exam 3: burns, sepsis, shock, delegation, ethics Flashcards
1
Q
inhalation damage s/s
A
- singed nasal hair
- sooty sputum
- hoarseness
- wheezing
- brassy cough
- stridor
- drooling
2
Q
carbon monoxide inhalation s/s
A
- h/a
- weakness
- dizziness
- confusion
- erythema
- upper airway edema
3
Q
the 5 types of burns
A
- chemical acid
- alkali
- electrical
- radiation
- thermal
4
Q
chemical acid burn description
A
causes coagulation injury, typically less deep than alkali burns
5
Q
alkali burn description
A
deep penetration into skin causing necrosis
6
Q
electrical burn description
A
may have a small entry and exit wound, but have significant damage under the skin
7
Q
radiation burn description
A
ranges from itching, redness, & edema to more severe burns
8
Q
thermal burn description
A
presentation dependent on the exposure to the heat source
9
Q
superficial burns: area involved and appearance
A
area: damage to epidermis only
appearance: pink to red with no blisters
10
Q
superficial partial thickness: area involved and appearance
A
area: damage to entire epidermis and superficial portion of dermis
appearance: wet pink to red blisters
11
Q
deep partial thickness: area involved and appearance
A
area: damage to entire epidermis and deep in dermis
appearance: white or yellow, dry and nonblanchable
12
Q
full thickness: area involved and appearance
A
area: damage to entire epidermis, dermis and subcutaneous tissue
appearance: white, black/brown, dry, leathery, nonblanchable
13
Q
labs to draw for burns
A
- CBC daily
- albumin
- BUN, creatinine, GFR
- ABGs, carboxyhemoglobin
- coag labs
- liver enzymes
14
Q
diagnostic studies for burns
A
- CXR
- Chest CT
- Pulmonary function tests
- Bronchoscopy PRN
15
Q
primary assessment survey for burns (ABC)
A
- A: airway
- B: breathing
- C: circulation
- D: disability
- E: exposure and environmental control
16
Q
secondary assessment survey for burns
A
- history of events
- health history
- head-to-toe
- determine depth, size, and severity of burn
17
Q
TBSA rule of nines
A
- head: 4.5% anterior and 4.5% posterior
- torso: 18% anterior and 18% posterior
- arms: 4.5% anterior and 4.5% posterior
- legs: 9% and 9% posterior
- perineum: 1%
- palm: 1% palm (use if burns are scattered)
18
Q
what should the nurse assess during cue analysis (burns)
A
- initial assessment, mechanism of injury, potential complications (ABCs)
- VS, labs (looking for fluid loss, infection, electrolyte imbalance, O2 and ventilation problems, and coagulation abnormalities)
- determine extent of burn to prepare for fluid volume resuscitation if burn is severe
18
Q
what should the nurse consider during the prioritization phase of burn analysis
A
- stability of ABCs
- severe burns that require sedation and IV pain meds may alter LOC and require intubation/vent
- monitor for hypovolemia: decreased BP, increased HR
19
Q
nursing interventions for burns
A
- apply cool water soaks or run cool water over injury for 3-5 mins (NO ICE OR ICE PACKS)
- ensure airway is patent and determine if pt needs fluid resuscitation
- pts >14 years should receive 500 mL LR IV per hr
- place catheter to monitor output
- dressing application
- pain management with active ROM if possible
20
Q
urine output goal for burn pts
A
0.5 mL/kg/hr
21
Q
parkland formula for burn pts
A
4mL x kg x %TBSA
22
Q
a victim who has burns to the face, is unresponsive, has agonal breaths, and a weak pulse (color triage)
A
black- expectant (facial burns and agonal respirations)
23
Q
a victim who has multiple abrasions to the right arm and leg (color triage)
A
green- minor (minimal injuries)
24
a victim who has a fracture to the left femur, RR 26, alert and oriented, strong pulse (color triage)
yellow- delayed (able to delay care for fracture, pt is stable)
25
a victim is unresponsive found with abdominal wound that is bleeding, RR 32, P 116 (color triage)
red- immediate (victim is unstable, RR >30)
26
a victim with extensive full-thickness burns to the face, torso, and arms, RR5 with no change after opening airway (color triage)
black- expectant (pt will not survive)
27
a victim with a head wound, RR 28, CR <2 sec, not obeying commands (color triage)
red- immediate (pt is deteriorating and needs immediate care, not obeying commands)
28
a victim with an abdominal wound, cap refill 1 second, RR 24, follows commands (color triage)
yellow- delayed (pt is stable but will need care soon)
29
a victim with a broken arm and nausea (color triage)
green- minor (pt is stable)
30
pt's MAP decreases from 75 to 52, rapid weak pulse, anuria (phase of shock)
progressive stage 3
31
pt is restless, HR 116, RR 24, BP 114/76 (was 122/74) (phase of shock)
initial stage 1
32
pt is restless, HR 132, RR 32, MAP decreases from 73 to 63 (phase of shock)
compensatory stage 2
33
pt is unresponsive, cold, dusky, with a nonpalpable pulse (phase of shock)
stage 4 refractory
34
a nurse is caring for a deteriorating pt in the ICU who is going into shock after an acute myocardial infarction, Which s/s should the nurse assess for? SATA
A. high CVP
B. cool, clammy skin
C. extreme diuresis
D. hypotension
E. rapid, thready pulse
A, B, D, E
This pt is in cardiogenic shock. Clinical manifestations of cardiogenic shock include dependent edema, elevated CVP, cool clammy skin, hypotension, tachypnea, crackles, pulmonary edema, and rapid thready pulse.
35
A nurse is assessing a patient for shock. Which of the following assessment data should the nurse expect to be the earliest manifestation of shock?
A. anuria
B. increased HR
C. bradypnea
D. hypotension
B
The earliest clinical signs of hypovolemic shock are cardiovascular: increased heart rate and respiratory rate are the earliest manifestations of shock. Changes in systolic blood pressure are not always present in the initial stage of shock because of compensatory mechanisms and should not be used as the main indicator of shock presence or progression.
36
A nurse is assessing a patient for shock. Which of the following assessment data should the nurse expect to be the earliest manifestation of shock?
A. oliguria
B. increased HR
C. increased RR
D. decreased BP
C
The patient’s respiratory rate will increase first. When shock occurs, the body attempts to compensate for the decreased level of oxygenation and tissue perfusion. Initially, the client will display an increased respiratory rate as the body tries to increase oxygen delivery to the tissues. Additional compensatory manifestations of shock include increased heart rate, decreased urine output, and cold, clammy skin.
37
Which clinical manifestations does the nurse recognize that indicates worsening in the condition of a patient in stage 4 of shock?
A. warm, flushed skin
B. urine output of 20 mL/hr
C. increased RR
D. bleeding, oozing from IV sites
D
The onset of disseminated intravascular coagulation (DIC) as evidenced by bleeding to include oozing from IV sites indicates a consumption of clotting factors that occurs in the refractory or 4th stage of shock. The refractory stage or irreversible stage of shock occurs when too much cell death and tissue damage result from too little oxygen reaching the tissues. Vital organs have overwhelming damage. The body can no longer respond effectively to interventions and shock continues.
38
A nurse is explaining to a student nurse how the body compensates when a client is in cardiogenic shock. Which statement is correct?
A. the systemic vascular resistance increases causing vasoconstriction to occur in the body.
B. the systemic vascular resistance decreases to increase the mean arterial pressure in the body.
C. The vascular bed increases, causing vasoconstriction to occur in the body.
D. the mean arterial pressure increases from the decreased heart rate in the body.
A
In cardiogenic shock the systemic vascular resistance (SVR) increases from vasoconstriction, which decreases the vascular bed and increases the MAP.
39
Which of these findings is the best indicator that the fluid resuscitation for a client with
hypovolemic shock has been successful?
A. Hgb is within normal limits
B. urine output is 60 mL over last hour
C. pulmonary artery wedge pressure (PAWP) is normal
D. mean arterial pressure (MAP) is 65 mmHg
B
Assessment of end organ perfusion, such as an adequate urine output, is the best indicator that fluid resuscitation has been successful. The hemoglobin level, PAWP, and MAP are useful in determining the effects of fluid administration, but they are not as useful as data indicating good organ perfusion.
40
A nurse is caring for a deteriorating client in the ICU who is going into shock after a motor vehicle accident that required surgery. Which signs and symptoms should the nurse expect? SATA
A. low SVR
B. tachycardia
C. tachypnea
D. high CVP
E. slow capillary refill
F. decreased urine output
B, C, E, F
The client is going into hypovolemic shock. All answers are correct, except the SVR will be high (vasoconstriction) and CVP will be low.
41
A patient with a severely abscessed tooth, BP 84/42, HR 136, RR 28, Spo2 90% on room air, temperature 96.7º. The nurse suspects that the patient has developed sepsis. What is the priority nursing intervention?
A. insert an indwelling urinary catheter
B. initiate IV fluid resuscitation
C. obtain a complete chemistry for lab analysis
D. administer prescribed antibiotics prior to blood cultures
B
Initiating IV fluids is the primary intervention, followed by obtaining laboratory values, blood cultures, and providing oxygen. Antibiotics should be started ASAP, however, after blood cultures are obtained. An indwelling urinary catheter is lower in the list of necessary priority interventions.
42
A nurse is caring for a client diagnosed with a urinary tract infection. HR 118, BP 84/42, cool, clammy skin, despite fluid resuscitation. What order should the nurse anticipate next?
A. nitroglycerine (Tridil)
B. hydrocortisone (Solu-cortef)
C. norepinephrine (Levophed)
D. sodium nitroprusside (Nipride)
C
When fluid resuscitation is unsuccessful, vasopressor drugs are administered to increase the systemic vascular resistance (SVR) and improve tissue perfusion. Nitroglycerin would decrease the preload and further drop cardiac output and BP. Solucortef may decrease inappropriate inflammation and help prevent systemic inflammatory response syndrome, but it will not directly improve blood pressure. Nitroprusside is an arterial vasodilator and would further decrease SVR.
43
A client is having trouble breathing, periorbital swelling, flushing, and itching. He had a diagnostic test in which an iodine-based dye was used about an hour earlier. What medication will the nurse anticipate administering?
A. a bronchodilator such as aminophylline
B. a corticosteroid such as dexamethasone
C. an antihistamine such as diphenhydramine
D. an adrenergic agonist such as epinephrine
D
Epinephrine, given subcutaneously or intravenously, is the drug of choice for anaphylactic reactions. The reaction described is a mild to moderate anaphylactic reaction. The other medications listed may be used in treatment of the reaction, but epinephrine is the immediate drug of choice.
44
A client with a diagnosis of sepsis is receiving tobramycin. The nurse realizes that the client is responding favorably to the medication therapy if which laboratory result is noted?
A. sodium of 145 mEq/L and chloride of 106 mEq/L
B. WBC count of 15,000 and a blood urea nitrogen of 38 mg/dL.
C. Sodium of 140 mEq/L and potassium of 3.9 mEq/L.
D. WBC count of 8,000 and a creatinine level of 0.9 mg/dL.
D
Tobramycin is an antibiotic that can cause nephrotoxicity and ototoxicity. The medication is effective if the WBC count drops back into the normal range and the kidney function remains normal. The WBC count and elevated BUN level in the other option are abnormal. The other labs are not related to the medication.
45
delegating
process of transferring the authority and responsibility to another team member to complete a task, while retaining accountability
46
delegation decisions are based on. . .
- client needs
- policies and job descriptions
- state nurse practice acts
- professional standards/legal/ethical concerns
47
client factors to consider when assigning
- condition and level of care needed
- specific care needed (ex: telemetry , mechanical ventilation)
- special precautions needed (ex: isolation, fall, seizure)
- procedures requiring a specific time commitment (ex: dressing changes)
48
healthcare team factors to consider when assigning
- knowledge and skill level of team members
- amount of supervision needed; nurse to client ratio
- staffing mix (RNs, PNs, APs)
49
factors to consider when making room assignments
- client's age
- dx
- safety
- comfort
- infection control
50
factors to consider when assigning patients to a float nurse
- assign stable clients
- should be treated as a new grad
51
5 rights of delegation
- right task
- right circumstance
- right person
- right communication/direction
- right supervision/evaluation
52
stable pts to delegate to LPNs
- chronic conditions
- stable VS, labs, urine output
- taking meds as ordered
- no changes
- diabetic with wound
- stable blood sugar
53
unstable pts to delegate to LPN (do NOT delegate)
- new admission
- change in VS or assessment data
- unstable blood sugar
- new onset of complication
- multiple IV fluids, meds
- lab changes
54
advocate
- speaks up for or acts on behalf of the client
- protects the client's right to make their decisions
- defends the pt from harm
55
effective advocacy
- be assertive
- be aware that conflicts may arise w/ leadership
56
advanced directive
legal document in which the client's decisions related to health care are documented
57
acronym for tasks RNs cannot delegate
N- nursing judgement
I- IV pushes (high-risk IV meds)
C- collaboration
E- evaluation
P- planning
A- assessments (initial assessment)
T- teaching (complex)
58
acronym for tasks UAPs can be delegated
V- vitals/I&O/Wt
A- ADLs/ambulation
P- positions/assist
E- eating/detach suction/remove foley
R- recording/remind/reinforce
59
the 5 professional values
- altruism
- dignity
- integrity
- autonomy
- social justice
60
tort
(intentional or unintentional) act or omission of act that results in harm
61
Good Samaritan Law
protects people in providing emergency aid
62
standards of practice
explanatory statements that describe a competent level of care for all nurses, using the critical thinking model known as the nursing process
63
the three types of intentional torts
- assault (threat; person fears harmful event)
- battery (touching someone without their consent)
- false imprisonment (restraining a pt that doesn't need to be restrained)
64
two types of unintentional torts
- negligence
- malpractice
65
deontology rules
essential right or wrong
66
utilitarianism (consequentialism)
greatest good for the greatest number
67
ethics of care
importance of responsibility, centers on interpersonal relationships, relationships over consequences
68
casuistry
case-based, consensus
69
what factor do you consider when prioritizing triage
potential for survival
70
red, yellow, green, black urgency and injury type
red: most urgent, 1st priority; life-threatening injuries
yellow: urgent, 2nd priority; injuries with systemic effects/complications
green: 3rd priority; minimal injuries with no systemic complications
black: dying or dead; catastrophic injuries
71
ABCDE of prioritizing patients
A: airway
B: breathing
C: circulation
D: disability
E: exposure
72
neuro assessment acronym for prioritization of patients
A: alert
V: responsive to voice
P: responsive to pain
U: unresponsive
73
the four disaster management phases
1. mitigation phase
2. preparedness phase
3. response phase
4. recovery phase
74
nursing roles in ethics committee
- ensure facts are correct
- appropriate decision makers identified
- pts best medical interests identified
- course of action is justified by ethical principles
75
the six biological agents in disasters/triage
- anthrax
- botulism
- smallpox
- hemorrhagic fever
- pneumonic plague
- inhalation tularemia
76
anthrax transmission, s/s, treatment
transmission: inhalation; handling/eating infected animals (not spreadable from person to person)
s/s: sores, painless blisters, ulcers w/ black centers, GI upset, flu/cold symptoms
treatment: antibiotics, prevention, vaccine available
77
botulism transmission, s/s, treatment
transmission: food, infected wounds (not spreadable from person to person)
s/s: double/blurred vision, drooping eyelids, difficulty swallowing/speaking, descending muscle weakness
treatment: antitoxin, supportive care, may require mechanical ventilation, no vaccine available
78
smallpox transmission, s/s, treatment
transmission: air droplets, body fluids, contaminated objects (HIGHLY CONTAGIOUS)
s/s: high fever, head/body aches, vomiting, rash that progresses to pus-filled blisters
treatment: support therapy, vaccine available
79
hemorrhagic fever transmission, s/s, treatment
transmission: viral reservoirs, such as rodents, close contact/body fluids
s/s: fever, h/a, exhaustion, loss of strength, can lead to shock, multiple organ failure
treatment: supportive therapy, no vaccine available
80
pneumonic plague transmission, s/s, treatment
transmission: air droplets, aerosol release, highly contagious (can survive in the air for up to 1 hour; destroyed by sunlight/drying)
s/s: fever, develop into pneumonia, will see shock/resp failure
- treatment: antibiotics, no vaccine available
81
inhalation tularemia transmission, s/s, treatment
transmission: ticks, deer flies, or contact with an infected animal/food (not contagious)
s/s: skin ulcers, sore throat, mouth sores, diarrhea, pneumonia
treatment: antibiotics, no vaccine available
82
the three levels of disasters
level I: massive disaster that involves significant damage and results in a presidential disaster declaration of an emergency, with major federal involvement and full engagement of federal, regional, and national resources
level II: moderate disaster that is likely to result in a presidential declaration of an emergency, with moderate federal assistance
level III: minor disaster that involves a minimal level of damage but could result in a presidential declaration of an emergency
83
whistleblowing
reporting wrongdoing to regulating bodies
84
sentinel event
adverse event that should never occur
85
paternalism
undesirable outcome where the healthcare provider decides what is best for the pt
doesn't take the pt's input into account
86
healthcare disparity
differences in pt access to or availability of appropriate healthcare services
87
veracity
duty to tell the truth
88
