Final Exam Module 7 & 8 Flashcards
What condition?
Genetic hemoglobin disorder; formation of abnormal hemoglobin chains. Autosomal recessive pattern of inheritance.
Patho: Clumps block flow (vaso-occlusive event) causing tissue to become hypoxic. Results in inadequate perfusion and ischemia
Sickle cell crisis
Conditions that may cause sickling
hypoxia, dehydration, infection, venous stasis, pregnancy, alcohol consumption, nicotine use, high altitudes, acidosis, strenuous exercise, emotional stress, anesthesia, low/high environmental or body temperature
Important to understand the s/sx of sickle cell crisis and to prioritize which one(s) are of most concern!
Pain and reduced perfusion
**Pain is the most common SCD crisis symptom
Cardiovascular changes
Murmurs, JVD, peripheral pulses, capillary refill. Signs of decreased perfusion?
Respiratory changes
Risk for recurrent pneumonia, pulmonary HTN; assess for shortness of breath
Skin changes
Pallor, cyanosis (lips, nail beds), etc.
Lower extremity ulcers > may become infected and necrotic
Abdominal changes
Damage to spleen and/or liver > enlargement; jaundice
Kidney and urinary changes
Decreased urine output? Risk for chronic kidney disease
Musculoskeletal changes
Joint pain; assess range of motion and pain with movement
Central nervous system changes
Seizures, stroke-like symptoms
Potential complications r/t Sickle cell crisis
-Infection
-Chronic Kidney Disease
-Necrotic Ulcers on LE
-Acute Chest Syndrome (common reason for hospitalization & most common cause of death)
-Respiratory infection or embolism
It is important to know the treatment options for managing pain in a sickle cell patient. Which pain management intervention is the better option?
Remember- SCD patients face a lot of healthcare stigma
-IV Analgesia – typically Morphine or Dilaudid for 48 hours via PCA
-Oral opiates or NSAIDS for moderate pain
-Integrative therapies: keeping room temp. warm, distraction and relaxation, aromatherapy, warm soaks and compresses
-Hydroxyurea: stimulates fetal hemoglobin production (long term risk for leukemia)
-Endari: delays and decreases complications of SCD. Composed of amino acid glutamine (lowers oxidative stress and decreases sickling rates)
-Crizanlizumab: monoclonal antibody that inhibits selection. Prevents adhesion and vaso-occlusive crises.
Why should we nebulize O2 when providing oxygen to SCD patients?
prevent dehydration
What antibiotic is used to prevent infection in SCD patients?
This antibiotic decreases the number of pneumonia and streptococcal infections.
Penicillin BID
SCD- Things to remember regarding transfusions
-Increased HbA levels and dilutes HbS levels
-Risk for iron overload with repeat transfusion
-Assess for transfusion reactions
What condition?
Destructive reduction of circulating platelets after normal platelet production
Thrombocytopenia
What are the three types of thrombocytopenia?
Autoimmune thrombocytopenia purpura (ATP)
Thrombotic thrombocytopenia purpura (TTP)
Heparin-induced thrombocytopenia (HIT)
What type of thrombocytopenia?
Antibodies are produced against platelets, then platelets are destroyed by macrophages in the spleen. Platelet production still occurs but may not be able to keep up with the number of platelets being destroyed.
Clotting impaired with decreased number of platelets
Autoimmune thrombocytopenia purpura (ATP)
Important to understand the medications used to treat ATP and why they are being used.
Treatment is initiated with platelet counts less than 50,000, active bleeding, or high risk for bleeding.
Main MOA is immunosuppression
-Corticosteroids
-Azathioprine (DMARD)
-Eltrombopag
-Rituximab
-Romiplostim
ATP complications include:
hemorrhage and intracranial bleeding-induced stroke
Surgical management for ATP?
splenectomy for pts who do not respond to drug therapy
Spleen is site of excessive platelet destruction
What type of thrombocytopenia?
Abnormality of platelet clumping during trauma or surgery. Caused by autoimmune reaction in small blood vessels that starts platelet clotting and aggregation at the endothelial cells. Clots and platelet plugs formed where not needed, and failure to clot at site of trauma. Tissue becomes ischemic leading to kidney failure, MI, and stroke.
Thrombotic thrombocytopenia purpura (TTP)
Drug therapy used for TTP
Antiplatelets (aspirin, alprostadil, plicamycin) and immunosuppressive therapy
How do we manage TTP?
Prevent platelet clumping and stopping the autoimmune process- plasma removal and FFP.
If TTP is left untreated it is fatal within 3 months.
What type of thrombocytopenia?
Potentially devastating immune-mediated adverse drug reaction caused by the emergence of antibodies that activate platelets in the presence of heparin. Can occur in patients receiving any type of heparin, although it is more common after exposure to unfractionated heparin.
Heparin-induced thrombocytopenia (HIT)
Higher incidence of HIT among patients with risk factors of:
-Duration of heparin use longer than one week
-Exposure to unfractionated heparin
-Postsurgical thromboprophylaxis
-Being female
S/sx of HIT
venous thromboembolism (VTE) such as DVT and PE
What is the hallmark sign of HIT? What labs are important to monitor?
Thrombocytopenia after heparin exposure.
Important to monitor pt’s platelet levels when they are on heparin therapy. A drastic drop in platelets is a RED FLAG and a can’t miss!
Drug management for HIT is focused on direct thrombin inhibitor. What meds are used?
argatroban (Acova) and lepirudin (Refludan)
HIT cues to watch out for?
large bruises, mucosal bleeding, petechial rash, and anemia
What type of transfusion?
Replaces cells lost form trauma or surgery. Donor and recipient must be assessed for compatibility.
RBC transfusion
What type of transfusion?
Given for low platelet counts (less than 10,000), active bleeding episode, or scheduled invasive procedure.
May be from multiple donors. Do not have to be from a donor with the same blood type. Must be immediately transfused once brought into the room & over 15-30 minute period of time.
Platelet transfusion
What type of transfusion?
Replaces blood volume and clotting factors.
May be given fresh, but is often frozen after donation.
Infuse immediately after thawing (clotting factors still active). Infuse rapidly over 30-60 minutes.
Plasma transfusions
What type of transfusion is given to neutropenic clients? Requires strict monitoring due to reaction rate being high.
Granulocyte (WBC) transfusion
What type of transfusion?
Given when H&H levels are low from trauma situation or other active bleed.
Massive transfusion
Active Transfusion Reactions
It is important to understand what an acute transfusion reaction looks like and what to do if the patient experiences a reaction!
Febrile – chills, fever, tachycardia, hypotension, and tachypnea
-Occurs in people with anti-WBC antibodies
-Leukocyte-reduce blood reduces risk
Hemolytic
-Blood type or Rh incompatibility
-Antigen-antibody complexes initiate inflammatory response
-May be mild (fever or chills; or severe (DIC)
Allergic – itching, bronchospasm, or anaphylaxis
-Experienced in individuals with multiple allergies
Bacterial – tachycardia, hypotension, fever, chills, and shock
-Contaminated blood products
Circulatory overload – HTN, bounding pulse, JVD, dyspnea, restlessness, and confusion
-Whole blood or multiple transfusions
Transfusion-associated graft-versus-host disease (TA-GVHD)
-Rare, but serious in immunocompromised individuals
-Thrombocytopenia, anorexia, n/v
Interventions, if transfusion reaction occurs
-Immediately stop the transfusion and disconnect the tubing
-Initiate Rapid Response team
-Notify blood bank
-Often blood products are returned for evaluation
-Flush IV site with NS
-Apply oxygen
-IV push diphenhydramine
-Assess vitals and need for hemodynamic monitoring
What do you do FIRST if there is a transfusion reaction?
STOP THE INFUSION
What condition?
A serious disorder in which proteins that control blood clotting become overactive. The underlying cause is usually due to inflammation, infection, or cancer.
Disseminated Intravascular Coagulation (DIC)
Most common cause of DIC? Other causes?
Sepsis is the most common cause.
Other causes: pancreatitis, severe burns, trauma or major surgery, cancer, pregnancy complications, blood transfusion reaction, organ transplant reaction, & snake bites
It is important to understand what DIC looks like & red flags
Assessment:
Skin- rash of small purplish spots or red spots, bruising
Acute renal failure, bleeding, blood clots, bruising, liver failure, mental confusion, or respiratory distress
What labs would be ordered for DIC?
CBC, PT/INR, PTT, Fibrinogen level, D-dimer to assess for blood clots
DIC Tx includes:
-Must treat underlying condition
-Plasma transfusion to reduce bleeding (usually FFP)
-PRBC and/or platelet transfusions
-Anticoagulant medication to release clothing factors
-Cryoprecipitate- prepared from plasma and contains fibrinogen, von Willebrand factor, factor VIII, factor XIII, and fibronectin. Only adequate fibrinogen concentrate available for IV use.
What condition?
Infection in bony tissue. Caused by bacteria, virus, parasites, or fungi
Osteomyelitis
It is important to know the s/sx of Osteomyelitis
-Bone pain- constant and localized
-Fever- greater than 101
-Erythema, tenderness, edema, and heat in the area of the infected bone
-Elevated WBC count
Osteomyelitis: MRI and radionuclide scans to evaluate extent of infection to surrounding soft tissue. MRI contraindications?
Consult with the provider if contraindications are present.
Antibiotic therapy key points for Osteomyelitis
-4-6 weeks IV antibiotic therapy (acute cases)
-Prolonged therapy >3 months (chronic cases)
Requires PICC line
-History of IV drug use? If so, patient will need skilled nursing facility to complete therapy.
Break or disruption in continuity of bone that affects mobility and comfort
Fractures
How to manage acute pain caused by fractures
-Opioid analgesics (oxycodone, oxycodone with acetaminophen, or oxycodone with hydrocodone), anti-inflammatory drugs, muscle relaxants
-Possible Patient-controlled analgesia (PCA)- morphine, fentanyl, or hydromorphone (Dilaudid) for severe and/or multiple fractures
Nonsurgical management for fractures include:
closed reduction and immobilization (most common), splints, orthopedic boots/shoes, casts, traction, drug therapy, and physical therapy
When a hard cast is applied, it is important to …
report any increased pain or numbness, regularly elevate the cast above the level of the heart to promote venous return, never get the cast wet, and continue to move fingers/toes
Surgical management: open reduction with internal fixation (ORIF) and external fixation with closed reduction (chosen for open fractures and involvement of soft tissue injuries)
Preop and post op care for these procedures include:
Preop care: regional nerve blockage
Postop care: Ketorolac (Toradol) to treat inflammation & pain, early ambulation
Stages of Bone Healing
Stage 1: hematoma forms at site of fracture 24-72 hours after injury
Stage 2: 3 days to 2 weeks, granulation tissue invades the hematoma > formation of fibrocartilage (foundation for healing)
Stage 3: vascular and cellular proliferation > callus formed by new vascular tissue.
Stage 4: callus is gradually resorbed and transformed into bone
Stage 5: final stage – consolidation and remodeling of bone. May be around 4-6 weeks after fracture, may continue up to one year
Complications r/t fractures:
Acute Compartment Syndrome
Crush Syndrome- kidney damage & MODS caused by the release of electrolytes and proteins into blood
Hemorrhage –> hypovolemic shock
Fat embolism syndrome
Venous thromboembolism
Infection- osteomyelitis
Avascular necrosis
Delayed bone healing
Complex regional pain syndrome
Compartment syndrome is a complication r/t fractures. Increased pressure leads to reduced circulation to the area.
What is the surgical management?
fasciotomy
Fat embolism is a serious complication r/t fractures. Fat from bone marrow is released into blood stream.
Hallmark sx? Other sx?
Hallmark sx: petechia on chest
Other sx: hypoxemia, dyspnea, and tachypnea
Performing neurovascular assessments prior to fracture treatment is PRIORITY. What are the 6 P’s?
6 P’s of fractures- Pain (even after analgesics are given), Paresthesia, Pressure, Paralysis, Pallor, and Pulselessness
Rib or sternum fracture, assess
ABC’s
Pelvis fractures, assess
for internal injuries.
Pelvic region is highly vascularized.
What type of traction?
-Includes use of Velcro boot (Buck’s traction), belt, or halter
-Used to decrease painful muscle spasms related to hip and proximal femur fractures
Skin traction
What type of traction?
-Screws surgically inserted directly into the bone
aids in bone realignment, but impairs mobility
-Major risks- skin integrity and infection
Skeletal traction
Traction- if pt experiences extreme pain, what should RN do?
-Assess that weights match prescriber’s orders
-Assess alignment- it is important to keep ropes and pulleys in straight alignment
-Weight may be too heavy
-Assess patient and equipment, medicate pt, and notify provider if pain relief is not achieved
-Monitor circulation q1h for first 24 hrs after applying traction, then usually q4h
Most elective amputations are r/t
perfusion complications (PVD, arteriosclerosis, DM)
Complications r/t amputations
-hemorrhage & hypovolemic shock
-infection
-phantom limb pain: usually subsides over time
-neuroma: tumor consisting of damaged nerve cells, common in UE
-flexion contractures of the knee and hip
Is phantom limb pain real?
Phantom limb pain is REAL PAIN and it should be treated as such. Validate the patient’s concerns.
Why must flexion contractures be avoided?
Must avoid this complication so that individuals can properly use prosthetic device
Interventions to prevent flexion contractures
Active ROM exercises, proper positioning
-Keep the patient’s residual limb raised on one to two pillows for ONLY the first 24 hours after surgery. This helps decrease swelling.
-After the first day, keep the residual limb flat on the bed to prevent the hip from tightening & having a contracture
It is important to understand planning and implementation for a patient that has an amputation
-Monitoring for decreased tissue perfusion
-Managing acute and/or chronic pain
-Promoting mobility
-Preventing infection
-Promoting self-esteem
Common method of wrapping amputation stump is figure eight wrapping. This method prevents
restriction of blood flow
Trauma may also result in cartilage, ligament, and tendon injuries. Largely related to sports injuries and strenuous physical activities.
Assume and treat as if there is a fracture until confirmed. Assess neurovascular status distal to the injury.
Knee injuries
RICE stands for?
-Rest and immobilize the joint above and below the injury
-Ice for the first 24-48 hours (may incorporate heat after)
-Compression for the first 24-48 hours (ACE wrap)
-Elevate to decrease swelling
Surgery may be required to repair the injured joint. Arthroscopy is often preferred, when possible.
Post op care includes:
Analgesics- NSAIDs and opioids
Physical therapy
Bracing/splinting
Neurovascular assessments frequently
It is important to understand the nurse’s role in death, dying, and end of life care.
Nurses can have a great impact on an adult’s experience w/ death.
-Preventing death w/o dignity
-Promoting a peaceful, meaningful death
-Helping patient remain free from distress
-Minimizing suffering for patient and family
-Observe patients’ and families’ wishes
-Observe clinical practice standards
If the patient’s family is in conflict, refer for palliative care consult. Goal of palliative care is to
improve the quality of life for patient and family. Assists with informed decision making & high quality symptom management.
What one wants, or does not want, if near death (CPR, nutrition and hydration, and artificial ventilation
Living will
True or False
CPR must be done if a DNR is not in place
True
End of Life - Physical Sx
-Sx of distress (respiratory distress, hemorrhage, pain)
-Weakness
-Sleeping more
-Anorexia
-Changes in organ system function
-LOC
-Changes in vital signs
EOL- If patient becomes restless, assess
the patient for pain, provide ordered IV analgesics, and promote comfort
Post-Mortem care includes:
NEVER remove tubes, lines, and devices. They must remain in place through the autopsy!
Triage nurse in the ED is the gatekeeper. “Triage means to
sort
Patient has immediate threat to life or limb, and requires immediate treatment
Emergent, Urgent, or Non-emergent?
Emergent
Conditions classified as Emergent
Respiratory distress, chest pain with diaphoresis, stroke, active hemorrhage, unstable vital signs
Patient should be treated quickly but immediate threat to life does not exist at the moment
Emergent, Urgent, or Non-emergent?
Urgent
Conditions classified as Urgent
Severe abdominal pain, renal colic, displaced and/or multiple fractures, complex or multiple soft tissue injuries
Patient can usually wait several hours for care without significant risk.
Emergent, Urgent, or Non-emergent?
Non-emergent
Conditions classified as Non-emergent
Skin rash, strains and sprains, “colds”, simple fracture
ER nurse plays a large role in collaborating when the decision is less clear.
If you question the physician’s disorder, you must
advocate for the patient
Example: if a patient is not safe to discharge home due to safety risk or mental status, you must discuss the concerns with the provider.
Initial assessment of the patient in the ER
Primary survey
Primary survey - ABCDE stands for
(A) Airway/cervical spine
-Many trauma patients will be placed in a cervical collar until imaging is obtained
-Airway interventions for patients with a GCS less than 8? Mechanical ventilation
(B) Breathing
(C) Circulation: CPR, bleeding control, IV fluid and blood administration, BP and HR, and drug therapy
(D) Disability: Neurological status (ex., GCS)
(E) Exposure: Remove clothing for a complete assessment
For what exception do we alter this order (ABCDE) of assessment?
In the presence of excessive bleeding
CABDE
Secondary survey includes:
*Comprehensive head-to-toe assessment
*Identifies other injuries/medical issues (after immediate life threats have been addressed)
The nurse anticipates
*Insertion of gastric tube and urinary catheter
*Splints applied to fractures
*Temporary dressings placed over wounds
*Preparation for diagnostic studies
At risk populations for environmental emergencies
Older adults (easily dehydrated)
Those with mental health conditions
Those who work outside
Homeless individuals
Users of illicit drugs
Outdoor athletes
Military persons in hot climates
What condition?
Primary issue is dehydration from heavy perspiration and inadequate fluid and electrolyte intake during heat exposure over hours to days. If untreated can lead to heat stroke which is a MEDICAL EMERGENCY.
Heat exhaustion
Assessment findings of heat exhaustion
orthostatic hypotension and tachycardia
Older adults can possibly have acute confusion and increased risk for falls.
Flu-like sx ( HA, weakness, N/V). body temp may not be elevated.
Electrolyte imbalance: decreased sodium (hyponatremia).
Treatment for Heat Exhaustion
IV fluids (normal saline), stop activity, and move to a cool place. Cooling packs to neck, chest, abdomen and groin. Oral rehydration therapy (avoid excessive plain water).
What condition?
True medical emergency
Body temp may go over 104F (40 C): Failure of thermoregulation mechanism.
High mortality rate without treatment.
Exertional: sudden onset; from strenuous physical activity in hot, humid conditions.
Non-exertional (classics): occurs over a period of time from chronic exposure to a hot, humid environment. Ex. living in a home without AC in the hot summer days.
Heat Stroke
Sx of Heat Stroke
Mental status change is the hallmark sx, due to thermal injury changes. Confusion, bizarre behavior, seizures, and even coma.
Other sx: hypotension, tachycardia, tachypnea. Pt will stop sweating due to loss of thermoregulation.
What labs should be reviewed to assess for organ damage r/t Heat Stroke?
Troponin I
You MUST know the treatments for Heat Stroke
*Oxygen therapy (eval neuro status and need for intubation)
*Large bore IV lines: Usually normal saline (preferably cooled)
*Urinary catheter
*Continuous cooling with cooling blanket. Must measure core body temperature. Stop cooling interventions when temp reaches 102 Fahrenheit (39 Celsius).
*Medication if shivering occurs? Benzodiazepine – serve as muscle relaxants
*Monitor for MODS & electrolyte imbalances
*Medication classes to avoid? Aspirin and antipyretics due to Increased risk of bleeding due to metabolic disturbances. Hypothalamus is overloaded, and antipyretics will not work (may cause more harm).
Types of Venomous Snakes in North America
Pit vipers, rattlesnakes, copperheads, cottonmouths.
Coral snakes (red touch yellow kill a fellow) are more poisonous than rattlesnakes or cottonmouths.
What is the most significant risk of a snakebite?
Most significant risk is airway compromise and respiratory failure
Snakebite tx includes:
*Supplemental oxygen
*Two large-bore IV lines for NS or LR
*Continuous cardiac, BP monitoring
*Have resuscitation equipment immediately available
*Opioids
*Wound care: Mark, measure and record extremity circumference
*Broad-spectrum antibiotics
*Obtain coagulation panels
*Contact poison control for antivenom dosing: Crotalidae, Polyvalent Immune Fab (CroFab), if indicated
Which venomous arthropods can cause a toxic reaction in human?
Brown recluse and black widow spiders, scorpions, bees and wasps
Anyone who develops an allergic reaction to bee or wasp stings should always
carry a prescription epinephrine auto-injector and wear a medical alert tag or bracelet.
It is important to know the in-hospital treatment for arthropods (i.e. wasp stings, spider bites, etc)
*Assess and measure skin surrounding bite
*Monitor vital signs and respiratory function
*Assess for any signs of allergic reaction
*Administer additional oxygen, as needed
*Tetanus prophylaxis, as needed
*Exercise caution with administration of opioids, benzodiazepines
*Loss of airway reflexes > respiratory failure
*May contact regional poison control
Populations at the highest risk for lightning injuries?
Outdoor recreation, hikers, campers, beach-goers, and swimmers
Cardiopulmonary and central nervous systems profoundly affected. Leaving many lightning strike victims are left w/
permanent disabilities
Lightning injuries assessment
-Mild: stunned or confused
-Moderate: confusion or comatose. Temporary paralysis.
-Severe: Cardiac arrest.
-Possible serious myocardial injury. EKG changes, dysrhythmias, and angina
-Vasospasms: mottled skin, decreased to absent peripheral pulses
-Immediate but temporary paralysis (lower extremities usually more affected)
-Skin burns
-Lichtenberg figures: tree-like branching marks- coagulation in the capillaries
It is important to understand the treatment for lightning injuries
-Spinal stabilization
-Maintain ABCs
-Immediate CPR in the field (no danger to rescuer because victim is not charged)
-Provide for advanced life support management
-12 lead ECG
-CT of head to identify intracranial hemorrhage
-Creatinine kinase (CK) Eval for skeletal muscle damage
-Severe cases – rhabdomyolysis
-Tetanus prophylaxis
-Burns that break skin integrity. Severe burns may need to be treated in a burn center.
What condition?
*Occurs at core body temperature <95° F (35° C)
*Mild: 90 to 95° F (32 to 35° C), Shivering, decreased muscle coordination, impaired cognition, diuresis?
*Moderate: 82.4 to 90° F (28 to 32° C), Muscle weakness, increase loss of coordination, acute confusion, incoherence, possible stupor, decreased clotting (impaired platelet aggregation)
*Severe: Below 82.4° F (<28° C), Bradycardia, severe hypotension, decreased respiratory rate, dysrhythmias, decreased neurological reflexes and pain response, acid-base imbalances
hypothermia
Common predisposing conditions to hypothermia
*Cold-water immersion
*Acute illness (sepsis), shock
*Traumatic injury
*Advanced age
*Alcohol intoxication
*Malnutrition
*Inadequate clothing in cold weather
Hypothermia tx includes:
*Shelter from the cold
*Remove wet clothing
*External and core (internal rewarming): Warm IV fluids, Heated oxygen or inspired gas, Heated peritoneal, pleural, gastric, or bladder lavage
*Monitor hospitalized patients for cardiovascular instability, ARDS, acute renal failure, pneumonia
*Metabolism is unpredictable when hypothermic: Possible drug toxicity when rewarming
What condition?
Occurs when body tissue freezes and causes tissue integrity damage
Frostbite
What condition?
Superficial cold injury > pain and numbness but do tissue damage. The extent of tissue damage cannot be determined until after rewarming has occurred.
Common on face, nose, fingers and toes (may progress to frostbite).
Frostnip
It is important to understand the treatment for frostbite
*Rapid rewarming
*Swirl body part in water; do not allow to touch side of the container to prevent tissue damage
*Analgesics, IV opiates, IV rehydration. Can be administered prior to beginning the rewarming bath.
*Ibuprofen every 8 hours as prescribed – anti-inflammatory response may reduce secondary injury
*Elevate body part above heart level if possible
*Assess for compartment syndrome
*Tetanus immunization
*Loose, nonadherent sterile dressings
*Avoid compression of injured tissue
*Topical and systemic antibiotics
*Arteriography may be needed
*Debridement of necrotic tissue or amputation may be needed
Three most common clinical conditions of high altitude illness/disease (HAD):
*Acute mountain sickness (AMS)
*High altitude cerebral edema (HACE)
*High altitude pulmonary edema (HAPE)
-Throbbing headache, anorexia, nausea, and vomiting
-May feel like “alcohol-inducted hangover”
AMS, HACE, HAPE?
Acute mountain sickness (AMS)
-Apathy, ataxia, mental status changes, progressive brain swelling > **seizures
-Bizarre behaviors
AMS, HACE, HAPE?
High altitude cerebral edema (HACE)
-Most common cause of death associated with high altitude
-Persistent dry cough, lip and nail bed cyanosis
-Pink, frothy sputum; crackles in lungs
-ABG shows respiratory alkalosis and hypoxemia
AMS, HACE, HAPE?
*High altitude pulmonary edema (HAPE)
Acute Mountain Sickness Interventions
*Descent to lower altitude – most important intervention. Rest & Oxygen. Ensure hydration and nutrition
*Acetazolamine (Diamox): Induces metabolic acidosis assisting with acclimatization
*HACE: Dexamethasone (Decadron)
Reduces cerebral edema (relieves symptoms of AMS)
*HAPE: Nifedipine
Assists to decrease pulmonary vascular resistance
*Admission with possible critical care management
It is important to understand the treatments (meds) of HACE vs HAPE
HACE: Dexamethasone (Decadron)
HAPE: Nifedipine
Drowning Tx:
*Oxygen, ET intubation, CPR, defibrillation may be necessary
*Monitor vital signs
*Gastric decompression via NG Tube may be required if abdomen becomes distended and firm. Patients may become tachypneic secondary to abdominal distension.
Management of complications:
*Pulmonary edema, infection, ARDS, and CNS impairment
*Critical care may be necessary
Which intervention would you delegate to a nurse tech?? CPR
It is important to know what defines mass casualty triage, i.e. which patient would receive Red, Yellow, Green, Black tags.
Red: Emergent needing immediate attention (class I)
Prioritize ABCs
Yellow: Can wait short time for care (class II)
Open fractures with a distal pulse
Green: Non-urgent or “walking wounded” (class III)
May be the largest number of injured individuals. Can often transport themselves to the nearest hospital.
Black: Expected to die or are dead (class IV)
Massive head trauma, extensive burns, cervical cord injury
Mitigate the possible acute and chronic stress after mass casualty events in the staff
Incident debriefing
4 main components of emergency preparedness and response
Mitigation, preparedness, response, and recovery
BURNS
It is important to know the goals of management during the emergent/resuscitation phase. Onset through initial 24 to 48 hours—until diuresis occurs.
Goals of management
*Secure airway
*Support circulation and perfusion—fluid replacement
*Prevent infection (i.e., wound care)
*Maintain body temperature
*Provide emotional support
*Providing pain relief (administering analgesics)
It is important to understand ways to prevent infection in a burn patient:
1.Have any family or visitors wash their hands before touching the patient.
2.Carefully monitor all burn wounds for signs of infection during dressing changes.
3.Use aseptic technique and wear gloves when performing wound care.
BURNS
Acute (healing) phase
*Begins about 36 to 48 hour after injury (fluid shift resolves); lasts until wound closure is completed
Care directed toward
-Continued assessment and maintenance of CV, respiratory systems
-Continued assessment and maintenance of GI and nutritional status
-Burn wound care
-Pain control
-Psychosocial interventions
BURNS
Rehabilitative Phase of Burn Injury
*Begins with wound closure, ends when patient returns to highest possible level of functioning. This phase may last years or even a lifetime if patient needs to adjust to permanent limitations.
Emphasis on
psychosocial adjustment, prevention of scars and contractures, resumption of preburn activity
Rule of Nines
*Size and depth of injury
*Percentage of total BSA affected
*“Rule of nines” body is divided into areas that are multiples of 9% of total BSA
Head 9%
Arms 9% each
Legs 18% each
Front 18%
Back 18%
Groin 1%
The priority collaborative problems for patients with burn injuries in the emergent/resuscitation phase who have sustained a burn injury greater than 25% of the TBSA include:
*Potential for decreased oxygenation
*Potential for shock
*Pain (acute and chronic)
*Potential for Acute Respiratory Distress Syndrome (ARDS)
*Wound care management
*Potential for infection
*Weight loss
*Decreased mobility
*Decreased self-esteem
It is important to know the different depths of damage to burn injuries, i.e. identify if a patient has a superficial thickness, superficial partial thickness, deep partial thickness, or full thickness burn.
*Least damage; epidermis is only part of skin that is injured
*Healing 3-6 days
*Desquamation (peeling of dead skin) occurs 2 to 3 days after burn
Superficial Thickness Burn
It is important to know the different depths of damage to burn injuries, i.e. identify if a patient has a superficial thickness, superficial partial thickness, deep partial thickness, or full thickness burn.
*Involves entire epidermis and dermis (varying depths).
*Healing 10-21 days w/o complications.
Superficial Partial Thickness Burn
It is important to know the different depths of damage to burn injuries, i.e. identify if a patient has a superficial thickness, superficial partial thickness, deep partial thickness, or full thickness burn.
*More extensive into the dermis
*Healing 2-6 weeks w/o complications
Deep Partial Thickness Burn
It is important to know the different depths of damage to burn injuries, i.e. identify if a patient has a superficial thickness, superficial partial thickness, deep partial thickness, or full thickness burn.
*Destruction of entire epidermis and dermis
*Sometimes includes subcutaneous fat
*Skin does NOT regrow on its own
*Little to no pain due to loss of nerve endings
Full thickness Burn
Why do we need a CMP on a burn patient?
The extensive thermal injuries create a massive inflammatory and metabolic stress.
