Unit VII: Advanced understanding of alterations in tissue integrity and mobility
Normal spinal cord 3
-Spinal cord begins at the foramen magnum in the cranium -Cord ends at the L1-L2 vertebra level -Spinal nerves continue to the last sacral vertebra
Chronic pain 3
-Surgery may not relieve pain -Nonpharmalogical methods to control pain -Pain clinic
Other Symptoms Lumbar HNP: 6
- Postural changes -Urinary/male sexual function changes -Paresis or paralysis -Foot drop -Paresthesias: tingleness -Numbness -Muscle spasms -absent cord reflexes
autonomic dysreflexia. Characteristics of this acute emergency are as follows: 7
- Severe hypertension - Slow heart rate - Pounding headache - Nausea - Blurred vision - Flushed skin - Sweating - Goosebumps (erection of pilomotor muscles in the skin) - Nasal stuffiness
This occurs within 24 to 96 hours after the accident
- The plasma-like fluid is picked up and reabsorbed from the third space in the burn areas, and the client may rapidly become hypervolemic (exhibit an abnormal increase in the blood volume in the circulatory system)
Trauma to the back can
- fracture or collapse one or more vertebrae, causing a portion of bone to injure the spinal cord and interfere with the transmission of nerve impulses. Even without a fracture, edema may lead to cord compression, which may permanently damage the cord.
Dopamine agonist 3 nursing action 3
-(bromocriptine, ropinirole, pramipezole) -activate the release of the dopamine -may be combine with dopaminergics for better results -monitor for ortatstatic hypotension, dyskinesias, and hallucintions
The Client With a Burn Injury diet 2
-- Calorie needs may increase to 4000 to 5000 calories/day. Protein needs are typically 2.0 to 2.5 g/kg, especially if burns are >10% of TBSA. Calorie and protein needs increase if complications develop, and they lessen as wound healing progresses. -- Fluid needs increase significantly. With damage to cells and skin, the body not only loses fluid but also struggles to retain fluids. In addition to strict intake and output records, much weight loss is the result of fluid loss. Clients should be weighed daily and sufficient fluid added to reflect the fluids lost in weight change.
Autonomic dysreflexia Interventions 2
-- raise HOB, find pain stimuli (distended bladder or impacted bowel, sheet could be wrinkled), if cannot find the cause need to lower BP with pharmacologic used nitroglycerin - Teach early signs, pay attention to bladder, bowel regimen: high fiber and prune juice, skin care
Nutritional support burn
-5000 calories/day-4 to 12 days after burns -increase protein intake to prevent tissue breakdown and promoting healing, and provide high carbohydrates to decrease protein catabolism
Constipation 4
-Bowels rely more on bulk than on nerves -Stimulate bowels at the same time each day. Best after a meal when normal peristalsis occurs -Individual may progress from Dulcolax suppository to glycerin then to gloved finger for digital stimulation -Assess bowel sounds prior to giving food for the first time- paralytic ileus!
LEVEL OF INJURY-C1-C3 COMMON MOTOR EFFECTS COMMON SENSORY EFFECTS FUNCTIONAL ABILITIES 2
-C1-C3 -Paralysis below neck; impaired breathing; bowel and bladder incontinence; sexual dysfunction -No sensation below neck -Use a power wheelchair with movement of head and neck control Operate computer or appliances, such as TV or lights, using voice-activation device or mouth stick
LEVEL OF INJURY-C4-C5 COMMON MOTOR EFFECTS COMMON SENSORY EFFECTS FUNCTIONAL ABILITIES 3
-C4-C5 -Shoulder elevation possible; ventilation support required -No sensation below clavicle -Breathe with ventilator assistance or possibly independently Use a power wheelchair with sip-and-puff or hand control Drink independently using a long straw and bottle
Classifications SCI hyperextension 2
-Caused by chin hitting a surface area, such as dashboard or bathtub -Usually causes central cord syndrome symptoms -chin hitting a surface area (bathtub, car, stairs)
Surgery for SCI 4
-Manipulation to correct dislocation or to unlock vertebrae -Decompression laminectomy: take the compression fx out -Spinal fusion: fuse the vertebrae together keep everything line; lose mobility -Wiring or rods to hold vertebrae together
Classifications SCI Flexion/rotation 3
-Most unstable -Results in tearing of ligamentous structures that normally stabilize the spine -Usually results in serious neurologic deficits
Impaired gas exchange 5
-Phrenic nerve (C3-5) controls the diaphragm bilaterally. If nerve is nonfunctioning then individual is ventilator dependent. -Thoracic nerves control the intercostals muscles for breathing and abdominal muscles aide in breathing and coughing -Respiratory rate, rhythm, depth, breath sounds, respiratory effort, ABG's, O2 saturation -Signs of impending extension of SCI up cord to phrenic nerve level (C3-5) -Need for ventilatory assistance tracheotomy, ventilator
Open method advantage 4 disadvantage 3
-Reduces labor-intensive care -Causes less pain during wound care -Facilitates inspection -Decreases expense -contributes to wound desiccation (dryness) -Promotes loss of water and body heat -Exposes wound to pathogens
risk for autonomic dysreflexia 6
-SCI above T6 -Results in loss of normal compensatory mechanisms when sympathetic nervous system is stimulated -Life threatening- if goes unchecked BP can result in cerebral hemorrhage -Vasodilatation symptoms above SCI -Vasoconstriction symptoms below SCI -The cause of SNS stimulation
Post op assessment HNP 4
-Sensory/motor assessment- care not to injure op site -Assess for CSF drainage (halo) or bleeding from op site -Encourage turn (log roll, cough, deep breath) -Assess for postural hypotension especially if client was on bed rest for several days/weeks prior to surgery
Superficial or First-Degree Burns
-The epidermis is injured, but there is no destruction of tissue or nerve endings. Thus, there is erythema, edema, and pain but prompt
Impaired urinary elimination 4
-Use bladder scan to see amount of urine in bladder -Goal- residual <100ml/20% bladder capacity -Some individuals may need catheter-Cath frequently -Assess effectiveness of medication -Urecholine to stimulate bladder contraction -Urinary antiseptic
Spinal shock is a 2
-a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury. -addition to paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin.
Anticholinergics nursing care 4
-benztropine, ropinirole, pramipexole -help control tremors and rigidity -dry mouth, constipation urinary retention, acute confusion
Medications in PD 2
-can take several weeks of use before improvement of manifestations is seen -combo of meds mainatainence of therapeutic med level is adequate control
autograft uses the
-client's own skin, which is transplanted from one part of the body to another. Only an autograft or skin transplanted from an identical twin can become a permanent part of the client's own skin
Tremors in parkinson disease 5
-commonly in hands and arms -pill rolling motion with the fingers -occurs most often at rest -may involve diaphragm, tongue, lips and jaw -increases with stress
Deep partial thickness areas involved appearance 4 sensation/healing
-damage to entire epidermis and deep into the dermis -red to white -blisters are rare -moderate edema -eschar soft and dry -painful and sensitive to touch -heals to 2 to 6 weeks -scarring likely -possible grafting
Superficial thickness areas involved appearance 4 sensation/healing 4
-damage to epidermis -pink to red -no blisters -mild edema -No eschar -painful/tender -sensitive to heat -heals within 3 to 6 days -no scarring
Full thickness areas involved 3 appearance 4 sensation/healing 3
-damage to the entire epidermis and dermis -can extend into the subcutaneous tissue -nerve damage -red, black, brown, yellow or white -no blisters -severe edema -eschar hard and inelastic -sensation minimal or absent -heals within weeks to months -scarring -grafting
Superficial partial thickness areas involved appearance 4 sensation/healing 3
-damage to the entire epidermis and some parts of the dermis -pink to red -blisters -moderate edema -no eschar -painful -heals within 2 to 3 weeks -no scaring but minor pigments changes
Deep full thickness areas involved2 appearance 4 sensation/healing 3
-damaging to all layers of skin -extends to muscle, tendons, and bones -black -no blisters -no edema -eschar hard and inelastic -no pain -heals within weeks to months -scarring -grafting
Other s/s PD 4
-difficulty chewing and swallowing -drooling -dysarthria (slurred speech) -cognitive impairment (dementia)
Classifications SCI Compression 3
-Caused by force from above, as hit on head -Or from below as landing on butt -Usually affects the lumbar region
treatment of conservative pt2 6
-Heat/cold therapy to decrease muscle spasms -Break the pain-spasm-pain cycle -Ultrasound, massage, relaxation techniques -Progressive mobilization with approved exercise program -includes abdominal/thigh strengthening -Teaching good body mechanics -Weight loss -TENS unit
spinal cord protection pt 2 4
-Internal and external ligaments -Dura -Meninges -CSF in subarachnoid space allow for movement within spinal canal
Traumatic SCI 5
-MVA- most common cause -Other: falls, violence, sport injuries -SCI typically occurs from indirect injury from vertebral bones compressing cord -SCI frequently occur with head injuries -Cord injury may be caused by direct trauma from knives, bullets, etc
treatment of conservative 3
Bed rest with firm mattress -log roll -side lying position with knees bent and pillow between legs to support legs Avoid flexion of the spine brace/corset, cervical collar to provide support Medications non-narcotic analgesics, anti-inflammatory, muscle relaxants, antispasmodics and tranquilizers
clinical manifestations SCI GU 3 Musculoskeletal 7
GU upper/lower motor bladder Impotence sexual dysfunction Musculoskeletal -joint contractures: passive ROM -bone demineralization -osteoporosis -muscle spasms -muscle atrophy -pathologic fractures -para/tetraplegia
Nursing management assessment 3
HEALTH HISTOY -Description of how and when injury occurred -Other illnesses or disease processes -Ability to move, breathe, and associated injury such as a head injury, fractures -know if they are on blood thinners: they may be bleeding internally and hemorrhaging could be compressing on the spinal cord
Impaired ventilation is associated with a burn involving the upper airway and results from 3
(1) swelling of the airway, (2) inhalation of carbon monoxide, and (3) acute respiratory failure, any or all of which are manifested within the first 12 to 24 hours after the burn injury
the severity of the burn is related to 4
(1) the temperature of the heat source, (2) its duration of contact, (3) the thickness of the tissue exposed to the heat source, and (4) the location of the burn.
Why cant Parkinson be given dopamine supplement?
- Its hard to supplement dopamine because of the blood-brain barrier
Full thickness (third degree)
-Epidermis, dermis, subcutaneous tissue -Red, white, tan, brown, or black; leathery covering (eschar); painless
Nursing care parkinson disease 3
-monitor swallowing and maintain adequate nutrition and weight ; consult speech and language therapist determine swallowing -consult dietitian for appropriate diet includes semisolid foods and thickened liquids -determine the need for high calorie high protein
Parkinson disease s/s 7
-onset usually gradual (slowly progressive) after age 50 -mask like-blank expression -stooped posture -pill rolling tremors -possible mental deterioration-depression -shuffling gait -rarely occurs in black community
spinal cord injury 4
-paralysis below the level of injury -injuries increase C4 = paralysis of respiratory muscles and all four extremities (quadriplegia) -higher the injury the greater the loss -temperature of regulation problems decrease level of injury
Promotion and prevention of burns 6
-reduce the setting of the water heaters to 120 F -turn handles of pots and pans to the side or use back burners -keep flammable objects away from heat sources (candles, space heaters) -wear protective clothing during sun exposure -avoid tanning beds -never add flammable substances
Hypovolemia and shock can result 4
-result from fluid shifts from the intercellular and intravascular space to interstitial space -hypotension -tachycardia -decreased cardiac output
Lab test 6
-resuscitation phase: initial fluid shift (occurs the first 12h and continues for 24-36h -Glucose elevated -BUN elevated due to fluid loss -HCT and HGB elevated due to loss of fluid third spacing -Sodium decreased due to third spacing -Potassium increased due to cell destruction
mechanical hydrotherapy chemical
-scissors and forceps are used to cut away the dead skins -assist the client into a warm tub of water to cleanse the wound -apply a topical enzyme to break down and remove dead tissue
Parkinson disease characterized by four primary findings:
-tremor -muscle rigidity -bradykinesia (slow movement) -postural instability
One method for determining the extent of injury is to assess the depth of the burn. Burn depth is classified as follows 3
1. Superficial (first degree) 2. Superficial partial thickness and deep partial thickness (second degree) 3. Full thickness (third and fourth degrees)
The nurse is instructing a client using a pressure garment after a burn. For how many hours each day at a minimum will the nurse advise the client to wear the device? Fill in the blank with a number.
23h
A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours? 1,200 mL 2,400 mL 3,600 mL 4,800 mL
2400
A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body? 9% 18% 27% 36%
27%
A client was burned in a home accident. The ED physician indicated the client's wound, with proper care, should heal within 2 weeks. How was this client's wound classified? second degree first degree third degree fourth degree
2nd degree
client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned? 18% 27% 30% 36%
36
A client has experienced burns covering the back and front of both legs. Using the Rule of Nines, what percentage would the nurse assign to the client's injury when documenting? Fill in the blank with a number.
36`
A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be? 50 mm Hg 60 mm Hg 70 mm Hg 80 mm Hg
70 mm Hg
The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement? A urinary output of 10 mL/hr A urinary output of 30 mL/hr A urinary output of 80 mL/hr A urinary output of 100 mL/hr
A urinary output of 30 mL/hr
A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP? Encourage coughing and deep breathing. Position the client with the head turned toward the side of the brain tumor. Administer stool softeners. Provide sensory stimulation.
Administer stool softeners.
A client who has been on long-term phenytoin therapy is admitted to the unit. In light of the adverse of effects of this medication, the nurse should prioritize which of the following in the client's plan of care? Monitoring of pulse oximetry Administration of a low-protein diet Administration of thorough oral hygiene Fluid restriction as prescribed
Administration of thorough oral hygiene
anticholinergics interaction 2
Amantadine- Increased anticholinergic effects Digoxin- Increased digoxin serum levels Haloperidol- Increased psychotic behavior Phenothiazines- Increased anticholinergic effects
A client has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? Instruct the client to keep the wound site in a dependent position Administer PRN analgesia as prescribed Assess the client's peripheral pulses distal to the dressing Assist with passive range-of-motion exercises to "set" the new dressing
Assess the client's peripheral pulses distal to the dressing
Preventative measures 4
Avoid extreme heat and cold. Do not stay out in the warm weather too long. Drink plenty of fluids when in the heat. In cold weather wear many layers.
Signs and symptoms hypothermia 3
Body temp falls Chills Teeth Chattering
Signs and symptoms for Hyperthermia 5
Body temp rises to 100 of higher Headache Dizziness Nausea Face and neck erythema
spinal cord protection
Bones- vertebral column 7 Cervical 12 Thoracic 5- Lumbar 5- Sacral Discs- between vertebra
Dopamine receptor agonists 4
Cimetidine, ranitidine- Increased dopamine agonist effectiveness Verapamil, quinidine- Increased dopamine agonist effectiveness Estrogen- Increased dopamine agonist effectiveness Phenothiazines- Decreased dopamine agonist effectiveness
A patient with generalized seizure disorder has just had a seizure. The nurse would assess for what characteristic associated with the postictal state? Epileptic cry Confusion Urinary incontinence Body rigidity
Confusion
The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings? Elevate the leg on pillows and reassess the leg in 1 hour. Document the findings and instruct the client to report numbness of the extremity. Contact the primary care provider and prepare for an escharotomy. Apply an elastic stocking to the extremity and administer SQ heparin per order.
Contact the primary care provider and prepare for an escharotomy.
A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock? Confusion High fever Decreased blood pressure Sudden agitation
Decreased blood pressure
When the nurse learns that the client suffered injury from a flash flame, the nurse anticipates which depth of burn? Deep partial thickness Superficial partial thickness Full thickness Superficial
Deep partial thickness
A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort? Education about home safety Education about safe storage of chemicals Education about workplace health threats Education about safe driving
Education about home safety
Which activity should be avoided in clients with increased intracranial pressure (ICP)? Suctioning Enemas Position changes Minimal environmental stimuli
Enemas
A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the: Epidermal layer only. Epidermis and a portion of deeper dermis. Entire dermis and subcutaneous tissue. Dermis and connective tissue.
Epidermis and a portion of deeper dermis.
Classifications SCI Flexion 2
Flexion (hyperflexion) -Most common because of natural protection position. -Generally cause neck to be unstable because stretching of ligaments
A client is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the client's arm? Superficial partial thickness Deep partial thickness Full partial thickness Full thickness
Full thickness
TBSA
Head/neck - 9% TBSA Each arm - 9% TBSA Anterior thorax - 18% TBSA Posterior thorax - 18% TBSA Each leg - 18% TBSA Perineum - 1% TBSA
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? Complaints of intense thirst Moderate to severe pain Urine output of 70 ml the first hour Hoarseness of the voice
Hoarseness of the voice
A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name? Autografts Heterografts Homografts Xenografts
Homografts
The nurse is caring for a client who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report if it occurs immediately after burn injury? Hypernatremia Hypokalemia Hyperkalemia Hypercalcemia
Hyperkalemia
The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns? Classification by the appearance of blisters Identification by the destruction of the dermis and epidermis Not associated with edema formation Usually very painful because of exposed nerve endings
Identification by the destruction of the dermis and epidermis
Post op assessment HNP pt 2 2 CERVICAL LUMBAR
If Anterior Cervical- -Assess injury to the carotid, esophagus, trachea, laryngeal nerve (speech- hoarseness)-bleeding in the back of the neck -Assess respiration, neck size, swallowing and speech If Post-Op Lumbar- -Assess bowels sounds, voiding. -Minimize stress of post-op site- flat with pillow between knees, log roll, etc
A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first? Albumin Dextrose 5% in water (D5W) Lactated Ringer's solution Normal saline solution with 20 mEq of potassium per 1,000 ml
Lactated Ringer's solution
What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? A bounding pulse Bradycardia Hypertension Lethargy and stupor
Lethargy and stupor
The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? Select all that apply. Loosening constrictive clothing Opening the patient's jaw and inserting a mouth gag Positioning the patient on his or her side with head flexed forward Providing for privacy Restraining the patient to avoid self injury
Loosening constrictive clothing Positioning the patient on his or her side with head flexed forward Providing for privacy
The nurse is participating in the care of a client with increased ICP. What diagnostic test is contraindicated in this client's treatment? Computed tomography (CT) scan Lumbar puncture Magnetic resonance imaging (MRI) Venous Doppler studies
Lumbar puncture
COMT inhibitors interaction 2
MAOI antidepressants- Increased risk of toxicity of both drugs Adrenergic drugs- Increased risk of cardiac symptoms
In a client who has been burned, which medication should the nurse expect to use to prevent infection? Lindane (Kwell) Diazepam (Valium) Mafenide (Sulfamylon) Meperidine (Demerol)
Mafenide (Sulfamylon)
A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome? Attains desired fluid balance Displays no signs or symptoms of infection Maintains a patent airway Demonstrates optimal cerebral tissue perfusion
Maintains a patent airway
Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar? Mechanical Surgical Natural Chemical
Mechanical
Classifications SCI 4
Mechanism of Injury Flexion Hyperextension Compression Flexion /Rotation
A client with increased ICP has a ventriculostomy for monitoring ICP. The nurse's most recent assessment reveals that the client is now exhibiting nuchal rigidity and photophobia. The nurse would be correct in suspecting the presence of what complication? Encephalitis CSF leak Meningitis Catheter occlusion
Meningitis
A client whose diagnosis includes head trauma is being closely observed for signs and symptoms of increasing intracranial pressure. The client is exhibiting nonverbal indications of experiencing pain. Why should the nurse avoid the administration of narcotic analgesics in this case? Narcotic analgesics increase CSF pressure. Narcotic analgesics are ineffective against pain in head trauma. Narcotic analgesics decrease CSF pressure. Avoidance is inappropriate because narcotic analgesics are the drug of choice in treating pain associated with head trauma.
Narcotic analgesics increase CSF pressure.
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document for this diagnosis? Copes with sensory deprivation. Registers normal body temperature. Pays attention to grooming. Obeys commands with appropriate motor responses.
Obeys commands with appropriate motor responses.
the nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of "ineffective cerebral tissue perfusion." What would be an expected outcome that the nurse would document for this diagnosis? Copes with sensory deprivation. Registers normal body temperature. Pays attention to grooming. Obeys commands with appropriate motor responses.
Obeys commands with appropriate motor responses.
When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women? Anemia Osteoarthritis Osteoporosis Obesity
Osteoporosis
The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn? Diverticulitis Hematemesis Paralytic ileus Ulcerative colitis
Paralytic ileus (intestinal blockage in the absence of an actual physical obstruction.)
- Assessment to look for with
Parkinson neuromuscular signs (tremors of the head and hands at rest, muscular rigidity, mask like facial expression, and ambulation stability)
The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client? Prednisone Dexamethasone Cafergot Phenytoin
Phenytoin
- Parkinson risk for aspiration 6
Place client in a sitting position. Keep suction equipment at the bedside; use it when the client chokes. Decrease environmental distractions. Cut food into small pieces. Incorporate mashed potatoes or other pasty foods. Thicken liquids with gelatin, cornstarch, applesauce, mashed bananas, ice cream, or a commercial thickener. Position client's chin on the chest during swallowing.
A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety? Place the client in a side-lying position. Pad the client's bed rails. Administer antianxiety medications as prescribed. Reassure the client and family members.
Place the client in a side-lying position.
A home care nurse is performing a visit to a client's home to perform wound care following the client's hospital treatment for severe burns. While interacting with the client, the nurse should assess for evidence of what complication? Psychosis Posttraumatic stress disorder Delirium Vascular dementia
Posttraumatic stress disorder
Following a burn injury, the nurse determines which area is the priority for nursing assessment? Pulmonary system Cardiovascular system Pain Nutrition
Pulmonary system
A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration? Solid food with thin liquids Pureed food with water Semisolid food with thick liquids Thin liquids only
Semisolid food with thick liquids
Cardiovascular of burns 2 Pulmonary Hepatic Gastrointestinal 4 Genitourinary Integumentary 4
Slow cap refill, increased Heart Rate Rapid Resp. Rate Increased metabolism Blood in stool, Decreased bowel sounds, slow or no mobility, abdominal distention, N/V Decreased Urinary output, concentrated urine Loss of body warmth, Edema, Fluid retention, Extremities pale and cool.
therapeutic interventions pt 2 5
Stabilization/ Immobilization Traction- Gardner-wells tongs Halo Casts Splints Collars Braces all design to keep everything align for them to heal
Leukopenia within 48 hours is a side effect associated with which topical antibacterial agent? Cerium nitrate solution Gentamicin sulfate Sulfadiazine, silver (Silvadene) Mafenide (Sulfamylon)
Sulfadiazine, silver (Silvadene)
A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following? Superficial Full-thickness Superficial partial-thickness Deep partial-thickness
Superficial
An emergency department nurse learns from the paramedics that the team is transporting a client who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? The causative agent The client's pre-injury health status The client's prognosis for recovery The circumstances of the accident
The causative agent
While performing a client's ordered wound care for the treatment of a burn, the client has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this client's behavior? The client may be experiencing an adverse drug reaction that is affecting his cognition and behavior. The client may be experiencing neurologic or psychiatric complications of his injuries. The client may be experiencing inconsistencies in the care that he is being provided. The client may be experiencing anger about his circumstances that he is deflecting toward the nurse.
The client may be experiencing anger about his circumstances that he is deflecting toward the nurse.
Which client should the nurse assess for degenerative neurologic symptoms? The client with Huntington disease. The client with Paget disease. The client with osteomyelitis. The client with glioma.
The client with Huntington disease.
Patients taking carbidopa/levodopa (Sinemet) may develop the on-off phenomenon. What is the on-off phenomenon and how can it be managed?
The on-off phenomenon is when the patient suddenly alternates between improved clinical status and loss of therapeutic effect. The on-off phenomenon may be managed using low doses of the drug, reserving the drug for severe cases, or using a "drug holiday."
the nurse is liaising with the physical therapist and occupational therapist to create an activity management plan for a patient who has multiple sclerosis. What principle should be integrated into guidelines for exercise and activity that the team will provide to this patient in anticipation of discharge? The patient should perform frequent physical activity but avoid becoming fatigued. The patient should perform exercises that are brief but high-intensity. The patient should prioritize energy conservation and remain on bed rest if possible. The patient should attempt to maintain prediagnosis levels of activity and mobility.
The patient should perform frequent physical activity but avoid becoming fatigued.
A nurse is developing a care plan for a client with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? To prevent neuropathies To prevent wound breakdown To prevent contractures To prevent heterotopic ossification
To prevent contractures
Dopaminergic interactions 3
Tricyclic antidepressants- increased risk of hypertension and dyskinesia (abnormality or impairment of voluntary movement.) Antacids- Increased effect of levodopa Anticonvulsants- Decreased effect of levodopa
A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem? Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg Urine output of 20 ml/hour White pulmonary secretions Rectal temperature of 100.4° F (38° C)
Urine output of 20 ml/hour
A client has a skin graft and is also using a pressure garment as part of the recovery following a burn injury. Which of the following measures would the nurse advise the client to follow? Use a sunscreen with a high SPF while outdoors to protect against pigment changes. Apply Mederma to the skin once or twice a week to reduce scarring. After washing the garment, use a clothes dryer to dry it and remove all moisture. Remove the garment regularly for 1 or 2 hours to allow the graft to breathe.
Use a sunscreen with a high SPF while outdoors to protect against pigment changes.
skin grafting
When a wound dressing alone is no longer appropriate for covering large areas of burned tissue, use of a skin substitute, a temporary covering, or skin grafting, transferring the client's own skin to another area, becomes advantageous
As the first priority of care, a patient with a burn injury will initially need: a patent airway established. an indwelling catheter inserted. fluids replaced. pain medication administered.
a patent airway established.
Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Which graft is described as a biologic source of skin similar to that of the client? allograft xenograft autograft slit graft
allograft
Respiratory arrest and spinal shock are immediate complications of spinal cord injury. Long-term complications include 7
autonomic dysreflexia, pressure ulcers, respiratory infections, urinary and fecal impairment, spasticity and contractures, weight gain or loss, calcium depletion, urinary calculi, sexual dysfunction, and pain
The most serious adverse reactions seen with levodopa include 2
choreiform movements (involuntary muscular twitching of the limbs or facial muscles) dystonic movements (muscular spasms most often affecting the tongue, jaw, eyes, and neck).
closed method is the
current preferred method of wound management because it creates a microbial barrier, reduces heat loss through evaporation, and provides a moist environment that facilitates healing.
The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to increase metabolic rate. increase glucose demands. increase skeletal muscle breakdown. decrease catabolism.
decrease catabolism. (digest food and the molecules break down in the body for use as energy.)
A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may: dislodge the autografts. increase edema in the arms. increase the amount of scarring. decrease circulation to the fingers.
dislodge the autografts.
The imbalance between
dopamine and acetylcholine results in a movement disorder that characterizes Parkinson's disease.
on-off phenomenon
fluctuation in levodopa therapy where inconsistent absorption causes alternating improved status and loss of therapeutic effect
burns to the front of the right arm, the anterior chest, and front of both legs %
front of right arm-4.5% anterior chest-9% front of both legs-18% =31.5%
A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared leathery. What depth of burn injury does the client have? full thickness (third degree) superficial (first degree) superficial partial-thickness or deep partial-thickness (second degree) fourth degree
full thickness (third degree)
Diskectomy—
removal of the ruptured disk
Which antimicrobials is not commonly used to treat burns? tetracycline silver sulfadiazine (Silvadene) mafenide (Sulfamylon) silver nitrate (AgNO3) 0.5% solution
tetracycline
When a herniated disk in the lumbar region compresses Physical examination
the sciatic nerve, the client describes feeling pain down the buttocks and into the posterior thigh and leg. -weakness or paralysis of the extremity innervated by the compressed nerve. If a nerve in the lumbar or sacral area is affected, the client experiences pain when lying supine and lifting the leg without bending the knee
- Paraplegia,
weakness or paralysis and compromised sensory functions of both legs and lower pelvis, occurs with spinal injuries below the T1 level. When the tracts of the spinal nerves are completely severed, no effective nerve regeneration occurs. Muscle spasms occur spontaneously, but they are not evidence that the client is regaining motor function.
wound care 3
} 1. Open Method "Exposure" ◦ Wound open to air ◦ Mainly used with Superficial burns-do not need to put anything on it ◦ Dries out surface and impeded delivery of nutrients to skin cells. ◦ May use topical solution ◦ Sterile techniques. } 2. Closed Method ◦ Topical antimicrobial is applied, and is covered with gauze or non-adherent dressing. ◦ Usually dressed 2x/day } Closed Methods: ◦ Wet-Dry dressing Prevents scab formation and debrides wound Sterile!! May also see Hydrotherapy: Dilates blood vessels; removes wastes from body tissues <30 min. to prevent chilling and metabolic stress.
2nd degree burns or partial thickness burns 2
} 1stlayer (epidermis) burned all the way through and some level of burning into the dermis. } Causes: heat (moist travels to tissues quicker)
classification of burns 2
} Depth- (affected layers involved) } Extent-(the % of body surface area involved) } The American Burn Association uses both depth and extend to classify burns.
The goals of fluid resuscitation include 3
· (1) restoration of intravascular volume, (2) prevention of tissue and cellular ischemia, and (3) maintenance of vital organ functions.
Dopaminergic Drugs: Adverse Reactions, Contraindications, and Precautions 6
• Dry mouth, difficulty in swallowing, anorexia, nausea, vomiting, abdominal pain, constipation, increased hand tremor, headache, dizziness • Adverse reactions seen with levodopa: Choreiform movements, dystonic movements • Contraindications: - Dopaminergic drugs: Patients with known hypersensitivity to the drugs
• Is the following statement true or false? • Parkinson's disease is a progressive neurologic disease caused by an increase in dopamine in the brain.
• False • Parkinson's disease is a progressive neurologic disease caused by a reduction in dopamine in the brain. Cardinal signs include tremors, rigidity, and bradykinesia.
Dopaminergic Drugs: Actions 3
• Symptoms of parkinsonism are caused by depletion of dopamine in CNS • Amantadine: Makes more dopamine available at receptor site; selegiline: Inhibits monoamine oxidase type B, again making more dopamine available • Combining levodopa with another drug allows more levodopa to reach brain, hence provide better pharmacologic effect in patients with Parkinson's disease
• Is the following statement true or false? • The drugs used to treat Parkinson's disease and parkinsonism either supplement dopamine or block excess acetylcholine to enhance neurotransmission.
• True • The drugs used to treat Parkinson's disease and parkinsonism either supplement dopamine or block excess acetylcholine to enhance neurotransmission. Blood-brain barrier issues make supplementing dopamine difficult.
Immediate care 6
-Transport with cervical collar -Assess ABC's; O2; tracheotomy/vent -Jaw-Thrust maneuver for CPR -IV for life line-16 G -NG to suction: swallow, hemorrhage, dont know if their gut will be working -Foley
clinical manifestations SCI Cardio: 5
-dysrhythmias -spinal shock -loss of SNS control over blood vessels -orthostatic hypotension, -poikilothermic: whose internal temperature varies considerably.
Nursing problems/interventions 7
1.Impaired mobility 2.Impaired gas exchange 3. Impaired skin integrity 4. Constipation 5. Impaired urinary elimination 6. Risk for autonomic dysreflexia 7. Ineffective coping
Therapeutic Interventions 6
Medications IV methylprednisolone (Solu-Medrol)-STERIORD within 8 hrs to decrease cord edema To control or to prevent complications of SCI and immobility: -Vasopressors (keep BP up) to maintain perfusion -Histamine H2 blockers to prevent stress ulcers -Anticoagulants-immobile -Stool softeners-perstalsis will be slow down -Antispasmodics
Impaired mobility pt 2 4
Prevent/treat orthostatic hypotension -Abdominal binder, calf compressors, TED hose when individual gets up -Assess BP, especially when rising -Teach use of transfer board -Physical Therapy
clinical manifestations SCI Respiratory-2 GI 3
Respiratory- -decrease chest expansion, cough reflex & vital capacity -diaphragm function-phrenic nerve GI stress ulcers paralytic ileus bowel- impaction & incontinence-fluids, fiber, make sure they go to bathroom after 30mins of eating
clinical manifestations SCI Skin: Neuro:4
Skin: pressure ulcers: wrinkle in sheets, not able to move to be comfortable -need someone to look at bottom and heels once a day Neuro: -pain -sensory loss -upper/lower motor deficits -autonomic dysreflexia
Early signs include 3
- stiffness, referred to as rigidity, and a pill-rolling tremor (a circular movement of the fingers and wrist as if manipulating a small object or pill within the palm) in one or both hands. The hand tremor is obvious at rest and typically decreases when movement is voluntary, such as picking up an object.
Spinal cord-injured (SCI) individuals are
- thermoregulatory compromised because of an inability to vasodilate and sweat below the injury, increasing the risk, proportional to the injury level, for marked core body temperature (CBT) rises.
Tetraplegia (a term that replaces quadriplegia) refers to 3
- weakness, paralysis, and sensory impairment of all extremities and the trunk when there is a spinal injury at or above the first thoracic (T1) vertebrae.
constipation 2
-As a result of bed rest and decreased mobility and fear of pain with straining of stool -Constipation prevention methods- fluids, diet, stool softner
S/S parkinson 6
-Bradykinesia, slowness in performing spontaneous movements, develops. -Clients have a masklike expression, -stooped posture, -hypophonia (low volume of speech), and -difficulty swallowing saliva and food. -Weight loss occurs
LEVEL OF INJURY-C6-C8 COMMON MOTOR EFFECTS COMMON SENSORY EFFECTS FUNCTIONAL ABILITIES 3
-C6-C8 -Some elbow, upper arm, and wrist movement; can do diaphragmatic breathing -Some sensation in arms and thumb; sensation in chest impaired -Eat, groom, bathe, and attain bed mobility with assistive devices Transfer from bed to chair using a slide board Perform self-catheterization (males); more difficult for females Use manual wheelchair in flat environment Drive with hand controls
Emergent (resuscitative phase) acute rehabillitative
-injury and continues for 24-48h -phase begins 36-48h after injury when the fluid shift resolves -phase ends with closure of the wound -the phase begins when most of the burns area has healed -phase ends when the client achieves the highest level of functioning ability
Expected findings PD 5
-stooped posture -slow shuffled gait -tremors/pill rolling gait -muscle rigidity -autonomic findings(orthostatic hypertension, flushing, diaphoresis)
C4 C6 T6 L1
-tetraplegia:(sometimes referred to as quadriplegia) is a term used to describe the inability to voluntarily move the upper and lower parts of the body. -tetraplegia:(sometimes referred to as quadriplegia) is a term used to describe the inability to voluntarily move the upper and lower parts of the body. -paraplegia:refers to the loss of movement and sensation in both legs and, sometimes, part of the lower abdomen. -paraplegia:refers to the loss of movement and sensation in both legs and, sometimes, part of the lower abdomen.
if there is a full-thickness burn in the
-the neck area, eschar (a hard, leathery crust of dehydrated skin) may compress the neck and pull it into flexion, making a tracheostomy the preferred technique for maintaining a patent airway
Carbon monoxide inhalation 5
-weakness -dizziness -confusion -erythma (pink or cherry red skin) -upper airway edema
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client? A urine output consistently above 40 ml/hour A weight gain of 4 lb (2 kg) in 24 hours Body temperature readings all within normal limits An electrocardiogram (ECG) showing no arrhythmias
A urine output consistently above 40 ml/hour
A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school? Generalized seizure Absence seizure Focal seizure Unclassified seizure
Absence seizure
A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What should the nurse in the ED receiving the call instruct the father to do? Cover the burn with ice and secure with a towel. Apply butter to the area that is burned. Immerse the child in a cool bath. Avoid touching the burned area under any circumstances.
Immerse the child in a cool bath.
Partial-Thickness or Second-Degree Burns
The epidermis and the underlying dermis are both injured and devitalized or destroyed. Blistering usually occurs with an escape of body plasma, but regeneration of the skin occurs from the remaining viable epithelial cells in the dermis
Victims of carbon monoxide poisoning may require
hyperbaric oxygen treatment (administration of 100% oxygen at three times greater than atmospheric pressure in a specially designed chamber) to increase the binding of oxygen rather than carbon monoxide to hemoglobin molecules
A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? inflammatory neuroendocrine intravascular fluid excess hypertension
inflammatory
deep partial thickness burns treatment 5
} Agent containing silver, either in the form of a cream or silver-impregnated membrane used as a dressing on the wound surface. } The cream must be removed and reapplied at least once a day. } Silver dressings continuously release silver over several days, minimizing the need for frequent dressing changes. These dressings need to be kept moist to activate release of the silver; the wound fluid from the burn injury is often sufficient. } A dry gauze dressing is used over the silver cream or dressing. } Pain Meds } May need burn center care or wound management } May need skin grafting } May leave permanent scars.
types of skin graft 3
} Autograft: ◦ Transplant of clients own tissue-only graft that is PERMANENT. ◦ Most successful ◦ Immobilize area after grafted } Xenograft: ◦ Skin replacements from animal to human. ◦ Not very successful ◦ Pig skin commonly used to temporarily cover a massive burn. } Homograft: ◦ Fresh skin from a human cadaver ◦ May be a precursor to autograft.
infection control 2 } Local Signs of Burn wound infections: 4
} Client will be on Isolation(no fresh flowers/fruit, no raw foods) -reverse isolation/neutropenia } Septicemia can occur at any time during hosptialization. -admission you start with discharge plan } Local Signs of Burn wound infections: ◦ Black or brown areas of discoloration ◦ Enhanced sloughing (shedding dead skins) of burned tissue ◦ Partial-thickness wound converting to full-thickness wound ◦ Increasing edema around the wound edges
How to protect a person who is on fire
· If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire. Laying the client flat prevents the fire, hot air, and smoke from rising toward the head and entering the respiratory passages.
Signs of Heat or Smoke Inhalation Injury 5
· Sore throat · Singed nasal hairs, eyebrows, eyelashes · Hoarseness · Carbon in sputum · Soot around mouth or nose · Shortness of breath · Stridor
herniated cervical disk is
· by immobilizing the cervical spine with a cervical collar or brace. Later, as inflammation subsides, the client wears the collar or brace intermittently when walking or sitting. Bed rest with a firm mattress and bed board is used for clients with a lumbar herniated disk.
COMT inhibitors adverse reaction 4
• Dizziness, dyskinesias, : Uncontrolled, involuntary muscle movement. hyperkinesias, nausea, anorexia, diarrhea, orthostatic hypotension, sleep disorders, excessive dreaming, somnolence, muscle cramps
• Is the following statement true or false? • When drugs or other illnesses cause Parkinson-like symptoms, these are termed parkinsonism or extrapyramidal symptoms.
• True • When drugs or other illnesses cause Parkinson-like symptoms, these are termed parkinsonism or extrapyramidal symptoms.
} Client has burns to the face, anterior right arm, and anterior trunk. What % of burns does she have? } Client has burns to the head, right anterior arm, and front torso. What % of burns does he have? } Client has burns to front and back torso, and both legs. What % of burns does she have?
◦ 27% TBSA ◦ 31.5 or 32% TBSA-head:9 + anterior arm-4.5+ torso 18 72% TBSA- one leg is 18%
1st 48 hours of nursing care -} Monitor for s/s of shock: (any partial thickness burn >9% can cause shock) 4 Treatment: 4
◦ Decreased BP ◦ Increased HR ◦ Pale/Clammy skin ◦ Cyanosis around lips -Monitor BP -Give LR and Albumin (major protein in the intravascular space; maintains intravascular pressure) -Monitor Electrolytes -Monitor Protein loss } Once fluids are started; begin by giving small amounts: ◦ Make sure urine output is at least 30ml/hr
burn contractures } 2 Types of Scars form: during the healing process
◦ Keloid-extends beyond original boundaries of the original wound-enlarged and raised ◦ Hypertrophic-overgrowth of dermal tissue that remains within boundaries of the wound.-thick ◦ During the healing process, the burn scar shrinks and becomes fixed and inelastic, which can result in contractures (permanent shortening of connective tissue)
how do we estimate the extent of burns 4
◦ Rapid method of estimating partial and full thickness burns. ◦ Determines % of Total body surface area (TBSA) burned. ◦ Usually used before arriving to hospital and during emergency care. ◦ Not used in Infants (b/c larger head to body ratio) ◦ Sometimes difficult to determine with short, obese or very thin people.
allograft or homograft is a
- biologic source of skin similar to that of the client. It may be obtained from a cadaver, from human donor cells such as stem cells from umbilical cord blood,
Full-Thickness or Third-Degree Burns
-The epidermis, dermis, and nerve endings are all destroyed
Superficial (first degree) 2
-epidermis and part of the dermis -Painful with pink or red edema, but subsides quickly; no scarring
Autonomic dysreflexia 2
-exaggerated sympathetic nervous system response in people with spinal cord injuries above T6. -suddenly at any time after spinal shock subsides
The nurse cares for a client with extensive burn injuries. Which parameter(s) would the nurse evaluate to determine if the client is receiving adequate fluid resuscitation? Select all that apply. Blood pressure Heart rate Urine output Oxygen saturation
Heart rate Urine output
An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury? The length of time since the burn The location of burned skin surfaces The source of the burn The total body surface area (TBSA) affected by the burn
The total body surface area (TBSA) affected by the burn
fluid replacement } Watch for s/s of fluid overload: 5
} Lactated Ringers is fluid most often used b/c it is most like the normal extracellular fluid. ◦ Edema ◦ Dyspnea ◦ Neck vein distention ◦ Ascites ◦ Wt. gain.
4 types of burn
} Thermal (heat- can be dry or moist): iron, hot stove, curling iron -moist:deeper and faster;steam, boiling water, scalding ◦ Most common type } Chemical ◦ Direct contact with acids or alkaline agents (work) } Electricity ◦ Have entry and exit wounds- may be widespread tissue damage underneath the wounds. } Radiation ◦ Sunburn or Radiation treatments (tend to be superficial or 1stdegree burns)
superficial partial thickness burn treatment 4 Areas such as the face and ears are treated open without a dressing 2 } What is the risk of leaving a wound open?
} Treatment of Superficial Partial Thickness Burn: ◦ Immerse in cool water for 15-20 minutes ◦ Do not break Blisters ◦ Elevate above level of heart ◦ Keep clean to prevent infection May cover with clean sheet. Bacitracin is often used-antibiotic May also use petroleum impregnated gauze-provides it to be most and not to stick ◦ Bacteria can enter.
Postcervical Diskectomy 3
· Keep a cervical collar in place at all times; do not remove without a physician's order. · Instruct client to keep the neck straight in midline position until healing occurs. · Support client's head, neck, and upper shoulders when moving from a lying to sitting to standing position or when getting into and out of a chair. · Observe for Horner's syndrome, a complication following anterior cervical diskectomy from cervical sympathetic nerve damage. Manifestations are lid ptosis (drooping), constricted pupil, regression of eye in the orbit, and lack of perspiration on one side of the face.
complication of burns 4
◦ Septicemia (from infection) ◦ Renal Failure ◦ Pneumonia ◦ Heart Failure
3rd degree burn treatment 3
◦ Will require hospitalization (Burn center) ◦ May need a skin graft b/c skin will not regenerate ◦ If has a skin graft will have: Graft site (burned area covered with skin graft) Donor site (unburned area that was removed to cover the burned site.) Graft site: Dressing for 2-5 days Donor Site: Dressing for 1-2 weeks Monitor for S/S of infection/Rejection.
path of burns 2
Immediate effect-destruction of protective skin area (Lead to) ◦ Disruption of Homeostasis Diffusion of fluid from intravascular space (bd vessels) into interstitial (tissue) spaces (AKA: Third Spacing) Electrolyte Imbalances Diminished blood volume.: hypovolemia shock Can lead to multi-system trauma.
A client who was severely burned begins to exhibit symptoms of renal failure during treatment. What physiologic process can cause acute renal failure? hemoconcentration anemia fluid, electrolyte status histamine
hemoconcentration
choreiform movements dystonic
involuntary muscular twitching of the limbs or facial muscles muscular spasms most often affecting the tongue, jaw, eyes, and neck
Quadraparesis means what?
is a condition characterized by weakness in all four limbs (both arms and both legs). It's also referred to as tetraparesis. The weakness may be temporary or permanent
Pain interventions for burns: 2
monitor every 2-4 hours to determine the childs comfort level administer analgesics 20-30 min before dressing changes and debriement
xenograft or heterograft is
obtained from animals, principally pigs or cows.
burn of classification of depth 3
} Classified according to the following: ◦ 1stDegree- also called Superficial Burns ◦ 2ndDegree- also called Partial Thickness Burns ◦ 3rdDegree- also called Full Thickness Burns
Common Causes of Autonomic Dysreflexia 6
· Full bladder · Abdominal distention · Impacted feces · Skin pressure or breakdown · Overstretched muscles · Sexual intercourse · Labor and delivery -Sunburn below the cord injury
Common manifestations/complication 2
HNP compresses -Spinal nerve (sensory or motor component) as it leaves the spinal cord -Or the cord itself- the white tracts within the cord- rare
Most common site for HNP classic symptoms
L4-5 disc- the 5thlumbar nerve root radiating pain from back to both legs; pain in the neck can radiate one or both arms
The purposes of a skin substitute or graft are to 6
- Lessen the potential for infection - Minimize fluid loss by evaporation - Diminish pain - Promote regeneration of tissue - Reduce scarring - Prevent loss of function
In late stages 4
-disease affects the jaw, tongue, and larynx; -speech is slurred; and chewing and swallowing become difficult. -Rigidity can lead to contractures. -Salivation increases, accompanied by drooling. There is a high risk for aspiration.
rejection to skin graft
pulling away and not being vascularized
parts of the body to burns 3
} Head, Neck, and Chest ◦ > Risk of Respiratory Problems ◦ Maintain patent airway ◦ Neck ◦ Prone to contractures ◦ Perineum ◦ Very susceptible to infection.
superficial burn is similar to 4
· a sunburn. The epidermis is injured, but the dermis is unaffected. Although the burn is red and painful, it heals in less than 5 days, usually spontaneously with symptomatic treatment. Infection, increased metabolism, and scarring do not occur.
Levodopa is associated 3
· periods of "breakthrough" or "end-of-dose wearing off" in which symptoms are exacerbated when a consistent drug level is not maintained. The nurse must administer the drugs closely to the schedule the client previously established at home. Over time, clients may decreasingly respond to their standard drug therapy and have more frequent "off episodes" of hypomobility in which they may be unable to rise from a chair, speak, or walk
open method (exposure method),
· which exposes the burned areas to air, has been virtually abandoned since the advent of effective topical antimicrobials. It is still used on a small scale, however, for burned areas such as the face and perineum, where it is difficult to apply dressing materials.
Treatment surgery Laminectomy-
removal of a portion of the lamina to relieve pressure and to get to the herniated nucleus pulposus that is protruding out
care of the patient 2
} Environment ◦ Keep room warm-Keep air currents down due to pain when air currents hit wound.--98 degrees } Nutrition: ◦ High calorie (metabolic demands triple) ◦ High protein (assists with wound healing) ◦ High in Vit. C (assists with collagen formation)
48-72 h burns for care 4 what is Sulfamylon Acetate
} Eschar forms-initially is sterile; however skin can no longer be a barrier and bacteria will colonize. } Goal: Reduce bacterial Count } Topical Antimicrobials(cream/lotion) ◦ Sulfamylon Acetate: Broad bacteriostatic action against many gram neg. and gram pos. organisms. -Easy to apply but drug causes pain/burning -May cause acid/base imbalances- Do not use on large areas of body. Medicate with pain meds before use. NSAIDS for minor burns Morphinefor major burns- IV preferred. May be on Morphine drip.
positioning 5
} Goal: Prevent contractures ◦ Change positions frequently ◦ Don't bend at joints for extended amt of time ◦ Supine best and reverse trendleburg ◦ Extension most often the best ◦ Don't use Fowler's position or pillows ◦ Follow MD orders re: splints/exercise program/activity levels
Levels of function in SCI 2
Skeletal level Vertebral level where the most damage to the bones -C4 higher mechanically venatalated -C6 able to breath (difficulty breathing the phrenic nerve inivates the diaphram), shrug shoulders -L1 just the loss of their legs Neurologic level The lowest segment of the spinal cord with normal sensory and motor function on both sides of the body
Spinal/neurogenic shock 5
Spinal Shock -Decreased reflexes and loss of sensation below the level of injury -Motor loss- flaccid paralysis below level injury -Sensory loss- loss touch, pressure, temperature pain and proprioception perception below injury -Hypotension, Bradycardia -Lasts days to months
Diagnostic test
X-ray identify deformities and narrowing of disk space CT/MRI Mylogram (lots of fluid after) Nerve conduction studies (EMG) detect electrical activity of skeletal muscles
Diagnostic studies SCI 4
X-ray of spinal column CT/MRI-Spinal cord not show on Xray not bones Blood gases Mylegram(give lots of fluids after)-inject dye look at the spinal cord for any obstruction
precautions of dopamine 2
- Levodopa: Patients with narrow-angle glaucoma, those receiving MAOI antidepressants • Precautions: - Levodopa is used cautiously in patients with cardiovascular or pulmonary diseases; peptic ulcer disease; renal or hepatic disease; and psychosis
Wound débridement is the removal of necrotic tissue. The procedure is potentially painful and warrants premedication with an analgesic. Débridement is accomplished in one of four ways:
- Naturally as the nonliving tissue sloughs away from uninjured tissue - Mechanically when dead tissue adheres to dressings or is detached during cleansing - Enzymatically through the application of topical enzymes to the burn wound - Surgically with the use of forceps and scissors during dressing changes or wound cleansing
• Dopaminergic drugs are used to treat: 4
- Parkinson's disease - Parkinson-like symptoms as a result of injury, drug therapy, or encephalitis - Restless leg syndrome - Viral infections
- Notifying the health care provider immediately is necessary if any of the following signs of the onset of this phase occurs: 3
- • Rapid rise in urinary output; may increase to 250 mL/hr or higher. - • Tachypnea followed by dyspnea. - • Increase in pulse pressure; mean blood pressure may also increase. Central venous pressure, if measured, is elevated.
Thermoregulation in Spinal Cord Injuries Causes
-Cervical and high thoracic spinal cord injuries. -Person is unable to control internal temperature resulting in hyperthermia or hypothermia.
Impaired skin integrity
-Change position frequently -Protection from extremes in temperature-cooling them off -Inspect skin at least 2x/day especially over boney prominences -Avoid shearing and friction to soft tissue with transfers -Removal of TED hose every 8 hours -Nutritional status: protein and calories
Deep partial thickness (second degree) 2
-Deeper layer of the dermis with damage to sweat and sebaceous glands -Variable color from patchy red to white, wet or waxy dry, does not blanch with pressure, sensitive to pressure only
risk for autonomic dysreflexia pt 2 5
-Elevate head of bed- causes orthostatic hypotension pull some of the blood out of the head -Identify cause/alleviate- if full bladder- cath; if skin- remove pressure, if full bowel- empty, etc -Remove support hose/abdominal binder -Monitor blood pressure- can get > 300 S-give nitro first so it wont bottom the BP -Give PRN medication to lower BP -If above not effective- call physician
Superficial partial thickness (second degree) 2
-Epidermis and dermis, hair follicles intact -Mottled pink to red, painful, blistered or exuding fluid, blanches with pressure
Full thickness (fourth degree)
-Epidermis, dermis, subcutaneous tissue; may include fat, fascia, muscle, and bone -Black, depressed, painless, scarring
Nursing interventions 5
-Get out of the heat or cold -If your temperature is cold cover with blankets and use someone else as body heat. -If your temperature is too warm go to an air-conditioned room and take off clothes. Sponge off with cool water. -DO NOT USE ICE PACKS OR HEAT PACKS. This can cause burns or frost bite. -If temperature remains high, it may be due to infection and will need pharmacologic intervention.
Spinal cord injury 3
-Hemorrhage and edema occur in the cord post injury, causing more damage to cord -Initially SCI experience spinal shock (neurogenic shock) -depression of all cord & ANS function below injury. Lasts from few min to wks
Herniated disk risk factors 5
-Herniated nucleus pulposus, (HNP) slipped disc, ruptured disc -HNP- annulus becomes weakened/torn and the nucleus pulposus herniates through it. Risk Factors- -Standing erect: factory workers, security guard, cashier, hair stylist -Aging changes: bones become weaker; good shoes, mats, stool -Poor body mechanics -Overweight -Trauma
impaired physical mobility 4
-Log roll as a single unit; provide assistance as needed to keep alignment; teach patient -Care traction, collars, splints, braces, assistive devices for ADL's -Flaccid paralysis- use high top tennis shoes or splints to prevent contractures. Remove at least every 2 hrs for ROM (active ROM best) -Assess skin breakdown -Assess for DVT
closed method advantage 5 disadvantage 5
-Maintains moist wound -Promotes maintenance of body temperature -Decreases cross-contamination of wound -Provides wound debridement during dressing removal -Reduces pain during position changes -Requires more time -Adds to expense -Enhances growth of pathogens beneath dressings -Interferes with wound assessment -Causes more blood loss with removal -Can interfere with circulation if tightly applied
Common manifestation/complications 2 prefix 2 suffix 2
-Spinal cord injuries are described by the level of the injury- the cord segment or dermatome level -Such as C6; L4 spinal cord injury -Terms used to describe motor deficits Prefix: -para- meaning two extremities -tetra- or quadra- all four extremities Suffix : -paresis meaning weakness -plegia meaning paralysis
full-thickness burn 4
-destroys all layers of the skin and is consequently painless.The tissue appears charred or lifeless. If not débrided, this type of burn injury leads to sepsis, extensive scarring, and contractures. Skin grafts are necessary for a full-thickness burn because the skin cells no longer are alive to regenerate. The most serious full-thickness burn, a fourth-degree burn, can involve ligaments, tendons, muscles, nerves, and bone
partial-thickness burn is classified as 3
-either superficial or deep partial thickness, depending on how much dermis is damaged. -superficial partial-thickness: burn heals within 14 days, with possibly some pigmentary changes but no scarring; it requires no surgical intervention -· deep partial-thickness burn takes more than 3 weeks to heal, may need débridement, is subject to hypertrophic scarring, and may require skin grafts
Catechol-O-methyltransferase (COMT) inhibitors nursing action 3
-entacapone -decrease the breakdown of levodopa making more available to the brain as dopamine -monitor for dyskinesia/hyperdyskinesia when used with levodopa -monitor for diarrhea -dark urine is a normal finding
Risk factors PD 5
-findings between 40-70 -more common in males -genetic predisposition -exposure to environmental toxins (inhaling copper) and chemical solvents -chronic use of antipsychotic medication
Dopaminergics 3 nursing care
-given orally Levodopa is converted to dopamine in the brain; increasing dopamine levels in the basal ganglia -combined with carbidopa to decrease peripheral metabolism of levodopa -timing i everything with this medication -monitor for the wearing off phenomonen and dyskinesias (problems with movement)
eschartomy
-incision through the eschar relieves pressure from the constricting force of fluid buildup under burns and improves circulation
muscle rigidity parkinson disease 2
-increase resistance to passive movement -cog wheel, jerky slow movement
Treatment of parkinson 2
-increasing the amount of dopamine -decreasing the amount of acetylcholine in a client's brain
The risk for acquiring a burn injury 2
-is highest among children and adults older than 60 years of age. -The most common causes of thermal burns in older adults at home are flames and scalding from steam or hot liquids; these fires are often secondary to smoking, alcohol ingestion, or flammable substances that ignite materials
bradykinesia with parkinson diease 5
-loss of normal arm swing while walking -decrease blinking of the eyelids -loss ability to swallow -blank expression -difficulty initiating movement
Inhalation damage findings with burns 6 indications of the impending loss of the airway include 3
-singed nasal hair -sooty sputum -hoarseness -wheezing -edema of nasal septum -smoky smelling breath -hoarseness -brassy cough -audible wheezing
Thermoregulation with burns 3
-skin helps control body temperature wit the skin being injured the body loses heat -decreased temp can happen the first few hours of injury -for decreased temp, use warm, inspired air, warm room, warming blanket
Autonomic Dysreflexia trigger sustained stimuli 4 vasodilation above 6 vasoconstriction below 3
-spinal cord injury at T-6 or higher -pressure areas -fecal impaction -full bladder or UTI -restrictive clothing -increase BP-severe and rapid -flushed face -headache -distended neck veins -decrease HR -increase sweating -pale -cool -no sweating
Client education burns 3
-wear compression dressing and garments as prescribed usually 23 h to minimize scarring and prevent difficulty mobility -massage scars with moisturizer -avoid tight clothing over burned areas
The outcome of a burn injury depends 3
on the initial first aid provided and the subsequent treatment in the hospital or burn center. Any one of three complications—inhalation injury, hypovolemic shock, and infection—can be life threatening
A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be: fluid resuscitation. infection. body image. pain management.
pain management.
A client fell while snowboarding, sustaining a blow to the head resulting in a loss of consciousness. Upon arrival at the emergency department, the client regained consciousness within 1 hour. What signs are symptoms would indicate increased ICP? Select all that apply. personality changes sleepiness nausea headache
personality changes sleepiness
care of the burn client 4 s/s 4 what to look for obstructed airway 4
} 1st24 hours(emergent stage): ◦ Priority: Maintain Patent Airway due to laryngeal edema. S/S of problems: Hoarseness, inspiratory wheezing, stridor Risk is highest with burns to the face, neck, chest. Elevated HOB to 30 degrees or more May need intubation. ◦ Determine extent and depth of burn. ◦ Fluid Replacement due to fluid shifts. ◦ Hourly urine output is measured 30-50ml/hr Because of n/v; oral fluids usually not given during this time.--LR
Age and burns 3
} Age: <4 years and >60 years have higher chance of complications and death from severe burns. } Infants: Poor antibody response and fluid requirements can be tricky ◦ Thinner skin causes deeper burns } Older adults: May have underlying conditions-complicates situation. ◦ Thinner skin causes deeper burns
silver based agent 3
} Can be used after debridement has removed most of the infected tissue. } Silver Nitrate-Liquid used to kill antibiotic resistant strains of bacteria. ◦ Not used much anymore ◦ Cover with moist dressing (petroleum impregnated) ◦ If allowed to dry out, further burns the site ◦ Turns everything BROWN or BLACK.
1st degree or superficial burn s/s 4 treatment 4 healing time
} Damage is to outer layer of skin. } S/S: Redness, swelling, pain. ◦ If covering a large amount of the body may have chills, headache, n/v. ◦ Most are from sunburn and radiation. ◦ Treatment: -Run burned area under cool water for 10-20 minutes. ◦ Give NSAIDS or Tylenol of pain ◦ May use topical creams. ◦ Never use ice(can cause more damage to burned area).-constricts blood vessel slows the healing -if skin is not intact need sterile ointments 3-6 days
deep partial thickness burns 5
} Destruction of most of the dermal layer, with few viable epidermal cells remaining } Reepithelialization is slow, sometimes taking months. } Blisters do not generally form b/c dead tissue layer is thick and adheres to the underlying viable dermis (eschar). } The wound appears white and dry. } Blood flow is compromised, making the wound vulnerable to infection -honey dressings
Burns definition incidence
} Injury in which the transfer of energy from a heat source to the human body results in tissue loss, damage or irreversible destruction. } Incidence: ◦ 2.5 million/year ◦ 35% are children Newborn-4 years (Bathroom and Kitchen) 5-74 years (outdoors and Kitchen)
3rd degree of burns or full thickness burns caused 3 s/s 4
} Involves ALL layers of the skin (can extend to SQ fat, connective tissue, muscle and bone). } Caused by: flames, steams, chemicals or high voltage electric current. } S/S: Skin will be white, brown, black or red ◦ Skin may appear waxy. ◦ Extreme edema ◦ No Pain b/c destruction of nerve-endings ◦ Life threatening-depends on % of body surface injured.
} How do we determine if they are Major burns 6
} Partial-thickness burns greater than 10% of TBSA } Burns that involve the face(airways), hands, feet, genitalia(infection, urinate), perineum, } or major joints (infection, contractures) } Full-thickness burns (3rddegree burn) in any age group, over 1% of TBSA } Electrical burns, including lightning injury } Chemical burns } Inhalation injury } A child with any of the above burn injuries } Burn injury in patients with preexisting medical disorders that could complicate management
superficial partial thickness burn s/s 4 patho what does the burn cause
} S/S: Bright red skin, edema, moist/glistening apperance, very painful, and BLISTERS! } Patho: ◦ The microvessels perfusing this area are injured, leading to leakage of large amounts of plasma. This lifts off the heat-destroyed epidermis and causes a blister to form. Resulting in pink, wet and painful burns. These are the most painful burns because the nerve endings of the skin are exposed to air
topical antimicrobials 3
} Silvadene ◦ Antibacterial topical cream. ◦ Use sterile technique ◦ Painless ◦ Do not use if Allergic to Septra ◦ Apply 1-2 x per day. ◦ Betadine ◦ Broad spectrum antiseptic (>30 years) ◦ Active ingredient: Providone Iodine prevents and treats wound infections ◦ Can cause staining } Neosporin or Bacitracin ◦ Usually used on Face
care 3
} Splints ◦ Used to mobilize body parts and prevents contractures. (p.1168) -ROM ◦ Active and passive ROM to prevent contractures } Elastic Pressure Garments ◦ Uniform pressure prevents or reduces hypertrophic scarring. ◦ Custom-made (Jobst garment) ◦ Wears for 6 months- 1 year post graft
fluid shifts 5
} With heat exposure, capillaries are damaged and become begin to leak. } Instead of sticking together (which keeps food inside of the blood vessel), the endothelial cells separate and become very porous. } This causes fluid to pour out into the tissues. (interstitial spaces) ◦ In small burns this fluid accumulates only in the burn area causing edema and blisters. ◦ In large burns fluid can accumulate anywhere in the body, causing edema. Blood volume goes down as edema increases causing HYPOVOLEMIA. } Fluid shifts are directly proportional to the extent and depth of the burn. } Treatment/fluid therapy is directly related to the severity of the burn. } Children become dehydrated more rapidly ◦ (r/t ratio of body surface area to weigh, increased metabolism, and thinner skin)
epithelialization escharotomy
· A hard crust forms over a partial-thickness burn in 2 or 3 days, and epithelialization (regrowth of skin)is completed in about 2 or 3 weeks. At this time, the crust falls off, is debrided, or is loosened by whirlpool baths. Eschar forms in areas of full-thickness burns. If the eschar constricts the area and impairs circulation, an escharotomy (an incision into the eschar)is done to relieve pressure on the affected area
The following cellular, chemical, and concurrent injuries occur following a burn: 4
· Anemia develops because the heat literally destroys erythrocytes. The sluggish flow of blood cells through blood vessels results in inadequate nutrition to healthy body cells and organs. · Myoglobin and hemoglobin are transported to the kidneys, where they may cause tubular necrosis and acute renal failure. · The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to developing gastric ulcers. · Cardiac arrhythmias and central nervous system complications are common among victims of electrical burns.
Key Points about Herniated Nucleus Pulposus 3
· Herniated disks are common and usually affect nerve roots at C6, C7, L5, or S1. · If symptoms develop suddenly and back pain is relieved with rest, suspect a herniated disk rather than an epidural tumor or abscess. · Recommend analgesics, light activity as tolerated, and exercises to improve posture and strength; however, if pain or deficits are severe or worsening, consider invasive procedures.
Postlumbar Laminectomy or Diskectomy With Spinal Fusion 3
· Logroll when turning client every 2 hours; maintain alignment at all times. · Caution client to avoid turning self. · Teach client to avoid twisting or jerking the back, sitting during the first week and prolonged sitting thereafter (client should use a straight-backed chair and not slump), and bending from the waist (client should bend from the knees and hips).
· Risk reduction teaching includes: 3
· Water temperature settings should be no higher than 110 oF · Working smoke detectors and scheduled battery changes every 6 months (may link to changing clocks for daylight savings time) · Working fire extinguisher