Exam 6 Flashcards
The nurse is caring for a patient was 30% total body surface area burn. During the first 12 to 36 hours the nurse carefully monitor the patient for which status changes related to capillary leak syndrome?
Tachycardia and hypotension
The home health nurse is visiting an older couple for the initial visit. In observing the household the nurse identify several behaviors and environmental factors to address. Which identify factors increase the risk for Burns and for household fires?
Ashtray with all the cigarette butts on the bedside table space heater very close to the bad single smoke detector in the kitchen back exit called the house use of the storage space
The nurse is caring for several patients on the burn unit was sustained extensive tissue damage. The nurse should monitor for which electrolyte imbalance that is typically associated with initial third spacing fluid shift?
Hyperkalemia
The nurse is reviewing the hemoglobin and hematocrit results for patient recently admitted for a severe burn. Which result is most likely related to vascular dehydration?
Hematocrit a 58%
The nurse is performing a morning assessment on a patient admitted for serious burns to the extremities. For what reason does the nurse assess the patient’s abdomen?
To assess for a paralytic ileus secondary to reduce blood flow
The nurse is interviewing and assessing an electrician was brought to the emergency department after being electrocuted. By standards are for that he was holding onto electrical source for a long time. Patient is currently alert with no respiratory distress. During the interview, what is the nurse assessed for?
Entrance and exit wounds
The patient was involved in a house fire and suffered extensive full thickness burns in the long term, what is she made this patient have trouble with?
Activation of vitamin D
During shift report, the nurse learned that a new patient with submitted for an inhalation injury. Auscultation of the lungs has revealed wheezing over the mainstream bronchi since admission. During the nurses assessment of the patient the wheezing sound or absent. What does the nurse do next?
Assess for respiratory distress because of potential airway obstruction
What is the maximum temperature of the skin can tolerate without injury?
104°
The nurse is caring for several patients who sustained burns. The patient with which initial injury is the least likely to experience severe pain when a sharp stimulus is applied?
Deep full thickness burn from electrical accident
The nurse is reviewing arterial blood gas results for patient with 35% TBS they burn in the emergent phase pH is 7.26 PCO2 was 36 MM HG and HCO3 is 19. What condition is the nurse suspect the patient has?
Metabolic acidosis
Patient comes to the clinic to be treated for burns from a barbecue fire. Although the patient does not appear to be in any respiratory distress, the nurse suspects and inhalation injury after observing which findings?
1, burns to the face
- Singed nose hair
- Adema of the nasal septum
- Black carbon particles around the mouth
The nurses caring for a burn patient received rigorous fluid recessive Tatian in the emergency department for hypotension and hypovolemic shock. In assessing renal function for the first 24 hours, what finding does the nurse anticipate?
Output will be decreased compared to fluid intake
A patient sustained a superficial thickness burn over a large area of the body. The patient is crying with discomfort and is very concerned about the long-term effects. What does the nurse tell the patient to expect?
Healing to occur in 3 to 6 days with no scarring or complications
The nurse is caring for a patient brought to the emergency department after bending over the engine of the car when it exploded in his face. What is the priority for this patient?
Secure the airway
The nurse is caring for a patient who sustained carbon monoxide poisoning while working on his car engine in an enclosed space. What assessment findings as a nurse anticipate?
Patient will report a headache
For which patient with the rule of nines method of calculating Burnside be most appropriate?
An adult his weight is proportionate to their height
Which criteria describes a full thickness burn wound?
- There is destruction to epidermis and dermis
- There are no skin cells for regrowth
- The burned tissue is a vascular
The nurse is assessing a patient with a brown one to the back and chest area. Which assessment findings are consistent with the superficial thickness burn wound?
Redness, pain, mild Adema
The nurse observes pealing of dead skin on the length of a patient with a superficial thickness burn. What is the most accurate description of this assessment findings?
Desquamation
The epidermis can go back after burn injury due to which component in this layer of skin?
Dermal appendages
Which type of burn one damages epidermis, dermis, fashion, and tissues?
Deep full thickness
Which type of burn destroy the sweat glands, resulting in decreased excretory ability?
Full thickness
During the early phase of a burn injury there is a drastic increase in capillary permeability him. What does this physiologic change place a patient at risk for?
Hypovolemic shock
An adult patient is admitted to the burn unit after being branded a house fire. Assessment reveals Branson entire face, back of the head, anterior torso, answer come French O’Briens to both arms. Using the rule of nines what is the extent of the burn injury?
45%
What is the most effective intervention for preventing transmission of infection to a burn patient?
Performing hand hygiene correctly and when appropriate
Which vaccine is routinely administered want to burn patient is admitted to the hospital?
Tetanus
Patient has severe burns the anterior surface of the body from a short exposure to high temps at a worksite furnace. Which area of the body’s most Bonable to a deep burn injury
Eyelids
The stain the berm much appears right invoice. The nurse gently apply pressure to the area to assess for what sign or symptom?
Blanching
What is the primary reason to avoid infection with burn injuries?
Prevent sepsis
The nurse is caring for several patients on the burn unit. Which patients have the greatest risk for developing respiratory problems?
- Patient who was in a storage room where chemicals caught fire
- Patient was working in an area where steam escape from a pipe
- Patient sustained a circumferential Brian to the chest area
- patient was found unconscious in a slow burning house fire
The nurse is caring for a firefighter who is trapped by for a prolonged period of time by burning debris. During the shift, the nurse know it’s a progressive hoarseness, Brasic off, and the patient reports increased difficulty with swallowing. How does the nurse interpret these changes?
Signs indicating a pulmonary injury and possible airway obstruction
The nurses just received a report on a patient admitted for a steam and elation burn. The patient is alert and conversant but reports that his throat feels wrong. His wife says that he sounds hoarse compared to usual. Considering these findings, which order does the nurse question?
Vital signs and airway assessment every shift
The nurse is caring for a burn patient was stabilized by and transferred from a small world hospital the patient develops a new complaint of shortness of breath on auscultation the nurse here’s crackles throughout the lung fields what does the nurse suspect is causing this patient’s symptoms?
Pulmonary fluid overload due to fluid resuscitation
The nurse is caring for several patients on the burn unit. Which of these patients has the most acute need for cardiac monitoring?
Young woman who was struck by lightning while jogging on the beach
A patient is transported to the emergency department for severe an extensive burns that occurred while he was trapped in a burning building. The patient is severely injured with respiratory distress and the resuscitation team us immediately begin multiple interventions. Which task is delegated to the UAP
Assist the respiratory therapist to maintain a seal during bag valve mask ventilation
The nursing student notes on the care plan of the burn patient she is caring for that risk for organist Kenya. Based on the students knowledge of the pathophysiology of Burns, which ideology does the nursing students select?
Related to hypovolemia and myhlobin release
The student nurses caring for a patient who is seen in the burn unit for several weeks. The patient needs assistance with the bedpan to have a bowel movement, and then student nurse notes at the store was black with Atari appearance. What does the sooners do next?
Test for the presence of a cold blood with the Hemoccult cards and reagent
Patient lives in a rural community sustain several Burns during a house fire at 10 AM. The rule is in MS started a peripheral IV at 11 AM to keep the van open the patient was admitted to hospital at 1 PM. And calculating the fluid replacement at what time is the fluid for the first air. Completed
6 PM
A burn patient with which condition is most likely to have mantle ordered as part of drug therapy?
Lexical burn and myoglobin in the urine
Patient was admitted to the burn unit approximately six hours ago after being rescued from a burning building and emergency department here according to dry irritated throat from breathing in the fumes complaints. During the shift the nurse notes of the patients only marked strider. The nurse and just been patient for what you
Intubation
The patient was admitted for Brian’s of the upper extremities after being trapped in a burning structure. The patient is also at risk for an adequate oxygenation related to inhalation of smoke and superheated fumes. Which diagnostic test best mattresses patient gas exchange?
Carboxyhemoglobin level
The patient in the burn intensive care unit is receiving Norcuron. What is the primary nursing intervention for this patient?
And sure that all the equipment alarms are on and functional
The priority expected outcome during the recess cetacean phase of a burn injury is to maintain which factor?
The airway
Which statement about the Risa cetacean phase of a brain injury is accurate?
It continues for about 48 hours after the burn
The release of myoglobin from damage muscle in patients with major brands can result in which potential complication?
Acute kidney injury
I’ll burn patient in the fluid resuscitation phase is experiencing dyspnea what are the priority interventions for this patient?
- Elevate head of bed
- Notify the rapid response team
- Apply humidified oxygen
The vasodilating affects the carbon monoxide in patients with Cara monoxide poisoning causes what clinical manifestation?
Cherry red skin color
The nurses caring for a burn patient about to undergo hydrotherapy. Which complementary therapies are appropriate for pain management in this patient?
Playing music in the background use of meditative breathing use a guided imagery
Burn patient refuses to eat. The potential problem of weight loss related to increased metabolic rate reduced calorie intake is identified for this patient. What method listeners used to quickly with patient?
Where daily without dressings or splints and compared to prepare and wait
Nurse is preparing to assist with hydrotherapy forever and patient. The supervising nurse instructs us to obtain the necessary equipment before beginning the procedure. What equipment is your nurse obtain?
- Scissors and forceps
- Mild soap or detergent
- Washcloths and God sponges
The nurse is applying addressing to cover a burn patients left leg. What technique does the nurse use?
Consider the depth of the injury and amount of drainage and work distal to proximal
The nurses just received a phone report on the burn patient being transferred from the burn intensive care unit to step down burn unit. Which task is appropriate to delegate to UAP in order to prepare the room?
Place a new disposal stethoscope in the room
The nurse is monitoring the nutritional status of a burn patient. Which indicators as a nurse use?
- Amount of food the patient needs
- Weight to height ratio
- Sarah I’m albumin
- Blood glucose
The nurses educating the patient was Sanbern said dominant hand. What kind of active range of motion exercises the nurse instruct the patient to perform?
Exercise a hand, thumb, fingers every hour while awake
Burn patient must have pressure dressings applied to prevent contractures and reduce scarring. For maximum effectiveness what procedure pertaining to the pressure garments is implemented?
One at least 23 hours a day until the scar tissue matures
Family reports of the burn patient unable to perform self-care measures of someone’s been doing everything for her. The nurse five the patient has an odd physical capability to independently perform self-care what is the nurses best response
What is been happening since you were discharged from the hospital
Basin who sustained severe burns her face with significant scarring and disfigurement will soon be discharged from the hospital. Which intervention is best to help the patient make the transition into the community?
Courage visits from friends and short public appearances before discharge
What does the process of a full thickness wound healing include?
- Healing occurs by wound contraction
- Eschar must be removed
- Skin grafting maybe necessary
- Fathi out of me maybe needed to relieve pressure and allow normal blood flow
Which statement about Thursday singer capillary leak syndrome in a patient with severe burns is accurate?
It is a leak a plasma fluids into the interstitial space
As a result of third spacing, during the acute phase, which electrolyte imbalance of made her
Hyperkalemia and hyponatremia
Because of the fluid shifts and burn patients what effect on cardiac output does the nurse expect to see?
Depressed up to 36 hours after the burn
Burn injuries is being discharged from the hospital. What important points does the nurse include in the discharge teaching?
- Signs and symptoms of infection
- Drug regimen and potential medication side effects
- Correct application and Cara pressure garments
- Dates for follow-up appointments
The patient has sustained significant Burns what you’ve created a hyper metabolic state. And planning care for this patient what does the nurse consider?
Increased caloric needs
The nurse is reviewing the lab results for several burn patients were approximately 24 to 36 hours post injury. What lab results related to fluid we mobilize Asian in these patients as a nurse expect to see?
Anemia
Local to see resistance to electricity varies in different parts of the body which tissue has the most resistance?
Skin epidermis
Patient was rescued from a burning house and treated with oxygen. Initially the patient had audible wheezing and wheezing on awful Tatian but after approximately 30 minutes the wheezing stop the patient now demonstrate subs are no retractions and anxiety. What action does the nurse take it this time?
Recognize an impending airway obstruction and prepare for a meeting at intubation
The nurses caring for a young woman who sustained brands on the upper extremities and anterior chest wall attempting to put out a kitchen grease fire. Which lab results of the nurse expect to see you during the recess cetacean phase?
- Glucose level of 180
- Hematocrit of 49%
- pH of 7.20
Patient is a saint a branch of the right ankle. The physician is applied the initial dressing to the angle and the nurse assist the patient into bed and positions and go to prevent contracture. What is the correct position the nurse uses?
Dorsey flexion
Patient is a saint a severe burn greater than 30% TV essay. What is the best way to assess renal function in this patient?
Measure you’re in output and compare this value with fluid intake
The nurse is caring for an African-American patient with the burn injury. Patient appears to be having severe pain and discomfort your unrelated to the burned area. The nurse advocate that the physician order which additional test?
Sickle cell for trait
The physician has ordered and escharotomy for the patient because of construction around the patient’s chest. The nurse is teaching the patient and family about the procedure. Which Steven by the family indicates a need for additional teaching?
He wouldn’t do well under general anesthesia
The nurses caring for a firefighter who was brought in for burns are on the face and upper chest. Eric maintenance for this patient with respiratory and bald men includes what action?
Monitoring for signs and symptoms of upper airway edema during fluid resuscitation
I won’t point does fluid mobilization occur in patients with burns?
After 36 hours when the fluid from the interstitial tissue
The nurses caring for a patient with chronic pain associated with and I’ll burn injury which nonpharmacological interventions as the nurses to help relieve the patient’s pain?
Massaging non-burned areas
A patient with the burn injury had an autograph. The nurse Lawrence and report with the donor site is on the upper thigh. What type of wine does the nurse expect to find a donor site?
Partial thickness
To prevent the complication of curlings all sir, what is the nurse anticipate the physician will order it?
H to histamine blockers
Several patients are transported from an industrial fire to a local emergency department. Which factors increase the risk of death for these patients?
- Age greater than 60 years
- Burn greater than 40% TBsa
- Presence of inhalation injury
What is the most essential patient data needed for calculating the fluid rates, energy requirements and drug doses for burn patients?
Pre-burn wait
Which drug therapy reduces the risk of loan infection for burn patients?
Silver sulfadiazine is on full thickness injuries every four hours
Patient has a Santa relatively large burn. The nurse anticipate that the patient’s nutritional requirements may exceed how many calories a day
5000
Feelings are most typically expressed by the burn patient?
Regression, denial, anger
Patient has been depressed and withdrawn since her injury and has expressed that life will never be the same. Which nursing intervention best for mugs a positive image for this burn patient?
Discussing the possibility of reconstructive surgery with the patient
A 28-year-old male sustained second and 3rd° burns on his legs 30% on his clothing got fire while he was burning leaves. He was hoes down by his neighbor and his arrival of the emergency department severe discomfort what is the primary problem for this patient at this time?
Acute pain related to damage her exposed nerve endings
Which patient has the highest risk for a fatal burn injury?
77-year-old man
The patient was burned on the forearm after tripping and falling against the wood-burning stove. They’re currently several small blisters over the burn area. What does the nurse advised the patient to do about the blisters?
Leave the blisters intact because they are protecting the one from infection
A 70-year-old client with a diagnosis of heart failure and chronic obstructive pulmonary disease is admitted to a unit in a long-term care facility for cardiopulmonary rehabilitation program. Pneumococcal and flu vaccines are administered. The client asked the nurse if the pneumococcal vaccine has to be taken every year like the flu vaccine. How should the nurse respond?
It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose
A client is receiving albuterol to relieve severe asthma. For which clinical indicators of the nurse monitor the client?
Tremors and palpitations
The client states that the healthcare provider said the title volume is slightly diminished and asked the nurse what this means. Which exclamation should the nurse provide about the volume of air being measured to determine title volume?
Exhaled after there is a normal inspiration
A nurse is instructing a client to use and incentives barometer. What client action indicates the need for further instruction?
Blowing vigorously end of the mouthpiece
A client is scheduled for a pulmonary function test. The nurse explains that during the test one of the instructions the rest of Troy therapist will give the client is to breathe normally. What should the nurse teaches being measured when the client follow these directions?
Tidal volume
The nurse identifies the clients hemoglobin level is decreasing and is concerned about tissue hypoxia. An increase in what diagnostic test results indicate an acceleration and oxygen dissociation from hemoglobin?
PCO2
What nursing action women hypoxia and sectioning a clients airway?
Apply suction only after catheter is inserted
A nurse assesses that several clients have low oxygen saturation apples. Which client would benefit the most from receiving oxygen via nasal cannula?
Receive many visitors while sitting in a chair
A nurse reposition the client was diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange?
Orthopenic
What nursing action will most help a client obtain maximum benefits after postural drainage?
Encourage coughing deeply
A client of emphysema experience is a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asked how could this have happened? What likely cause of the spontaneous pneumothorax so the nurses response take into consideration?
Rupture of a subpleural blab
A client is diagnosed with emphysema. For what long-term problems with the nurse monitor this client?
Carbon dioxide retention
What is the underlying rationale my nurse assesses the client with emphysema for clinical indicators of hypoxia?
Loss of aerating surface
The nurse administers oxygen at 2 L a minute be a nasal cannula to a client with emphysema. For which clinical indicators of the nurse closely observed the client for?
Drowsiness and mental confusion
And there’s this teaching breathing exercises to a client with emphysema. What is the reason the nurse should include in the teaching as to why these exercises are necessary to promote effective use of the diaphragm?
The residual capacity of the lungs has been increased
While receiving and adrenergic beta-2 agonist drug for asthma the client complains of palpitations chest pain a throbbing headache. What is the most appropriate nursing action?
Withhold the drug until additional orders are obtained
What is the priority go for a client with asthma was being discharged from the hospital?
Demonstrate use of a metered dose inhaler and
The client with a long history of asthma is scheduled for surgery. What information should be included in preoperative teaching?
There is an increased risk of respiratory tract infections
Acclimate asthmas been taught how to use the peak flow meter to monitor how well the house was being controlled. What should the nurse instruct the client to do?
And he’ll completely and then blow out as hard and as fast as possible through the mouthpiece
A client is admitted for an act laceration of emphysema. The client has fever, chills, difficulty breathing on exertion. What is the priority nursing action based on the clients history and present status?
Encouraging increased fluid intake
The arterial blood gases of a client with chronic obstructive pulmonary disease deteriorate, respiratory failure is in pending. For which clinical indicators should the nurse assessed first?
Mental confusion
A nurses caring for a client with severe dyspnea who is receiving oxygen via Venturi mask. Which of the nurse to you and Karen for this client?
Monitor oxygen saturation levels when eating
The client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client?
Give prescribe drugs to promote bronchial dilation
And nurses caring for a client with a history of chronic obstructive pulmonary disease. What complications are most commonly associated with COPD?
Cardiac problems
After resection of a lower lobe of the long, client is excessive respiratory secretions. What independent nursing action should the nurse implement?
Turning and repositioning
A nurses caring for a client experiencing acute episode of bronchial asthma. What outcome should be achieved?
Raising mucus secretions from the chest
The nurses caring for a patient admitted to the emergency department of cardiac tamponade. What assessment findings of the nurse expect to see?
- Jugular vein distention
- Decreased cardiac output it
- Muffled heart sounds
A patient in the emergency department has been diagnosed with a flail chest following a fall from a two-story height. What findings of the nurse expect to see upon assessment?
- Dyspnea
2. Paradoxic chest movement
True or false educational materials at discharge instructions should be available at the six grade reading level or lower
True
The patient and emergency department has been diagnosed with the flu I’ll just following a three-story fall from a ladder. Which interventions as a nurse include for this patient?
- Requesting pain medication
2. Providing humidified oxygen
The patient has been admitted to the emergency department following a motor vehicle crash and has a history of substance abuse. What must be a priority for the nurse to include an assessment?
Assess the patient’s risk factors for suicide
Patient admitted to the emergency department has a close tibia fracture from a fall. What question is essential to the requirement of the continuum of care?
With the patient’s home medications
Patient comes to the emergency department with severe respiratory distress he has a long history of chronic respiratory disease and now requires endotracheal intubation. How does the nurse assesses patient’s lung compliance?
Since the degree of difficulty in ventilating with the bag valve mask
The patient involved in a boating accident has extensive injuries and comes emergency department and wet clothes the nurse identifies the risk for hypothermia which interventions does the nurse implement?
- Remove wet clothing
- Infuse warm IV solutions
- Use a heat lamp
The nurses caring for a patient with a head injury was Glasgow coma scale is three. The score indicates the patient is most likely to do what?
Be totally unresponsive
The nurses next-door neighbor has sustained a deep laceration to the right upper arm and there’s active bright red bleeding. What does the nurse due to immediately control the bleeding?
- Have the neighbor lie flat and elevate the arm
2. Apply direct pressure with a thick, dry towel
A patient sustained multiple injuries in a job site accident has a blood pressure of 100/60 and a pulse of 120 per minute. Two large bore IVs are established an IV fluid resuscitation is initiated. After receiving IV fluids, repeat vital signs are blood pressure 94/56, pulse 135, then blood pressure 80/50, pulse 150. with these vital signs, the patient is likely to require blood products after how many liters of IV fluid’s?
2 L
The nurses helping the physician treat a patient with a tension pneumothorax. What type of equipment is a nurse obtained to Mili alleviate the life-threatening condition?
Chest tube insertion tray
The patient comes to the emergency department after falling off the roof. He displays absent breath sounds over the left chest, severe rest of Tory distress, hypotension, jugular vein distention, and tracheal deviation. Based on his assessment findings for which condition does the nurse anticipate the patient must receive immediate treatment?
Tension pneumothorax
What is the fastest way for the nurse to estimate the systolic blood pressure and a patient who is being resuscitated?
Palpate for the presence of a radial pulse
A 61-year-old patient is brought to the emergency department reporting difficulty breathing and fatigue. The patient is currently receiving radiation treatments for lung cancer. The physician diagnosis is cardiac tamponade. Which assessment findings as a nurse expect the patient to exhibit?
Decreased cardiac output it
A parent brings her two-year-old to the birdseed apartment stating she fell and bumped her head and forearm. Which behavior by the child causes the nurses the least concern during the initial triage interview?
Crying and reaching for the parents of the nurse approaches
Emergency department trauma team is preparing to receive a motor vehicle crash victim with severe chest drama with coughing up blood and a crush injury to the right leg. What type of personal protective equipment does the nurse assigned to be the recorder put on?
Down, gloves, I protection, facemask, I And shoe covers
The nurse is evaluating the lower extremities of several patients. Which description represents the least serious physical presentation?
Decreased sensation , lower leg has wide spread brownish discoloration
Three people came to emergency department with the patient had become verbally argumentative and threatening towards each other. Which action Sisson emergency department nurse take to ensure staff safety?
- Follow the hospital security plan
- Attempt to de-escalate the situation
- Look for an escape route
A patient died in the emergency department after sustaining multiple injuries that occurred during an aggravated assault. The family arrives after the patient is pronounced dead in the ass to go see the body. What does the nurse do?
Explain what they will see, did the lights, leave the patient’s face expose, but cover the rest of the body with a blanket
Which functions represent appropriate referrals to the case manager?
- Facilitate referral to a primary caregiver provider who is taking new patients
- Investigate whether the patient is abusing and overusing emergency department services
Patient is brought to the emergency department by the family because he is verbally threatened other than attempted to stab the neighbors dog. What does the nurse do in order to in sure the safety of the patient and others?
- Search the patient’s belongings and secure personal effects2. Remove dangerous equipment from the room, such as sharps containers or portable instruments.
- Use a metal detector to search for objects that can be used as weapons
- Instructed nursing students to avoid wearing a stethoscope around their necks
The patient was involved in a high-speed motor vehicle crash. The physician instructs the nurse to prepare for several urgent procedures because of severe injury and physical compromise. Which procedure does the nurse prepare for first?
Endotracheal intubation
Emergency department nurse is caring for several patients, all of whom are currently lying on the stretchers either pending discharge or awaiting transfer to a hospital bed. Which patients are at risk for falls?
- Opioid naïve teenager with a fracture who receive 3 mg IV morphine for painm
- . Middle-age woman with severe vomiting and frequent watery stools
- Older adult patient with acute dementia secondary to infection
Patient is brought to the emergency department by friends who report he probably overdosed on downers. The patient has a decreased level of consciousness and decreased gait reflux, his face and chest are covered with emesis, he demonstrates spontaneous sonorous respirations and pulls oximetry is 87% on room air. What type of airway management does the nurse expect this patient to receive?
Endotracheal intubation with initial high concentration of oxygen
An older couple I’m Acacian come so emergency department. The man appears to be having a stroke and is unable to speak clearly or court hearing. His wife is very distraught and states he has many allergies and takes many medications but I can’t remember anything right now. What does the nurse to quickly to obtain accurate drug allergy information?
- Call the patient’s family physician for a phone report about is drugs and allergies
- Call one of the patients children and stress urgency in Porten’s for accurate information
- Call the pharmacy where the patient obtained his medications
- Check for a medical alert bracelet and help the wife to look in the patient suitcase
An older adult patient has been waiting in the emergency department for over 48 hours due to extremely high-volume. Risk for impaired skin integrity is identified in the charge nurse delegates turning the patient every two hours to the nursing assistance. Since emergency apartments busy the patient is not always turn begin set up a pressure ulcer. What is the charge nurse do to prevent a recurrence of this type of problem for future patients?
- Make anecdotal Notes and counsel all them Bob nursing assistance
- File an incident report and seek resolution of the systems level
- Read educate staff on the need to turn patients at risk for skin breakdown
The nurses working in the emergency department with an emergency physician, but the physician is currently involved in the care of several critical patients. Emergency department nurse must initiate care for patients under entered a disciplinary a medical protocols. Which intervention is the least likely to be covered by standing protocol?
Ventilate per Ambu bag with 100% oxygen and intubate
The emergency department nurse is caring for a patient was found in an alley with no identification and no known family. The nurse must give medications to the patient. What is the correct procedure?
The patient is designated as John Doe and the nurses use to unique identifier
The nurses working alone in triage. It is a busy night in the waiting room is full of people who are restless and unhappy about having to wait. Which situation warrants the nurse to activate the panic button under the triage desk?
A person walks in and starts threatening the registration staff with a weapon
The nurse is interviewing a psychiatric patient was been verbally aggressive for the past several hours according to the family. Family states he won’t hurt anybody however the patient is pacing appear suspicious and angry. With strategy does the nurse used to conduct the interview?
Conduct the interview standing near the door in a quiet room
Emergency department nurse is attempting to transfer a patient to the medical surgical unit. When they’re receiving nurse answers the phone he says you people always dump these admissions on us during shift change. Which response by the emergency department nurse represents the best attempt at a respect for negotiation
I apologize for the timing I will call back in 15 minutes
A patient received in the emergency department is diagnosed with stroke upon assessment the patient exhibits difficulty swallowing. When taking a sip of water the patient jokes and coughs. What priority safety measure does the nurse implement for this patient?
Set oral suction device
Emergency department nurse is preparing a report on a patient being admitted for bacterial meningitis. Which points are included in the emergency department report to the medical surgical nurse?
- Patient reports severe headache with high fever that started four days ago
- Patient currently alert and is oriented times two, speech clear, but rambling
- IV normal saline into left anterior forearm received first dose of IV Cetra flaxen at oh 800
- Lumbar puncture results are pending but Manning cockle meningitis is suspected
5received 1000 mg acetaminophen for pain nine out of 10 and fever of hundred and three at 400 pain continues seven out of 10 temperature now 10 100.9
A nurse discusses the philosophy of Alcoholics Anonymous with the client who has a history of alcoholism. What need must self help groups such as AA meet to be successful?
Belonging
A nurse is caring for a client with a diagnosis of acute pancreatitis and alcoholism. The client asks what does my drinking have to do with my diagnosis? What effect of alcohol should the nurse include when responding?
Increases enzyme secretion and pancreatic duct pressure causes backflow of enzymes into the pancreas
Acclimated minute with a tentative diagnosis of pancreatitis. The medical and nursing measures for this client our aim toward maintaining nutrition, promoting rest, maintaining fluid and electrolyte balance, and decreasing anxiety. Which intervention should the nurse implement?
- Administer analgesics
- Teach relaxation exercises
- Monitor cardiac rate and rhythm
The client is recovering from an acute episode of alcoholism that included esophageal involvement. What are the components of a therapeutic diet that are most appropriate for the nurse include in the teaching plan for this client?
- Soft diet
- High protein diet
- High carb diet
Thiamine or vitamin B and nice thin vitamin B three are prescribed for a client with alcoholism. Which body function maintained by these vitamins should the nurse include in the teaching plan?
Neuronal activity
A client is admitted to the hospital with a diagnosis of alcohol withdrawal syndrome. By Oregon should the nurse teach the client will be protected by the ingestion of a high calorie diet fortified with vitamins?
Liver
The client with a history of alcohol abuse says to the nurse drinking is a way out of my depression. Which strategy probably is most effective for the client at this time?
A self-help group
A client who is in an automobile collision is admitted to the hospital with multiple injuries. Approximately 14 hours after admission, the client begins to experience signs and symptoms of withdrawal from alcohol. Which of these signs and symptoms of the nurse relate to alcohol with drawls?
- Anxiety
- Diaphoresis
- Psycho motor agitation
A nurse assesses the client recently admitted to an alcohol detoxification unit. What common clinical manifestations of the nurse expect during the initial stage of alcohol detoxification?
Nausea
Alcohol dependence is defined by the national Institute of alcohol abuse and alcoholism is a disease with which for symptoms?
- Craving
- Loss of control
- Physical dependence
- Tolerance
What is the alcohol questionnaire called?
The CAGE ( cut annoyed guilty eye) question are
What are two additional tools that are being used to identify alcohol use disorders?
The AUDIT and alcohol screening and brief intervention for youth of practitioners God public by the national Institute of health
Signs and symptoms of alcohol withdrawal include
Anorexia, chills, craving, muscle cramps, irritability, palpitations, disorientation, tachycardia, hypertension, low-grade fever, mood changes, slurred speech, impaired gait, for dexterity, fatigue, abdominal pain
Under diagnostic criteria specified by the day Gnostic statistical manual of mental disorders alcohol withdrawal has what components
- Cessation are reduction of heavy and prolonged alcohol use
- Two or more the following developing more than several hours to a few days after criteria (symptoms)
What is the most severe form of alcohol withdrawal?
Delirium tremens
What is the gold standard with drawl assessment rating scale
The clinical institute withdrawal assessment for alcohol
What to all documents with drawl trends
The withdrawal trend profile tool. list of all the nursing
What are the most commonly used benzodiazepines
Diazepam , lorazepam, chlordiazepoxide, and oxazepam
True or false
Ethanol replacement therapy is out model and not recommended
True
True or false
One and five patients admits to a hospital suffering from an alcohol use disorder
True
A nurse assesses the client recently admitted to an alcohol detoxification unit. What common clinical manifestations of the nurse expect during the initial stage of alcohol detoxification?
Nausea
Normal lab values for ph
pH 7.35 – 7.45
Normal lab values for PaCO2 and Pa02
PaCO2 35-45 mm Hg
PaO2 80-100 mm Hg
HCO3 22-26 mEq/L
SaO2 94-100 %
Normal lab values for HCO3 and
SaO2
HCO3 22-26 mEq/L
SaO2 94-100 %
Difference between asthma and COPD
Asthma is
- Intermittent
- Reversible airflow obstruction & wheezing
COPD is Chronic Bronchitis Pulmonary Emphysema Tissue damage not reversible Increases in severity Leads to respiratory failure
What is asthma?
Asthma is a disease of the lower airways
The airways of people with asthma are extra sensitive to the things they’re allergic to and to other irritating things in the air
What causes symptoms of asthma
What causes symptoms of asthma?
Asthma symptoms start when allergens or other irritants cause the lining of the airways to swell and narrow.
The muscles around the airways can then spasm, causing the airways to narrow even more.
When the lining of the airways is inflamed, it produces more mucus. The mucus clogs the airways and further blocks the flow of air. This is called an “asthma attack.”
Pathophysilogy of asthma
Airway Inflammation
Mucous membrane lining the airway
Irritants may also trigger hyper responsiveness
Airway Hyperresponsiveness
Constricts bronchial smooth muscle
Narrows the airway from the outside
Irritants may also trigger inflammation
Pathophysilogy of asthma
Airway Inflammation
Mucous membrane lining the airway
Irritants may also trigger hyper responsiveness
Airway Hyperresponsiveness
Constricts bronchial smooth muscle
Narrows the airway from the outside
Irritants may also trigger inflammation
Path of asthma cont..
Both problems can occur at the same time, and often do
Inflammation
Response to specific allergens
Nonallergenis irritants such as cold air, dry air, particles
Microorganisms
Aspirin
Hyperresponsiveness (Bronchospasm)
Can occur with exercise
Upper respiratory illness
Poor control of asthma with resultant chronic inflammation can lead to damage and hyperplasia of the bronchial epithelial cells and bronchial smooth muscle (Airway remodeling)
What is delirium tremens characterized by
Is characterized by altered mental status and severe autonomic hyperactivity that may lead to cardiovascular collapse
Path of asthma cont..
Both problems can occur at the same time, and often do
Inflammation
Response to specific allergens
Nonallergenis irritants such as cold air, dry air, particles
Microorganisms
Aspirin
Hyperresponsiveness (Bronchospasm)
Can occur with exercise
Upper respiratory illness
Poor control of asthma with resultant chronic inflammation can lead to damage and hyperplasia of the bronchial epithelial cells and bronchial smooth muscle (Airway remodeling)
Asthma whats going on beneath the surface
With asthma, what we see is the tip of the iceberg, the symptoms.
At the base of the iceberg is the airway inflammation.
This inflammation underlies the bronchial hyperresponsiveness of asthma, the air flow obstruction, and the culmination of the inflammatory process is the tip of the iceberg, the symptoms.
*Active inflammation of the airways can be present for 6 to 8 weeks following a severe respiratory infection.
*Airflow obstruction results from bronchoconstriction, bronchial edema, mucus hypersecretion, and inflammatory cell recruitment including eosinophils, a key inflammatory cell.
Water eyes, itchy nose, throat
6-8 weeks following respiraotyr illness
**esinophills (know part they play)
How do eosinophils play a part in asthma
hhh
What is atopy?
atopy /at·o·py/ (at´ah-pe) a genetic predisposition toward the development of immediate hypersensitivity reactions against common environmental antigens (atopic allergy), most commonly manifested as allergic rhinitis but also as bronchial asthma, atopic dermatitis, or food allergy.
What is nonatopic asthma?
Nonatopic Asthma
(Non-allergic/intrinsic)
Viral-induced inflammation of respiratory mucosa lowers threshold of receptors to irritants
Aspirin-sensitive asthma (rhinitis, nasal polyps)
Occupational asthma
Response may occur hours later
No family history
What is atopic asthma?
Atopic Asthma
(Allergic/extrinsic)
Type-I (IgE-mediated) hypersensitivity or allergic reaction
Triggered by environmental antigens (dust, pollens, food)
Chemical mediators (histamine, cytokines, leukotrienes)
Causes acute immediate response
Family history of atopy
Role of Ige in asthma?
Ige
-trigger release of performed mediators
Mediators cuase iincreased permability, smooth muscle spasms, tissue infiltation
Is age of asthma diagnosis important?
Age at onset is important: Childhood asthma is atopic, after age 30 it is not*** on test
What is intrinsic asthma
Intrinsic Asthma
a nonseasonal, nonallergic form of asthma, which usually first occurs later in life than allergic asthma and tends to be chronic and persistent rather than episodic. Precipitating factors include inhalation of irritating pollutants, such as dust particles, smoke, aerosols, strong cooking odors, and paint fumes and other volatile substances. Intrinsic asthma may also be triggered by exposure to cold, damp weather; sudden inhalation of cold, dry air; physical exercise; violent coughing or laughing; respiratory infections, such as the common cold; or psychologic factors, such as anxiety.
What is extrinsic asthma
Extrinsic Asthma
a form of asthma caused by exposure of the bronchial mucosa to an inhaled airborne antigen. The antigen causes the production of antibodies that bind to mast cells in the bronchial tree. The mast cells then release histamine, which stimulates contraction of bronchial smooth muscle and causes mucosal edema. Hyposensitization treatments are more effective for pollen sensitivity than for allergies to house dust, animal dander, mold, and insects. Psychologic factors may provoke asthma attacks in bronchi already sensitized by antigens. Medication, including immunotherapy, can help relieve allergy symptoms. Often a diurnal pattern of histamine release occurs, causing variable degrees of bronchospasm at different times of the day. Also called atopic asthma.
ON TEST!!!!!!!!!!!!!!!!
What is cough variant asthma
Persistent cough without wheezing or dyspnea
Significant airway inflammation
Pathophysiologic features of asthma
What is a pulmonary function test?
Pulmonary function Test: what is it?
Methylcoline test is too evaluate hyper responsiveness ( healthy people wont have a response at all, only if you have asthma will you have a positive response
Primary data
“When it’s cold outside I cough and cough and I can’t catch my breath”
“My chest feels so tight, it’s hard to take a deep breath”
“My nose is constantly full or draining”
“When I catch a cold it lasts for a month”
Secondary data
Audible wheezes and ↑ RR Wheezes louder on exhalation ↑ coughing if inflammation present Longer breathing cycle requiring more effort Use of accessory muscles Barrel chest if symptoms long-term Cyanosis Tachycardia
Tertiary data
ABGs (arterial blood gases)
PaO2 ↓ during attack (normal 80-100 mmHg)
PaCO2 ↓ early during attack with ↑ RR
PaCO2 ↑ later with CO2 retention(normal 35-45 mmHg)
↑ Eosinophil and IgE levels; mucus plugs
PFTs (pulmonary function tests)*
↓ FVC (forced vital capacity)
↓ FEV1 (forced expiratory volume in 1st sec)
↓ PEF (peak expiratory flow)
What is FVC?
Forced Vital Capacity (FVC) – full inhalation to full exhalation
What is FEV1?
Forced Expiratory Volume (FEV1) - volume of air blown out as hard and fast as possible during the first second of most forceful exhalation following greatest in
What is PERF?
Peak Expiratory Rate Flow (PERF) – fastest airflow rate reached at any time during exhalation
What is a pulmonary function test?
The most accurate measures for asthma are pulmonary function tests using spirometry including:
Forced vital capacity (FVC)
Forced expiratory volume in the first second (FEV1)
Peak expiratory flow rate (PEFR)
15-20% below expected for age, gender,size
What is the most accurate test to diagnose asthma?
MOST ACCURATE TEST TO DIAGNOSIS ASTHMA (pulmonary function)
Relievers or Bronchodilators
Relaxes muscles in the airways to help relieve asthma symptoms
Should be taken as needed for symptoms
Need to wait 1-2 minutes between puffs for best deposition of medication in the lungs
Overuse is a sign indicating the asthma may not be well controlled
Relax bronchial smooth muscles, resulting in bronchodilation usually within 5 to 10 minutes of inhalation
Therapy of choice for relieving acute symptoms and preventing EIA
Overuse indicates need to evaluate and possibly increase (or start) long term control therapy
ON TEST!!!!!
EIA : exercise induced asthma
Relievers or Bronchodilators
Relaxes muscles in the airways to help relieve asthma symptoms
Should be taken as needed for symptoms
Need to wait 1-2 minutes between puffs for best deposition of medication in the lungs
Overuse is a sign indicating the asthma may not be well controlled
Relax bronchial smooth muscles, resulting in bronchodilation usually within 5 to 10 minutes of inhalation
Therapy of choice for relieving acute symptoms and preventing EIA
Overuse indicates need to evaluate and possibly increase (or start) long term control therapy
ON TEST!!!!!
EIA : exercise induced asthma
Short-acting Beta 2 Agonists Inhaled Bronchodilators 4- 6 hours
Albuterol (Proventil, Ventolin)
Levalbuterol (Xopenex)
Pirbutero (Maxair Autohaler) Biolterol (Tornalate)
Purpose
Relief of acute symptoms for acute bronchospasm or as preventive treatment prior to exercise; bind to & activate pulmonary beta2 receptors
Potential adverse effects:Tremors, tachycardia, headache
Nursing teaching: Carry at all times; monitor heart rate; take 5 minutes before other inhaled drugs; spacer; correct technique: shake, inhale & hold breath 10 sec, 1 minute between puffs (Chart 32-8)
Long-acting Beta2 Agonist Inhaled Bronchodilators 12 hours
Purpose : Relaxes bronchiolar smooth muscle; slow onset
Potential adverse effects: Tachycardia, tremors, hypokalemia
Nursing teaching: Do not use as a rescue of acute symptoms; Correct technique MDI or DPI
Relaxes bronchial smooth muscle.
Add-on therapy to inhaled corticosteroids for long term control of symptoms, especially nighttime symptoms.
Improves symptoms and reduces need for quick reliefe (reliever) meds.
MDI, DPI.
Slower onset and longer duration of action than short acting beta2 agonists (approx 12 hours)
Salmeterol- is sometimes used by itself (w/o ICS) to prevent EIA for athletes requiring long term bronchospasm relief. Eg. Long distance runners
Cholinergic Antagonist orAnticholinergic Inhaled
Meds block the parasympathetic nervous system which allows for increased
NOT INTENEDED FOR FIRST LINE THERAPY: AKA AS A RESCUE MED*
USE ONLY ONCE A DAY
Ipratropium (Atrovent) short acting
Purpose: inhibits parasympathetic nervous system allowing sympathetic system to dominate releasing norepinephrine that activates beta 2 receptors; relieves and prevents asthma–can be used as rescue several times a day when beta2 agonist not tolerated.
Potential adverse effects: blurred vision, eye pain, headache, nausea, palpitations, tremors, unable to sleep
Nursing teaching: If used as rescue, carry with; correct technique
Tiotropium (Spiriva) long-acting
Purpose/adverse effects/teaching same; Use once a day
Combination Drugs
Combivent Inhalation aerosol
(Ipratropium bromide + Albuterol)
Combivent Respimat (Ipratropium bromide +
Albuterol
Duo-Neb (Albuterol sulfate + ipratropium
bromide) inhaled solution
Possible additive benefit to inhaled beta2 agonists for severe exacerbations.
Possible alternative bronchodilator for patients who do not tolerate inhaled beta2 agonists. (Atrovent)
Drug of choice in beta blocker induced bronchospasm
Not indicated as first line therapy
Combination Drugs
Combivent Inhalation aerosol
(Ipratropium bromide + Albuterol)
Combivent Respimat (Ipratropium bromide +
Albuterol
Duo-Neb (Albuterol sulfate + ipratropium
bromide) inhaled solution
Possible additive benefit to inhaled beta2 agonists for severe exacerbations.
Possible alternative bronchodilator for patients who do not tolerate inhaled beta2 agonists. (Atrovent)
Drug of choice in beta blocker induced bronchospasm
Not indicated as first line therapy
Methylzanthines Oral
Theophylline Aminophylline Potential adverse effects Insomnia, upset stomach, hyperactivity Therapeutic issues Must monitor blood level concentrations closely Do not use as reliever Used only when other management not effective
Methylzanthines orla cont..
Produce mild to moderate bronchodilation
Add on therapy to anti inflammatory medications for long term control of symptoms, especially nighttime symptoms
Theophylline is an alternative, but not preferred, therapy for persistent asthma.
Available as tablets, Gyrocaps and syrup (Slophyllin)
Slo- bid, Theo-Dur, Theo-Dur Sprinkle, Uniphyl)
Monitoring is required to maintain serum levels between 5 and 15 mcg/ml
Febrile viral illnesses, age, certain meds (e.g. erythromycin) and diet can increase absorption and bioavailability, thereby increasing serum levels.
Adverse affects: Seizures can occur if recommended serum levels are exceeded.
Side effects increase w increasing serum levels.
“Controllers” Anti-Inflammatory Inhaled Corticosteroids
Reduces airway swelling over time, decreases airway hyper-responsiveness and inflammation
Must be taken daily, even if no symptoms
Will not relieve acute asthma symptoms
Used consistently over time will prevent/control inflammation and acute episodes
Dose/strength may need to be increased or decreased depending on season of the year (step up / step down)
Inhaled steroids start to work in days to weeks, oral steroids within 6-24 hours
“Controllers” Anti-Inflammatory Inhaled Corticosteroids cont….
Most potent and effective long term anti inflammatory medications currently available
Available as MDI and DPI
Used for management of persistent asthma at all severity levels
Broad action on inflammatory processes.
Improves symptoms and pulmonary function
Reduces the need for quick-relief medications
Fewer side effects than oral corticosteroids
Spacer/holding chamber devices w MDI’s and mouth washing after inhalation decreases local side effects and systemic absorption from the GI tract.
Need to use a spacer, wash mouth after use
IT WILL NOT ERLIEVE ACUTE ASTHMA SYMPTOMS!!
Examples of Controllers” Anti-Inflammatory Inhaled Corticosteroids
Fluticasone (Flovent MDI)
Budesonide (Pulmicort DPI or nebs)
Mometasone (Asmanex)
Purpose: decreases inflammatory and immune responses & prevent synthesis of mediators. Short term for mod. & long term for severe.
Potential adverse effects: Cough, dysphonia, thrush
Nursing teaching: Good mouth care; check mouth daily lesions; take daily
PREVENTIVE & MUST BE USED ON SCHEDULED BASIS
- Best to rinse and spit after use (if contains ICS)
- Pulmicort is DPI or Respules
HIGH POTENCY USED ONCE A DAY FOR MAINTANCE, HELPFUL IN CONTROLLING AND THUS PREVENITN G THE MANIFESTATIONS OF ASTHMA
NOT EFFECTIVE IN REVERSIIG SYMPTOMS IN AN ASTHMA ATTACK
“Controller” InhaledNonsteroidal Anti-inflammatory
Cromolyn (Intal )
Tilade (Nedocromil)
Purpose: mast cell stabilizer & prevent release of inflammatory mediators; preventive treatment triggered by inflammation or allergen exposure
Potential adverse effects: Tilade tastes bad
Nursing teaching: Must be taken up to 4 times a day, maximum benefit after 4-6 weeks; Do not use as reliever; correct technique
How do “Controller” InhaledNonsteroidal Anti-inflammatory work
HELP REDUCE NEED FOR ….MEDS
Inhaled anti-inflammatory agents.
NOT for acute exacerbations
Available as Metered dose inhaler( MDI). Cromolyn is also available as neb solution.
Alternative therapy to low-doses of inhaled corticosteroids in mild persistent asthma.
Nedocromil may also be added to inhaled ICS in moderate asthma.
Can be used to prevent symptoms to anticipated exposures (cold air, exercise (EIA), allergens) on an as needed basis.
Improves symptoms and pulmonary function
Reduces the need for quick relief medications
Good safety profiles
Nedocromil has an unpleasant taste
Leukotriene Antagonists Inhaled
Montelukast (Singulair)-block leukotriene receptor
Zafirlukast (Accolate)- block leukotriene receptor
Zileuton (Zyflo)-prevents leukotriene synthesis
Prevention of symptoms in mild persistent asthma, and/or to enable a reduction in dosage of inhaled steroids in moderate to severe persistent asthma
Potential adverse effects
None significant, elevation of liver enzymes
Therapeutic issues
Drug interactions, monitor hepatic enzymes (esp. Zyflo)
Nursing Teaching: Do not use as reliever; Do help prevent atopic asthma attack
How do Leukotriene Antagonists Inhaled work
Leukotriene receptor antagonists (eg montelukast, zafirulkast) block LTD4 receptors; 5 lipoxygenase inhibitors (block synthesis of all leukotrienes)
Tablet form
May be considered as alternative therapy to low doses ICS for mild persistent asthma.
Has been given as an added tx to ICS’s in the management of moderate persistent asthma and when given the night before exercise to prevent exercise induced bronchospasm.
Improves symptoms and pulmonary function
Reduces the need for quick relief meds
Elevated liver enzymes w/Zyflo- monitoring is highly recommended
Immunoglobulin (IgE) Blocker SQ
Omalizumab (Xolair)
Used for poorly controlled asthma or non-compliance with standard recommended therapy
Monoclonal antibodies directed against IgE molecules—when bind to IgE molecules that have allergens attached, cannot bind to mast cells and basophils preventing release of mediators.
Must have evidence of specific allergy sensitivity
Used if have high IgE blood levels
Delivered by SQ injection every 2-3 weeks
Prevent atopic asthma attacks—do not use as rescue.
Newly approved in 2003-4. Should most likely be prescribed by an allergy and or pulmonary specialist.
Used only in adolescents over 12 yrs and adults.
Not for acute exacerbations
Use in conjunction with other agents
Make them wait For 2 hours and then they will be prescribed an epi pen
Examples of Systemic Corticosteroids
Pediapred
Prelone
Prednisone
Orapred
Prevents progression of moderate to severe exacerbations, reduces inflammation
Potential adverse effects
Short-term- increased appetite, fluid retention, mood changes, facial flushing, stomachache. Long term- growth suppression, hypertension, glucose intolerance, muscle weakness, cataracts
What are Systemic Corticosteroids used for?
For use as a “reliever” medication in short-term “bursts” on a short-term basis (hospitalization) for moderate asthma
Sometimes used daily in patients with severe asthma to control symptoms
TREAT MODERATE ASTHMA; USED WHILE HOSPITALS ON A SHORT TERM BASIS
Technique for Inhaling Meds
USE BRONCHIODILATORS FIRST
WAIT 2-5 MINUTES
WASH YOUR MOUTH OUT
YOU PUT IT IN WATER, IF IT FLOATS ITS EMPTY IF IT SINKS THERES SOME IN THERE
REVIEW HPW TO USE SPACERS AND DRY POWDER INHALERS
Status asthmaticus
Status asthmaticus is a severe, life-threatening, acute episode of airway obstruction that intensifies once it begins and often does not respond to common therapy
If the condition is not reversed, the patient may develop pneumothorax and cardiac or respiratory arrest
Treatment: IV fluids, potent systemic bronchodilator, steroids, epinephrine, and oxygen
WHEN YOU DON’T HERE WHEEZING END UP TRACHING PATIENTS,
INCREASED RISK FOR AIR TRAPPING
BIGGER ET TUBE BECUAS EOF THE MUCOUS THEY NEED TO SUCTION
DON’T WANT TO INTUBATE THEM VERY OFTEN
AMGNSIUM SULFATE TO TREAT ASTHMA ATTACKS :PREVENT INTUBATION
What is COPD?
Characterized by presence of airflow obstruction
Caused by emphysema or chronic bronchitis or chronic asthma
May be accompanied by airway hyper-reactivity
Progressive
Etiology of COPD
Cigarette Smoking
Alpha1 – Antitrypsin Deficiency (Genetic)
Hereditary disorder causes 1% of cases
Serum protein produced in the liver and normally found in the lungs.
Environmental pollutants—outdoor, indoor, occupational
Respiratory infect
Age
Some degree of emphysema is common, even non-smokers
Gradual loss of elastic recoil
Etiology of COPD cont..
AAT
The proteins would protect the lungs normally.
In AAT, the neutrophils and macrophages destroy the lung tissue.
People with this type of emphysema are typically of northern European origin
Age
Some degree of emphysema is common, even non-smokers
Gradual loss of elastic recoil
Lungs become rounded and smaller
Decreased compliance of the chest wall
Increased work of breathing
Chest becomes barrel shaped in advanced COPD
True or false
Exposure to tobacco smoke is the primary cause of COPD in US
True
COPD and Cigarette smoking
Clinically significant airway obstruction develops in 15% of smokers
80% to 90% of COPD deaths in the USA are related to tobacco smoking
More than one out of every five deaths in the USA is the result of cigarette smoking
Emphysema
Loss of lung elasticity Hyperinflation of alveoli (KNOW ON TEST) Narrowed airways Destruction of alveolar walls Destruction of alveolar capillary walls Development of blebs and bullae AIR CAN GO IN BUT CANT GET OUT ON TEST Recurrent infectious process that leads to ….nuetrophils and macrophages
Chronic bronchitits
Hyperplasia of mucus-secreting glands in the trachea and bronchi
Increase in goblet cells (mucus secreting cells)
Bronchial walls thicken
Airflow and gas exchange hindered by mucus plugs, narrow airways
Path of emphysema
Emphysema
Air goes into the lungs but is unable to come out on its own and remains in the lung
Alveoli become hyperinflated and collapse
As more alveoli collapse, blebs (outer) and bullae (inner) may develop.
Look like larger air pockets
Small bronchioles become obstructed
Smooth muscle spasm
Inflammatory process
Collapse of bronchiolar walls
Recurrent infectious processes lead to increased production and stimulation of neutrophils and macrophages
Surface area for oxygen diffusion in the blood decreases
Compensation is achieved by increasing respiratory rate to increase alveolar ventilation
Hypoxia develops late in the disease
Path of Bronchitits
Bronchitis
Chronic inflammatory changes of airways causes:
Vasodilation
Congestion
Mucosal edema
Causes narrowing of airway and diminished airflow
Cough is often ineffective to remove secretions because the person cannot breathe deeply enough to cause air flow distal to the secretions.
Emphysema : death
Bullae if rupture →tension Pneumothorax (↑ air in pleural space)
Death due to compression great vessels of heart to the point of occlusion ( barrel chest, lungs getting bigger)
Bronchitis vs emphysema
Chronic bronchitis In this type, chronic bronchitis plays the major role. Chronic bronchitis is defined by excessive mucus production with airway obstruction and notable hyperplasia of mucus-producing glands. Damage to the endothelium impairs the mucociliary response that clears bacteria and mucus. Inflammation and secretions provide the obstructive component of chronic bronchitis. In contrast to emphysema, chronic bronchitis is associated with a relatively undamaged pulmonary capillary bed. Emphysema is present to a variable degree but usually is centrilobular rather than panlobular. The body responds by decreasing ventilation and increasing cardiac output. This V/Q mismatch results in rapid circulation in a poorly ventilated lung, leading to hypoxemia and polycythemia. Eventually, hypercapnia and respiratory acidosis develop, leading to pulmonary artery vasoconstriction and cor pulmonale. With the ensuing hypoxemia, polycythemia, and increased CO2 retention, these patients have signs of right heart failure and are known as “blue bloaters.” Emphysema The second major type is that in which emphysema is the primary underlying process. Emphysema is defined by destruction of airways distal to the terminal bronchiole. Physiology of emphysema involves gradual destruction of alveolar septae and of the pulmonary capillary bed, leading to decreased ability to oxygenate blood. The body compensates with lowered cardiac output and hyperventilation. This V/Q mismatch results in relatively limited blood flow through a fairly well oxygenated lung with normal blood gases and pressures in the lung, in contrast to the situation in blue bloaters. Because of low cardiac output, however, the rest of the body suffers from tissue hypoxia and pulmonary cachexia. Eventually, these patients develop muscle wasting and weight loss and are identified as “pink puffers.”
What are pink puffers and blue bloaters
KNOW ON TEST
Pink puffersWhen someone refers to a ‘pink puffer’, it means that the primary diagnosis within his or her COPD is emphysema. This is also referred to as type A COPD.
The symptoms of type A COPD include an increased respiratory rate, also called tachypneia (from the Greek for speedy breathing), causing hyperventilation, and increased redness of the skin, leading to the ‘pink puffer’ description of a sufferer. There will be less hypoxemia - lack of oxygen in the blood - than in type B, and less storage of carbon dioxide. (TYPE A COPD, TACHYPNECI, CAUSES HYPERVENTILATION AND INCREASED REDENSS IN HT ESKIN)
Blue bloatersBlue bloaters, on the other hand, suffer from type B COPD, with a primary diagnosis of chronic bronchitis. Sufferers will have had several months of coughing with sputum being produced; they may experience cyanosis (the skin going blue) related to a lack of oxygen in the blood, and swelling of the ankles and of veins. They may also develop the symptoms of right-sided heart failure.
Prognosis is notably better for sufferers of type A than type B COPD. (COUHGHING FITS, CYANOSIS, PATHOGENIC EVIDCNE AND SEVERE EMPHYSEMA)
Complications of COPD
Hypoxemia & Acidosis ↓ tissue perfusion and function Respiratory Infections ↑ mucus and poor oxygenation Cardiac Failure Cor pulmonale Cardiac Dysrhythmias From cardiac tissue ischemia
CLinical manifestations: Primary data
“I’ve smoked 1 ½ ppd for 15 years”
“My feet are often swollen”
“I’m so tired when I’m eating, it’s not worth the effort”
“I cough up thick yellow stuff for about a
half-hour every morning’
“It’s just easier to sleep in my recliner”
Clinical manifestations: Secondary data
Chronic Bronchititis: Earliest symptoms Frequent, productive cough during winter Frequent respiratory infections Bronchospasm Dyspnea on exertion History of smoking Normal weight or heavy Cyanosis
Emphysema:
Dyspnea
Minimal cough with none to small amounts of sputum
Diaphragm flattens and chest diameter increases (Barrel Chest)
Patient relies on accessory muscles
Underweight
Emphysema Progressive
Will first complain of dypsnea on exertion and later will have dyspnea with ADLs and at rest
Bronchitis Cough exacerbated by cold air and respiratory irritants
ON TEST KNOW THE DIFFERENCES!!
Clinical manifestations: tertiary data
ABG values for abnormal oxygenation, ventilation, and acid-base status Sputum samples CBC Hemoglobin and hematocrit blood tests Serum electrolyte levels Serum Alpha1-antitrypsin deficiency AAT Chest x-ray Pulmonary function test: vital capacity, forced expiratory vol. 1 sec, residual vol.
Impaired gas exchange for drug therapy
Drug Therapy (as for asthma)
Beta-adrenergics, cholinergics, mast cell stabilizers
Methylxanthines & corticosteroids (systemic)
Mucolytics to thin secretions (nebulized)
Mucomyst, Pulmozyme, Organidin (oral)
Drug therapy for COPD
Bronchodilators
Beta2-agonists: relax smooth muscle
short Salbutamol(4-6 hr); long Salmeterol(12 hr)
s/e: sinus tachycardia, dysrhytmias, tremors
Anticholinergics: block acetylcholine receptor
sites & prevent bronchcoconstriction
short Ipratropium (8 hr); long tiotropium (24 + hr)
s/e dry mouth, bitter taste
Methylxanthines: inhibit phosphodiesterase which increases cyclic adenosine monophosphate, relaxes bronchial smooth muscle, & promotes bronchodilation.
Theophylline;s/e headache,insomnia,nausea,heartburn
Glucocorticosteroids: anti-inflammatory
Limited use in stages III & IV
Risk pneumonia
Oral form my induce steroid myopathy increasing muscle weakness contributing to respiratory failure.
Chronic oxygen therapy at home
Goal: Keep O2 Sats ↑ 90% during activity Improved prognosis Improved neurophysical function Increased activity tolerance Reduced pulmonary hypertension DO NOT CHANGE FLOW RATE Call MD if confusion, ↑ sleepiness, headache NO SMOKING WHEN USING OXYGEN
. When reviewing the arterial blood gases of a patient with COPD, the nurse identifies late stage COPD with which of the following results?
1. pH 7.26, PaCO2 58 mm Hg, PaO2 60 mm Hg, HCO3 30 mEq/L 2. pH 7.30, PaCO2 45 mm Hg, PaO2 55 mm Hg, HCO3 18 mEq/L 3. pH 7.40, PaCO2 40 mm Hg, PaO2 70 mm Hg, HCO3 25 mEq/L 4. pH 7.52, PaCO2 30 mm Hg, PaO2 80 mm Hg, HCO3 35 mEq/L
pH 7.26, PaCO2 58 mm Hg, PaO2 60 mm Hg, HCO3 30 mEq/L
What is pulmonary rehabilitation?
????
What are normal blood gases?
pH 7.35 - 7.45 7.32 - 7.42
PaO2 80 to 100 mm Hg. 28 - 48 mm Hg
HCO3 22 to 26 mEq/liter
PaCO2 35-45 mm Hg
What are normal blood gases?
pH 7.35 - 7.45 7.32 - 7.42
PaO2 80 to 100 mm Hg. 28 - 48 mm Hg
HCO3 22 to 26 mEq/liter
PaCO2 35-45 mm Hg
How much alcohol can men drink vs women
Standard size drink is a 12 oz beer has 1 oz
5 oz of wine has 5 oz alchol
Less than 14 drinks in any given week for men (low risk)
High risk for men is 4 or more drinks a day or 28 drinks a week
Low risk for women is 3 or fewer a day and no more than 7 drinks a week
High risk for women is 2 drinks a day or 14 drinks a week
Men can drink more because of weight and percent of body water
Long term abuse of alcohol can lead to?
Long term abuse: high BP, complications to heart, nerve damage, pancreatitis, depression
CAGE Questions
Tried to CUT DOWN
ANNOYED by others criticizing your drinking
Felt GUILTY
EYE-OPENER (Two positives answers are indicators for alcohol problems).
What is alcohol withdrawal syndrome
Alcohol withdrawal syndrome occurs when someone who is dependent on alcohol suddenly stops drinking or rapidly decreases the amount he/she drinks.
The autonomic nervous system becomes hyperactive, resulting in many physiologic changes as the body tries to adapt.
What are the first signs of alcohol withdrawal?
Nausea and vomiting are the first signs and symptoms of alcohol withdrawal!!!!
What medications are used most often in alcohol withdrawal?
Diazepam and lorazepam used most often
What medications are used most often in alcohol withdrawal?
Diazepam and lorazepam used most often
Signs and symptoms of alcohol withdrawal
Autonomic hyperactivity (tachycardia; hypertension, sweating) Increased hand tremor Insomnia Nausea or vomiting Hallucinations or illusions(visual, auditory, tactile) Psychomotor agitation Anxiety Seizures Disorientation
Alcohol withdrawal timeframe
Minor alcohol withdrawal occurs 6-12 hours
12-24 hours the hallucinations come
24-48 hours you will see withdrawal seizures
48-72 hours the dts (disorentation, confusion, severe anxiety, hallucination, hypertension and severe tremors)
Alcohol withdrawal cont
Alcohol withdrawals may range from a mild and uncomfortable disorder to a serious, life-threatening condition.
Symptoms usually begin 6-12 hours after the last drink. The symptoms peak in 48-72 hours and may persist for a week or more.
Symptoms such as sleep changes, rapid changes in mood, and fatigue may last for 3-12 months or even longer.
Clinical Institute of Withdrawal Assessment (CIWA)
The CIWA Scale measures nine categories of symptoms on a scale of 0-7 and one symptom (clouding the sensorium) on a scale of 0-4.
Mild symptoms15.
Patients with a score of > 8 are usually treated with drug therapy to reduce the risk of seizures and delirium tremors (DT)
Random alcohol info
Notify physician if greater THAN 20 or if their experiencing DTS
Review literature and take notes
Know magnesium, potassium and phosphorous lab values!!
Need to look at creatine before giving magnesium
Number one supplement will be thiamine and folic acid
Managing physical symptoms
Management of behavioral symptoms is haladolol
What are type A symptoms
Type A Symptoms (CNS Excitation)
- Anxious, Nervous
- Restless
- Bothered by light
- Bothered by noise
What are type B symptoms
Type B Symptoms (Adrenergic Hyperactivity)
- Nausea or vomiting present
- Is a tremor visible with or without arm extended.
- Is a tongue tremor present
- Is sweat visible on palms or forehead
- Is systolic B/P > than 140
- Is diastolic B/P > than 90
- Heart rate > 100 beats per minute
Delirium tremors or DTs
Delirium tremens are the most severe form of alcohol withdrawals (48-72 hours) which are characterized by an altered mental status along with severe autonomic hyperactivity, which lead to cardiovascular collapse.
Related to the high mortality DT’s are considered an emergency
Usually 48-72 hours
See or hear things, confusion, irritability, severe trembling and seizures
DTs are considered an emergency and can lead to death I f not treated
Alcohol treatment
Treatments are individualized according to the severity of the symptoms.
Supportive care consists of fluid and electrolyte replacement, nutrition, thiamine, glucose, and multivitamins.
Medications such as benzodiazepines are the main drugs of choice, they have proven to be safe and efficient when treating withdrawals and prevention of seizures.
Common benzos used for alcohol withdrawal
- Diazepam (Valium)
- Lorazepan (Ativan)
- Librium
These medication are a class of psychoactive drugs that work to slow down the central nervous system by activating the GABA receptors
Normal AST level
AST (aspartate aminotransferace)
Normal: 5-40 IU/L
AST is an enzyme associated with liver parenchymal cells, lab values are raised in acute liver damage.
Normal ALT level
ALT (alanine aminotransferase)
Normal: 7-56 IU/L
ALT is an enzyme present in hepatocytes (liver cells), a decrease in ALT with an increase in cholesterol levels is noted in alcoholism, liver damage and, kidney infection
Normal LDH level
LDH (Lactate dehydrogenase)
Normal: 45-90 U/L
LDH, decreased levels are seen in low tissue and low organ activity
Normal ALP level
ALP (Alkaline phosphatase)
Normal: 30-120 IU/L
ALP, low levels are found in vitamin deficiencies.
True or False
An AST/ALT ratio greater than 2 is usually found in alcoholic liver disease.
True
What is (CIWAs?
??
Foods with high levels of thiamine
Thiamine: green peas, squash, asparagus, and sunflower seeds, pistachios all have thiamine in it
Foods with high levels of thiamine
Thiamine: green peas, squash, asparagus, and sunflower seeds, pistachios all have thiamine in it
What are the four categories of burn depth?
Four categories of burn depth
First degree: epidermis (sun burn)
Second degree: Dermis (scald, blistering) most painful (under blister if skin is pale that is bad)
Third degree: Full thickness entire dermis and epidermis : heals by contracture (if don’t do rom lose flexibility), needs grafting : xeno graft (pig skin)
Fourth degree: Burn into underlying structure, disfigurement, disability ( may need to amputate)
Physical therapy is huge for these people and will need it for many years
Body will not accept other people skin, has to be your own skin from areas that are not burned
True or false
Burn patients have higher incidence of skin cancer
True
True or false
All fluids rush to the area of your burn, so giving IV fluids is very important
True
Thermal and chemical burns
Adults: thermal and chemical burns
U/O 30-50 ml/hr
Adults: Hemochromogens in urine
U/O 75-100 ml/hr
What is an eshirotomy?
Eschirotomy: slit and open burn to allow for chest expansion ect…
Average stay for grafting
Average stay for grafting 7 days
Large burns patient can stay for months
What is TPA used for?
Give TPA to treat frostbite
What is a superficial burn?
Least damage; epidermis is only part of skin that is injured
Desquamation (peeling of dead skin) occurs 2 to 3 days after burn
Partial thickness burn
Involves entire epidermis and dermis (varying depths) Categorized as: Superficial Superficial partial-thickness Partial-thickness Deep partial-thickness injuries
Full thickness burn
Destruction of entire epidermis and dermis
Skin does NOT regrow
Injuries to the respiratory system from burns
Direct airway injury Carbon monoxide poisoning and cyanide Thermal injury Smoke poisoning Pulmonary fluid overload External factors
Pulmonary fluid overload
Occurs even when lung tissues have not been damaged directly
Histamine, other inflammatory mediators cause capillaries to leak fluid into pulmonary tissue space
True or false
Hypovolemic shock common cause of death in early phase in patients with serious injuries
True
Kidney/urinary ass.
Changes related to cellular debris, decreased kidney blood flow
Myoglobin released from damaged muscle, circulates to kidney
Kidney function, BUN, serum creatinine, serum sodium levels.
Urine color, odor, presence of particles/foam
What is the rule of nines?
“Rule of nines” using multiples of 9% of total BSA
GI ass. associated with burns
Changes in GI function expected
Decreased blood flow and sympathetic stimulation during early phase cause reduced GI motility, paralytic ileus
GI bleeding
Vascular chnages ass. with burns
Fluid shift: Third spacing or capillary leak syndrome, usually occurs in first 12 hr, can continue 24 to 36 hr
Profound imbalance of fluid, electrolyte, acid-base; hyperkalemia and hyponatremia levels; hemoconcentration
Fluid remobilization after 24 hr, diuretic stage begins 48 to 72 hr after injury, hyponatremia and hypokalemia
Metabolic changes with burns
Increased secretions of catecholamines, antidiuretic hormone, aldosterone, cortisol
Increased core body temperature as response to temperature regulation by hypothalamus
Acute phase of Burn Injury
Begins about 36 to 48 hr after injury; lasts until wound closure is completed
Care directed toward continued assessment and maintenance of CV and respiratory systems, as well as GI and nutritional status, burn wound care, pain control, psychosocial interventions
Rehab phase of burn injury
Begins with wound closure, ends when patient returns to highest possible level of functioning
Emphasis on psychosocial adjustment, prevention of scars and contractures, resumption of preburn activity
Rehab phase of burn injury
Begins with wound closure, ends when patient returns to highest possible level of functioning
Emphasis on psychosocial adjustment, prevention of scars and contractures, resumption of preburn activity
Emergent vs urgent
Emergent implies that a condition exists that poses an immediate threat to life or limb.
Urgent indicates the patient should be treated quickly but that an immediate threat to life does not exist
Common systemic problems associated with burns
fluid and protein loss, sepsis, changes in metabolic, endocrine, respiratory, cardiac, hematologic, immune functioning
Extent of local and systemic problems is related to what?
age, general health, extent of injury, depth of injury, specific body area injured
Extent of local and systemic problems is related to what?
age, general health, extent of injury, depth of injury, specific body area injured
Vitally important with burns wounds
Prevention of infection and closure of burn wound
What are dermal appendages?
sweat and oil glands and hair follicles
What happens when the entire dermis is destroyed?
all epithelial cells and dermal appendages are destroyed and the skin can no longer restore itself
What temp can the skin tolerate up to without injury?
104 degrees
What temp and above is cell destruction so rapid that brief exposure damages the skin and tissue below the skin
158 degrees
Depth of burn injury is measured how?
- severity determined by how much body surface is involved
- the depth
Superficial thickness
- least damage
- epidermis only part injured
- desquamation (peeling of dead skin) occurs 2-3 days after burn
- redness w mild edema
- prolonged exposure to low intensity heat or short (flash) exposure to high intensity heat
Partial thickness
involves entire epidermis and dermis (varying depths)
-superficial partial OR deep partial
Superficial partial- thickness
- injury to upper third of the dermis
- red & moist
- leaves good blood supply
- small vessels damaged-> leakage of large amounts of plasma which cause blisters
- nerve endings exposed
Deep partial thickness
- extend deep into dermis
- no blisters
- red & dry with white areas in deeper parts (dry because fewer patent blood vessels)
- blanches slowly to touch or not at all
- moderate edema
- nerve endings destroyed (less pain than superficial partial)
When deep partial thickness wounds experience infection, hypoxia, or ischemia
deep partial thickness converts to full thickness wounds
Full thickness
- destruction of entire epidermis and dermis
- skin does NOT regrow
- hard, dry, leathery eschar
- edema severe under eschar
- waxy white, deep red, yellow, brown, or black
- nerve endings destroyed
Escharotomies or fasiotomies
- incisions through the eschar
- incisions through eschar and fascia
Deep Full thickness
- extend beyond skin and into fascia and tissues
- damage bone, muscle, and tendons
- blackened, depressed, sensation absent
- excision and grafting needed
- amputation may be necessary
The nurse assesses the wound of a client burned as a result of stepping into a bathtub filled with very hot water. Which assessment finding of the burned areas on the tops of both feed does the nurse use as a bias to document a probable full thickness injury?
thrombosed blood vessels are visible beneath the skins surface
Fluid shift
- occurs after initial vasoconstriction because blood vessels near the burn dilating and leaking fluid into the interstitial space
- fluid shift w excessive weight gain occurs in first 12 hrs
third spacing or capillary leak syndrome
- continuous leak of plasma from the vascular space into the interstitial space
- usually occurs in first 12 hrs-> can continue 24-36 hr
Hemoconcentration
- elevated blood osmolarity, hematocrit, and hgb
- from vascular dehydration
- this problem increases blood viscosity, reducing flow through small vessels and increasing tissue hypoxia
Hemoconcentration
- elevated blood osmolarity, hematocrit, and hgb
- from vascular dehydration
- this problem increases blood viscosity, reducing flow through small vessels and increasing tissue hypoxia
Fluid remobilization
- starts about 24 hrs after injury when capillary leak stops
- diuretic stage starts at 48-72 hrs
- increased kidney excretion= hyponatremia/kalemia
Resuscitation: Early phase of burn injury
-24-48 hrs goals: -secure airway -support circulation (fluid replacement) -prevent infection -maintain body temperature -provide emotional support
Injuries to the respiratory system
- direct airway injury
- carbon monoxide poisoning and cyanide
- thermal injury
- smoke poisoning
- pulmonary fluid overload
- external factors
Cardiac changes
- heart rate increases and CO decreases
- CO increases with fluid resuscitation
Respiratory failure r/t burn injury
- airway edema during fluid resuscitation
- pulmonary capillary leak
- chest burns that restrict chest movement
- carbon monoxide poisoning
Reflex closure of vocal cords
-protective reflex reduces the entry of smoke and toxic gases into the lungs
Pulmonary fluid overload
- occurs even when lung tissues have not been damaged directly
- histamine, other inflammatory mediators cause capillaries to leak fluid into pulmonary tissue space
Cardiovascular Assessment
- hypovolemic shock common cause of death in early phase in pts with serious injuries
- vital signs
- cardiac status, especially in cases of electrical burn injuries
- noninvasive BP readings inaccurate in pts with large burns involving upper extremities
What happens when the lining of the trachea and bronchi slough w/in 48-72 hrs
-obstructs the lower airways
Leaking capillaries cause alveolar edema
- this edema can occur immediately or as late as 1 week after the injury
- fluid that diffuses into the lung tissue spaces contains proteins that form fibrinous membranes and lead to resp distress
GI changes
- GI has decreased blood flow
- paralytic ileus may develop
- secretions and gases collect in intestines causing abdominal distention
GI changes
- GI has decreased blood flow
- paralytic ileus may develop
- secretions and gases collect in intestines causing abdominal distention
Curling’s Injury
acute gastroduodenal ulcer that occurs with the stress of severe injury
- may develop 24 hrs after a severe burn b/c reduced blood flow to GI and mucosal damage
- hydrogen ion reason
metabolic changes
- increases metabolism by increasing secretion of catecholamines, antidiuretic hormone, aldosterone, and cortisol
- O2 use and cal needs are high
Temperature change in burn pts
- pts are hypermetabolic which increases body core temp but pts loses the heat through the burned area
- core body temp “resets” to a higher baseline
- low grade fever
- regulation by hypothalamus
Kidney/Urinary Assessment
- changes related to cellular debris, decreased kidney blood flow
- myoglobin released from damaged muscle, circulates to kidney
- destroyed RBC release hgb and k
- kidney function, BUN, serum creatinine, serum sodium levels
- urine color, odor, presence of particles/foam
Which assessment does the nurse perform first on the client just admitted after an electrical injury with contact sites on the left hand and left foot?
electrocardiography
Skin Assessment
- Size and depth of injury
- percentage of total BSA affected
- “rule of nines” using multiples of 9% of total BSA
The client who tripped while carrying an open kettle of hot water received scald burns to the entire chest, entire anterior section of the right arm, the right half of the abdomen, and the anterior portion of the right leg from the groin to the knee. At what percentage of total body surface area does the nurse calculate the injury using the rule of nines?
22-23%
chest: 18%
right arm anterior: 4.5
right half of abd: 2
right leg groin to knee: 4.5
GI assessment
- changes in GI function expected
- decreased blood flow and sympathetic stiumulation during early phase cause reduced GI motility, paralytic ileus
- GI bleeding
- ausculate for bowel sounds: commonly reduced or absent with severe burns
- test for occult blood on any vomit or stool
- check NG for coffee ground appearance (digested blood)
paralytic ileus manifestations
-nausea, vomiting, abdominal distention
Compensatory Response to burn injury
- inflammatory compensation can trigger healing
- SNS compensation occurs when any physical or psychological stressors are present
Nonsurgical Management of Burns
- IV fluids
- monitoring patient response to fluid therapy
- drug therapy
Dry heat injuries
- caused by open flame
- house fires and explosions
Moist heath (scald) injuries
- caused by contact with hot liquids or steam
- more common among older adults than among younger adults
- hot liquid-> front areas of body
- immersion scald-> lower body
contact burns
- occur when hot metal, tar, or grease contacts the skin often leading to a full thickness injury
- hot grease injuries
chemical burns
- severity depends on duration of contact, concentration of chemical, amount of tissue exposed, and action of the chemical
- if dry chemicals DO NOT WET THEM
- brush off any dry chemicals present on skin or clothing and remove pts clothing
- do not attempt to neutralize chemical unless known for sure
Electrical injries
- “grand masquerader”
- course of flow defined by locations of the contact sites (entrance and exit wounds)
- initiate CPR
- obtain ECG (electrical current is **ed in heart)
Radiation burns
- remove the pt from the radiation source
- it pt has been exposed to radiation from an unsealed sources, remove clothing with PPE
- it pt has radioactive particles on the skin send pt to nearest designated radiation decontamination center
- help pt bathe or shower
Radiation burns
- remove the pt from the radiation source
- it pt has been exposed to radiation from an unsealed sources, remove clothing with PPE
- it pt has radioactive particles on the skin send pt to nearest designated radiation decontamination center
- help pt bathe or shower
General Management for all types of burns
- assess for airway patency
- administer oxygen PRN
- cover pt with blanket
- keep pt NPO
- elevate the extremities if no fractures are obvious
- vital signs
- initiate an IV line and begin fluid replacement
- administer tetanus toxoid for prophylaxis
- perform a head to toe assessment
Factors that increase risk of death with burn injury
older than 60 yrs
- burn greater than 40% TBSA
- presence of inhalation injury
- if pt has all 3 factors then risk for death is very high
goals of resuscitation phase
1) secure airway
2) support circulation by fluid replacement
3) keep pt comfortable with analgesics
4) prevent infection through careful wound care
5) maintain body temp
6) provide emotional support
dry weight
pts weight before injury and before the edema occurred.
Age related changes increasing complications from burn injury
- thinner skin, sensory impairment, decreased mobility
- slower healing time
- more likely to have cardiac impairments
- reduced inflammatory and immune responses
- reduced thoracic and pulmonary compliance
- more likely to have preexisting med conditions (diabetes, kidney impairment, pulmonary impairment)
Factors determining inhalation injury or airway obstruction
- pts who were injured in a closed space
- pts with extensive burns or with burns of the face
- intra oral charcoal, especially on teeth and gums
- pts who were unconscious at the time of injury
- pts with singed scalp hair, nasal hairs, eyelids or eyelashes
- pts who are cough up carbonaceous sputum
- changes in voice such as hoarseness or brassy cough
- use of accessory muscles or stridor
- poor oxygenation or ventilation
- edema, erythema, and ulceration of airway mucosa
- wheezing, bronchospasm
CRITICAL RESCUE: burn pt in the resuscitation phase who is hoarse, brassy cough, drools or has difficulty swallowing, produces an audible breath sound on exhalation…
-immediately apply oxygen and notify the rapid response team
If wheezing sounds disappear..
Intubate immediately!
Carbon Monoxide Level:
1%-10% normal
increased threshold to visual stimuli, Increased blood flow to vital organs
Carbon Monoxide Level:
11%-20% mild poisoning
headache
decreased cerebral function
decreased visual acuity
slight breathlessness
Carbon Monoxide Level:
21%-40% moderate poisoning
headache tinnitus nausea drowsiness vertigo altered mental state confusion stupor irritability decreased blood pressure (increased and irregular hr) depressed ST segment on ECG and dysrhythmias pale to reddish purple skin
Carbon Monoxide Level:
41%-60% severe poisoning
coma
convulsions
cardiopulmonary instability
Carbon Monoxide Level:
61%-80% fatal poisoning
death
What creates the cherry red color? Or at least the absence of cyanosis with CO pts?
Carbon monoxide has a vasodilating
Thermal (heat) injury
Heat damage of the pharynx is often severe enough to produce edema and upper airway obstruction, espeically epiglottitis. The problem can occur any time during resuscitation. In the unresusciatated pt, supraglottic edema may be delayed because of the dehydration that occurs with hypovolemia. During fluid resusciation, the tissues rehydrate and then swell. When it is known that the upper airways were exposed to heat, intubation may be performed as an early intervention before obstruction occurs.
SAFETY PRIORITY: ACTION ALERT
when intubation has not been performed in a pt whose upper airways were exposed to heat or toxic gases, continually assess the upper airway for recognition of edema and obstruction
CRITICAL RESCUE: pulmonary edema
when symptoms of pulmonary edema are present, elevate the head of the bed to at least 45 degrees, apply humidified oxygen, and notify the burn team or the rapid response team
CRITICAL RESCUE: pulmonary edema
when symptoms of pulmonary edema are present, elevate the head of the bed to at least 45 degrees, apply humidified oxygen, and notify the burn team or the rapid response team
Lab Values during resuscitation phase
- elevated hgb, hct, urea, glucose, k, chloride
- decreased na, total protein, albumin
Upper airway edema
becomes pronounced 8 to 12 hours after the beginning of fluid resuscitation. These pts often require nasal or oral intubation if crowing, stridor, or dyspnea is present
Cyanide poisoning
may occur in pts burned in house fires. An elevated plasma lactate level is one indicator of cyanide toxicity.
Pt and increased activity during mechanical ventilation
- use of paralytic drug may be necessary
- atracurium (tracrium) or vecuronium (norcuron)
- removes all breathing control from pt
- pt can still see, hear, fear, pain.. must also give sedation, analgesia, and antianxiety unless contraindicated
Most common and most sensitive noninvasive assessment parameter for cardiac output and tissue perfusion
urine output
Amount of fluid given depends on how much IV fluid per hour is needed to maintain the hourly urine output of what?
30 ml/hr
titration of fluid
adjustment of the IV fluid rate on the basis of urine output plus serum electrolyte values
use of diuretics
not typically used in burn pts because we need to give fluids, not take fluids out
-electric burns: muscle and deep tissue damage release large protein molecules (myoglobin) which precipitate in and obstruct the renal tubules (manniotol {osmitrol})
Considerations for older adults and fluid resuscitation
in OA, especially with cardiac disease, a complicating factor may be heart failure or myocardial infarction. Drugs that increase cardiac output (dopamine- Intropin) or that strengthen the force of myocardial contraction (digoxin- lanoxin) may be used along with fluid therapy
Drug therapy for pain management
- opioid analgesics ( morphine, hydromorphone, fentanyl)
- non-opioid analgesics
- these meds do not provide complete relief
- cause resp depression and reduce intestinal motility
- nonpharmacologic interventions needed
Opioids for pain during resuscitation phase
-only given by IV
Acute Phase of Burn Injury
- begins about 36 to 48 hrs after injury; lasts until wound closure is completed
- care directed toward continued assessment and maintenance of CV and respiratory systems, as well as GI and nutritional status, burn wound care, pain control, psychosocial interventions
Cardiopulmonary assessment
priority assessment is cardio and respiratory
-pt may develop pneumonia
Neuro-endocrine assessment
- increased metabolic demands placed on body after severe burn injury depletes body’s nutritional stores
- 2% loss of body weight indicates a mild deficit
- VCO2 taken while pt is at rest (indirect calorimetry)
Immune Assessment
- infection is the leading cause of death during the acute phase of recovery
- assess for wound appearance changes
Musculoskeletal Assessment
result of other injuries, immobility, healing processes, and treatment
Debridement
priority nursing intervention include assessing the wound, providing wound care, and preventing infection and other complications
Mechanical Debridement
- hydrotherapy the application of water for treatment
- showering pt on a specially designed table or washing small areas at bedside
- mild soap or detergent water
Enzymatic debridement
can occur naturally by autolysis or artifically by the application of exogenous agents
-autolysis or collagenase
autolysis
disintegration of tissue by the action of the pts own cellular enzymes
collagenase (santyl)
- topical enzyme
- used for rapid wound debridement
- enzyme digest collagen in necrotic tissues
Dressing the burn wound
- standard wound dressing
- depends on:
- depth of injury
- amount of drainage expected
- area injured
- pts mobility
- frequency of dressing changes
Biologic dressings
- Homograft—human skin (allografts)
- Heterograft—skin from other species (xenografts)
- Amniotic membrane
- Cultured skin: grow in lab
- Artificial skin
Biosynthetic wound dressing
- combo of biosynthetic and synthetic materials
- biobrane is commonly used and effective with clean of superficial partial thickness
Synthetic
- solid silicone and plastic membranes
- pain is reduced at site cause agents cover nerve endings from air
- faster healing with low infection rates, minimal pain, reduced costs
Surgical Excision
- most common treatment for full thickness and deep partial thickness wounds
- bleeding indicates healthy tissue
Wound covering
- skin graft
- may have repeated removla of skin from the same donor site
- meshing the split thickness skin grafts to allow a small graft to cover a large area
Common burn wound infefction
- occurs through auto-contamination: pts own flora overgrows and invades other body areas
- cross-contamination: organisms from other ppl or environments are transferred to the pt
Common burn wound infefction
- occurs through auto-contamination: pts own flora overgrows and invades other body areas
- cross-contamination: organisms from other ppl or environments are transferred to the pt
Priority nursing dx during wound healing
*using principles of asepsis to prevent infection transmission, providing a safe environment, and monitoring for early detection of infection
Clostridium tetani
- burn wound conditions promote growth of this dangerous infection
- tetanus is recommended
topical agents (infection prevention)
Silvadene, flamazine, sulfamylon
-topicals not applied to freshly grafted areas because they may inhibit cell growth
Drug therapy for treatment of Infection
- systemic antibiotics used when burn pts have symptoms of actual infection
- because of increased metabolism pts may have higher dose of these drugs
- for some antimicrobials, serial peak and trough blood levels are monitored to determine the efficacy and evaluate potential ear and kidney toxicity
Providing a safe environment
- may include isolation therapy
- involves coordinating all members of health care team w/ use of asepsis
- monitor for early recognition of actual infection
Isolation therapy
- belief it reduces cross contamination
- controversial
- all isolation methods use proper and consistence hand washing as the most effective technique for preventing infection transmission
GLOVES
- change gloves when handling different wounds on different parts of the body
- clean gloves vs sterile depends on facility
Psuedomonas
- have been found in plants so they are prohibited
- some units may not allow pts to ear raw foods (salads, fruit, peppers)
- rugs and upholstered articles harbor organisms and not allowed
Early detection of infection at wound site
- pervasive odor
- color changes (focal, dark red, brown discoloration in the eschar)
- change in texture
- purulent drainage
- exudate
- sloughing grafts
- redness at the wound edges extending to nonburned skin
Quantitative biopsies of eschar and granulation tissue
- performed routinely and as needed to monitor growth of organisms
- lab cultures and biopsies recommended
Surgical management of infected burn wounds
- infected burn wounds with colony counts of or approaching 10(exponent 5) colonies per gram of tissue may be life threatening even with antibiotic therapy
- surgical excision of the burn wound may be necessary
ABGs (arterial blood gases) in asthma attack
PaO2 ↓ during attack (normal 80-100 mmHg)
PaCO2 ↓ early during attack with ↑ RR
PaCO2 ↑ later with CO2 retention(normal 35-45 mmHg)
Esoiniphils in asthma attack
↑ Eosinophil and IgE levels; mucus plugs
PFTs (pulmonary function tests)* in asthma attack
↓ FVC (forced vital capacity)
↓ FEV1 (forced expiratory volume in 1st sec)
↓ PEF (peak expiratory flow)
Short-acting Beta 2 Agonists Inhaled Bronchodilators 4-6 hours
- Albuterol (Proventil, Ventolin)
- Levalbuterol (Xopenex)
- Pirbutero (Maxair Autohaler) Biolterol (Tornalate)
Short-acting Beta 2 Agonists Inhaled Bronchodilators 4-6 hours: PURPOSE
Relief of acute symptoms for acute bronchospasm or as preventive treatment prior to exercise; bind to & activate pulmonary beta2 receptors
Long-acting Beta 2 agonist inhaled bronchodilators 12 hours
Salmeterol (serevent)
Long-acting Beta 2 agonist inhaled bronchodilators 12 hours: PURPOSE
Relaxes bronchiolar smooth muscle; slow onset
Long-acting Beta 2 agonist inhaled bronchodilators 12 hours: NURSE TEACHING
Long-acting Beta 2 agonist inhaled bronchodilators 12 hours: NURSE TEACHING Do not use as a rescue of acute symptoms; Correct technique MDI or DPI
Cholinergic Antagonist or Anticholinergic Inhaled: short acting
Ipratropium (Atrovent) short acting
Cholinergic Antagonist or Anticholinergic Inhaled: PURPOSE
inhibits parasympathetic nervous system allowing sympathetic system to dominate releasing norepinephrine that activates beta 2 receptors; relieves and prevents asthma–can be used as rescue several times a day when beta2 agonist not tolerated
Cholinergic Antagonist or Anticholinergic Inhaled: long acting
tiotropium (spirival)
Possible alternative bronchodilator for patients who do not tolerate inhaled beta2 agonists
Atrovent
Methylzanthines Oral: meds
Theophylline
Aminophylline
-added therapy to anti inflammatory meds for long term control of symptoms; especially nighttime symptoms
Methylzanthines Oral: THERAPEUTIC ISSUES
- Must monitor blood level concentrations closely
- Do not use as reliever
- Used only when other management not effective
Methylzanthines Oral: When is this the chosen med?
used for management when pt not responsive to other forms of treatment
Methylzanthines Oral: What monitoring is necessary? -monitoring required to maintain serum levels between 5 and 15 mcg/ml
-seizures can occur with increasing serum levels
“controllers” anti-inflammatory inhaled corticosteroids
“controllers” anti-inflammatory inhaled corticosteroids -fluticasone (flovent MDI)
- budesonide (pulmicort DPI or nebs)
- mometasone (asmanex)
“Controller” Inhaled Nonsteroidal Anti-inflammatory: MEDS
“Controller” Inhaled Nonsteroidal Anti-inflammatory: MEDS Cromolyn (intal)
Tilade (nedocromil)
Leukotriene Antagonists Inhaled: MEDS; block leukotriene receptor
- Montelukast (singulair)
- Zafirlukast (accolate)
Leukotriene Antagonists Inhaled: MEDS; prevents leukotriene synthesis
Zileuton (zyflo)
LIVER ENZYMES
Immunoglobulin (IgE) Blocker SQ: MED
Omalizumab (xolair)
Immunoglobulin (IgE) Blocker SQ: PURPOSE
used for poorly controlled asthma or non-compliance with standard recommended therapy
blue bloaters
chronic bronchitis
- have signs of right side heart failure
- type B COPD with primary dx of chronic bronchitis
- worse than A
- chronic carbon retention
pink puffers
pink puffers -primary dx within COPD is emphysema
- type A COPD
- increased resp rate, tachypnea, hyperventilation, increased redness of skin
- less hypoxemia
Complications of COPD
hypoxemia and acidosis (decrease tissue perfusion and function)
- respiratory infections (increase mucus and poor oxygenation)
- cardiac failure (cor pulmonale)
- cardiac dysrhythmias (from cardiac tissue ischemia)
emphysmea: defining symptoms (secondary data)
- dyspnea
- underweight
- relies on accessory muscles
- barrel chest
- no sputum
- minimum cough
- progressive
chronic bronchitis (secondary data)
- productive cough
- resp infections
- bronchospasm
- dyspnea on exertion
- hx of smoking
- normal weight to heavy
- cyanosis
- cough exacerbated by cold air and irritants
