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