FINAL STUFF Flashcards
(183 cards)
1
Q
What occurs when there is an injury to the tissues of the body caused by heat, chemicals, electrical current, or radiation?
A
Burns
2
Q
What are the different kinds of burns?
A
Thermal
Chemical
Smoke Inhalation
Cold thermal
3
Q
__________ burns are caused by flame, flash, scald, or contact with a hot object?
A
Thermal
4
Q
What is the most common type of burn?
A
Thermal burns
5
Q
________ burns are seen in elderly and babies with neuro impairments
A
Thermal
6
Q
What results from tissue injury and destruction od acids, alkalis, and organic compounds?
A
Chemical burns
7
Q
What kind of burns are harder to manage?
A
Alkali burns
8
Q
Why are Alkali burns harder to manage?
A
Because all the damage happens after the alkali is neutralized (Hemolyzed for 72 hours after)
9
Q
What are the common sites for chemical burns?
A
skin
eyes
RR tract
liver and kidney
10
Q
What is some nursing care for someone with a chemical burn?
A
Remove the causative agent
Wash the skin
Remove clothes that came in contact with the chemical
Irrigate with large amounts of water
11
Q
What are three things to do AS A NURSE that comes in contact with a chemical burn?
A
- PPE
- brush off chemicals- will look like pasta/powder
- wash after brushing with copious amount of water.
12
Q
What is the inhalation of hot air or noxious chemicals that injures respiratory tract
A
Smoke Inhalation Injury
13
Q
Smoke inhalation injury can cause mortality, this it needs __________ intervention
A
QUICK!
14
Q
What is the treatment for carbon monoxide poisioning?
A
100% nonrebreather with humidified oxygen
15
Q
If there has been skin damage caused by carbon monoxide poisoning, they will have a ______-_____ appearance
A
Cherry-red
16
Q
If there is an _____ airway smoke inhalation injury ; it is above the epiglottis
A
UPPER
17
Q
An upper airway smoke inhalation injury can be caused by what?
A
Hot air
Steam
Smoke
18
Q
An upper airway smoke inhalation injury can cause ___________ burn of the oropharynx and larynx?
A
Mucosal
19
Q
An upper airway burn can quickly lead to a mechanical obstruction, thus making it an
A
EMERGENCY
20
Q
What are signs and symptoms of a upper airway inhalation injury?
A
Facial burns
Singed nose hairs
Hoarseness and painful swallowing
Darkened oral mucous membranes.
21
Q
What may be considered if there is an upper airway inhalation injury?
A
INTUBATION
22
Q
A _______ airway smoke inhalation injury is below the epiglottis
A
LOWER
23
Q
What causes a lower airway inhalation injury?
A
prolonged exposure to smoke and toxic fumes
24
Q
What are some possible manifestations of a lower airway inhalation injury?
A
Pulmonary edema (12-24 hours) may progress to ARDS
You need to monitor them for 24 hours!!!!!!!!! This could get bad!
25
What results from coagulation necrosis caused by intense heat generated by electrical currents
Electrical burns
26
What kind of burn can result from direct damage to nerves/vessels and causes tissue anoxia and death
Electrical burns
27
Electrical burns have an ____ and ______ point
Entry and EXIT
28
A patient with electrical burns is at risk for what 3 things?
Dysrhythmias
Severe metabolic acidosis
Myoglobinuria
29
Why is severity of electrical burns had to determine?
Because most of the damage is under the skin and hard to determine the burn surface area
30
Severity of electrical burns is determined by...
- Voltage
- Tissue resistance
- Current pathways
- Surface area
- Duration of the flow
31
What makes an electrical burn possibly life threatening
- when the pathway passes through vital organs
32
What occurs from true tissue freezing?
Frostbite
33
What occurs causing frostbite?
Ice crystal formation in intercellular spaces and destruction of intercellular sodium, chloride, and cell membrane
34
What are the components of superficial frostbite?
Skin and subQ tissues (ear, nose, fingers, and toes)
35
What are the components of deep frostbite?
Muscle
Bone
Tendons
36
What is some nursing care for cold thermal injury?
Immerse in water bath between 98.6-104 / tetnaus prophylaxis
37
What is the biggest concern as far as cold thermal injuries
Watch for compartment syndrome
38
What is the modern name for a 1st degree burn?
Superficial partial thickness burn
39
What does a superficial partial thickness burn involve?
EPIDERMIS
40
What are the manifestations of a superficial partial thickness burn?
***Think of a sunburn***
Redness but no initial blistering
Blanching with pressure and some pain
41
What is the modern name for 2nd degree burns?
Deep partial thickness burn
42
What part of the skin is involved in a deep partial thickness burn?
THE DERMIS
43
What are the manifestations of a deep partial thickness burn?
Red, shiny skin.
Looks wet and blisters
Lot of pain
44
Does a deep partial thickness burn involving the dermis need a skin graft?
Skin can regrow, so no, no need for a graft
45
What is the modern name for a 3rd degree burn?
Full thickness burn
46
What parts of the skin does full thickness burn include
Fat
Muscle
Bone
47
What are some manifestations of a full thickness burn?
Dry, waxy, leathery look
NO pain (kills the nerve)
48
Will a dull thickness burn need a graft?
YES!
49
A patient comes into the ED, and has a burn with a lot of blistering and an excruciating amount of pain, you would assume that they have a __________ partial thickness burn
DEEP!
50
Knowing the rule of Nines for burns, what is the front of the legs?
9
51
Knowing the rule of Nines for burns, what is the back of the legs?
9%
52
Knowing the rule of Nines for burns, what is thegroin?
1%
53
Knowing the rule of Nines for burns, what is the front of the arms?
4.5%
54
Knowing the rule of Nines for burns, what is the back of the arms?
4.5%
55
Knowing the rule of Nines for burns, what is the front of the abdomen?
18%
56
Knowing the rule of Nines for burns, what is the back of the abdomen/back?
18%
57
Knowing the rule of Nines for burns, what is the front of the head/neck?
4.5%
58
Knowing the rule of Nines for burns, what is the back of the head/neck?
4.5%
59
What is the possible complications when there is a burn to the face, neck, or chest?
Respiratory problems and a possible obstruction
60
What is the possible complications when there is a burn to hands, feet, joints, and eyes?
Difficulty with self care and independence
61
What is the possible complications when there is a burn ears and nose?
Infection risk
62
What is the possible complications when there is a burn to circumferential areas?
Circulatory compromise and compartment syndrome
63
What are patient risks related to burns?
Elderly heal slower than younger
Pre-existing cardiovascular, renal, and respiratory problems
Diabetes/ peripheral vascular disease
Alcohol/ drug use, malnutrition, and chronic disease
64
What is nursing / medical care for a burn patient even before they get to the hospital
- remove them from the thing that is doing the burning
- DO NOT immerse in cool water or pack with ice
- REMOVE burned clothing, wrap in clean dry sheets
65
What is the first step when you run into a patient that has a chemical burn?
Brush solid particles off the skin and water lavage
66
What is the first step when you run into a patient that has had an electrical burn?
Remove from contact to source
67
If a patient has a small burn (<10% TBSA) you should........
Cover with clean/cool dampened towel
68
If a patient has a small burn (>10% TBSA) you should check the ___________
ABCs
69
The time after a burn where we need to resolve the immediate life threatening problems and can last up to 72 hours is what phase?
Emergent
70
The emergent phase starts with _____________ and _______ formation and continues until fluid mobilization and diuresis begins
HYPOVOLEMIA & EDEMA
71
There is a risk of __________ shock in the emergent phase because of a massive fluid shift
HYPOVOLEMIC
72
What are clinical manifestations that are seen in the emergent phase of burn victims
Shock from hypovolemia and pain
Blisters
Adynamic ileus r/t decreased motility and poor perfusion
Shivering
Change in LOC- assume possible head trauma
73
What is the normal insensible loss?
30-50 mL/hr
74
In severe burns, what is the fluid loss?
200-400 mL/hr
75
In burns, RBCs are hemolyzed thus causes thrombosis, and an elevation in what lab value?
Increased hematocrit
76
What electrolyte shifts into the interstitial space and remains until ______________ formation ceases?
edema
77
Burn injuries cause a widespread ____________ of the integument system
IMPAIRMENT
78
In burns, skin barriers are destroyed lead to decreased __________________________ and changes in ____
Decreased immunoglobins and changes in WBCs
79
Why is there an increased risk of infection in burn patients
- inflammatory cascade is high but then is depleted later.
80
What are possible Cardiovascular complications seen in the emergent phase of burns
Dysrhythmias and hypovolemic shock
Edema, ischemia, necrosis, paresthesia
Gangrene, and impaired microcirculation
Increased blood viscosity
81
What are possible respiratory complication of the emergent phase of burns
Inhalation injury - may not show up til after 24 hours
Upper respiratory tract injury- edema, mechanical airway obstruction, asphyxia, pneumonia, and pulmonary edema
82
What are possible urinary complications in the emergent phase of burns
Decreased blood flow to kidneys which can cause renal ischemia and acute tubular necrosis
83
What is some nursing care for the Emergent phase of burns?
- Early intubation and airway management
- 1-2 large bore IVs for fluid replacement
- Wound care
84
What is the goal of urine output in the parkland formula?
UO should be 0.5-1.0 mL/kg/hr
85
What is the parkland formula
4 mL x total burn surface area
(1/2 in the 1st 8 hours, then 1/4 in the next two 8 hours)
86
What are parts of the acute phase of burns?
- Mobilization of extracellular fluids
- Diuresis
87
When is the acute phase of a burn over?
When the burned area is completely covered with skin grafts and the wounds are healed
88
What stage do bowel sounds return to normal in?
Acute phase --> fluid mobilization
89
What are the clinical manifestations for the acute phase of burns?
Partial thickness wounds form eschar, removed, and then re-epithelization starts.
With a full thickness burn wounds need debridement
90
What lab values would need considered in the acute phase of burns
- Hypernatremia r/t to fluid replacement
- Hyponatremia r/t hydrotherapy or water intoxication
- Hyperkalemia r/t renal failure of muscle injury
- Hypokalmenia r/t hydrotherapy or IV therapy without supplementation
91
What are possible infection complications in the acute phase of burn healing
bacteremia or if really bad septisemia
92
What are possible respiratory and cardiac complications in the acute phase of burn healing?
Pneumonia
93
What are possible neuro complications in the acute phase of burn healing?
Disorientation
Combative behavior and hallucination
ICU psychosis syndrome
94
What are possible musculoskeletal complications of acute phase of burn healing?
Decreased ROM and contractures
95
What are possible GI complications of acute phase of burn healing?
Paralytic ileus and curling ulcer
96
What are possible endocrine of acute phase of burn healing?
INcreased BG and insulin
97
Nursing care for the acute phase of burn healing?
- Wound care
- Cover the graft
- Pain management- PRETREAT
- Physical and occupational therapy
- Nutritional therapy - high protein and carb
- Psychosocial care
98
What kind of graft comes from the patient's own skin?
Cultured epithelial autograft
99
What kind of graft is temporary until and autograft is available?
Artificial skin
100
What stage of burn healing when the burn wounds are covered with skin/ healed and patient is able to resume a level of self-care activity
Rehabilitation phase
101
How long does the rehab phase normally last?
4-6 weeks
102
What does the skin look like in the rehab phase?
Raised and hypermic
103
Mature healing is reached from ____ months to __ years
6 mo. to 2 years
104
What are some education points regarding the rehab phase?
Never regains origical color
Will be sensitive to cold, heat, and touch
Protect from sunlight for 1 year (super sensitive)
105
What is nursing care for the rehab phase?
Educate about healing wounds
Use emollient water based creams
Cosmetic surgery
ROM for PT and OT
NEEDS
High calorie and high protein diet
106
What is the process that is used to determine patient acuity to allow treatment of most critical first?
Triage
107
Who is treated first in Triage?
Life
Vision
Limb
108
What ESI classification is used when there is an immediate threat to life, likely to code?
ESI-1
109
What ESI classification is used when there is a threat to life within minutes?
ESI-2
110
What are some examples of injuries that would classified as ESI-2?
Open fracture
Stable chest pain
Risk of losing respiratory drive
111
What ESI classification is used when they could be considered stable for up to 1 hour?
ESI-3
112
What are some examples of ESI-3 situations?
Acute abdomen
Closed fracture -->Not compartment syndrome
113
What ESI classification is used when they are stable and the treatment can be delayed and only requires some little study or procedure?
ESI-4
114
What are some examples of ESI-4 situations
Suture
Vaccines
115
What ESI classification is used when they are stable, and they only need an exam and observation?
ESI-5
116
A stand for __________ and _____
ALERTNESS AND AIRWAY
117
How do you determine LOC by using AVPU?
A- alert
V- responds to voice
P- responds to pain
U- unresposive
118
What are signs of a compromised airway?
dyspnea, inability to talk, foreign body in airway (hoarse), trauma to the face and neck (fracture of the face)
119
What are ways to maintain an airway?
stabilize C-spine
jaw thrust
suction and remove foreign body
insert naso/oropharyngeal airway
lastly would be intubation
120
B stands for ____________-
Breathing
121
What are important things to assess for when it comes to breathing?
Dyspnea, cyanosis, paradoxical, asymmetric chest wall movement, decreased/absent breath sounds, tachycardia and low BP.
122
What are interventions for a patient who is having trouble breathing?
high flow O2 by nonrebreather
bag valve mask for life threatening conditions
monitor the patient response to treatments
123
What are some things to assess when looking at circulation?
pulses (peripheral may be absent with vasoconstriction)
skin (color, temp, moisture)
mental status and capillary refill
124
What are interventions for circulation?
Insert 2 large bore IVs (18 gauge)
Provide aggressive fluid resuscitation with NS/LR
125
In order to feel pulses.... Radial must be over ______ and femoral must be over ______ and carotid must be over _____
SBP 80 to feel radial pulses
SBP 60 to feel femoral pulses
SBP 40 to feel carotid pulse
126
What is mild impariment on the GCS?
13-15
127
What is moderate impairment of GCS?
9-12
128
What is severe impairment on GCS?
3-8 (INTUBATION MUST OCCUR)
129
What are important things to consider and assess when looking at disability
LOC according to GCS
Pupil size
Shape
Response to light and equality
130
What should you to when looking at exposure and environmental control?
Remove clothing to inspect all areas of the pt.
Minimize temp. loss to avoid hypothermia
131
What are important things to do while resuscitation?
Lab tests
Monitor EKG
NG tube
Oxygenate
Pain management-- not done until neuro assessments are completed
132
What are important things to establish in a head to toe?
Symptoms
Allergies
Med history
PMH
Last meal - important for surgery
Events leading to illness
133
Why is it important to inspect the posterior surface?
Logroll the patient to maintain C-spine while inspecting the posterior surface
Provide continued monitoring of the patient and their response to interventions
Prepare for transport to diagnostic tests, units, or facilities
134
What is the prolonged exposure to heat causing a core temp of 99.6-100.4 and can progress to heat stroke
Heat exhaustion
135
What are the S/S of heat exhaustion?
fatigue, lightheaded, N/V, diarrhea, feeling of impending doom, tachypnea, tachycardia, dilated pupils, mild confusion, ashen color, profuse diaphoresis, hypotension
136
What is the treatment of heat exhaustion?
Place in a cool area
Remove clothing
Apply moist sheet and PO fluids
IV fluids in nauseated and replace electrolytes.
137
What is a hallmark sign on heat exhaustion?
Perfuse diaphoresis
138
What is the failure of the hypothalamus after heat exhaustion progresses?
Heat stroke
139
What are the S/S of heat stroke?
vasodilation, increased sweating and respiratory rate deplete fluids and electrolytes (esp. sodium)
At 104 F, sweat glands stop working !!!! altered mentation and circulatory collapse can follow; cerebral edema and hemorrhage occur with thermal brain injury
140
What is the treatment of heat stroke?
stabilize ABCs and rapidly reduce temp
remove clothing, cover with wet sheets, large fans, cooling blankets, ice to groin and axilla, immerse in cold bath, administer cool fluid
Once cooled to 104, Tylenol can be given. Higher than that it has no effect (bc the hypothalamus shut down)
Temperature reduction must be aggressive until 102 F
Give chlorpromazine to decrease shivering
Monitor for signs of rhabdomyolysis, myoglobinuria, and DIC
141
What are the risks with rewarming in hypothermia?
Afterdrop
Hypotension
Dysrhythmias
142
What is the temp. for mild hypothermia
93-97
143
What are the S/S for mild hypothermia? (93-97)
shivering, lethargy, confusion, rational to irrational behavior, mild tachycardia
144
What are some things to do to help in mild hypothermia?
External warming: passive – move to warm place, warm blankets, remove damp clothes, active – body-body contact, fluid/air filled warming blankets, radiant heat lamps
145
What is the temp. for moderate hypothermia?
90-93
146
What are some S/S of moderate hypothermia?
Rigidity
Bradycardia and bradypnea
Metabolic and respiratory acidosis
147
What are some interventions for Moderate hypothermia
Heated and humidified O2
Warmed IV fluids
Peritoneal and gastric lavage
148
What is the temp. for severe hypothermia?
under 90
149
What are the S/S of severe hypothermia?
Look dead
Bradypnea and cardia
Asystole and V fib
150
A patient must be warmed to _____ F before being pronounced dead
86 F
151
When do you stop rewarming a patient
When they reach 90-93 F
152
What occurs when someone become hypoxemic due to submersion in water
Submersion Injury
153
What is respiratory impairment after submersion?
Drowing
154
What causes immediate pulmonary edema from fluid shifts?
Salt water aspiration
155
What causes late pulmonary edema from pathogens
Lake water aspiration
156
What is the treatment for a submersion injury?
Aggressive resuscitation and may require mechanical ventilation
- Require 24 hours of observation
157
What if a patient has come into the ED after a submersion injury, and there is a decline in mental status, what should you consider?
Cerebral edema
Worsening hypoxia
Acidosis
158
What are 2 things that help to decrease absorption in poisoning
Gastric Lavage
Activated Charcoal
159
When do you need to perform gastric lavage after poisoning?
within 2 hours
160
How do you preform gastric lavage in a poisoned patient
Insert NG tibe
Inject 60 mL to dilute contents
Suction back out
161
What are contraindications for Gastric lavage?
Caustic agent
Ingestion of sharp agent
Nontoxic substance
162
In order for activated charcoal to be beneficial, it needs to be given within ____ minutes
60
163
What are contraindications for activated charcoal?
Diminished bowel sounds
Paralytic ileus
Ingestion of antidote
164
What are 2 ways to enhance elimination in poisoning?
Cathartics- stimulates motility
Hemodialysis- For acidosis
165
Anthrax, plague, and tularemia are things used in bioterroris, but it can be treated with _____
ABX
166
_________ can be prevented or ameliorated with vaccines given 72 hours before
Smallpox
167
What is treated with antitoxin
Botulism
168
What is the thing used in terrorism that has no known treatment>
Hemorrhagic fever
169
What is a chemical terrorism that is a toxic nerve gas that paralyzes respiratory muscles?
Sarin
170
What is the treatment for Sarin?
Give atropine
Pralidoxime chloride
171
What is a colorless gas that can cause respiratory distress and death with long enough exposure
Phosgene
172
What is yellow/brown gas that irritates eyes and causes skin blistering
Mustard Gas
173
Mustard gas turns into a liquid and then a _________
Paste; remove it!
174
After a bomb goes off, a patient comes in with exposure to 100 RAD, what S/S will they have
N/NV, HA, feel sick, malaise
175
After a bomb goes off, a patient comes in with exposure to 100-600 RAD, what S/S will they have
Can cause deformity and increase risk of death
176
After a bomb goes off, a patient was to 600 RADs, what will hapen?
Immediate death
177
What is an event that overwhelms the community’s ability to respond with existing resources. Produces many casualties
Mass causality incident
178
In order to calculate the number of causalities, hospital need to ________ the number of casualties that arrive in the first hour
DOUBLE
179
In the colored tag system, black or blue means what?
Dead or expectant death
180
In the colored tag system, what does red mean?
Immediate threat to life (decreased perfusion and head traume)
181
In the colored tag system, yellow means what?
Can delay treatment but may progress to unstable rapidly
182
In the colored tag system, green means what?
Minor injuries that can be treated later
183
In the colored tag system, White means what?
At the site, but not hurt. Need to be tagged bc they need a psych follow up!
