Nursing 3 Exam 1

Staging of cancer

*Staging determines the exact location of the cancer and whether metastasis has occurred.* Staging of Cancer—TNM Classification -Primary tumor (T) -Regional Lymph nodes (N) -Distant Metastasis (M)

Pulmonary changes

-Airway edema can causes respiratory failure, as well as pulmonary capillary leak, chest burns that restrict movement, and carbon monoxide poisoning. -Cilia can be paralyzed from toxins & allow irritants like smoke to reach deep into the lungs. -The lining of the trachea and bronchi may slough up to 48-72 hours and obstruct the airway. -Pulmonary insufficiency and infection can result when alveoli become damaged.

Immunologic changes

-Burn injury activates the inflammatory response & supresses immune function. -Open wounds put the patient at high risk for infection

Vascular changes with burns

-Circulation is disrupted from vessel occlusion -Fluid-shift occurs from burnt vessels leaking into the interstitial space. It causes edema and fluid & electrolyte imbalance. *Occurs in the first 12-36 hours* -Fluid & electrolyte imbalance causes hypovolemia, metabolic acidosis, hyperkalemia, and hyponatremia. -Hemoconcentration happens from vascular dehydration. This increases viscosity reducing bloodflow & causing hypoxia. -Fluid remobilization starts at 24 hours. The diuretic stage begins at 48-72 hours. Blood volume increases, kidney flow increases, thus causing diuresis. Hyponatremia & hypokalemia develop during this stage from increased secretion. Protein continues to be lost from the wound, metabolic acidosis develops from loss of bicarb in urine.

Managing weakness near death

-Client placed on bed rest, foley inserted to promote comfort (*infection is not a concern for the dying patient*) -May lose ability to swallow. Initiate aspiration precautions, do not provide fluid replacement because it can be uncomfortable for the dying patient. During terminal dehydration to avoid a dry mouth and lips, moisten them with soft applicators and apply an emollient to lips

Gastrointestinal changes

-Fluid shifts cause decreased bloodflow to the GI tract, causing impaired gastric mucosa & motility. Release of epinephrine and norepinephrine cause further reduced bloodflow & motility. -Paralytic ilieus may develop -Secretions and gasses collect in the GI tract, causing abdominal distension. -Curling's Ulcer: Curling's ulcer (acute gastroduodenal ulcer that occurs with the stress of severe injury) may develop within 24 hours after a severe burn injury because of reduced GI blood flow and mucosal damage. The mucus lining the stomach normally protects the tissue from the hydrogen ions secreted into the stomach. With decreased gastric mucus production and increased hydrogen ion production, ulcers may develop. This complication is now less common because of the use of H2 histamine blockers, proton pump inhibitors, drugs that protect GI tissues, and early enteral feeding.

Formal Systematic Review or Debriefing

-Pre-crisis through post-crisis -Acute stress disorder/PTSD

Administrative review of staff and system performance

-analyze hospital/agency response while still fresh -What went right & wrong -Involves representatives from all groups involved

Superficial-thickness burns

-only the epidermis is injured -causes erythema, mild edema, discomfort, & increased sensitivity to heat -Ex: Sunburn

Respiratory dysfunction as death approaches

Changes in breathing pattern are common, with breaths becoming very shallow and rapid. Periods of apnea and Cheyne-Stokes respirations (apnea alternating with periods of rapid breathing) are also common

The priority collaborative problems for patients with burn injuries in the resuscitation phase who have sustained a burn injury greater than 25% of the TBSA include:

1. Potential for decreased oxygenation due to upper airway edema, pulmonary edema, airway obstruction, or pneumonia 2. Potential for shock due to increase in capillary permeability, active fluid volume loss, electrolyte imbalance, and inadequate fluid resuscitation 3. Pain (acute and chronic) due to tissue injury, damaged or exposed nerve endings, débridement, dressing changes, invasive procedures, and donor sites 4. Potential for acute respiratory distress syndrome (ARDS) due to inhalation injury

Multi-casualty event vs Mass casualty event

A Multi-casualty event can be managed by a hospital using local resources; a mass casualty event overwhelms local medical capabilities and may require the collaboration of multiple agencies and health care facilities to handle the crisis. State, regional, and/or national resources may be needed to support the areas affected by the event. Trauma centers have a special role in all emergency preparedness activities because they provide a critical level of expertise and specialized resources for complex injury management.

Disaster Medical Assistance Team (DMAT)

A DMAT is a medical relief team made up of civilian medical, paraprofessional, and support personnel that is deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours (U.S. Department of Health & Human Services, 2015). DMATs are part of the National Disaster Medical System (NDMS) in the United States. They provide relief services ranging from primary health care and triage to evacuation and staffing to assist health care facilities that have become overwhelmed with casualties. Because licensed health care providers such as nurses act as federal employees when they are deployed, their professional licenses are recognized and valid in all states.

Proportionate Palliative Sedation

A care management approach involving the administration of drugs such as benzodiazepines (e.g., midazolam [Versed]), neuroleptics, barbiturates, or anesthetic agents (e.g., propofol [Diprivan]) for the purpose of decreasing suffering by lowering patient consciousness. The intent of proportionate palliative sedation to promote comfort and not hasten death distinguishes it from euthanasia

Pandemic

A pandemic (an infection or disease that occurs throughout the population of a country or the world) leads a vast number of people to seek medical care, even the "worried well." Although not yet ill, the "worried well" want evaluation, preventive treatment, or reassurance from a health care provider.

What is a peaceful/good death?

A peaceful death is one that is free from avoidable distress and suffering for patients and families, in agreement with patients' and families' wishes, and consistent with clinical practice standards.

What race is at higher risk for cancer and death from cancer?

African Americans

Internal Disaster

An event occurring inside a health care facility or campus that could endanger the SAFETY of patients or staff is considered to be an internal disaster. The event creates a need for evacuation or relocation. It often requires extra personnel and the activation of the facility's emergency preparedness and response plan (also called an emergency management plan). Examples of potential internal disasters include fire, explosion, loss of critical utilities (e.g., electricity, water, computer systems, and COMMUNICATION capabilities), and violence. Each health care organization develops policies and procedures for preventing these events through organized facility and security management plans. The most important outcome for any internal disaster is to maintain patient, staff, and visitor safety.

External Disaster

An event outside the health care facility or campus, somewhere in the community, which requires the activation of the facility's emergency management plan is considered an external disaster. The number of facility staff and resources may not be adequate for the incoming emergency department (ED) patients. External disasters can be either natural such as a hurricane, earthquake, or tornado, or technologic such as an act of terrorism with explosive devices or a malfunction of a nuclear reactor with radiation exposure. Recent external disasters include the 2015 Ebola virus crisis in a Dallas hospital, the 2013 Boston Marathon bombing, and the West Texas fertilizer plant explosion. St. John's Regional Medical Center in Joplin, Missouri, had an internal disaster compounding an external disaster in 2011 when it was directly hit by an EF-5 tornado that destroyed a large part of the town. Of the 142 dead, 6 people inside the hospital died

Hospice

As both a philosophy and a system of care, hospice is considered to be the model for quality, compassionate care for people facing a life-limiting illness or injury. Hospice uses a team-oriented approach to providing expert medical care, pain management, and emotional and spiritual support expressly tailored to the person's needs and wishes. Support is also provided to the person's loved ones.

Features of benign tumor cells

Benign tumor cells are normal cells growing in the wrong place or at the wrong time as a result of a problem with CELLULAR REGULATION. Examples include moles, uterine fibroid tumors, skin tags, endometriosis, and nasal polyps. Benign tumor cells have these characteristics: • Specific morphology occurs with benign tumors. They look like the tissues they come from, retaining the specific morphology of parent cells. • A smaller nuclear-to-cytoplasmic ratio is a feature of benign tumors just like completely normal cells. • Specific differentiated functions continue to be performed by benign tumors. For example, in endometriosis, a type of benign tumor, the normal lining of the uterus (endometrium) grows in an abnormal place (e.g., on an ovary or elsewhere in the abdominal or even the chest cavity). This displaced endometrium acts just like normal endometrium by changing each month under the influence of estrogen. When the hormone level drops and the normal endometrium sheds from the uterus, the displaced endometrium, wherever it is, also sheds. • Tight adherence of benign tumor cells to each other occurs because they continue to make fibronectin. • No migration or wandering of benign tissues occurs because they remain tightly bound and do not invade other body tissues. • Orderly growth with normal growth patterns occurs in benign tumor cells even though their growth is not needed. The fact that growth continues beyond an appropriate time or occurs in the wrong place indicates some problem with CELLULAR REGULATION, but the rate of growth is normal. The benign tumor grows by expansion. It does not invade. • Euploidy (normal chromosomes) are usually found in benign tumor cells, with a few exceptions. Most of these cells have 23 pairs of chromosomes, the correct number for humans.

How does most cancer become widely spread?

Bloodborne metastasis (tumor cell release into the blood) is the most common cause of cancer spread. Enzymes secreted by tumor cells also make large pores in the patient's blood vessels, allowing tumor cells to enter the blood and circulate. Because tumor cells are loosely held together, clumps of cells break off from the primary tumor into blood vessels for transport.

Common Sites of Metastasis for Different Cancer Types

Breast Cancer • Bone* • Lung* • Liver • Brain Lung Cancer • Brain* • Bone • Liver • Lymph nodes • Pancreas Colorectal Cancer • Liver* • Lymph nodes • Adjacent structures Prostate Cancer • Bone (especially spine and legs)* • Pelvic nodes Melanoma • GI tract • Lymph nodes • Lung • Brain Primary Brain Cancer • Central nervous system

The 7 warning signs of cancer (CAUTION)

C Changes in bowel or bladder habits A A sore that does not heal U Unusual bleeding or discharge T Thickening or lump in the breast or elsewhere I Indigestion or difficulty swallowing O Obvious change in a wart or mole N Nagging cough or hoarseness

Cardiovascular dysfunction as death approaches

Cardiovascular dysfunction leads to decreases in peripheral circulation and poor tissue PERFUSION manifested as cold, mottled, and cyanotic extremities. Blood pressure decreases and often is only palpable. The dying person's heart rate may increase, become irregular, and gradually decrease before stopping.

Carbon Monoxide poisoning

Carbon monoxide (CO) is one of the leading causes of death from a fire. It is a colorless, odorless, tasteless gas released in the process of combustion. Inhalation injury is a risk for carbon monoxide poisoning 61%-81% = FATAL

Features of cancer cells

Cancer (malignant) cells are abnormal, serve no useful function, and are harmful to normal body tissues. Cancers commonly have these features: • Anaplasia is the cancer cells' loss of the specific appearance of their parent cells. As a cancer cell becomes more malignant, it becomes smaller and rounded. Thus many different types of cancer cells look alike under the microscope. • A larger nuclear-cytoplasmic ratio occurs because the cancer cell nucleus is larger than that of a normal cell and the cancer cell is smaller than a normal cell. The nucleus occupies much of the space within the cancer cell, especially during mitosis, creating a large nuclear-to-cytoplasmic ratio. • Specific functions are lost partially or completely in cancer cells. Cancer cells serve no useful purpose. • Loose adherence is typical for cancer cells because they do not make fibronectin. As a result, cancer cells easily break off from the main tumor. • Migration occurs because cancer cells do not bind tightly together and have many enzymes on their cell surfaces. These features allow the cells to slip through blood vessel walls and between tissues, spreading from the main tumor site to many other body sites. The ability to spread (metastasize) is unique to cancer cells and is a major cause of death. Cancer cells invade other tissues, both close by and more remote from the original tumor. Invasion and persistent growth make untreated cancer deadly. • Contact inhibition does not occur in cancer cells because of lost CELLULAR REGULATION, even when all sides of these cells are in continuous contact with the surfaces of other cells. This persistence of cell division makes the disease difficult to manage. • Rapid or continuous cell division occurs in many types of cancer cells because they do not respond to check-point control of cell division because of gene changes that reduce the effectiveness of CELLULAR REGULATION and re-enter the cell cycle for mitosis almost continuously. In addition, these cells also do not respond to signals for apoptosis. Most cancer cells have a lot of the enzyme telomerase, which maintains telomeric DNA. As a result, cancer cells do not respond to apoptotic signals and have an unlimited life span (are "immortal"). • Abnormal chromosomes in which the chromosome number and/or structure is not normal (aneuploidy) are common in cancer cells as they become more malignant. Chromosomes are lost, gained, or broken; thus cancer cells can have more than 23 pairs or fewer than 23 pairs. Cancer cells also may have broken and rearranged chromosomes with mutated genes.

Common Emotional Signs of Death

Chart 7-2 Patient and Family Education: Preparing for Self-Management Common Emotional Signs of Approaching Death Withdrawal The person is preparing to "let go" from surroundings and relationships. Vision-Like Experiences The person may talk to people you cannot see or hear and see objects and places not visible to you. These are not hallucinations or drug reactions. • Do not deny or argue with what the person claims. • Affirm the experience. Letting Go The person may become agitated or continue to perform repetitive tasks. Often this indicates that something is unresolved or is preventing the person from letting go. As difficult as it may be to do or say, the dying person takes on a more peaceful demeanor when loved ones are able to say things such as, "It's okay to go. We'll be alright." Saying Goodbye When the person is ready to die and you are ready to let go, saying "goodbye" is important for both of you. Touching, hugging, crying, and saying "I love you," "Thank you," "I'm sorry," or "I'll miss you so much" are all natural expressions of sadness and loss. Verbalizing these sentiments can bring comfort both to the dying person and to those left behind.

Cancer assessment in the older adult

Colorectal cancer Ask the patient whether bowel habits have changed over the past year (e.g., in consistency, frequency, color). Is there any obvious blood in the stool? Test at least one stool specimen for occult blood during the patient's hospitalization. Encourage the patient to have a baseline colonoscopy. Encourage the patient to reduce dietary intake of animal fats, red meat, and smoked meats. Encourage the patient to increase dietary intake of bran, vegetables, and fruit. Bladder cancer Ask the patient about the presence of: Pain on urination Blood in the urine Cloudy urine Increased frequency or urgency Prostate cancer Ask the patient about: Hesitancy Change in the size of the urine stream Pain in the back or legs History of urinary tract infections Skin cancer Examine skin areas for moles or warts. Ask the patient about changes in moles (e.g., color, edges, sensation). Leukemia Observe the skin for color, petechiae, or ecchymosis. Ask the patient about: Fatigue Bruising Bleeding tendency History of infections and illnesses Night sweats Unexplained fevers Lung cancer Observe the skin and mucous membranes for color. How many words can the patient say between breaths? Ask the patient about: Cough Hoarseness Smoking history Exposure to inhalation irritants Exposure to asbestos Shortness of breath Activity tolerance Frothy or bloody sputum Pain in the arms or chest Difficulty swallowing

Main goal of emergency preparedness

Common to all mass casualty events, the goal of emergency preparedness is to effectively meet the extraordinary need for resources such as hospital beds, staff, drugs, PPE, supplies, and medical devices such as mechanical ventilators. The U.S. government stockpiles critical equipment and supplies in case they are needed for a pandemic influenza outbreak and organizes large-scale vaccination programs

Death

Death is defined as the cessation of integrated tissue and organ function, manifested by lack of heartbeat, absence of spontaneous respirations, or irreversible brain dysfunction. It generally occurs as a result of an illness or trauma that overwhelms the compensatory mechanisms of the body, eventually leading to cardiopulmonary failure/arrest.

Disaster

Defined as an event in which illness or injuries exceed resource capabilities of a health care facility or community because of destruction and devastation

Full-Thickness Burns

Destruction of epidermis & dermis, wound cannot regrow. Areas that do not close on their own require skin grafting. Skin is hard, dry, leathery with eschar & severe edema under the eschar. -An escharotomy or fasciotomy may be needed to relieve pressure and allow for blood flow and chest expansion. -The wound may be waxy-white, deep red, yellow, brown, or black. The nerves are completely destroyed. *Healing time could be weeks to months.* -Deep Full-Thickness burns: Extend to muscles, ligaments, and bone, amputation may be needed.

Pain Management in burn patients

Drug therapy for pain usually requires opioid analgesics (e.g., morphine sulfate, hydromorphone [Dilaudid], fentanyl) and nonopioid analgesics. Although these drugs may provide adequate pain relief when no procedures are being performed, they rarely offer more than moderate relief during painful procedures. They may depress respiratory function and reduce intestinal motility. Thus nonpharmacologic interventions also are needed for the burn patient. *Drug Alert* Give opioid drugs for pain only by the IV route during the resuscitation phase to prevent delayed rapid absorption leading to lethal blood levels.

Acute phase priority problems

During the acute phase of the burn injury, the patient may have initial problems that extend into the acute phase and may develop new problems. The priority collaborative problems for patients with burn injuries greater than 25% TBSA in the acute phase of recovery include: 1. Wound care management due to impaired TISSUE INTEGRITY associated with burn injury and skin grafting procedures 2. Potential for infection of open burn wounds due to the presence of multiple invasive catheters, reduced immune function, and poor NUTRITION 3. Weight loss due to increased metabolic rate, reduced calorie intake, and increased urinary nitrogen losses 4. Decreased MOBILITY due to open burn wounds, pain, scars, and contractures 5. Decreased self-esteem due to trauma, changes in physical appearance and lifestyle, and alterations in sensory and motor function

Euthanasia

Euthanasia is a term that has been used to describe the process of ending one's life. Active euthanasia implies that primary health care providers take action (e.g., give medication or treatment) that purposefully and directly causes the patient's death. Active euthanasia, even with the patient's permission, is not supported by most health professional organizations in the United States, including the American Nurses Association.

Grading of malignant tumors

GRADE CELLULAR CHARACTERISTICS Gx Grade cannot be determined. G1 Tumor cells are well differentiated and closely resemble the normal cells from which they arose. This grade is considered a low grade of malignant change. These tumors are malignant but are relatively slow growing. G2 Tumor cells are moderately differentiated; they still retain some of the characteristics of normal cells, but also have more malignant characteristics than do G1 tumor cells. G3 Tumor cells are poorly differentiated, but the tissue of origin can usually be established. The cells have few normal cell characteristics. G4 Tumor cells are poorly differentiated and retain no normal cell characteristics. Determination of the tissue of origin is difficult and perhaps impossible.

Emergency management of burns

General Management for All Types of Burns • Assess for airway patency. • Administer oxygen as needed. • Cover the patient with a blanket. • Keep the patient on NPO status. • Elevate the extremities if no fractures are obvious. • Obtain vital signs. • Initiate an IV line and begin fluid replacement. • Administer tetanus toxoid for prophylaxis. • Perform a head-to-toe assessment.

Grief

Grief is the emotional feeling related to the perception of the loss. Patients who are dying suffer not only from the anticipated death but also from the loss of the ability to engage with others and in the world.

Cardiac Changes

Heart rate increases, cardiac output decreases from hypovolemia. Cardiac output improves with fluid resuscitation.

Summary of Key Personnel Roles and Functions for Emergency Preparedness and Response Plan

Hospital incident commander: Physician or administrator who assumes overall leadership for implementing the emergency plan Medical command physician: Physician who decides the number, acuity, and resource needs of patients Triage officer: Physician or nurse who rapidly evaluates each patient to determine priorities for treatment Community relations or public information officer: Person who serves as a liaison between the health care facility and the media

Managing Nausea and Vomiting near Death

If constipation is the cause, give a fleet enema (Biphosphate enema) For other causes of N/V, give antiemetics such as prochlorperazine (Compazine), ondansetron (Zofran), dexamethasone (Decadron, Deronil, Dexasone), or metoclopramide (Reglan, Maxeran) -Aromatherapy using chamomile, camphor, fennel, lavender, peppermint, and rose may reduce or relieve vomiting. However, some patients may have worse nausea with aroma. Ask the patient and family about their preferences and respect culturally established practices.

Patient Self-Determination Act

In 1991 the U.S. Congress passed the Patient Self-determination Act (PSDA), which granted Americans the right to determine the medical care they wanted if they became incapacitated. Documentation of self-determination is accomplished by completing an advance directive (AD). The PSDA requires that a representative in every health care agency ask patients when admitted if they have written advance directives. Patients who do not have ADs should be provided with information on the value of having an AD in place and given the opportunity to complete the state-required forms. Ideally advance directives should be completed long before a medical crisis.

How does the Joint Commission mandate emergency preparedness?

In the United States, The Joint Commission (2017) mandates that hospitals have an emergency preparedness plan that is tested through drills or actual participation in a real event at least twice a year. One of the drills or events must involve community-wide resources and an influx of actual or simulated patients to assess the ability of collaborative efforts and command structures

Nursing safety priority & action alert

Include emergency contact names, addresses, and telephone numbers to use in a crisis as part of a personal emergency preparedness plan. In addition, preassemble personal readiness supplies or a "go bag" (disaster supply kit) for the home and automobile with clothing and basic survival supplies, which allows for a rapid response for disaster staffing coverage (Table 10-3). "Go bags" are needed for all members of the family, including pets, in the event the disaster requires evacuation of the community or people to take shelter in their own homes.

Palliative Care

Palliative care is a philosophy of care for people with life-threatening disease that helps patients and families identify their outcomes for care, assists them with informed decision making, and facilitates quality symptom management. Unlike hospice, palliation is provided by a physician, nurse practitioner, or team of providers as a consultation visit, with one or more follow-up visits.

Nursing Interventions for the client with burns

Interventions include airway maintenance, promotion of ventilation, monitoring GAS EXCHANGE, oxygen therapy, drug therapy, positioning, and deep breathing. Airway maintenance begins at the burn scene in an unconscious patient and may involve only a chin-lift or a head-tilt maneuver. Remember that upper airway edema becomes pronounced 8 to 12 hours after the beginning of fluid resuscitation. Then patients often require nasal or oral intubation if crowing, stridor, or dyspnea is present. A bronchoscopy is performed to examine the vocal cords and airways of patients at risk for obstruction. Patients with severe smoke inhalation or poisoning may require a bronchoscopy on admission and routinely thereafter for examination of the respiratory tract, deep suctioning of the lungs, and removal of sloughing necrotic tissue. Assess the endotracheal tube hourly to ensure patency and location in intubated patients. Other causes of airway obstruction are excessive secretions and sloughed tissue from damaged lungs. Suction as indicated based on clinical assessment. Vigorous endotracheal or nasotracheal tube suctioning is performed after chest physiotherapy and aerosol treatments. Patients report that deep endotracheal suctioning is extremely painful. Therefore suctioning the endotracheal tube often requires increased analgesia or sedation. Promoting ventilation includes ensuring that skeletal muscle movement of the chest is adequate for ventilation. Chest movement can be restricted by eschar and tight dressings that cover the neck, chest, and abdomen. Observe the patient for ease of respiratory movements and loosen tight dressings as needed to assist with ventilation. Monitor for GAS EXCHANGE by using laboratory tests (e.g., arterial blood gas, carboxyhemoglobin levels) and assessing for cyanosis, disorientation, and increased pulse rate. Additional monitoring may include chest x-ray findings, pulmonary artery catheter pressures, and central venous pressure measurement. Cyanide poisoning may occur in patients burned in house fires. An elevated plasma lactate level is one indicator of cyanide toxicity even in patients who do not have severe burns. Oxygen therapy with humidified oxygen by facemask, cannula, or hood is used to manage any breathing impairment in the burn patient. Arterial oxygenation less than 60 mm Hg is an indication for intubation and mechanical ventilation. Keep emergency airway equipment near the bedside. This equipment includes oxygen, masks, cannulas, manual resuscitation bags, laryngoscope, endotracheal tubes, and equipment for tracheostomy. Chapter 32 addresses specific nursing actions for patients during mechanical ventilation. Drug therapy with antibiotics is used when pneumonia or other pulmonary infections impair breathing. Drug selection is based on known culture and sensitivity reports or on the specific organisms common to that burn unit. Patients with pulmonary edema and any degree of heart failure may receive beta blockers to improve left ventricular function and prevent or treat pulmonary edema. Diuretics, a mainstay of therapy for pulmonary edema from other causes, may or may not be used in the resuscitation phase, depending on the patient's blood volume and kidney function. When a patient's activity during mechanical ventilation severely compromises respiratory mechanics, it may be necessary to use a paralytic drug, such as atracurium or vecuronium. Paralytic drugs remove all breathing control from the patient, making mechanical ventilation easier. These drugs do not prevent the patient from seeing and hearing or from experiencing fear, pain, and loss of control. Any patient receiving neuromuscular blockade drugs must also receive drugs for sedation, analgesia, and antianxiety unless clinically contraindicated. Positioning and deep breathing can improve breathing and GAS EXCHANGE. Turn the patient frequently and assist him or her out of bed to a chair as much as possible. Teach the patient to use coughing and deep-breathing exercises. Urge him or her to use incentive spirometry hourly while awake. Chest physiotherapy may be helpful to mobilize lung secretions.

Interventions to minimize weight loss in the burn patient

Interventions include calculating the patient's calorie needs and providing an adequate daily source of calories and nutrients that the patient can ingest. Coordinate with a registered dietitian to meet the expected outcomes regarding the patient's NUTRITION status. Therapy begins with calculating the patient's current daily calorie needs. Several formulas and charts are used for this calculation. Nutrition requirements for a patient with a large burn area can exceed 5000 kcal/day. Not meeting this need leads to very rapid weight loss. In addition to a high-calorie intake, a diet high in protein is needed for wound healing. Work with the dietitian and the patient to plan additions to standard nutrition patterns. Oral diet therapy may be delayed for several days after the injury until the GI tract is motile. Nasoduodenal tube feedings are often started soon after admission. Beginning enteral feedings early helps decrease weight loss, gut atrophy, bacterial translocation, and sepsis. This type of supplement prevents NUTRITION deficits in severely burned patients. Encourage patients who can eat solid foods to ingest as many calories as possible. Consider the patient's preferences with diet planning and food selection. Encourage patients to request food whenever they feel they can eat, not just according to the hospital's standard meal schedule. Offer frequent high-calorie, high-protein supplemental feedings. Keep an accurate calorie count for foods and beverages that are actually ingested by the patient. Patients who cannot swallow but who have adequate gastric motility may meet calorie and NUTRITION needs through enteral tube feedings (see Chapter 60). Parenteral nutrition may be used when the GI tract is not functional or when the patient's nutrition needs cannot be met by oral and enteral feeding. This method is used as a last resort because it is invasive and can lead to infectious and metabolic complications.

Mourning

Mourning is the outward social expression of the loss. Interventions to help patients and families grieve and mourn are based on cultural beliefs, values, and practices.

Burn wound management

Nonsurgical burn wound management involves removing exudates and necrotic tissue, cleaning the area, stimulating granulation and revascularization, and applying dressings. Restoring skin TISSUE INTEGRITY, whether by natural healing or grafting, starts with the removal of eschar and other cellular debris from the burn wound. This removal is called débridement and can be performed nonsurgically through mechanical or enzymatic actions that separate eschar over time. The purpose is to prepare the wound for grafting and wound closure by a natural process. Priority nursing interventions include assessing the wound, providing wound care, and preventing infection and other complications.

IES-R

One tool that can be used to assess survivor response to a disaster is the Impact of Event Scale—Revised (IES-R). The IES-R is a 22-item self-administered questionnaire that includes several subscales such as avoidance. Before giving the tool, determine the patient's reading level because it is written at a 10th-grade reading level. The tool should not be used for patients with short-term memory loss. For this reason, many older survivors often are not adequately assessed for post-disaster PTSD. Assess all older survivors of a disaster for this complication when possible. Action Alert A high score on any IES-R subscale indicates a need for further evaluation and counseling. Refer the patient to a social worker, psychiatric mental health nurse specialist, or qualified mental health counselor. A high score on all subscales requires referral to a psychiatrist, clinical psychologist, or psychiatric mental health nurse practitioner or clinical specialist to evaluate the possibility of current or past trauma, such as abuse or neglect.

Pain management with the Dying Patient

Opioids, non-opioids, music therapy, therapeutic touch, aromatherapy, and massage

Smoke poisoning

Smoke poisoning, or chemical injury from the inhalation of combustion by-products, is a common type of inhalation injury. Toxic by-products are produced when plastics or home furnishings are burned. The products impair respiratory cell function.

Preventing Acute respiratory distress syndrome (ARDS) in the burn patient

Patients who develop acute respiratory distress syndrome (ARDS) from burn injuries require thorough assessments and interventions. Interventions focus on increasing lung compliance and improving partial pressure of arterial oxygen (PaO2) levels. The priority nursing care actions are coordinating respiratory therapy strategies and monitoring the patient's response to these interventions. In collaboration with the health care provider and respiratory therapist, give positive end-expiratory pressure (PEEP) to provide a continuous positive pressure in the airways and alveoli. This procedure enhances the diffusion of oxygen across the alveolar-capillary membrane. PEEP can be combined with intermittent mandatory volume (IMV) to enhance its effectiveness. Assess and document the patient's response so needed ventilator changes can be made. Monitor pulse oximetry and ABG levels to assess changes in respiratory status. *Critical Rescue* Recognize indications of respiratory distress or change in respiratory patterns and respond by immediately reporting assessment findings to the burn team and the respiratory therapist.

Physician-Assisted Suicide

Physician-assisted suicide (PAS), sometimes referred to as assisted dying, is gaining worldwide public support. A few European countries, including Belgium, Switzerland, Luxembourg, and the Netherlands, have had legalized physician-assisted suicide for terminally ill patients for a number of years. In 2015 the Canadian Supreme Court recently overturned a ban on physician-assisted suicide. In the United States PAS is now legally approved in Oregon, Washington, Vermont, Montana, and New Mexico. Twenty-six other states and the District of Columbia are considering legislation on end-of-life options. At this time nurses are generally not involved in physician-assisted suicide but need to be knowledgeable about the legislation in the state where they practice.

Postmortem Care

Postmortem Care • Provide all care with respect to communicate that the person was important and valued. • Ask the family or significant others if they wish to help wash the patient or comb his or her hair; respect and follow their cultural practices for body preparation. • If no autopsy is planned, remove or cut all tubes and lines according to agency policy. • Close the patient's eyes unless the cultural/religious practice is for a family member or other person to close the eyes. • Insert dentures if the patient wore them. • Straighten the patient and lower the bed to a flat position. • Place a pillow under the patient's head. • Wash the patient as needed and comb and arrange the patient's hair unless the family desires to perform bathing and body preparation. • Place waterproof pads under the patient's hips and around the perineum to absorb any excrement. • Clean the patient's room or unit. • Allow the family or significant others to see the patient in private and to perform any religious or cultural customs they wish (e.g., prayer). • Assess that all who need to see the patient have done so before transferring to the funeral home or morgue. • Notify the hospital chaplain or appropriate religious leader if requested by the family or significant others. • Ensure that the nurse or physician has completed and signed the death certificate. • Prepare the patient for transfer to either a morgue or funeral home; wrap the patient in a shroud (unless the family has a special shroud to use), and attach identification tags per agency policy.

Cancer prevention

Primary prevention: avoidance of carcinogens (smoke), modifying risk factors (consuming excess alcohol), removal of "at-risk" tissue, vaccinations Secondary prevention: Get regular scheduled screenings. • The choice of annual mammography for women 40 to 44 years of age, annual mammography for women 45 to 54 years of age, and annual or biennial mammography for women over 55 years of age • Annual clinical breast examination for women older than 40 years; every 3 years for women age 20 to 39 years. • Colonoscopy at age 50 years and then every 10 years • Annual fecal occult blood for adults of all ages • Digital rectal examination (DRE) for men older than 50 years

Priority for patients with burns?

Priorities of care are the prevention of infection and closure of the burn wound. A lack of or delay in wound healing is a key factor for all systemic problems and a major cause of disability and death among patients who are burned.

Pronouncement of Death

Pronouncement of Death • Note time of death that the family or staff reported the cessation of respirations. • Identify the patient by identification (ID) tag if in facility. Note the general appearance of the body. • Ascertain that the patient does not rouse to verbal or tactile stimuli. Avoid overtly painful stimuli, especially if family members are present. • Auscultate for the absence of heart sounds; palpate for the absence of carotid pulse. • Look and listen for the absence of spontaneous respirations. • Document the time of pronouncement and all notifications in the medical record (i.e., to attending physician). Document if the medical examiner needs to be notified (may be required for unexpected or suspicious death). Document if an autopsy is planned per the attending primary health care provider and family. • If your state and agency policy allows an RN to pronounce death, document as indicated on the death certificate.

Managing Seizures near death

Seizures are not common at the end of life but may occur in patients with brain tumors, advanced AIDS, and pre-existing seizure disorders. Around-the-clock drug therapy is needed to maintain a high seizure threshold for patients who can no longer swallow antiepileptic drugs (AEDs). Benzodiazepines such as diazepam (Valium) and lorazepam (Ativan) are the drugs of choice. For home use rectal diazepam gel or sublingual lorazepam oral solution (2 mg/mL) may be preferred. As a second choice, barbiturates such as phenobarbital may be given rectally or IV

Pulmonary Fluid Overload

Pulmonary edema can occur even when the lung tissues have not been damaged directly. Other damaged tissues release such large amounts of inflammatory mediators, causing capillary leak, that even lung capillaries leak fluid into the pulmonary tissue spaces. Circulatory overload from fluid resuscitation may cause congestive heart failure. This problem creates high pressure within pulmonary blood vessels that pushes fluid into the lung tissue spaces. Excess lung tissue fluid makes GAS EXCHANGE difficult. The patient is short of breath and has dyspnea in the supine position. Crackles are heard on auscultation. *Critical Rescue* Monitor patients' respiratory efforts closely to recognize possible development of pulmonary edema. When signs and symptoms of pulmonary edema are present, respond by elevating the head of the bed to at least 45 degrees, applying oxygen, and notifying the burn team or the Rapid Response Team.

Red, Yellow, and Green Tagging

Red-tagged patients have immediate threats to life such as airway obstruction or shock, and they require immediate attention. --Emergent, potential loss of life/limb Yellow-tagged patients have major injuries such as open fractures with a distal pulse and large wounds that need treatment within 30 minutes to 2 hours. --Urgent, acute condition requiring attention Green-tagged patients have minor injuries that can be managed in a delayed fashion, generally more than 2 hours. Examples of green-tagged injuries include closed fractures, sprains, strains, abrasions, and contusions. --Stable: no risk of deterioration, tx can be delayed

Management of specific burns

Specific Management Flame Burns • Smother the flames. • Remove smoldering clothing and all metal objects. Chemical Burns • If dry chemicals are present on skin or clothing, DO NOT WET THEM. • Brush off any dry chemicals present on the skin or clothing. • Remove the patient's clothing. • Ascertain the type of chemical causing the burn. • Do not attempt to neutralize the chemical unless it has been positively identified and the appropriate neutralizing agent is available. Electrical Burns • At the scene, separate the patient from the electrical current. • Smother any flames that are present. • Initiate cardiopulmonary resuscitation. • Obtain an electrocardiogram (ECG). Radiation Burns • Remove the patient from the radiation source. • If the patient has been exposed to radiation from an unsealed source, remove his or her clothing (using tongs or lead protective gloves). • If the patient has radioactive particles on the skin, send him or her to the nearest designated radiation decontamination center. • Help the patient bathe or shower.

Durable Power of Attorney

The DPOAHC, often referred to as a health care proxy, health care agent, or surrogate decision maker, does not make health care decisions until a physician states that the person lacks capacity to make his or her own health care decisions. This is usually the result of impairment in COGNITION. To have decision-making ability, a person must be able to perform three tasks: • Receive information (but not necessarily be totally oriented) • Evaluate, deliberate, and mentally manipulate information • Communicate a treatment preference

Direct airway injury

The degree of inhalation damage depends on the fire source, temperature, environment, and types of toxic gases generated. Ask about the source of the fire, duration of exposure, and whether the fire was in an enclosed space. Inspect the mouth, nose, and pharynx. Burns of the lips, face, ears, neck, eyelids, eyebrows, and eyelashes are strong indicators that an inhalation injury may be present. Burns inside the mouth and singed nasal hairs also indicate possible inhalation injury. Black particles of carbon in the nose, mouth, and sputum and edema of the nasal septum indicate smoke inhalation, as does a "smoky" smell to the patient's breath. A change in respiratory pattern may indicate a pulmonary injury. The patient may: • Become progressively hoarse • Develop a brassy cough • Drool or have difficulty swallowing • Produce sounds on exhalation that include audible wheezes, crowing, and stridor Any of these changes may mean the patient is about to lose his or her airway. *Monitor patient's respiratory efforts closely to recognize possible airway involvement. For a burn patient in the resuscitation phase who is hoarse, has a brassy cough, drools or has difficulty swallowing, or produces an audible breath sound on exhalation, respond by immediately applying oxygen and notifying the Rapid Response Team.*

The Dermis with burns

The dermis is thicker than the epidermis and is made up of collagen, fibrous connective tissue, and elastic fibers. Within the dermis are the blood vessels, sensory nerves, hair follicles, lymph vessels, sebaceous glands, and sweat glands. When burn injury occurs, skin can regrow as long as parts of the dermis are present. When the entire dermal layer is burned, all cells and dermal appendages are destroyed, and the skin can no longer restore itself. The subcutaneous tissue lies below the dermis and is separated from the dermis by the basement membrane, a thin, noncellular protein surface. With deep burns, the subcutaneous tissues may be damaged, leaving bones, tendons, and muscles exposed.

Outcomes for Patients Approaching Death

The desired outcomes for a patient near the end of life (EOL) are that the patient will have: • Needs and preferences met • Control of symptoms of distress • Meaningful interactions with family • A peaceful death

The epidermis with burns

The epidermis can grow back because the sweat/oil glands and hair follicles (called dermal appendages) are located deep in the dermis The epidermis has no blood vessels, and nutrients must diffuse from the second layer of skin, the dermis.

Hospital Incident Command System

The facility-level organizational model for disaster management is the Hospital Incident Command System (HICS), which is a part of the National Incident Management System (NIMS) implemented by the Department of Homeland Security and FEMA to standardize disaster operations. In this system, roles are formally structured under the hospital or long-term care facility incident commander with clear lines of authority and accountability for specific resources

Evaluating Cultural/spiritual beliefs of dying pt & family

The nurse should Identify: H: Sources of hope and strength O: Organized religion (if any) and role that it plays in one's life P: Personal spirituality, rituals, and practices E: Effects of religion and spirituality on care and end-of-life decisions

Living Will

The second part of the advance directive is a living will (LW), which identifies what one would (or would not) want if he or she were near death. Treatments that are discussed include cardiopulmonary resuscitation (CPR), artificial ventilation, and artificial nutrition or hydration. The third type of advance directive is a do-not-resuscitate (DNR) or do-not-attempt-to-resuscitate (DNAR) order, signed by a physician or other authorized primary health care provider, which instructs that CPR not be attempted in the event of cardiac or respiratory arrest. DNRs/DNARs are intended for people with life-limiting conditions, for whom resuscitation is not prudent.

Acute Phase of burn injury

Time Period: Begins 36-48 hours after injury, lasts until wound closure is complete Goals: Main nursing priorities are to assess the respiratory and cardiovascular system and maintain function as well as identify and prevent potential complications. Examples are pneumonia, risk for infection, and sepsis. Nursing Diagnosis: Acute pain Disturbed body image Impaired skin integrity Risk for ineffective airway clearance Fear/Anxiety Risk for imbalanced nutrition Assessment: A neuroendocrine assessment is very important because burn victims have increased metabolic demands. Weight patient daily without dressings and note weight loss/gain. A 2% weight loss Is a mild deficit, and a 10% loss of weight is serious and the caloric needs must be reassessed. Assess immune function because patient is at risk for infection from impaired skin integrity. Monitor for signs of infection. Assess neuromuscular function because patient is at risk for complications of immobility. Conduct active and passive ROM for all joints. Pay special attention to the area of the burn and note the limitations of each joint. Conduct an ongoing assessment for pain. Interventions: Focus on skin integrity, wound healing, and preventing further complications. This can be achieved by wound debridement, wound dressings that enhance the healing process, wound excision, wound covering through skin grafts, and infection prevention protocols such as enforcing hand washing.

Emergent (Resuscitation) Phase of burn injury

Time Period: Within the first hour after the burn injury occurred and extends up to 24-48 hours Goals: Maintain airway, breathing, and circulation, maintain organ function (by providing fluid replacement), and limit the extent of the injury. Provide analgesics to prevent suffering, maintain body temperature, and provide thorough wound care to prevent infection. Nursing Diagnosis: Risk for fluid and electrolyte imbalance Risk for infection Acute pain Deficient fluid volume Risk for ineffective tissue perfusion Assessment: Find out from the patient (if not possible, ask family members or those involved) how the injury occurred, what time it happened and where it took place. It is also important to document health history, events leading up to the injury, and any care that was provided between the occurrence and the arrival of EMS. Demographic data is very important to include, especially before the client begins to suffer from edema. Weight is especially important because it is used to calculate the client's fluid, energy, and drug requirements. Assess for airway injury or obstruction, cardiovascular system including hypovolemic shock and tissue perfusion. Kidney perfusion is important for urinary output, especially when fluid replacement is used. Use the rule of 9's to determine the extent of the burn injury, as well as the type and depth of the injury. Assess the GI system for paralytic ileus due to decreased tissue perfusion. Labs to be monitored include electrolyte values, hgn, hct, glucose, BUN, arterial blood gas, WBC count, and albumin. Interventions: Airway maintenance, beginning fluid resuscitation, promoting ventilation, monitor gas exchange, provide oxygen and drug therapy, positioning and deep breathing to promote gas exchange. Surgical management such as escharotomy to increase tissue perfusion. Prevention of acute respiratory distress syndrome (ARDS)

Rehabillitative Phase of burn injury

Time frame: Begins with wound closure and ends when the patient reaches highest level of functioning. This phase differs with every patient and could Last a lifetime. Goals: The goals of this phase are to restore pre-burn psychosocial and physical functioning. This phase also focuses on the prevention of scars and contractions. Nursing Diagnosis: Chronic Pain Disturbed body image Impaired physical mobility Knowledge deficit Fear/Anxiety Impaired skin integrity Assessment: The biggest factors that play a role in assessment of this phase is psychological well-being and wound healing/skin integrity. The client should be referred to a psychologist if any problems are evident. Needs of the patient must be assessed prior to discharge, such as financial status, the need for home health care, or a referral to a specialist. Clients should be prepared with an understanding that they do look different, and depending on the burn, people may react differently. Home care management, self-care management, and health care resources should be assessed prior to discharge. Interventions: Refer client to a counselor. Teach client how to perform dressing changes at home and ask the client/care-taker to perform the task before discharge. The nurse should also explain S/S of infection, drug regimens, proper use of prosthetic and positioning devices, correct application and care of pressure garments, COMFORT measures to reduce pruritus, and dates for follow-up appointments.

Upper airway edema

Upper-airway edema and inhalation injury are most common in the trachea and mainstem bronchi. Auscultation of these areas may reveal wheezes, which indicate partial obstruction. Patients with severe inhalation injuries may have such rapid obstruction that, within a short time, they cannot force air through the narrowed airways. As a result, the wheezing sounds disappear. This finding indicates impending airway obstruction and demands immediate intubation. Many patients are intubated when an inhalation injury is first suspected rather than waiting until obstruction makes intubation difficult or impossible.

S/S of impending death

Weakness, sleeping more, anorexia, inability to speak, changes in LOC/CV function/genitourinary function/respiratory function.

Passive euthanasia

Withdrawing or withholding life-sustaining therapy, formerly called passive euthanasia, involves discontinuing one or more therapies that might prolong the life of a person who cannot be cured by the therapy. Another phrase sometimes used is "letting the person die naturally" or "allowing natural death (AND)," as discussed earlier in this chapter. In this situation, the withdrawal of the intervention does not directly cause the patient's death. The progression of the patient's disease or poor health status is the cause of death. Professional health care organizations and some religious communities support the right of patients and their surrogate decision makers to refuse or stop treatment when patients are close to death and interventions are considered medically futile or capable of causing harm. The U.S. court system also supports withdrawal of aggressive treatment and the rights of surrogate decision makers to refuse or stop treatment.

Systemic signs of infection in the burn patient

• Altered level of consciousness • Changes in vital signs (tachycardia, tachypnea, temperature instability, hypotension) • Increased fluid requirements for maintenance of a normal urine output • Hemodynamic instability • Oliguria • GI dysfunction (diarrhea, vomiting, abdominal distention, paralytic ileus) • Hyperglycemia • Thrombocytopenia • Change in total white blood cell count (above or below normal) • Metabolic acidosis • Hypoxemia

Dietary habits to reduce cancer risk

• Avoid excessive intake of animal fat. • Avoid nitrites (prepared lunch meats, sausage, bacon). • Minimize your intake of red meat. • Keep your alcohol consumption to no more than one or two drinks per day. • Eat more bran. • Eat more cruciferous vegetables such as broccoli, cauliflower, Brussels sprouts, and cabbage. • Eat foods high in vitamin A (e.g., apricots, carrots, leafy green and yellow vegetables) and vitamin C (e.g., fresh fruits and vegetables, especially citrus fruits).

Basic Supplies for Personal Preparedness (3-Day Supply)

• Backpack • Clean, durable weather-appropriate clothing; sturdy footwear • Potable water—at least 1 gallon per person per day for at least 3 days • Food-nonperishable, no cooking required • Headlamp or flashlight—battery powered; extra batteries and/or chemical light sticks (NOTE: a headlamp is superior because it allows hands-free operation) • Pocket knife or multi-tool • Personal identification (ID) with emergency contacts and phone numbers, allergies, and medical information; lists of credit card numbers and bank accounts (keep in watertight container) • Towel and washcloth; towelettes, soap, hand sanitizer • Paper, pens, and pencils; regional maps • Cell phone and charger • Sunglasses/protective and/or corrective eyewear • Emergency blanket and/or sleeping bag and pillow • Work gloves • Personal first aid kit with over-the-counter (OTC) and prescription medications • Rain gear • Roll of duct tape and plastic sheeting • Radio—battery powered or hand-crank generator • Toiletries (toothbrush and toothpaste, comb, brush, razor, shaving cream, mirror, feminine supplies, deodorant, shampoo, lip balm, sunscreen, insect repellent, toilet paper) • Plastic garbage bags and ties, resealable plastic bags • Matches in a waterproof container • Whistle • Household liquid bleach for disinfection

Islam views on death

• Based on belief in one God Allah and his prophet Muhammad. Qur'an is the scripture of Islam, composed of Muhammad's revelations of the Word of God (Allah). • Death is seen as the beginning of a new and better life. • God has prescribed an appointed time of death for everyone. • Qur'an encourages humans to seek treatment and not to refuse treatment. Belief is that only Allah cures but that Allah cures through the work of humans. • On death the eyelids are to be closed, and the body should be covered. Before moving and handling the body, contact someone from the person's mosque to perform rituals of bathing and wrapping body in cloth.

Physical Manifestations Indicating That Death Has Occurred

• Breathing stops. • Heart stops beating. • Pupils become fixed and dilated. • Body color becomes pale and waxen. • Body temperature drops. • Muscles and sphincters relax. • Urine and stool may be released. • Eyes may remain open, and there is no blinking. • The jaw may fall open. • Observers may hear trickling of fluids internally.

Local Signs of Infection in the burn patient

• Conversion of a partial-thickness injury to a full-thickness injury • Ulceration of healthy skin at the burn site • Erythematous, nodular lesions in uninvolved skin and vesicular lesions in healed skin • Edema of healthy skin surrounding the burn wound • Excessive burn wound drainage • Pale, boggy, dry, or crusted granulation tissue • Sloughing of grafts • Wound breakdown after closure • Odor

Needs to address before discharging a burn patient

• Early patient assessment • Financial assessment • Evaluation of family resources • Weekly discharge planning meeting • Psychological referral • Patient and family teaching (home care) • Designation of principal learners (specific family members or significant others who will help with care) • Development of teaching plan • Training for wound care • Rehabilitation referral • Home assessment (on-site visit) • Medical equipment • Public health nursing referral • Evaluation of community resources • Visit to referral agency • Re-entry programs for school or work environment • Long-term care placement • Environmental interventions • Auditory testing • Speech therapy • Prosthetic rehabilitation

Leading causes of death in the United States?

• Heart disease • Cancer (malignant neoplasms) • Chronic lower respiratory disease • Accidents (intentional injuries) • Stroke • Alzheimer's disease • Diabetes mellitus • Influenza and pneumonia • Kidney disease (nephritis, nephrotic syndrome, and nephrosis) • Suicide (intentional self-harm)

Direct causes of death

• Heart failure secondary to cardiac dysrhythmias, myocardial infarction, or cardiogenic shock • Respiratory failure secondary to pulmonary embolism, heart failure, pneumonia, lung disease, or respiratory arrest caused by increased intracranial pressure • Shock secondary to infection, blood loss, or organ dysfunction, which leads to lack of blood flow (i.e., PERFUSION) to vital organs

The most common end-of-life symptoms that can cause the patient distress are:

• Pain • Weakness • Breathlessness/dyspnea • Nausea and vomiting • Agitation and delirium • Seizures Interventions to relieve symptoms of distress include positioning, administration of medications, and a variety of complementary and integrative therapies. When medications are used, they are often scheduled around the clock to maintain COMFORT and prevent recurrence of the symptom.

Factors Determining Inhalation Injury or Airway Obstruction

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

Fluid resuscitation of the burn patient

• Initiate and maintain at least one large-bore IV line in an area of intact skin (if possible). • Coordinate with physicians to determine the appropriate fluid type and total volume to be infused during the first 24 hours postburn. • Administer one half of the total 24-hour prescribed volume within the first 8 hours postburn and the remaining volume over the next 16 hours. • Assess IV access site, infusion rate, and infused volume at least hourly. • Monitor these vital signs at least hourly: • Blood pressure • Pulse rate • Respiratory rate • Breath sounds • Voice quality (if not intubated) • Oxygen saturation • End-tidal carbon dioxide levels • Assess urine output at least hourly: • Volume • Color • Specific gravity • Character • Presence of protein • Assess for fluid overload: • Formation of dependent edema • Engorged neck veins • Rapid, thready pulse • Presence of lung crackles or wheezes on auscultation • Measure additional body fluid output hourly. Resuscitation for a severe burn requires large fluid loads in a short time to maintain blood flow to vital organs. All common formulas recommend that half of the calculated fluid volume for 24 hours be given in the first 8 hours after injury. The other half is given over the next 16 hours for a total of 24 hours (Culleiton & Simko, 2013a). Fluid boluses are avoided because they increase capillary pressure and worsen edema. In the second 24-hour period after a burn injury, the volume and content of the IV fluids are based on the patient's specific FLUID AND ELECTROLYTE BALANCE needs and his or her response to treatment. This resuscitation involves hourly infusion volumes that are greatly in excess of the 125 mL to 150 mL per hour common infusion rates. Fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital. For example, if a burn injury occurred at 8 AM but the patient was not admitted to the hospital until 10 AM, the first 8-hour period would be completed at 4 PM (8 hours after the injury). Thus if resuscitation was delayed by 2 hours until admission to the hospital, calculated fluids would need to be given over the next 6-hour period rather than an 8-hour period. Burn resuscitation formulas are guides. The patient's response to therapy determines exact fluid requirements.

Judaism views on Death

• The dying person is encouraged to recite the confessional or the affirmation of faith, called the Shema. • According to Jewish law, a person who is extremely ill and dying should not be left alone. • The body, which was the vessel and vehicle to the soul, deserves reverence and respect. • The body should not be left unattended until the funeral, which should take place as soon as possible (preferably within 24 hours). • Autopsies are not allowed by Orthodox Jews, except under special circumstances. • The body should not be embalmed, displayed, or cremated.

Christianity views on Death

• There are many Christian denominations, which have variations in beliefs regarding medical care near the end of life. • Roman Catholic tradition encourages people to receive Sacrament of the Sick, administered by a priest at any point during an illness. This sacrament may be administered more than once. Not receiving this sacrament will NOT prohibit them from entering heaven after death. • People may be baptized as Roman Catholics in an emergency situation (e.g., person is dying) by a layperson. Otherwise they are baptized by a priest. • Christians believe in an afterlife of heaven or hell once the soul has left the body after death

Preventing Staff Acute Stress Disorder and Post-Traumatic Stress Disorder Following a Mass Casualty Event

• Use available counseling. • Encourage and support co-workers. • Monitor each other's stress level and performance. • Take breaks when needed. • Talk about feelings with staff and managers. • Drink plenty of water and eat healthy snacks for energy. • Keep in touch with family, friends, and significant others. • Do not work more than 12 hours per day.

Managing agitation and Delirium near Death

-Agitation at the end of life first requires assessing for pain or urinary retention, constipation, or another reversible cause. If pain, urinary retention, and constipation are ruled out as causes, delirium (acute confusion) is suspected. -Delirium is an acute and fluctuating change in mental status and is accompanied by inattention, disorganized thinking, and/or an altered level of consciousness. It can be hyperactive, hypoactive, or mixed (both). Hypoactive (quiet) delirium is probably not uncomfortable for patients. Agitated (noisy) delirium with psychotic and behavioral symptoms (e.g., yelling, hallucinations) can be uncomfortable, especially for family. When delirium occurs in the week or two before death, it is referred to as terminal delirium. Possible causes include the adverse effects of opioids, benzodiazepines, anticholinergics, or steroids. If medications are suspected causes, they may be decreased or discontinued. Ideally antipsychotic drugs are given only to control psychotic symptoms such as hallucinations and delusions. However, if they are needed to facilitate COMFORT, they should be available.

Functional changes with burns

-Full-thickness burns reduce the ability of the skin to sweat -Massive fluid loss happens through evaporation -Partial-thickness burns expose nerves causing extreme sensitivity -Activation of Vitamin D is reduced or lost -Cells of the skin are destroyed with heat

Compensatory responses

-Inflammatory compensation triggers healing in the injured tissues and is responsible for the serious problems that occur with the fluid shift. It causes blood vessels to leak fluid into the interstitial space. This causes massive fluid shift (third spacing), edema, and hypovolemia in the resuscitation phase. -The sympathetic nervous system compensates by the release of epinephrine and nor-epinephrine as a stress response. The body: -Increased heart rate, thirst, respirations, catecholamine secretions, metabolic & caloric needs, aldosterone secretions, blood sugar level -Decreased gastric motility, urinary output, -Blood in the stool, N/V, abdominal distension, fluid retention, edema, weight gain, extremities pale & cool, capillary refill slow

Partial-Thickness burns

-Loss of epidermis & parts of dermis -Superficial Partial-thickness: Injury to upper third of dermis but leaves a good blood supply. They are pink, moist, blanchable, blistered, extreme pain & sensitivity. *Healing time is 10-21 days w/no scar, just minor pigment changes.* -Deep Partial-Thickness: injury to deep dermis, few healthy cells remain. Wound is red and dry with white areas, moderate edema, pain is diminished, bloodflow is reduced causing hypoxia & ischemia. These wounds can convert to full-thickness if complications arise. *Healing time is 2-6 weeks with scars.*

Metabolic Changes

-Metabolism increases, causing increased secretion of catecholamines, ADH, aldosterone, & cortisol. Oxygen needs and caloric needs increase greatly (roughly 4000-5000kcal/day) -Normal calorie needs double or triple, beginning at 4-12 days & lasting until wound closure. -Patient has a low-grade fever because the body is in a hypermetabolic state.

Medical Reserve Corps (MRC)

An MRC is made up of a group of volunteer medical and public health care professionals, including physicians and nurses. They offer their services to health care facilities or to the community in a supportive or supplemental capacity during times of need such as a disaster or pandemic disease outbreak. This group may help staff hospitals or community health settings that face personnel shortages and establish first aid stations or special-needs shelters. As a means to alleviate ED and hospital overcrowding, the MRC may also set up an acute care center (ACC) in the community for patients who need acute care (but not intensive care) for days to weeks.

Common S/S of death with Interventions

Common Physical Signs and Symptoms of Approaching Death With Recommended Comfort Measures Coolness of Extremities Circulation to the extremities is decreased; the skin may become mottled or discolored. • Cover the person with a blanket. • Do not use an electric blanket, hot water bottle, electric heating pad, or hair dryer to warm the person. Increased Sleeping Metabolism is decreased. • Spend time sitting quietly with the person. • Do not force the person to stay awake. • Talk to the person as you normally would, even if he or she does not respond. Fluid and Food Decrease Metabolic needs have decreased. • Do not force the person to eat or drink. • Offer small sips of liquids or ice chips at frequent intervals if the person is alert and able to swallow. • Use moist swabs to keep the mouth and lips moist and comfortable. • Coat the lips with lip balm. Incontinence The perineal muscles relax. • Keep the perineal area clean and dry. Use disposable underpads (Chux) and disposable undergarments. • Offer a Foley catheter for comfort. Congestion and Gurgling The person is unable to cough up secretions effectively. • Position the patient on his or her side. Use toothette to gently clean mouth of secretions. • Administer medications to decrease the production of secretions. Breathing Pattern Change Slowed circulation to the brain may cause the breathing pattern to become irregular, with brief periods of no breathing or shallow breathing. • Elevate the person's head. • Position the person on his or her side. Disorientation Decreased metabolism and slowed circulation to the brain. • Identify yourself whenever you communicate with the person. • Reorient the patient as needed. • Speak softly, clearly, and truthfully. Restlessness Decreased metabolism and slowed circulation to the brain. • Play soothing music and use aromatherapy. • Do not restrain the person. • Massage the person's forehead. • Reduce the number of people in the room. • Talk quietly. • Keep the room dimly lit. • Keep the noise level to a minimum. • Consider sedation if other methods do not work.

Thermal (Heat) Injury

Except for steam inhalation, aspiration of scalding liquid, or explosion of flammable gases under pressure, thermal burns to the respiratory tract are usually limited to the upper airway above the glottis (nasopharynx, oropharynx, and larynx). *Action Alert* Heat damage of the pharynx is often severe enough to produce edema and upper airway obstruction, especially epiglottitis. The problem can occur any time during resuscitation. In the unresuscitated patient, supraglottic edema may be delayed because of the dehydration that occurs with hypovolemia. However, during fluid resuscitation, the tissues rehydrate and then swell. When it is known that the upper airways were exposed to heat, intubation may be performed as an early intervention before obstruction occurs. When intubation has not been performed in a patient whose upper airways were exposed to heat or toxic gases, continually assess the upper airway for recognition of edema and obstruction.

Maintaining mobility in the patient with burns

Nonsurgical management includes the nursing interventions of positioning, range-of-motion exercises, ambulation, and pressure dressings. Positioning is critical for patients with burn injuries because the position of COMFORT for the patient is often one of joint flexion, which leads to contracture development. Maintain the patient in a neutral body position with minimal flexion. Best practices for preventing contractures are listed in Chart 26-6. Splints and other devices may be used to maintain good positioning of the hands, elbows, knees, neck, and axillae. Range-of-motion exercises to maintain MOBILITY are performed actively at least three times a day. If the patient cannot move a joint actively, perform passive range-of-motion exercises. Give burned hands special attention. Urge the patient to perform active range-of-motion exercises for the hand, thumb, and fingers every hour while he or she is awake. Ambulation is started as soon as possible after the fluid shifts have resolved because it maintains MOBILITY, inhibits bone density loss, strengthens muscles, stimulates immune function, promotes ventilation, and prevents many complications. Patients with attached equipment (IV catheters, nasogastric tubes, ECG leads, extensive dressings) can ambulate with preparation and assistance. This activity is performed two or three times a day and progresses in length each time. Compression dressings are applied after grafts heal to help prevent contractures and tight hypertrophic scars, which can inhibit MOBILITY. They also inhibit venous stasis and edema in areas with decreased lymph flow. Compression dressings may be elastic wraps or specially designed, custom-fitted, elasticized clothing that provides continuous pressure. Fig. 26-15 shows such a garment. For best effectiveness, pressure garments must be worn at least 23 hours a day, every day, until the scar tissue is mature (12 to 24 months). They can be uncomfortable with itchiness and increased warmth. Reinforce to the patient and family that wearing pressure garments is beneficial in saving mobility and reducing scarring.

Managing Dyspnea near death

Perform a thorough assessment of the patient's dyspnea. Include onset, severity and precipitating factors. Precipitating factors may include time of day, position, anxiety, pain, cough, or emotional distress. Pharmacologic interventions should begin early in the course of dyspnea. Nonpharmacologic interventions are used in conjunction with but not in place of drug therapy. *Opioids such as morphine sulfate are the standard treatment for dyspnea near death.* Oxygen therapy for dyspnea near death has not been established as a standard of care for all patients. However, those who do not respond promptly to morphine or other drugs should be tried on oxygen (2 to 6 L by nasal cannula) to assess its effect. Patients often feel more comfortable when the oxygen saturation is greater than 90%. If possible, provide oxygen by nasal cannula (NC) because masks can be frightening. If oxygen is not effective, discontinue it. Offer oxygen to any patient with dyspnea near death, regardless of his or her oxygen saturation, because COMFORT is the desired outcome. If the patient is feeling dyspneic even though the oxygen saturation is above 90%, be sure that he or she receives oxygen to relieve respiratory distress. In addition, offer an electric fan directed toward the patient's face. Some patients find the circulating air more helpful than oxygen therapy. Secretions in the respiratory tract and oral cavity may also contribute to dyspnea near death. Loud, wet respirations (referred to as death rattle) are disturbing to family and caregivers even when they do not seem to cause dyspnea or respiratory distress. Reposition the patient onto one side to reduce gurgling and place a small towel under his or her mouth to collect secretions. Anticholinergics such as atropine (ophthalmic) solution 1% given sublingually every 4 hours as needed or hyoscyamine (Levsin) every 6 hours are commonly given to dry up secretions. Scopolamine may also be given transdermally to reduce secretion production. Oropharyngeal suctioning is not recommended for loud secretions in the bronchi or oropharynx because it is often not effective and may only agitate the patient.

The Medicare Hospice Benefit

The Medicare Hospice Benefit serves as a guide for hospice care in the United States. This benefit pays for hospice services for Medicare recipients who have a prognosis of 6 months or less to live and who agree to forego curative treatment for their terminal illness.

Triage in a mass-casualty situation

• Emergent (class I) patients are identified with a red tag. • Patients who can wait a short time for care (class II) are marked with a yellow tag. • Nonurgent or "walking wounded" (class III) patients are given a green tag. • Patients who are expected (and allowed) to die or are dead are issued a black tag (class IV). *In mass casualty or disaster situations, implement a military form of triage with the overall desired outcome of doing the greatest good for the greatest number of people* This means that patients who are critically ill or injured and might otherwise receive attempted resuscitation during usual operations may be triaged into an "expectant" or "black-tagged" category and allowed to die or not be treated until others received care. Typical examples of black-tagged patients are those with massive head trauma, extensive full-thickness body burns, and high cervical spinal cord injury requiring mechanical ventilation. The rationale for this very difficult decision is that limited resources must be dedicated to saving the most lives rather than expending valuable resources to save one life at the possible expense of many others

Nurse's Role in Responding to Health Care Facility Fires

• Remove any patient or staff from immediate danger of the fire or smoke. • Discontinue oxygen for all patients who can breathe without it. • For patients on life support, maintain their respiratory status manually until removed from the fire area. • Direct ambulatory patients to walk to a safe location. • If possible, ask ambulatory patients to help push wheelchair patients out of danger. • Move bedridden patients from the fire area in bed, by stretcher, or in a wheelchair; if needed, have one or two staff members move patients on blankets or carry them. • After everyone is out of danger, seek to contain the fire by closing doors and windows and using an ABC extinguisher (can put out any type of fire) if possible. • Do not risk injury to yourself or staff members while moving patients or attempting to extinguish the fire.