
|
|
Term
| What technique to care for burn wounds? |
|
Definition
|
|
Term
| Increased metabolic demands (nursing care) |
|
Definition
| Weigh the patient daily without dressings or splints, and compare itwith his or her preburn weight. 2% mild deficit and 10% or more is important and requires the evaluation and modification of calorie intake. (calorimetry may be preformed (at rest 30 min after dressing change) |
|
|
Term
| Serious complication during acute phase of recovery |
|
Definition
| Burn wound sepsis and infection |
|
|
Term
| Musculoskeletal assessment of burn patient |
|
Definition
| Assess active and passive ROM for all joints including neck. Give special attention to joints in burn area. |
|
|
Term
| Priority problems for patients with burn injuries greater that 25% |
|
Definition
1. Wound care management related to burn injury, skin grafting procedures, and immobilization.
2.Potential for infection related to open burn wounds, the presenceof multiple invasive catheters, reduced immune function, and malnutrition.
3.Excessive weight loss related to increased metabolic rate, reduced calorie intake, and increased urinary nitrogen losses.
4. Reduced mobility related to open wounds, pain, and scares and contractures.
5. Reduced self-image related to trauma, changes in physical appearance and lifestyle, and alterations in sensory and motor function. |
|
|
Term
| Indicators of no wound extension and wound healing |
|
Definition
1.Has presense of granulation, re-epithelialization, and scare tissue.
2. Has decreased wound size.
3. Has no new wounds. |
|
|
Term
| Nonsurgical burn wound management |
|
Definition
| removing exudates and necrotic tissue (debridement), cleaning the area, stimulating granulation, andrevascularization, and applying dressings. |
|
|
Term
| Prepaing wound for grafting and wound closure-priority nursins interventions |
|
Definition
| Accessing the wound, providing wound care, and preventing infection and other complications. |
|
|
Term
| Hydrotherapy- Mechanical Debridement |
|
Definition
| one or two times each day- preform to debride and examine the wounds. Often performed by showering the patient on a specially designed shower table,or washingonly small areas ofthewound at bedside. wash burn areas thoroughly and gently with mild soap or detergent and water. Then rinse these areas with room-temperature water. (Use forceps and scissors to remove loose, nonviable tissue. |
|
|
Term
| Enzymatic debridement (autolysis) |
|
Definition
| disintegation of tissue by the active of the patient's own cellular enzymes. to slow for large wounds |
|
|
Term
| Enymatic debridement (topical agents) |
|
Definition
| collagenase (Santyl)- rapid- digest necrotic tissues- require most enviroment within a specific pH. |
|
|
Term
| number of gauze layers depends on |
|
Definition
| Depth of the injury, amount of drainage, Area injured, Patient's mobility,Frequency of dressing changes. |
|
|
Term
| How often dressing usually changed and reapplied |
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| patient's skin grown in laboratory to form cell sheets |
|
|
Term
|
Definition
| biologic dressing0 does not develop blood supply and disintegrates in 48 hours. |
|
|
Term
|
Definition
| two layer (beef collagen and shark cartilage)fibroblasts move in artifical dermis dissolves and replaced with blood vessels. |
|
|
Term
| Biosynthetic wound dressings |
|
Definition
| collagen + nylon fabric- The nylon fabic comes into contact with the wound surface and adheres to it until epithelialization has occurred. Porous= exudates pass through. |
|
|
Term
|
Definition
| solid silicone and plastic membranes- transparent or translucent- decrease pain because wound edges not exposed to air. This dressing type promotes faster healing with low infection rates, minimal pain, and reduced cost. |
|
|
Term
|
Definition
| most common tx for full-thickness and deep partial-thickness wounds. operated on 5 days after injury and again as needed until wounds closed. |
|
|
Term
| More coverage from donor sites |
|
Definition
| Repeated removal of skin from the donor site allowing time better harvests for healing or mesh |
|
|
Term
| Interventions- Nonsurgical management priorities |
|
Definition
| Priciples of asepsis to prevent infection transmission, providing a safe environment, and monitoring for early detention of infection. |
|
|
Term
|
Definition
| Pervasive odor, Color changes (focal, dark red, brown in the eschar), Changes in texture, Purulent drainage, Exudate, Sloughing grafts, Redness at the wound edges, extending to nonburned skin |
|
|
Term
| Patient expected to maintain adequate nutrient intake for meeting the body's calorie needs..... these should stay in range |
|
Definition
* Weight/height ratio
* Food intake
* Hematocrit and hemoglobin
* Serum albumin
* Blood glucose |
|
|
Term
minimal limitations to
*Muscle movement, Joint movement, Walking, and body positioning performance- interventions |
|
Definition
| Nonsurgical management include the nursing interventions of positioning, ROM excercises, ambulation, and pressure dressings. |
|
|
Term
|
Definition
| because the position of comfort for the patient is often one of joint flexion, which leads to contracture development. Maintain the patient in a neutral body position with minimal flexion. |
|
|
Term
| ROM excises how many times a day? |
|
Definition
|
|
Term
| When is ambulation started |
|
Definition
| as soon as possible after the fluid shifts have resolved. (2 or 3 times a day and progresses in length each time. |
|
|
Term
|
Definition
| inhibits bone density loss, strengthens muscles, stimulates immune function, promotes ventilation, and prevents many complications. |
|
|
Term
|
Definition
Thermal
Chemical
Electrical
Radioactive |
|
|
Term
| Most common radiation burn |
|
Definition
|
|
Term
|
Definition
Temp regulation
Sweat and sebaceous gland function
Sensory function
Metabolism increases to maintain body heat |
|
|
Term
| Severity of burn depends on |
|
Definition
Percentage of total body surface area (TCSA)
Depth of the burn
Age
Causative agent
Involvement of respiratory system
Overall health
Body location or the burn (thinner skin areas face, hand, perineum, feet) |
|
|
Term
|
Definition
*Emergent first 24 to 48 hours (resuscitative phase)
* Acute- begins with fluid resuscitation is finished- ends when the wound is covered by tissue.
* Rehabilitative- begins when ost of the burn area is healed, ends when reconstructive and corrective procedues are complete. |
|
|
Term
|
Definition
|
|
Term
| Risk for Death from burns |
|
Definition
Age > 60 years
Burn involves > 40% (TBSA)
Inhalation injury |
|
|
Term
| Why are pressure dressings used |
|
Definition
| applied after grafts heal to help prevent contractures and tight hypertrophic scars,which can inhibit mobility. they also inhibit venous stasis and edema in areas with decreased lymph flow. Worn at least 23 hours a day, every day until scar tissue is mature (12 to 24 months). |
|
|
Term
| sighs of positive perception of appearance |
|
Definition
| * Willingness to touch the affected body part, Adjustment to changes in body function, Willingness to use stratigies to enhance appearance and function, Successful progression through the grieving process, Use of support systems. |
|
|
Term
| Rehabilitative phase includes? |
|
Definition
| The emphasis is on the phsychosocial adjustment of the patient, the prevention of scars and contractures, and the resumption of preburn activity, including resuming work, family, and social roles. (takes years) |
|
|
Term
| What do you evaluate the home for? |
|
Definition
| cleanliness, access to bathing facilities, electricity, and running rater; stairways; number of occupants; temperature control; and safety. |
|
|
Term
| Before dischange all people who will be involved in patient's home care should know.... |
|
Definition
S/s of infection
Drug regimens
Proper use of prosthetic and positioning devices
Correct application and care of pressure garments
Comfort measures to reduce pruritus
Dates for follow-up appointments |
|
|
Term
| Inhalation damage may include |
|
Definition
| singed nasal hair, eye brows, and eye lashes, sooty appearance to sputum; hoarseness; and wheezing |
|
|
Term
| Clinical manifestations of inhalation damage |
|
Definition
| May not manifest until 24 to 48 hours after even.... and are seen as wheezing, hoarseness, and increased respiratory secretions. |
|
|
Term
| s/s of carbon monoxide inhalation |
|
Definition
| erythema (pink or cherry red color of skin) and upper airway edema, followed by sloughing of the respiratory tracft mucosa |
|
|
Term
| Hypovolemic and shock (20% to 30% TBSA occurs) |
|
Definition
| Fluid shifts from the intercellular and intravascular space to the interstitial space (hypotension, tachycardia, and decreased cardiac output. |
|
|
Term
| Inital fluid shift (Hct and Hgb, Sodium, and Potassium) |
|
Definition
Hct/Hgb- elevated due to loss of fluid volume and fluid shifts into interstitial spacing (third spacing)
Sodium-decreased due to third spaceing
Potassium- Increased due to cell destruction |
|
|
Term
| Fluid mobilization (48 to 72 after injury)- (Hgb and Hct, Sodium, Potassium) |
|
Definition
Hgb and Hct- Decreased due to fluid shift from interstitial back into vascular fluid
Sodium- Remains decreased due to renal and wound loss
Potassium- decreased due to renal loss and movement back into cells
WBC- initiall increased then decrease with left shift.
Blood glucose- elevated because of stress
ABGs- Slight hypoxemia and metabolic acidosis
Total protein and albumin- low due to fluid loss |
|
|
Term
|
Definition
confusion
Increased capillary refill time
Urine output less than 30 ml/hr
Spiking fever
Decreased bowel sounds
Blood pressure may remain normotensive, even in hypovolemia. |
|
|
Term
| because of hypermetabolic and hypercatabolic state how many calories might a person need |
|
Definition
|
|
Term
| Wound care- nursing actions |
|
Definition
Premedicate the client
Remove all previous dressings
Assess for odors, drainage, and discharge
Clease the wound as a prescribed, removing all previous ointments (it is importantto cleanse the wound thoroughly) |
|
|
Term
| Airway s/s of injury (after 24 to 48 hours) |
|
Definition
| progressive hoarseness, brassy cough, difficulty swallowing, drooling, increased secretions, adventitious breath sounds, and expiratory sounds that increase audible wheezes, crowing and stidor. |
|
|
