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BURNS Advanced Adult Nursing questions & answers.
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BURNS Advanced Adult Nursingquestions & answers.
Thermal Burn ANS - Result when clothes ignite from heat or flames that electrical sparks produce.
Chemical Burn ANS - Results from exposure to a caustic agent. Cleaning agents in the home (drain
cleaner, oven cleaner, bleach) agents in the industrial setting (caustic soda, sulfuric acid) can cause
chemical burns.
Electrical burns ANS - Result when an electrical current passes through the body and can cause severe
damage, including loss of organ function, tissue destruction with subsequent need for amputation of
limb, and cardiac or respiratory arrest.
Rule of Nines ANS - Quick method to approximate the extent of burns by dividing the body into
multiples of nine. The sum equals the TBSA.
Lund and Browder Method ANS - A more exact method of estimating the extent of burns by the
percentage of surface area of specific anatomic parts, particularly the head and legs.
Child rule of nine ANS - Add 1/2% to each leg for each year over age 1.
Subtract 1% from the head area for each year over age 1.
Adult rule of nine ANS -
Palmar Method ANS - Quick method to approximate scattered burns using the palm of the client's hand.
The palm of the hand (including the fingers) is equal to 1% TBSA.
Phases of burn care ANS - Emergent
Acute
Rehabilitative
, Emergent phase of burn care ANS - Begins with the injury and continues for 24 to 48 hours
Priorities include securing the airway, supporting circulation and organ perfusion by fluid replacement,
managing pain, preventing infection through wound care, maintaining body temperature, and providing
emotional support.
Acute phase of burn care ANS - Begins 36 to 48 hours after injury when the fluid shift resolves
Ends with closure of the wound
Priorities include assessment and maintenance of the cardiovascular, respiratory, and gastrointestinal
systems (including nutrition); wound care, pain control, and psychosocial interventions
Rehabilitative phase of burn care ANS - Begins when most of the burn areas are healed.
Ends when the client achieves the highest level of functioning possible.
Priorities include psychosocial support, prevention of scars, and contractures, and resumption of
activities, including work, family, and social roles.
This phase can last for years.
Superficial thickness burn ANS - Damage to epidermis
Pink to red
No blisters
Mild edema
No eschar
Painful/tender
Sensitive to touch and heat
Heals within 3 to 6 days
No scarring
Examples: sunburn and/or flash burn (sudden intense heat)
Superficial partial thickness burn ANS - Damage to the entire epidermis and some parts of the dermis
Pink to red
BLISTERS are present
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