Test 3 (Mod 3) Flashcards
Burn that involves the epidermis
Superficial partial-thickness burn
offer most resistance to electrical burns
fat and bones
Severity of burn injury is determined by
Depth, extent of burn in percent of TBSA, location, and patient risk factors
Burn that involves the dermis
Deep partial-thickness burn
Burn that involves fat, muscle, bone
Full-thickness burn
With burns of the face, neck, and chest, think-
respiratory obstruction
With burns of the hands, feet, joints, eyes, think-
self-care
With burns to the ears, nose, buttocks, perineum, think-
infection
Areas of the wound not closed by wound contraction will require
grafting
a continuous leak of plasma from the vascular space into the interstitial space.
Capillary leak syndrome (third spacing)
Cool large burns for no longer than
10 minutes
Fluid remobilization starts ______________, when the capillary leak stops and capillary integrity is restored.
about 24 hours after injury
Primary concerns during emergent phase of burns include
hypovolemic shock and edema
The diuretic stage begins _____________as capillary membrane integrity returns.
at about 48 to 72 hours after the burn injury
because of the initial fluid shifts and hypovolemia that occur after a burn injury, heart rate goes _____, and cardiac output goes ______.
up, down
In burns, a normal insensible loss is
30 to 50 mL / hr
In severe burns, fluid loss may be
200 to 400 mL /hr
Cardiac output may remain low with burns until
18 to 36 hours after the burn injury
In burns, this electrolyte shifts to the interstitial spaces and remains until edema formation ceases.
Sodium (Na+)
This electrolyte shift develops with burns because injured cells and hemolyzed RBCs release this into extracellular spaces
Potassium (K+)
an acute gastroduodenal ulcer that occurs with the stress of severe injury, may develop within 24 hours after a severe burn injury because of reduced GI blood flow and mucosal damage.
Curling’s ulcer
Immediate care of burns focuses on
maintaining an open airway, ensuring adequate breathing and
circulation, limiting the extent of injury, and maintaining the function of vital organs.
Assess the burn patient’s _____ and ___________ before assessing any other body system.
airway, adequacy of breathing
Ventilator alarms should be checked ______, for patients who are receiving paralytic drugs during mechanical ventilation
hourly
Patients receiving paralytic drugs during mechanical ventilation should be given
analgesics, sedatives, and antianxiety drugs
______ of the fluid volume calculated for the first 24 hours after burn injury should be given in the first _____ hours post burn
Half, eight
As soon as fluid shifts have resolved, assist patients to
Ambulate several times each day
two large bore IV’s for TBSA greater than
15%
Central line for TBSA of greater than
30%
Should be delayed until a patent airway, adequate circulation, and adequate fluid replacement have been established with burns
Wound care
Source of infection in a pt with burns is from
the pt’s own flora
dressings on burns may be changed every
12 to 24 hours to once every 14 days. Moist wound healing is preferred.
When performing burn wound care with open burn wounds, the RN must wear
Disposable hat, mask, gown, and gloves
a chronic, episodic disorder with multiple subtypes classified as a long-duration headache because it usually lasts more than four hours.
Migraine headache
is characterized by an intense pain in one side of the head (unilateral) worsening with movement, and occurs with either photophobia (sensitive to light) or phonophobia (sensitive to noise).
Migraine
alleviates pain during the aura phase or soon after the start
Abortive therapy
Given routinely to all burn patients
Tetanus immunization
triptans, ergotamine preparations, and anti-epileptic drugs.
Drugs used to treat migraines
manifested by brief (30 minutes to 2 hours), intense unilateral pain that generally occurs in the spring and fall without warning.
Cluster headaches
classified as the most common chronic short-duration headaches.
Cluster headaches
Caloric needs for a burn patient
about 5000 kcal / day
Resting metabolic expenditure may be increased by ___ to ___ above normal in the burn patient
50 to 100%
The pain from this is usually accompanied by ipsilateral eye tearing, rhinorrhea, congestion, ptosis, facial sweating, eyelid edema, and miosis.
cluster headache
the most common type of chronic long-duration headache, lasting more than 4 hours and are caused by stress and tension.
Tension headache
Early, continuous enteral feeding promotes optimal conditions for wound healing with
burns
an abnormal, sudden, excessive, uncontrolled electrical discharge of neurons resulting in alteration in consciousness, motor or sensory ability, or behavior.
Seizure
defined as two or more seizures experienced by a person.
Epilepsy
The _____ phase of burns begins with the mobilization of extracellular fluid and subsequent diuresis
Acute
The ______ phase of burns is concluded when the burned area is completely covered by skin grafts, or when the wounds are healed
Acute
A partial thickness burn wound heals from the
edges
must be covered by skin grafts
full thickness burns
Full thickness wounds require
debridement
In burns, hyponatremia can develop from
excessive GI suction and diarrhea
Hypernatremia with burns can develop following
successful fluid replacement, improper tube feedings, inappropriate fluid administration
Hyperkalemia may be noted in a burn patient if the patient has
renal failure, adrenocortical insufficiency, massive deep muscle injury
cardiac dysrhythmias and ventricular failure, muscle weakness, ECG changes, can all be caused by
Hyperkalemia
lengthy IV therapy without potassium, vomiting, diarrhea, prolonged gastrointestinal suction, can all lead to
Hypokalemia
Partial thickness burns can become full thickness in the presence of
Infection
The International Classification of Epileptic Seizures recognizes three broad categories of seizure disorders
generalized seizures, partial seizures, and unclassified seizures.
is not associated with any identifiable cause.
Primary or idiopathic epilepsy
result from an underlying brain lesion, most commonly a tumor, trauma, or metabolic or other disorders.
Secondary seizures
involve both cerebral hemispheres
generalized seizures, such as the tonic-clonic seizure
usually involve only one hemisphere.
Partial seizures, also called focal or local seizures
includes having oxygen and suctioning emergency equipment available, starting an IV access, and keeping the siderails up at all times. Indicate the reasons for the siderails to meet The Joint Commission requirements.
Seizure precautions
decreased ROM and contractures can occur during the acute phase of
burns
a medical emergency characterized by prolonged seizures lasting more than 5 minutes or repeated seizures over the course of 30 minutes.
Status Epilepticus
an inflammation of the meninges surrounding the brain and spinal cord.
Meningitis
is usually self-limiting and the patient has a complete recovery
Viral meningitis
potentially life-threatening form of meningitis
Bacterial meningitis
Speeds up removal of dead tissue from healthy wound bed with burns
Enzymatic debridement
may occur as a result of blockage of the flow of CSF, change in cerebral blood flow, or thrombus formation.
Increased ICP
Analysis of the cerebrospinal fluid is used to diagnose
Meningitis
an inflammation of the brain tissue and often the surrounding meninges, affecting the cerebrum, the brainstem, and the cerebellum.
Encephalitis
can be life-threatening or lead to persistent neurological problems such as learning disabilities, epilepsy, memory loss, and fine motor deficits.
Viral encephalitis
Assess level of consciousness (LOC) as a priority in patients with
Encephalitis
C1-7
Innervate neck accessory muscles
T1-11
Innervate intercostals
C3-5
Diaphragm
Initially bleeding and edema occur _____ segments higher than the spinal injury
2
Incomplete injury affecting upper extremities
Central cord injury
Incomplete lesion that involves loss of motor, pain, and temp. Proprioception, vibration, and touch intact
Anterior cord injury
Incomplete lesion that involves ipsilateral loss of motion, contra lateral loss of pain and temp
Brown-Sequard
Impaired mobility or sensation
Wounds of head neck back shoulders
Pain tenderness deformities near the spine
Unconscious after the injury
Unexplained shock (neurogenic vs spinal shock)
Indications of cord injury
T6-L2
Innervate abdominal muscles
Total loss of motion and sensation below the lesion
Spinal shock
Occurs with lesions above T6
Occurs after spinal shock has resolved
Bladder/bowel distention are common triggers but anything can irritate this response
Autonomic dysreflexia
Affect CNS above area of function
Spinal arcs below lesion are intact
Incontinent bowel and bladder
Upper motor neuron lesions
Disrupt reflex arc resulting in loss of activity at that level
Ex. Lesion on sacral segment results in bladder retention or loss of erection
Lower motor neuron lesions
Most have reflex erections but cannot ejaculate
Upper motor neuron lesion
Most cannot have erections
Lower motor neuron lesions
An inhibitory neurotransmitter and some meds for epilepsy alter the amount of this in the brain or alter how the brain responds to it
GABA (gamma-aminobutyric acid)
Originate from a local cortical region and include temporal, frontal, and occipital lobe epilepsy; childhood epilepsy
Localization related (focal, partial) seizures.
Activation of neurons in both hemispheres and include absence, myoclonic, grand mal, Lennox-Gastaut syndrome
Generalized seizures
Continuous seizure lasting more than 5 minutes or two or more seizures that occur without a recovery period
Status epileptics
3 components in the non-expandable skull
brain, blood CSF
Widening pulse pressure means
Increasing ICP
Widening pulse pressure, Bradycardia, and change in respirations, make up
Cushing’s Triad (late sign)
Increased systolic BP is what leads to _______
Widening pulse pressure with increased ICP
carotid bodies ilicit a parasympathetic response using the vagus nerve to combat the
increase in systolic BP with increased ICP
As a result of the vagus nerve stimulation
bradycardia occurs
Hypoventilation leads to an______ in CO2 in the body
Increase (CO2 potent vasodilator in the brain, thus increasing ICP even more)
Hypoxia will ______ ICP
Increase
Numerical scale making up verbal, motor, and eye opening responses
Glasgow Coma Scale
With GCS less than eight, think
Intubate!
Ideal GCS range
13-15
Normal pupil size
2-6 mm
If client is c/o a headache, assume
increased ICP
A high level of brain functioning is demonstrated if the client can
speak
Absence of movement is the ______ level of response
lowest
This test assesses brain stem function; eyelids open…quickly turn head to the right…eyes should move to the left; If eyes remain stationary…reflex absent
Oculocephalic Reflex (Doll’s eye reflex)
This test assesses brain stem function; irrigate ear with 50mL of cool water…normally eyes will move to irrigated ear and rapidly back to mid-position
Ice cold water caloric test (oculovestibular reflex)
lateral aspect of foot is stroked and toes flex or curl up. Less than 1 year of age a positive result is ok; negative is bad
Babinski or plantar reflex
Normal adult response to Babinski
toes roll under or flex
A negative babinski is ok for ages greater than_________. Positive is _______
1 year of age
Bad
For an ICP patient, to facilitate venous drainage, elevate HOB to
20 to 30 degrees
For an ICP patient, to reduce an increase in intra abdominal/thoracic/cranial pressure, prevent or reduce
hip flexion
With reflexes, 0=
absent
With reflexes, 1+=
present, diminished
Potent osmotic diuretic that draws fluid out of brain, puts it into vasculature, and is then excreted through the kidneys
Mannitol
Often used with Mannitol to facilitate the removal of fluid from the vasculature
Lasix
With reflexes, 2+=
normal
With reflexes, 3+=
increased but not necessarily pathological
Reduces cerebral edema
Decadron
With reflexes, 4+=
hyperactive
Names of drains used post-op for brain injuries
JP or hemovac
A shunt works by
removing excess CSF from around the brain and shunting it to the abdominal cavity, or other location
x-ray of cerebral circulation that goes through the femoral artery
Cerebral Angiography
prior to a cerebral angiography, make sure pt is
well hydrated, has voided, has peripheral pulses, and the groin is prepped
Anytime an iodine based dye is used the client will need to be well hydrated to promote
excretion of the dye
bed rest is required after a cerebral angiography for
4-6 hours
Major complication of cerebral angiography
Embolus (arm, heart, kidney, lung, brain)
If a client has a change in LOC, one sided weakness, and paralysis, or motor/sensory deficits post cerebral angiography, think
brain embolus (blood clot) (STROKE!)
With ICP patient, mechanical ventilation is needed to
control ventilation (prevent hypoventilation)
In order to maintain a calm and quiet environment for a patient with ICP, ________ activities
space out activities as much as possible
Records electrical activity to help diagnose ________, and is used as a screening procedure for _____, and is an indicator of ______ death.
Seizure disorders
Coma
Brain
Important to hold ____ prior to an EEG
Caffine
Make sure pt is not _____ prior to an EEG due to a possible drop in blood sugar
NPO
Punture site for a lumbar puncture
Lumbar subarachnoid (3rd - 4th)
Measures ICP with a mamometer
Lumbar puncture
Position client over a table with head down and arched back, or on side in the fetal position for
Lumbar puncture (opens subarachnoid space)
Meningitis is a complication of a
Lumbar puncture
Frontal lobe is responsible for
Speech, expressive language, awareness, memory, skilled movements, emotion behavior, smell
Temporal lobe responsible for
Language reception and understanding, hearing
Cerebellum is responsible for
Balance and muscle coordination and posture
Brain stem regulates
basic body function
Occipital lobe responsible for
Vision, language, reading, visual recognition
Parietal lobe responsible for
body sensations, spoken and written language
Signs of this include chills, fever, positive Kernig and Brudzinski, vomiting, nuchal rigidity, photophobia
Meningitis
This form of meningitis requires droplet precautions
Bacterial
This should be clear and colorless (looks like water)
CSF
Post lumbar puncture, pt needs to lie flat or prone for
2-3 hours
Increase ______ post lumbar puncture
fluids
Most common complication of a lumbar puncture
headache
Headache from lumbar puncture will _____ when the client sits up and ____ when they lie down
increase
decrease
Headache from lumbar puncture is treated with
bed rest, fluids, pain meds, and blood patches
When brain tissue is pulled down through foramen magnum as a result of a sudden drop in ICP
Herniation
When the client’s hip is flexed 90 degrees, then extending the clients knee causes pain, this is a
Positive Kernig sign
When flexing the client’s neck causes flexion of the clients hips and knees, this is a
positive Brudzinski sign
Scalp is very
Vascular
