how long is the acute phase of burns? what is the patient at risk for?
48-72 hours and goes until wound heals Risk for interventions
Buck's traction is a type of skeletal traction? True/ False
False, skin traction
A 5-year-old boy suffers burns to the anterior right arm, entire head, and anterior right leg. Calculate the total BSA percentage affected using the Rule of Nines for children.
22.5%
A 70kg patient has 9% burns to their body, determine the amount of fluid needed over 24 hours? 8hr mark, 16 hr mark, 24 hour mark.
2520, 1st 8 hours: 50% of total → 1260 mL 2nd 8 hours: 25% of total → 630 mL 3rd 8 hours: 25% of total → 630 mL
Increased bone resorption and decreased bone formation cause a loss of bone density in the aging adult? True/ False
True
numbness and tingling, "pins and needles" sensation
Paresthesia
Unequal leg length bilaterally is a normal assessment finding? True/ False
False, abnormal finding
what interventions should a nurse take during the emergent phase of a burn
time of injury Immediate Assess for the airways complications Hypovolemic shock risk is high IV fluid replacement
what is carbon monoxide poisoning classified as?
thermal burn
iceberg effect
electrical burn
lnhilation injury
A patient is having increased swelling and pressure status post fracture of left radius. Patient reports pain, numbness and tingling. The nurse notes that pulses are decreased upon assessment. What does the nurse suspect?
rhabdomyolysis
VTE
PE
compartment syndrome
When a patient is status post hip fracture/ repair, the nursing priorities should be pain management and fall prevention. True/ False
True
what % of carbon monoxide inhalation is toxic
12%
5%
10%
15%
how do you deliver oxygen to a patient with carbon monoxide poisoning?
100% on nonrebreather
100% on venturi mask
room air
4l nasal canula
Buck's traction is often used with what types of fractures?
hip and femur, sometimes knee
What would indicate the need for further teaching for pt post THR?
"I can drive in a few weeks."
"I should not cross legs at knees or ankles."
"I should use an elevated toilet seat."
"I should use a shower chair in the shower or tub."
frequent, audible crackling sound with palpable grating that accompanies movement
torticollis
spasicity
subluxation
crepitation (crepitus)
Nurses can mark location of pulses to aid repeat assessments. True/ False
True
a patient is in the hospital receiving IV antibiotic therapy for acute osteomyelitis of his left tibia. Which intervention would be implemented by the nurse?
immobilization of affected leg
avoid administration of NSAIDS
Support affected leg in flexed posisiton
frequent weight-bearing exercises
what does increased carbon monoxide poisioning mean in the body?
increases oxygen in the blood
decrease in carbon in the body
Increased carbon monoxide means it replaces oxygen in RBC
what is a fourth degree burn
muscles tendons and bones
(superficial) epidermis Dry but blanchable, superficial
full thickness) Black, Non blanchable, charred
full thickness) Black, Non blanchable, charred
A child has burns on the anterior torso, right leg, and the entire left arm. Use the Rule of Nines to calculate the total BSA percentage affected.
45%
A patient is an adult male who has burns to the anterior chest, left arm, and the entire right leg. Calculate the total BSA percentage affected.
45%
A patient with an open fracture to the right fibula and soft tissue damage underwent a ORIF with debridement of tissue and had drain placed. When assessing the pt during the postop period, what finding would the nurse be most concerned?
fever with chills and night sweats
muscle spasms around the affected bone
pain on movement of affected limb
light yellow drainage from the wound
An adult male has burns on the anterior head, both arms, and the posterior trunk. What is the total BSA percentage affected?
40.5%
What fracture is most disabling for an older adult?
hip fracture
Pt experiencing bruising and swelling of the wrist. Pt. reports loos of function and pain. What does the nurse suspect?
fracture of the wrist
Prioritize: 15% TBSA burns (partial thickness) on the arms and legs, stable vital signs B: 25% TBSA burns (full thickness) on the torso, exhibiting signs of shock. C: 5% TBSA burns (partial thickness) on the face and neck,
B
Cast Care: Which one does not belong? Do not get cast wet, do not insert objects into the cast, if the cast begins to smell cover with plastic, move joints above and below the cast
cover the cast with plastic if it begins to smell
A 30-year-old woman has burns covering her posterior trunk, the entire left leg, and the anterior right arm. Determine the total BSA percentage affected.
40.5%
what are signs and symptoms of carbon monoxide poisoning?
confusion, anxiety, facial burns, sooty nose or mouth
what are interventions for the acute phase?
Wound care Healing starts to occur Skin grafting if needed Monitor labs (F/E) Diuretics
A patient presents with right sided shoulder weakness, pain and decreased ROM. The patient reports pain when the arm is abducted between 60 and 120 degrees. What type of injury does the nurse suspect?
Rotator cuff injury
A 70 kg patient has 36% burns to their body, determine the amount of fluid needed over 24 hours? 8hr mark, 16 hr mark, 24 hour mark.
10080, 1st 8 hours: 50% of total → 5040 mL 2nd 8 hours: 25% of total → 2520 mL 3rd 8 hours: 25% of total → 2520 mL
A patient is post op a rotator cuff repair. What post op education would the nurse provide to the patient?
there are no weight restrictions on lifting
passive exercise should begin 1st post op day
recovery usually takes 6 weeks
keep arm at side during recovery
With suspected compartment syndrome the afffected extremity should be elevated above the heart and cold compresses applied. True/ False
False, these two actions may cause vasoconstriction and worsen the compartment syndrome.
Orthopedic surgical patients are often given prophylactic anticoagulant drugs for at least 10-14 days. True/ False
True, orthopedic surgical patients are high risk for venous thromboembolism (VTE)
What 5 things are checked during a neurovascular assessment of an affected extremity, distal to a fracture?