Medsurg 2 Exam 1
Acute phase nursing interventions
-prevent complications -vital signs hourly or every 4 hours -assess respiratory function -administer tetanus booster -administer anti-infective -IV or oral analgesics -turn every 2 hours to prevent contractures
Main function of the skin
-protect underlying body tissues by serving as a barrier to the external environment
Noninvasive PPV (positive pressure ventilation)
-provides O2 and decreases WOB with spontaneous breathing- must be awake, alert, and vital signs stable -two forms CPAP and BiPAP
Empyema
-purulent fluid in pleural space
Assessment: Flail Chest
-rapid, shallow respirations -asymmetric and uncoordinated chest movement -inadequate ventilation -splinting -crepitus near fractures
Toxic Epidermal Necrolysis (TEN)
-rash that usually starts on the palms, soles, and trunk and then spreads to the face and extremities -stop offending drug
Risk factors for malignant melanoma
-red or blonde hair -light colored eyes fair skin that freckles -chronic sun exposure -family history
Excisional biopsy
-removal of an entire lesion -used when good cosmetic results and/or entire lesion removal is desired
Curettage
-removal or scooping away of tissue using an instrument called a curette
Clinical manifestations of hypoxemia
-restlessness, confusion, agitation -prolonged expiration, nasal flaring, intercostal muscle retraction, and use of accessory muscles -cyanosis is an unreliable indicator- LATE SIGN PaO2 less than or equal to 45mm Hg
Acute Respiratory failure
-results from inadequate gas exchange -not a disease but a reflection of lung function
Fractured ribs are most common in....
-ribs 5 to 9 -can damage pleura, lungs, heart, and other internal organs
Mobilization of secretions
-secretions can block or limit the exchange of gases -secretions can be mobilized by positioning, effective coughing, chest physiotherapy, suctioning, humidification, hydration
Emergent phase goals
-secure airway and assess oxygen needs -support circulation by fluid replacement -keep client comfortable with analgesics -prevent infection through wound care -maintain body temperature -provide emotional support -assess nutritional support -assess I/O's- foley catheter
ARDS Predisposing Factors
-sepsis -direct lung injury- pathogen comes into contact with the lung tissue -Indirect lung injury- develops due to problem somewhere else in the body (usually from sepsis or massive trauma)
Tension pneumothorax clinical manifestations
-severe dyspnea -tachycardia -tracheal deviation -decreased or absent breath sounds on affected side -neck vein distention -cyanosis -diaphoresis
Smoke and inhalation injuries- clinical manifestations
-singed nasal hairs -burns to face, neck, or lips -darkened oral/nasal mucosa -soot material around nose/mouth -hoarseness, stridor or respiratory changes -restlessness and confusion -convulsions and coma in severe cases
Treatment for melanoma is determined by
-site of original tumor -stage of the cancer
Acute phase: wound healing
-starts 48-72 hours after burn -begins with mobilization of extracellular fluid and subsequent diuresis -ends when partial thickness wounds are healed or full thickness burns are covered by skin grafts
Acute respiratory distress syndrome (ARDS)
-sudden progressive form of acute respiratory failure -alveolar capillary membrane becomes damaged and more permeable to intravascular fluid
Erysipelas
-superficial cellulitis primarily involving the dermis -treat with systemic antibiotics
Early signs of ARF include:
-tachycardia -tachypnea -slight diaphoresis -mild hypertension
Treatment for electrical burns
-telemetry -IV access and fluids -monitor kidney function (the myoglobin released can cause kidney damage) -possible surgical intervention
Staged cough
-the patient assumes a sitting position, breathes three or four times in and out through the mouth, and coughs while bending forward and pressing a pillow inward against the diaphragm.
Palmar method uses who's palm to assess burns?
-the patient's palm
Angioma
-tumor consisting of blood or lymph vessels
Cryosurgery
-use of subfreezing temperatures to destroy epidermal lesions
Steven Johnson Syndrome (SJS)
-violent immune responses that often occur a severe adverse reaction to a medication or infection
Herpes zoster (shingles)
-viral infection affecting peripheral nerves -linear distribution along a dermatome of grouped vesicles
Incisional biopsy
-wedge shaped incision made in a lesion too large for excisional biopsy
Nursing management skin
-wet compresses -baths -topical medications -control of pruritus -break the itch/scratch cycle -cool environment -hydration, wet compresses, moisturizers -prevention of spread -specific skin care
ARDS Injury/Exudative Phase
.-*Occurs within 24 to 48 hours after injury* -Alveolar and interstitial edema results in a severe V/Q mismatch -There is also damage to the alveolar cells that produce surfactant. Surfactant is responsible for maintaining alveolar surface tension. Alveolar surface tension keeps the alveoli from fully collapsing at the end of expiration. *If alveolar surface tension is lost, then the alveoli collapse (atelectasis)*
Gerontologic considerations- gray/white hair
-caused by decreased melanin and melanocytes
Gerontologic considerations- thick brittle nails
-caused by decreased peripheral blood supply
Gerontologic considerations- delayed wound healing
-caused by decreased proliferative capacity
Latrogenic pneumothorax
-caused by medical procedures -unintentional
Clinical manifestations: full thickness burns
-charred appearance -black or white in color -dry and leathery to touch -NO pain -surgical intervention is required -thermal regulation is required
Psoriasis
-chronic autoimmune disease -lesions are distinct and appear as red, scaling papules that merge to form plaques -lesions are pruritic and often painful
Idiopathic pulmonary fibrosis
-chronic progressive disorder- chronic inflammation and scar tissue in connective tissue -risk factors smoking, wood and metal dust -poor prognosis
Nursing management after chest tube placement
-complete comprehensive pulmonary assessment -HOB up 30 degrees -pain management -assess the drainage -provide supplemental oxygen as needed -keep the chest drainage system below the level of the chest -prevent loops or kinks in the tubing -check the dressing around the chest
Gerontologic considerations- bruising
-decreased extracellular water, dry flaking skin, and increased capillary fragility
Gerontologic considerations- wrinkling
-decreased subcutaneous fat, muscle, degeneration of elastic fibers, and collagen stiffening
Patient teaching for fractured ribs
-deep breathing and coughing -incentive spirometry -appropriate use of analgesics
Nursing interventions for ARDS
-deep breathing and coughing -incentive spirometry -early ambulation -correct acid base imbalance -observe response and monitor for changes in mental status, RR, and ABGs
Interstitial lung disease
-diffuse parenchymal lung disease -two most common are idiopathic pulmonary fibrosis and sarcoidosis
Gerontologic considerations- decrease in rosy appearance
-diminished blood supply
Acute Phase Pathophysiology
-diuresis from fluid mobilization occurs- patient has less edema -bowel sounds return -healing begins as WBCs surround burn and phagocytosis occurs -necrotic tissue begins to slough -granulation tissue forms -partial thickness burns heal from wound edges -full thickness burns must have eschar removed and skin grafts applied
Clinical manifestations of pneumothorax
-dyspnea -tachycardia -"no" breath sounds in affected lung area -hypoxia
Hypercapnia clinical manifestations
-dyspnea -use of tripod position -pursed lip breathing -limited chest wall movement
Electrodessication
-electrical energy is converted to heat, the heat burns and destroys tissue -major uses are coagulation of bleeding vessels to obtain hemostasis
Treatment of smoke and inhalation injuries
-endoscopy -oxygen -labs- carboxy hemoglobin
Flail chest interventions
-ensure adequate ventilation/lung expansion -adequate oxygenation -pain management -fluid replacement -intubation and mechanical ventilation if needed -surgical fixation if needed
Clinical manifestations: deep partial thickness burn
-erythema -painful -fluid filled vesicles -heals in 14-21 days
Clinical manifestations: superficial partial thickness burns
-erythema- blanches on pressure -moderate to severe pain -NO fluid filled vesicles
Hirsutism
-excessive hair growth
Clinical manifestations of idiopathic pulmonary fibrosis
-exertional dyspnea -dry, nonproductive cough -clubbing -crackles
Skin risk factors
-fair skin -blonde or red hair and blue eyes -outdoor sunbathing -living near the equator or high altitudes -history of skin cancer
Verruca vulgaris (common wart)
-flesh colored papule limited to the epidermis -caused by HPV
Tidaling in water-seal chamber
-fluctuation of water with pressure changes during respiration -disappears as lung re-expands -if it stops suddenly check for occlusion
Fluid resuscitation
-goal to maintain tissue perfusion and organ function while avoiding complications of inadequate fluid therapy -insert 2 large bore IVs
Varicosity
-increased appearance of superficial veins
Clark level
-indicates the depth of invasion of the tumor, the higher the number the deeper the melanoma
Breslow measurement
-indicates the depth of the tumor in millimeters
Cellulitis
-inflammation of subcutaneous tissues -treat with moist heat, immobilization, elevation, and antibiotics
Folliculitis
-inflammation of the hair follicles -treat with topical antibiotics, warm compress, or antistaph soap
Pleurisy
-inflammation of the pleura -etiology: infection, cancer, autoimmune disorders, chest trauma, GI disease, and some medications
What position would you place a patient in for unilateral lung disorders?
-lateral or side lying position -"good lung down" to improve V/Q matching by draining secretions to remove with suctioning
Restrictive respiratory disorders- Extrapulmonary
-lung tissue normal but caused by CNS, neuro-muscular, or chest wall disorders
Treatment for patients with shunts
-may require mechanical ventilation and FiO2 -patients with shunts are more hypoxemic than those with V/Q mismatch
Mohs surgery
-microscopically controlled removal of skin cancer -HCP removes tissue sections in thin horizontal layers -all the specimens margins are examined to see if any cancer cells remain
Basal cell carcinoma
-most common type of skin cancer -least deadly -most common in head/neck area -related to excessive sun exposure, genetic skin type, x-ray radiation, and scars
Treatment for tension pneumothorax
-needle decompression -chest tube
Closed pneumothorax
-no associated external wound -Spontaneous pneumothorax -Can be caused by rupture of blebs on the visceral pleura. -suspect with chest wall trauma
Tension pneumothorax
-occurs when air is trapped in the pleural space and cannot escape -may be fatal if the pressure in the pleural space is not relieved
Barotrauma
-occurs when fragile alveoli are over distended with excess pressure during mechanical ventilation
Open pneumothorax
-opening in the chest wall -usually caused by a penetrating trauma- sucking chest wound ex) gunshot wound
Herpes simplex virus
-oral or genital lesions -recurrent, lifelong infections -symptomatic- moist compresses and antiviral drugs can be used
Ventilation/Perfusion mismatch
-oxygenation failure -inadequate exchange of O2 between alveoli and capillaries -oxygen therapy is first step to reverse
Post operative care
-pain management (PCA, epidural, nerve blocks) -assess respiratory status -infection (temperature, incision)
Clinical manifestations of fractured ribs
-pain with inspiration and coughing -splinting -shallow respirations
Clinical manifestations of Pleurisy
-pain- sharp, worse with inspiration -breathing shallow- reduced movement -pleural friction rub-peak of inspiration
Flail chest causes
-paradoxical breathing -unstable chest wall
Alveolar hypoventilation
-A generalized decrease in ventilation that results in an increase in the PaCO2 and a consequent decrease in PaO2. -can be caused by CNS conditions, chest wall dysfunction, acute asthma, and restrictive lung disease
Rule of nines
-A system that assigns percentages to sections of the body, allowing calculation of the amount of skin surface involved in the burn area -use this for initial determination of TBSA
Thoracentesis
-Aspiration of intrapleural fluid for diagnostic and treatment purposes -lie on unaffected side after procedure with bed raised 30 degrees
Furnacle
-Boil; acute, localized bacterial infection of the hair follicle that produces constant pain.
Infection in burn patients
-patients are immunosuppressed after major burn injury -can convert a partial thickness burn to full thickness wound -watch out for sepsis!
Causes of hypercapnic respiratory failure
-CNS problems= suppresses drive to breathe -Neuromuscular conditions= muscle weakness or paralysis -Chest wall abnormalities= prevents normal movement of chest and limits expansion
Hypercapnic respiratory failure
-CO2 levels cannot be maintained within normal limits -can be due to an increase in CO2 production OR a decrease in alveolar ventilation
Signs of respiratory failure are related to:
-Extent of changes in PaO2 or PaCO2 -the speed of change -ability to compensate
Dermascopy
-HCP uses a lighted instrument with optical magnification to see skin structures and colors not visible with the naked eye
ABCDE rule
-asymmetry -border -color -diameter greater than 6mm -evolving in appearance
Complications from fractured ribs
-atelectasis -pneumonia -occurs because patient is in pain and is having shallow respirations respirations- not opening the lungs up fully
Sarcoidosis
-autoimmune disease with fibrous lesions forming in lymph nodes, liver, skin, lungs, spleen, eyes, and small bones of hands and feet
Impetigo
-bacterial skin infection characterized by isolated pustules that become crusted and rupture -lesions develop thick, honey colored crust surrounded by erythema
Staging of cancer
-based on tumor size (thickness), nodal involvement, and metastasis
Cardiac parameters for burns
-best to measure MAP and BP with an arterial line -mean arterial pressure greater than 65mm/hg -pulse less than 120 bpm -systolic greater than 90mm/hg
Hemopneumothorax
-blood AND air in pleural space
Hemothorax
-blood in the pleural space -treat with chest tube
Consequences of hypercapnia
-body can tolerate increased CO2 levels better than decreased O2 levels -slow changes in CO2 allow for compensation
Electrical burns-clinical manifestations
-burn odor -possible cardiac arrest or dysrhythmias -myoglobin released from injured muscle -minimal or absent pain -entry AND exit wound
Chemical burns- clinical manifestations
-burning -discoloration of skin -localized pain -tissue destruction up to 72 hours later
Spontaneous pneumothorax
-can occur in healthy or chronically ill persons (COPD, asthma, cystic fibrosis, pneumonia) -risk factors include tall, thin, male, family history, or previous spontaneous pneumothorax
ARDS Reparative/Proliferative Phase
-1-2 weeks past injury -Neutrophils, monocytes, lymphocytes, fibroblasts-influx -Lung=dense fibrous tissue -Hypoxemia worsens -Potential for pulmonary HTN -Decreased compliance -If continues-widespread fibrosis, if stopped-lesions resolve
ARDS fibrotic phase
-2-3 weeks after initial insult; chronic/late phase -diffuse scarring and fibrosis (decreased lung compliance); decrease surface area for gas exchange -poor prognosis for those who enter fibrotic stage
Flail chest
-3 or more consecutive fractured ribs -2 or more places or fractured sternum and several consecutive ribs
Consequences of hypoxemia
-Hypoxemia can lead to hypoxia if not corrected. occurs when the PaO2 falls enough to cause signs and symptoms of inadequate oxygenation. If hypoxia or hypoxemia is severe, the cells shift from aerobic to anaerobic metabolism. Anaerobic metabolism uses more fuel, produces less energy, and is less efficient than aerobic metabolism. The waste product of anaerobic metabolism is lactic acid. Lactic acid is harder to remove from the body than CO2, because it must be buffered with sodium bicarbonate. When the body does not have enough sodium bicarbonate to buffer the lactic acid, metabolic acidosis occurs. Left uncorrected, tissue and cell dysfunction, and ultimately cell death, occurs.
Emergent drug therapy
-IV analgesics (if it is a large burn then medication will not be given orally) -sedatives -vitamins -famotidine/pantroprazole (because GI system is being stressed-help prevent stomach ulcer) -silvadene (silver impregnated dressing used on wounds) -basic Dakin's antimicrobial
Huff coughing
-Inhale deeply while leaning forward -Exhale sharply with a "huff" sound to help keep airways open while mobilizing secretions
Emergent phase: resuscitative
-Lasts up to 72 hrs from time of burn -Fluid shift IVF to ICF ***Primary concern: prevention of hypovolemic shock and edema formation -ends when fluid mobilization and diuresis begins
Lund-Browder chart
-Most accurate method for estimating burn extent, & must be used in the evaluation of all pediatric patients -more in depth than the rule of nines
Malignant melanoma
-Most serious form of skin cancer; often characterized by black or dark brown patches on the skin that may appear uneven in texture, jagged, or raised. -tumor arising from melanocytes and can spread anywhere in the body -poor prognosis unless diagnosed and treated early
Nutrition for burn patients
-NPO initially -begin oral fluids after bowel sounds return -high protein/high calorie diet
ARDS best practices
-O2 administration -mechanical ventilation -low tidal volume ventilation -permissive hypercapnia -positive end expiratory pressure (PEEP) -prone positioning -ECMO
Physical therapy for burn patients
-PT/OT may work with the nurse during dressing changes -neck burn patient should not sleep with a pillow to encourage hyperextension of the head -apply custom splints
Actinic Keratosis
-Premalignant lesion from sun exposure -increase in number with age -most common pre-cancerous lesion
Parkland Formula
-Ringers lactate 4ml x kg x TBSA -infuse the 1st half of the calculated amount in the first 8 hours -infuse the 2nd half of the calculated amount over the remaining 16 hours
Squamous cell carcinoma
-Type of skin cancer more serious than basal cell carcinoma; often characterized by scaly red papules or nodules. -frequent occurrence on previously damaged skin -potential to metastasize
Psoriasis Nursing Management
-Understand that this condition negatively affects the clients quality of social life -Assess the impact of the disease on the client and coping strategies -Reassure the client that psoriasis is not infectious, not a reflection of poor personal hygiene, and not cancer Potential complications -Infection -Psoriatic arthritis (A form of arthritis that affects some people who have the skin condition psoriasis.) -Educate on provocative factors for psoriasis: irritation or injury to the skin, current illness, trauma to the skin, unfavorable environment (e.g., cold) and emotional stress -Explain treatment regimens to promote ADHERENCE -Improve self-concept and body image -Monitor and manage complications -Educate client NOT to pick at the skin, keep the skin from being dry, don't wash too frequently, wash in warm water and avoid hot water, dry with patting rather than rubbing, use emollients to trap water in the skin, try bath oil or emollient cleansing agent to increase comfort
Four mechanisms of hypoxemic respiratory failure
-Ventilation/Perfusion mismatch -Shunt -Diffusion limitation -Alveolar hypoventilation
Carbuncle
-a cluster of connected furuncles (boils) -can be treated with incision and drainage, antibiotics, and meticulous skin care
Hypoxemic respiratory failure
-a condition in which the PaO2 is 60 mm Hg or less when the patient is receiving an inspired oxygen concentration of 60% or greater.
Shave biopsy
-a technique using a surgical blade to "shave" tissue from the epidermis and upper dermis -used to shave off superficial lesions or a small sample of a large lesion
Pleural effusion
-abnormal amount of fluid in pleural space
Restrictive respiratory disorders- Intrapulmonary
-abnormal pleural or lung tissue disorders
Pneumothorax
-air enters the pleural cavity -positive pressure in pleural space causes lungs to partially or fully collapse -increased air in pleural space equals reduced lung volume
Shunt
-anatomic shunt= blood exits the heart without participating in gas exchange -Intrapulmonary shunt= blood flows through pulmonary capillaries with participating in gas exchange
Candidiasis
-appears in warm, moist areas such as groin, oral mucosa, and sub-mammary folds -immunosuppression allows yeast to become pathogenic -antifungals to treat
Preoperative nursing care
-assess cardiopulmonary status -anesthesia consult -smoking cessation -diagnostic studies (chest x-ray, ECG, BUN, creatinine, glucose, electrolytes, CBC) -post operative teaching
Chest trauma assessment
-assess for respiratory distress -assess for signs of cardiovascular compromise -ongoing monitoring -potential intubation
Allergic Dermatologic Problems
-associated with allergies and hypersensitivity reactions -family history and exposure -avoidance of causative agent
