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%
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
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
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
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
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
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
8
Q
What needs to be in place on a burn patient during fluid resuscitation to closly monitor I & O?
A
Foley catheter
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.
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
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.
12
Q
What could happen if intubation is delayed when needed?
A
Edema and inflammation may make it impossible to untubate
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.
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
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.
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
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
18
Q
Expected vital signs in the emergent phase of burn wound injuries
A
- Low BP
- High HR
- Low temp
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)
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
21
Q
How long after a burn injury should a patient be monitored for inhalation injuries?
A
24 hr
22
Q
How can inhalation injuries be definitively dx?
A
Fiberoptic Bronchoscopy
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%
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
25
What is the combination of distributive and hypovolemic shock. Occurs from massive fluid shift due to increased capillary permeability (first 8-36 hours)
Burn Shock
26
How is burn shock treated?
Fuid resuscitation
27
If a patient is suffering from burn shock and does not recieve fluid resuscitation/adequate fluid resuscitation what can happen?
* Hypotension
* Tachycardia
* Decreased urine output
* Multi-organ failure
* Edema
28
What time fram after a burn injury is a patient at risk for burn shock?
8-24 hrs
29
What time frame does fluid remobilization take place in a patient with a burn injury?
24-48 hrs
30
# 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
Fluid remobilization
31
# What burn depth would this be classified as?
Pink/red
Superficial
32
# What burn depth would this be classified as?
Superficial
33
# What burn depth would this be classified as?
Blisters, pink/red, pain, blanches
Superficial Partial-Thickness
34
# What burn depth would this be classified as?
Superficial partial thickness
35
# What burn depth would this be classified as?
Superficial partial thickness
36
# What burn depth would this be classified as?
Superficial partial-thickness
37
# What burn depth would this be classified as?
Deep partial thickness
38
# What burn depth would this be classified as?
Deep partial thickness
39
# What burn depth would this be classified as?
Deep partial thickness
40
# What burn depth classification is this?
Leathery, dry white/brown/tan/black eschar, no blanching, no pain
Full thickness
41
# What burn depth classification is this?
Full thickness
42
# What classification of burn depth is this?
Full thickness
43
What procedure is performed to relieve the pressure and should extend only through the eschar and into the immediate subcutaneous fat
Escharotomy
44
An chest wall escarotomy is considered what?
A medical emergency
45
What needs to be done for a patient that has circumfrential burns to the chest that are restricting chest wall expansion
Chest wall Escharotomy
46
In full thickness burns eschar can act as a what?
Tourniquet
47
# 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
CO2 inhalation
48
# The following are S/S of what?
* Singed hair, eyebrows, eyelashes
* Sooty sputum
* hoarsness
* Wheezing
* edema of nasal septum
* smoky smelling breath
Inhalation injury
49
S/S that a patient with an inhalation injury is about to loose their airway?
* Hoarsness
* cough
* brassy cough
* drooling or difficulty swallowing
* audible wheezing
* crowing
* stridor
50
Procedures to treat compartment syndrome
Escharotomy and Fasciotomy
51
How would you know if an escharotomy is successful?
Pulse, color, movement, and sensation of affected extremity return
bleeding is controlled
52
How to determine if a skin graft is suscessful
* 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
53
What kind of diet do burn patients require
High calorie High protein
54
What kind of diet are burn patients on initially?
NPO
55
What can indicate need for additional caloric intake?
10% loss in body weight
56
What can be placed to help a burn patient recieved the nutrition they require if they are having trouble tolerating PO intake?
* NG tube
* Duodenal tbe
57
________ is not used in burn patients much d/t increased risk for infection and hyperglycemia
Total parenteal nutrition
58
What is associated with reduction in ileus and stress ulcers in burn patients?
Early enteral nutrition
59
# 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.
Zone of coagulation
60
# 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.
Zone of stasis
61
How to prevent the zone of stasis from converting to a zone of coagulation?
fluid resuscitation
62
# 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
Zone of hypernatremia
63
Name the zones
64
Nursing interventions in the immediate/acute phase of burn would injuries
* 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
___________ needs to be done daily and assessed to promote wound healing and prevent infection
wound care
66
How should pain medication be administered to a burn patient?
on a schedule rather than PRN
67
# 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.
Autograft
68
Benefits of an autograft skingraft
This is the ideal coverage for all patients’ burns and has the highest chance of wound closure.
69
Disadvantages of an autograft skin graft
May be delicate if meshed widely before application. Staple removal may be tedious.
70
# 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.
Cultured epithelial autograft (CEA)
71
Benefits for a CEA
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
Disadvantages for a CEA
Is extremely expensive, very fragile, and susceptible to infection once applied. Dermal layer will never regenerate.
73
# 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
Integra or artificial skin
74
Benefits to integra or artificial skin
May provide a functional dermis and better chance of wound closure
75
Disadvantages for integra or artificial skin
High risk for infection of the Integra and subsequent graft loss
76
# What kind of skin graft is this?
Temporary skin graft. Uses Cadaver skin
Allograft
77
Benefits of an allograft
Used as a temporary covering once eschar is removed to help close and protect wound
78
Disadvantages of an allograft
Will eventually reject and have to be replaced by permanent grafting
79
# What kind of skin graft is this?
Temporary skinn graft. Can be porcine or bovine
Xenograft
80
Benefits of a xenograft
Used as a temporary covering once eschar is removed to help close and protect wound
81
Disadvantages of a xenograft
Will eventually reject and have to be replaced by permanent grafting
82
Teaching points for patients in the rehabilitation phase of a burn injury
* 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
# 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
Bacitracin
84
# What topical treatment for burns is this?
* Aminoglycoside anti-infective
* Advantages: bactericidal amnioglycoside
* Disadvantages: nephrotoxic, ototoxic
Gentamicin
85
Pain medications used for patients with burn injuries
* Morphine sulfate (morphine)
* Hydromorphone (Dilaudid)
* Fentanyl (Sublimaze)
* Ketamine (Ketalar)
* Oxycodone (OxyContin, Tylox)
* Methadone (Dolophine)
* Nonsteroidal anti-inflammatory medications (ibuprofen or naproxen sodium)
86
Proton pump inhibitrs for GI support in burn patients
* Esemeprazole or Nexium
* Pantoprazole or protonix
87
Normal lab findings for AKI
* Elevated BUN & CREATNINE
* DECRASED URINE OUTPUT
* DECREASED NA AND CALCIUM
* INCREASED PHOSPHORUS
* Metabolic acidosis
* Decreased HCT
* FVO
* Reduced GFR
* Increased urine specific gravity
88
Abnormal lab findings for AKI
increased potassium
89
normal lab findings for CKD
* 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
Abnormal findings of CKD
GRF of <15 indicated ESRD
Increased K+
91
Pt teaching for ESRD
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
Diet for pt with ESRD or dialysis
* Low protein
* low sodium
* low potassium
* low phosphate
* Increase carbs
* Fluid intake 1-2L
93
Teaching for PD patients
* check for kinks
* proper positioning
* check Abd dressing for dampness
* when to change dressing to prevent infection.
94
When to call doc during HD
* Hypotension
* muscle cramps
* HA
* N/v
* dizziness
* infection
* dialysis dementia
* clotting or thrombosis of fistula
95
When to call the doc during PD
* Catheter infection
* peritonitis (cloudy effluent)
* Abd pain
* Hypergylcemia
* outflow problems
* Respiratory compromise
* Protein loss
96
# 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
CKD
97
Clinical manifestations of CKD
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
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)
Prerenal AKI
| Think before
99
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
Intra-renal AKI
| Think in
100
Causes involve mechanical obstruction of the lower urinary tract (ureters,
bladder, and urethra)
BPH
Prostate cancer
Calculi
Trauma
Tumors
Blood clots
Neuro damage (stroke)
Post-renal AKI
| Think after
101
Describe Prerenal AKI and list causes
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
Describe Intra-renal AKI and list causes
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
List nephrotoxic drugs
* NSAIDs
* ABX: Aminoglycosides-vancomycin and Gentamycin
* Chemo
* Contrast dye
* Magnesium containing antacids
* Digoxin
* Phenytoin
* ACE Inhibitors
* Metformin
104
Infections that would cause Intra-renal AKI
Glomerulonephritis, acute tubular necrosis
105
Describe post-renal AKI
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
Complications associated with PD
Peritonitis – cloudy effluent
Repeated infections
Catheter site infection
Abscess
Abd pain
Hyperglycemia/ increased triglyceride levels
Outflow problems
Respiratory compromise
Protein loss
107
pt has decreased outflow during PD What should the nurse do?
* Check for kinks in cath
* reposition pt
* Gently massage abd
108
Priority interventions for PD
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
What to assess before a pt goes to HD
* Get vitals
* Check labs
* Hold BP meds
* Check lab values: BUN, Crea, electrolytes, HCT
110
# All of the following are S/S of what?
* N/v
* Change in LOC
* seizures,
* agitation
Disequilibrium syndrome
111
What to assess when a pt returns from HD
* Labs: BUN, Crea, Electrolytes, HCT
* Vitals
* Weight
* Give any medications that were held
* Check HD access site for bleeding
112
# All of the following are S/S of what?
* Hypotension
* Dizziness
* Tachycardia
Hypovolemia
113
What should be avoided after HD? For how long
Invasive prodecures for 4-6hrs
114
What is to be expected post HD?
Decreased BP and labs
115
# 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
Metabolic acidosis
116
List S/S of Metabolic acidosis
* HA
* DECREASED BP
* HYPERKALEMIA
* MUSCLE TWITCHING
* WARM,FLUSHES, SKIN
* N/V/D
* CHANGES IN LOC
* KUSSMAUL RESPIRATION
117
Recommended protein intake for a CKD pt
0.6-0.8 g/kg
118
Recommended sodium and potassium intake for a CKD pt
2-4 g/kg
119
Recommended fluid intake for a pt with CKD
1-2 L/day
120
# The Following S/S in a kidney transplant pt indicates what?
o Onset w/in 48 hours
o Malaise, high fever , graft tenderness
Hyperacute rejection
121
How is hyperacute rejection treated?
Immediate removal of the organ
122
# 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
Acute rejection
123
How to treat acute rejection in a kidney transplant patient
Increase dose of immunosuppressives
124
# 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
Chronic rejection
125
How is chronic rejection treated in kidney transplant patients?
Conservitively: kidney status monitored and immunosuppressive therapy continued until dialysis is required
126
Priority nursing dx for ESRD pt's
* 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
Increased plasma lactate can indicate what?
Cyanide toxicity
128
If carboxyhemoglobin is more than 10% it can indicate what?
Smoke inhalation
129
Expected lab findings in a burn patient during the resuscitation phase
* Hyperglycemia
* Elevated BUN
* HGB&HCT Elevated
* Hyponatremia
* Hyperkalemia
* Hyperchloremia
* Decreased total protein
* Decreased serum albumin
* ABG: Metabolic acidosis
130
Expected lab findings During the remobilization phase
* HGB&HCT: decreased
* Sodium: decreased
* WBC: increased
* Glucose: increased
* ABG: Slight hypoxemia, metabolic acidosis
