exam 3

Question 1

three phases of burn care

Answer 1

1. emergent
2. acute
3. rehabilitative

Question 2

emergent phase of burn care

Answer 2

the time of the injury up to 72 hours- FIRST 24 HOURS IS MOST CRITICAL
-focus on stabilization and transportation to the burn unit
-hypovolemia= massive fluid shift out of the intravascular compartment (hemodynamic shift may lead to hypovolemia)

Question 3

acute phase of burn care

Answer 3

time in the hospital! from the ED to the floor to get taken care of
-focus on wound care, pain management, infection control, and nutrition- we need to promote healing!

Question 4

rehabilitative phase of burn care

Answer 4

POST hospital discharge
-focus on scar management, corrective surgery, ongoing rehabilitation (contracture prevention, stretching, strengthening), adaptation to new disabilities, emotional support, and education.

Question 5

burn definition/pathophysiology and types

Answer 5

a burn injury results when the tissues of the body are damaged by a heat source
types:
-thermal
-electrical
-chemical
-radiation

Question 6

thermal burns

Answer 6

flash, scald, or contact with hot objects or flames
-temperature and duration- depends on these factors of the agent
-house fires, care fires, cooking accidents

Question 7

electrical burns

Answer 7

electricity passes through the body, potential to cause damage to multiple organs. wide spectrum of injuries, mild to lethal.
-extensive burns that may even require amputation
-power lines- gas and electrical workers!

Question 8

chemical burns

Answer 8

acids, alkalines, organic compounds- industrial or household

Question 9

radiation burns

Answer 9

industrial use of ionizing radiation, nuclear accidents, and therapeutic radiation treatment, sunburns - UV radiation
- type, dose, length of exposure- all guide treatment!

Question 10

types of burn depths

Answer 10

-superficial= epidermal
-superficial partial thickness= epidermis and superficial dermis
-deep partial thickness= epidermis and deeper portions or bottom layer of dermis
-full thickness= destruction of epidermis, dermis, and portions of subq tissue

Question 11

superficial burns

Answer 11

epidermal later
-mild erythema and hypersensitivity
-heal quickly: 24-72 hours
-do not usually require medical intervention, or cause scarring

Question 12

superficial partial thickness burns

Answer 12

epidermis and the superficial or layers of dermis
-exposed nerve endings located within the dermal later= EXTREMELY PAINFUL
-wet, weeping blisters, pink in color
-heal in 1-2 weeks
-minimal to no scarring

Question 13

deep partial thickness burns

Answer 13

epidermis and extends into the deeper portions or bottom laters of the dermis
-varying areas of pain and decreased sensation
-waxy appearance, no blisters due to extent of epidermal and dermal damage
-light pink or cherry red in color

Question 14

full thickness burns

Answer 14

destruction of the epidermis, dermis, and portions of subcutaneous tissue
-all epidermal and dermal structures are destroyed- hair follicles, sweat glands, and nerve endings
-dry, leather feeling, eschar
-do NOT heal spontaneously

Question 15

body surface area

Answer 15

TBSA= essential to guiding adequate fluid resuscitation and treatment!
- rule of palm=quick method used in prehospital setting: the size of the patient’s hand, including the fingers, accounts for approximately 1% TBSA
-rule of nines=MOST COMMON METHOD: adult body surface areas are broken down into 9% or multiples thereof. modified in infants and children.
-Lund and Browder classification: used for children. measurements take into account surface area related to age, are assigned to each body part.

Question 16

factors that play an important role in determining the severity of a burn and directly affect overall patient outcome

Answer 16

-patient age: children and older adults- nutrition! look at albumin
-past medical history: co-morbidities like HF or diabetes. when fluid shifts, a problem is created with these co-morbidities which alters oxygenation and blood flow
-presence of inhalation or concomitant injury
-anatomical location of burn injury

Question 17

respiratory/pulmonary effects of major burns injuries

Answer 17

-circumferential chest burns: impaired breathing- need escharotomy
-pulmonary edema, pulmonary damage, airway edema, airway obstruction
-inhalation injuries (above the glottis/vocal cords- inhaling chemicals or carbon monoxide)- emergent intubation may be required to maintain the airway
-swelling may occur within minutes to hours of the injury
-cues= facial burns, singed nasal and facial hairs, carbon in sputum, redness of oropharynx, inability to swallow, tachypnea

Question 18

cardiovascular effects of major burn injuries

Answer 18

-electrical burns: dysrhythmias, cardiac arrest, asystole
-need continuous cardiac monitoring-recommended for at least 24 hours to 48 hours, need baseline EKG
-burn shock= GREATEST THREAT that results secondary to a massive fluid shift due tot he first 8-36 hours: a combination of distributive and hypovolemic shock. electrolytes, water, plasma, and proteins lead OUT of the intravascular space and INTO the interstitial space because of the increase in capillary permeability-leads to hypovolemia. large loss of fluid within the intravascular space increases blood viscosity leading to sluggish blood flow, decreased oxygenation, and overall decreased CO and tissue perfusion-worry about clots. symptoms of inadequate fluid resuscitation include hypotension, tachycardia, reduced UO, AMS, and potential MODS or death.
-you have 15 minutes to call a rev team, 6 hours before organ failure, and 9 hours before death

Question 19

other systemic effects of major burn injuries

Answer 19

-fluid and electrolytes: shifts in potassium and sodium=hypokalemia, hyponatremia- shifted out of the blood!
-abdominal compartment syndrome
-renal: decreased renal perfusion-acute kidney injury due to increased myoglobin and hemoglobin released into blood from damaged muscles which can obstruct renal tubules.
-gastrointestinal: decreased nutrient absorption leads to need for supplemental nutrition, and decreased GI motility leads to paralytic ileus caused by hypovolemia (auscultate for peristalsis in all four abdominal quadrants)
-risk for infection-sepsis
-inability to regulate temperature (skin is what helps keep heat int he body, and now we have lost this mechanism)
-neuro: personality changes due to stress, electrolyte disturbances, hypoxemia, medications.

Question 20

special considerations in the patient with burns

Answer 20

-inhalation injury can exist in the presence or absence of a cutaneous burn. injury increases mortality rate-develops pneumonia or hypoxemia, length ventilatory support. look at labs for inhalation injuries- pneumonia needs positive x-ray, WBC count.
-electrical injury: extend of tissue damage is. not always apparent on the surface of the skin!
-chemical injury: early recognition and immediate initiation of continuous irrigation-alkali burns tend to penetrate deeper, causing liquefaction necrosis of the underlying tissue requiring a lengthy irrigation period.
-escharotomy and fasciotomy: any circumferential burn to an extremity is at risk for developing compartment syndrome= EMERGENCY!

Question 21

escharotomy vs. fasciotomy

Answer 21

-escharotomy: eschar results from no blood, meaning no oxygen. this procedure cuts through eschar into the subq fat.
-fasciotomy: needs to be done when swelling from third spacing is pressing on the vessels (shutting off blood supply), and must be relieved. healing done through wound vacs, which we medicate first with!

Question 22

emergent phase management

Answer 22

primary goal= resolve immediate life-threatening issues resulting from the burn injury-baseline diagnostic evaluation, airway management, fluid resuscitation, pain management, prevention of hypothermia, initiation of wound care.
-4 categories: ABCs/airway, fluids, temperature control, pain control.
-diagnosis with brochoscopy, ECG, labs
-treatment: non-rebreather on 100% on ALL PATIENTS, intubation for facial burns with voice changes or soot in sputum, LR with 2 large bore IVs (20 g<) for burns of 20% TBSA or greater, prevent hypothermia by keeping covered, monitor temp, increase ambient room temp, pain meds with IV narcotics (morphine, fentanyl, hydromorphone), monitor for respiratory depression, avoid IMs, OTC pain control NOT PRN!!!!!!!!!
-remove charred clothing, cleanse wounds, topical agents or debridement prep may be needed, dressing changes, skin grafts if needed
-nutritional support: severe burns can double the metabolic rate, we need a nutritional, consult! enteraal feedings started within 24 hours. DAILY WEIGHTS AND IS AND OS!!!
-assess for immediate/life-threatening injuries: facial burns, hoarseness, soot in sputum, wheezing, tachypnea (COUNT FOR ONE FULL MINUTE) retractions, hypotension, confusion, HA, pain, decreased UO, hypothermia
-all burn patients get tetanus vaccine
-minor burns: cleanliness and infection control! cover with lean and dry sheet, cleanse gently with soap and water 2-3x daily, apply topical agent-silver sulfadiazine or mafenide to prevent infection
-incentive spirometer

Question 23

intermediate/acute phase management

Answer 23

-usually 48 to 72 hours after the initial burn injury-immediately after resuscitation and stabilization have been achieved!
-wound healing and closure
-optimal nutrition for prevention of infection
-medications for pain and anxiety
-surgical management: debridement, wound closure and grafts
-assessments: WBC and watch for sepsis, DAILY WEIGHTS, caloric intake, protein and albumin, wound color and consistency, eschar, graft sites, s/sx of infection
-calorie counts, reassess pain, meds, would care daily or 2x/day (medicate for pain prior), assist with ADLs, keep room warm (80-100F), if hypothermic-reduce drafts by limiting traffic in and out of room, keep patient covered with sterile sheets

Question 24

rehabilitative phase management

Answer 24

-treatment is extended care beyond discharge from the hospital.
-complications include contractures and scarring.
-assessments: infection, nutrition, contractures, scarring, disfigurement, limited mobility and ROM, flat affect, depression, fear and anxiety, tx compliance, readiness for integration into society
-actions: pressure garments to decrease severity of scarring and help the scar mature, splints and braces for reducing contracture potential, wound management, manage pain, active/passive ROM and stretching, psychosocial support, teaching, community resources, burn prevention, follow up plan.

Question 25

shock

Answer 25

syndrome of decreased tissue perfusion and impaired cellular metabolism. -oxygen and nutrient supply and demand imbalance- exchange is ESSENTIAL for life! -cellular ischemia leads to cell injury, to organ dysfunction, to death.

Question 26

assessment and monitoring for shock

Answer 26

-must quickly determine the presence and extent of shock -monitor progression through hemodynamic monitoring and labs -assess perfusion at tissue level: LOC, UO, respiratory status, pulse quality, skin color, mottling, temperature -hemodynamic monitoring and laboratory analyses: lactate, venous oxygen saturation, blood gas analysis

Question 27

four stages of shock

Answer 27

stage 1=initial stage 2= compensatory stage 3=progressive stage 4=refractory must intervene in the earliest stage possible!!!

Question 28

stage 1=initial shock s/sx

Answer 28

-hypoxia occurs: look at sat, respiratory status for 60 seconds, are refractory muscles being used -restlessness -increased HR -cool and pale skin -agitation -MAP may decrease

Question 29

stage 2=compensatory shock s/sx

Answer 29

compensatory mechanisms begin to maintain adequate volume, cardiac output, and blood flow to the tissues- we MUST HAVE A BASELINE! -tachycardia -tachypnea -vasoconstriction -Na and H20 reabsorption in kidneys -decreased CO of <4-6 LPM -SBP <100 mmHg -decreased UO -confusion -cerebral perfusion pressure <70 mmHg

Question 30

stage 3= progressive shock s/sx

Answer 30

compensatory mechanisms fail. shunting of blood to vital organs and profound hypoperfusion to periphery. -metabolic and respiratory acidosis -electrolyte imalances -edema -excessively low BP -dysrhythmias -weak and thready pulses

Question 31

stage 4=refractory shock s/sx

Answer 31

prolonged inadequate blood supply to the cells, resulting in cell death and multi-system organ failure. irreversible at this stage. -unresponsive to vasopressors -profound hypotension -HR slows -multiple organ failure -most often will not survive

Question 32

Algorithm for shock

Answer 32

if 2 or more organs fail= MODS -elevated white count, elevated temperature, hypo or hypertensive PUSH REV TEAM BUTTON- we have 15 minutes to do blood cultures!

Question 33

elements of hemodynamic monitoring: cardiac output

Answer 33

reflects blood flow reaching the tissue -normal= 4-6 L/min -may see change in mentation and MAP/BP if CO drops

Question 34

elements of hemodynamic monitoring: mean arterial pressure=MAP

Answer 34

amount of pressure the blood is placing on the walls of the vessels as the blood leaves the heart -normal= 70-105 mmHg and NEED greater than 60-65 for adequate perfusion -important indicator o adequacy of CO

Question 35

elements of hemodynamic monitoring: central venous pressure= CVP

Answer 35

measure of pressure of right ventricular preload. measures the pressure of the blood returning from the body to the heart. -normal= 3-8 mmHg

Question 36

elements of hemodynamic monitoring: cerebral perfusion pressure= CPP

Answer 36

measure of perfusion to the brain -normal= 70-100 mmHg -less than 50 is ischemia and tissue death, less than 30 is incompatible with life.

Question 37

elements of hemodynamic monitoring: pulmonary artery/capillary wedge pressure= PAWP/PCWP

Answer 37

measure of left ventricular pressure and the diastolic pressure/left ventricle filling time. -normal= 4-12 mmHg -less than 4 is hypovolemia, greater than 12 is hypervolemia (LV failure) -SWANS catheter to measure

Question 38

elements of hemodynamic monitoring: systemic vascular resistance= SVR

Answer 38

left ventricle must overcome the pressure in the aorta to open the aortic valve so blood can leave the ventricle and go to the body. -normal= 800-1200

Question 39

SWANS

Answer 39

measure pulmonary artery pressure, usually in HF patients. -measures pressure in atria and ventricles -measures cardiac output -measures oxygen on the right side of the heart -measures valvular function

Question 40

lab analysis for all types of shock

Answer 40

-ABGs: oxygenation, ventilation, presence of acidosis or alkalosis. in early shock there is hyperventilation and respiratory alkalosis, and in later shock there is metabolic acidosis. ARDS due to hypoxemia and decreased PaOx, leads to respiratory complications. -Venous oxygenation: amount of oxygenated blood returned to the heart. normal is 60-75%. oxygen debt is when tissues are extracting more oxygen than normal due to low oxygen content, hemoglobin, or CO. -Lactate: assess the state of shock and as an evaluation of the resuscitative effort. elevated shows increased anaerobic metabolism due to tissue hypoperfusion. produced by tissues when oxygen is low. normal is 1-1,5 and when in shock levels are >2. this represents hypoperfusion and we NEED A REPEAT LACTATE IF NUMBER IS ABNORMAL.

Question 41

types of shock

Answer 41

-cardiogenic -hypovolemic= most common -distributive: anaphylactic, neurogenic, septic (most life threatening)!

Question 42

cardiogenic shock

Answer 42

characterized as inadequate pumping ability of the heart muscle. -results in decreased CO and poor perfusion- watch ejection fraction and give dobutamine if needed. -potential causes include MI, severe valvular dysfunction, severe HF, cardiac tamponade, cardiomyopathy, dysrhythmias, ventricular hypertrophy , tension pneumothorax, blunt cardiac injury, and pulmonary HTN.

Question 43

signs and symptoms of cardiogenic shock

Answer 43

-chest pain -diaphoresis -NV -hypotension -decreased LOC -decreased UO -weak pulses -pale, cool skin -decreased bowel sounds -SOB, crackles -if worsened: profound hypotension and bradycardia, organ failure- coma, cyanotic, mottled skin, absent bowel sounds, anuria

Question 44

hypovolemic shock

Answer 44

rapid fluid loss resulting in inadequate circulating volume- internal or external blood or fluid loss -potential causes: external blood loss due to trauma, GI bleeds, surgery, internal bleeds due to fractures, dissecting aneurysms, hemothorax, retroperitoneal bleed, fluid loss secondary to vomiting, diarrhea, and excessive urination or burns, third space/transcellular fluid loss (pleural, peritoneal, joint spaces)

Question 45

signs and symptoms of hypovolemic shock

Answer 45

-initial: potentially no symptoms -compensatory: normal BP, tachycardia, restless, confused, decreased UO, skin is pale cool and clammy, weak pulses, slow cap refill, hyperventilation, hypoactive bowel sounds -progressive: lethargy, hypotension, anuria, cold and cyanotic skin, weak or absent pulses, dysrhythmias -refractory: coma, severe hypotension, ischemic and necrotic cold extremities, renal failure, hepatic failure, irreversible damage.

Question 46

distributive shock

Answer 46

-IMMENSE VASODILATION -increased vascular capacity and venous pooling -relative hypovolemia due to vasodilation without an increase in volume -venous pooling: causes decreased venous return to the heart -causes include sepsis, anaphylaxis, and brain/spinal injury or spinal anesthesia

Question 47

anaphylactic shock

Answer 47

allergic reaction to substances that leads to shock. results in an acute and life-threatening hypersensitivity reaction -causes massive vasodilation (histamine), release of vasoactive mediators, and an increase in capillary permeability -S/Sx: airway compromise (SOB, tachypnea, wheezing, stridor, cyanosis, confusion, hypoxia, rep failure), tachycardia, hypotension, orthostatic hypotension, cool pale and clammy skin, weak pulses, edema, skin has sudden onset and rapid progression of flushing, angioedema, and urticaria

Question 48

neurogenic shock

Answer 48

a phenomenon that occurs after spinal cord injury. vascular tone is significantly decreased, there is an inability to vasoconstrict, and vessels are left relaxed and dilated. this leads to decreased return to the heart and decreased cardiac output. we are unable to compensaste via tachycardia, so we may have profound bradycardia.

Question 48

S/Sx of neurogenic shock

Answer 48

-warm, dry skin -flushed appearance -hypotension due to sympathetic nervous system -bradycardia

Question 48

hypovolemic shock management

Answer 48

-assess and stabilize airway -large bore IVs= 18s, 20s -rapid fluid resuscitation (NS, LR, PRBCs, FFP, platelets) -identify cause of bleeding to control or stop it

Question 48

shock medical management

Answer 48

DEPENDENT ON TYPE OF SHOCK -monitor hemodynamic status -assess CVP, urine output, heart rate, and status every 5-15 minutes -oxygen administration -isotonic and electrolyte IV solutions -rapid infusion of expanding fluids -improve tissue perfusion is GOAL -once improvement of perfusion is achieved, interventions then directed toward the underlying cause

Question 49

anaphylactic shock management

Answer 49

-immediately remove trigger -IM epi: can repeat 2-3x -IV ep if IM ineffective -maximize oxygenation- oxygen via 10% nonrebreather, prep for intubation if airway is compromised -IV fluid for circulatory support -meds include antihistamines, corticosteroids, and inhaled bronchodilators

Question 49

cardiogenic shock management

Answer 49

-12 lead ECG and cardiac enzymes- tule out MI as cause -if MI, PCI in cath lab -chest x ray- rule out tension pneumothorax, cardiac tamponade, confirm presence of pulmonary edema -stabilize oxygen- 100% O2 non-rebreather, intubation, and ventilation -drug therapy: increase BP and CO vasopressors for BP=dopamine and norepinephrine; inotropes for contractility=dobutamine and dopamine) -inta-aortic balloon pump: temporary -ventricular assist device: permanent

Question 50

neurogenic shock management

Answer 50

-cardiovascular support while attempting to resolve the primary cause -fluid resuscitation -vasoactive IV medications:dopamine, epinephrine, norepinephrine, phenylephrine -bradycardia: atropine, transcutaneous or transvenous pacing -intubation and mechanical ventilation

Question 51

shock nursing assessments and actions

Answer 51

-assessments: neuro, VS, UO, skin color and temp, respiratory sounds, respiratory effort and rate, O2 saturation, hemodynamic monitoring -actions: 100% non-rebreather O2 mask, prepare for intubation and mechanical ventilation, large bore IV lines for fluids as prescribed

Question 52

sepsis definition

Answer 52

a group of symptoms in response to an infection that can include organ dysfunction related to the infection.

Question 53

septic shock

Answer 53

massive infection leads to sepsis as a result of the release of endotoxins from bacteria; this causes vasodilation and pooling of blood.

Question 54

six things that happen with septic shock

Answer 54

-CO increased due to body compensating for infection -HR increases -pulmonary wedge pressure goes down -vascular resistance goes down because of vasodilation -oxygenation is elevated due to increased CO

Question 55

early signs and symptoms of septic shock

Answer 55

-tachycardia -bounding pulses -BP may be normal due to compensation -warm, flushed skin -febrile -confusion -decreased UO

Question 56

late signs and symptoms of septic shock

Answer 56

-tachycardia -weak, thready pulses -hypotension -cool, pale skin, necrosis -hypothermia -lethargy or coma -anuria -bleeding: because of disseminated intravascular coagulation-proteins in the body control blood clotting so in late shock there is a decrease in these clotting factors and platelets or clotting factors.

Question 57

sepsis bundles

Answer 57

evidence-based bundled interventions is to foster early recognition and interventions in patients with sepsis. -current goals are to identify and initiate treatment for patients in early sepsis within 1 hour to optimize patient outcomes.

Question 58

diagnosis of septic shock

Answer 58

-indicators of infection= fever, high WBC, changes in BP, RR, HR -lung consolidation: pneumonia, frequent or painful urination-UTI, severe abdominal pain-peritonitis -laboratory testing: CBC, BMP, urine testing, and cultures-blood cultures (take a long time to come back/couple of days/3 days, start broad spectrum antibiotics must be started) and lactate -imaging: x rays, CT scans, MRI-identify areas of abnormalities -screening tools- SIRS criteria, SOFA or qSOFA, MEWS

Question 59

nursing actions of septic shock

Answer 59

-meticulous hand washing and aseptic technique -provide mouth care every 4 hours -administer oxygen as ordered -anticipate and prepare for intubation -administer fluid replacement as ordered -obtain lactate level -obtain two blood cultures- 2 different sites -administer antibiotics as ordered after cultures are obtained -administer vasoactive drips (norepi) as ordered -supportive care: nutrition (parenteral or enteral), turning, DVT, and stress ulcer prophylaxis, ROM exercises, delirium management mobilize as tolerated

Question 60

septic shock complications

Answer 60

-stress ulcers: ulceration of the upper GI tract, typically in the fundus or body of the stomach-increase the risk of HI bleeding or perforation. proton pump inhibitors given -DIC= disseminated intravascular coagullopathy: hematological disorder most commonly caused by sepsis with two phases: 1- clotting or thrombotic, 2- bleeding -MODS= multiple organ dysfunction syndrome: result of the excessive inflammation: poor perfusion coupled with increased oxygen demand and poor oxygen utilization results in profoundly impaired cellular functioning, metabolic acidosis, and organ failure. treatment is to control infection, maximize oxygenation, restore and maintain intravascular volume (abx, fluid, blood products, mechanical ventilation)

Question 61

trauma

Answer 61

physical injury or emotional harm -environmental factors: heat related injury such as hyperthermia, hypothermia, or frostbite, drowning, injury from space heaters or fire place -disasters -interpersonal violence -abuse -neglect -poisoning -motor vehicle collisions -falls -suicide -homicide

Question 62

the golden hour in trauma

Answer 62

critical time between when an injury occurs and when definitive care is initiated -rapid assessment of patients with traumatic injury: ABCD= airway, breathing, circulation, disability -on scene: field triage, identify life threatening injuries, perform urgent interventions and resuscitation, minimize time spent on scene

Question 62

trauma ED triage

Answer 62

-emergency department triage: identify patients who are more critically ill or injured and cannot tolerate a delay in receiving care -goal is to identify and treat the most seriously ill or injured first! -triage nursE: determines acuity level, performs quick assessment including patient interview, history, and VS, rapid and accurate for optimal patient outcomes! -acuity is based on ABCDE priorities! airway (with c-spine precautions), breathing and ventilation, circulation with hemorrhage control, disability and resource management (neuro assessment, LOC, GCS), exposure/environment (undress to expose obvious and potential injuries, prevent hypothermia)

Question 62

trauma nursing actions/interventions

Answer 62

-ensure patient airway -optimize oxygenation -prepare for an advanced airway -establish IV access -maintain adequate circulating volume/prevent hypothermia-fluid resuscitation as ordered with warmed fluids -monitor temperature to prevent hypothermia -accurate anticipation of necessary interventions, prepare for stabilizing or definitive treatment -teach: safe lifestyle skills, avoid high risk behaviors or potential situations that may result in unintentional injury

Question 63

hyperthermia= heat stroke

Answer 63

MOST COMMON -risk factors: <5, >65 years, illness that causes a fever, diabetes, PVD, uncontrolled HTN, drugs or alcohol, exercising strenuously in hot climates, obesity (generate more heat during activity and dissipate heat more slowly)

Question 64

assessment and actions of hyperthermia

Answer 64

-assess: VS (pulse and RR increased but BP goes down- watch for signs of cerebral edema), neuro status, skin assessment, might have cramps -actions: move patient to cool environment, encourage oral fluid, IVF as necessary, active cooling methods.

Question 65

types of hypothermia

Answer 65

-mild: estimated core temperature of 89.6-95: alert but mental status may be altered. shivering present, not functioning normal, not able to care for self. -moderate: estimated core temperature 82.4-89.6: agitation, hallucinations, conscious or unconscious, with or without shivering. -severe/profound: estimated core temperature <82.4: unconscious, not shivering, muscle rigidity, body shuts down, death.

Question 66

treatment of hypothermia

Answer 66

-ensure patent airway and effective ventilation -insert IV line, start IVF -remove from the environment and remove wet clothes -plan for controlled warming: passive external for mild, active external for mild to moderate, internal for moderate to severe.

Question 67

assessment and actions for hypothermia

Answer 67

-assessment: VS with rectal temperature, neuro status, lab values such as ABGs, potassium, glucose -actions: administer oxygen, continuous cardiac monitoring, establish IV access, prepare for appropriate rewarming technique, limit invasive procedures and overall movement of the patient when hypothermic

Question 68

frostbite and stages

Answer 68

frostbite= damage to tissues and blood vessels as a result of prolonged exposure to cold. -stage 1= frostnip: superficial skin surface damage, initial symptom is numbness with an area of pallor and edema, damage is not permanent -stage 2: clear blisters are evident with hardened skin, over time the affected area becomes black dries and peels, there is typically no tissue loss -stage 3: tissues below the superficial skin layers freeze, blood blisters and a blue-gray discoloration appears, pain is persistent and blackened eschar develops -stage 4: tissue damage extends to muscle and bone, involves complete tissue necrosis and permanent damage

Question 69

nursing actions for frostbite

Answer 69

-PREVENTION but stabilize first!!!!! -warm environment -remove wet clothing -affected area in warm water for rewarming -avoid walking on frostbitten feet-more tissue damage

Question 70

poisoning

Answer 70

when a person takes, gives, or is given a substance that is harmful to the body when ingested, inhaled, injected, or absorbed through the skin -unintentional -intentional

Question 71

SIRES for poisoning

Answer 71

-Stabilize the clients condition: assess patient condition, respiratory support, IV access, -Identify the toxic substance: obtain an accurate history, retrieve poison, notify poison control, emergency facility, provider for immediate treatment advice and care. -Remove the substance to decrease absorption: shower or wash, antidotes, ingested substances: -Eliminate the substance from the client's body: activated charcoal FIRST, dialysis, ipecac (outdated) -Support the client physically and psychologically: intentional? accidental?

Question 72

poisoning assessments and actions

Answer 72

-assessment: VS, neuro, continuous cardiac monitoring, labs- tox screen, ABGs, potassium, serum glucose, urine pH, CBC and clotting studies, LFTs, repeat urine and serum medication levels. -actions: airway management, establish IV access, ECG, administer medications, prepare for decontamination through GI, ocular, or dermal irrigation or flushing

Question 73

corrosive poisoning

Answer 73

items that can cause poisoning include household cleaners, detergents, bleach, pain or pain thinners, and batteries. liquid corrosives can cause more damage to the victim than other types of corrosives, such as granular. vancomycin is VERY CORROSIVE. -aspirin poisoning: ringing in the ears, restlessness, sweating, pain, CV collapse, may administer with bicarb to counteract the salicylate, may give anticonvulsants, vitamin K if bleeding, cool them down -acetaminophen overdose: RUQ pain

Question 74

bee and wasp stings

Answer 74

-usually cause a wheal and flare reaction -emergency care= quick removal of the stinger and application of an ice pack -remove stinger by scraping or brushing, not tweezers -if the victim is allergic, a severe allergic response can occur that can progress to anaphylaxis- immediate emergency care is required.

Question 75

spider bites

Answer 75

almost all venomous, most not harmful -tetanus prophylaxis should be current due to contaminated spider bites -brown recluse spider: skin lesion with necrotic wound- hemotoxic venom and localized- apply ice for up to 4 days after the bite, topic antiseptics and antibiotics if infected -black widow sider: bite is small and red papule, venom causes neurotoxicity, apply ice, systemic toxicity can occur and victim may need supportive therapy- there is diffuse muscle spasms, extreme stomach pain, and rigidity

Question 76

disaster definitions

Answer 76

-WHO: a serious disruption of the functioning of a community or a society causing widespread human, material, economic, or environmental losses which exceed the ability of the affected community of society to cope using its own resources -United Nations: a serios disruption of the functioning of a society, causing widespread human, material, or environmental losses which exceed the ability of affected society to cope using only its own resources -natural or man-made! is large scale destructive event with effects to the infrastructure of a society. -three characteristics: must be of a large magnitude, cause injury/death/suffering to a significant number of people or places, and requires need for external assistance.

Question 77

disaster nursing

Answer 77

the adaptation of nursing knowledge and skills to recognize and meet the health and emotional needs of individuals during such times of crises known as disasters

Question 78

emergency response plan

Answer 78

formal plan of action for coordinating the response of the health care agency staff in the event of a disaster in the health care agency or surrounding community

Question 79

decontamination definition

Answer 79

removing accumulated contaminants or rendering them harmless, is critical to the health and safety of health care providers by preventing secondary contamination -step 1L removal of clothing and jewelry and then rinsing with water -step 2: thorough soap and water wash and rinse PPE levels: level A through D (A is highest)

Question 80

phases of disaster management identified by FEMA= federal emergency management agency

Answer 80

1. mitigation: action to prevent occurrence or reduce the damaging effects of a disaster, determine community hazards and risks, awareness of available community resources, health personnel to facilitate mobilization of activities, determination of resources available for care to infants, older adults, disabled individuals, and those with chronic health problems. 2. preparedness: plan for rescue, evacuation, care of victims, plan for training personel, gather resources, equipment, and materials needed, identify responsibilities for various personnel, establish community emergency response plan and effective public communication system, develop emergency medical system and plan to activate, verify functioning of emergency equipment, collect anticipatory provisions, inventory of supplies on a regular basis, practice community mock disaster drills 3. response: putting disaster planning services into action, primary concerns include safety and the physical and mental health of victims and members of the disaster response team 4. recovery: actions taken to return to normal after the disaster, preventing debilitating effects and restoring personal, economic, and environmental health and stability to the community, acute stress or PTSD is a concern for survivors

Question 81

three levels of disaster identified by FEMA

Answer 81

1. level 1: massive disaster involving significant damage and resulting in a presidential disaster declaration 2. level 2: moderate disaster that is likely to result in a presidential declaration of an emergency 3. level 3: minor disaster that involves a minimal level of damage

Question 82

disaster triage

Answer 82

allocation of limited resources during a disaster, applies to all resources, "patient care" is the most often thought of concept when using the term. -goal= place the right patient in the right place, at the right time to receive the right level of care -to ensure doing the most good for the greatest number of people rather than doing everything possible to save every life-which may mean delaying care to selected patients who have little hope of survival.

Question 83

triage tags/colors

Answer 83

-red: priority 1= immediate care needed, injuries are life threatening but survivable with minimal intervention. -yellow: priority 2= delated care, injuries are significant and require medical care but can wait hours without threat to life or limb. -green: priority 3= minimal care. injuries are minor, treatment can be delayed hours to days. move away from main triage area. -black: priority 4= expectant: injuries are extensive, and chances of survival are unlikely even with definitive care. separated from other casualties but not abandoned, and comfort measures should be provided when possible.

Question 84

secondary triage at the hospital!

Answer 84

-primary assessment: identify any problem that poses an immediate or potential threat to life and immediately initiates interventions. uses ABCDE to assess a clients need, use CAB as guideline for CPR -secondary assessment: occurs after addressing immediate treats identified during primary assessment. identify other problems, obtain subjective and objective data.

Question 85

hospital emergency preparedness plans

Answer 85

required to create a plan for emergency preparedness and to practice this plan with all employees at least twice a year. developed by the facility's safety/disaster management committee and are overseen by an administrative liaison. -goal is to remain self-sufficient to provide and sustain core services without the support of external assistance for at least 96 hours from the inception of the incident, ideally for 7 days.

Question 86

palliative vs hospice care

Answer 86

-palliative: curative and can still be cured- treatment is still going on. life sustaining, in conjunction with other care, at home in the hospital, any time during illness, focus on quality of life. for patients of any age and any stage of serious illness, services/care provided even while receiving curative treatment. goals: improve quality of life, relief of suffering, symptom management, psychosocial/spiritual support, improve patient and family satisfaction. -hospice: comfort care- no curative treatment. at home or in a facility, care is no longer life-prolonging, focus on preparing for end of life. type of palliative care, patient with a terminal illness who has less than 6 months to live, support and care for patient of any age in the last phases of incurable diseases so that they might live as fully and as comfortably as possible, patient and family needs are the focus of any intervention, focus is on comfort at the end-of-life: stop curative therapies, focus solely on relief of symptoms associated with their illness and the dying process, pain and symptoms are controlled

Question 87

end of life interventions

Answer 87

-psychosocial support -promote spiritual comfort -encourage family to participate in care -promote culturally competent care -assist patient to understand end of life options: DNR, AND, full code, palliative, hospice, location of care, legal documents

Question 88

advance care planning: advanced directives

Answer 88

legal documents that provide instructions for medical care and only go into effect if you cannot communicate your own wishes -most common advance directives for healthcare: durable power of attorney and living will durable power of attorney for healthcare: names a person/agent to make medical decisions if no longer able to make healthcare decisions, also known as a health care proxy or health care power of attorney. living will: a written, legal document that spells out medical treatment preferences to be used to keep the patient alive, as well as preferences for other medical decisions.

Question 89

provider/medical orders for life-sustaining treatment (POLST/MOLST)

Answer 89

for people who have been diagnosed with a serious illness, does not replace other directives, serves as provider-ordered instructions to ensure that, in case of an emergency, the patient receives their preferred treatment. provider will fill out the form based on the contents of advance directives and the discussions had about the course of illness and treatment preferences. also indicates if patient has POA and advanced directives. dictated by the state.

Question 90

legal and ethical issues with end of life planning

Answer 90

outcomes related to care during illness and the dying experience should be based on patient wishes -issues for consideration: organ and tissue donations, advance directives or other legal documents, withholding or withdrawing treatment, cardiopulmonary resuscitation, cultural and religious considerations.

Question 91

near death physiological manifestations and stages

Answer 91

-early stage: acceptance that death is approaching. patient begins to withdraw, loss of interest in social contacts, as the body slows there may be a loss of appetite because the. body has decreased needs. the patient does not experience hunger or thirst, may decrease participation in activities and begin to sleep more. -middle stage: weeks before death. decline in mental status, patient may become confused and disoriented, sleeping most of the time, physical changes include decreases in temperature and BP, pulse is irregular, respirations are labored and rapid- periods of apnea, skin color often changes due to diminished circulation, speaking can slow or cease all together. -late stage: days or hours before deaths. may experience a very brief and limited surge of energy in a last effort at physical exertion and expression, previous symptoms worsen, coma ensues, extremities become cool and mottled, respiratory pattern becomes more rapid and labored (Cheyne-Stokes respirations), loss of ability to manage secretions because the swallow reflex ceases, congestion in the airway can cause respirations to sound loud and wet, hearing is last sense to go!

Question 92

physiological manifestations of death

Answer 92

-metabolism is reduced, body gradually slows down until all functions end -sensory: blurred vision, decreased sense of taste and smell, decreased pain and touch perception, loss of. blink reflex and appears to stare, pupils non-reactive, hearing is the last sense lost -respirations: may be rapid or slow, shallow, irregular, cheyne-stokes is alternating periods of apnea and deep, rapid breathing, increased upper airway mucus-noisy and wet sounding (death rattle), inability to cough, clear aiway -neuro: decreased LOC -circulation: HR slows, BP falls progressively (decreased CO), skin-cool to touch, extremities pale, mottled, cyanotic (mouth and nails) -urinary output: decreases, incontinence -GI: motility and peristalsis slow leading to constipation and incontinence -musculoskeletal: gradually loses ability to move, difficulty speaking and swallowing, lost gag reflex -integumentary: kennedy terminal ulcer on sacrum, dark sore that develops rapidly. sudden onset/appearance, unavoidable skin breakdown which occurs as part of the dying process, most often on sacrum or coccyx but can appear elsewhere, shape of a pear, butterfly, horseshoe, or irregular-shape.

Question 93

physical care for the dying patient

Answer 93

-pain: morphine treats pain, air hunger, and anxiety -dyspnea: elevate HOB, reposition to maintain patent airway and for comfort, administer supplemental oxygen as needed for comfort, suction fluids from airway -assess skin -maintain regular oral care and prevent dehydration -anorexia or NV: antiemetics before meals, favorite foods, small portions -elimination: monitor output, absorbent pads in place -weakness and fatigue: rest periods, assess activity tolerance -restlessness: provide caring touch, relaxation techniques, calm and soothing environment, do not restrain

Question 94

two big medications for controlling secretions and respiratory congestion at the end of life

Answer 94

-atropine -scopolamine patch

Question 95

post-mortem care

Answer 95

-maintain respect and dignity -determine if an organ donor and follow procedures -consider cultural and religious rituals, state laws, and agency procedures -prepare body for immediate viewing by the family -provide privacy and time for the family to be with the deceased person -medical examiner guidelines are determined by state but include traumatic or unnatural deaths, or those of question with criminal involvement: forensic evidence needed, body not cleaned or prepared prior to morgue transfer

Question 96

stages of grief

Answer 96

-denial: difficulty believing in an expected or actual loss -anger: directs anger towards self, others, deity, objects, circumstances -bargaining: negotiates for more time or cure -depression: overwhelmingly saddened by the inability to change the situation -acceptance: acknowledges what is happening and plans for the future by moving forward order changes for everyone, as well as the length of each stage