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PCC IV > Exam 4 > Flashcards

Exam 4 Flashcards

1
Q

What organ are we worried about when dealing with electrical burns?

A

heart (dysrhythmias)

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2
Q

What kind of precautions are electrical burn pts on?

A

C-spine precautions because bone could be fractured

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3
Q

What is a 1st degree burn?

A

effects the epidermis

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4
Q

What is a 2nd degree burn?

A

effects the dermis

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5
Q

What does a 2nd degree burn look like?

A

shiny, moist, blistered

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6
Q

What is a 3rd degree burn?

A

total skin destruction

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7
Q

What does a 3rd degree burn look like?

A

black eschar, more white than level above

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8
Q

What is a 4th degree burn?

A

bones, muscles, tendons

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9
Q

What does a 4th degree burn look like?

A

dead tissue (don’t feel pain)

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10
Q

What is priority with emergent care of burns?

A

personal safety

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11
Q

When might care involve decontamination of the burn?

A

with chemical burns

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12
Q

What are two major risks for people with burns?

A

hypothermia
infection

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13
Q

Emergent care of wounds?

A

cool, lukewarm water and cover

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14
Q

Why does the nurse elevate extremities with burns?

A

to counteract inflammation

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15
Q

What is a major predictor of mortality in burn victims?

A

inhalation injuries

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16
Q

What two side effects can quickly develop with inhalation injuries?

A

airway compromise
pulmonary edema

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17
Q

What are the 3 types of inhalation injuries?

A

upper airway injury
lower airway injury
metabolic asphyxiation

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18
Q

What is a key finding with carbon monoxide poisoning?

A

cherry-red facial color

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19
Q

How does carbon monoxide poisoning work?

A

chemical binds with Hgb to decrease O2 carrying capacity

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20
Q

What are S/S of an inhalation injury? (10)

A

soot in mouth/nose
AMS
pale skin
decreased O2 sat
productive cough
increased work of breathing
hoarseness
stridor
wheezy/crackly lung sounds
burnt nasal hairs or eyebrow hairs

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21
Q

What is the duration of the resuscitation/emergent phase of a burn injury?

A

from onset of injury to completion of fluid resuscitation (72hrs)

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22
Q

What is the focus during the resuscitation/emergent phase of a burn injury?

A

ABCs and hemodynamic stabilization

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23
Q

What is the duration of the acute phase of a burn injury?

A

from beginning of diuresis to wound closure (72hrs)

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24
Q

What is the focus during the acute phase of a burn injury?

A

maintenance of cardiovascular and pulmonary systems

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25
Q

When is fluid resuscitation present?

A

when pts start to diuresis

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26
Q

What is the duration of the rehab phase of a burn injury?

A

from wound closure to optimal physical mobility

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27
Q

What is the focus during the rehab phase of a burn injury?

A

psychosocial adjustment - return to society

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28
Q

What are complications during the emergent phase of burn injuries? (5)

A

electrolyte imbalances
hypovolemic shock
third spacing
inflammation
immune changes

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29
Q

What is third spacing?

A

inflammation makes capillaries permeable which causes the movement of fluid into interstitial spaces

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30
Q

What is the sodium imbalance with major burns?

A

hyponatremic (Na going into cell)

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31
Q

What assessment is priority with hyponatremia?

A

neuro assess

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32
Q

What is the potassium imbalance with major burns?

A

hyperkalemic (K going out of cell)

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33
Q

What assessment is priority with hyperkalemia?

A

cardiac assess

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34
Q

What infusion restores vasculature and fluid volume?

A

albumin

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35
Q

What is the isolation protocol with major burns?

A

reverse isolation

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36
Q

What do nurses use the Parkland Formula for?

A

fluid resuscitation

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37
Q

How much of total fluid vol does the nurse administer over the 1st 8hrs?

A

1/2

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38
Q

How much of total fluid vol does the nurse administer over the next 8hrs?

A

1/4

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39
Q

How much of total fluid vol does the nurse administer over the last 8hrs?

A

1/4

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40
Q

What are the goals to maintain during fluid resuscitation?

A

SBP >90
HR <120
MAP >65
Urine output 0.5mL/kg/hr
(30-50mL/hr)

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41
Q

Under what circumstances will a burn pt be transferred to a burn center? (6)

A

face, hands, feet, genitalia, major joints
partial thickness burns >10% TBSA
3rd degree burns
electrical or chemical burns
inhalation injury
circumferential

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42
Q

What does circumferential mean?

A

burns are all the way around extremities, thorax, or neck

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43
Q

What is a high risk for circumferential burns?

A

compartment syndrome

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44
Q

With what type of burn injury is the development of compartment syndrome common?

A

full thickness injury; leathery eschar appearance
(3rd/4th degree burns)

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45
Q

What are S/E of compartment syndrome? (3)

A

lack of pulse in distal extremities
absence of movement
deep, aching pain

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46
Q

What is a escharotomy?

A

longitudinal incisions to relieve pressure from edema

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47
Q

What does cleaning the burn wound stimulate?

A

granulation and revascularization

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48
Q

What are 3 interventions for managing burn wounds?

A

debridement
hydrotherapy
dressings

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49
Q

How often are dressing changes with burn wounds?

A

daily

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50
Q

How often are dressing changes with skin grafts for burn wounds?

A

occlusive; changed q3-5 days

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51
Q

When can a nurse begin caring for a skin graft?

A

after the surgeon inspects it

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52
Q

What are 3 disorders of wound healing?

A

scars/keloids
contractures
failure to heal

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53
Q

What is autograft?

A

receiving a graft from your own tissue

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54
Q

What is allograft?

A

receiving a graft from another living thing

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55
Q

What interventions are included in nursing management of burns? (7)

A

PPE
airway management
fluid therapy
pain management
wound care
nutrition therapy
tetanus shot

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56
Q

Which meds are used IV during the emergent and acute phases of burn injuries?

A

morphine
fentanyl

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57
Q

Which meds are used for anxiety and pain management for burn injuries?

A

Lorazepam (ativan)
Midazolam (versed)

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58
Q

What are priority nursing management interventions during the acute phase of burn injuries? (5)

A

labs
infection
mobility
GI system
excision & grafting

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59
Q

What can happen to the GI system after a burn injury?

A

paralytic ileus, stress ulcers
intervention: NG tube

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60
Q

What kind of diet is recommended to a burn pt?

A

high calorie, high protein, high carbohydrate diet

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61
Q

Amount and frequency of meals for burn pt?

A

small portions, frequently

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62
Q

What meds are prescribed to burn pts to provide nutritional support?

A

insulin
carafate
histamine blockers

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63
Q

5-12 days after a traumatic injury what might happen to calorie needs?

A

double or triple
up to 5,000kcal

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64
Q

What is a nutritional high risk for burn pts?

A

hyperglycemia bc of insulin resistance

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65
Q

What is the MOA of Carafate?

A

coats lining of esophagus to prevent ulcers from forming

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66
Q

What are interventions for maintaining mobility with burn pts?

A

positioning
ROM exercises
ambulation
compression dressings

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67
Q

What is included in home care instructions for burn pts? (7)

A

skin & wound care
exercise & activity
physical & occupational therapies
nutrition
pain management
thermoregulation & clothing
mental health counseling

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68
Q

What is the exocrine function of the pancreas?

A

manufactures and secretes digestive enzymes

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69
Q

What enzyme breaks apart carbohydrates?

A

amylase

70
Q

What enzyme breaks apart fats?

A

lipase

71
Q

What enzymes break apart protein?

A

trypsin
chymotrypsin

72
Q

What is the endocrine function of the pancreas?

A

manufactures and secretes insulin and glucagon

73
Q

Pathophysiology of pancreatitis?

A

enzymes that are usually inactive until they reach the small intestine are activated in the pancreas and prompts inflammation

74
Q

What is a hallmark sign of acute pancreatitis?

A

lipolysis

75
Q

What occurs during lipolysis to the pancreas?

A

auto-digestion of pancreas (fibrosis)

76
Q

Proteolysis may lead to…

A

thrombosis & gangrene of pancreas

77
Q

What electrolyte imbalance is common with lipolysis?

A

hypercalcemia

78
Q

What are pts at a high risk for because of proteolysis & necrosis of the pancreas?

A

risk for bleeding because of vasodilation

79
Q

What might inflammation look like with acute pancreatitis?

A

pus formation, lesions

80
Q

What are signs of acute pancreatitis?

A

lipolysis
proteolysis
necrosis of blood vessels
inflammation

81
Q

How is chronic pancreatitis diagnosed?

A

repeated episodes (flare ups) of acute pancreatitis

82
Q

What is the pathophysiology of chronic pancreatitis?

A

pancreatic secretions precipitate and plug pancreatic ducts leading to inflammation, fibrosis, ulcer formation, and the destruction of the secreting cells

83
Q

What is the etiology of chronic calcifying pancreatitis?

A

alcoholism

84
Q

What is the etiology of chronic obstructive pancreatitis?

A

inflammation, cholelithiasis

85
Q

What is the etiology of autoimmune/genetic chronic pancreatitis?

A

immunoglobulins invade pancreas

86
Q

What are pts with autoimmune/genetic chronic pancreatitis at a high risk of developing?

A

pancreatic cancer

87
Q

What is the most common risk factor for pancreatitis?

A

gallstones

88
Q

What are risk factors for developing pancreatitis? (7)

A

middle-aged man
alcoholism
trauma
smoking
familial
viral infection/abscesses
hyperlipidemia

89
Q

What medications can cause pancreatitis? (3)

A

thiazides
NSAIDS
salicylates

90
Q

If the cause of pancreatitis is related to alcoholism what is the prognosis?

A

poor

91
Q

During what times of the year is pancreatitis most common?

A

during the holidays and vacation times

92
Q

Manifestations of acute pancreatitis? (8)

A

N/V
Fever
Jaundice
Confusion & agitation
Ecchymosis in the flank or umbilical area
Hypovolemia & shock
Renal failure
Ascites

93
Q

What is the key manifestation of acute pancreatitis?

A

severe abdominal pain

94
Q

Manifestations of chronic pancreatitis?

A

Recurrent attacks of intense abdominal pain & back pain
Vomiting
Wt loss
Jaundice; dark urine
Foul smelling fatty stools (Steatorrhea)
S/S of diabetes

95
Q

What are the 3 P’s of diabetes?

A

polyphagia
polydipsia
polyuria

96
Q

What assessments are important for the nurse to perform on pts with pancreatitis?

A

GI & Skin assessments

97
Q

What is Grey-Turner’s sign?

A

flank bruising indicating acute pancreatitis

98
Q

What is Cullen’s sign?

A

bruising around the umbilicus indicating acute pancreatitis

99
Q

What is a lab result that is highly indicative of acute pancreatitis?

A

elevated amylase within 12-24hrs

100
Q

Which lab results are elevated with pancreatitis?

A

amylase
lipase
glucose
WBC

101
Q

Which lab results are decreased with pancreatitis?

A

calcium & magnesium

102
Q

What is ERCP?

A

Endoscopic Retrograde Cholangiopancreatography: invasive procedure where they inset stents or remove cysts

103
Q

What two radiology diagnostics are utilized to diagnose pancreatitis?

A

CT
ultrasound

104
Q

What is the primary nursing diagnosis associated with pancreatitis?

A

acute pain related to inflammation & enzyme leakage

105
Q

What opioid medications are often prescribed to help manage acute pain related to pancreatitis?

A

morphine
dilaudid
fentanyl
(PCA pump)

106
Q

What histamine receptor antagonists is often prescribed to help manage pancreatitis?

A

ranitidine

107
Q

What PPI is often prescribed to help manage pancreatitis?

A

prilosec

108
Q

What nursing intervention is often performed to manage pancreatitis?

A

NG tube insertion to decompression the stomach

109
Q

What position often provides the most comfort to pts with pancreatitis?

A

fetal position

110
Q

Why are PPI’s prescribed to pts with pancreatitis?

A

decreasing gastric acid production can promote enzyme replacement

111
Q

What are secondary and tertiary nursing diagnoses for pancreatitis?

A

risk for fluid volume deficit related to fluid shifts
imbalanced nutrition less than body requirements

112
Q

What are 3 nursing interventions for the risk for fluid vol deficit associated with pancreatitis?

A

IVF- isotonic solution (NS 150mL/hr)
NPO during acute period
I & O

113
Q

What are 3 nursing interventions for imbalanced nutrition less than body requirements associated with pancreatitis?

A

NPO
antiemetics
enteral tube feeding

114
Q

When is enteral feeding often initiated?

A

if NPO for 24-48hrs & no ileus

115
Q

What must pts recovering from pancreatitis avoid when they return home?

A

alcohol & high fat foods

116
Q

How many kcal may a pt with pancreatitis need a day?

A

4,000-6,000

117
Q

What are 10 complications of pancreatitis?

A

death
infection (shock)
decreased CO (hypovol shock)
AKI
paralytic ileus
pleural effusion (L)
ARDS
DIC
MODS
DM type II

118
Q

When can a pancreatitis pt discontinue the NPO status?

A

when serum amylase is normal, active bowel sounds, and no pain

119
Q

What is pt education the nurse should provide when the pancreatitis pt is beginning to eat and drink again?

A

moderate to high carb, high protein, low fat diet
small, frequent, bland meals
avoid caffeine products
eliminate alcohol
may need pancreatic enzyme supplements

120
Q

What additional pt education points may the nurse provide to the pancreatitis pt?

A

relaxed atmosphere
smoking cessation

121
Q

What are S/S of pancreatitis complications? (8)

A

anorexia
n/v
abdominal distention with increasing fullness
persistent wt loss
severe epigastric or back pain
frothy/foul smelling BM
irritability, confusion
persistent fever

122
Q

Because of hyperthyroidism what state does the body enter?

A

hyper-metabolic state

123
Q

What hormones does the thyroid produce?

A

calcitonin
T3
T4

124
Q

What are two risk factors for developing hyperthyroidism?

A

graves disease (autoimmune)
thyroiditis

125
Q

What is the role of the pituitary gland?

A

promotes secretion and regulation of thyroid

126
Q

What diagnostics are preformed to diagnose hyperthyroidism?

A

ultrasound
EKG
thyroid scan

127
Q

In hyperthyroidism, the blood TSH level is

A

decreased

128
Q

In hyperthyroidism, the T3 & T4 level is

A

elevated

129
Q

What is a thyroid scan?

A

nuclear medicine
administer radioactive isotope day before scan and if there is elevated uptake of the isotope, hyperthyroidism can be diagnosed

130
Q

What are nursing interventions for hyperthyroidism?

A

calm environment/safety
nutrition support, I & O, wt
eye protection (eye drops)
lower room temp (cold showers)

131
Q

What medications are used to help manage hyperthyroidism?

A

thionamides (methimazole, propylthiouracil)
beta blockers
iodine solutions

132
Q

What is the MOA of thioamides for hyperthyroidism?

A

inhibit the production of thyroid hormones by decreasing iodine use

133
Q

What is the indication of beta blockers for hyperthyroidism?

A

palpitations
tachycardia

134
Q

What is the MOA of iodine for hyperthyroidism?

A

short-term use
inhibit production of thyroid hormones

135
Q

What are the treatments for hyperthyroidism?

A

iodine therapy
thyroidectomy

136
Q

What are complications associated with a thyroidectomy? (5)

A

hemorrhage
thyroid storm/crisis
airway obstruction
hypocalcemia
nerve damage (vocal cords)

137
Q

What is the MOA of iodine therapy?

A

destroys some thyroid producing cells

138
Q

When is iodine therapy contraindicated?

A

pregnancy

139
Q

What does iodine administration decrease?

A

size of thyroid gland
bleeding

140
Q

What position should the pt be in after a thyroidectomy?

A

semi-folwers

141
Q

What is a thyroid storm?

A

Common with graves disease and involves increased circulation of thyroid hormones in the blood.

142
Q

What can be the result of thyroid storm?

A

high mortality rate
hypermetabolic state

143
Q

What are S/S of thyroid storm? (6)

A

hyperthermia
HTN
SOB
delirium
vomiting
abdominal & chest pain

144
Q

What are S/S of hypocalcemia? (3)

A

tetany
tingling of fingers/toes
convulsions

145
Q

What condition can onset rapidly with hypothyroidism?

A

myxedema

146
Q

What state does the body enter with hypothyroidism?

A

hypometabolic state

147
Q

Why does hypothyroidism often go unnoticed?

A

can mimic normal aging process

148
Q

What are risk factors for hypothyroidism? (3)

A

female (30-60 years)
inadequate intake of iodine
radiation therapy to head/neck

149
Q

What area experiences hair loss with hypothyroidism?

A

eyebrows

150
Q

What is myxedema?

A

swelling of face, tongue, hands

151
Q

What diagnostics are performed to diagnose hypothyroidism?

A

thyroid scan
EKG

152
Q

In hypothyroidism, the T3 and T4 level are

A

decreased

153
Q

In hypothyroidism, the TSH level is

A

increased

154
Q

In hypothyroidism, the cholesterol level is

A

increased

155
Q

What are nursing interventions for managing hypothyroidism? (5)

A

monitor cardiac and respiratory systems
monitor wt, dietician consult
skin care
warming measures
stool softeners

156
Q

What kind of diet is recommended with hypothyroidism?

A

low calorie/high bulk diet

157
Q

What should the nurse refrain from administering to pts with hypothyroidism?

A

fiber laxatives

158
Q

What is the treatment for hypothyroidism?

A

thyroid hormone replacement therapy

159
Q

What is a possible complication of untreated hypothyroidism?

A

myxedema coma

160
Q

What are S/S of myxedema coma? (5)

A

cold
respiratory failure
low BP
low BS
low HR

161
Q

What kind of metabolism produces a build-up of lactic acid?

A

anaerobic

162
Q

What are the 4 types of shock?

A

distributive
hypovolemic
cardiogeneic
obstructive

163
Q

What are the 2 subcategories of hypovolemic shock?

A

absolute & relative

164
Q

What is absolute hypovolemic shock?

A

external loss of whole blood or bodily fluids

165
Q

What is relative hypovolemic shock?

A

fluid volume moves out of intravascular spaces and into interstitial spaces

166
Q

What is third-spacing?

A

fluid moves out of intravascular spaces and into interstitial spaces

167
Q

What is obstructive shock?

A

there is a physical obstruction distrupting the heart’s functioning

168
Q

What kind of complications can cause obstructive shock?

A

tension pneumothorax
cardiac tamponade
PE

169
Q

What is cardiogenic shock?

A

the heart’s fault

170
Q

What kind of complications can cause cardiogenic shock?

A

MI
dysrhythmias

171
Q
A

PCC IV (4 decks)

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