NURSING 480 STUDY GUIDE AND ANSWERED FINAL EXAM (GUARANTEED SUCCESS)
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Course
NUR 480
Institution
NUR 480
NUR 480 STUDY GUIDE AND ANSWERED FINAL EXAM
Rule of 9's
● Head: front and back each is 4.5%
● Torso: chest and abdomen 9% each
● Back: upper and lower 9% each
● Arms: front and back 4.5% each, 9% total for one arm
● Groin: 1%
● Legs: front and back 9% each, 18% total for ...
Rule of 9's
● Head: front and back each is 4.5%
● Torso: chest and abdomen 9% each
● Back: upper and lower 9% each
● Arms: front and back 4.5% each, 9% total for one arm
● Groin: 1%
● Legs: front and back 9% each, 18% total for one leg
●
Burns
● Body tissue injuries by thermal, chemical, electrical or radioactive agents
● Results in destruction of skin layers, and underlying tissues
● Loss of temperature regulation, sweat and sebaceous gland function and sensory
function
● Health Promotion/Disease Prevention
○ Fire extinguishers, smoke alarms, emergency numbers, never re-enter a
burning building, exit plan for fires, “stop, drop, & roll”, store matches &
lighters out of reach, reduce water heater setting to below 120oF, annual
inspection & cleaning of fireplace, cover electrical outlets, wear gloves with
chemicals, avoid tanning beds, avoid smoking in bed, matches/lighters out of
reach for children, don’t leave hot objects on the edge of counter, never add
flammable substances (gasoline, lighter fluid, kerosene) to an open flame
,● Severity depends on:
○ Percentage of total body area
○ Depth of burn
○ Location of burn
○ Patient’s age
○ Causative agent
○ Presence of other injuries
○ And involvement of the respiratory system and the overall health of the patient
● Extent of body surface
○ Rule of Nine: quick, multiples of 9
○ Lund and Browder Method: more exact, percentages for anatomical parts
○ Palmer method: quick, scattered burns, patient’s palm size is 1% of total body
surface area (TBSA)
● Depth of Burn and Manifestations
Class Degree Layer Appearance Example Pain
heali
ng
, superficial 1st epidermis Pink-red, sunburn Yes
tender, mild 3-6 days
edema
Superficial 2nd Epidermi Pink-red, Flame Yes
partial s Part of blisters, mild- Burn 3 weeks
dermis moderate edema scalds
Deep partial 3rd Epiderm Red-white, Grease Yes
is Deep moderate Tar 2-6
dermis edema, soft/dry Chemi weeks
eschar cal
scarring/graftin Electri
g cal
burns
Full thickness 3rd Epiderm Red-tan, black, Grease Yes or
is Deep brown, white, Tar no
dermis severe edema, Chemi Weeks
Extende hard inelastic cal -
d to eschar Electri month
subcutaneous cal s
tissue Nerve burns
damage
Deep full 4th All layers, Black with no Electri No
muscles, edema, eschar cal Wee
tendons, and hard inelastic burns ks-
bones flames mont
hs
● Assessment
○ Risk factors for death from burns
■ Older than 60
■ Burn involves more than 40% of total body surface area
■ Inhalation injury
● Lab Tests
○ CBC
○ Electrolytes
○ BUN
○ Carboxyhemoglobin
○ ABGs
○ Glucose
○ Liver function tests (LFT)
○ Urinalysis
○ Clotting studies
● Phases of Burn Care
○ Emergent: Resuscitative ( 1st 24-48 hours)
○ Acute: wound healing (begins when fluid resuscitation is done and ends when
, wound is covered by tissue)
○ Rehabilitative: restorative (begins when most of burn area is healed and
ends when client achieves highest level of functioning possible
● Nursing Interventions
○ Moderate to Major burns
■ IV fluid replacement using Parkland Formula (amount of fluid for 1st
24 hours from burn)
● 4 ml/kg/% burn
● Give ½ fluids in 1st 8 hours
● Give 2nd ½ over remaining 16 hours
● Deduct any fluid given prehospital from amount to be infused in
1st 8 hours
■ Monitor respiratory, cardiovascular, GI, and urinary systems
■ Give warm blankets for hypothermia
■ Pain management
■ Infection prevention
■ Nutritional support
■ Restoration of mobility to prevent contractures
■ Psych support
● Medications: Topical Agents: Antimicrobial Creams
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