Exam 4 Flashcards
1
Q
What is ESI?
A
emergency severity index
assigns 5 levels based on life-threatening to least urgent
2
Q
How are emergency assessments triaged by color? Which are stable and unstable?
A
Red: life-threatening, unstable
orange: potentially life-threatening, unstable
yellow: stable but needs emergency care
green: stable but needs medical treatment within a reasonable time
blue: may be taken care of with another care level
stable: yellow, green, blue
unstable: orange, red
3
Q
What is the ABCDE of asessment?
A
airway
breathing
circulation
disability
exposure
4
Q
How is breathing thoroughly assessed?
A
- Auscultate breath sounds bilaterally
- Observation of chest expansion and respiratory effort (work of breathing)
- Rate and depth of respirations
Identification of chest trauma - Assess tracheal position (midline or deviated?)
- Assess for JVD
- Manual ventilation with bag valve mask if not breathing
- Set up for endotracheal intubation if not ventilating or oxygenating
5
Q
What is a thorough primary survey of circulation?
A
- HR, BP, peripheral pulses, skin color
- CPR
- external or internal bleeding
- control hemorrhage
- reverse anitcoag therapies if possible
- IV access
*stabilize with fluids and blood
6
Q
what constitutes a primary survey of disability?
A
determine LOC
AVPU: alert, verbal stimuli, painful stimuli, unresponsive
Glasgow coma scale
frequent neurological assessments
7
Q
What can cause hypothermia in an emergency situation? What is the threshold for a hypthermic temp? What can result?
A
exposure
cold IV fluids
unwarmed O2
wet clothing
35 degrees
com, hypoxemia, acidosis
8
Q
What is included in the secondary survey?
A
health history
head to toe
diagnostic and lab testing
monitoring devices, ECG, arterial lines, catheters
splinting fractures
wound care
interventions based on the condition
if instability occurs go back to ABCDEs
9
Q
What are potential chest injuries (10)? What are interventions (6)?
A
Rib fractures
flail chest (2 fracture sites of at least 2 ribs)
Sternal fractures
Pulmonary contusion
Pneumothorax
Hemothorax
Cardiac contusion
cardiac tamponade
cardiac dysrhythmias
Aortic rupture
- Needle chest decompression if a tension pneumothorax
- Chest tube insertion for pneumothorax or hemothorax
- Cardiac monitor for dysrhythmias
- Pericardiocentesis if cardiac tamponade is occurring
- IV analgesia for pain control
- Frequent monitoring of breathing, including RR,O2 sats,and work of breathing
10
Q
What is a wound cleaned with? What should not be used?
A
NS
betadine
11
Q
What is assessed with crush injuries?
A
Hypovolemic shock
Spinal cord injury
Erythema and blistering
Fractures; usually extremity
Acute kidney injury
12
Q
What are cooling methods?
A
Cool sheets, towels, or sponging with cool water
Ice to neck, groin, chest, and axillae
Cooling blankets
Immersion in cold water bath
13
Q
What are the degrees measuring the severity of frostbite?
A
1st degree superficial
Only layers of exposed skin are affected with hyperemia and edema. Numb central white area without blistering.
2nd degree partial thickness
Blisters cover the exposed skin areas causing necrotic tissue death and swelling.
3rd degree full thickness
Extensive edema and hemorrhagic vesicles andblisters. No blanching. Need debridement.
4th degree full thickness
Full thickness freezing with necrosis. Complete lack of blood flow. Potential for gangrene.
14
Q
What are clinical manifestations of frostbite? Immediate treatment? What can treatment cause? What is administered? What should not be done? What are nursing actions after rewarming?
A
progress from distal to proximal
Hard, cold, and insensitive to touch
Skin may appear white or mottled
Skin may turn red and become painful when re-warmed
Immediate treatment: cover affected areas and rewarming
Controlled but rapid rewarming with warm bath (104 to 108 °F)
Can cause severe pain
Administer tetanus toxoid if > 5 years
Administer analgesics forpain during rewarming
Do not massage, rub or handle; if feet are involved, do not allow client towalk
Once re-warmed, elevate affected extremity
Assess for compartment syndrome
Swelling
Increase in pain
Needs immediate treatment!
15
Q
What are rewarming methods for hypothermia? What is the risk of cold blood returning from the extremities?
A
Active core re-warming: Cardiopulmonary bypass, warm fluid administration, warm humidified oxygen, and warm peritoneal lavage, warm bladder irrigation
Passive external re-warming:
Warm blankets and over-the-bed heaters (Bear-Huggers)
cardiac dysrhythmias and electrolyte imbalances because of the high levels of lactic acid in the cold blood
16
Q
What are intervention methods with ingested poisons? What should not be induced with corrosive (acids/alkaline) agents?
A
N/G tube suction
gastric lavage
activated charcoal
specific antidote
diuresis, dialysis, hemoperfusion
most poisons just need supportive care
induce vomiting, corrosive agents cause destruction to tissue
17
Q
what is the patho of carbon monoxide inhalation? Manifestations? What are unreliable signs?
A
Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin, which prevents the transport oxygen
Hemoglobin binds carbon monoxide 200 times more readily than oxygen
Manifestations
CNS symptoms predominate, HA, Dizziness
Skin color is not a reliable sign and pulse oximetry is not valid
Color ranges from pink to cherry-red to cyanotic and pale
18
Q
What are common bacteria that cause food borne illness?
A
salmonella
shigella
E coli
campylobacter
19
Q
Why should antidiarrheals be avoided with food borne illness?
A
prevents flushing out of the bacteria through the diarrhea
20
Q
What food poisoning sources can result in respiratory paralysis and death?
A
botulism (honey)
certain fish poisonings
21
Q
What are IV drug users at high risk for?
A
HIV infection
Hep B and C
tetanus
22
Q
What can acute alcohol poisoning result in? Primary actions? What other causes can present like alcohol intoxication? What is indicted for withdrawal syndrome? What is CIWA?
A
death (respiratory depression)
Maintain airway and observe for CNS depression and hypotension
head injury,stroke,illness
Withdrawal syndrome will require high doses of benzodiazepines to control symptoms (lorazepam or diazepam)
CIWA (Clinical Institute Withdrawal Assessment for Alcohol)score is used to assess and manage the withdrawal stage of alcohol
23
Q
What is the treatment for snakebites? What is contraindicated and for how long? What is the timeframe for antivenom administration? How often should the nurse assess for edema?
A
Lie down
Remove constrictive items (rings)
Provide warmth
Cleanse the wound
Cover with dressing
Immobilize injured body part below the level of the heart
No ice, tourniquets, heparin, and corticosteroids in the first 6 to 8 hours after the bite
4 to 12 hours
Assess for edema every 15-30 minutes
24
Q
What antipsychotics are used for hallucinations? Agitation?
A
haloperidol,olanzapine, quetiapine, or risperidone are used for hallucinations, delusions
benzodiazapines such as diazapam or lorazapam
25
What are the 4 levels of PPE?
Level A: self-contained breathing apparatus (SCBA) and vapor-tight chemical resistant suit, gloves, and boots
Level B: high level of respiratory protection (SCBA) but lesser skin and eye protection; chemical-resistant suit
Level C: air-purified respirator, coverall with splash hood, chemical-resistant gloves and boots
Level D: typical work uniform
26
What are the 4 color codes for disaster triage?
red: priority 1, immediate
yellow: priority 2, urgent
greed: priority 3, delayed
black: dead or dying
27
What is the patho of anthrax? Transmission? Symptoms? Treatment?
Bacteria that results in hemorrhage, edema, and necrosis
Incubation: 1-6 days
Transmission: skin contact, GI ingestion, inhalation
Symptoms: skin lesions, fever, N&V, abdominal pain, diarrhea (some manifestations depend on route of transmission)
Respiratory symptoms that mimic influenza
Treatment: ciprofloxacin
28
What type of illness is small pox? Transmission? Symptoms? Treatment?
Virus
Extremely contagious; spread by direct contact, by contact with clothing or linens, or by droplets person-to-person
Manifestations: High fever, malaise, headache, backache, and prostration; after 1 to 2 days a maculopapular rash appears on the face, mouth, pharynx, and forearms
Treatment is supportive care
Vaccine can be given after known exposure. Not routinely prophylactically administered except in active military
29
What are examples of vesicant chemical agents? What do they cause? Nursing action? Treatment for lewisite?
Lewisite, sulfur mustard, nitrogen mustard, phosgene
Cause blistering and burning
Respiratory effects can be serious and cause death
Decontamination with soap and water; do not scrub or use hypochlorite solutions
Eye exposure requires copious irrigation
Treatment for lewisite exposure: dimercaprol IV or topically
30
What are examples of chemical nerve agents? Patho? Treatment? Decontamination? Why is plastic contraindicated?
Sarin, soman, tabun, organophosphates, and VX
Inhibit cholinesterase, causing cholinergic symptoms progressing to loss of consciousness, seizures, copious secretions, apnea, and death
Treatment: supportive care, atropine, benzodiazepine, and pralidoxime
Decontaminate with copious amounts of soap and water or saline for at least 20 minutes
Blot; do not wipe off
Plastic equipment will absorb sarin gas- do not use oral airway
31
What is hemodynamic shock? What occurs in all forms of shock? What has already occured before the BP drops? What is the physiologic response?
A condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organs and cellular function and can lead to organ failure
Low blood pressure occurs in all forms of shock!
cellular and tissue damage has begun
Rapidly progressing and life-threatening process
hypoperfusion of tissues, hypermetabolism, and activation of the inflammatory response
32
What are the 4 types of shock?
Hypovolemic: A decrease in intravascular volume of at least 15% to 30%
Cardiogenic: failure of the heart to pump effectively due to a cardiac factor
Obstructive: Impairment of the heart to pump effectively as a result of a noncardiac factor
Distributive: Widespread vasodilation and increased capillary permeability, including neurogenic, septic, and anaphylactic shock
33
What are the 4 stages of shock?
Initial: no visible changes in client parameters; only changes on cellular level
MAP decreases 5 to 10 mm Hg from baseline; mild vasoconstriction; HR increases
Compensatory (non-progressive): Measures that increase CO to restore tissue perfusion and oxygenation
Vasoconstriction increases; HR increases; MAP decreases 10 to 15 mm Hg from baseline; mild acidosis and hyperkalemia
Progressive: Compensatory mechanisms start to fail to maintain CO and BP
MAP decreases >20 mm Hg from baseline; vital organs experience hypoxia; moderate acidosis and hyperkalemia
Refractory (irreversible): Irreversible shock and total body failure
Severe tissue hypoxia; MODS; possibly death
34
What are the physiologic responses during the compensatory stage of shock?
Sympathetic NS causes vasoconstriction, increased HR, and increased contractility
This attempts to maintain blood pressure and CO
Body shunts blood away from skin, kidneys, and GI tract
Results in cool, clammy skin, hypoactive BS, and decreased UO
Perfusion of tissues has become inadequate
Acidosis occurs because of anaerobic metabolism (lactic acid formation)
Respiratory rate increases due to acids circulating in the bloodstream
Confusion may occur from evolving acidosis
35
What mechanisms are activated during compensatory shock? What is the main purpose?
Activation of Sympathetic NS Activation of RAAS
Release of cortisol*
* It's all about mechanisms trying to maintain blood pressure to vital organs**
36
What are physiologic responses during the progressive stage of shock?
Mechanisms that regulate BP can no longer compensate, and BP and MAP decrease
All organs suffer from hypoperfusion (including heart, lung, and brain)
Vasoconstriction of arterioles continues, further compromising cellular perfusion to organs
Mental status further deteriorates because of decreased cerebral perfusion and hypoxia
37
What dysfunctions can occur during the progressive stage of shock?
Lungs begin to fail: Hypoxemia, CO2 increases, alveoli collapse, pulmonary edema
Inadequate perfusion of the heart leads to dysrhythmias and ischemia
GFR cannot be maintained, and acute renal failure may occur when MAP falls below 65 mmHg-
metabolic acidosis develops
Liver function, GI function, and hematologic function are all affected
DIC (disseminated intravascular coagulation) with consumption of clotting factors
38
What physiologic manifestations occur during the irreversible stage of shock?
organ damage so severe, does not respond to treatment
Critically low BP
Renal and liver failure
metabolic acidosis
MODS to complete organ failure
39
What is the nursing care for shock?
Monitor the following:
Oxygenation status- PRIORITY!
VS
Continuous ECG monitoring
Hourly urine output
LOC (level of consciousness depends on BP)
Skin color, temp, moisture, cap refill, turgor
Place the client on high-flow oxygen such as 15L nonrebreather mask (if the client has COPD use 2L NC)
Be prepared to intubate
Maintain patent IV access
For hypotension, place the client flat with both legs elevated (modified Trendelenburg)
Prepare for and perform hemodynamic monitoring: CVP, arterial line and/or pulmonary artery catheter, CO
40
What are nursing actions for preintubation?
Monitor ECG, SaO2, breath sounds, and skin color
Preoxygenate with 100% oxygen
Assist with ventilation with manual resuscitation bag and mask
Suction as needed
Sedation and paralysis will be usually required (Ex: propofol and succinylcholine)
41
What are nursing actions post intubation?
Assess bilateral breath sounds, symmetrical chest movement
End-tidal CO2 monitoring and O2 saturation
CXR to confirm placement of tube in trachea
Secure ETT to avoid dislodgment
Post procedural sedation and analgesia needed (never allow paralysis alone)
Monitor all ventilator alarms (low pressure and high pressure)
42
What are causes of fluid loss that can lead to hypovolemic shock?
Excessive fluid loss from burns, diuresis, vomiting or diarrhea, or blood loss secondary to surgery, trauma, gynecologic/obstetric causes
43
What is the cascade of events occuring with hypovolemic shock? What reduction in volume can casue hypovolemic shock?
decreased intravascular volume
causes decreased venous return
causes decreased stroke volume
causes decreased cardiac output
causes decreased tissue perfusion
15-30% reduction (750-1500 mL blood in average adult)
44
How is hypovolemic shock managed? Medications? What do vasoactive meds do?
Treat the underlying condition resulting in fluid loss!
Restore the fluids and stop the fluid loss concurrently
Fluid and/or blood replacement- isotonic crystalloids and/or colloids, blood products
O2
Medications
Fill the tank first! (rehydrate with IV fluids and blood products)
Replace fluid volume before using vasopressors/medications
Vasoactive meds result in constricting arterioles, helping to maintain systemic BP
45
What are causes of cardiogenic shock? Mortality rate? Treatment?
MI
HF
cardiomyopathy
dysrhythmias
valvular rupture/stenosis
70%
Difficult to treat
Client cannot tolerate a fluid bolus to raise blood pressure
Results in lack of forward flow of blood (CO) and back-flow of blood into lungs
Inotropes (dopamine, dobutamine) can be used to stimulate HR and contractility
Vasopressors (norepinephrine) can be used to raise BP by increasing vascular resistance
Oxygen, morphine
Nitroglycerin (works in conjunction with dobutamine and dopamine)
46
What re 3 drug classes used to treat cardiogenic shock? MOAs? AEs? Reversal agents?
Inotropic agents (milrinone, dobutamine)
Strengthens cardiac contraction and increases CO while decreasing afterload
Can result in dysrhythmias and rapid heart rates which may need lowering/stopping of medication
Phentolamine is reversal agent if extravasates into tissue
Vasopressors (dopamine, norepinephrine, epinephrine)
Increases vascular resistance by constricting arterioles thereby helping increase BP
Raises BP by vasoconstricting which helps in keeping the blood on the arterial side
Increases kidney perfusion at low doses; decreases kidney perfusion at high doses
administer through a central line to prevent extravasation
Phentolamine is reversal agent if vasopressor extravasates into tissue
Vasodilators (nitroglycerin)
Low doses- venous vasodilator and reduces preload
Higher doses- arterial vasodilation and reduces afterload, increases CO (in combination with dobutamine), minimizes cardiac workload, enhances blood flow to myocardium
47
What is the cascade of events in the patho of distributive shock? What are 3 types of distributive shock?
precipitating event
causes vasodilation
activates the inflammatory response
causes an imbalance of intravascular volume
causes decreased venous return
causes decreased cardiac output
causes decreased tissue perfusion
Septic shock: circulating bacteria cause inflammation/vasodilation, causing leaky blood vessels (low BP)
Neurogenic shock: lack of sympathetic NS causes vasodilation, and bradycardia (low BP)
Anaphylactic shock: allergen causes inflammation, vasodilation, and leaky blood vessels (low BP)
48
What is SIRS? Result? Common causes? Criteria?
systemic inflammatory response syndrome
Results from a clinical insult that initiates a systemic inflammatory response
Clients with SIRS may be exhibiting protective inflammatory response to the initial insult or exhibiting a response to infection, which may
lead to sepsis
Multiple trauma
Infection (sepsis)
Only need 2/4
Temp >38.3°C (101°F) or <36°C (96.8°F)
Tachycardia >90
Tachypnea >20
WBC > 12,000 cells/mm3 or < 4000 cells/mm3 or >10% bands or 10% of immature bands
49
What is the nature of septic shock? Deadliest type? Mortality rate?
Most common type of distributive shock
Widespread infection (usually bacterial) that has entered the bloodstream
Endotoxins and other mediators causing massive vasodilation and inflammation
The deadliest type is gram-negative bacteria
40% mortality rate
50
What risk factors can contribute to septic shock occuring?
Immunosuppression (disease state or from chemotherapy)
Age extremes
Malnourishment
Chronic illness
Invasive procedures
Lack of immunizations
Emergent and/or multiple surgeries
Serious illness that causes bacteria to enter the blood (pyelonephritis, pneumonia, etc.)
** Anything that allows bacteria to enter the bloodstream may result in sepsis**
51
What are sepsis guidelines for the first hour?
Measure lactate and remeasure if initial lactate is > 2 mmol/L
Obtain blood cultures before administering antibiotics
Administer broad-spectrum antibiotics
Begin rapid administration of crystalloid (LR is recommended) for hypotension or lactate ≥ 4mmol/L
Start vasopressors if hypotensive during or after fluid resuscitation to maintain MAP ≥ 65 mmHg
52
What causes neurogenic shock? Manifestation? Risk factors?
Caused by widespread vasodilation r/t loss of balance between parasympathetic and sympathetic stimulation
Usually occurs from injury to the sympathetic nervous system
BP drops due to this vasodilation and bradycardia d/t PNS response
Risk Factors
Head trauma
SCI
Epidural anesthesia
Depressant action of medications
Lack of glucose
53
What is nursing management for neurogenic shock?
* Stabilization of SCI with neck immobilization, rigid backboard or firm mattress
* Proper positioning, avoid movements unless proper logrolling for assessment
* BP needs maintaining with vasopressor
* bradycardia may require atropine
*Ensure proper positioning
HOB at least 30 degrees with spinal anesthesia
*Prevention of thrombus formation (LMWH SC or heparin SC)
*Monitor for skin breakdown and skin ulcers
54
What are life-threatening reactions with anaphylactic shock? Common allergens?
Life-threatening reaction:
airway (swelling)
breathing (short of breath, wheezing)
circulation (hypotension, tachycardia)
skin (urticaria)
GI (nausea and vomiting)
Risk Factors: (can potentially be any allergen)
Contrast media
Transfusion reaction
Bee stings, snake bites
Latex sensitivity
Severe allergy to food (peanuts) or medications (penicillin)
55
What causes obstructive shock? Culprits?
Cardiac pump failure d/t an indirect cardiac factor (all result in hypotension)
Pulmonary embolus (blocks pulmonary artery)
Cardiac tamponade (surrounding fluid in pericardium compresses heart chambers)
Tension pneumothorax (collapsed lung under pressure compresses heart chambers)
56
What are nursing actions when participating in a needle decompression or chest tube isertion? What is the purpose for a needle decompression?
*Monitor ECG, SaO2, breath sounds, and color
*Sedate as needed
*Apply high flow oxygen
*Set up water seal chest-drainage system and attach it to suction
*Apply an airtight dressing to chest-tube insertion site
*Assess chest tube for leaks along entire length of tube
*Monitor and document drainage
*Assess bubbling in water seal chamber
*Obtain CXR post-procedure for tube position
immediately removes pressure from pleural space with a tension pneumothorax
57
What is the risk from excessive pericardial fluid accumulating? What s/s constitute Beck's triad? How can it be releived? Nuring actions?
Excessive pericardial fluid can result in cardiac tamponade and obstructive shock
Becks triad: hypotension, elevated JVD, muffled heart sounds
A pericardiocentesis is the procedure to attempt drainage of the pericardial fluid
Nursing actions
Monitor ECG, SaO2, breath sounds, and color
Assess for clinically improving vital signs: BP, HR, and JVD
HOB at 45°angle
Obtain CXR post-procedure
58
What are vasoactive medications indicated? Nursing actions? Why should they not be stopped abruptly? What are vasoactive drugs (6)?
Used when fluid therapy alone does not maintain MAP
Check vital signs frequently; continuous monitoring of vital signs every 15 minutes or more often
Given through central line if possible
Extravasation may cause extensive tissue damage
All can result in cardiac dysrhythmias, needs cardiac monitoring
Dosages usually titrated to client response and vitals
can cause hemodynamic instability furthering the shocked state
phenylephrine
norepinephrine
epinephrine
dopamine
dobutamine
isoproterenol
59
What is MODS? Patho? What is the criteria for MODS? What organ is usually affected first? Mortality rate? Prevention? RF that can result in MODS?
multi organ dysfunction syndrome
Occurs from the release of toxic metabolites and destructive enzymes in response to inadequate oxygenation
Can develop from inadequate tissue perfusion and reperfusion of ischemic cells, causing further tissue injury
At least 2 organs are failing in MODS not including the immediate cause
lungs
High mortality rate
60% when more than 4 organs fail
ICU setting
Prevention and aggressive treatment of shock is key
dialysis
ventilation
Most associated with sepsis/septic shock
Severe trauma
Burns
Acute pancreatitis
Major surgery
ARDS (acute respiratory distress syndrome)
DIC
** Any severe illness that results in hypotension and reduced organ perfusion
60
What are causative agents for burns?
thermal
chemical
electrical
radioactive
61
What is the rule of 9s? What are some percentages of note?
Used to determine TBSA% that is burned
Percentage of total body surface area (TBSA) to identify the extent of injury, calculate medication doses, fluid replacement, and caloric needs
front of legs 9%
back 9%
All the leg 18% each
Thoracic region: 9%
peritoneum: 9%
full front trunk: 18%
genitals 1%
front and back of arms: 4.5% each
total arm: 9%
front of head, back of head: 4.5% each
total head: 9%
62
What is the palmer method good for? What is used to measure
Used to estimate extent of scattered burns
Size of client’s hand, including fingers, is 1% TBSA
63
How is a minor burn classified? Moderate burn? major burn?
Minor Burn
Follow up in local ED
Full-thickness <2% TBSA
Partial-thickness <10% TBSA
Moderate Burn
Transported to burn center or specialized facility
Full-thickness 2-10% TBSA
Partial thickness 15-25% TBSA
Major Burn
Immediate treatment then transfer to burn center
Full-thickness >10% TBSA
Partial-thickness >25% TBSA
>60 years-old
Chronic cardiac, pulmonary, or endocrine condition
Electrical injury
Inhalation injury
Burns to eyes, ears, face, hands, feet, or perineum
64
what are the 4 degrees of burns and their extent of injury?
1st degree: superficial, painful, does not blister, does not scar
2nd degree: has 2 criteria
superficial partial: painful, blisters, may scar, only in the epidermis
deep partial thickness: extends into the dermis, weeps, blisters, may scar
3rd degree: full thickness, dry, insensate, scarring and contracture, may need grafting, extended into the dermis
4th degree: involves muscle or bone, leads to amputation, necrosis
65
What are airway injuries associated with major burns?
Thermal burns can result in severe edema within mouth, throat
May cause hoarse voice, drooling, difficulty swallowing
Facial and neck burns are associated with edema within airway (look for singed facial/nostril hair)
Lower airway
Chemical burns
Smoke inhalation injuries cause loss of ciliary action, trigger an inflammatory response causing hypersecretion, and produce severe mucosal edema and possibly bronchospasm. Alveolar surfactant production is reduced, resulting in atelectasis (collapse of alveoli). Expectoration of carbon particles in the sputum is the cardinal sign of this injury
Carbon monoxide poisoning occurs with smoke inhalation
66
What happens to fluids and electrolytes with major burn injuries?
Capillary leaking causes generalized edema, hypovolemia, and hyponatremia
Cell death causes hyperkalemia
67
What are cardiovascular effects from major burn injuries? GI effects? Integumentary?
Increased cardiac workload and oxygen demand from hypermetabolism
Decreased cardiac output from hypotension/3rd space fluid loss
Decreased perfusion
Altered GI motility
Paralytic ileus
Curling ulcer (gastric stress ulcer)
Inability to regulate body temperature from loss of skin
68
What are possible assessment findings associated with inhalation burn injuries?
singed facial hair
carbonaceous sputum (sooty)
hoarseness
wheezing
edema of nasal septum
smokey smelling breath
brassy cough
drooling
difficulty swallowing
stridor
69
What are the 3 phases of burn injury and the their timeframe?
emergent/recusative: onset of injury to complete fluid resuscitation (24-48hrs)
Acute: from the beginning of diuresis to wound closure (48-72 hours after injury)
rehabilitative: wound closure to return to optimal outcome (can take ahile)
70
What are nursing actions for emergent and recuscitative phase of burn injuries?
*Assess respiratory rate and depth
*Monitor for crowing, stridor, and dyspnea
*Provide humidified oxygen
*If PaO2 is less than 60 mm Hg, prepare for intubation
*Tracheostomy care if long-term intubation
*Cardiovascular: monitor cap refill, pulse oximetry, BP, ECG, and edema
*monitor pulses in extremities especially in case of circumferential burns
*elevate burned extremities above the heart to help decrease edema
*Monitor CVP and arterial lines if needed
71
What is in-hospital care during emergent or resuscitative phases of major burn injury? Wht should e done if burns exceed 20-25%? What addition is needed with electrical burns?
*Fluid resuscitation is begun (volume of fluid will be based on extent of burn)
*Foley catheter is inserted (monitoring fluid input and output is critical)
*Only IV meds. Opioids for pain
*Initiate IV access using a large-bore needle
*Assess for fluid volume overload
*Daily weights
Monitor UOP hourly for color, specific gravity, protein, and ensure output of at least 30 mL/hr
*Prepare to administer blood products if DIC occurs from the burns
*Monitor for manifestations of shock (hypotension, tachycardia, tachypnea, confusion)
Client with burns exceeding 20% to 25% should have an NG tube inserted and placed to suction (paralytic ileus)
*Clients with electrical burns should have ECG for dysrhythmias
72
What is third spacing?
(capillary leak syndrome) is a continuous leak of plasma from the vascular space into the interstitial space, which results in electrolyte imbalances and hypotension
73
What is the Parkland formula for fluid replacement when treating burns?
4 mL x % burn (TBSA) x pt wt in kg = total fluids (mL) for 24-hr
½ of the total volume is given over the first 8 hours from time the burn occurred and the remaining volume over the next 16 hours
74
What is the most common cause of death post burn injury? Prevention measures?
sepsis
Barrier techniques
Reverse isolation- gown, gloves, surgical mask
Restrict plants, flowers, along with fresh fruits and vegetables
Limit visitors
Use client-dedicated equipment
Administer tetanus toxoid
Application of topical antimicrobials
Use strict asepsis with wound care
Wound debridement to remove dead tissue
Early excision and closure
Control of hyperglycemia
Monitor for infection
Loss of barrier, necrotic tissue + serum proteins = happy bacteria, immunity compromised
75
Why is nutrition support so important with burn injuries? Calorie requirements? What nutrients should increase?
Burn injuries produce profound metabolic abnormalities related to the stress response, hypermetabolism, and wound healing
Require 5,000 calories a day
Calorie needs double or triple 4-12 days after the burn
Increase protein intake (rebuilding of tissue)
High carbohydrate: 55-60% of intake (prevents muscle protein breakdown)
76
What is an escharotomy? Fasciotomy? Their purpose?
Escharotomy:
Incision through eschar for compartment syndrome
Treat circumferential burns on extremity or chest
Improves circulation by relieving pressure
Fasciotomy:
Incision through eschar and fascia (deeper), also used for compartment syndrome
Relieves tissue pressure when escharotomy alone does not
77
What do the colors of burn wounds indicate?
Red and beefy color is a good sign (blood supply present)
Grayish color indicates poor wound healing and oxygenation of tissues (loss of blood vessels)
Black color (eschar)
Dead tissue, Wound cannot heal until the eschar is removed
78
What are the purposes of elastic pressure garments? how long is it worn?
Protect fragile skin
Promote better circulation of damaged tissues
Decrease extremity pain through vascular support
Decrease itching
Reduce thick, hard scars = increased mobility
Increase skin length by putting pressure on contracture bands
Wear as much as possible with the goal of 23 hours per day
Use compression dressings for up to 24 months
79
What types of shock has symptoms of bradycardia rather than tachycardia?
neurogenic shoc
80
When blood pressure is low what else is low? What does this indicate? What is the value that indicates it is low?
MAP: mean arterial pressure
low tissue profusion
lesss than 65
81
What are the manifestations of shock (11)? S/S of liver decline? S/S of GI dysfunction decline?
low BP
tachycardia (except neurogenic)
hypoxemia
metabolic acidosis
MAP below 65
dysrhythmias
liver and GI dysfunction
decreased LOC
increased cap refill time
decreased UO
cyanotic
jaundice
increased LFTs
parastalic paralysis
paralytic ilieus
82
What are the 4 steps of the 1-hr sepsis bundle? 5Th? #1 med? What is the purpose of administer this type of med? What is priority with these steps?
fluids 30mL/kg
measure lactate, bad if over 2
antibiotics
blood cultures
vasopressor if fluid is not bringing up BP
norepinephrine
2-line: dobutamine
increase MAP and CO
antibiotic, treat the underlying cause first
83
What is cardiomyopathy?
disease of heart that makes it more difficult to pump blood. Results in HF
84
What is the point for the insertion of a chest tube? Are bubbles expected? What can a pneumothorax progress to if not reversed? What would you see?
to re-expand the lung
yes, especially in the beginning
tension pneumothorax
deviated trachea
absence of breath sounds
85
What are nursing interventions that can prevent neurogenic shock? What is important is spinal anestethsia is administered?
always suspect spinal cord injury
C-collar, log roll, immobilize
calm environment
they cannot lay flat so anesthesia does not travel up and diaphragm paralyzes
86
What is priority setting with burns is upper airway is involved? What if burns are only on lower expremities?
protect airway. Intubate
if airway is not compromised, fluids would be priority
87
How do you know fluid administration has been effective?
BP is up
good UO
stable VS
MAP is over 65
decreased HR
88
What are the 5 rights of delegation? Where can you find the scope of practice? What can LPNs do?
person
task
circumstance
communication/direction
supervision/evaluation
nurse practice act
administer meds
evaluate VS of a stable person
insert catheter
reinforce teaching
apply restraints
89
What is agonal breathing? What is the label is in a mass causualty situation? What respiratory signs are a red?
labored
snorting
moaning
shallow, irregular breaths
Cheyenne stokes
death is imminent
black
stridor
pneumothorax
90
