Test 1: Burns & Shock Flashcards
- Burns: Priority Care
• Priority care is give 02 as order
• Use powder free sterile gloves.
• Restrict oral intake.
• IV access; Fluids and analgesics (morphine sulfate)
• NON-facture you may elevate legs.
• If burns in the face area, they might have a little bit of hoarseness. If it is getting worse, it’s a sign of Respiratory distress.
• You might see signed nasal hair (black soot) means there has been smoke that can compromise their respirations.
- Burns: Nursing Actions
• For each area of burns, change gloves each area of the body to not introduce infection.
• Use a cradle sheet to keep them warm.
• No use of sponges or sponge bath since it can get caught in the debris.
- Burns: Diet
• Increased calorie and protein
• Take Vitamin A (Animal fats
Butter, cheese, and cream,Egg yolks, Whole milk, Fish liver oil and liver, Dark green, leafy vegetables, Deep orange fruits and vegetables
- Take Vitamin C (citrus fruits (oranges, orange juice, strawberries)
• good for healing
- Take Vitamin Zinc (Liver and seafood)
- Skin Grafting for burns: Client education
• Wear sunscreen to prevent permanent pigmentations.
• First 2-4 weeks restrict movements.
• Use Mild soap, wash off complete, and patted dry.
• Wear warm clothing.
• Avoid Items like Lalami? alcohol, perfume since it can irritate newly heal skin.
- Skin Grafting for burns: nursing actions
• Prescribe analgesic.
• Monitor infection.
- film dressing to cover skin grafts at first, pressure garments after they heal
- Hypovolemic Shock: Nursing Actions
• Prepare for administration of blood and fluids.
• Monitor weight.
• Monitor vitals, including temperature-risk for hypothermia with large volumes of fluids.
• O2 administrations
• Position client supine or Trendelenburg with feet slightly elevated. Never high flowers. Adjust for respiratory s/s.
• O2 saturation is taken on the forehead not the fingers for accurate reading.
- Hypovolemic Shock: Medical Mangement
• Ringer Lactate and 0.9% Normal Saline (isotonic solution)
• DMAST garment helps reverse it.
- Hypovolemic Shock: Evaluation Outcomes
• Urinary output within normal range
• Normal Vital Signs
- Septic Shock: Early initial phase manifestations
• Elevated WBC
• Fever
• Warm, flushed skin Progresses initial phase manifestations Cool, pale skin
• Rapid, bounding pulse
- Septic Shock: Late manifestations
• Hypotensive
• Delayed capillary refill
• Disorientation
- Impending Shock: nursing action
Decreased cardiac output impending shock.
• Restrict activity to total rest.
• Establish IV sites.
• Assist with fluids/bloods.
- Impaired tissue perfusion
• Assess with neurovascular checks.
• Control frank bleeding
• Elevated legs
- Hemorrhagic shock: medical management
• O negative is the universal donor.
• Ringer Lactate(Crystaollid) is preferred because it minimizes acidosis.
- Neurogenic shock: manifestations
• Dry, Warm skin
• Hypotension
• Bradycardia
- Stages of shock: manifestations: Initial
• Too little O2 in blood to feed organs-
anaerobic metabolism-mostly absent s/s.
