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Concepts 3 > Exam 3 > Flashcards

Exam 3 Flashcards

1
Q

Renal Elimination: Older age risks (5)

A
  • Organs systems decline (atrophy of kidney)
  • Decreased # of functional nephrons -> decreased GFR
  • More prone to development of AKI, CKD, and ESKD
  • higher risk for HTN and DM which cause ESKD
  • Risk for dehydration r/t sodium retention, increased dilution of urine, and decreased thirst perception
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2
Q

Renal Elimination: Risky Medications (5)

A
  • Antibiotics (aminoglycosides)
  • Iodine Contrast-dye
  • Immunosuppressives (steroids, transplant meds)
  • NSAIDs
  • ARBs and ACEIs
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3
Q

Most common causes of AKI (4)

A
  • Sepsis or overwhelming infection - leading cause of death
  • Hypovolemia
  • Drug or medication-related
  • Cardiogenic shock
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4
Q

AKI: Basics (5)

A
  • Abrupt reduction in renal function over a period of hours or days
  • Decrease in GFR
  • increased BUN, Creatinine, and K+
  • with/without oliguria (urine output < 30cc/hr or <400 cc/day).
  • Retention of waste products (azotemia)
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5
Q

Multisystem effects of ESKD

  • neurologic
  • hematologic
  • skeletal
  • cardiovascular
  • GI
  • GU
  • Dermatologic
  • Respiratory
A
  • Neurologic (coma, headache, inattentiveness, lethargy, seizures)
  • Hematologic (bleeding, immunosuppression, platelet dysfunction)
  • Skeletal (hyperphosphatemia, hypocalcemia, weak, brittle bones)
  • Cardiovascular (arrhythmias, Edema, heart failure, HTN, pericarditis, pericardial)
  • GI (anorexia, decreased appetite, hypomotility, glucose intolerance, hyperphosphatemia)
  • GU (amenorrhea, hematuria, proteinuria)
  • Dermatologic (dry skin, poor healing, pruritus)
  • Respiratory (Pleural effusions)
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6
Q

RIFLE Criteria

A

Risk
- Crt 1.5x normal OR Crt increases ≥ 0.3 mg/dL

Injury
- Crt 2x normal

Failure
- Crt 3x normal OR ≥ 4 mg/dL

Loss
- Persistent AKI = complete loss of kidney function for more than 4 wks.

ESKD
- End-stage kidney disease

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7
Q

AKI: Onset Phase (3)

A
  • Begins when the kidney is injured causing ischemia and decreased GFR
  • Ends when oliguria develops (goal to detect prior to this)
  • Duration: lasts from hours to days.
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8
Q

AKI: Oliguric/Anuric Phase

Duration
S/s (2)
Labs (4)

A

Duration: a range of 8-14 days depending on nonoliguric vs. oliguric.

s/s
- Urine production is < 400 cc for 24 hrs
- Fluid overload (b-c inability to excrete water)

Labs
- Greatly reduced GFR and urine formation due to renal tubule damage
- increased BUN, Creatinine,
- Electrolyte disturbances (Hyperkalemia, hyperphosphatemia, hypocalcemia)
- Metabolic acidosis

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9
Q

AKI: Diuretic Phase

Duration

5 notes

A

Duration: Lasts 7- 14 days

  • Occurs when cause of AKI corrected
  • GFR increases but nephrons still not fully functional
  • Unable to excrete some waste products
  • tubule scarring and damage and edema present
  • Urine > 400 cc in 24 hours (up to 2-5L/24 hr) -> high BUN (observe for dehydration)
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10
Q

AKI: Recovery Phase

Duration

3 notes

A

Duration: lasts several months to 1 yr.

  • Normalization of F/E balance or onset of polyuria
  • Return of GFR to 70-80% normal (Normal GFR: 120)
  • Tubular edema resolves and renal function improves
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11
Q

Pre-renal AKI: Causes (4)

A
  • Prolonged hypotension (sepsis, vasodilation)
  • Prolonged low CO (CHF, cardiogenic shock)
  • Prolonged volume depletion (Hemorrhage, Diarrhea, dehydration, burns)
  • Renovascular thrombosis
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12
Q

Intrarenal/Intrinsic AKI: Causes (6)

A
  • Acute tubular necrosis [ischemic (trauma, sepsis); advanced prerenal AKI]
  • Meds (NSAIDS, aminoglycosides (gentamicin), cephalosporins, amphotericin B, acyclovir)
  • Glomerular diseases [glomerulonephritis (acute), lupus, nephritis)
  • Nephrotoxic agents (environmental, contrast dye, cocaine)
  • Rhabdomyolysis
  • Tumor lysis syndrome
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13
Q

Postrenal AKI: Causes (4)

A
  • BPH
  • Kidney stones (calculi)
  • Urethral strictures
  • Tumors
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14
Q

Categories of AKI (what is it and priority care)

  • Prerenal (2)
  • Intrarenal (2)
  • Postrenal (2)
A

Prerenal
- Decreased perfusion (renal blood flow, BP, Low cardiac output, MAP < 65) cause kidney ischemia
- Priority: establish hemodynamic stability

Intrarenal
- direct damage to kidneys
- Priority: maintain renal perfusion, discontinue nephrotoxic drugs, treat cause

Postrenal
- obstruction of urine flow from kidneys
- Priority: prevent UTI, remove source of obstruction, ensure catheter patency, maintain renal perfusion

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15
Q

Sepsis and AKI

Patho (2)
Labs
Care (3)

A

Patho
- Sepsis causes reduced perfusion to kidney -> hemodynamic instability and ischemia
- Inflammation increases vascular permeability and causes third spacing

Labs: elevated WBC and lactate plus AKI labs

Care
- Need rapid fluid resuscitation then vasopressors in septic shock
- Avoid aminoglycosides
- Prevention: MAP > 65

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16
Q

Trauma and AKI: Rhabdomyolysis

What is it?
Risks (3)
S/s (3)
Primary treatment (3)

A

What is it?
- release of myoglobin and creatine from damaged muscle cells after burns, trauma, crush injuries

Risks
- life-threatening hyperkalemia due to cell lysis
- metabolic acidosis
- AKI from myoglobin toxicity (myoglobinuria and hemoglobinuria)

S/s
- compartment syndrome
- elevated CK, crt, K
- dark brown or tea colored urine (myoglobinuria and hematuria)

Primary treatment
- IV crystalloid fluid resuscitation (NS, LR)
- sodium bicarb for acidosis and to alkalize urine for myoglobin excretion
- Mannitol to increase renal blood flow and GFR for myoglobin clearance

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17
Q

At-risk disease states and AKI

  • Heart failure (2)
  • Respiratory failure (2)
A

Heart failure and AKI
- Several risk factors overlap
- BP: 130/80 and normal range glucose recommended to prevent CKD and atherosclerotic changes (CAD, PAD)

Respiratory failure and AKI
- Mechanical ventilation (PEEP and positive-pressure) alter kidney via reduced renal blood flow, GFR, UOP
- AKI increases inflammation and risk for ARDS which can lead to ventilation dependence

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18
Q

Contrast-induced nephrotoxic (CIN) injury and AKI

Risk factors (4)
Prevention (5)

A

Risk factors: CKD, Crt > 1.5, dehydrated pts, CHF, advanced age (> 75)

Prevention
- Stop metformin day before and resume 48 hrs procedure w/ contrast dye (risk for lactic acidosis)
- Promote hydration and avoid dehydration (IV fluids) before, during, and after
- use lowest dose of dye
- do not repeat dye doses within 48 hrs
- Remove nephrotoxic drugs (NSAIDs, diuretics, ACEI, ARBs)

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19
Q

AKI: Labs (7)

A
  • metabolic acidosis (increased anion gap, low bicarb, low pH)
  • elevated BUN (not reliable indicator of AKI)
  • elevated Crt (late indicator)
  • Decreased Creatinine Clearance /GFR (<50) ->most accurate indicator of kidney function
  • BUN: Crt ratio (normal = intrarenal AKI; high = prerenal AKI from high BUN)
  • Electrolytes (hyperkalemia, hypocalcemia, hyperphosphatemia; hypo/hypernatremia)
  • Anemia (decreased H/H due to kidneys not producing erythropoietin)
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20
Q

AKI: Physical Assessment (7)

A
  • Chest pain or pressure
  • Fluid overload or loss (oliguria to diuretic)
  • Intravascular overload (CHF, pulmonary congestion, high BP)
  • Edema r/t fluid retention, low albumin, inflammation
  • Grey-turner sign (kidney trauma seen on flank)
  • Bruit = aneurysm or stenosis
  • Azotemia = uremia
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21
Q

Prerenal AKI: Urine Changes (4)

A
  • Increased urine osmolality (decreased serum osmolality)
  • Increased urine specific gravity
  • Decreased urine sodium
  • Urine sediment is absent
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22
Q

Intrarenal AKI: Urine changes (6)

A
  • Increased acidity of urine (retention of sodium and acids by body causes retention of bicarb)
  • RBC in urine (hematuria, smoky, red)
  • BUN in urine
  • Decreased urine osmolality (increased serum osmolality)
  • increased or normal urine sodium
  • Sediment (casts and epithelial cells), protein, glucose in urine b-c damaged tubules (glucosuria unreliable marker for DM in AKI)
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23
Q

AKI and Electrolyte Balance: Treatments

  • Hyperkalemia (2)
  • Hypocalcemia
  • Hyperphosphatemia (3)
A

Hyperkalemia (>5)
- IV diuretics if making urine (dialysis if oliguria)
- DICK (Dextrose, Insulin, Calcium gluconate, kayexalate)

Hypocalcemia (< 8.5)
- calcium and vitamin D supplements b-c risk for renal osteodystrophy

Hyperphosphatemia (> 4.5)
- give phosphorus binders w/ every meal
- frequent skin care for pruritus
- Limit phosphorus food (high protein aka meat, fish, dairy, additives, carbonated beverages)

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24
Q

AKI: Fluid balance care (5)

A
  • fluid resuscitation (2-3L/day)
  • fluid restriction if UOP < 400 cc/24 hr)
  • daily weights and I & O ( 1L = 1 Kg; output 30 mL/hr)
  • remove foley once pt stable to prevent CAUTI
  • monitor for s/s of bleeding or anemia
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25
Q

AKI: Meds for Treatment

  • IV fluids (3)
  • Sodium bicarb (2)
  • RBC production (2)
  • Acetylcysteine
A

IV Fluids
- Crystalloids (NS, ½NS, LR) – to increase renal perfusion and output
- avoid LR b-c has potassium)
- Colloids (Albumin) – volume expanders to maintain hemodynamic stability

Sodium Bicarbonate
- For Metabolic acidosis
- must be in separate line, no y-site connections

Red blood cell production stimulation/production
- Give iron, PRBCs, erythropoietin (epoetin alfa), vitamin B12, B6, folate
- stress ulcer prophylaxis to prevent GI bleed

Acetylcysteine (Mucomyst)
- Used to reduce contrast-dye induced AKI

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26
Q

AKI: Meds for Treatment

Diuretics
- purpose
- Loop (budesonide, furosemide) - 2
- Thiazide (Hydrochlorothiazide) - 2
- Carbonic anhydrase inhibitor (Acetazolamide) - 1
- Potassium-sparing (spironolactone) - 2

A

Purpose: stimulate UOP if fluid overload and functioning kidneys

Loop (budesonide, furosemide)
- Caution if sulfa allergy
- Furosemide is ototoxic

Thiazide (Hydrochlorothiazide)
- Caution if sulfa allergy
- Ineffective if GFR < 10

Carbonic anhydrase inhibitor
- for metabolic alkalosis after aggressive diuresis to increase release of bicarb

Potassium-sparing (spironolactone)
- Weak diuretic
- No potassium supplements

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27
Q

Mannitol (Osmotic Diuretic)

Use (3)
Action (2)
Care (3)

A
  • Use: cerebral edema, excretion of toxins, increased ICP

Action
- Increases UOP and GFR via high plasma osmolality and water flow
- increase cerebral blood flow by pulling water out of intracellular space but causes cerebral vasoconstriction as part of autoregulation

Care
- need filter
- risk for hypernatremia, hypokalemia
- need CVP to prevent hypovolemia

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28
Q

Indications for Dialysis: AEIOU

A

A = Acidosis (metabolic <7.1) or Azotemia

E = Electrolyte Imbalance (hyperkalemia)

I = Intoxication/Toxins (drug or alcohol)

O = Oliguria or Overload of Fluid

U = Uremia (azotemia with symptoms i.e. metallic taste in mouth, anorexia, muscle cramps, dyspnea, hiccups, uremic frost on skin, change in mentation, pericarditis (pericardial friction rub), neuropathy (paresthesia)) = Elevated BUN

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29
Q

Hemodialysis

Basics (2)
Disadvantages (4)

A
  • Separates and removes excess electrolytes, fluids, and toxins from blood
  • Loss of fluid over short period of time (3-4 hrs)

Disadvantages
- Needs Anticoagulation (heparin)
- needs special nurse
- Risks of hypotension, infection, graft-clotting, hemorrhage, and embolism
- Contraindicated in hemodynamically unstable patient

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30
Q

Hemodialysis: Access Sites

  • Temporary Vascular access - 2
  • Permanent (AV fistula, AV graft, tunneled catheter) - 3
A

Temporary vascular access
- Only for dialysis (Not for meds, blood samples, or monitor CVP)
- Assess for s/s of infection, perfusion, bleeding

Permanent
- not used in AKI
- Fill the thrill, hear the bruit
- No BP measures, IV infusions, phlebotomy in arm of fistula

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31
Q

Continuous Kidney Replacement Therapy (CKRT): Process (4)

A
  • Uremic toxins and fluids are removed, while acid–base status and electrolytes adjusted slowly and continuously
  • Blood filtered and cleansed with dialysate solution
  • Venous blood circulated via porous hemofilter back into body
  • continuous over several days (large volume over long period)
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32
Q

CKRT: Care (6)

A
  • Monitor ultrafiltration hourly
  • add replacement fluid if large volume removed
  • Hemofilter change q24-48 hours
  • Anticoagulation (heparin) is required
  • Only in ICU
  • contraindicated if Hct > 45% or terminal illness
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33
Q

CKRT: Indications (7)

A
  • hemodynamically unstable pt who requires removal of large volumes of fluid
  • Hypervolemic or edematous pts. unresponsive to diuretic therapy
  • Pts. with MODS (multi-organ dysfunction syndrome)
  • Ease of fluid management in pts requiring large daily fluid volume
  • Replacement for oliguria
  • Admin of TPN
  • Inability to be anticoagulated
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34
Q

CKRT: Complications (8)

A
  • decreased ultrafiltration rate (risk for clotting) - place pt supine, lower container
  • filter clotting - reset up system and use anticoagulant
  • hypotension - clamp line
  • f/e imbalance
  • bleeding (hemorrhage)
  • Access dislodgement or infection - sterile dressing changes
  • EKG interference - assess pt
  • Air embolus - prime tube properly
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35
Q

SCUF: Slow continuous ultra filtration

Use (3)
Notes (4)

A

Use
- acute HF
- unresponsive to diuretics
- when azotemia or uremia not a concern b-c only fluid loss (no electrolyte loss)

Notes
* No replacement fluid added
* Rate: 100 to 300 ml/ hour (slow)
* Requires both arterial and venous access
* Clots easily

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36
Q

CVVH: continuous venovenous
hemofiltration

Use
Notes (3)

A

Use: fluid and moderate solute removal via convection (urea, creatinine, and other small non-protein toxins)

Notes
* Must have MAP of 60 (BP driving force)
* Rate: 5 -20 mL/min or up to 7- 30 L/24 hr
* Replacement fluid is added

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37
Q

CVVHD: continuous venovenous
hemodialysis

Use (3)
Notes (5)

A

Use
- fluid and max solute removal via diffusion (dialysate pumped concurrent to blood)
- resistance to diuretics
- severe uremia or critical acid-base problems

Notes
* most like traditional HD
*Must have MAP of 70 (BP is driving force)
*Rate: 500-800 mL/hr (more effective over days)
*Replacement fluid added
* Ideal for hemodynamically unstable in ICU b-c do experience abrupt fluid and solute changes

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38
Q

CVVHDF: continuous venovenous
hemodiafiltration

Use (2)
Notes (2)

A

Use
- max fluid and max solute removal via convection and diffusion
- Combines CVVH and CVVHD - most complex

Notes
- Requires a MAP of at least 60 (BP driving force)
- Replacement fluid is added

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39
Q

Older Adults: Urinary Incontinence

Contributing Factors (7)

A
  • Drugs (anticholinergics, diuretics, CNS depressants)
  • Diseases (Depression, Arthritis, Parkinson, Dementia)
  • Inadequate Resources (lack of support, lack of assistive devices, high cost of products)
  • Nocturia
  • urinary retention from age or drugs
  • weakened urinary sphincter
  • decreased bladder capacity
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40
Q

Intracranial Regulation: Older adults risks

  • CNS (6)
  • Sensory (4)
A

CNS
- Confusion due to infection and delirium often seen
- Neurodegeneration (Reduced brain volume and weight, blood flow)
- Decrease in neurotransmitters (Ach, dopamine, serotonin, glutamate)
- altered sleep-wake cycle (increases risk for delirium and dementia)
- Increased blood brain barrier permeability (increased drug effects)
- slower processing times and memory loss)

Sensory
- Decreased pupil size and reactivity (vision)
- Decreased touch sensation (falls)
- Reduced reflexes r/t neuronal loss (falls)
- decreased taste, hearing, and smell

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41
Q

5 components of Neuro Exam

A
  • LOC (earliest indicator of change in neuro status)
  • Motor function
  • pupillary function
  • respiratory function
  • vital signs
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42
Q

Levels of Consciousness (7)

A
  • Alert
  • Confused
  • Delirious (disoriented to time, patient, place and may have hallucinations)
  • Lethargic
  • Obtundent (dull indifference to any stimuli)
  • Stuporous (only respond to continuous stimuli)
  • Comatose (no response to any stimulus)
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43
Q

LOC: Areas

  • Arousal (3)
  • Alertness (1)
  • Awareness (1)
A

Arousal
- ability to respond to verbal or noxious stimulus. (Verbal (calm then loud), sternal rub, trapezius muscle pinch)
- Central stimulation preferred (trapezius muscle pinch or sternal rub) over Peripheral stimulation (nailbed pinch) for overall body response.
- no need for noxious stimuli if follows commands

Alert (LOC)

Awareness (orientation to person, place, time, situation) if arousable

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44
Q

Glasgow Coma Scale: Tips (5)

A
  • Highest = 15 & lowest = 3.
  • < 7 = comatose i.e. “Less than 8, intubate”.
  • Never use GCS in place of complete neurologic assessment
  • does not account for patients with aphasia or mechanically ventilated.
  • Change in 2 or more points is significant
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45
Q

GCS

Eye Opening
Verbal Response
Motor response

A

Eye opening (4-1)
- spontaneously
- to speech
- to pain
- none

Verbal Response (5-1)
- oriented
- confused (appropriate language but disoriented)
- inappropriate
- incomprehensible (mumbles, moans, groans)
- none

Motor response (6-1)
- obeys commands
- localizes pain (spontaneous w/ purpose away from noxious stimuli)
- withdraws from pain (does not cross midline but moves away)
- flexion to pain (Decorticate)
- extension to pain (decerebrate) - brainstem dysfunction
- none

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46
Q

ICR: Motor Function

Posturing - 1
Reflexes - 4

A

Posturing
- denote decorticate (flexion), decerebrate (extension), or flaccid after peripheral noxious stimuli

Reflexes
- DTRs (achilles, quadriceps, biceps, triceps) should be present
- corneal (CN 5 and CN7) should be present
- pharyngeal/gag (CNIX and CNX) should be present
- Babinski, grasping, rooting if > 2 yrs = brainstem lesion or herniation

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47
Q

ICR: Motor Function

Muscle
- size and shape (1)
- tone (2)
- strength (3)

A

Muscle size and shape
- any atrophy

Muscle tone
- via passive movement
- flaccid, hypotonia, hypertonia

Muscle strength
- via active movement
- graded 0 to 5
- pronator drift (arm held out and pronated then drops due to weakness)

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48
Q

ICR: Pupillary function

  • Size, shape, symmetry (2)
  • Reaction to light (4)
  • Eye movement (2)
A

Size, shape, symmetry
- pupils should be equal b/w 2-5 mm
- any new discrepancy = significant b-c may be herniation or increased ICP)

Reaction to light
- should be direct and consensual response
- Dilated, nonreactive or oval shape= CN III (oculomotor compression)
- Pinpoint & fixed = brainstem dysfunction/ loss of sympathetic control from opioid
- Asymmetric, loss of reaction, unilateral/bilaterally dilated = brain herniation

Eye movement
- use H test if conscious
- If unconscious, use doll’s eye reflex or ice caloric text

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49
Q

ICR: Eye Movement

  • Doll’s eye reflex (oculocephalic reflex) - 3
  • Ice caloric text (oculovestibular reflex) - 3
A

”Doll’s eyes”
- Action: turn head side to side quickly while someone holds eyes open (DO NOT DO IF CERVICAL INJURY)
- positive = eyes move in opposite direction of head movement = intact brainstem.
- Negative = eyes stay fixed and midline or move in same direction as head movement = significant brainstem injury

Cold caloric test”
- Action: place 20-100 ml of ice water in ear while head raised to 30 degrees (HCP ensures tympanic membrane is intact first)- very NOXIOUS
- Positive: eyes turn toward ear with water in it
- Negative: disconjugate/abnormal or absent reflex = degree of brainstem injury

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50
Q

ICR: Vital signs

Initial (4)
Late (3)

A

Initial
- increased BP
- Increased HR and CO
- Decreased RR (hypoventilation i.e. hypoxemia and hypercapnia lead to cerebral vasodilation = increased ICP
- Temp (hypo or hyperthermia b-c unable to regulate)

Late (Cushing’s Triad- opposite of shock)
- Increased SBP (widened pulse pressure
- Abnormal respirations/Airway status (Cheyne stokes, cluster breathing, apnea)
- Bradycardia

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51
Q

ICR: CT

Use
Care (4)

A

Use: gold standard rapid noninvasive test for TBI, vascularity, mass lesions

Care
- Serial CT to detect changes (increased ICP or midline shifts)
- May be w/ or w/o contrast dye (need contrast dye care i.e. hydration, allergy check, kidney check, previous reactions (antihistamine or corticosteroids if mild reactions previously))
- Stay w/ patient during procedure to monitor neuro, VS, and ICP
- keep patient flat

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52
Q

Meningitis: Diagnostics

  • LP
  • CT/MRI
  • X-ray
  • C & S
  • CSF - 3
  • CBC
A
  • LP (definitive diagnosis)
  • CT/MRI – identify increased ICP, hydrocephalus or brain abscess
  • XRAY – determine if infection present
  • Culture & sensitivity - identify causative agent if LP delayed

CSF
- cloudy
- increased protein, WBC, lactate, specific gravity
- decreased glucose

CBC- WBC (elevated b-c infection)

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53
Q

ICR: Cerebral angiography

Use
Contraindications (3)
Care (5)

A

Use: Allows visualization of lumen of vessels to provide info on patency, size (narrowing or dilation), irregularities, occlusion (thrombosis) i.e. aneurysm, vasospasm, AV malformation, carotid artery disease, vascular tumor, stroke

Contraindications: renal insufficiency, bleeding, cardiac instability

Care
- NPO for 4 hrs prior b-c sedated
- Uses contrast dye (check for allergies and check kidney function; enhance hydration)
- Bedrest for 8-12 hrs after
- Care similar to cardiac cath (Keep patient flat and leg straight for 2-6 hrs, monitor puncture site and pulses after procedure)
- Monitor: VS, Neuro and neurovascular q15 for 1 h

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54
Q

ICR: Diagnostics

  • MRI (3)
  • EEG (1)
  • X-ray (2)
A

MRI
- more detail than CT to show subtle details (small tumors, cerebral infarct, CNS infections and inflammation, malignancy, metastatic lesions, spinal cord injury
- Requires patient to be motionless in tight space for long time (blindfold, music, or light sedation may be needed)
- Remove all metal from pt body and clothing (do not use if ICP monitoring)

EEG
- Looks at electrical impulses to view seizure activity, cerebral infarct, metabolic encephalopathies, alt LOC, infectious disease, head injury, confirm brain death

X-ray
- Identify fractures (except basilar), anomalies, or possible tumors
- may be unnecessary if CT

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55
Q

ICR: Lumbar Puncture

Use
Contraindications (2)
Care (3)

A

Use: visualize CSF and analyze to diagnose meningitis

Contraindications
- increased ICP associated with space-occupying lesion, mass or trauma b-c risk of brain herniation
- increased bleeding risk (anticoagulants, thrombocytopenia, coagulopathies)

Care
- Monitor for changes in neuro or breathing pattern
- properly align patient (flexed lateral)
- Do CT first to rule out mass, lesion, or trauma prior to LP if increased ICP suspected

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56
Q

Cerebral blood flow

How is it managed in body?
Notes (3)

A

Management: Cerebral Autoregulation (ability of cerebral vessels to maintain cerebral blood flow regardless of body’s blood pressure)

Notes
- corresponds w/ metabolic demands of body
- MAP of 50-150 = okay if autoregulation working but not okay if impaired autoregulation
- If impaired autoregulation, maintain SBP > 90

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57
Q

Cerebral blood flow: Altering factors

  • Increased (2)
  • Decreased (2)
  • Disorders (3)
A

Increased = increased ICP to compensate which worsens ischemia
- Acidosis (hypoxia, hypercapnia, ischemia,) -> vasodilation
- Increased metabolic demand (hyperthermia)

Decreased
- Alkalosis (hypocapnia) -> vasoconstriction -> ischemia due to decreased cerebral blood volume
- Reduced metabolic demand (hypothermia or barbiturates)

Disorders
- CSF Space (meningitis, Pseudotumor Cerebri, hydrocephalus)
- Intracranial Blood Flow
- Brain Substance (brain tumors)

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58
Q

Increased ICP

Goal of management

General Management (5)

A

Goal: reduce ICP by decreasing volume of blood, brain, or CSF in cranial vault

General Management
- Elevate HOB to improve perfusion pressure.
- Oxygen therapy to prevent hypoxia for patients with O2 less than 95%
- Hyperoxygenate the patient before and after suctioning to avoid transient hypoxemia
- quiet environment w/ low lights
- frequent neuro exam and GCS to find changes early

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59
Q

Increased ICP

Pharmacological Management (8)

A
  • AEDs to prevent seizures
  • Antipyretics and cooling blankets to decrease metabolic demand.
  • sedation and antihypertensives to reduce CPP
  • hypertonic saline (keep Na on high side of normal and reduce cerebral edema)
  • Steroids (decrease cerebral edema and inflammation)
  • Diuretics (mannitol or furosemide)
  • Opioids (fentanyl, morphine) and sedatives (propofol)- smallest amount b-c interferes w/ neuro exam
  • Neuromuscular blocking agents – must use ICP monitor b-c not able to get neuro exam w/ these
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60
Q

Increased ICP: Things to Avoid (7)

A
  • head, hip or neck flexion
  • clustering of nursing procedures
  • unnecessary suctioning
  • PEEP > 20 cm H2)
  • vomiting (antiemetics)
  • Constipation and straining (stool softeners)
  • Coughing (lidocaine)
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61
Q

Increased ICP: Key features

Early (4)
Late (7)

A

Early
- Decreased LOC (earliest)
- behavior changes (restlessness, irritability, confusion)
- speech changes (aphasia
- sensorimotor changes (CN dysfunction, ataxia, motor dysfunction, change in muscle tone)

Late
- Severe headache
- Nausea and vomiting (may be projectile)
- Seizures (usually within first 24 hours after stroke)
- Cushing triad (very late sign):
- Abnormal posturing (very late sign): Decerebrate or Decorticate
- Pupillary changes: fixed, constricted, dilated
- Papilledema (edema and hyperemia due to increased blood flow to eye)

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62
Q

Cerebral Perfusion Pressure (CPP

What is it? (2)
Normal range
Note (2)

A
  • pressure needed to ensure blood flow to brain
  • MAP - ICP = CPP

Normal range: 50-70 ( CPP < 30 = neuronal hypoxia and cellular death)

Notes
- Increased ICP -> decreased CPP and causes cytotoxic edema
- maintain SBP > 90

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63
Q

ICP Monitoring

Use
Normal range
Care (6)

A

Use: monitoring or treatment via draining CSF in EVD (external ventricular drain) for TBI, ICH, stroke, meningitis, hepatic encephalopathy,

Normal range ICP: 5-15 mmHG (Persistent elevation > 20 remains most significant factor associated with fatal outcomes

Care for device
- Need waveform (3 notches) along w. numeric value
- Zero device once per shift
- Check for catheter dislodgement or kinks in tubing
- Transducer must be leveled w/ ear (external auditory meatus) once a shift
- Do not move HOB b-c misaligns transducer and changes drainage
- reinforce but do not change cranial dressings

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64
Q

ICP Monitoring

Contraindication
Complications (4)

A

Contraindication: coagulopathy

Complications:
- Ventriculitis (decrease risk w/ antibiotic impregnated catheter)
- Meningitis
- Post-op hemorrhage,
- Decreased drainage (increases ICP)

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65
Q

Craniotomy

Use (3)
Types
- Transcranial
- Transsphenoidal approach

A

Uses: cerebral decompression, resection of tumor, clipping to remove hematoma or aneurysm

Types of craniotomy
- Transcranial approach: Scalp incision w/ series of Burr holes and remove bone flap
- Transsphenoidal approach (MIS): Create entrance into cranium via nasal cavity to remove pituitary tumors

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66
Q

CSF Leak: s/s (3)

A
  • Halo sign (place fluid on absorbent pad (see serosanguineous in middle and CSF forms yellow or clear halo around fluid)
  • test clear drainage for Test for glucose ( ≧ 30)
  • otorrhea/rhinorrhea
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67
Q

Craniotomy: Complications (7)

A
  • Periorbital edema and ecchymosis (common and need need cold compress and eye drops
  • Intracranial HTN (Increased ICP and cerebral edema)
  • Surgical hemorrhage (If transsphenoidal, frequent swallowing, postnasal drip (pt complaint), or external drainage OR loss of vision after pituitary)
  • Fluid imbalance (self-limiting DI/SIADH) – fluid management/restriction
  • CSF leak (rhinorrhea, otorrhea, sweet/salty taste, headache, Halo sign, persistent postnasal drip/excessive swallowing) – from subarachnoid space
  • DVT (focus on prevention i.e. SCD, subQ heparin or enoxaparin (unless active hemorrhage), early ambulation)– s/s: leg or calf pain, erythema, warmth, selling
  • Infections (meningitis, cerebral abscesses, bone flap infections, subdural emphema)
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68
Q

Craniotomy: Post-op Goals

  • Cerebral Perfusion (3)
  • Oxygenation (4)
  • Nutrition (2)
A

Preserve adequate CPP (> 70)
- Monitor neuro and VS q15-30 min for first 4-6 hrs then hourly
- Increased ICP prevention (neutral head, no hip/neck flexion, raise HOB, pharmacologics)
- Fluid mgmt (hourly I & Os, monitor sodium)

Promote arterial oxygenation
- Mechanical ventilation for 24-48 hrs (no PEEP > 20)
- Sedation (propofol or benzos) for pain and anxiety if breathing over ventilator rate
- Maintain airway clearance via Suction PRN & proper technique (pre-oxygenate and no more than 2 passes)
- Early rehabilitation (deep breathing and repositioning q2h

Enteral nutrition
- OG or NGT within 24 hrs post-op
- Stress ulcer prophylaxis (PPI, H2A)

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69
Q

Meningitis

What is it?

Types (5)

A
  • infection of meninges of brain and spinal cord i.e pia mater and arachnoid where organism enters via blood stream

Types
- Sterile (Cancer, NSAIDs, antibiotics, IV Igs)
- Viral (aseptic i.e HSV2, varizella, mumps, HIV)
- Bacterial (Meningococcal meningitis = emergency) –contagious and life-threatening in first 24 hrs
- Fungal (cryptococcus neoformans)
- Protozoal

70
Q

Meningitis:

Risk Factors (4)
Prevention (2)

A

Risk factors
- trauma (head, neck, basilar fracture
- Surgical procedures to brain or spine
- infection (ear, nose, mouth, eye, otitis media, sinus infection, brain abscess
- Immunocompromised (asplenia, immunosuppressant drugs, older adults)

Prevention
- Vaccination (meningococcal and all vaccines (hib, pneumococcal, mumphs, varicella)) esp if high pop density area (college dorm, military barracks, crowded living area)
- prophylaxis antibiotics for those in close contact)

71
Q

Meningitis: Care (6)

A

Care
- frequent neuro and neurovascular assessments q2h
- CN assessment (CN VI deficit: inability to move eyes laterally (may indicate hydrocephalus same if increased ICP or incontinence))
- Pain management (opioids and nonopioids)
- Isolation precautions (droplet if bacterial; standard if others)
- IV Broad spectrum Antibiotic administration ASAP (may discontinue or change after culture results are in; needed for 2 weeks )
- Pharmacologic interventions to decrease ICP or manage seizure activity (Mannitol, hypertonic saline, AEDs)

72
Q

Meningitis: Key features (10)

A
  • Nuchal rigidity
  • Positive Kernig (leg extension) & Brudzinski (neck flexion) signs
  • Pupils (photophobia, nystagmus)
  • Severe headache
  • Motor (CN dysfunction (II, IV, VI, VII, VIII), Myalgia; Hemiparesis, hemiplegia, decreased muscle tone
  • Fever/chills (may be absent in older adults, immunocompromised or those on antibiotics)
  • Tachycardia
  • Red macular rash (only bacterial)
  • Memory problems (short attention span; personality and behavior changeS)
  • increased ICP and hydrocephalus
73
Q

Meningitis: Complications (6)

A
  • Increased ICP
  • Vascular dysfunction and coagulation disorders (risk for gangrene (thrombotic complications seen in hands i.e. cap refill, temp of extremities, pulses, color)
  • f/e imbalance (i.e. SIADH)- get I & O
  • Seizures
  • Sepsis (shock and arthritis)
  • ARDS
74
Q

TBI: Types

  • Primary (Ex. Contusion, lacerations, shearing injuries, hemorrhage) (2)
  • Secondary (2)
A

Primary TBI (mild to severe)
- during trauma and at moment of impact due to mechanical forces to head
- can be open (dura mater torn) or closed (dura mater not closed)

Secondary TBI
- after initial injury from cellular response that exacerbates primary TBI and causes add’l damage and impairment in brain
- due to 4 things: ischemia (r/t hypotension (MAP <70) or hypoxia (PaO2 <80) and hypercapnia), intracranial HTN, cerebral edema, initial cerebral vasodilation

75
Q

TBI: Basilar Skull Fracture

s/s (4)
Care (2)

A

S/s
- CSF leak (otorrhea, rhinorrhea)
- Battles sign (ecchymosis behind the ear over mastoid process)
- Raccoon eyes (purplish discoloration around eyes)
- Palsy of CN VII

Care
- detect w/ CT
- NO NGT for this client! (rule out basilar fracture b-c can accidentally insert into brain)

76
Q

TBI: Concussion

What is it?
Diagnostic
S/s (6)

A

Mild brain injury (GCS 13-15 and d/c home) w/ brief loss of neurologic function, particularly loss of consciousness.

Diagnostic: based on hx

S/s
- Loss of consciousness (few minutes to hour) -> anterograde or retrograde amnesia
- confusion/disorientation/dizziness
- irritability/headache
- NV
- ringing in ear
- may have long term secondary effects (CTE or post concussion syndrome)

77
Q

TBI: Contusion

What is it? (2)
Diagnostic
S/s (5)

A
  • bruising of brain (blood collects) due to acceleration-deceleration injuries
  • coup (at point of impact) or contrecoup (secondary opposite point of impact)

Diagnostic: CT

S/s
- inability to concentrate
- numbness and tingling
- issues speaking
- risk for intracerebral hematoma or hemorrhage
- risk for cerebral edema - may need surgery

78
Q

TBI: Epidural Hematoma

What is it?
S/s (3)
Care

A
  • Arterial Bleeding (FAST) into the space between the skull and outermost layer of the dura mater

S/s
- Severe, localized headache (sleepy)
- Dilated and fixed pupil on impact side
- Brief loss of consciousness followed by a period of lucidity then rapid deterioration of LOC (Walk – Talk – Die phenomenon)

Care: Requires EMERGENCY surgical evacuation to remove blood and cauterize vessels

79
Q

TBI: Subdural Hematoma

What is it? (2)
Risk Factors (2)
Care

A
  • Venous bleeding (SLOW) into the space between the dura and above the arachnoid space.
  • Most frequently seen intracranial hemorrhage

Risk factors:
- Coordination or balance disturbance
- Anticoagulants

Care: craniectomy or craniotomy

80
Q

TBI: General Care (8)

A
  • ABCs = priority (b-c risk for Hypoxia, hypercapnia; Hypertension/Hypotension, fever) - need controlled hyperventilation and hypothermia
  • Continuous and Frequent Neurologic Assessment and GCS q1h for early detection and treatment
  • Assess electrolytes q6h if diuretics used
  • Spine precautions (cervical collar, supine, neutral, log roll) until cervical injury ruled out)
  • Seizure precautions
  • Use Foley and PEG/ NG for strict I & O measurement
  • Avoid noxious stimuli (excess suctioning, coughing, irritation, clustering care)
  • Early consults: OT/PT/SLP/social work/organ donation
81
Q

Mobility: Older Adult risks (6)

A
  • Decrease in lean body mass
  • Increase in body fat
  • Decline in muscle strength (osteoporosis, fractures, immobility)
  • Decreased sensation
  • polypharmacy (fall risk w/ benzos, SSRIs, TCA, neuroleptics, and AEDs = highest risk of falls)
  • frailty (decreased muscle mass, poor nutrition, diminished cognition)
82
Q

Guillain-Barre Syndrome (GBS): Basics (3)

A
  • autoimmune disease
  • demyelination of peripheral nerves causes inflammatory peripheral neuropathy
  • TEMPORARY
83
Q

GBS: Risk Factors (4)

A
  • Men
  • vaccines (flu, swine flu, tetanus)
  • prior respiratory and intestinal infection
  • trauma (surgery lymphoma)
84
Q

GBS

S/s (5)
Complications (2)

A

-Initial muscle weakness and pain
- bilateral paresthesia, ataxia -> paralysis
- Ascending paralysis (flaccidity to respiratory paralysis) over 2-3 weeks then plateaus
- No effect on LOC or cerebral function (may have CN dysfunction)
- Decreased DTR

Complications
- Pulmonary (atelectasis, pneumonia, pneumothorax)
- Autonomic dysfunction (HTN, Tachycardia -> beta blocker needed)

85
Q

GBS: Diagnostics (3)

A
  • autoimmune antibodies
  • CSF analysis (Elevated CSF protein with normal cell count)
  • Nerve conduction studies (Reduced conduction in GBS)
86
Q

GBS: Care (7)

A
  • sensory and neuro assessment q1h
  • no cure but hasten recovery w/ Plasmapheresis, IVIG, and steroids for inflammation
  • Respiratory care (may need ventilatory support)- admitted to ICU if requires respiratory support
  • Pain management (opioids)
  • Nutritional management (NG or OG tube if swallowing difficulties)
  • Communication boards or writing if on ventilator and has strength
  • Initiating OT and PT rehabilitation
87
Q

Plasmapheresis

Use
Action
Pre-op care (2)
Contraindications (2)

A

Use: GBS, MG

Action: Removes circulating antibodies assumed to cause disease from blood then reinfuse blood (similar to dialysis)

Pre-procedure
- place vascular Cath
- need informed consent

Contraindications: sepsis, hemodynamic and venous access complications

88
Q

Intravenous immune globulin (IVIG)

Use
Minor discomforts (3)
Major complications (3)
Contraindications (3)

A

Use: GBS

Minor discomforts ( mild fever/chills, myalgia, and headache)

Major complications (anaphylaxis, retinal necrosis, AKI)

Contraindications: hypercoagulable states, renal failure, hypersensitivity

89
Q

Multiple Sclerosis (MS): Basics (4)

A
  • Chronic autoimmune disease
  • Destruction of myelin (fatty and protein materials) sheath that cover certain fibers in the brain and spinal cord
  • Slows or stops impulse transmission via neuronal injury and muscle atrophy
  • Periods of remission and exacerbation
90
Q

MS: Risk factors (5)

A
  • More common in women, northern European
  • Increased risk w/ first degree relative
  • Onset b/w 20-50s
  • exacerbated by metabolic demands (fatigue, stress, exertion, hot temp)
  • Infection, genetic, or immune factors
91
Q

MS: S/s

Mobility (3)
Visual (4)
Audio (3)

A

Musculoskeletal/mobility
- Muscle weakness and spasticity (paresthesia, flexor spasms) -> paralysis
- Intention tremors (when doing activities) i.e. dysmetria
- Ataxia

Visual
- Nystagmus
- Diplopia
- Decreased acuity (blurry)
- Scotoma (change in peripheral vision)

Audio
- Decreased hearing acuity
- Tinnitus
- Vertigo (dizziness)

92
Q

MS: S/s

Speech (2)
Cognitive (3)
Elimination/Repro (3)

A

Speech
- Dysarthria (difficulty speaking)
- Dysphagia (difficulty swallowing)

Cognitive changes
- memory loss, impaired judgment, inattention
- Mood swings (euphoria; depression)
- Pain -> hypoalgesia (decreased pain sensation)

Elimination/repro
- Urinary retention (Spastic bladder)
- Constipation
- Decreased sexual function (sensation, interest, erection)

93
Q

MS: Diagnostics (4)

A
  • CSF: elevated proteins and increased WBC count
  • CSF electrophoresis: increased myelin basic protein and presence of increased IgG
  • MRI (shows at least two areas of diffuse random or patchy areas of plaque in white matter of CNS ) = definitive finding
  • Evoked potential testing (Visual evoked response (VER)): identify impaired transmission along optic nerve pathway
94
Q

MS: General Care (4)

A
  • ABCs (promote mobility)
  • collab w/ PT, OT, SLP
  • reorient if cognitive deficits
  • eye patch and scanning techniques for visual problems
95
Q

MS: Drug Therapy (5)

A
  • Immunosuppressive therapy (Cyclophosphamide (Cytoxan);
    methylprednisolone (Solu-Medrol))
  • Anticholinergic agents for overactive bladder
  • Antispasmodics (baclofen or tizanidine) for muscle spasticity which cause pain
  • Antiepileptics (carbamazepine) and TCA for paresthesia
  • Analgesics– pain
96
Q

Myasthenia Gravis (MG): Basics (3)

A
  • Autoantibody attack on the acetylcholine receptor sites (AChRs) in the muscle end plate membranes
  • Inadequate ACh = result which prevents muscle contraction
  • exacerbations and remissions
97
Q

MG: Exacerbation Factors (4)

A
  • thymus dysfunction ( Size decreases w/ age but large in MG)
  • infections (pneumonia, bronchitis, UTI, C.diff, bacteremia)
  • hypo/hyperthyroidism
  • increased metabolic demand (exertion, pregnancy, emotions, fever)
98
Q

MG: s/s (6)

A
  • Fatigue/extremity weakness -> Respiratory muscle compromise
  • Poor posture
  • Ptosis/ diplopia
  • Dysarthria (difficulty speaking)
  • Dysphagia (difficulty swallowing) –Risk for aspiration
  • Loss of bowel and bladder control
99
Q

MG: Tensilon Test

Procedure
Results (2)
Risks (2)
Care (3)

A

Procedure: patient in controlled environment and given acetylcholine or edrophonium (acetylcholinerase inhibitor)

Result (observe or take before and after pics of ptosis)
Symptoms improve = MG crisis
Symptoms worsen = cholinergic crisis

Risks
- cardiac dysrhythmias and cardiac arrest (bradycardia, hypotension, bronchospasm, syncope)
- Ach Toxicity: lacrimation, salivation, hyperhidrosis, abdominal cramping, diarrhea

Care
- Antidote = atropine
- Have continuous BP, O2, and cardiac monitoring
- contraindicated w/ asthma or cardiac diseases

100
Q

MG: Diagnostics (6)

A
  • Ice pack test (Procedure: place ice pack for 2 min and see if ptosis improves)
  • Thyroid function
  • CT: show thymus gland abnormalities or confirm presence of thymoma (tumor outside thymus)
  • Antibodies to acetylcholine receptor antibody (AChRs)
  • Repetitive nerve stimulation (RNS) or Electromyography (EMG): show impaired neuromuscular transmission
  • Tensilon test

Note: MRI not used b-c contrast can worsen weakness

101
Q

Crises

  • Myasthenic (3)
  • Cholinergic (2)
A

Myasthenic crisis
- Acute exacerbation of MG from enough anticholinesterase drugs (too little Ach)
- s/s: dysphagia, nasal regurgitation, nasal speech, jaw or tongue weakness, decreased facial sensation, dyspnea, acute respiratory failure
- Treat: Mestinon (pyridostigmine);IVIG or plasmapheresis; respiratory support w/ artificial airway

Cholinergic crisis
- Acute exacerbation of muscle weakness caused by too much anticholinesterase drugs (too much Ach)
- Treat: atropine

102
Q

MG: Care

Nonsurgical (3)
Surgical (1)

A

Non-surgical Management
- Ventilator support (ETT or noninvasive)
- Pulmonary support (CPT, vibration, airway clearance; adequate nutrition, f/e balance)
- Promote mobility to prevent DVT and other immobility complications

Surgical Management
- Thymectomy (take thymus out)-

103
Q

MG: Pharmacological Care

  • Cholinesterase (ChE) inhibitor drug (Mestinon (pyridostigmine)) – (2)
  • Immunosuppressants (steroids, cyclosporin, methotrexate) – (2)
  • IVIG or Plasmapheresis – (1)
A

Mestinon (pyridostigmine) (Cholinesterase (ChE) inhibitor drug)
- Gold standard for MG (no impact on autoimmune response)
- enhances functional AChRs by increasing ACh release

Immunosuppressants (steroids, cyclosporin, methotrexate)
- reduce autoimmune process and progression
- avoid crowds and report s/s of infection; don’t stop steroids abruptly b-c adrenal insufficiency

IVIG or Plasmapheresis
- If severe w/ bulbar dysfunction or respiratory insufficiency

104
Q

Amyotrophic Lateral Sclerosis (ALS)

Description (3)
Care (2)

A

Description (Lou Gehrig’s disease)
- Upper and lower motor neurons degenerate and leave dead tissue until entire body involved
- Progressive and neurodegenerative
- No cure (life expectancy = 3 yrs. after diagnosis)

Care (all treatment is support)
- ABCs (trach and vent, perfusion) to treat/prevent respiratory failure
- Riluzole - FDA approved to slow progression (not a cure)

105
Q

ALS

  • S/s (6)
  • Diagnostics (2)
A

S/s
- Severe Weakness and fatigue (muscle atrophy) -> respiratory failure
- Stiff and clumsy gait
- Abnormal reflexes (facial twitching)
- Dysphagia (Difficulty swallowing)
- Dysarthria(Slurred speech)
- Psychosis (late)

Diagnostics
- Muscle biopsy – atrophy fibers
- EMG – fibrillation of muscle

106
Q

Levels of Spinal Nerves

Cervical (2)
Thoracic (1)
Lumbar (1)

A

Cervical (8)
- control diaphragm, chest wall muscles, arms, shoulders
- If C4 and up leads to paralysis of respiratory muscles and all four extremities (tetraplegia) or quadriparesis (weakness)

Thoracic (12)
- control upper body, GI function i.e. paraplegia (lower extremity paralysis) or paraparesis (lower extremity weakness)

Lumbar (5) and Sacral (5)
- controls lower body, bowel, bladder

107
Q

Spinal Cord Injury

Complete vs. incomplete

A
  • Complete (Total loss of motor and sensory below level of injury)
  • Incomplete (more common w/ some sensation and motor activity below level of injury)
108
Q

Spinal Cord Injury: Primary Mechanisms (5)

A
  • Hyperflexion (esp Cervical area (level of C5/C6 b-c most mobile from head on collision)
  • Hyperextension (whiplash from rear end accidents OR falls onto chin)
  • Axial loading, or vertical compression (From falls landing on feet or butt; diving)
  • Excessive rotation
  • Penetrating injuries to the spinal cord (i.e. knife or gunshot)
109
Q

Spinal Cord Injury: Secondary Mechanisms (5)

A
  • inflammation (cytokine release)
  • Hemorrhage (contusion or internal CNS petechial leaking)
  • Ischemia ( lack of oxygen r/t reduced blood flow)
  • Hypovolemia
  • Local edema -> capillary compression and cord ischemia
110
Q

Neurogenic Shock

Basics (4)

A
  • secondary mechanism of spinal cord injury
  • medical emergency
  • Loss of vasomotor tone -> systemic vasodilation -> hypotension and hypoperfusion (give fluids)
  • Bradycardia (give atropine and norepinephrine)
111
Q

Spinal shock

Basics (4)

A
  • Temporary (Happens immediately and usually lasts 48h but can Last up to 4-12 weeks)
  • complete paralysis/weakness below injury (may lack reflexes and have priapism)
  • Decreased bowel sounds and gastric distention -> hypotonic bowel
  • must resolve before level of injury can be determined
112
Q

SCI: Care

Assessments (3)
Nonsurgical (6)

A
  • assess neurological status ( GCS <8 = intubate) q1h for 4-6h
  • Assess for hemorrhage (internal bleeding; may need blood)
  • Determine level of injury based on ROM, paralysis, DTRs, weakness

Nonsurgical management
- ABCs (evaluation respirations and perfusion) q2-4h
- spinal precautions (collar, bed rest, log roll, jaw thrust)
- ventilation ( no nerve blocking agents; often difficulty weaning)
- pulmonary support (suctioning, chest percussion, incentive spirometer)
- Traction (skeletal, halo fixation)- assess for infection and bleeding; do not adjust
- Prevent complications (musculoskeletal, integumentary, elimination)

113
Q

SCI: Diagnostics (2)

A
  • X-rays of spine to identify vertebral fractures, subluxation, or dislocation
  • CT and MRI to rule out cervicothoracic injury or determine degree and extent of damage to spinal AND determine if blood or bone in spinal column
114
Q

SCI: Complications (7)

A
  • Shock (hypovolemic, spinal, neurogenic)
  • Cardiac (Dysrhythmias esp. if C3-C5 level, symptomatic bradyarrhythmias, treated w/ atropine or inotropic meds then pacemaker; DVT; orthostatic hypotension)
  • Pulmonary complications (O2 < 92%, atelectasis, pneumonia, respiratory paralysis)
  • Musculoskeletal complications ( contractures, osteopenia, osteoporosis, heterotopic ossification (bony overgrowth onto muscle) —Care: PT/OT for ROM exercises, foot drop splints, hand splints, celecoxib to prevent heterotopic ossification
  • Integumentary complications (Risk for pressure ulcers, temp dysregulation, VTE) – use cooling blanket prior to antipyretics
  • Elimination complications (Risk for abdominal distention, constipation, fecal impaction; Spastic bladder if upper SCI; flaccid bladder if lower SCI) – care: Foley and stool softeners; bowel program (Fluids, fiber, proper position, physical activity, reflex stimulation)
  • Autonomic dysreflexia (EMERGENCY)
115
Q

SCI: Pharmacologic care (6)

A
  • Methylprednisolone (Medrol) for edema and inflammation
  • Baclofen for spasms (risk for CNS depression, hypotension; OR Hallucination and seizures if sudden withdrawal)
  • Stress ulcer prophylaxis (PPI)
  • IV fluids and vasopressor support to keep SBP > 90 and MAP > 85-90 to prevent hypotension
  • Dextran (plasma expander) to increase capillary blood flow in spinal cord and prevent/treat hypotension
  • Atropine sulfate to treat bradycardia if pulse < 50-60 beats/min
116
Q

SCI: Care

Surgical (4)

A

(within 24 hrs to stabilize if needed to remove bone fragments, hematomas, or penetrating objects)

  • Laminectomy (lamina removed from posterior spine to provide decompression
  • Spinal fusion (fusion of 2 to 6 vertebral bodies to provide stability and prevent motion)
  • Pedicle screw fixation (for thoracic and lumbar fracture)
  • Vertical plates and bone grafting
117
Q

Autonomic Dysreflexia: Risk factors (7)

A
  • Restrictive clothing
  • Pressure area (Epididymitis or scrotal compression; Sheet wrinkles or hard objects)
  • UTI
  • Irritation of hemorrhoids
  • Pain
  • Distended bladder (Areflexic (neurogenic) bladder)
  • Constipation (fecal impaction)
118
Q

Autonomic Dysreflexia

  • S/s (3)
  • risks (3)
A

S/s
- Vasodilation above level of injury
(Severe HTN, severe headache, nasal stuffiness, blurred vision, spots in visual field, Flushing, Diaphoresis, goosebumps, JVD, apprehension)

  • Bradycardia
  • Vasoconstriction below level of injury (Pale, Cool, No sweating)

Risks
- cerebral hemorrhage
- seizures
- stroke

119
Q

Autonomic Dysreflexia

Basics
Care (5)

A

Basics
- Exaggerated sympathetic response to stimuli in people w/ high level SCI (T6 or higher)

Care
- Raise HOB to reduce BP
- Treat the cause i.e. remove impact, check catheter, loosen clothes, identify UTI, examine for pressure ulcer
- Notify MRT
- Monitor BP q10-15 min
- Give nifedipine or nitrate to lower BP

120
Q

Stevens-Johnson Syndrome (SJS)

Causes (6)

A
  • Immunologic mechanism
  • Bactrim (trimethoprim-sulfamethoxazole)
  • Allopurinol
  • AEDs (Carbamazepine, Lamotrigine, phenytoin)
  • Phenobarbital
  • sulfasalazine
121
Q

SJS: Assessment

Mild (2)
Severe (7)

A

Mild
- Skin lesions widely distributed and bilateral
- Rash

Severe
- Fever (sepsis risk)
- Aching joints and muscles
- Excessive fluid loss (risk for dehydration)
- Renal failure and renal problems
- Blindness
- Oral and respiratory mucous membranes involvement
- Vesicles, erosions and crusts (epidermal detachment) -> Permanent skin damage (necrosis)

122
Q

SJS: Care (7)

A
  • Mild forms self limiting (10-14 days)
  • Removal of offending drug
  • Antibiotics to prevent infection
  • Steroids to suppress immune and inflammatory response
  • Fluid replacement
  • Mechanical ventilation if respiratory problems
  • Supportive (skin, CRT for renal)
123
Q

Snake Bites: Pit Vipers

  • general s/s (6)
  • late s/s (4)
A

General
- Severe pain
- Swelling (vesicles or bullae)
- Redness or ecchymosis
- Minty, rubbery, or metallic taste in mouth
- Muscle paresthesia (twitch or tingling of face and head) and weakness
- NV

Later developments
- Seizures
- Hypotension
- subQ ecchymosis
- DIC (bleeding and depletion of coagulation factors)

124
Q

Snake Bites: Coral Snakes

s/s (7)

A
  • reduced pain perception (mild abdominal and site pain)
  • ascending paralysis -> respiratory paralysis and cardiac collapse
  • Mental status change (headache)
  • CN deficits (ptosis, diplopia, difficulty swallowing, speaking)
  • N/V
  • Pallor
  • Paresthesia, Numbness
125
Q

Snake Bites

General Care (9)

A
  • Move to safe place away from snake
  • continuous cardiac, blood pressure and pulse oximetry monitoring
  • Assess distal circulation q1hr
  • Measure and record the circumference of the bitten extremity every 15- 30 min with skin marker
  • Oxygen
  • Give IV fluids
  • Pain management
  • give tetanus shot
  • give Antivenom (Crotalidae Polyvalent Immune Fab (CroFab) for pit vipers; Antivenin (Micrurus fulvius) for coral snakes)
126
Q

Snakebites: Diagnostics (6)

A
  • Coagulation studies (b-c DIC risk w/ pit viper
  • UA (b-c myoglobinuria w/ coral)
  • CBC
  • BMP
  • CK (b-c increased in coral)
  • EKG to assess for myocardial ischemia or other abnormalities
127
Q

Snakebites: Prevent venom circulation (6)

A
  • Remove jewelry and constrictive clothing (no tourniquets)
  • Immobilize affected extremity at level of heart (do not elevate)
  • Encourage rest
  • No alcohol
  • No sucking or cutting the wound
  • No ice
128
Q

Older adults: Common skin problems (5)

A
  • Xerosis (dry, cracked, itchy skin) –Worsened by inadequate water intake or environmental conditions; interventions: moisturizers, natural oils
  • Seborrheic keratosis (Noncancerous growths)
  • Cancer (skin cancer)– avoid hot day, protective clothes, sunscreen, check sin
  • Skin tears (wound from shear, friction, and or blunt force which separates skin layers)
  • Pressure ulcers –assess w/ Braden Scale
129
Q

Older adults: Skin Changes (5)

A
  • Less elastic r/t collagen depletion
  • Drier ((less moisture) so prone to dermal-epidermal separation, reduced subQ blood flow, decreased dermal lymphatic drainage
  • More fragile b-c epidermis thins, BVs break easy
  • Decreased wound healing r/t decreased cytokine and growth factor production; diminished inflammatory response and reduced cell proliferation
  • increased breakdown r/t incontinence, immobility, diarrhea
130
Q

Burn

What is it?
Classification (5)

A
  • Anytime there is injury to the tissues of the body caused by heat, chemicals, electrical current, cold, or radiation

Classification
- Size of Burn Injury
- Depth of Burn Injury
- Type of Burn Injury
- Location of Burn Injury
- Patient Age and History

131
Q

Patients Best Treated in Burn Center (6)

A
  • partial thickness of 10% TBSA
  • Any full thickness/ 3rd degree
  • Burn to face, genitals, major joints, perineum, hands, feet
  • special Injuries (electrical, inhalation, chemical, frostbite)
  • Burn w/ preexisting conditions (DM, pulmonary, cardiac, kidney, or CNS disorders) that increase risk of mortality
  • Burn injury + former trauma (fracture)
132
Q

Size of Burn: Rule of Nines

Components (6)

A

Components
- chest (18%)
- back (18%)
- genitals (1%)
- Each leg (18%- one side = 9%)
- Each arm (9%- one side = 4.5%)
- Head (9%- face = 4.5%)

Tidbits
- Circumferential from shoulder to elbow = 4.5%
- Palmar surface of hand = 1%

133
Q

Size of Burns: Rule of Nines

Tips (3)

A
  • Must be accurate for burn shock interventions, calculation of TBSA, and caloric needs
  • Quickest way to calculate size of burn injury in adults
  • Do not include first degree burns in rule of nines
134
Q

Depth of Burn (3)

A
  • how much of two skin layers involved
  • impacted by location (thinner skin on eye vs arm)
  • impacted by age (thinner in child vs adult)
135
Q

Depth of Burns: Superficial (1st)

What is it?
S/s (3)
Care (4)

A

Epidermal burn (not included in rule of nines)

s/s
- Red, erythema
- Painful, Tender which resolves in 48-72 hrs
- Possible swelling

Care
- Heals in 2-7 days
- Pain relief
- Anti-Pruritics
- Oral fluids

136
Q

Depth of Burns: Superficial partial (2nd)

What is it?
S/s (5)
Care (2)

A
  • involves all of epidermis and part of underlying dermis

S/s
- Light to bright red or mottled appearance
- Blanch w/ pressure due to inadequate perfusion
- Bullae OR wet and weeping blisters due to microvessel injury increasing permeability and causing leakage of plasma into interstitium
- Extremely painful
- sensitive to air currents

Care
- Uncomplicated heals in 7-21 days w/ minimal scarring
- IV fluids

137
Q

Depth of Burns: deep partial (2nd)

What is it?
S/s (3)
Care (4)

A

Burn involving entire epidermal layer and deeper layers of the dermis w/ Severe blood supply impairment

S/s
- Red with patchy white areas that blanch with pressure
- Turns from white to yellow due to dermal necrosis and surface coagulated protein
- NO blister formation

Care
- Extensive healing time (up to 6 weeks) – full-thickness if infected, inadequate perfusion, or more trauma
- Spontaneous healing (hypertrophic scarring and contractures due to unstable epithelium)
- Surgical excision
- Skin grafting

138
Q

Depth of Burns: Full-Thickness (3rd)

What is it?
S/s (5)
Care (2)

A
  • All 3 layers of skin involved so skin does not grow back on its own

S/s
- Pale white or charred, red or brown
- Leathery and dry - bleed from vessel damage
- Painless (May have background or procedural pain)
- Insensitive to palpitation
- systemic effects on f/e balance, infection, metabolism, thermoregulation

Treatment
- Does not heal by epithelialization or on its own
- Skin grafting

139
Q

Thermal Burn (3)

A
  • Most common type of burn
  • Most at risk: <2 yrs. (scalds) AND > 60 yrs.
  • Temperature and duration of contact determine extent and depth of injury
140
Q

Electrical Burn

Notes (2)
Amount of damage determined by (4)

A

Notes
- Highest incidence in children
- risk for tissue destruction, contracture formation, acid-base balance. Rhabdomyolysis

Amount of damage determined by
- Type and voltage of circuit
- Resistance (insulation)
- Pathway of transmission through body (More serious than outside appearance due to current traveling inside the body and damaging inner tissues)
- Duration of contact

141
Q

Radiation Burn (3)

A
  • Usually localized from high dose radiation (accelerators, cyclotrons, medical treatment) or prolonged sun
  • Appearance similar to thermal injury (Differentiate based on timing of injury and clinical manifestations)
  • Care: not extensive (may need fluids and anti-pruritic)
142
Q

Chemical Burn

Amount of injury determined by: (4)
Care (4)

A

Amount of injury determined by
- Concentration of chemical
- duration of contact
- chemical action (alkaline more severe than acid)
- amount of tissue

Care
- Remove contacts prior to flushing eye
- Remove contaminated clothing and shoes
- Flush area w/ large amounts of water for hours after injury
- Neutralization can worsen injury

143
Q

Stages of Burn Care

Resuscitation/Emergent (3)
Acute (3)
Rehabilitative (2)

A

Resuscitation/Emergent
- Begins at the time of injury and continues for about 48 hrs
- ends when capillary integrity restored and plasma volume repleted
- 1st hour after injury is crucial

Acute
- begins after resuscitation (36-48 hr) w/ diuresis (end of edema)
- lasts until complete wound closure is achieved
- Early eschar excision and grafting = early resolution of inflammation and better healing

Rehabilitative
- Begins with major wound closure to return to optimum level of health (independence and maximum function)
- Usually about 6 months to 2 yrs but may take a lifetime b-c ends when highest level of functioning reached.

144
Q

Burns: Acute Care

Goals (3)

A
  • Save patient’s life (maintain vital organ function and perfusion)
  • Minimize complications and disability (wound healing and prevention of infection)
  • Prepare for rehabilitation and definitive care
145
Q

Burns: History (7)

A
  • Age (higher risk if <2 or > 60)
  • How did it happen? (mechanism of injury) - rule out trauma, fractures, abuse
  • Assess source and cause
  • Where did it happen? (time and place; think CO poisoning if in confined space)
  • Assess for known allergies
  • Assess status of tetanus immunizations
  • significant medical history (preexisting conditions, current meds)
146
Q

Burns: Resuscitation/Emergent Phase

Priorities (6)

A
  • Maintain adequate oxygenation (airway)
  • Maintain adequate fluid balance (circulation to prevent hypovolemic shock from fluid shift)
  • Promote adequate tissue perfusion (may need w/ art line or CVP; remove watches/jewelry which can have tourniquet effect)
  • Maintain body temperature (risk for hypothermia via evaporation and radiation)
  • Prevent infection
  • Keep patient comfortable w/ analgesics and emotional support
147
Q

Burns: Factors that impair healing (8)

A
  • Toxic mediators of inflammatory process
  • Infection (endogenous or exogenous flora; eschar or exudate)
  • Inappropriate volume resuscitation
  • Malnutrition
  • Chronic illness (steroid therapy, diabetes, extreme obesity)
  • Age
  • Impaired perfusion (inappropriate resuscitation)
  • Trauma from daily dressing changes
148
Q

Burns: Airway Management

Care (7)

A
  • Ventilator support (100% oxygen, (low tidal volume, high PEEP, permissive hypercarbia)
  • HOB elevated
  • Early intubation
  • Mobilize and remove secretions (cough, deep breathing, suctioning, bronchodilators, early mobility, elevate HOB)
  • Careful fluid resuscitation to prevent pulmonary edema
  • Cervical precautions if possibility of instability
  • Nebulized heparin (increase airway clearance of debris)
149
Q

Burns: Airway Management

Goal

S/s of airway damage (4)

A

Goal: avoid ARDS, pneumonia, pulmonary edema

s/s of airway damage
- Assess ( singed nasal hairs or eyebrows, hoarseness, facial burn carbonaceous sputum, drooling)
- Sudden stop of stridor or wheezing = unable to breath (EMERGENCY)
- Facial edema = intubate prior to airway closing
- Hypoxemia (tachypnea, agitation, anxiety, upper airway obstruction)

150
Q

Inhalation Injury: Types

Smoke-related - 1
Upper airway - 1
Lower airway - 3

A

Smoke-related
- s/s: coughing, SOB, hoarseness, orofacial burns, black carbon particles in nose, mouth, sputum; smoky breath smell

Upper airway injury (pharynx, larynx, glottis, trachea, large bronchie)- most common
- Due to direct heat or chemical inflammation and necrosis

Lower airway injury
– usually r/t chemical damage to mucosa (chemical pneumonitis
- s/s: tracheobronchitis (severe spasm and wheezing)
- Diagnosis: chest x-ray and CT

151
Q

Inhalation Injury: Carbon monoxide poisoning

S/s (2)
Care (2)

A

S/s
- Early: tachycardia, tachypnea, confusion, lightheadedness,
- Late: decreased level of responsiveness, pale to reddish purple skin, ST depression, hypotension, dysrhythmia

Care
- Obtain HbCO level (binding of CO to hemoglobin which prevents binding of O2 to hemoglobin)- normal < 2%
O2 sat will be normal
- Start 100% oxygen via ETT or nonrebreather

152
Q

Burn: Respiratory Management

Concern
Care (4)

A

Concerns
- chest restriction (reduced expansion and compliance) w/ circumferential full thickness chest burns

Care
- Escharotomy to chest wall ASAP
- Monitor ABGs and O2 sat (Respiratory acidosis -> respiratory alkalosis)
- Monitor respiratory rate and effort
- Monitor for cyanosis (late sign)

153
Q

Burn: Circulatory Managment

Goal
Concerns (2)
Care (4)

A

Goal: maintain end organ perfusion and avoid fluid overload

Concerns
- Under resuscitation = inadequate cardiac output = inadequate perfusion and wound conversion (AKI, cardiovascular collapse, death from shock)
- Over resuscitation = excess wound edema -> moderate to severe pulmonary edema -> decreased perfusion of unburned tissue

Care
- Requires accurate fluid resuscitation
- No diuretics
- Assess HR, BP, pulses, cap. Refill, I & Os, LOC (perfusion to brain)
- Continuous EKG (May need nontraditional placement of leads due to burn locations)- initial if electrical wound or preexisting hear condition

154
Q

Burn Shock

What is it? (3)

Effects (4)

A
  • common cause of death in the emergent phase (Higher TBSA (>20%) = higher chance of shock)
  • Loss of fluid from vascular compartment to area of injury
  • Leads to blisters and edema from damaged blood vessels increasing permeability to protein and water

Effects
- hypovolemic shock
- tissue trauma
- increased PVR (leads to pulmonary edema)
- decreased myocardial contractility and cardiac output b-c increased SVR

155
Q

Burn: Fluid Resuscitation

Parkland Formula (3)
Tips (3)

A

Parkland Formula
- 4cc LR * body weight in Kg* % TBSA burned
- ½ given over first 8 hours post-injury
- ½ given over the following 16 hours post-injury

Tips
- LR via large bore (18 G or 20 G) IV
- LR > NS b-c matches ECF
- Plasma replacement and isotonic fluids used after 24 hours to increase circulating volume

156
Q

Burn: Renal Management

S/s of impairment (AKI) - 4

Care - 5

A
  • urine (hemoglobinuria, myoglobinuria)
  • inadequate fluid replacement (hypoperfusion, hypovolemia)
  • inadequate UOP (edema, elevated BP)
  • Change in LOC (lethargy, confusion)

Care
- Monitor labs (BUN, Crt, GFR, K/Na), PO4
- Assess urine (color, bloody, myoglobin, odor, particles, foamy)
- Monitor UOP and specific gravity
- May need dialysis (hemodialysis or CRT)
- Place foley (if TBSA > 20% or perineum burn)

157
Q

Burn: GI system Management

Risks due to stress response (3)

Care (5)

A

Effects of stress response
- Paralytic Ileus and gastric dilation (also due to burn shock, hypokalemia, SNS response to trauma)
- stress ulcer (Curling’s ulcer)
- Decreased GI activity (also due to hypovolemia and neurologic injury)

Care
- Initial NPO
- Abdominal exam q2h then q4h (incl. eval for abdominal compartment syndrome)
- Place NGT or OGT to low intermittent suction (Prevention of aspiration, distention, emesis)
- Administer GI prophylaxis (PPI, H2A, sucralfate, antacids)
- Enteral nutrition (Purpose: increase intestinal flow, intestinal blood flow, and GI motility)

158
Q

Burn: Extremity Management

Clinical manifestations (3)
Care (5)

A

Clinical manifestations
- arterial insufficiency due to wound edema, circumferential burns (leads to ischemia and necrosis)
- Diminished to absent peripheral pulses
- Loss of muscle function

Care
- Assess neurovascular integrity q6h ( Pulselessness, pallor, pain, paresthesia, paralysis, poikilothermy)
- Doppler flow probe (evaluate arterial pulses)
- escharotomy if circumferential burn to restore circulation and allow swelling
- Extend and elevate extremities to decrease peripheral edema and enhance venous return
- Avoid crossed legs, dependent positions, pillows behind knees

159
Q

Burn: Immune Management

Effects due to stress response

Care (5)

A

Effects due to stress response
- Overwhelming stress leads to bone marrow suppression, anemia, and infection

Care
- IV antibiotics
- Meticulous wound care (hand hygiene)
- Wound monitoring ( for exudate, odor, warmth, fever, and color)
- Supportive care (isolation techniques w/ dedicated equipment)
- Blood transfusions b-c prone to anemia

160
Q

Burn: Labs (7)

A
  • Hgb, Hct, & BUN HIGH (Due to fluid volume loss)
  • Glucose HIGH (Due to stess response
  • Na+ LOW (Due to trapped in wound edema, fluid loss, vomiting, NGT drainage, diarrhea)
  • K+ HIGH or LOW (High due to release from damaged cells, metabolic acidosis, impaired kidney function (hemoglobinuria, myoglobinuria, decreased renal perfusion) –> Care: correct acidosis (no DICK) OR Low due to massive fluid loss or hemodilution)
  • pH LOW (Due to metabolic acidosis
  • Total protein & albumin LOW (Due to loss via burn wound)
  • WBC initial rise then drop as immune system unable to sustain its defenses. (may be sepsis)
161
Q

Burn: Pain Management

Types (3)
When to manage pain (3)

A

Types
- background (physiological including damage and exposure of nerve endings) r/t ROM, routine activities
- Breakthrough which is not relieved by routine pain meds
- Procedural (PT, OT, dressing changes, splints)

When to manage pain
- Only after IV fluid resuscitation is underway
- Not initial priority b-c pain sensation diminished if well oxygenated and wound covered
- Premedicated prior to procedural care

162
Q

Burn: Pain Management

Care (4)

A
  • Reduce BMR via preventing catecholamine release i.e. from pain, fear, anxiety, cold
  • use IV in resuscitation phase (no subQ or IM b-c unpredictable absorption
  • use nonpharmacological (imagery, hypnosis, virtual reality, distraction)
  • use opioids (NSAIDs and acetaminophen only if no risk for bleeding)
163
Q

Burn: Contractures

What is it?
Prevention (4)

A

Contracture: shortening of scar over joint and causes functional deficit

Prevention
- Physical and occupational therapy
- Passive and active ROM to prevent complications
- Splint (Keep joints fully extended in anatomical position on pillows)
- no pillow behind head if face burn to prevent flexion of neck

164
Q

Burn: Wound Care

General (6)

A
  • Daily observation and assessment
  • Multiple dressing changes (application and reapplication of clean, dry dressing.
  • skin graft must be placed on clean, viable, tissue
  • Analgesics and sedatives (morphine, midazolam (versed), hydromorphone) to prevent procedural pain
  • Topical antibiotics (silver sulfadiazine, mafenide acetate cream, bacitracin, silver) to control/decrease bacterial colonization
  • Refer to Burn Center (delivers all therapy incl. rehabilitation and can perform personnel training and burn research)
165
Q

Burn: Cleansing

Goal

Notes (2)

A

Goal: maintain moist environment while limiting exposure to prevent hypothermia and bacteria exposure

Notes
- Done in a hydrotherapy tub, cart shower, shower, or bedside
- Hydrotherapy limited to 30 min to prevent hypokalemia

166
Q

Burn: Nutrition Therapy (4)

A
  • Early continuous enteral feeds
  • Caloric needs are about 5000 kcal/day due to high BMR
  • High-protein, high-carbohydrate foods
  • May need supplmental albumin, iron, zinc, calcium, phosphate, potassium
167
Q

Burn: Debridement

Goal
Types (3)

A

Goal: remove devitalized (nonviable) tissue down to bleeding stable tissue to control inflammation and remove contaminated tissue to prepare for grafting

Types
- Mechanical (via scissors or forceps)
- Enzymatic (via topical substance to loosen and dissolve eschar)
- Surgical (gold standard in OR once hemodynamically stable)

168
Q

Skin grafts: types

  • autograft (3)
  • allograft (3)
  • xenograft (2)
  • synthetic (1)
A

Autograft
- Patient’s own skin (abdomen, thigh, back)
- Provides permanent coverage
- Donor site must be treated as partial thickness wound and needs wound care

Homografts (allografts)
- From cadaver or living donor
- high cost and risk for infection
- Temporary (Rejected 2 weeks after application)

Heterografts (xenografts)
- From another species (pig)
- Must assess daily for adherence b-c can be rejected

Synthetic skin
- very expensive (Integra, cultured epithelial autograft)

169
Q

Burn: Rehabilitative Phase

Skin care (4)
Mobility (2)
Emotional (2)

A

Skin care
- Discoloration of scar fades with time but not invisible and may not fully go away
- Newly healed areas can be hypersensitive or hyposensitive to cold, heat, and touch
- Healed areas must be protected from direct sunlight for 1 year
- use lotion for itching

Mobility
- Engage in PT, OT
- exercise important

Emotional
- praise minor and major accomplishment
- use group therapy

170
Q

Burn: Scarring

Prevention (6)

A
  • pressure garments which reduce scar blood flow, help organize collagen, prevent venous stasis and edema
  • Scar massage via providing moisture, stretching scar, and preventing contracture
  • High SPF sun protection via preventing long term pigment change
  • Silicone gel sheeting via maintaining scar hydration and reduce tension
  • Laser therapy
  • Steroids for hypertrophic scars via inhibiting fibroblast growth

Concepts 3 (4 decks)

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