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NUR 213 > Unit one exam > Flashcards

Unit one exam Flashcards

1
Q

Rule of nines for adults
What age range is this for?

A

15 yrs and greater
Head: 9%
R arm: 9%
L arm: 9%
Anterior abd: 18%
Posterior abd: 18%
Perinium: 1%
L leg: 18%
R leg: 18%

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2
Q

Adult fluid resuscitation rate for burn patients?
What is the age range for this formula?

A
  • LR @ 4mL x weight(kg) x TBSA
  • 15 yrs or older
  • ½ of the volume in the first 8 hrs
  • ½ of the volume in the first 16 hrs
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3
Q

Fluid resuscitation calculation for children
What is the age range for this formula?

A
  • LR @ 3mL x weight (kg) x TBSA
  • 14 yrs or youger
  • ½ of the volume in the first 8 hrs
  • ½ of the volume in the first 16 hrs
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4
Q

What type of burns require a different type of fluid resuscitation?
What is the formula for it?
What age range is this formula for?

A
  • Electrical injuries
  • LR @ 4 mL x weight(kg) x TBSA
  • ½ of the volume in the first 8 hrs
  • ½ of the volume in the first 16 hrs
  • All ages
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5
Q

When calculating fluid resuscitation what time do you use for the formula

A

The time when the injury happens not time of arrival at ER

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6
Q

What are some circumstancs that may require higher volumes of fluid for fluids resuscitation in a burn patient?

A
  • Presence of inhalation injury
  • Electrical injurues
  • Associated trauma
  • Alcohol & drug dependence
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7
Q

What guage IV is needed for fluid resuscitation in burn patients?

A

20 G or greater on unburnt skin if at all possible

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8
Q

What needs to be in place on a burn patient during fluid resuscitation to closly monitor I & O?

A

Foley catheter

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9
Q

Priority Nursing interventions in the EMERGENT phase of burn injuries

A
  • Place pt on 100% humidified o2
  • Trend ABG values and carboxyhemoglobin levels.
  • Elevate the head of the bed to allow for better oxygenation.
  • Maintain emergency airway (intubation and tracheostomy) trays at the bedside.
  • Assist with intubation as necessary.
  • Ensure securement of the endotracheal tube if the patient is intubated.
  • Monitor mechanically ventilated patients closely for signs of respiratory compromise.
  • Place two large-bore IV catheters and begin fluid resuscitation with lactated Ringer’s.
  • Roughly estimate the %TBSA burned and patient weight in kilograms.
  • Cover wounds with a clean, dry sheet.
  • Institute warming measures in the form of blankets or other external heat sources.
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10
Q

To minimize evaporation heat loss and prevent hypothermia what can be done?
Typically what phase is this?

A

Institute warming measures in the form of blankets or other external heat sources.
Emergent phase

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11
Q

Burn pt’s that require intubation need to be closly monitored. Why?

A

Close monitoring of mechanically ventilated patients allows for early detection of respiratory distress. If the tube is dislodged, it may be impossible to reinsert due to the edema. In addition, the securement device will require adjustment (e.g., twill) as the edema continues to worsen/decrease.

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12
Q

What could happen if intubation is delayed when needed?

A

Edema and inflammation may make it impossible to untubate

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13
Q

A burn pt required intibation, what should the nurse make sure stays at bedside and why?

A

a tracheostomy tray should be maintained at the bedside in the event of an unplanned extubation.

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14
Q

Why is it important to monitor ABG trends and carboxyhemoglobin levels?

A

Increasing PaCO2 and decreasing PaO2 and oxygen saturation may indicate the need for intubation. As carboxyhemoglobin levels lower, weaning of oxygen support (FiO2) to a minimal level to sustain oxygenation is indicated

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15
Q

What needs to be done ASAP during treamtent of a pt in the emergent phase of a burn injury? Why?

A

Place patient on 100% humidified oxygen or assist with intubation if necessary. Immediate intervention is necessary for respiratory distress and to provide humidified oxygen and assist in the clearing of carbon monoxide.

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16
Q

Nursing assessments for patients in the emergent phase of a burn injury

A
  • Breath sounds, respiratory rate, and indicators of inhalation injury
  • Oxygen saturation, ABGs, and carboxyhemoglobin levels
  • Face and neck for burns, singed nasal and/or facial hair, and singed eyebrows/eyelashes
  • Upper airway
  • Changes in voice, hoarseness, and swallowing difficulty
  • Vital signs
  • Urine output
  • Anxiety
  • Burn wound size and depth
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17
Q

What is the optimal urine output for a burn patient that indicates adequate fluid resuscitation

A

0.5 mL/kg/hr
or
If myoglobin present: 1 mL/kg/hr

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18
Q

Expected vital signs in the emergent phase of burn wound injuries

A
  • Low BP
  • High HR
  • Low temp
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19
Q

Indications of inhalation injury

A
  • Hypoxemia
  • Wheezing, Crowing, Rhonchi, & Stridor
  • Change in voice or hoarsness
  • Tachypnea, retractions, and nasal flaring
  • Singed nasal hairs, eyebrows and eyelashes
  • Brassy cough
  • Drooling and/or dysphagia
  • Anxiety and/or agitation (r/t hypoxia)
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20
Q

Why are inhalation injuries hard to be caught in pts?

A

They rarely exhibit S/S of resiratory distress
CHXR are usually normal

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21
Q

How long after a burn injury should a patient be monitored for inhalation injuries?

A

24 hr

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22
Q

How can inhalation injuries be definitively dx?

A

Fiberoptic Bronchoscopy

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23
Q

If a pt dos not require intubation for an inhalation injury what needs to be done? And for how long?

A

They need to be put on 100% humidified oxygen until carboxyhemoglobin levels are mantained below 10%

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24
Q

Signs that fluid resuscitation is adequate for a patient

A
  • Urine output: 0.5 mL/kg/hr or 1 mL/kg/hr if myoglobin present
  • Systolic blood pressure: Greater than 100 mm Hg
  • Heart rate:Less than 120 bpm
  • Central venous pressure (CVP)5–10 mm Hg
  • Pulmonary: Lungs sound clear, blood pH within normal range (7.35–7.45)
  • Gastrointestinal: Abdomen soft, non-tender; no nausea, vomiting, or ileus; bladder pressure less than 10 mm Hg
  • Level of consciousness: Clear; alert; and oriented to person, place, and time
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25
Q

What is the combination of distributive and hypovolemic shock. Occurs from massive fluid shift due to increased capillary permeability (first 8-36 hours)

A

Burn Shock

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26
Q

How is burn shock treated?

A

Fuid resuscitation

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27
Q

If a patient is suffering from burn shock and does not recieve fluid resuscitation/adequate fluid resuscitation what can happen?

A
  • Hypotension
  • Tachycardia
  • Decreased urine output
  • Multi-organ failure
  • Edema
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28
Q

What time fram after a burn injury is a patient at risk for burn shock?

A

8-24 hrs

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29
Q

What time frame does fluid remobilization take place in a patient with a burn injury?

A

24-48 hrs

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30
Q

What does this describe?

  • Capillary leak stops
  • Edema fluid shifts from the interstitial spaces into the vascular space
  • Blood volume increases leading to increased renal blood flow and diuresis
  • Body weight returns to normal

Burns

A

Fluid remobilization

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31
Q

What burn depth would this be classified as?

Pink/red

A

Superficial

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32
Q

What burn depth would this be classified as?

A

Superficial

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33
Q

What burn depth would this be classified as?

Blisters, pink/red, pain, blanches

A

Superficial Partial-Thickness

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34
Q

What burn depth would this be classified as?

A

Superficial partial thickness

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35
Q

What burn depth would this be classified as?

A

Superficial partial thickness

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36
Q

What burn depth would this be classified as?

A

Superficial partial-thickness

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37
Q

What burn depth would this be classified as?

A

Deep partial thickness

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38
Q

What burn depth would this be classified as?

A

Deep partial thickness

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39
Q

What burn depth would this be classified as?

A

Deep partial thickness

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40
Q

What burn depth classification is this?

Leathery, dry white/brown/tan/black eschar, no blanching, no pain

A

Full thickness

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41
Q

What burn depth classification is this?

A

Full thickness

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42
Q

What classification of burn depth is this?

A

Full thickness

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43
Q

What procedure is performed to relieve the pressure and should extend only through the eschar and into the immediate subcutaneous fat

A

Escharotomy

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44
Q

An chest wall escarotomy is considered what?

A

A medical emergency

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45
Q

What needs to be done for a patient that has circumfrential burns to the chest that are restricting chest wall expansion

A

Chest wall Escharotomy

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46
Q

In full thickness burns eschar can act as a what?

A

Tourniquet

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47
Q

All of the following are S/S of what?

  • Headache
  • weakness
  • dizziness
  • confusion
  • erythema or pink cherry red skin
  • upper airway edema
  • sloughing of respiratory tracht mucosa
A

CO2 inhalation

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48
Q

The following are S/S of what?

  • Singed hair, eyebrows, eyelashes
  • Sooty sputum
  • hoarsness
  • Wheezing
  • edema of nasal septum
  • smoky smelling breath
A

Inhalation injury

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49
Q

S/S that a patient with an inhalation injury is about to loose their airway?

A
  • Hoarsness
  • cough
  • brassy cough
  • drooling or difficulty swallowing
  • audible wheezing
  • crowing
  • stridor
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50
Q

Procedures to treat compartment syndrome

A

Escharotomy and Fasciotomy

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51
Q

How would you know if an escharotomy is successful?

A

Pulse, color, movement, and sensation of affected extremity return
bleeding is controlled

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52
Q

How to determine if a skin graft is suscessful

A
  • no signs of infection
  • Stable vital signs, including normal heart rate and blood pressure
  • adequate fluid volume status and pain management
  • Normal temperature and normal white blood cell counts support a lack of infection
  • pt is comfortable enought to resume ADL’s
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53
Q

What kind of diet do burn patients require

A

High calorie High protein

54
Q

What kind of diet are burn patients on initially?

A

NPO

55
Q

What can indicate need for additional caloric intake?

A

10% loss in body weight

56
Q

What can be placed to help a burn patient recieved the nutrition they require if they are having trouble tolerating PO intake?

A
  • NG tube
  • Duodenal tbe
57
Q

________ is not used in burn patients much d/t increased risk for infection and hyperglycemia

A

Total parenteal nutrition

58
Q

What is associated with reduction in ileus and stress ulcers in burn patients?

A

Early enteral nutrition

59
Q

What ‘zone’ would this be classified as?

The area that had the most contact with the heat source and is the location of the most severe damage. The tissue undergoes protein coagulation, eschar is often present, pt often reports no pain d/t nerve cells being destroyed.

A

Zone of coagulation

60
Q

What ‘zone’ would this be classified as?

immediately surrounds the zone of coagulation and is characterized by damaged cells and impaired circulation. It is the area of the burn that is most at risk for conversion if the patient does not receive adequate resuscitation.

A

Zone of stasis

61
Q

How to prevent the zone of stasis from converting to a zone of coagulation?

A

fluid resuscitation

62
Q

What ‘zone’ would this be classified as?

the outermost area. Sustains minimal injury and recovers within 1-2 wks spontaneously. The full extent of damage may not be evident for 24-72 hrs post-injury because it may take that long for burns to reveal the true depth of injury

A

Zone of hypernatremia

63
Q

Name the zones

A
64
Q

Nursing interventions in the immediate/acute phase of burn would injuries

A
  • Time medication administration so that the patient receives the full benefit during wound-care procedures
  • Give pain medication on a scheduled basis instead of on an as-needed (prn) basis.
  • Explore the effectiveness of nonpharmacological pain relief techniques
  • Calorie counts and encouragement of oral intake
  • Wound care
  • Assist with ADLs and compliance with rehabilitation exercises
65
Q

___________ needs to be done daily and assessed to promote wound healing and prevent infection

A

wound care

66
Q

How should pain medication be administered to a burn patient?

A

on a schedule rather than PRN

67
Q

What kind of skin graft is this?

A permanent skin graft. Patients own unburnt skin. There can be mesh in place to cover larger areas or places as a sheet on faces and hands for a smoother, more cosmetic apperance.

A

Autograft

68
Q

Benefits of an autograft skingraft

A

This is the ideal coverage for all patients’ burns and has the highest chance of wound closure.

69
Q

Disadvantages of an autograft skin graft

A

May be delicate if meshed widely before application. Staple removal may be tedious.

70
Q

What kind of skin graft is this?

Permanent skin graft. Patient’s own skin sample is sent to a laboratory, where the epidermis is grown in larger patches.

A

Cultured epithelial autograft (CEA)

71
Q

Benefits for a CEA

A

Is a good choice in patients with large burns of 70% or more TBSA burn who do not have enough unburned skin to use as donor for autografting

72
Q

Disadvantages for a CEA

A

Is extremely expensive, very fragile, and susceptible to infection once applied. Dermal layer will never regenerate.

73
Q

What type of skin graft is this?

Permanent skin graft. Two-layer man-made silicone membrane used to replace dermis and is covered with autograft

A

Integra or artificial skin

74
Q

Benefits to integra or artificial skin

A

May provide a functional dermis and better chance of wound closure

75
Q

Disadvantages for integra or artificial skin

A

High risk for infection of the Integra and subsequent graft loss

76
Q

What kind of skin graft is this?

Temporary skin graft. Uses Cadaver skin

A

Allograft

77
Q

Benefits of an allograft

A

Used as a temporary covering once eschar is removed to help close and protect wound

78
Q

Disadvantages of an allograft

A

Will eventually reject and have to be replaced by permanent grafting

79
Q

What kind of skin graft is this?

Temporary skinn graft. Can be porcine or bovine

A

Xenograft

80
Q

Benefits of a xenograft

A

Used as a temporary covering once eschar is removed to help close and protect wound

81
Q

Disadvantages of a xenograft

A

Will eventually reject and have to be replaced by permanent grafting

82
Q

Teaching points for patients in the rehabilitation phase of a burn injury

A
  • Splinting and encouragement of rehabilitation exercises and ADLs
  • Include psychology in patient treatment decisions.
  • Provide community resources for support upon discharge
  • Teach patient and family the importance of and how to apply pressure garments and/or face masks.
  • Teach patient and family about burn prevention, sun protection, and prevention of hyperthermia.
83
Q

What kind of topical treamtent for burns is this?

  • apply every 2-8hr to keep burn moist
  • Advantages: bacterostatic against gram-positive organisms. Painless and easy to apply
  • Disadvantages: hypersensitivity can develop
A

Bacitracin

84
Q

What topical treatment for burns is this?

  • Aminoglycoside anti-infective
  • Advantages: bactericidal amnioglycoside
  • Disadvantages: nephrotoxic, ototoxic
A

Gentamicin

85
Q

Pain medications used for patients with burn injuries

A
  • Morphine sulfate (morphine)
  • Hydromorphone (Dilaudid)
  • Fentanyl (Sublimaze)
  • Ketamine (Ketalar)
  • Oxycodone (OxyContin, Tylox)
  • Methadone (Dolophine)
  • Nonsteroidal anti-inflammatory medications (ibuprofen or naproxen sodium)
86
Q

Proton pump inhibitrs for GI support in burn patients

A
  • Esemeprazole or Nexium
  • Pantoprazole or protonix
87
Q

Normal lab findings for AKI

A
  • Elevated BUN & CREATNINE
  • DECRASED URINE OUTPUT
  • DECREASED NA AND CALCIUM
  • INCREASED PHOSPHORUS
  • Metabolic acidosis
  • Decreased HCT
  • FVO
  • Reduced GFR
  • Increased urine specific gravity
88
Q

Abnormal lab findings for AKI

A

increased potassium

89
Q

normal lab findings for CKD

A
  • Metabolic acidosis (decreased bicarb/ ph)
  • Decreased HGB and HCT
  • Decreased calcium and NA
  • Increased mag, Bun, creatinine, Phos, and K
  • Hematuria, proteinuria, decreased specific gravity
  • Low GFR
90
Q

Abnormal findings of CKD

A

 GRF of <15 indicated ESRD
 Increased K+

91
Q

Pt teaching for ESRD

A

 do not miss dialysis appointments
 Low protein, low sodium, low Potassium, low phosphate diet
 limit fluid intake to 1-2L a day
 monitor weight daily and BP
 increase carbs
 medication compliance
 avoid nephrotoxic substances
 notify PCP of skin breakdown
 notify PCP of complications
 cease smoking

92
Q

Diet for pt with ESRD or dialysis

A
  • Low protein
  • low sodium
  • low potassium
  • low phosphate
  • Increase carbs
  • Fluid intake 1-2L
93
Q

Teaching for PD patients

A
  • check for kinks
  • proper positioning
  • check Abd dressing for dampness
  • when to change dressing to prevent infection.
94
Q

When to call doc during HD

A
  • Hypotension
  • muscle cramps
  • HA
  • N/v
  • dizziness
  • infection
  • dialysis dementia
  • clotting or thrombosis of fistula
95
Q

When to call the doc during PD

A
  • Catheter infection
  • peritonitis (cloudy effluent)
  • Abd pain
  • Hypergylcemia
  • outflow problems
  • Respiratory compromise
  • Protein loss
96
Q

All of the following are clinical manifestations of what?

 Slow onset ; can be asymptomatic until very little function remains
 Anemia
 Calcium and vit d deficiency
 Oliguria
 Azotemia
 HTN
 Decreased GFR
 Fluid retention
 Uremia

A

CKD

97
Q

Clinical manifestations of CKD

A

 Slow onset ; can be asymptomatic until very little renal function remains
 Anemia
 Calcium and vit d deficiency
 Oliguria
 Azotemia
 HTN
 Decreased GFR
 Fluid retention
 Uremia

98
Q

Most common cause of AKI result of external factors
Reduce renal blood flow and lead to decreased glomerular perfusion and filtration
 Cardiac damage (decreased cardiac output)
 Vasodilation
 Hemorrhage
 Burn
 GI losses(Vomiting/diarrhea)

A

Prerenal AKI

Think before

99
Q

Causes of AKI involve direct damage to the renal parenchymal tissue resulting in impaired nephron functioning. The damage occurs as a result of prolonged ischemia.
 Myoglobinuria
 Hemoglobinuria
 Nephrotoxic drugs
 Infections

A

Intra-renal AKI

Think in

100
Q

Causes involve mechanical obstruction of the lower urinary tract (ureters,
bladder, and urethra)
 BPH
 Prostate cancer
 Calculi
 Trauma
 Tumors
 Blood clots
 Neuro damage (stroke)

A

Post-renal AKI

Think after

101
Q

Describe Prerenal AKI and list causes

A

Most common cause of AKI result of external factors
Reduce renal blood flow and lead to decreased glomerular perfusion and filtration
 Cardiac damage (decreased cardiac output)
 Vasodilation
 Hemorrhage
 Burn
 GI losses(Vomiting/diarrhea)

102
Q

Describe Intra-renal AKI and list causes

A

Causes of AKI involve direct damage to the renal parenchymal tissue resulting in impaired nephron functioning. The damage occurs as a result of prolonged ischemia.
 Myoglobinuria
 Hemoglobinuria
 Nephrotoxic drugs
 Infections

103
Q

List nephrotoxic drugs

A
  • NSAIDs
  • ABX: Aminoglycosides-vancomycin and Gentamycin
  • Chemo
  • Contrast dye
  • Magnesium containing antacids
  • Digoxin
  • Phenytoin
  • ACE Inhibitors
  • Metformin
104
Q

Infections that would cause Intra-renal AKI

A

Glomerulonephritis, acute tubular necrosis

105
Q

Describe post-renal AKI

A

Causes involve mechanical obstruction of the lower urinary tract (ureters,
bladder, and urethra)
 BPH
 Prostate cancer
 Calculi
 Trauma
 Tumors
 Blood clots
 Neuro damage (stroke)

106
Q

Complications associated with PD

A

 Peritonitis – cloudy effluent
 Repeated infections
 Catheter site infection
 Abscess
 Abd pain
 Hyperglycemia/ increased triglyceride levels
 Outflow problems
 Respiratory compromise
 Protein loss

107
Q

pt has decreased outflow during PD What should the nurse do?

A
  • Check for kinks in cath
  • reposition pt
  • Gently massage abd
108
Q

Priority interventions for PD

A

 Assess vital signs (BP and HR)
 Assess respiratory status
 Assess temperature
 Assess daily weight
 Assess filtrate appearance
 Assess WBC count
 Assess nutritional intake
 Measure abdominal girth
 Monitor outflow

109
Q

What to assess before a pt goes to HD

A
  • Get vitals
  • Check labs
  • Hold BP meds
  • Check lab values: BUN, Crea, electrolytes, HCT
110
Q

All of the following are S/S of what?

  • N/v
  • Change in LOC
  • seizures,
  • agitation
A

Disequilibrium syndrome

111
Q

What to assess when a pt returns from HD

A
  • Labs: BUN, Crea, Electrolytes, HCT
  • Vitals
  • Weight
  • Give any medications that were held
  • Check HD access site for bleeding
112
Q

All of the following are S/S of what?

  • Hypotension
  • Dizziness
  • Tachycardia
A

Hypovolemia

113
Q

What should be avoided after HD? For how long

A

Invasive prodecures for 4-6hrs

114
Q

What is to be expected post HD?

A

Decreased BP and labs

115
Q

All of the following are S/S of what?

  • HA
  • DECREASED BP
  • HYPERKALEMIA
  • MUSCLE TWITCHING
  • WARM,FLUSHES, SKIN
  • N/V/D
  • CHANGES IN LOC
  • KUSSMAUL RESPIRATION
A

Metabolic acidosis

116
Q

List S/S of Metabolic acidosis

A
  • HA
  • DECREASED BP
  • HYPERKALEMIA
  • MUSCLE TWITCHING
  • WARM,FLUSHES, SKIN
  • N/V/D
  • CHANGES IN LOC
  • KUSSMAUL RESPIRATION
117
Q

Recommended protein intake for a CKD pt

A

0.6-0.8 g/kg

118
Q

Recommended sodium and potassium intake for a CKD pt

A

2-4 g/kg

119
Q

Recommended fluid intake for a pt with CKD

A

1-2 L/day

120
Q

The Following S/S in a kidney transplant pt indicates what?

o Onset w/in 48 hours
o Malaise, high fever , graft tenderness

A

Hyperacute rejection

121
Q

How is hyperacute rejection treated?

A

Immediate removal of the organ

122
Q

The following indicates what in a kidney transplant patient

  • 1 week to 2 years
  • s/s: oliguria , anuria, fever, htn, flank tenderness, lethargy, increased bun/k /creatinine, fluid retention
A

Acute rejection

123
Q

How to treat acute rejection in a kidney transplant patient

A

Increase dose of immunosuppressives

124
Q

The following can indicate what in a kidney transplant patient

o over months to years
o s/s: azotemia, proteinuria and HTN, increased BUN/creatinine, imbalance in electrolyte, fatigue

A

Chronic rejection

125
Q

How is chronic rejection treated in kidney transplant patients?

A

Conservitively: kidney status monitored and immunosuppressive therapy continued until dialysis is required

126
Q

Priority nursing dx for ESRD pt’s

A
  • Excess fluid volume related to renal failure and retention
  • Disturbed thought process
  • Fatigue related to anemia, metabolic acidosis and uremic toxins
  • Potential complications: dysrhythmias arising from electrolyte imbalances
127
Q

Increased plasma lactate can indicate what?

A

Cyanide toxicity

128
Q

If carboxyhemoglobin is more than 10% it can indicate what?

A

Smoke inhalation

129
Q

Expected lab findings in a burn patient during the resuscitation phase

A
  • Hyperglycemia
  • Elevated BUN
  • HGB&HCT Elevated
  • Hyponatremia
  • Hyperkalemia
  • Hyperchloremia
  • Decreased total protein
  • Decreased serum albumin
  • ABG: Metabolic acidosis
130
Q

Expected lab findings During the remobilization phase

A
  • HGB&HCT: decreased
  • Sodium: decreased
  • WBC: increased
  • Glucose: increased
  • ABG: Slight hypoxemia, metabolic acidosis

NUR 213 (29 decks)

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