NSG 252 Exam 4

A 35-year-old client is brought to the emergency department with second- and third-degree burns over 15% of the body. Admission vital signs are blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply. Administer 6 mg of IV morphine. Begin an intravenous (I.V.) infusion of lactated Ringer's solution. Place ice directly on the burn areas. Cover the burns with saline-soaked towels. Administer tetanus prophylaxis, as ordered. Clean the burns with hydrogen peroxide.

1, 2, 5

A 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?

36% The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area.

rate of fluid resuscitation for burns

50% given over first 8 hours, then remainder is given for 16 hours

A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? A. Recent stress level B. Compliance w/prescribed med regimen C. Recent weight gain and loss D. Type of anticonvulsant prescribed to manage the epileptic condition

B The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?

BUN: 28 mg/dL The elevated BUN would cause the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated.

nursing care for patient in emergent/resuscitative phase

Fluid resuscitation Foley catheter inserted Patient w/burns exceeding 20-25% should have NG tube inserted/placed to suction Patient with electrical burns should have ECG Address pain; only IV meds should be administered Psychosocial consideration/emotional support

The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately?

Intravenous diazepam

A nasojejunal tube is inserted for enteral feedings. Which of the following statements should be included in the nurse's teaching regarding the nasojejunal tube/feedings?

Nutrition is important in preventing and promoting wound healing

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? a) Obesity b) Osteoarthritis c) Anemia d) Osteoporosis

Osteoporosis Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of osteoporosis (AANN, 2009).

A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of:

Parkinson's disease.

febrile seizure

Seizure activity brought on by an excessively high fever (102.2 or higher) in a young child or an infant.

skin involvement 2nd degree burns

epidermis, portion of dermis

focalized seizures

originate within one hemisphere in the brain

clinical manifestations of second degree burns

pain hyperesthesia sensitive to air currents

paraplegia

paralysis of the lower half of the body

Autonomic Dysreflexia nursing interventions

(potentially life threatening emergency!) HOB elevate 90 degrees, loosen constrictive clothing, assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure)

Diet for parkinsons

- adequate fiber and fruit - 6 small meals a day - thickened liquids if patient has dysphagia

For adults with burns, a urine output of what is used as an indication of appropriate resuscitation in thermal and chemical injuries?

0.5 to 1 mL/kg/h

treatment for carboxyhemoglobin

100% O2, hyperbaric O2

Parkland formula

4ml X kilo X TBSA

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.

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?

Absence seizure

Which medication classification is used preoperatively to decrease the risk of postoperative seizures?

Anticonvulsants

treatments for carbon monoxide poisoning

B12-Hydroxycobalamin Oxygen 100%

most common Parkinson's medications

Carbidopa-Levodopa

neurogenic shock

Circulatory failure caused by paralysis of the nerves that control the size of the blood vessels, leading to widespread dilation; seen in patients with spinal cord injuries.

While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?

Confusion

Nikolsky sign

Diagnostic sign whereby the superficial epithelium separates easily from the basal layer on exertion of firm, sliding manual pressure with the fingers

most common type of seizure seen in children less than 5 years old

Febrile

main causes of burns

Flame related Scalds Direct source contact Electrical Chemical contact Inhalation Miscellaneous

side effect of long-term use of Phenytoin

Gingival Hyperplasia (Swollen and tender gums)

potential complications from burns acute phase

HF pulmonary edema ARF visceral damage

The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?

High in protein and low in carbohydrate

Which of the following is to be expected soon after a major burn? Select all that apply.

Hypotension Tachycardia Anxiety

symptoms of autonomic dysreflexia

Immediate pounding headache, anxiety, perspiration, flushing, chills, nasal congestion, sudden onset of hypertension, and bradycardia

Which IV solution is appropriate to administer during the first 24 hours of fluid resuscitation following a burn injury?

Lactated Ringer's [[LR is an Isotonic IV solution]]

A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?

Loosen the client's restrictive clothing.

burn prevention

Minimize sun exposure Never leave children unattended around fire Education about installation of smoke & carbon monoxide detectors Educate about smoking near oxygen

The nurse cares for a client in the burn unit. What is an early sign of sepsis in the client with burn injury?

Narrowing pulse pressure Clients with burns are hypermetabolic. This results in tachycardia, tachypnea, and elevated body temperature. These physiological norms in clients with burns make the diagnosis of sepsis more challenging. The signs of early systemic sepsis are subtle and require a high index of suspicion and very close monitoring of changes in the client's status. Early signs of sepsis may include increased temperature, increased pulse rate, widened pulse pressure, and flushed, dry skin in unburned areas.

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?

Paralytic ileus

nursing interventions for parkinsons

Physical therapy Encourage independence Limit sleep disturbances Nutrition (diff. swallowing, thicken liquids) Speech difficulties Psychosocial support Monitor I & Os/VS

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.

After being exposed to smoke and flames from a house fire, which assessment finding is most important in determining care of the client?

Presence of soot around nasal passages If the client has soot or evidence of carbon about the nasal passages, the nurse should anticipate respiratory difficulties. Edema and swelling of the internal airways may not be present initially but can progress quickly.

Which instruction is the most important to give a client who has recently had a skin graft?

Protect the graft from direct sunlight. To prevent burning and sloughing, the nurse must instruct the client to protect the graft from direct sunlight. Continuing physical therapy, using cosmetic camouflage techniques, and applying lotion to the graft site are appropriate instructions, but they aren't the most important concern in the client's recovery.

methods to estimate TBSA affected by burns

Rule of nines Lund and Browder method palmer method

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?

Semisolid food with thick liquids

topicals used for burn patients

Silver sulfadiazine antimicrobial ointment Mafenide acetate Silver nitrate

spinal shock vs neurogenic shock

Spinal shock is acute and related to the impairment of the nervous system below the level of injury that may cause shock symptoms if below T6. Decreased reflexes! Neurogenic shock can happen later & lasts longer (T5 and above)

diagnostics for seizures

Stat accu-check CBC, CMP CT or MRI EEG (Electroencephalogram) +/- LP Medication and Substance history

A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of:

Tremors and muscle rigidity

Palmer method

Used with scattered burns Size of pts hand including fingers is approximately 1%

generalized seizures

a seizure that affects both sides of the brain

recuperative course & tx 4th degree burns

amputations likely grafting of no benefit, given depth & severity of wound (s)

epilepsy

at least 2 unprovoked seizures occuring more than 24 hrs apart

would appearance of second degree burns

blistered, mottled red base disrupted epidermis weeping surface edema

Brown-Sequard Syndrome

damage to one side of the spinal cord

cardiovascular alterations from burns

decrease in CO workload of heart & O2 demand increase due to vasoconstrictive compensatory responses hypovolemia is immediate As fluid loss continues due to capillary leakage, and vascular volume decreases, cardiac output continues to decrease and the blood pressure drops the sympathetic nervous system releases catecholamines, resulting in an increase in peripheral resistance (vasoconstriction) and an increase in pulse rate that further decreases tissue perfusion

skin involvement 4th degree burns

deep tissue muscle bone

wound appearance 3rd degree burns

dry, pale white, red, brown leathery/charred coagulated vessels may be visible edema

underlying cause of seizures

electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges

things that contribute to survivability and recovery from burn injuries

fluid resuscitation, infection control, nutrition delivery, early burn excision (surgical removal of tissue), wound closure

three main seizure types

focal, generalized, and unknown

tonic-clonic seizure

generalized seizure in which the patient loses consciousness and has jerking movements of paired muscle groups

autograft

graft derived from one part of a patient's body and used on another part of that same patient's body

A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:

place the client on his side, remove dangerous objects, and protect his head.

major causes of death with SCI

pneumonia PE sepsis

most common complication of burns of older adults

pneumonia followed by UTIs

Onset of Parkinson's

predominantly male gradual and insidious, with an ongoing progression

causes of fourth degree burns (full thickness that includes fat, fascia, muscle, and/or bone)

prolonged exposure or high voltage electrical injury

signs of skin breakdown

redness, poor skin turgor, bleeding, pain

teaching guidelines for extensive burns on child

remove clothing only if it comes off easily check the child's ABCs do not apply butter/cream/ointment cover the burn with a clean, lint-free bandage/sheet avoid applying large, wet sheets (child can get too cold) do not attempt to break any blisters if the child appears to be in shock, elevate the legs while protecting burn & call 911

skin breakdown interventions

reposition q 2 hrs pressure relief maintain clean and dry skin adequate nutrition and hydration

burn care for child with first degree

run cool water over burned area until pain lessens do not apply ice to skin do not apply butter/ointment/cream cover burn lightly with a clean, nonadhesive bandage Administer Ibuprofen or Tylenol

causes of second degree burns (partial thickness)

scalds flash flame contact

clinical manifestations of 4th degree burns

shock myoglobinuria possible hemolysis

how should a pt with a seizure be placed?

side-lying position to prevent aspiration

Atonic seizures

sudden loss of muscle tone

skin functions

thermoregulation protection innate immune protection synthesize vitamin D water & salt excretion dilated capillaries are a blood reservoir

postictal

time after a seizure

clinical manifestations of 1st degree burns

tingling hyperesthesia pain that is soothed by cooling peeling itching

xenograft

transplantation (dermis only) from a foreign donor (usually a pig/rabbit/dog skin) and transferred to a human; also called heterograft

allograft

transplantation of healthy tissue from one person to another person; also called homograft (cadaver skin)

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.) a) Loosening constrictive clothing b) Providing for privacy c) Restraining the patient to avoid self injury d) Positioning the patient on his or her side with head flexed forward e) Opening the patient's jaw and inserting a mouth gag

• Loosening constrictive clothing • Positioning the patient on his or her side with the head flexed forward • Providing for privacy During a patient's seizure, the nurse should do the following. Loosen constrictive clothing. If possible, place the patient on one side with the head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) The nurse should not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.

After sustaining a closed head injury, a client is prescribed phenytoin 100 mg intravenously every 8 hours for seizure prophylaxis. Which nursing interventions are necessary when administering phenytoin? Select all that apply. 1. Monitor the client for signs of early toxicity, such as drowsiness, nystagmus, ataxia, dysarthria, tremor, and slurred speech. 2. Administer phenytoin slowly, diluted in 250 cc. 3. Mix intravenous doses in solutions containing dextrose 5% in water. 4. Administer an intravenous bolus no faster than 50 mg/minute. 5. Do not use an in-line filter when administering the drug. 6. Monitor electrocardiogram (ECG), blood pressure, and respiratory status continuously when administering phenytoin intravenous.

1, 4, 6 Explanation: Administer an intravenous bolus by slow (50 mg/minute) intravenous push method; too rapid an injection may cause hypotension and circulatory collapse. Continuous monitoring of ECG, blood pressure, and respiratory status is essential when administering phenytoin intravenously. A dilution of 250 cc is not required. Early toxicity may cause drowsiness, nausea, vomiting, nystagmus, ataxia, dysarthria, tremor, and slurred speech. Later effects may include hypotension, arrhythmias, respiratory depression, and coma. Death may result from respiratory and circulatory depression. Phenytoin would not be administered by intravenous push in veins on the back of the hand; larger veins are needed to prevent discoloration associated with purple glove syndrome. Mix intravenous doses in normal saline solution and use the solution within 30 minutes; doses mixed in dextrose 5% in water will precipitate. Use of an inline filter is recommended.

An explosion at a chemical plant produces flames and smoke. More than 20 persons have burn injuries. Which victims, all adults, should be transported to a burn center? Select all that apply. The victim who has: inhaled smoke first-degree burns of both hands chemical spills on both arms third-degree burns of both legs respiratory distress

1,2,4,5 (Victims with chemical burns, 2nd and 3rd degree burns over more than 20% of the BSA and those with inhalation injury should be transported to a burn center The victim with 1st degree burn of the hands can be treated on scene and referred to health care facility)

Which of the following are indications of possible pulmonary damage after a burn injury? SATA 1. hypotension 2. singed nasal hair 3. incident occurred in an enclosed space 4. facial and/or neck burns

2, 3, 4

A patient is being discharged after sustaining a deep-partial thickness burn during a house fire. The patient is asking when the burn will be healed. The nurse understands that this type of burn injury heals within which of the following time frames?

2-4 weeks

An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?

36% According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities that have sustained burns to entire surfaces will equal to 36% of total surface area.

status epilepticus

A condition in which seizures recur every few minutes or last more than 30 minutes.

Parkinson's disease

A disorder of the central nervous system that affects movement, often including tremors. Low dopamine, high acetylcoline

Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided?

Application of ice Application of ice causes vasoconstriction and diminishes needed blood flow to the zone of injury. Clothing and hair are removed from perimeter of burned area in an effort to remove course of bacterial contamination. Irrigation of the wound assists in the removal of debris.

some anticonvulsant medications

Carbamazepine Clonazepam Ethosuximide felbamate Gabapentin Lamotrigine Levetiracetam Oxcarbazepine Phenobarbital Phenytoin Primidone Tiagabine Topiramate Valproate Zonisamide

Carboxyhemoglobin

Carbon monoxide bound with hemoglobin

which back injury can cause respiratory compromise?

Cervical (C3/C4)

When caring for a graft site, the nurse needs to understand which of the following statements? 1. When turning or positioning the patient, care should be taken to avoid pressure on the graft site 2. The extremity that has been grafted should be elevated 3. Occlusive dressings and splints may be used to immobilize the graft 4. The dressing of a graft site should be changed every 12 hours

1, 2, 3 The initial dressing change is usually not performed until 2 to 5 days after surgery

diagnostics for SCI

ABGs (for respiratory) XRAY Frequent neuro assessments CT MRI

potential complications from burns emergent phase

ARF Distributive shock AKI Compartment syndrome Paralytic Ileus Curling ulcer

3 potential complications from burns

ARF/ARDS HF/Pulmonary Edema Sepsis

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? a) Absence b) Generalized c) Jacksonian d) Sensory

Generalized A generalized seizure causes generalized electrical abnormality in the brain. The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur. A Jacksonian seizure begins as a localized motor seizure. The client experiences a stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. Absence seizures occur most commonly in children. They usually begin with a brief change in the level of consciousness, signaled by blinking or rolling of the eyes, a blank stare, and slight mouth movements. Symptoms of a sensory seizure include hallucinations, flashing lights, tingling sensations, vertigo, déjà vu, and smelling a foul odor.

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is:

Hyperkalemia. Circulating blood volume decreases dramatically during burn shock due to severe capillary leak with variation of serum sodium levels in response to fluid resuscitation. Usually, hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement.

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?

Identification by the destruction of the dermis and epidermis Third-degree (full-thickness) burns involve total destruction of the epidermis and dermis and, in some cases, destruction of underlying tissue. Second-degree burns are associated with blister formation.

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?

Phenytoin

Meds for SCI

Steroids Pain meds (Morphine, Fentanyl) Baclofen Heparin

T or F: If necessary, a blood pressure cuff can be placed around a patient's burned extremity. The cuff must be of the correct size with accommodations made for edema.

True

Myoclonic seizures

brief, jerky, may or my not loss consciousness, loss of tone

standard test for definitive diagnosis of inhalation injury

bronchoscopy

causes of seizures

cerebrovascular disease fever (childhood) hypoxemia of any cause head injury HTN CNS infections metabolic & toxic conditions brain tumor drug and ETOH withdrawal allergies

wound appearance 4th degree burns

charred

treatments for edema with burns

elevation of the extremity removal of eschar via escharotomy decompression of edema formation via fasciotomy

skin involvement first degree burns

epidermis

skin involvement of third degree burns

epidermis dermis sometimes subcutaneous tissue may involve connective tissue & muscle

recuperative course & tx 3rd degree burns

eschar may slough grafting necessary scarring/loss of contour/function

rescue workers' priorities when a patient has a burn

establish an airway supply O2 insert at least one large-bore IV line cover wound with a clean, dry cloth or gauze

most common etiology of burns in the older adult

fire/flame

causes of third degree burns (full thickness)

flame prolonged exposure to hot liquids electric current chemical contact

The percentages of the "Rule of Nines"

head 9% each arm 9% each leg 18% anterior 18% posterior 18% pelvic region 1%

what is one of the main causes of epilepsy that can be prevented?

head injury

diet for patient with burns

high calorie, high protein if able to eat if not, TPN

three of the most common GI alterations in patients with burns

paralytic ileus curling's ulcer (gastric or duodenal erosion) translocation of bacteria

nursing care during a seizure

provide privacy ease patient to floor protect the head with a pad to prevent injury loosen constrictive clothing and remove eyeglasses if pt is in bed, remove pillows and raise side rails do not put anything in pts mouth*** if possible, place pt on side with head flexed forward

recuperative course & tx for second degree burns

recovery in 2-3 weeks some scarring/depigmentation possible may require grafting

recuperative course & tx for 1st degree burns

recovery within a few days oral pain meds cool compresses skin lubricants topical antimicrobial agents not indicated

1st degree burn would appearance

reddened blanches with pressure & dry minimal or no edema possible blisters

Here are more indications of possible pulmonary damage after a burn injury. SATA 1. Labored respirations 2. Voice change, stridor 3. Tachycardia 4. Soot-tinged sputum

1, 2, 4

An intoxicated client not wearing a seatbelt drives into a metal barricade. The client's head has hit the windshield and the client is unconscious. What nurse actions are appropriate? 1. Assess the client for a carotid pulse 2. Determine the client's GCS 3. Maintain airway with head-tilt/chin lift 4. Place a hard cervical collar on the client 5. Remove the client from the car onto a backboard

1, 2, 4, 5

stages of burn care

1. Emergent/resuscitative - from onset to completion of fluid resuscitation; 48-72 hours; hypovolemic shock; need IV fluids 2. Acute - from the start of diuresis to near completion of wound closure 3. Rehabilitation - from wound closure to return of optimal level of physical/psychosocial function

The school nurse notes a 6-year-old running across the playground with friends. The child stops in mid-stride, freezing for a few seconds. Then the child resumes their progress across the playground. The school nurse suspects what in this child? a) A tonic-clonic seizure b) A complex seizure c) A partial seizure d) An absence seizure

An absence seizure Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness, during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. A generalized seizure involves the whole brain

The nurses teaches the parent of a child with severe burns about the importance of specific nutritional support in burn management. The nurse recognizes the need for more teaching if the parents select which food for their child? cheeseburger, cottage cheese and pineapple salad, chocolate milk, and a brownie beef, bean, and cheese burrito; a banana; fruit-flavored yogurt; and skim milk chicken nuggets, orange and grapefruit sections, and a vanilla milkshake bacon, lettuce, and tomato sandwich; milk; and celery and carrot sticks

D

The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for?

Dyskinesia

A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize?

Generalized seizure

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

Hoarseness of the voice Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation.

Following a major burn injury, what is the recommended route for opioid administration?

IV

What causes autonomic dysreflexia?

Noxious Stimuli The stimuli can be a *full bladder or bowel*, tight clothes, pressure sores, wrinkled bedding or infection. This condition is life threatening & requires immediate resolution.

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary?

Risk for Impaired Gas Exchange During the initial assessment of a burn victim, the nurse must look for evidence of inhalation injury. Once oxygen saturation and respirations are determined, pain intensity is evaluated. The assessment of damage to the tissues and prevention of infection are secondary to airway issues.

The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?

The client's activities immediately prior to the seizure.

Nursing care after a seizure

keep the pt on its side make sure airway is patent on awakening, reorient pt to environment

patients with burn injuries may exhibit low what in the early hours after injury due to thermoregulatory alterations?

low body temperatures

Tetraplegia

paralysis of all four limbs; quadriplegia

seizure precautions

reduce environmental stimuli identify triggers pad side rails bed lowest position O2 and suction available

complications of SCI

spinal shock, neurogenic shock, autonomic dysreflexia, paralytic ileus

physiologic changes with severe burns

cardiac depression edema hypovolemia vasoconstriction impaired motility/absorption

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:

carefully move the client to a flat surface and turn him on his side.

What does a pressure garment do?

causes collagen to restructure and decreases vascularity

immediately after burn injury, what may result from massive cell destruction?

hyperkalemia possible hyponatremia due to plasma loss anemia due to RBC damaged hematocrit elevated due to plasma loss thrombocytopenia

clinical manifestations of 3rd degree burns

insensate shock myoglobinuria (red pigment in urine) possible hemolysis possible contact points (entrance/exit wounds in electrical burns)

How to respond when your child has a seizure

instruct parents and caregivers: -remain calm -if child is standing or sitting, ease child to ground -time seizure episode -tight clothing and jewelry around neck should be removed or loosened -place child on one side, and open airway -do not restrain child -remove hazards from area -do not forcibly open jaw with tongue blade or fingers -document length of seizure and movements noted, loss of bladder control -remain with child until full conscious -call EMS if: child stops breathing injury has occurred seizure lasts more than 5 min this is the childs first seizure child is unresponsive to painful stimuli afterwards

what do seizures result from?

sudden, excessive discharge from cerebral neurons

causes of first degree burns (superficial)

sunburn low-intensity flash superficial scald

third spacing

the accumulation and sequestration of trapped extracellular fluid in an actual or potential body space as a result of disease or injury, also called edema

Symptoms of Parkinson's Disease

tremors, shuffling gait, muscle rigidity, bradykinesia, postural instability, affective flattening, dementia

T or F: For a patient with burns, No food or fluid is given by mouth, and the patient is placed in a position that will prevent aspiration of vomitus because nausea and vomiting may occur and protection of the airway is always a priority.

true

During a seizure the nurse should document

types of movements involved area of body involve first thing the pt does in a seizure size of both pupils incontinence of urine or stool

patho of seizures

uncontrolled, abnormal discharges of neurons occur repeatedly

Absence seizures (petit mal)

usually include a loss of consciousness and unresponsiveness for short periods without muscle involvement.

nursing care for patient in acute/intermediate phase of burn

wound care pain management early positioning/mobility prevent infection

age groups with highest mortality with burns

young children and older adults due to thinner skin

predominant risk factors for SCI

younger age male gender ETOH/drug use