185 FINAL EXAM Flashcards
Benzodiazepine, anti-anxiety, muslce relaxant, anti-convulsant
- Short acting
Use: Sedative (given in pre-op)
- Amnesia effect, produces sleep
Side effects:
- Drowsiness
- Confusion
- Hypotension
- Hepatotoxicity
- Low HR
Interventions: Vitals
Antidote: Flumazenil (Romazicon)
Midazolam
Dissolves chemical bonds w/in mucus making it separate/ liquiefying/ reducing viscosity
- Given as nebulizer
Use: Pneumonia, emphysema, asthma, & bronchitis
Side effects:
- N/V
- Tachycardia
- Hypotension
- Rotten egg oder
- Bronchospams (adverse)
Interventions:
- Vitals
- monitor cough & bronchial secretions
- Record GI symptoms before/after therapy
Antidote for Tylenol OD - Given PO
Mucomyst (Acetyl Cysteine)
Inhibits interaction of acetylcholine at recepter site on bronchial smooth muscle, resulting in bronchodilation
Use: Asthma, long term Tx or reversible bronchospasms associated w/ COPD
Adverse:
- Mouth dryness
- Throat irritation
- Dizziness
- Nasal congestion
Serious effects:
- Tachycardia
- Urinary retention
- Exacerbation of symptoms
Interventions:
- Vitals
- monitor cough & bronchial secretions
- Record GI symptoms before/after therapy
Ipratropium (Atrovent)
Corticosteroid - PO
- Decreases inflammation
- Caution w/ Diabetes (increases BS)
Use: severe inflammation, MS, asthma, COPD, pulmonary fibrosis
Side effects:
- Weight gain
- Depression, mood changes
- Poor wound healing
- Decreased immunity
Patient teaching:
- DO NOT STOP ABRUPTLY
- Taper off as Dr. directed
Prednisone
Deficiency of Pituitary hormone (TSH - Secondary hypothyroidism)
Deficiency of TSH decreases secretion of thyroid hormones
S/s:
* Decreased metabolic rate
* Lethargy, forgetfulness, irritability
* Headache, constipation
* Decreased HR, dyspnea
* Swelling/edema, dry/thick skin
* Coarse hair
Tx:
* Hormone replacement therapy - most commonly Levothyroxine (Synthroid)
Hypothyroid
Abnormal increased synthesis & secretions on the thyroid gland w/ overproduction of the thyroid hormone T3/T4 resulting inexaggeration of the metabolic processes
- Geaves disease & Multinodular goiter most common
S/s:
* Weight loss, hair loss, insomnia
* Intolerance of heat, personality changes
* Tachycardia, increased systolic BP/ HTN
* Afib, increased metabolic rate
* Edema to neck, termors, exophthalamos (eye buldging)
Tx:
* Radiation: destroys thyroid tissue, decreases homrone production
* Surgery: Thyroidectomy
* Drug therapy: Tapazole, PTU, Beta blockers, Iodides, Antithyroids, ect
Hyperthyroid
(Graves disease or Thyrotoxicosis)
What labs determine the diagnosis of hypothyroid?
Determination of free T4 & TSH
* Free T4 is low w/ hypothyroidism
Large amounts of thyroid hormone enter the bloodstream during surgery or when patients w/ severe hyperthyroidism develop a severe illness of infection
Approx. 12hrs after surgery is when s/s will occur
S/s:
- Tachycardia, cardiac dysrhythmias
- Vomiting, fever, confusion
Thyroid Storm
What electrolyte deficiency may occur with a thyroidectomy?
Hypocalcemia
Hypomagnesemia
low level of calcium in the blood (below 8)
* Results from diarrhea, inadequate dietary intake of vit. D, multiple blood transfusions, ect.
hypoalbuminemia is the most common
S/s:
* Trousseau’s sign
* Chvostek’s sign
* diarrhea
* tingling of fingertips and mouth, severe muscle cramps
* laryngospasms (most severe)
* Cardiac dysrhythmias, seizures
treat with oral or IV supplements
hypocalcemia
Synthetic hormone - IV,IM, PO
Use: Hypothyroidism, Myxedema coma, Thyroid replacement
Side effects:
* Anxiety, tachycardia
* Angina, HTN,palpitations, tachycardia
* N/V/H, cramps
* Thyroid storm (Adverse)
* Cardiac arrest (Adverse)
Nursing considerations:
* Assess BP & pulses periodically
* Daily weight (same time, clothes, ect)
* Monitor cardiac status
* Monitor vitals & labs T3/T4
BBW: Obesity Tx - Not taken to decrease weight
Education:
* Don’t switch brands unless approved
* Take in AM on empty stomach 30 min before food
* Monitor anticoagulent level & adjust dose PRN
Levothyroxine (synthroid, eltroxin, Levo-T)
Use: Makes thyroid hormones, bone & brain development in pregnancy
Route: PO, IV
Side effects:
* Burning mouth, throat, and stomach
* N/V/D/fever
* Weak pulse (adverse)
* Coma (adverse)
* Thyroid gland inflammaiton/cancer (adverse)
Nursing considerations:
* Monitor HR
* Monitor for hypersensitivity and GI bleed
BBW: Hepatic disease, No breastfeeding
Education:
* Take prenatals or Iodine supplements if preg
* Report abnormal bleeding
Iodine
Use: Prep for thyroidectomy, thyrotoxic crisis, hyperthyroidism, & thyroid storm
Route: PO
Side effects:
* N/V/D/H
* Vertigo
* Rash, alopecia
* Jaundice
* Liver failure
* Death
Nursing consideration:
* Assess for weight loss, fever, constipation, & weakness
* Monitor T4 (increases)
BBW: Hepatic disease, No breastfeeding
Education:
* Report redness, swelling, sore throat, mouth lesions, yellow skin/eyes, and dark stool/urine
Propylthiouracil (PTU)
Inhibits the synthesis of the thyroid hormones
Used after course of PTU
Used w/ a Lugol solution & SSKI (5% iodine & 10% SSKI)
Some relief w/in 24hrs
Can cause discoloration to teeth & gastric upset
Iodides
Excessive cortisol
Hypersecretion of the adrenal cortex resulting in production of excess amounts of corticosteroids
Causes:
* Endogenous - Pituitary tumor/ Adrenal tumor
* Exogenous - Prolonged admin. of high dose corticosteroids
S/s:
* Moon face, Buffalo hump
* Trucal obestiy, purple straie on abd., breast, or butt
* Hypokalemia, hyperglycemia, poor wound healing
* HTN
Tx/ interventions:
* Drug therapy: Mitotane, Metyrapone
* Radiation: Internally/Externally, destroys tissue
* Surgery: Transsphenodial hypophysectomy (pituitary gland), Adrenalectomy (adrenal tumor)
* Vitals & labs
* Skin assessment
* Educate on wearing a medical band
* Monitor for SI
* Caution on long term use of some herbs (celery, juniper, licorice, & parsley - Causes hypokalemia)
Cushings syndrome
What labs/tests can you use to Dx Cushings syndrome?
Labs:
* Plasma cortisol levels (High)
* ACTH (high)
Tests:
* Xray
* CT, MRI
* Angiography
What patient education would be provided for a Pt Dx w/ Cushings syndrome?
Do not blow nose (after surgery)
Monitor bleeding
Wound care (packing)
S/s of infection (Smell breath & packing if drainage)
What surgical intervention willl occur if their is a pituitary tumor causing Cushings disease?
Transsphenoidal microsurgery
Removal of adrenal glans
Post-op care:
* Admit to ICU
* Monitor vitals for s/s of shock
* monitor kidneys & strict I/Os
* Give vasopressor to decrease BP & HR
Adrenalectomy
Destructive disease process affecting adrenal glands that cause deficiencies of cortisol & aldosterone
* Most common cause is auto immune (adrenal tissue destroyed by antibodies formed by immune system)
Secondary adrenal insufficiency is the result of the hypothalamus or pituitary which caused decreased androgen & cortisol production
* Include oituitary tumors, radiation therapy, ect
S/s:
* Orthostatic hypotension
* Skin hyperpigmentation
* Hypoglycemia, hyponatermia, hyperkalemia
* Severe headaches, abd. pain, joint pain
* Wight loss, weakness/fatigue
* Salt cravings
Interventions/Tx:
* Restore fluids/ electrolytes
* Low K diet, high Na diet
* Replace adrenal hormone (Hydrocortisol)
* Assess for addisons crisis
* Carry medical kit & 100mg od IM hydrocortisone/dexamethasone
* Take meds as ordered
* Educate on life long therapy & monitoring
Addisons Disease (Adrenal Hypofunction of pituitary)
Life threatening emergency caused by insuffieicient adrenocortical hormones / sudden sharp drop in hormones
S/s:
* hypotension
* Tachycardia
* Dehydration (N/V)
* High temp
* Cyanosis
* Progresses to vasomotor collapse/ possible death
Interventions/Tx:
* IV fluids (Isotonic/ Hypertonic/ D5LR)
* Hydrocortisone
* Electrolyes
* Dextrose to restore normal BP
Addisons crisis
What electrolyte imbalances occur w/ Addisons disease?
Hypercalemia
Hyperkalemia
Hyponatremia
Hypoglycemia
Tip: Hyper before Hypo
What electrolyte imbalances occur w/ Cushings disease?
Hypocalemia
Hypokalemia
Hypernatremia
Hyperglycemia
Tip: Hypo before Hyper
Steroid - PO/IV/IM
Use:
* Severe inflammation, UC
* Adrenal Insufficiency, COPD
Side effects:
* Depression, mood changes
* Flushing, Increased appetite
* HF, HTN
Interventions:
* Vitals & labs (CBC,BMP)
* Monitor for depression
Hydrocortisone
Steroid - PO
Use:
* Adrenal insufficiency
* Addisons Disease
Side effects:
* Flushing, sweating
* Seizures, HTN
* Tachycardia, hyperglycemia
Interventions:
* Daily weight
* Vitals & labs (CBC, BMP)
Florinef (Flurocortisone)
Interferes w/ cortisone production
Cytotoxic substance that is used as a palliative treatment for inoperable
Use: Cushings disease
Mitotane (Lysodren)
Used in combination w/ mitotane for enchanced effects
Use: Cushings disease
Metyrapone (Metopirone)
What are the 2 types of hypothyroid?
Cretinism:
* Congenital hypothyroidism
* 1/4000 births
Myxedema:
* Denotes severe hypothyroidism in adults
* Includes: Edema, to hands/face/feet/eye area (periorbital)
What are some interventions/ education for a Pt who is post-op from a thyroidectomy?
Voice may be hoarse for 48hrs
Turn neck slowly, Semi- fowlers position to enhance RR & decrease edema
Monitor incision site, labs, & vitals
Assess for hypocalcemia:
* Chvostek/trousseau
* Laryngospasm (most critical)
* Tetany, numbness/tingling in fingers/toes
Assess for hemorrhage, resp. distress, & thyroid storm
Lifelong thyroid replacement
Assess resp. status
Inhibits synthesis of thyroid storm by decreasing iodine use in manufacture of thyroglobulin & iodothyronine
Use: Hyperthyroidism
Side effects:
* Drowsiness
* N/D/H
* Enlarged thyroid
* Jaundice (adverse)
* Hepatitis, nephritis (adverse)
* Bone marrow supression (adverse)
* Thrombocytopenia (adverse)
Interventions/education:
* Assess for S/s of hypothyroism
* Monitor vitals & labs (liver function, T3/T4, TSH)
* Daily weight/ monitor weight
* Do not breast feed
* Take as prescribed, DO NOT double dose
Methimazole (Tapazole)
Fits around the face & directly into the nares by 2 prongs
Low flow O2 1-6L/ min
FiO2: 0.24-0.40 (24-40% O2)
Nasal Canula
FiO2: 0.35-0.55 (35-55% O2)
Flow rate: 6-10L/ min
* Min flow rate of 6L/min is necessary to prevent any chance of CO2 build up from occuring
Simple O2 mask
FiO2: 0.7 (70%)
Specific flowmeter setting for desired FiO2
Ventimask / Venturi mask
What are some interventions for airway obstruction?
Admin antimicrobuals, decongestant, & expectorants as ordered
Deep breathing, & a good cough to break up secretions
* Antitussive medications can be given if pt become fatigue by coughing
* Pts w/ weak cough may need suctioned
Encourage position change Q2h to help mobilize secretions
Chest physiotherapy, aerosol therapy
Provide tissue & a receptable for disposal of secretions
* Note amount, color, consistancy
Auscultate lung sounds frequently to assess interventions
How do you assess gas exchange?
Monitor vitals, lung sounds, & skin assessment
Alert for S/s of hypoxemia:
* Restlessness, tachycardia, tachypnea
ABG meaures, report abnormalities to HCP
Monitor hemoglobin (Hgb)
* low levels indicate reduced O2-carrying capacity of RBCs
Elevate HOB, maintain O2 therapy as ordered
Semi-fowlers to decrease pressure of abd. organs on diaphram so pt can breath easier
What are some interventions for a pt who is fatigued & dyspnic?
Restrict activity for pt w/ pneumonia
* Ranges from complete bed rest to limited activity
Organize care to prevent overtiring & allow period of uninterrupted rests
Provide assistance as needed (ADLs) until pt can do them on own, evaluate tolorance of ADL
Keep converations short & encourage visitor to not tire pt
What are some interventions for inadequate nutrition?
Assess clients usual dietary habits to provide baseline information
* Individualize diet
Monitor weight same time every day before breakfast using the same scale
Monitor albumin, electrolyes, glucose, & BUN/Cr to detect inadequate nutrition
What is the typical diet for a Pt w/ pneumonia?
Diet: High protien, soft diet
what interventions would you implement for a Pt w/ pneumonia?
Interventions:
* Provide diet as ordered
* Document intake
* Assess w/ feeding if needed
* Provide oral care before & after meals
* Elevate HOB
* Arrange tray in attractive & convenient manner
* If O2 required, apply NC
* If fatigued easily, do frequant small meal
T/F - Iodized salt is the best way to obtain adequate amounts of Iodine in the diet of someone Dx w/ hyperthyroidim
True
Rare chronic condition that causes the body to produce too much urine and feel extremely thirsty
Classified as:
* Nephrotoxic - Inherited defect in which renal tubules of kidney do not respond to ADH, resulting inadequate water reabsorption by kidneys
- Neurologic (central / hypothalamic) - Can result from hypothalamic tumors, head trauma, infection, surgical procedures (hypophysectomy) or metataic tumors originating in lungs. Triggered by CVA, aneurysm, or intracranial hemorrhage
- Dipsogenic - Disorder of thirst timulation. When pt ingests water, serum osmolality decreases causing reduced vasopressin secretion. Other factors are associated by habitual water intake/ psych. conditions
Diabetes Insipidus (DI)
Affects ONLY epidermis - mildest
S/S:
* Pink/red
* Painful, minor swelling
* Dry w/o blisters
* Blanches
* No vesicles
Healing time:
* 3-6 days
* Superficial layer overskin may peel off in 1 or 2 days
Ex: Sunburn
Superficial Burn (1st Degree)
Affects epidermis & dermis
S/s:
* Painful
* Large, moist, weepy blister
* Pale, pink, red
Ex: severe sunburn, large blister
Superficial partial thickness burn (2nd degree)
Exposed dermis
* Skin, fat, muscle
S/s:
* Large, thick walled blister/edema
* weeping, cherry red
* Painful, sensative to cold air
Tx:
* Hospitalization
* monitor for shock
* Keep covered
Deep partial thickness burn
Involves epidermis, dermis, & underlying tissues including fat, muscle, & bone
S/s:
* Dry, leathery, eschar
* May be red, brown, black, or white
* Lacks sensation
Tx:
* Hospitalization
* monitor for shock
* Keep covered
Full thickness burn
What are the percentages of each body part involved in the rule of nine?
Head (Front & back)
Arms (Front & back)
Abd (2 sections - upper/lower (Front & back))
Legs (Front & back)
Groin (Front & back)
Head (Front & back) - 4.5%
Arms (Front & back) - 4.5%
Abd (2 sections - upper/lower (Front & back)) - 9%
Legs (Front & back) - 9%
Groin (Front & back) - 1%
When is fluid resuscitation the most critical in a burn pt?
24-48 hrs after injury
I/O’s strictly monitored to prevent shock
What is the most common skin infection for a burn patient that is found in the U.S?
Methicillin-resistant staphylococcus aureus (MRSA)
Releases chemicals that cause increased capillary permeability
* Tissue injury caused by thermal/chemical/ect. burns
Permits excess Na to enter the cell & allows K to escape into the extracellular compartment
Shift causes edema & decreases cardiac output, & decline in blood volume (Olguria, hypovolemic shock)
* 18-36 hrs after injury, capillary permeability normalizes & reabsorption of edema fluid begins. Cardiac o/p normalizes & increases to meet increased metabolic demands
Decreased blood flow a ileus may occus
Stress ulcer may occur (Curling ulcer)
Pathophysiology of Burn injuries
What is the most common skin infection for a burn patient that is found OUTSIDE of the U.S?
Acinetobacter
What lab should you draw for a military pt who has returned to the U.S for treatment?
Culture on admission to rule out any infection (Acinetobacter / MRSA)
Begins when burn starts & ends when fluid shifts stabilize
* First 12-48 hrs critical
S/s:
* Hemoconcentration (Increased Hct)
* Acute renal failure (ARF), olguria
* Hyperkalemia, hyponatremia
* Hypovolemic shock
* Metabolic acidosis
* Risk of cardiac dysrhythmias
Tx:
* ABCs, ABGs
* Start IV (PIV/central)
* Insert cath. & NGT, tetanus prophylaxis
* Pain managment/assessment & tetanus
* Clean/debride wounds, topical antibiodics
* Blood for baseline blood studies (Hct, electrolytes)
* Assess for smoke inhalation injury - intubate if needed
* Hydrotherapy (softens eschar), escharotomy
* ROM, skin graft
Emergent / hypovolemic stage of burn injury
(1st of 3 stages of burn injuries)
Begins 48-72 hrs after fluids stabilize
* Some marked when all but 10% of burn wounds are closed or until all wounds are closed
S/s:
* Hemodilution (decreased Hct)
* CHF risk
* Metabolic acidosis
* Hypokalemia, hyponatremia
* Circulatory overload / hypervolemia (Main concern)
* Polyuria (kidney problem - Insert fowly cath)
Acute/Diuretic stage of burn injury
(2nd of 3 stages of burn injuries)
Goal: Prevent infection & return pt to “normal”
* Can take months
Overlaps w/ acute stage
* Starts when pt is stable
PT/OT begin tx
Interventions:
* Restore independence
* Adjusting to body image
* Preventing contractures
* Coping
Rehabilitation stage of burn injury
(3rd of 3 stages of burn injuries)
Which burn may blister, peel & heal w/ minimal long-term effects?
A) Partial-thickness
B) Full-thickness
C) Deep Partial-thickness
Chpt 57 pg 1165
A) Partial-thickness
Which burn is often covered by a thick, leathery layer of burned tissue/eschar that shelters microorganisms & inhibits healing?
A) Partial-thickness
B) Full-thickness
C) Deep Partial-thickness
Chpt 57 pg 1165
B) Full-thickness
Removal of debris & necrotic tissue from a wound
* Eschar must be removed or healing will not take place
Types:
* Surgical excision: Escharotomy
- Mechanical: Removing eschar/ necrosis w/ scissors/ forcepts
- Enzymatic: Use of topical medications containing enzymes capable of dissolving necrotic tissue. (Cause pain & bleeding)
Debridement
What is the goal of wound care after a burn injury?
Promote healing
Prevent infection
Controll heat loss
Retain function
Minimize disfigurement
What are the 2 standard wound care treatments for patients w/ burns?
Open care method:
* Topical antimicrobials but no dressings
* Less restrictive & simpler but provides increased opportunity for loss of fluid & heal through wounds surface
Closed care method:
* Topical antimicrobials but covered by dressings
Examples of Topical medications:
* Silvadiazine (Silvadene)
* Mafenide acetate (Sulfamylon)
What is the preferred IV solution for burn patients?
Lactated Ringers (LR)
Surgical procedure done by making an incision through the eschar to relieve underlying pressure, measuring the pressure in the compartment, closed space nerves, muscle tissue, & blood vessels
Used to relieve circulatory construction
Escharotomy
What are 3 different types of grafts used for plastic surgery?
Autograft (skin graft)
* A burn covered by the pts own skin
* preferred sites are thigh or butt removed by dermatome (tool used to remove graft)
Split-thickness graft
* A type of skin graft applied to a thin layer of skin
* May be an intact layer of skin or meshed graft
* Meshed grafts have multpile tiny slits to allow skin to be stretched to cover a large area
Full thickness graft
* A type of skin graft used for deep burns to face, neck, & hands
* Include subq tissue & skin
* Cosmetically provied better results
What are some nursing interventions for a pt w/ a skin graft?
Assess site for bleeding
Immobilization of affected area for 3-7 days to ensure attachment of the graft
Remove dressings and allow wound to air dry 24 hrs after surgery
* Can use heat lamp to dry area
* While site dries, a fine-mesh gaze or Zeroform will lift off of the skin
What s/s should you notify the HCP immediatley for in a client w/ burn injuries?
Take vitals first & report:
* Restlessness, Tachypnea (Hypoxia)
* Bounding pulse, HTN (Fluid volume excess)
* Tachycardia, hypotension (Hypovolemia)
* Fever, Tachycardia (Infection)
What intervention should be done ASAP during an inital assessment of a stable pt w/ a burn injury?
Height & weight
Occurs w/ flame burns or from being trapped in an enclosed space filled w/ smoke
Pts can have pulmonary edema resulting in resp. failure
S/s:
* Facial burns
* Redness, swelling of pharynx
* Restlessness, Tachypnea (Hypoxia)
* Dyspnea, sooty sputum
* Death
Interventions:
* Protect airway (intubate) and evaluate for resp. distress syndrome
* Apply O2
* pulmonary function studies done before discharge to complete lung function
Smoke inhalation
Carbon monoxied displaces O2 on _____ , so the blood is unable to transport O2 into the tissues
A) Hgb
B) Hct
C) WBC
D) platelets
A) Hgb
What type of pain meds would you give to a burn pt?
Morphine, fentanyl, & other opioids
* Pre-medicate priot to any procedure (Required)
What do the letters stand for in R.A.C.E & P.A.S.S?
R: Rescue
A: Alarm
C: Contain fire
E: Extinguish/ Evacuate
P: Pull
A: Aim
S: Squeeze
S: Sweep
2 Types:
* Aesthetic (cosmetic) procedures: Performed to improve apperance
- Reconstructive procedures: Performed to correct abnormalities/ disfigured scars
Ex:
* Rhytidectomy (facelift): Remove wrinkles & tightens sagging tissue
- Blepharoplasty: Removal of excess tissue arround the eyes imparing vision, aesthetic procedure
- Chin implants: Done by placeing a prosthesis to correct a receding chin
- Rhinoplasty: Nose job, alters shape/size
- Abdominoplasty: Excess skin & adipose tissue are removed & abd. muscles are tightned
- Breast augmentation: Breast enlargment
- Breast reduction
Plastic surgery
What is the purpose of a reconstructive procedure?
Repair disfigured scars
Restore body contours after radical surgery (Mastectomy)
Restore features damaged from trauma/disease
Correct developmental defects
How would you educate a burn patient?
Practice good hygiene & avoiding others w/ infections
Eat 6 small frequent meals a day plus supplements
* Make sure to eat all food on plate
Change positions, exercise, & use splints to help prevent stiffening of the joints, skin breakdown, & blood clots in legs
Pain managment
* Contact HCP if pain is uncontrolled
Protect grafts from pressure & shearing
Clothing, make-up, hairpieces, & prostheses can be used to conceal scars & improve apperance
Adaptive devices are avalible to compensate for disabilities
Rehabilitation resources will be provided once the acute phase has passed
A burn pt on the unit is showing signs and symptoms of inadequate circulation. What signs and symptoms would you see?
S/s:
* Hypotension d/t blood volume not being maintained causing impaired tissue perfusion
* Tachycardia, decreased urine o/p (blood volume)
* Cool, pale, cyanotic skin (impaired tissue perfusion)
* Restlessness, confusion (impaired tissue perfusion)
what interventions would be in place for a burn pt who is showing signs and symptoms of inadequate circulation?
Monitor vital (BP & HR especially)
Monitor cardiac o/p (Pulmonary artery cath)
Monitor I/O, strict I/O
Admin IV fluids as ordered w/ close continuous monitoring of fluid status
Neuro assessment / skin assessment
A burn pt on the unit is showing signs and symptoms of fluid volume excess. What interventions would the nurse perform?
Monitor vitals for HTN, dyspnea, & full, bounding pulse (increased risk for heart failure)
Measure urine o/p & compare to intake
Aminister IV fluids as ordered & monitor pt closely
Document data collected during assessments
what interventions would be in place for a burn pt on who’s temp is declining?
Monitor temp to detect changes
Keep room about 76 degrees on the floor an 85 degress or higher on ICU
Attempt to limit body surface exposure during wound care
Body heat loss may increase is pt is on air-fluisized bed - monitor temp of the bed
what interventions would be in place for a burn pt who is showing S/s of inadequate nutrition?
Consult w/ dietitian about nutritional needs & preferences
* Calorie needs may be as much as twice the pts baseline needs
Try to create an environment conductive to eating & encourage the pt to eat all food served
Provide tube feeding or total parenteral nutrition (TPN) to meet calorie needs if needed
Encourage pt to drink protein drinks rather than water
Calorie count at bedside to ensure pt is consuming enough calories to meet increased metabolic needs associated w/ burns
what interventions would be in place for a burn pt who is showing S/s of infection?
Monitor for local infection
* Pus, foul odor, increased redness
Strict handwashing from anyone who enters the room
* Infection can come from anywhere/anyone
Shave body hair around wound w/ exception of eyebrows (can grow back disorganized)
Carry out wound care as ordered or according to specialty unit
Used to avoid / treat skin infections in patients with burns
Side effects:
* Back, leg, or stomach pain
* Blistering, peeling, lossening skin
* Blue/green to black skin discoloration (dark urine)
* Increased light sensitivity (especially w/ burns on large areas)
* Light colored stools
* Lower back pain
Silver Sulfadiazine
Used to treat severe/serious bacterial infections
Side effects:
* Hearing loss, roaring sound in ear
* Severe/ongoing dizziness
* Weak, shallow breathing
* Numbness/ tingling
* Muscle tightness/contraction
Garamycin
Opiod / narcotic
Relieves acute/ chronic / mod-severe pain
Can be used for pre-op or supplement to anesthesia
Side effects:
* Noisy breathing, sighing, shallow breathing, sleep apnea
* Confusion, extreme happiness or sadness
* Severe weakness or drowsiness
* Light-headedness, dizziness
* Vomiting, anorexia
Adverse effects:
* Resp. depression
* Urinary retention
* Excessive use / abuse
* Increased effect w/ CNS depression
Dilaudid
Beta-blocker
Affects the heart & circulation (blood flow through arteries & veins)
Used to treat:
* Tremors
* Angina (CP)
* HTN
* Heart rhythm disorders
* Heart / circulatory conditions
Side effects:
* Bradycardia
* Hypotension
* Light-headedness
* Wheezes
* Liver problems
Interventions:
* Always take BP before admin.
Propranolol (Inderal)
Opioid - IV, TD (patch), nasal spray, buccal (Gums/cheek)
Used for mod-severe pain
Side effects:
* Bradycardia
* Euphoria
* Sedation, resp. depression
* Dizziness
* Hypotension
Fentanyl (Subliminze)
When water is less than normal amount in the body
S/s:
* Hypotension
* Weak, rapid pulse
* Decreased temperature
* Weight loss
* Decreased urine output
Tx:
* Correct the cause
* Fluid replacement & electrolyte replacement
* Daily weights
* Monitor I/O
* Encourage oral fluids
Fluid volume deficit (FVD) / Hypovolemia
When there is too much water in the body
S/s:
* Edema and or pulmonary edema
* Weight gain
* Pupils will be sluggish to light
* Hypertension
* Increased respiration (crackles)
Fluid volume excess (FVE) / Hypervolemia
Decreased sodium
Causes:
* excessive intake of H2O
* loss of sodium, diarrhea, vomiting
S/s:
* headache, fatigue,
* muscle weakness, cramps, weakness
* confusion
* hypotension
Tx:
* fluid restriction
* NS or LR, Lasix
* increased sodium in diet
* Monitor I&O, lab results, & VS
* Safety precautions
Hyponatremia
Increased sodium
S/s:
* Thirst
* Flushed skin,
* Dry mucous membranes, low urine output
* Increased heart rate
* Convulsions
* Flushed skin
Tx:
* IV or fluid replacement
* Low Na diet
* Monitor IV infusion
* Reinforce diet (Na restriction)
* Monitor Renal function tests
Hypernatremia
Decreased K
Causes:
* Vomiting, diarrhea
* NG-tube suction
* DKA
* Diuretics
S/s:
* Vomiting, diarrhea
* Muscle cramps
* Dysrthythmias
* Abdominal distention
* Hypotension
Tx:
* Correct the problem
* Replace K (Give PO/IV)
* Monitor heart rate & rhythm
* High K diet
Hypokalemia
Increased K
Causes:
* Decreased renal function
* Metabolic acidosis
* Burn patients
S/s:
* Bradycardia, then tachycardia
* Cardiac arrest
* Muscle cramps
* Weakness
Tx:
* K restriction
* IV calcium gluconate
* IV insulin
* Kayexalate (PO)
* Place on heart monitor
* Monitor labs
New drugs used:
* Veltassa
* Zirconium
Hyperkalemia
Low Ca
S/s:
* Neuromuscular irritability
* Tingling sensation to face, hands & lips
* Muscle twitches, muscle cramps
Hypocalemia
T/F: Hypercalcemia is a complication of certain cancers
True
A systemic inflammatory response to a documented/ suspected infection
S/s:
* Hypotension, tachycardia
* Fever, elevated WBCs
* Lethargic
* Shivers/very cold
* Extreme pain/general discomfort
* Pale/discolored skin
* Sleepy/difficult to arrouse, disoriented
* “I feel like i might die”
* SOB, tachypnea
Tx:
* IV antibiodics
* NS bolus (over an hour)
* Antipyretics (Tylenol & Ibuprofen)
Sepsis
Inadequate tissue perfusion resulting in impaired cellular metabolism
Derives cells of essential oxygen & nutrients forcing cells to rely on anaerobic metabolism
Stages:
1. Preshock
* Tachycardia & peripheral vasoconstruction may maintain BP
* Mild elevation of lactic acid levels (Observe tachycardia & slight BP increase)
2. Shock
* S/s of organ dysfunction become apparent as compensatory mechanisms become overwhelmed
3. End-organ-dysfunction
* Multiple organ failure and death will occur if not corrected
* Blood vessel constricts & prevents blood flow to organs
Shock
What are S/s of the End-Organ Dysfunctional stage of shock?
Decreased mental status
Hypotension
Tachycardia
Elevated temp
Cyanosis, Necrosis
Decreased urine O/P
Occurs when the circulating blood volume is inadequate to maintain the supply of oxygen & nurtients to body tissue
Results from blood loss or extreme dehydration
Causes:
* GI loss d/t severe diarrhea, blood loss, or vomiting
* Diuresis (urinating) from diabetes insipidus or too much diuretic
* DKA
S/s:
* Tachycardia
* Hypotension
* Tachypnea
* Decreased urine output
* Decreased central venous pressure
Tx:
* IV fluids (NS/LR) replacement
* If blood loss, may have transfusion of blood or blood products
* Correct the cause
* If dehydration is cause, replace electrolytes & fluid replacement
* Oxygen
Hypovolemic shock
Caused by pathogens (bacteria, fungi, viruses) that release toxins that case blood vessels to dilate, thereby decreasing vascular resistance & increasing capillary permeability
S/s:
* Hypotension
* Olguria
* Metabolic acidosis
* Acute encephalopathy
* Coagulation disorders
* Extreme elevated temperature
* Elevated lactic acid
* Multiple organ dysfunction syndrom (MODS - worst case)
Tx:
* IV antibiodics (Zosyn, meropenem)
* Fluids (NS)
* Corticosteroids
* Antipyretics (Tylenol)
* Vasopressors (Epinephrine, norepinephrine & dopamine)
Septic Shock
Heart fails as a pump
Decrease in myocardial contractility results in decreased cardiac output & impaired tissue perfusion
Difficult to treat
Causes:
* Malignancies, uremia, idiopathic pericarditis, infectious disease
S/s:
* Fluid collects in pericardial sac, causing compression of the myocardium resulting reduced cardiac output & iscemia
Cardiogenic shock
Severe allergic reaction that results in relase of chemicals that dilate blood vessels & increase capillary permeability
Causes:
* Food
* Drugs, Vaccines, Contrast Media
* Mold, Pollen
* Insects
S/s:
* SOB, unable to swallow
* Hives, itchy rash
* Redness, swelling
* Cramps, N/V/D
* Drop in BP
* Increased tachycardia, weak pulse
* Feeling faint
Anaphylactic shock
Vasoconstriction in skin, viscera, & mucous membranes
* Relaxation of bronchi
* Given IV/IM
Use:
* Anaphylactic shock
* Hypotension
* Bronchial construction
Side effects:
* Hypertension
* Tachycardia
* Dysrthymias
Interventions:
* Monitor vitals
* Monitor IV site
Epinephrine (Adrenaline)
Catercholamine
* Given IV
Use:
* Shock (Cardiogenic/septic)
Side Effects:
* Palpitations
* Hypotension
* N/V/D/H
* Anxiety
Nursing interventions:
* Vital signs Q15 min
* Cardiac monitor
* Monitor I/O
* monitor angina/ HF
Dopamine
Anti-infective (broad spectrum)
* Given IV
Uses:
* Resp. Infection
* UTIs
* E-coli
Side effects:
* Lethargy
* N/V
* Rash
* Liver damage
* Steven-Johnson-syndrome
Interventions:
* Monitor vitals
* Monitor labs: AST, ALT, Renal function
Zosyn (Piperacillin)
Anti-infective
Use:
* Multiple Infections
Side effects:
* N/V
* Rash
* Hepatotoxicity
* Gastritis
* Jaundice
Interventions:
* CBC
* Monitor liver function
* Monitor vital signs
Meropenem (Merrem)
What are the antidotes for the following medications?
Warfarin/Coumadin
Heparin
Tylenol/Acetominophen
Opioids
Lovenox
Warfarin/Coumadin - Vitamin K
Heparin - Protamine Sulfate
Tylenol/Acetominophen - Mucomyst
Opioids - Narcan
Lovenox - Protamine Sulfate
Growths found in sigmoid & rectal regions of colon
* Third most common cancer in the U.S
Cause remains unknown
Risk factors:
* Adenomatous polyps
* UC, Diverticulitis
* Heredity
* High fat, low fiber diet
* Smoking
S/s:
Right side
* Right sided abd. pain
* Vage cramping until advances
* Anemia, unexplained blood loss
* Weakness & fatigue
Left Side
* Diarrhea or constipation
* Blood in stool
* May report feeling full or pressure in the abd. or rectum
Medical Tx/Interventions:
* Surgery - depending on location
* If rectum is removed, permanent colostomy will be created
* Chemotherapy done post-op, radiation
* IV antibiodics
* Treat pain
* Assess & monitor vitals
* coping w/ change
* Sexual dysfunction
Colorectal Cancer
Where are colostomies placed & what type of stool do they collect?
Ascending colon - Liquid stool
Transverse colon - Pasty stool
Descending & sigmoid - Semi-formed
How would you perform nursing care for a pt with a colostomy?
Perform focus assessment
Assess the capatability to manage colostomy self-care
Irrigate the colostomy everyday to mantain regular & controlled elimination
Administer prescribed medications
Monitor labs
Help with coping
What dietary teachings would you teach a for a pt w/ an ostomy?
Avoid Cabbage, alcohol, onions, & eggs
* Cause gas
Avoid corn, popcorn, seeds, & nuts
* Especially w/ ileostomies
Most common malignancy of the urinary tract
Causes:
* Chemical carcinogens, smoking, aniline dyes found in industrial compounds, & tryptophan all have been implicated in the development of bladder cancer
S/s:
* Painless (most common)
* Intermittent hematuria
* Bladdered irritability
* infection w/ dysuria
* Frequency & urgency
* Decreased stream of urine
Tx:
* Malignancy is present
* Cystectomy is surgery of choice
* Chemotherapy, radiation
* Immunotherapy
* Urinary diversion
* Laser photocoagulation (Intense beam of light (argon laser) that destroy tissue)
Bladder cancer
What tests would you run to Dx bladder cancer?
Urinalysis with urine cytology
Cystoscopy to visualize the bladder & obtained biopsy
CT/MRI
Intravenous pyelogram (IVP)
CT-urogram
Chest radiography
Radionuclide bone scan
What are nursing interventions for a post-op pt who underwent elimination surgery?
Assess bowel sounds & abdomen in general
Assess stool
Assess stoma site for s/s of infection, bleeding & pain
Monitor & chart I/O
Teach pt about coping
Cleans site daily & as needed
Empty pouch & irrigating bag
Change pouch daily or as needed per order
Splinting the incision
Antibiodics
Ambulation after surgery
Splinting w/ pillow while coughing
Irrigating the stoma can help train the bowel
Antibiodic
* Vesicant
2 toxicities:
* Nephrotoxic - Toxic to kidneys
* Ototoxic - Can’t hear well
Should monitor peak & trough
Monitor BUN/Cr
Side effects:
* Nephrotoxcicity
* Red man syndrome
Assess for hearing problems (ototoxicity)
Vancomycin
Used for diarrhea
Combinations meds:
* Atropine = anticholinergic, can be used to dry things
* Diphenoxylate = decrease spasms & slows the gut
Know it works when there is no diarrhea
Lomotil
(Atropine/Diphenoxylate)
Antibiodic
Used for skin, vaginal, & GI infections
Side effects:
* Dark urine
* Metallic taste
* GI upset (No alc. puts GI in distress)
* Diarrhea
Flagyl
(Metronidazole)
Used to prep the bowel for colonoscopy or surgical procedure
* NPO at midnight
Tips:
* Make icy cold - don’t freeze
* Do NOT use straws
* Clear liquid diet
Golytely
(Polyethylene Glycol)
Give SubQ in fatty tissue
Stimulates production of RBCs
Use:
* Treats anemia
* Anemia related to chemo
Procrit /Epogen (Epoetin Alpha)
Given SubQ
Stimulates production of neutrophilic white cells
* Reduces neutropenia interval in bone marrow transplantation
Neupogen (Filgramtim)
What are the 9 steps for suctioning traches?
- Sterile tech. & Face shield
- Lube on tubing
- Oxygenate patient before suction
- Open vent during cath. insertion
- Suction intermittently while rotating and moving cath back and forth while withdrawling
- Suction no longer than 10-15 seconds
- Rinse cath suctioning w/ NS
- Oxygenate patient after suction
- Document status before & after
What are the 10 steps for proper trach care?
- Standard precaution
- suction before removing old dressings
- Don sterile gloves
- Use sterile solution (NS) to clean the inner cannula
- Rinse and dry inner cannula. Reinsert into outer cannula
- Cleans stoma and surrounding skin
- Dont get solution into stoma
- Change tracheostemy ties
- Replace trach dressing w/ precut pad/ gauze
- Tie the ties at sides
What are 4 nursing responsibilities for a patient who has a trach?
- Keep airway clean
- Keep inner cannula clean
- Prevent impairment of surroundings
- Provide patient a means for communication
What are nursing interventions for a patient who has a trach?
Evaluate - Look for secretions & suction
Provide - Constant airway humidification/ oxygenation
Change/clean - All equipment q8h or PRN
Remove - Water condensed in equipment tubing
Provide - Mouth care (moisturize lips), communication board/ tablet, & safety
What are the 10 care essentials for patients on a vent?
- Review communication board
- Check vent settings (resp rate, tidal volume, peak (PIP))
- Suction appropriately
- Assess pain & sedation needs
- Prevent infection
- Prevent hemodynamic instability
- Manage airway
- Meet nutritional needs
- Wean off vent
- Education
What 6 interventions would you provide for a patient on a vent?
- Monitor settings to ensure they match
- Ensure high & low pressure alarms are set
- Have manual resuscitator & O2 avalible
- Don’t allow water to accumulate in tubing
- Monitor vitals & breath sounds, suction PRN
- Establish communication methods
What are the 3 main things community nursing focuses on?
- Improving the health status of communities or groups of people
- Screening for early detection of disease
- Providing service for people who need care outside of acute care setting
T/F: Home health nursing blends community health nursing & direct nursing
True
Process of restoring an individual to the best possible health & functioning after a physical or mental impairment
Concepts:
1. Process of restoration
2. Impairment is disturbance in functioning
3. Disability is measurable loss of function
Goal:
* Maximize quality of life of pt
* Assist pt w/ adjusting to alternate lifestyle
* Directed towards promoting wellness & minimizing complications
* Assist pt in attending the highest degree of function & self-sufficiency
* Assist pt w/ home & community reentry
Rehabilitation
How does impairment effect motor functioning?
Impairment may either be physical or psychological
Ex: Paralysis of limbs d/t stroke or mental impairment (AD)
How does a disability effect motor functioning?
Measurable loss of function & usually delineated to indicate a diminished capacity for work
Ex: Injured back may be classifie as 50% disabled
What are the 4 levels of diability?
- Slight limitation in one or more ADL, able to work
- Moderate limitation in one or more ADL, may work but need modifications
- Severe limitation in one or more ADL, unable to work
- Totally disabled, characterized by nearly complete dependence on others for assistance w/ ADL, unable to work
Who is included in, but not limited to, the rehab team?
The patient
Dr
Rehab RN/LPN
PT/OT/ST
Recreational therapist
Chaplin
SW
Dietician
Pharmacy
Slowing down initation & execution of movement (bradykenesia), increased muscle tone (rigity), tremors, & impaired postural reflexes
S/s:
* Tremors
* Bradykenesia
* Rigity
* Shuffling
* Pill roll
* Dementia
* Speech changes
Parkinsons
Antiparkinsonian
Use: Parkinsons, restless leg syndrom
Helpts tremors & rigidity
Side effects:
* Hypotension
* Severe depression
* Hallucinations
* Urinary retention
* Dry mouth
Nursing intervention:
* Assess for tremors, pill rolling, drooling, rigidity, shuffuling gate
* Monitor BP, RR, & mood
Carbidopa-levodopa (Sinemet)
Antiparkinsonion, antiviral
Use: Prophylaxis or Tx of influenza A, parkinsons
Side effects:
* Change in mood, suicidal thoughts
* Vision & color changes, eye pain
* Confusion, hallucinations
* Seizures
* N/V
Interventions:
* Monitor labs: BUN. CBC, Cr
* Monitor vitals
* Monitor for decrease S/s of parkinsons
Symmetrel / Amantadine
Class: Erectial agent, Antihypertensive, vasodialoator
Use: Erectile dysfunction (Viagra), HTN (Revatia)
* Women may use too
Side effects:
* Sudden death
* MI, TIA, CP
* Flushing
* Orthostatic Hypotension
* Dysrhythmias
* Headache, dizziness, nasal congestion
Interventions:
* Monitor vital signs
* Monitor for vision loss
* Maintain safety (bad if erection does not go away)
BBW: Contradiction w/ people who take nitroglycerin/ nitro paste
Sildenafil (Revatio, Viagra)
Class: Sedative / hypnotic
Use: Insomnia, skeletal muscle relaxer
Side effects:
* Dizziness, drowsiness, sedation
* Poor coordination
* Resp. depression
Interventions:
* Maintain safety
* Monitor vitals (RR)
* Monitor sleep pattern
* Teach not to drink alcohol
Zolpidem (Ambien)
Anticoagulant
Inhibits activity of Vit K, which activates certain clotting factors
Use: DVT, PE, embolization from Afib or heart valve replacements
BBW: Monitor for bleeding
Lab value (PT/INR): 2-3
* Less than 2 = give
* Greater than 3 = hold
Antidote: Vit K
* Teach to avoid dark green leafy foods
Warfarin (Coumadin)
Anticoagulant - SubQ (in abd), IV push, infusion
Use: DVT after hip replacement/ abd surg, AM, combined w/ aspirin (ASA)
Common adverse effects:
* Hematoma, bleeding at site
Serious side effects:
* Bleeding
* Thrombocytopenia
Monitor PTT, platelets, hematocrit
Antidote: Protamine sulfate
Low-molecular- weight Heparin (LMWH)
What are the general principles of emergency care?
Remain calm
Survery scence
Primary survey (detect and further prevent life-threatening injuries)
Secondary survey (conducted once the patient is relatively stable and includes fact-finding about what may have happened)
First aid Tx
Assessments & interventions done quickly & efficiently to identify & treat needs immediately
Priority: Preserve life & minimize effects of injuries
During disaster planning, what 2 orginizations can you expect to quickly move in to help?
American Red cross
Sulvation Army
Extraordinary situation that is brouhgt about by events w/in the health care facility
Ex: Fire
Internl Disaster
Originates outside facility & result in a influx of casualities brought to the facility
Rely on outside agencies for help:
* Fire department
* Police
* Health department
* County
* Hospital
Ex: Explosion in chemical plant, tornado, train accident
External Disaster
Deliberate release of pathogens to kill / injure people
* Easily spread - potential to cause many deaths
Most common biologic agents:
* Anthrax
* Botulism
* Plague
* Smallpox
* Tularemia
HCPs must know how to protects themselves & others
* Staff should know how to obtain PPE & the precaution types
Bioterrorism
How do you DON PPE from the very begining?
TIP: Start from identifying the type of isolation
Identify and gather the proper PPE
* Blood-borne = gloves, a mask, protective eyewear / goggles
* Airborne = gloves, gown, & N95
* Droplet = gloves, gown, & mask
Hand hygiene
Gown
Mask
Face shield or goggles
Gloves
Enter the patient’s room
Stay in one area/country
* Does not cross oceans
Ex: Smallpox, measles, polio
Nursing responsibilities:
* Recognize casualty of biologic attack & carry out roles assigned during the attack
Epidemic
Disease that emerges rapidly at an uncharacteristics time or is an unusual pattern
* Crossss continents
Ex: COVID, Flu
Nursing responsibilities:
* Recognize casualty of biologic attack & carry out roles assigned during the attack
Pandemic
Antiplatelet
Use: CVA, post MI, TIA
Side effects:
* Dizziness
* HTN
* Bleeding
* Diarrhea
* Anemia
Plavix (Clopidogrel)
Nonopioid analgesic, NSAID, antipyretic, antiplatelet
Use: mild pain, RA, OA, TIA, CVA, post mis, angina, kawasaki disease
Side effects:
* Bleeding
* Tinnitus
* N/V
* Rash
BBW: Do not give to children (Reyes syndrome)
Aspirin (ASA)
Antihypertensive, ACE inhibitor
Use: HTN, HF, acute MI
Side effects:
* Vertigo, dizziness
* Depression
* Headaches
* Nasal congestion
* N/D
Lisinopril (Prinivil)
