Unit Four Exam Study Guide

Resuscitation/Early Phase of Burn Injury

1st phase of burn injury Continues for about 24 to 48 hours Injury is evaluated Immediate problems of fluid loss, edema, and reduced blood flow are assessed Priorities of management: -#1 Secure airway -Support circulation by fluid replacement (biggest complication will be hypovolemic shock) -Keep pt comfortable with analgesics -Prevent infection with careful wound care -Maintain body temperature -Provide emotional support

Heat Exhaustion

A syndrome caused primarily by dehydration, stemming from heavy perspiration and inadequate fluid and electrolyte consumption during heat exposure over a period of hours to days. Pts feel ill, and their clinical manifestations resemble the flu, with minimal temp elevation. Treatment involves immediate termination of physical activity and transfer to a cool place, sports drink, cold packs to neck, chest, abdomen & groin

Heat Stroke

A true medical emergency in which body temperature may exceed 104° F (40° C). High mortality rate if not treated in a timely manner. Exertional heat stroke—sudden onset, typically caused by strenuous physical activity in hot, humid conditions. Classic heat stroke—occurs over a period of time as a result of chronic exposure to a hot, humid environment.

UTI Treatment

Adequate fluids to maintain dilute urine Diet therapy includes all food groups, calorie increase due to increase in metabolism caused by the infection, fluids, possible intake of cranberry juice preventatively (>4wks) Avoid caffeine, carbonated beverages, tomato products- irritants Other pain relief measures: warm sitz baths, peri-bottle with urination Surgical: Surgery aimed at treating conditions leading to recurrent UTIs i.e. Cystoscopy for obstructions, reflux

External Disaster

An external disaster is any event outside the health care facility or campus, somewhere in the community, which requires the activation of the facility's Emergency Management Plan. The number of facility staff is not adequate for the incoming patients. External disasters can be either natural, such as a hurricane, or technological, such as a biological terror attack

UTI Treatment: Drug Therapy

Antibiotics: 3-day course Trimethoprim 60mg/ Sulfamethoxazole 800mg BID. Also, Quinolones, PCNs, Cephalosporins. Teach clients to complete full course of treatment with or without symptom resolution Analgesics: Pyridium/AZO for pain and burning, may discolor urine red/orange Antispasmodics: Anaspaz (anticholinergic) Antifungal agents: Amphotericin B, Ketoconazole Fungal infections more common among immunocompromised and diabetic pts Long-term (7-21 dys.) antibiotic therapy for chronic, recurring infections; hospitalized pts, pregnancy, catheters, stones, DM, immunosuppression Estrogen vaginally for postmenopause (controversial)

Skin Assessment

Assess skin to determine size and depth of injury The size of the injury is first estimated in comparison with the total body surface area (TBSA). Inspect the skin to identify injured areas and changes in color and appearance. Percentage of TBSA affected use the "Rule of nines" using multiples of 9% With this method, the body is divided into areas that are multiples of 9%.

Collaborative Management

Assessment: thorough client history with detailed questions Physically Assess for bladder fullness, urethral or uterine prolapse, cystocele, rectocele, urethral discharge (males), DRE for nerve integrity, BPH Laboratory: UA r/o infection Imaging: Voiding cystourethrogram (VCUG) for size shape support and function of bladder Urography for locating the kidneys & ureters if considering surgery Other diagnostic assessments: Bladder scan for PVR,

Acute Phase of Burn Injury

Begins about 36 to 48hr after injury; lasts until wound closure is completed Care directed toward continued assessment and maintenance of CV and respiratory systems, as well as GI and nutritional status, burn wound care, pain control, psychosocial interventions Nonsurgical management: Mechanical debridement- Hydrotherapy Enzymatic debridement- Autolysis-hydrocolloids/hydrogels Collagenase

Injuries to the Respiratory System: Carbon monoxide poisoning

Carbon monoxide poisoning Leading cause of death from a fire Cherry red appearance/lack of cyanosis See Table 28-4

Bladder Trauma

Causes may be due to injury to the lower abdomen, stabbing or gunshot wounds, sexual assault. Most common cause is fractured pelvis with puncture to bladder Surgical intervention is required- repairing bladder wall & peritoneal membrane. Foley & Penrose drains post-op

BPH: Nursing Management

Client Teaching: Avoid bearing down for BM - suppository Avoid lifting heavy objects Avoid intercourse for 6 weeks to prevent bleeding following discharge Orthostatic hypotension with alpha blockers (take at bedtime)

Urinary Incontinence

Continence is control over time & place of urination; occurs when urethral pressure >bladder pressure, for normal voiding the urethra must relax & bladder must contract Temporary or chronic Incontinence (loss of control) Causes: Surgical, Injury, Bladder irritation secondary to chronic infection, stones, chemotherapy, radiation and Inappropriate bladder contractions secondary to disorders of brain & nervous system

Event Resolution

Defusing allows staff to talk about their feelings to process their emotions informs normal stress responses versus prolonged responses Debriefing: more formal all HCP are invited to attend; not critique of situation but opportunity to express their feelings & gain insight to others Critical incident stress management debriefing Administrative review Psychosocial response of survivors to mass casualty events Post traumatic stress disorders (PTSD)

Nonsurgical Management

Drug therapy -Opioid analgesics -Non-opioid analgesics CAM therapies -Relaxation therapy -Meditative breathing -Guided Imagery -Music therapy -Healing/therapeutic touch -Acupuncture/acupressure Environmental changes -Quiet environment -increased patient control

Superficial partial-thickness:

Entire epidermis and parts of the dermis layer of skin are destroyed. Uncomplicated healing Occurs to upper third of the dermis, leaving a good blood supply, wounds are red and moist blanch when pressure is applied pain increased- nerve endings are exposed mild edema blisters Heal in 10-21 days with no scar formation but minor pigment changes may occur Examples: scalds, flames, & brief contact with hot surface

BPH (benign prostatic hyperplasia)

Hyperplasia (enlarged cells) resulting in hypertrophy (enlarged prostate) Causes obstruction resulting in stasis or overflow incontinence Prostate gland enlarges with age. No risk factors identified. Some prostate tissue replaced with scarlike fibrotic tissue - Benign Prostatic Hypertrophy. Affects about 50% of men - 90% by age 80. Causes problems with urination & ejaculation. BPH partially blocks urethra.

Metabolic Changes

Increased secretions of catecholamines, antidiuretic hormone, aldosterone, cortisol Increased oxygenation and caloric needs Increased core body temp as response to temp regulation by hypothalamus

Urethritis: inflammation of the urethra

Inflammation of the urethra that causes symptoms similar to urinary tract infection Men: S/S- include burning or difficulty urinating and a discharge from the urethral meatus. Usually caused by STD; Tx with appropriate antibiotic therapy -UA: pyuria (WBCs in urine) with few bacteria -Urethral culture: STD Most common in postmenopausal women due to low estrogen tissue changes seen on pelvic exam and/or Urethroscopy -UA/urethral cx negative—treat with vaginal estrogen

Partial-Thickness Wounds

Involves entire epidermis and parts of the dermis Subdivided based on amount of dermal tissue damaged. Categorized as: Superficial partial-thickness and Deep partial-thickness injuries

Snake Bites Two families of poisonous snakes in N. America; 1. Pit vipers (rattlesnakes, copperheads, and cottonmouths) 2. Coral Snakes

Key Features for both: weakness, nausea, vomiting, hypotension, seizures, coagulopathy, severe pain, localized tissue swelling or redness. 1. Pit vipers S/S include: * Severe pain, swelling, and redness or ecchymosis around bite * Hrs later, vesicles or hemorrhagic bullae may form. * Systemic responses include a minty, rubbery, or metallic taste paresthesias of the scalp, face, and lips. *Muscle fasciculations (twitching) and weakness, nausea, vomiting, hypotension, seizures, and coagulopathy (clotting abnormalities) or DIC. *If the bite site does not show evidence of local tissue swelling or redness within 8 hours, systemic effects less likely to develop. TABLE 11-1 GRADES OF PIT VIPER ENVENOMATION None- Fang marks, but no local or systemic reactions Minimal- Fang marks, local swelling/pain, no systemic reactions Moderate- Fang marks and swelling progressing beyond the site of the bite; systemic s/s such as N/V, paresthesias, & hypotension Severe- Fang marks with swelling of the extremity, subcutaneous ecchymosis, severe symptoms, including manifestations of coagulopathy 2. Coral Snakes S/S include: The effect is to block neurotransmission, producing *ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis *Unlike the pain from pit viper bites, pain at site may be only mild *The venom is spread via the lymphatic system, but swelling is unlikely. *Fang marks may be difficult to find because of small teeth. *The toxic effects of venom may be delayed up to 12-18hrs, but then produce rapid clinical deterioration. **Early signs and symptoms are nausea, vomiting, headache, pallor, and abdominal pain. *Assess for neurologic manifestations; paresthesias, numbness, and mental status changes, as well as cranial nerve and peripheral nerve deficits. *Total flaccid paralysis may occur later, and may have difficulty speaking, swallowing, and breathing. *Clotting changes do not occur. *Respiratory problems and cardiovascular collapse can occur in severe cases *ABGs reveal respiratory insufficiency. *The muscle toxin in the venom can cause an elevation in (CK) from muscle breakdown and produce myoglobinuria (release of muscle myoglobulin into the urine). Despite these clinical effects, death is rare if the patient receives timely management

Anaphylaxis

Life-threatening, allergic response Symptoms—respiratory distress with bronchospasm, laryngeal edema, hypotension, decline in mental status, cardiac dysrhythmias Constitutes true medical emergency; imminently life threatening and may lead to cardiac arrest Allergic reaction vs. toxic venom reaction - may be indistinguishable; both can cause same early signs/symptoms

Urothelial Cancer

Malignant tumors of lining of transitional cells in kidney, renal pelvis, ureters, urinary bladder and urethra. Most occur in bladder. a.k.a. "bladder cancer": 73% of all urinary tract cancers are transitional cell carcinomas of the bladder Second most common site is kidney and renal pelvis High incidence of recurrence Risk factors: Greatest risk factor is tobacco use. Diagnostics: Hematuria is often only significant finding on UA Biopsies (cystoscopy) & bladder-wash specimens- most specific CT for invasion of surrounding tissues MRI for deep, invasive tumors

Urethral Strictures

Noninfectious, Narrowing of the urethra Do to complication of STD, trauma with catheterization, urologic procedures, childbirth, and 1/3 is unknown Most common symptom is painless, obstruction of urine flow---this puts pt at risk for UTI May have overflow incontinence- the involuntary loss of urine when the bladder is over distended. Assess the patient for these 2 problems. Stricture is tx surgically: Dilation of the urethra (using local anesthetic)- temporary tx Stent placement can be used on some Best long-term care is by Urethroplasty: removal of affected area with or without grafting to create larger opening—best chance of long-term cure...recurrence rate still high most need repeat surgeries The urethral stricture location and length are the most important factors affecting choice of interventions and recovery.

Urothelial Cancer: Tx

Nonsurgical management Prophylactic immunotherapy Chemotherapy: Intravesical is instilled in bladder with only local side effects Radiation therapy Surgical Management: Cystectomy (best chance of cure) with post-op alternatives (p. 1514, Figure 69-4): Ileal conduit - pouch, watch stoma post-op Ileal reservoir - surgically-created continent pouch "neobladder" - self cath Ureterostomies- stoma w/ external pouch Ureterosigmoidostomy - no stoma, urine with BM Postoperative care includes: Collaboration with enterostomal therapist Neobladder- drains post-op for irrigation, patency

Injuries to the Respiratory System: Pulmonary Fluid Overload

Occurs even when lung tissues have not been damaged directly Histamine, other inflammatory mediators cause capillaries to leak fluid into pulmonary tissue space Circulatory overload from resuscitation may cause left sided congestive heart failure Patient short of breath/dyspnea in supine position, crackles heard on auscultation **Nursing Safety Priority- Critical Rescue: When symptoms of pulmonary edema are present, elevate the head of the bed to at least 45 degrees, apply humidified oxygen, and notify the burn team or the Rapid Response Team.

Triage nurse in the ED

Performs rapid assessment includes: Chief C/O VS Overall appearance pain level to determine pt acuity triage priority by category: Emergent triage, Urgent triage, Nonurgent triage

Snake Bites: Treatment

Pre-hospital: *First priority is to move the person to a safe area away from the snake and encourage rest to decrease venom circulation. *Remove jewelry and constricting clothing. *Immobilize affected extremity in a position of function. *Maintain the extremity below the level of the heart. *Keep individual warm and calm. *Do not offer any stimulants such as caffeine *If transport is delayed, apply a 2-4 cm constricting band *Assess distal circulation frequently. *Do not incise and suck or apply ice to the wound. Hospital Care: *Supplemental oxygen *Two large-bore IV lines for NSS or RL *Continuous cardiac and BP monitoring *Opioids *Tetanus prophylaxis *Wound care *Broad-spectrum antibiotics *Baseline labs and coagulation profile

Burn injury: Skin changes resulting from burn injury: Depth of burn injury

Severity determined by how much body surface area is involved ,as well as depth of the burn. Classified as Superficial, Partial & Full-thickness wounds Differences of thickness in various parts of the body is a factor. Sensitive areas: eyelids, ears, nose, hands, feet, genitalia and elderly skin There is a direct relationship between the intensity of heat and duration of exposure: Exposure for prolonged periods causes burns, even with milder temps. At more extreme temps, tissue damage results after only seconds Classification of Burn Depth: Table 28-1

Surgical management

Surgical excision Wound covering Skin graft

Urolithiasis (kidney stones

The presence of calculi (stones) in the urinary tract. Stones do not cause symptoms until they pass into the urinary tract, where they can cause excruciating pain. Nephrolithiasis is the formation of stones in the kidney. Formation of stones in the ureter is ureterolithiasis. Greatest risk factor is history of previous stones! Manifestations: - Sudden Severe Pain (renal colic); can extend to abdomen, groin; nausea, vomiting, pallor, diaphoresis. - Frequency/Dysuria when stone reaches bladder - Oliguria/Anuria = obstruction EMERGENCY!!! - Assess for bladder distension, flank pain Testing: Laboratory assessment: UA (hematuria, pyuria if stasis), urine pH, serum WBC, Ca++, Phosphorus, Uric Acid Radiographic assessment: KUB, IV pyelogram, CT, MRI Other diagnostic tests: renal ultrasound to identify hydronephrosis

Nurse Role in Community Preparedness

Triage First aid /emergency care Shelter assistance Teaching Supervising volunteers Be calm & reassuring, establish rapport with active listening and honest communication and help the victims to adapt to changes & new surroundings

Cystitis: Bladder infection- Diagnostics

UA- for leukocyte esterase & nitrate; pyuria, hematuria is positive= infection Culture- confirms type of organism and #colonies---expensive, 48hr results Sensitivity- determine appropriate antibiotics Serum WBC: May be elevated with "left shift"- indicates increased # of immature WBCs (bands) increasing in response to infection. "Left Shift" may indicate urosepsis and should be reported. Cystoscopy- for recurrent UTIs (>3-4/yr.) -Identifies bladder calculi, diverticula, urethral strictures, foreign bodies, trabeculation, dx Interstitial Cystitis Retrograde pyelography w/ Cystoscopy- identifies obstructions and reflux

Specific management: Radiation Burns

•Remove the patient from the radiation source. •If the patient has been exposed to radiation from an unsealed source, remove his or her clothing (using tongs or lead protective gloves). •If the patient has radioactive particles on the skin, send him or her to the nearest designated radiation decontamination center. •Help the patient bathe or shower.

Specific Management: Flame Burns

•Smother the flames. •Remove smoldering clothing and all metal objects.

Rehabilitative Phase of Burn Injury

Begins with wound closure, ends when patient returns to highest possible level of functioning Emphasis on psychosocial adjustment, prevention of scars and contractures, resumption of preburn activity This phase may last years or even a lifetime if patient needs to adjust to permanent limitations

Frostbite Treatment: Hospital Care

*For all degrees of partial-thickness to full-thickness frostbite, rapid rewarming in a water bath at a temp range of 104° to 108° F (40° to 42° C) is indicated to thaw the frozen part *If a warming tub is not available, use hot towels instead. Because patients experience severe pain during the rewarming process, administer analgesics, especially IV opiates, and IV rehydration **Nursing Safety Priority- Critical Rescue: Do not apply dry heat or massage the frostbitten areas as part of the warming process. These actions can produce further tissue injury. *When the rewarming process is complete, handle the injured areas gently and elevate them above heart level if possible to decrease tissue edema. *Assess the person hourly for the development of compartment syndrome *Observe for early S/S- increasing pain (even after analgesics are given) and paresthesias (painful tingling and numbness). *Compare the affected extremity with the unaffected one to assess for pallor, pulses and muscle weakness. Frostbite destroys tissue and produces a deep tetanus-prone wound; the patient should be immunized to prevent tetanus. *Apply only loose, nonadherent sterile dressings to the damaged areas. *Both topical and systemic antibiotics may be used. *Severe, deep frostbite, débridement of necrotic tissue may be needed to evaluate tissue viability and provide wound management. *Amputation may be indicated for pts with severe injuries or who develop gangrene or severe compartment syndrome.

Hypothermia Treatment: First Aid Pre-hospital Care:

*Mild hypothermia Tx: sheltered from cold environment, have all wet clothing removed, and undergo passive or active external rewarming. Passive methods- applying warm clothing or blankets. Active methods- heating blankets, warm packs, and convective air heaters or warmers to speed rewarming. *Mild, uncomplicated hypothermia- drink warm high-carbohydrate liquids that do not contain alcohol or caffeine aid in rewarming. The citation provided is a guideline.

Frostbite Treatment: First Aid/Pre-hospital Care:

*Recognition is essential to early, effective tx and prevention of further tissue damage. *Frequently observe for early signs of frostbite such as: a white, waxy appearance to exposed skin, especially on the nose, cheeks, and ears, is an effective strategy to identify the problem before it worsens. *Best remedy is to have the person seek shelter from the wind and cold and to attend to the affected body part *Superficial frostbite is easily managed using body heat to warm the affected area. *Teach pts to place their warm hands over the affected areas on their face or to place cold hands under the arms.

Spider Bites 1) Brown Recluse 2) Black Widow

1. Bites from brown recluse spiders result in ulcerative lesions: Necrotic wound (necrotic arachnidism) Systemic effects (loxoscelism) *Central bite site may appear as a bleb/vesicle surrounded by edema and erythema, which may expand over the course of hrs as the toxin spreads *Center of bite becomes bluish purple. Some have few or no tissue changes and don't require medical attention. In others who are bitten, over 1-3 days the central part of the wound becomes dark and necrotic. *Eschar (a necrotic, leathery covering over the wound) eventually forms *When the eschar sloughs, an open wound or ulcer can remain for weeks-months **Rare cases, some pt's may also have S/S of systemic toxicity to brown recluse spider bites. These can include: a rash, fever, chills, nausea, vomiting, malaise, and joint pain. In the worst cases, hemolytic reactions, renal failure, pulmonary edema, cardiovascular collapse, and death can occur. 2. Envenomation from black widow produces latrodectism; severe abd pain, muscle rigidity and spasm, HTN, and N/V *Other symptoms include facial edema, ptosis, diaphoresis, weakness, increased salivation, priapism, respiratory difficulty, increased respiratory secretions, fasciculations, and paresthesias.

Spider Bite: Treatment

1. Brown Recluse: First Aid *Use ice intermittently during the first 4 days after the bite. *Don't use heat it increases enzyme activity *Elevate the affected extremity. *Provide local wound care. Rest the extremity. 2. Black Widow First Aid: Apply an ice pack. Monitor for systemic toxicity Support the pt's ABCs Transport the pt to a medical facility In hospital: Monitor vital signs Opioid pain meds Muscle relaxants such as Valium, Calcium gluconate Tetanus prophylaxis Antihypertensive agents as needed Treatment of pulmonary edema, uncontrollable HTN, and shock

Urolithiasis (kidney stones) Tx

Drug therapy: -Opioid analgesics—often used to control pain -Nonsteroidal anti-inflammatory drugs -Pain medications at regular intervals -Spasmolytic drugs—important for relief of pain(Ditropan/oxybutynin chloride) Complementary and alternative therapy: ENCOURAGE FLUIDS! AVOID DEHYDRATION! Avoid foods containing large amts. of oxalate (spinach, greens, chocolate, nuts)

Continuous Bladder Irrigation

3 way system for bladder irrigation Triple-lumen or 3-way Foley catheter Two fold purpose: Irrigate bladder to remove blood clots Put pressure on resected areas of urethra Important to frequently assess patency of catheter. Assess color of drainage - for bright red blood - immediate action. Strict I & O's

High altitude illness: Key Features

AMS includes: *Throbbing HA, N/V, chilled, irritable, and apathetic *Vital signs are variable *May experience dyspnea both on exertion and at rest. *Exertional dyspnea is expected as a person adjusts to high altitude. However, dyspnea at rest is abnormal and may signal the onset of HAPE. High altitude cerebral edema (HACE), extreme form of AMS: *Cannot perform ADLs and has extreme apathy. *Key sign of HACE is the development of ataxia (defective muscular coordination). *Change in mental status with confusion and impaired judgment. *If untreated, a further decline results- Stupor, coma, and death can result from brain swelling and damage caused by ICP over the course of 1 to 3 days. High altitude pulmonary edema (HAPE): *Have poor exercise tolerance and a prolonged recovery time after exertion. Important S/S of HAPE include: *a persistent dry cough and cyanosis of the lips and nail beds. *Tachycardia and tachypnea occur at rest. *Crackles may be auscultated in one or both lungs. *Pink, frothy sputum is a late sign of HAPE. *A chest x-ray show pulmonary infiltrates and pulmonary edema. *ABGs show respiratory alkalosis and hypoxemia *Pneumonia also may be present. *Pulmonary artery pressure is usually very elevated due to pulmonary edema

Diagnostics for kidney dysfunction: Excretory urography

Excretory urography: To measure kidney size To detect obstruction To assess parenchymal mass Radiopaque contrast medium may cause an allergic (hypersensitivity) reaction in iodine-sensitive patients. Contrast agent is also hypertonic and increases the risk for acute kidney injury in adults with serum creatinine levels greater than 1.5 mg/dL. Nephrotoxic complications can be prevented by parenteral fluid administration.

Drowning

Duration and severity of hypoxia the 2 most important factors **Prevention is key * Immediate emergent care focuses on safe rescue of the victim *Remove from water *Airway clearance and Ventilatory support ASAP! **DON'T attempt to get water out of lungs; provide abd or chest thrusts only if necessary due to airway obstruction Hospital Care: once safely removed from waterb Airway and cardiopulmonary support interventions begin including *O2 admin *Trache intubation *CPR & D-fib if necessary *Gastric decompression *Support of body systems

Heat Stroke *Critical rescue*

After ensuring a patent airway, effective breathing, and adequate circulation, use rapid cooling!! **Rapid Cooling is the #1 priority of care after assessing ABCs Methods for rapidly cooling include: •Removing clothing •Placing ice packs on the neck, axillae, chest, and groin •Immersing the victim in cold water •Wetting the pat's body with tepid water and then fanning rapidly to aid in cooling by evaporation Drenching the victim with large amounts of icy water may be the fastest, most effective means to reduce core body temperature

Internal Disaster

An internal disaster is any event inside a health care facility or campus that could endanger patients or staff and creates a need for evacuation or relocation. It often requires extra personnel and the activation of the facility's Emergency Preparedness and Response Plan. Examples of potential internal disasters include fire, explosion, and violence

Burn injury: Skin changes resulting from burn injury: Anatomic

Anatomic changes: Skin is the largest organ of the body with two major layers; epidermis & dermis- both have sublayers Epidermis (outer layer) made up of epithelial cells can regrow after a burn injury because epidermal cells surrounding sweat and oil glands, and hair follicles extend into dermis tissue and regrow to heal partial thickness wounds. Dermis is thicker and made up of collagen, fibrous connective tissue, and elastic fibers. Within the dermis are blood vessels, sensory nerves, hair follicles, lymph vessels, sebaceous and sweat glands. When burn injury occurs skin can regrow as long as parts of the dermis are present. When the entire layer of dermis is burned, all epithelial cells and dermal appendages are destroyed and the skin can no longer restore itself. The subcutaneous tissue lies below the dermis and varies in thickness. The Basement membrane a thin non-cellular protein surface separates the dermis from the subcutaneous tissue layer. With deep burns the subcutaneous tissues may be damaged leaving bone, tendons, and muscles exposed

Heat Stroke Treatment

At the Scene (pre-hospital)- •Ensure a patent airway. •Remove the patient from the hot environment (into air-conditioning or into the shade). •Remove the pt's clothing. •Pour or spray water on the pt's body and scalp. •Fan the pt (not only the person providing care, but all surrounding people should fan the patient with newspapers or whatever is available). •If ice is available, place ice in cloth or bags and position the packs on the patient's scalp, in the groin area, behind the neck, and in the armpits. •Get the pt to the nearest ED! Hospital care- •The first priority for collaborative care is to monitor and support ABC's. •Provide high-concentration O2 therapy, start several IV lines with 0.9% saline solution, and insert a urinary catheter. •Continue aggressive interventions to cool the patient until the rectal temperature is 100° F (37.8° C) •Obtain baseline laboratory tests as quickly as possible: serum electrolytes, cardiac enzymes, liver enzymes, and complete blood count (CBC). •Obtain urinalysis, and monitor urine output. •Assess arterial blood gases. •Administer muscle relaxants (benzodiazepines) if the patient begins to shiver. •Measure urine output and specific gravity to determine fluid needs. •Slow cooling interventions when core body temperature is reduced to 102° F (39° C); stop cooling when rectal temperature is 100° F (37.8° C). *If shivering occurs during the cooling process, give a parenteral benzodiazepine- (Valium) or (Thorazine) is an alternative agent. Because seizure activity can further elevate body temp, have an IV benzo immediately available.

Diagnostics for kidney dysfunction: Blood Osmolarity

Blood osmolarity is a measure of the overall concentration of particles in the blood and is a good indicator of hydration status. The kidneys excrete or reabsorb water to keep blood osmolarity in the range of 285 to 295 mOsm/L. Osmolarity is slightly higher in older adults (285 to 301 mOsm/L). When blood osmolarity is decreased, the release of antidiuretic hormone (ADH) is inhibited. Without ADH, the distal tubule and collecting ducts are not permeable to water. As a result, water is excreted, not reabsorbed, and blood osmolarity increases. When blood osmolarity increases, ADH is released. ADH increases the permeability of the distal tubule to water. Then water is reabsorbed and blood osmolarity decreases.

Diagnostics for kidney dysfunction: BUN

Blood urea nitrogen (BUN) measures the kidney excretion of urea nitrogen, a by-product of protein breakdown in the liver. Urea nitrogen is produced mostly from liver metabolism of food sources of protein. The kidneys filter urea nitrogen from the blood and excrete the waste in urine. BUN levels indicate the extent of kidney clearance of this nitrogen waste product. Adults: 10-20 mg/dL Older adults: 60-90 yr: 8-23 mg/dL Older than 90 yr: 10-31 mg/dL An increased level may indicate hepatic or renal disease, dehydration or decreased kidney perfusion, a high-protein diet, infection, stress, steroid use, Gl bleeding, or other situations in which blood is in body tissues. A decreased level may indicate malnutrition, fluid volume excess, or severe hepatic damage. The liver must function properly to produce urea nitrogen. When liver and kidney dysfunction are present, urea nitrogen levels are decreased because the liver failure limits urea production.

Diagnostics for kidney dysfunction: Bun-Creatinine Ratio

Blood urea nitrogen to serum creatinine ratio can help determine whether non-kidney-related factors, such as low cardiac output or red blood cell destruction, are causing the elevated BUN level. When blood volume is deficient (e.g., dehydration) or cardiac output is low, the BUN level rises more rapidly than the serum creatinine level and the ratio of BUN to creatinine is increased. BUN/creatinine ratio Mass ratio: 12:1 to 20:1 Mole ratio: 48.5:1 to 80.8:1 An increased ratio may indicate fluid volume deficit, obstructive uropathy, catabolic state, or a high-protein diet. A decreased ratio may indicate fluid volume excess or acute renal tubular acidosis. No change in the ratio with increases in both the BUN and creatinine levels indicates renal impairment.

Lightning Injuries

Both the cardiopulmonary and the central nervous systems are profoundly affected by lightning injuries. *Most lethal initial effect on the cardiopulmonary system is cardiac arrest (asystole). *May have mottled skin and decreased to absent peripheral pulse *CNS injury- temp paralysis in lower extremities more than upper *Skin burns *Uncommon but characteristic skin symptom is the appearance of branching marks on the skin called Lichtenberg figures Treatment includes: *initial care spinal immobilization w/ priority to ABCs *immediate resuscitation measures w/ CPR when pt is in cardiac arrest In Hospital: *ALS management including: ECG, Ventilation, CK testing, tx of burn wounds, and tetanus prophylaxis

High altitude illness (HAD)

Cause pathophysiologic responses in the body as a result of exposure to low partial pressure of oxygen at high elevations. Elevations >5000 ft can produce fatal responses *As altitude increases, atmospheric (barometric) pressure decreases. Oxygen makes up 21% of the pressure. Therefore, as this pressure falls, the partial pressure of oxygen in the air decreases, resulting in less available oxygen *The pathophysiologic consequence is hypoxia >2500 ft -Acute mountain sickness (AMS) High altitude cerebral edema (HACE) High altitude pulmonary edema (HAPE) most common cause of death associate with high altitude Acclimatization- process of adapting to high altitude involving changes tht help the body adapt to less available O2

GI Burn Assessment

Changes in GI function expected Decreased blood flow and sympathetic stimulation during early phase cause reduced GI motility, paralytic ileus due to increased secretion of epinephrine nd norepinephrine GI bleeding Curling's Ulcer

Cardiovascular Changes from Burn Injury

Changes in cardiovascular system occur immediately after burn injury and include shock. Hypovolemic shock common cause of death in early phase in patients with serious injuries Vital signs: increased HR and decreased CO Cardiac status, especially in cases of electrical burn injuries Do peripheral vascular checks Will need to do invasive BP monitoring At first, cardiac S/S are from hypovolemia & decreased CO. Monitor the degree of edema, and assess cardiac status by measuring central and peripheral pulses, blood pressure, cap refill, and pulse ox, invasive BP monitoring may be needed. At first, the pt has: tachycardia, decreased BP, and decreased peripheral pulses. Peripheral capillary refill is slow or absent as tissue blood flow decreases. With fluid resuscitation, peripheral edema increases, as does the patient's body weight. ECG changes can indicate damage to the heart as a result of electrical burn injuries or stress that induces MI BP will remain low for 18-36hrs after injury

Kidney/Urinary Assessment

Changes related to cellular debris, decreased kidney blood flow Myoglobin released from damaged muscle, circulates to kidney Kidney function, BUN, serum creatinine, lactic acid, will all RISE!!! Serum sodium levels go down!! Urine color, odor, presence of particles/foam

Hypothermia Key Features

Chart 11-7 Key Features Hypothermia Mild 90°-97° F (32° C to 35° C) •Shivering •Dysarthria (slurred speech) •Decreased muscle coordination •Impaired cognition ("mental slowness") •Diuresis (caused by shunting of blood to major organs) Moderate 82°-90° F (28° C to 32° C) •Muscle weakness •Increased loss of coordination •Acute confusion •Apathy •Incoherence •Possible stupor •Decreased clotting (caused by impaired platelet aggregation and thrombocytopenia) Severe <82° F (<28° C) •Bradycardia •Severe hypotension •Decreased respiratory rate •Cardiac dysrhythmias, including possible ventricular fibrillation or asystole •Decreased neurologic reflexes •Decreased pain responsiveness •Acid-base imbalance

General Management for All Types of Burns

Chart 28-1 Emergency Management of Burns •Assess for airway patency. •Administer oxygen as needed. •Cover the patient with a blanket. •Keep the patient on NPO status. •Elevate the extremities if no fractures are obvious. •Obtain vital signs. •Administer tetanus toxoid for prophylaxis. •Perform a head-to-toe assessment. •Initiate an IV line, and begin rapid fluid replacement. Electrolytes, crystalloids, (colloids- usually used after first 24hrs) 3 formulas: Parkland, modified Parkland, modified Brooke Monitoring patient response to fluid therapy Drug therapy

Vascular Changes from Burn Injury

Circulatory changes occur at burn site immediately Fluid shift occurs -third spacing or capillary leak syndrome Fluid shift with weight gain occurs in the first 12 hours after the burn and can continue for 24-36 hours Capillary leak occurs when there is more than 20-30% TBSA involved Fluid remobilization occurs about 24 hours after injury

Secondary survey for ER

Comprehensive head-to-toe assessment to identify other injuries or medical issues that need to be managed or that impact the course of treatment Can include: Insertion of gastric tubes for decompression of the GI tract to prevent vomiting and aspiration Insertion of a urinary catheter to measure urine output Preparation for diagnostic studies

Diagnostics for kidney dysfunction: CT

Computed tomography (CT): To measure kidney size To evaluate contour to assess for masses or obstruction Contrast medium may provoke acute kidney injury. See comments with excretory urography for high-risk patients and preventive measures related to contrast. May be performed without contrast medium and still obtain adequate visualization.

Cystitis: Bladder infection

Cystitis is an inflammation of the bladder. It can be caused by irritation or, more commonly, by infection from bacteria, viruses, fungi, or parasites. Infectious cystitis is the most common of the UTIs. Most common organisms are from intestinal tract: 90% E. coli Noninfectious cystitis is caused by irritation from chemicals or radiation. Interstitial cystitis- is an inflammatory disease that has unknown etiology

Diagnostics for kidney dysfunction: Cystography & Cystoscopy

Cystography and cystoscopy: To identify abnormalities of the bladder wall and urethral and ureteral occlusions Instrumentation of the urinary tract increases the risk for infection. To treat small obstructions or lesions via fulguration, lithotripsy, or removal with a stone basket Monitor for infection for 48-72 hr after the procedure.

Full Thickness

Destruction of entire epidermis and dermis: so there is no skin cells present for regrowth and areas aren't closed with contraction. May need skin grafting Has a hard, dry, leathery eschar that forms from coagulated particles of destroyed dermis Eschar (if black or brown) is dead tissue and must be removed before healing can occur Appearance is generally waxy white, deep red, yellow, brown or black. Thrombosed blood vessels may be visible Dermal blood vessels are coagulated, causing burned tissue to be avascular (without blood supply) Sensation reduced or absent Edema is severe under the eschar Circumferential (completely surrounds an extremity or the chest) blood flow and chest movement my be reduced from tight eschar Escharotomies (incisions through the eschar) or fasciotomies (through fascia) may be necessary to relieve pressure Healing depends on establishment of good blood supply: Weeks to months

Deep Full Thickness Wounds

Extend beyond the skin into underlying fascia and tissues. occur with flame, electrical, or chemical injuries These deep injuries damage muscle, bone, and tendons and leave them exposed. The wound is blackened and depressed, and sensation is completely absent. All full-thickness burns need early excision and grafting. Grafting decreases pain and length of stay and hastens recovery. Amputation may be needed when an extremity is involved.

Deep partial-thickness injuries:

Extend deeper into the dermis, and fewer healthy cells remain. Usually no blisters Wound surface is red and dry with white area in the deeper part (dry because fewer patent blood vessels) Blanches slowly or not at all Edema is moderate Pain is less than superficial because more of nerve ending has been destroyed. Blood flow is reduced by blood vessel constriction Can progress to deeper injury (full thickness wound) from hypoxia & ischemia *Adequate hydration, nutrients, & O2 is needed for regrowth and prevention of becoming deeper Generally heal in 3-6 weeks, but scar formation results

Urolithiasis (kidney stones) Lithotripsy Tx

Extracorporeal shock wave lithotripsy (ESWL) uses sound, laser, or dry shock wave energy to break the stone into small fragments. Client undergoes conscious sedation Topical anesthetic cream is applied to skin site of stone Continuous monitoring by ECG Strain urine for stone fragments Some bruising may occur on flank of affected side- use ice!!!

Hospital Incident Command System (HICS)

Facility level organized model for disaster management Roles formally structured under the hospital or long-term care facility incident commander with clear lines of authority and accountability for specific resources Officers- named to oversee essential emergency preparedness functions such as public information, safety and security, and medical command. Chiefs- appointed to manage logistics, planning, finance, and operations as appropriate to type and scale of the event. Chiefs also delegate specific duties to other departmental officers & unit leaders **The idea is to achieve a manageable span of control over the personnel or resources allocated to achieve efficiency . Role of nurse- meet pt needs Personal emergency preparedness plan Personal readiness supplies or "go bag"

Cystitis: Bladder infection - Symptoms

Frequent urge to urinate Dysuria Urgency Hesitancy Low back pain Suprapubic tenderness/fullness Feeling of incomplete bladder emptying Urine: cloudy, blood-tinged, foul Rare: fever, chills, N/V, malaise, flank pain (Pyelo.) Older Adults: Women @ greatest risk (50% of >80y/o) Men increased risk with increased age Increasing mental confusion Frequent, unexplained falls Sudden onset or worsening of incontinence Loss of appetite, nocturia, dysuria Fever, tachycardia, tachypnea, & hypotension with or without urinary symptoms—may be signs of urosepsis!

Hypothermia Treatment: Hospital Care

General management principles apply to both moderate and severe hypothermia: •Protect from further heat loss and handle gently to prevent ventricular fibrillation. •Positioning the patient in the supine position prevents orthostatic changes in BP from cardiovascular instability. •Follow standard resuscitation efforts with special attention to maintenance of ABCs •Admin drugs with caution and/or spaced at longer intervals because metabolism is unpredictable in hypothermic conditions. •Remember that drugs can accumulate without obvious therapeutic effect while the patient is cold but may become active and potentially lead to drug toxicity as effective rewarming is underway. •Consider withholding IV drugs until the core temperature is above 86° F (30° C). •Initiate CPR for patients without spontaneous circulation. •Be aware that defibrillation attempts may be ineffective until the core temperature is above 86° F (30° C). Treatment of moderate hypothermia: •Active external and core rewarming methods. •Applying external heat with heating blankets can promote core temp "after-drop" by producing peripheral vasodilation. •"After-drop" is the continued decrease in core body temp after being removed from the cold environment; it is caused by the return of cold blood from the periphery to the central circulation. •Therefore the pt's trunk should be actively rewarmed before the extremities. •Core rewarming methods for moderate hypothermia include administration of warm IV fluids, heated oxygen or inspired gas to prevent further heat loss via the respiratory tract, and heated peritoneal, pleural, gastric, or bladder lavage. **Nursing Safety Priority- Critical Rescue: Pts who are severely hypothermic are at high risk for cardiac arrest. Avoid using active external rewarming with heating devices because it is dangerous and contraindicated in this population due to rapid vasodilation. Treatment for severe hypothermia is: •use internal rewarming methods such as cardiopulmonary bypass, hemodialysis, venovenous or arteriovenous rewarming, or intravascular rewarming via a closed-loop indwelling catheter •Cardiopulmonary bypass is the fastest core rewarming technique. .

Erectile Dysfunction

Inability to achieve or maintain erection for sexual intercourse Causes: Organic(disease, injury etc.) vs. functional(psychological) Assessment: Medical, social, sexual history Complete physical examination Diagnostics to r/o other causes Hormone levels Duplex Doppler ultrasonography test Drug therapy: Phosphodiesterace-5 (PDE-5) inhibitors Other therapies: Vacuum constriction device Vasodilators (local) Penile implants

Compensatory Responses to Burn Injury

Inflammatory compensation can trigger healing Responsible for problems caused by fluid shift Intended to function on local and short term basis SNS compensation occurs when any physical or psychological stressors are present Stress response ( CV, pulmonary , and GI) Together cause the changes that result in many of the manifestations that are seen in the first 2-3 days Supposed to happen quickly but not last long if the swelling last too long the pt then has: Cardiac- Decrease CO, increased HR, and BP usually goes down Respiration- may see pulmonary compromise, tachypnea

Urge Urinary Incontinence Tx

Interventions include: Drugs: (Ditropan XL, Detrol LA) to reduce incontinence by causing bladder muscle relaxation Tricyclic antidepressants (TCAs)- have some anticholinergic actions and also block acetylcholine receptors. Both actions can relieve urinary incontinence. Diet therapy: avoid caffeine and alcohol Behavioral interventions: pelvic floor exercises, bladder training (client needs to be able to understand and cooperate), habit training (cognitively impaired), electrical stimulation (intravaginal or intrarectal)

Stress Urinary Incontinence Tx

Interventions include: Keeping a detailed diary, behavioral interventions : wt. reduction (↑ abdominal pressure worsens symptoms); avoid bladder irritants; pelvic floor exercises (Kegels) Drug therapy: estrogen Collection devices and vaginal cone weights Surgery: anterior vaginal repair; slings; periurethral collagen injection (Table 69-4) Helping client avoid social isolation

Functional Urinary Incontinence Tx

Interventions include: Treatment of reversible causes If incontinence is not reversible--urinary habit training Applied devices (intravaginal pessaries and penile clamps)-risk of tissue damage, infection Containment of urine and protection of the client's skin Urinary catheterization (intermittent or indwelling)-- only as last resort

Diagnostics for kidney dysfunction: fluoroscopy

Intravenous pyelography (IVP) (fluoroscopy): To assess kidney function, identify anomaliesTo image kidney/urinary stones (size, location, radiodensity)To screen for kidney injury after trauma Contraindicated during pregnancy (ionizing radiation is a risk to the fetus). Contrast dye can cause renal dysfunction. Colonic cleaning improves quality of image.

Hypothermia

Is a core body temperature of <95° F (35° C) Mild hypothermia: 90°-97° F (32° C to 35° C) Moderate hypothermia: 82°-90° F (28° C to 32° C) Severe hypothermia: <82° F (<28° C)

Superficial-Thickness Wounds

Least damage; because epidermis is the only part of skin that is injured; epithelial cells and basement membrane needed for total regrowth remain present Pink to Red, mild edema, pain, and increased sensitivity to heat Desquamation (peeling of dead skin) occurs 2 to 3 days after burn Healing occurs within in 3-6 days without scar or complications Examples: Sunburn- prolonged exposure to low-intensity heat Flash- short exposure to high intensity heat

Trauma Center Level

Level I regional resource facility, large teaching hospital & serve dense population Level II community provide care to vase majority of injured pts. May not have all resources needed for very complex injury management; emergency preparedness Level III small rural hospital , low population injury stabilization & pt transfer Level IV offer ALS in rural or remote settings , stabilize if possible before transport

Urolithiasis (kidney stones) Surgical Tx

Minimally invasive surgical procedures: Stenting- in ureter by ureteroscopy Retrograde ureteroscopy- ureterscope thru urethra to ureter. Stone removed via forceps or lithotripsy performed. Percutaneous ureterolithotomy and nephrolithotomy- removal of stone thru skin; nephrostomy tube Open surgical procedures- large or impacted stones Preoperative care -NPO; bowel prep Operative procedure- flank or lower abdominal incision

BPH: Tx

Nonsurgical: Medications used -5-alpha reductase inhibitors -Alpha-blocking agents -BPH + HTN - use alpha blocker CAM therapies Thermotherapy Adequate fluids (small amts. @ frequent intervals, avoid lg. amts. @ short intervals) Avoid alcohol, caffeine, diuretics, medications that cause urinary retention Surgical Procedures: Transurethral Incision of the Prostate (TUIP)- Used with smaller prostate Enlarge opening of urethra & bladder outlet via small incisions. Enlarged portion removed with endoscopy Open Prostatectomy- Removal of the prostate. Suprapubic Retropubic Perineal Post-Op care: Urinary catheter with retention balloon placed into bladder Traction via taping to patient's abdomen or thigh Uncomfortable urge to void continuously Chart 75-1 page 1636 Bladder irrigation Increase fluids Hemorrhage

Burn Resuscitation Formulas

Parkland Formula 4cc x Kg x BSA (why you need to know the BSA ASAP) first 1/2 is given over the 1st 8 hourssecond 1/2 is given over the last 16 hours No colloids in first 24 hours Modified Parkland formula Parkland formula plus maintenance fluids, used in patients who weigh less than 20 kg (MAJOR monitoring for this) Modified Brooke formula 1.5 ml/kg/%burn, plus colloids at 0.5 ml/kg/%burn, plus 2000 ml glucose in water.

Bees and Wasps

Potential for anaphylactic reaction Emergency First Aid: remove stinger and apply an ice pack Advanced emergency care in a hospital: to ensure that the ABCs are maintained "EpiPen" administration of epinephrine

THREE-TIER TRIAGE SYSTEM

TABLE 10-2 Emergent (life threatening)- Respiratory distress Chest pain with diaphoresis Active hemorrhage Unstable vital signs Urgent (needs quick treatment, but not immediately life threatening)- Severe abdominal pain Renal colic Displaced or multiple fractures Complex or multiple soft tissue injuries New-onset respiratory infection, especially pneumonia in older adults Nonurgent (could wait several hours if needed without fear of deterioration)- Skin rash Strains and sprains "Colds" Simple fracture

Heat Stroke: Key Features

Profoundly elevated body temperature (>104° F or 40° C) Hot and dry skin; however, persons may continue to perspire Mental status changes as a result of thermal injury to the brain •Acute confusion •Bizarre behavior •Anxiety •Loss of coordination •Hallucinations •Agitation Vital sign changes, including: •Hypotension •Tachycardia •Tachypnea •Electrolyte imbalances, especially sodium and potassium •Decreased renal function (oliguria) •Coagulopathy (abnormal clotting) •Pulmonary edema (crackles) Complications that can occur: • Multiple organ dysfunction syndrome • Renal impairment • Electrolyte and acid-base disturbances •Coagulopathy •Pulmonary edema •Cerebral edema

Respiratory System injury assessment

Pts with major burn injuries and those with inhalation injury are at risk for respiratory problems. **Thus continuous airway assessment is a nursing priority Direct airway injury: Inspect the mouth, nose, and pharynx. Burns of the lips, face, ears, neck, eyelids, eyebrows, and eyelashes are strong indicators that an inhalation injury may be present. Upper airway edema and inhalation injury are most common in the trachea and mainstem bronchi. Auscultate these areas may reveal wheezes, which indicate partial obstruction. Pts with severe inhalation injuries may have such rapid obstruction that, within a short time, they cannot force air through the narrowed airways. As a result, the wheezing sounds disappear. This finding indicates impending airway obstruction and demands immediate intubation.

Diagnostics for kidney dysfunction: X-Ray, MRI, MAG3 study 99m, & Nephrotomography,

Radiography of kidneys, ureters, and bladder (KUB) (plain film of abdomen): To screen for the presence of two kidneys To measure kidney size To detect gross obstruction Nephrotomography: To assess various planes of kidney tissue for cysts, tumors, or calculi MAG3 study 99m: To assess kidney function, structural abnormalities, kidney injury or impairment, obstruction, and kidney stones Radioactive material (technetium Tc mertiatide) is used for this test. Magnetic resonance imaging (MRI): Staging of cancers, similar to CT Patient must be able to lie still (motion can interfere with imaging).

Diagnostics for kidney dysfunction: Renal Scan

Renal scan: Evaluation of kidney blood flowEstimation of glomerular filtration rateProvides functional information without exposing the patient to iodinated contrast dye ACE inhibitors should be held for 48 hours before the test. ACE inhibitors may be given during the test, placing the patient at risk for episodes of hypotension. Ensure adequate hydration for best results

Burn Pt Assessment

Respiratory: Major burns and inhalation injuries greatest risk Nursing priority Cardiopulmonary: Hypovolemic shock common cause of death during resuscitation phase Kidney/Urinary: Changes related to decreased blood flow and cellular debris Resuscitation provided to keep urine output 30-50ml or 0.5mL/kg/hr Neuro-endocrine: Increased catecholemines Immune: Protective barrier disrupted or destroyed, increased risk of infection

Urolithiasis (kidney stones) Post-Op Care

Routine postoperative care procedures for assessment of bleeding, urine, and adequate fluid intake; drain & Foley care Strain urine Infection prevention Drug therapy: selection to prevent obstruction depends on what is forming the stone: Calcium: thiazide diuretics (Diuril), HydroDIURIL Oxalate: allopurinol (Zyloprim); Vit B6 Uric acid: allopurinol (prevents formation of urate) Cystine: AMPG and Captopril (Capoten) Diet therapy: depends on type of stone formation (p. 1511, Table 69-6)

Injuries to the Respiratory System: Thermal injury

Scalding liquids Explosion of flammable gases Heat damage of the pharynx is often severe enough to produce edema and upper airway obstruction, especially epiglottitis. The problem can occur any time during resuscitation. In the unresuscitated patient, supraglottic edema may be delayed because of the dehydration that occurs with hypovolemia. During fluid resuscitation, however, the tissues rehydrate and then swell. When it is known that the upper airways were exposed to heat, intubation may be performed as an early intervention **When intubation has not been performed in a patient whose upper airways were exposed to heat or toxic gases, continually assess the upper airway for recognition of edema and obstruction.

Emergency Preparedness Response Plan Roles

TABLE 12-2 PERSONNEL ROLE & FUNCTION FOR EMERGENCY PREPAREDNESS AND RESPONSE PLAN Hospital incident commander- Physician or administrator who assumes overall leadership for implementing the emergency plan Medical command physician- Physician who decides the number, acuity, and resource needs of patients Triage officer- Physician or nurse who rapidly evaluates each patient to determine priorities for treatment Community relations or public information officer- Person who serves as a liaison between the health care facility and the media

Diagnostics for kidney dysfunction: Creatinine

Serum creatinine Produced when protein or muscle breaks down. Creatinine is filtered by the kidneys and excreted in the urine. Because muscle mass and protein breakdown are usually constant, the serum creatinine level is a good indicator of kidney function. Males: 0.6-1.2 mg/dL (53-106 mmol/L) Females: 0.5-1.1 mg/dL (44-97 mmol/L) Older adults: may be decreased No common pathologic condition other than kidney disease increases the serum creatinine level. The serum creatinine level does not increase until at least 50% of the kidney function is lost, and therefore any elevation of serum creatinine values is important and should be assessed further. **Nursing Safety Priority Action Alert An increase of serum creatinine 1.5 times above baseline or a decrease of urine output to <0.5 mL/kg/hr for 6 or more hours places a patient at risk for acute kidney injury. Monitor both baseline and trend values to determine risk for and actual kidney damage, especially among patients exposed to agents that can cause kidney dysfunction. Inform the health care provider of increased serum creatinine and decreased urine output values promptly.

Burn injury: Skin changes resulting from burn injury: Functional Changes

Skin is a protective barrier against injury and microbial invasion Burns break that barrier, increasing risk for infection After a burn massive fluid loss occurs because evaporation occurs 4x more rapidly than through intact skin. Rate of evaporation is based on total body surface area (TBSA) burned and the depth of injury Skin can normally tolerate temps up to 104, but at temps of 158 and above rapid cell destruction occurs

Triage for ER

Sorting or classifying patients into priority levels depends on illness or injury severity. Rapid assessing pt & assigning them a classification or priority for care Pts who present to the ED ( non disaster situation ) with the highest acuity needs receive the soonest evaluation, treatment, and prioritized resource utilization. Emergency Severity Index (ESI) categorizes both patient acuity and resource utilization.

Dressing the Burn Wound

Standard wound dressings Biologic dressings: Homograft—human skin Heterograft—skin from other species Amniotic membrane Cultured skin Artificial skin Biosynthetic dressings Synthetic dressings

Urolithiasis (kidney stones) Formation

Stones are caused by many disorders. Everyone excretes crystals in the urine at some time, but fewer than 10% of people form stones. Most stones contain calcium as one part of the stone complex. Struvite (15%), uric acid (8%), and cystine (3%) are more rare compositions of stones. Formation due to - slow urine flow/dehydration (supersaturation with element), tract lining damage, ↓inhibitor substances (to prevent supersaturation), drugs, high urine acidity or alkalinity, immobility One example of a metabolic problem causing stone formation begins when excessive amounts of calcium are absorbed through the intestinal tract (the most common cause of hypercalciuria). As blood circulates through the kidneys, the excess calcium is filtered into the urine, causing supersaturation of calcium in the urine. If fluid intake is poor, such as when a patient is dehydrated, supersaturation is more likely to occur and the risk for calcium combining with another compound to form a larger molecule increases. Calcium complexes often serve as a center for other deposits, and eventually a stone forms.

Five types of urinary incontinence include:

Stress: most common; loss of small amt. urine during coughing, sneezing, etc.; client cannot tighten urethra enough, common after childbirth, pelvic muscles stretched & weakened, also caused by low estrogen levels, client may avoid fluids Urge "overactive bladder": The involuntary loss of urine associated with a strong desire to urinate. Pts cannot suppress the signal from the bladder muscle to the brain that it is time to urinate, can't override & relax muscle. Mixed: >1 type; loss of urine due to both, seen in older women Overflow: involuntary loss of urine associated with overdistention when the bladder's capacity has reached its maximum. Can be caused when the urethra is obstructed, so it fails to relax sufficiently to allow urine to flow, resulting in incomplete bladder emptying or complete urinary retention Functional: normal function of bladder & urethra; loss of cognitive bladder control... i.e. dementia

Respiratory Issues common with a burn injury are:

Table 28-3. •Patients who were injured in a closed space •Patients with extensive burns or with burns of the face •Intra-oral charcoal, especially on teeth and gums •Patients who were unconscious at the time of injury •Patients with singed scalp hair, nasal hairs, eyelids, or eyelashes •Patients who are coughing up carbonaceous sputum •Changes in voice such as hoarseness or brassy cough •Use of accessory muscles or stridor •Poor oxygenation or ventilation •Edema, erythema, and ulceration of airway mucosa •Wheezing, bronchospasm

Emergency Operations Center (EOC) or Command Center

The HICS personnel also establish an (EOC) or command center in a designated location with accessible communication technology. They then use their collective expertise to manage the overall incident. All internal requests for additional personnel and resources, as well as communication with field teams and external agencies, should be coordinated through the EOC to maintain unity of command.

High altitude illness: Treatment

The most important intervention is to descent to a lower altitude. Patients must be monitored carefully for any evidence of symptom progression. Chart 11-8 Preventing, Recognizing, and Treating Altitude-Related Illnesses •Plan a slow ascent to allow for acclimatization. •Learn to recognize clinical manifestations of altitude-related illnesses. •Avoid overexertion and overexposure to cold; rest at present altitude. •Ensure adequate hydration and nutrition. •Avoid alcohol and sleeping pills when at high altitude. •For progressive or advanced acute mountain sickness (AMS), recognize symptoms and implement an immediate descent; provide oxygen at high concentration. •To prevent the occurrence of AMS, discuss the use of acetazolamide (Diamox) and other agents as indicated with your health care provider. •Protect skin and eyes from the sun's harmful ultraviolet rays at high altitude. Wear sunscreen (at least SPF 30) and high-quality wraparound sunglasses or goggles.

Diagnostics for kidney dysfunction: US

Ultrasonography (US): To identify the size of the kidneys or obstruction in the kidneys or the lower urinary tract Ultrasonography entails minimal risk to the patient. Ultrasonography is a good alternative to excretory urography. May detect tumors or cysts

A change in respiratory pattern may indicate a pulmonary injury

The patient may: •Become progressively hoarse •Develop a brassy cough •Drool or have difficulty swallowing •Produce sounds on exhalation that include audible wheezes, crowing, and stridor **Any of these changes may mean the patient is about to lose his or her airway. **Nursing Safety Priority- Critical Rescue: For a burn pt in the resuscitation phase who is hoarse, has a brassy cough, drools or has difficulty swallowing, or produces an audible breath sound on exhalation, immediately apply oxygen and notify the Rapid Response Team.

Primary Survey for ED

The primary survey organizes the order of approach to the patient by mnemonic device: (A) Airway/cervical spine (B) Breathing (C) Circulation- asses VS with perfusion, start IV 16g, NS, RL, central lines, intraosseous access (D) Disability- rapid neuro status "AVPU" = Alert, Response to Voice, response to pain, unresponsive (E) Exposure- removal of clothing

Diagnostics for kidney dysfunction: Urinalysis

Urinalysis is a part of any complete physical examination and is especially useful for patients with suspected kidney or urologic disorders Color- Pale yellow Dark amber indicates concentrated urine. Very pale yellow indicates dilute urine. Dark red or brown indicates blood in the urine. Brown also may indicate increased urinary bilirubin level. Red also may indicate the presence of myoglobin. Odor- Specific aroma, similar to ammonia Foul smell indicates possible infection, dehydration, or ingestion of certain foods or drugs. Turbidity- Clear Cloudy urine indicates infection, sediment, or high levels of urinary protein. Specific gravity Usually 1.005-1.030; possible range 1.000-1.040 (after 12-hr fluid restriction, >1.025) Increased in decreased kidney perfusion, inappropriate antidiuretic hormone secretion, or congestive heart failure. Decreased in chronic kidney disease, diabetes insipidus, malignant hypertension, diuretic administration, and lithium toxicity. Older adult: Decreased because of decreased concentrating ability pH- Average: 6; possible range: 4.6-8 Changes are caused by diet, the administration of drugs, infection, freshness of the specimen, acid-base imbalance, and altered renal function. Glucose <0.5 g/day Presence reflects hyperglycemia or a decrease in the renal threshold for glucose. Ketones- None Presence reflects incomplete metabolism of fatty acids, as in diabetic ketoacidosis, prolonged fasting, anorexia nervosa. Protein- 0.8 mg/dL Increased amounts may indicate stress, infection, recent strenuous exercise, or glomerular disorders. Bilirubin (urobilinogen)- None Presence suggests liver or biliary disease or obstruction. Red blood cells (RBCs)- 0-2 per high-power field Increased amounts are normal with indwelling or intermittent catheterization or menses but may reflect tumor, stones, trauma, glomerular disorders, cystitis, or bleeding disorders. White blood cells (WBCs)- Males: 0-3 Females: 0-5 Increased amounts may indicate an infectious or inflammatory process anywhere in the renal/urinary tract, renal transplant rejection, fever, or exercise. Casts A few or none, composed of RBC, WBC, protein, or tubular cell casts Increased amounts indicate the presence of bacteria or protein, which is seen in severe kidney disease and could also indicate urinary calculi. Crystals- None Presence of normal or abnormal crystals may indicate that the specimen has been allowed to stand. Bacteria <1000 colonies/mL Increased amounts indicate the need for urine culture to determine the presence of urinary tract infection. Parasites- None Presence of Trichomonas vaginalis indicates infection, usually of the urethra, prostate, or vagina. Leukoesterase- None Presence suggests urinary tract infection. Nitrites- None Presence suggests urinary Escherichia coli.

Urinary tract infections: UTI's

Urinary tract infections are described by their location in the tract. The site of infection is important to know because site, along with the specific type of bacteria present, determines treatment. Acute lower UTI: Urethritis (urethra) Cystitis (bladder) Prostatitis (prostate gland) Acute upper UTI: Pyelonephritis (kidney) **Pregnant women with a bacterial UTI need prompt and aggressive tx because simple cystitis can lead to acute pyelonephritis during pregnancy. Pyelonephritis in pregnancy can cause preterm labor and affect the fetus.

Diagnostics for kidney dysfunction: VCUG

Voiding cystourethrography (VCUG): To outline bladder's contour and detect urinary reflux from vesicourethral junctions The risk for infection is similar to that in cystography because urinary catheterization is necessary. Monitor for postprocedure infection.

Reflux/Overflow Urinary Incontinence Tx

Voiding reflex NOT intact Interventions include: Surgery to relieve the obstruction (prostate, genital prolapse) Intermittent self-catheterization r/t detrusor muscle weakness (clean, not sterile; long-term problems) Bladder compression to promote bladder emptying (Crede method, Valsalva, Double-voiding) Drug therapy: Urecholine to increase bladder pressure (short-term/post-op)

Frostbite

When body tissue freezes and causes damage. Like burns, frostbite injuries can be superficial, partial, or full thickness Frostbite is accompanied by initial pain, numbness, and pallor of the affected area. Deep frostbite requires aggressive management in a medical facility. *First-degree frostbite, the least severe type of frostbite, involves hyperemia (increased blood flow) of the involved area and edema formation. *In second-degree frostbite, large fluid-filled blisters develop with partial-thickness skin necrosis *Third-degree frostbite appears as small blisters that contain dark fluid and an affected body part that is cool, numb, blue, or red and does not blanch. Full-thickness and subcutaneous tissue necrosis occur and require débridement. *In fourth-degree frostbite, the most severe form, there are no blisters or edema; the part is numb, cold, and bloodless. The full-thickness necrosis extends into the muscle and bone. At this stage, gangrene develops, which may require amputation of the affected part.

Specific management: Electrical Burns

•At the scene, separate the patient from the electrical current. •Smother any flames that are present. •Initiate cardiopulmonary resuscitation. •Obtain an electrocardiogram (ECG).

Preventing a Urinary Tract Infection

•Drink at least 2 to 3 L of sugarless fluid every day. •Be sure to get enough sleep, rest, and nutrition daily. •[For women] Clean your perineum (the area between your legs) from front to back. •[For women] Avoid using or wearing irritating substances, such as bubble bath, nylon underwear, and scented toilet tissue. Wear loose-fitting cotton underwear. •[For women] Empty your bladder before and after intercourse. •For both women and men, gently wash the perineal area before intercourse. •Avoid the use of scented or flavored lubricants. •If you experience burning when you urinate, if you have to urinate frequently, or if you find it difficult to begin urinating, notify your physician or other health care provider right away, especially if you have a chronic medical condition (e.g., diabetes) or are pregnant. •Empty your bladder as soon as you feel the urge to urinate. •Empty your bladder regularly (every 4 hours), even if you do not feel the urge to urinate. You may try these home therapies: •Cranberry juice (pure), 50 mL daily •Apple cider vinegar, 2 tablespoons three times daily in juice •Vitamin C, 500 mg daily to acidify the urine To prevent recurrent infection: •Take your prescribed antibiotic or other drug as directed, even after the symptoms go away. •Schedule a follow-up appointment for 10 to 14 days after you finish taking the drug. At your follow-up visit, another urine sample may be taken for analysis or culture.

Specific management: Chemical Burns

•If dry chemicals are present on skin or clothing, DO NOT WET THEM. •Brush off any dry chemicals present on the skin or clothing. •Remove the patient's clothing. •Ascertain the type of chemical causing the burn. •Do not attempt to neutralize the chemical unless it has been positively identified and the appropriate neutralizing agent is available.