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NUR275 Exam Two Questions And Correct Answers
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NUR275 Exam Two Questions And Correct AnswersImmediate Care of Burn
Stop the burning process
-Cool the wound with cold water to reduce oxygen consumption & circulation, thus
reducing edema & total cellular damage
Superficial (First-Degree) Burns
AKA SUNBURN
Superficial (First-Degree) Burns
-Involves damage only to the epidermis
-Skin is pink to red, without blisters & dry to painful to the touch
-Healing occurs within 3-5 days
Superficial Partial-Thickness (Second-Degree) Burns
Superficial Partial-Thickness (Second-Degree) Burns
-May be further classified as superficial partial thickness or deep partial thickness
-Involves epidermis & upper layers of dermis
,-Blistering is a classic sign
-Burns blanch when pressure is applied
-Healing occurs in 10-21 days with minimal scarring
-When blisters rupture, burns appear moist, bright red, or mottled in color, extremely
pain to touch Deep Partial-Thickness Burn
-Destruction of epidermis & most of dermis
May blister, most often appears slightly moist to dry & dark red to pale in color
Patient may complain of more discomfort than pain
Skin grafting may be necessary
Pressure applied to burn may blanch slowly or not at all
Full Thickness Third-Degree Burns
Destroys all layers of skin
Burns dry, leathery & firm
Appears white or charred
,Insensate to touch Not painful
Doesn't blanch when pressure is applied
Signs of Smoke Inhalation
Altered level of consciousness
Coughing up smoke
-Singed nose hairs
-Burnt oral tissues
Carbon Monoxide Poisoning:
-Cherry red mucous membranes
-Carboxyhemoglobin over 9%
-Altered LOC
-Headache
-Dizziness
-N/V
, -Chest pain
Smoke Inhalation:
Priority Interventions
-Administer high flow o2 ASAP (8-10 via face mask)
-Continuously monitor o2 with pulse ox
-Obtain ABGS & Carboxyhemoglobin levels
-PaO2 <60 indicates a need to intubate as well as swelling of trachea or airway
obstruction *Report immediately*
-Monitor LOC
Electrical Burns:
Priority Care
-NO WATER at the time of burn, water conducts electricity
Assess pt for entry/exit wounds, anything between them could be compromised/burned
Heart can be affected, get on heart monitor ASAP
Burns:
Rule of 9s
Apply the rule of nines to the burn casualty to determine the percentage of body area
burned in an adult
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