T5
Portal HTN
-Increased pressure through portal venous system resulting from obstruction of blood flow into and through the damaged liver -Associated with cirrhosis, other liver disease, splenomegaly -Complications: ascites and varices
Esophageal Varices Medical Treatment
-Initial: vasoconstriction (ocreotide, vassopressin) -Prevention: beta-blockers -Rare: balloon tamponade (serious complications, ICU monitoring) -Other: Endocopic sclerotherapy, endoscopic ligation, shunt
Partial Thickness (Second degree)
-Involves epidermis and part of dermis -Scalds, flash flame -Pain, hypersensitive to air -Blistered, weeping surface r/t disrupted epidermis, edema -Recovery- 2-3 weeks -May require grafting
Full thickness (Third degree
-Involves epidermis, dermis, sometimes subcutaneous fat, and may involve muscle and connective tissue -Flame, electrical current (entrance and exit wound), chemical contact, molten metal -Lacking feeling, shock, myoglobinuria, hemolysis -Dry, pale white, red, brown, leathery or charred -Edema -Eschar may slough, grafting necessary and scaring and contractures -May lose extremity -Capillary integrity loss
Abnormal Wound Healing
-May suffer from PTSD -Keloid scars (Normal scars begin 7-10 post injury) -Burn garments (burn anti-pressure garments) include gloves, face hoods, chin straps, jackets, pants, leotards, hose, or entire body suits (body gloves) which provide pressure to burned areas to help with healing.
S/S Hepatic Encephalopathy
-Mental status changes -Motor disturbances (asterixis w/stage II and constructional apraxia) -Disrupted sleeping pattern -Coma -Seizures -Fecal breath (fetor hepaticus)
Hepatitis D
-Occurs only in some cases of Hep B -More likely to develop fulminant hepatic failure
Pathogenesis of esophageal varices
-Portal hypertension--development of pressure gradient--- venous collaterals---- abnormal varicoid vessels---- vessels may rupture causing life threatening hemorrhage.
Mobility, Coping, Support
-Prevent complications-contractures -Strengthen coping strategies -Support pt. and family
Alcoholic Cirrhosis
-Scar tissue surrounds portal areas -Caused by chronic alcoholism -Most common type
Hepatitis E
-Transmission: fecal-oral -Clinical course resembles Hep A -Jaundice almost always present -No chronic forms develop -Very severe in pregnant women
Management of Hepatic Encephalopathy
-Treat underlying problem -Lactulose given to remove ammonia -IV glucose -Electrolyte correction -Antibiotics
Pulmonary Injury
-Upper airway/Inhalation below the glottis -Lower airway -Carbon monoxide poisoning -Restrictive deficits Smoke may contain 400 toxic Compounds!
Electrical Burns
-occur rapidly as electricity passes through the body. -typically more severe, causing more damage to tissue layers beneath the skin. -the severity of electrical burns are underestimated and underdiagnosed. -Severe electrical burns may cause shock or strain to internal organs, including the brain or heart.
Dietary Management of Hep
-small freq meals - 25-30kcal daily - protein 1-1.5 daily -Monitor I&O - enteral feedings if anorexia, n/v persist - avoid substances that affect liver function (St. John's wort.)
When using the palmar method to estimate the extent of the burn injury, the palm is equal to which percentage of TBSA? a) 3 b) .5 c) 4 d) 2
.5 Explanation: In patients with scattered burns, or for a quick prehospital assessment, the palmer method may be used to estimate the extent of the burns. The size of the patient's palm, not including the surface area of the digits, is approximately 0.5% of the TBSA
GGT, GGTP
0-30 U/L Values are elevated in alcohol abuse and markers for biliary cholestasis.
Urine urobilinogen
0.05-2,5 mg/24 h These studies measure the ability of the liver to conjugate and excrete bilirubin. Results are abnormal in the liver and biliary tract disease and are associated with jaundice clinically.
Serum bilirubin total
0.3-1 mg/dL These studies measure the ability of the liver to conjugate and excrete bilirubin. Results are abnormal in the liver and biliary tract disease and are associated with jaundice clinically.
When using the Palmar method to estimate the extent of a small or scattered burn injury, the palm is equal to which percentage of total body surface area (TBSA)? a) 2 b) 4 c) 1 d) 3
1 Correct Explanation: In patients with scattered burns, or for a quick prehospital assessment, the Palmer method may be used to estimate the extent of the burns. The size of the patient's palm, not including the surface area of the digits, is approximately 1% of the TBSA.
Which of the following measures can be used to cool a burn? a) Using cold soaks or dressings for at least 1 hour b) Application of cool water c) Wrapping the person in ice d) Application of ice directly to burn
Application of cool water Explanation: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns.
A patient is brought to the ED by a coworker following a burn injury from a high-voltage electrical power line. The triage nurse will complete which of the following interventions first? a) Take the patient's vital signs. b) Obtain a 12-lead ECG. c) Insert a urinary Foley catheter. d) Apply a cervical collar on the patient.
Apply a cervical collar on the patient. Correct Explanation: Until it is known that the patient has no fractures, it is imperative that a neck collar be applied and remain in place and that the patient is log rolled to eliminate the chance of further spinal cord injury. With high-voltage electrical injuries, cervical spine immobilization is a priority until cervical spine injury is ruled out. The other interventions may be completed; however, the priority intervention is to apply the collar.
causes of hypothermia?
ETOH, medications, medical conditions- can not shiver so can not generate body heat, trauma (cold fluids, exposure, un-warmed oxygen)
s/s of frostbite?
Hard, cold and insensitive to touch- may be white/mottled or may turn red and painful as rewarmed
negative feedback
Regulating mechanism in which an increase or decrease in the level of a substance decreases or increases the function of the oran producing the substance.
s/s of progressive deterioration?
Poor judgment, drowsy, pulmonary edema, clotting issues, acid-base abnormalities, coma
Priority measures for all patients?
SAFETY!!! Bioterrorism, Weapons,Violent behavior Closely observe patient interaction with family Assess the families ability to adapt to crisis Interventions to provide holistic care based on stage of crisis: Denial, remorse/guilt, anger, grief and reconciliation Reduce anxiety- family stay with patient Keep informed Talk to family about feelings
Esophageal Varices Surgical Treatment
SECOND LINE -Bypass -Devascularization and transection
exocrine
Secreting externally; Hormonal Secretion from Excretory Ducts
cause of hemorrhage
blood thinners, trauma and genetic disorders
if body temp below 90 degrees
body can't shiver
Wound Grafting
-Autografts -Hemografts and xenografts -Biosynthetic and synthetic dressings (less costly)
Hep B Prevention
-Avoid transmission -Active immunity: vaccination -Passive Immunity: immunoglobulin for those exposed
Postnecrotic Cirrhosis
-Broad bands of scar tissue -Late result of previous bout of viral hepatitis
Abuse
-In relation to the home environment, most burns occur in the kitchen involving food preparation and mealtimes. -Seasonal variance indicates the winter months as a time of increased risk. -Injury may occur whilst under the supervision, of one or both parents.
acetaminophen (tylenol) poisoning? s/e and treatment
Greater than 4 grams in 24 hours Hepatic failure RUQ pain charcoal/dialysis Acetylcysteine (Mucomyst)- don't give with charcoal
overdose may...
*may be a heightened level of the therapeutic effects seen with regular use * may trigger a person's chronic disease
Genetic Hepatic Disorders
- Alpha-antitrypsin deficiency -Alagille syndrome - Budd-Chiari syndrome -Congenital hepatic fibrosis -Wilson's disease -Gilbert's syndrome -Hemochromotosis
Hep C Risk Factors
- Freq exposure to blood/body fluids -Hemodialysis -Male homosexual/bisexual - IV drug use - Mother to child transmission - Multiple sexual partners - Recent hx of STI -Receipt of blood/blood products -Tattooing
Nutritional Management of Hepatic Encephalopathy
- Minimize formation and absorption of toxins -Daily protein 1.2-1.5 g/kg - Avoid protein rx - Provide amino acid supplement for protein intolerant - small freq meals
Esophageal Varices Daignostics
-Endoscopy -Portal vein measurements -Lab tests
AST
10-40 U/mL These studies are based on release on enzymes from damaged liver cells. These enzymes are elevated in liver cell damage. Normal values differ in men and women.
Prothrombin Time
100% or 12-16 seconds Prothrombin time may be prolonged in liver disease. It will not return to normal with vitamin K in severe liver cell damage.
LDH
100-200 units Values are elevated in alcohol abuse and markers for biliary cholestasis.
Ammonia
15-45 mcg/dL Liver converts ammonia to urea. Ammonia level rises in liver failure.
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? a) 8 weeks b) 1 week c) 6 weeks d) 2 to 4 weeks
2 to 4 weeks Correct Explanation: For deep partial-thickness burn injuries, recovery is expected in 2 to 4 weeks.
A patient has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery? a) Within 12 hours after surgery b) As soon as sanguineous drainage is noted c) 2 to 5 days after surgery d) Within 24 hours after surgery
2 to 5 days after surgery Explanation: The first dressing change usually occurs 2 to 5 days after surgery. In addition, a foul odor or purulence may indicate infection and should be reported to the surgeon immediately. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively.
Serum globulin
2.3-3.5 g/dL Proteins are manufactured by the liver. Their levels may be affected in a variety of liver impairments: albumin is affected in cirrhosis, chronic hepatitis, edema, ascites; globulins are affected in cirrhosis, liver disease, chronic obstructive jaundice, and viral hepatitis.
Serum albumin
3.5-5.5 g/dL Proteins are manufactured by the liver. Their levels may be affected in a variety of liver impairments: albumin is affected in cirrhosis, chronic hepatitis, edema, ascites; globulins are affected in cirrhosis, liver disease, chronic obstructive jaundice, and viral hepatitis.
A patient presents to the ED following a burn injury. The patient has burns to the anterior chest and entire left leg. Using the rule of nines, the nurse documents the total body surface area (TBSA) percentage as which of the following? a) 9% b) 36% c) 18% d) 27%
36% (questionable) Explanation: The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the TBSA, quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%).
Moderate burn-
3rd degree burns covering 2% to 10% BSA, EXCLUDING face, hands, feet, genitalia, or respiratory tract. 2nd degree burns of 15% to 30% BSA 1st degree burns of greater than 50% BSA
Minor burn-
3rd degree burns involving less than 2% BSA 2nd degree burns involving less than 15% BSA
Albumin
4-6 g/dL Proteins are manufactured by the liver. Their levels may be affected in a variety of liver impairments: albumin is affected in cirrhosis, chronic hepatitis, edema, ascites; globulins are affected in cirrhosis, liver disease, chronic obstructive jaundice, and viral hepatitis.
Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which timeframe?
5 days
Total serum protein
7-7.5 g/dL Proteins are manufactured by the liver. Their levels may be affected in a variety of liver impairments: albumin is affected in cirrhosis, chronic hepatitis, edema, ascites; globulins are affected in cirrhosis, liver disease, chronic obstructive jaundice, and viral hepatitis.
LDL
<130 mcg/dL Cholesterol levels are elevated in biliary obstruction and decreased in parenchymal liver disease.
s/e of inhalants (freon, toluene0
HA, euphoria, dizzy, altered LOC, drunk-like feeling Monitor resp status, treat hypotension
Cirrhosis
A chronic liver disease characterized by fibrotic changes, the formation of dense connective tissue within the liver, subsequent degenerative changes, and loss of functioning cells.
Graves' Disease
A form of HyperThyroidism; Sx: Diffuse Goiter and Exopthalamos.
Vasopressin
ADH secreted by Posterior Pituitary
how to stop internal bleeding?
ASSESS increace HR tachy bp drop anxious pale cool skin thirsty!! Prevent shock/ and organ failure
Potential Complications and Collaborative Problems
Acute respiratory failure Distributive shock Acute renal failure Compartment syndrome Paralytic ileus Curling's ulcer
pheochromocytoma
Adrenal Medulla Tumor
Burn Mortality
Age + %TBSA = Mortality 25 + 25% = 50 % Survival Rate
Ascites
An albumin-rich fluid accumulation in the peritoneal cavity.
Infection Prevention
At risk for: -Health care associated infections d/t Barrier loss -Necrotic tissue in burn eschar + serum proteins = environment for bacterial growth -Burns Compromise local and systemic immunity
A patient with a severe electrical burn injury is being treated in the burn unit. Which of the following laboratory results would cause the nurse the most concern? a) K+: 5.0 mEq/L b) BUN: 28 mg/dL c) Na+: 145 mEq/L d) Ca: 9 mg/dL
BUN: 28 mg/dL Correct Explanation: The elevated BUN would case 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, which is associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.
Managing Pain
Burn pain - described as one of the most severe forms of acute pain -Pain accompanies care and treatments such as wound cleaning and dressing changes Types of burn pain -Background or resting -Procedural -Breakthrough
Burns Chapt. 62 PrepU
Burns Chapt. 62 PrepU
Pathophysiologic Changes with Severe Burns
CV Pulmonary GI Kidney
Hormones
Chemical neurotransmitter substances produced in one organ or part of the body and carried by the bloodstream to other cells or organs on which they have a specific regulatory effect; Produced mainly by Endocrine Glands
basal metabolic rate
Chemical reactions occurring when the body is at rest.
Assessing for cirrhosis
Compensated: -Intermittent mild fever - Vascular spiders - reddened palms (palmar erythema) - unexplained epistaxis - Ankle edema - Vague morning indigestion -Flatulence - ABD pain - Firm enlarged liver - Splenomegaly Decompensated: -Ascites -Jaundice -Weakness - Muscle wasting -Weightloss - Continuous mild fever -Clubbing of fingers -Purpura - Spontaneous bruising -Epistaxis - Hypotension -Sparse body hair -White nails -Gonadal atrophy
A client is in hypovolemic shock. To determine the effectiveness of fluid replacement therapy, the nurse should monitor the client's: heart rate. blood pressure. temperature. hemoglobin level.
Correct response: blood pressure. Explanation: With adequate fluid replacement, fluid volume in the intravascular space expands, raising the client's blood pressure. The hemoglobin level reflects red blood cell concentration, not overall fluid status. Temperature and heart rate aren't directly related to fluid status.
When the emergency nurse learns that the patient suffered injury from a flash flame, the nurse anticipates which depth of burn? a) Full thickness b) Deep partial thickness c) Superficial partial thickness d) Superficial
Deep partial thickness Explanation: A deep partial thickness burn is similar to a second-degree burn and is associated with scalds and flash flames. Superficial partial thickness burns are similar to first-degree burns and are associated with sunburns. Full thickness burns are similar to third-degree burns and are associated with direct flame, electric current, and chemical contact. Injury from a flash flame is not associated with a burn that is limited to the epidermis.
s/e of opiod (heroin, opium, morphine) reversed by
Dizzy, n/v, bradycardia, dyspnea, pinpoint pupils naloxone
goiter
Enlargement of the thyroid gland.
management of trauma
Establish priorities !!! control hemorrhage, prevent and treat hypovolemic shock, assess for head& neck injuries, evaluate for other injuries, splint fractures and then check pulses and NV status. Documentation (wounds, mechanism of injury, time of events, collect evidence): be careful when taking off cloths fold in on itself on a towel so police can collect ME in the event of suicide/homicide/sudden without cause/prisons, overdose, child without cause/job related/suspected SIDS [ automatoc if death comes from trauma, pronounced dead don't touch anything no tubes are removed]
Within the practice of nursing at the burn unit, there are specific potential complications common to specific types of burns. Which burns can impair ventilation? a) Face, neck, chest b) Perineal c) All options are correct. d) Hands, major joints
Face, neck, chest Correct Explanation: Burns of the face, neck, or chest have the potential to impair ventilation.
adrenocorticotropic hormone (ACTH)
Hormone secreted by the anterior pituitary, essential for growth & development.
calcitonin
Hormone secreted by the thyroid gland; Participates in CALCIUM regulation.
Which of the following provides clues about fluid volume status? Select all that apply.
Hourly urine output • Daily weights Explanation: Monitoring of hourly urine output and daily weights provides clues about fluid volume status. Percentage of meals eaten, skin turgor, and oxygen saturation would not be reliable indicators of fluid volume status in the burn injured patient.
Constructional apraxia
Inability to draw figures in two or three dimensions.
whom is at greater risk?
Increased risk to very young and elderly Decreased ability to perform self-care Chronic/debilitating diseases Medications
Thyroiditis
Inflammation of the thyroid gland; may lead to Chronic Hypothyroidism or may resolve spontaneously.
A 6-year-old girl was playing near her family's campfire when she fell into the fire, suffering significant burns. She was taken by air ambulance to the burn unit where you practice nursing. What physiologic process furthers her burn injury? a) Inflammatory b) Intravascular fluid excess c) Neuroendocrine d) Hypertension
Inflammatory Correct Explanation: The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury.
S/S of Liver Disease
Jaundice, malaise, melena, hematochezia, easy bruising, changes in mental acuity, personality changes, sleep disturbances, decreased libido, amenorrhea
management of ingested poison?
Know what was ingested *Corrosive Poisons- *Alkaline/Acidic *Amount, timeline, S/S *Assessment findings (redness, burns, dysphagia, vomit, drool ABC's VS, LOC, EKG and Urine Age and weight Remove or decrease absorption Corrosive- milk or water for dilution w/o airway compromise Syrup of ipecac- no longer recommended due to aspiration Never use with a corrosive agent Gastric lavage for obtunded patient within one hour of ingestion, sustained release, or massive amounts-can have complications Activated charcoal (NG or oral) Consider children Gown, face shield, gloves If unknown, call local poison control center During detox, frequent monitoring VS, CVP, chemistry profile Refer mental health if intentional
ABA (American Burn Association)
Lactated Ringers -Dosage Form: IV solution 2ml - 4ml LR x pts wt in kg x %TBSA 2nd, 3rd, 4th- degree burns ½ of total in 1st 8 hrs 2nd half next 16 hours Titrate to u/o
inhaling or ingesting poison means what
Medical Emergancy
Lund and Browder method
More precise % of surface area r/t age of pt
Percentage of Liver Parenchyma Damaged before Liver Function Test Abnormalities
More than 70%
Which of the following is the analgesic of choice for burn pain? a) Fentanyl b) Demerol c) Tylenol with codeine d) Morphine sulfate
Morphine sulfate remains the analgesic of choice. It is titrated to obtain pain relief on the patient's self-report of pain. Fentanyl is particularly useful for procedural pain, because it has a rapid onset, high potency, and short duration, all of which make it effective for use with procedures. Demerol and Tylenol with codeine are not analgesics of choice for burn pain.
Endoscopic variceal ligation (EVL)
Procedure that uses a modified endoscope loaded with an elastic rubber band passed through an overtube directly onto varix.
what are the priorities in a poisioning?
Remove or inactivate Supportive care to decrease damage to organs Antidote administration Treat to quickly eliminate absorbed poison
Management/Fluid Resuscitation-Acute Phase
Restore normal fluid balance -Fluid re-enters the vascular space from the interstitial space -Hemo-dilution- increase in the volume of plasma in relation to red blood cells; reduced concentration of red blood cells in the circulation. -Diuresis begins -Sodium is lost with diuresis and dilution as fluid enters vascular space: hyponatremia -Potassium shifts from extracellular fluid into cells: potential hypokalemia -Metabolic acidosis
management of wounds
Restore physical integrity and function PROPER DOCUMENTATION Photography: consent Clean and close: jet irrigation system if deep wound,close sutures, staples, dermabond, cover open wound sterile gauze, dry Education: infection, Tetanus,s/s of infection and find out last tetanus shot
myxedema
Severe HYPOTHYROIDISM; can be with or without coma.
Which of the following topical burn preparations act as wick for sodium and potassium? a) Silver nitrate solution b) Silver sulfadiazine (Silvadene) c) Mafenide acetate (Sulfamylon) d) Acticoat
Silver nitrate solution Correct Explanation: Silver nitrate solution is hypotonic and acts as a wick for sodium and potassium. The other preparations do not act as a wick for sodium and potassium.
mineralcorticosteroids
Steroid hormones secreted by the Adrenal Cortex
Fulminant hepatic failure
Sudden, severe onset of acute liver failure that occurs within 8 wks after the first symptoms of jaundice.
Which of the following is a potential cause of a superficial partial-thickness burn? a) Scald b) Flash flame c) Sunburn d) Electrical current
Sunburn Correct Explanation: A potential cause of a superficial partial-thickness burn is a sunburn or low-intensity flash. Causes of deep partial-thickness burns are scalds and flash flames. Full-thickness burns may be caused by an electrical current or prolonged exposure to hot liquids.
assessment for heat stroke
Thermal injury at the cellular level- damage to liver, kidneys and heart Patient history Signs and symptoms: confusion, delirium, coma, seizures, hot, dry skin (anhidrosis), tachypnea, hypotension, tachycardia, low sodium and potassium, body temp 105f
Palmer method
Used with scattered burns Size of pts hand including fingers is approximately 1%
Hep A Prevention
Vaccines!!! 95-100% effective after 2-3 doses
SIADH
X-Cessive secretion of ADH from the Pituitary Gland despite low serum osmolality levels
addisonian crisis
acute adrenocorticol insufficiency; Characterized by: HYPOTN, Cyanosis, Fever, N/V, & classic signs of shock.
heat stroke is ?
an acute medical emergancy
causes for airway obstruction?
anaphylaxis, choking, tonsils touching, older adults with food trapped
why may heat regulating mechanisms fail?
anticholinergics, beta-blockers, diuretics, may stop ability to sweat and cool
s/s of substance abuse
anything from VS changes to comatose
Additional risk factors
are low-socioeconomic status, low educational level of the primary care giver, home crowding (as estimated by number of household rooms) and psychosocial family stress.
Flexor sparing-patterns
are seen when the victim's joints are held in flexion from fear, pain or by others in forced immersion. Commonly involve the hips anteriorly and popliteal fossa posteriorly. The lower abdomen may also be spared when the trunk is in flexion when adopting a typical defensive position.
salicylate poisoning and s/e? and treatments
aspirin Tinnitus, blurred vision, sweaty, respiratory alkalosis/metabolic acidosis, bleeding Sodium Bicarb, fluids, diuretics, hemodialysis
Which of the following actions is a quick assessment technique that the nurse might use to assess the percentage of a small or scattered burn injury? a) Checking the patient's vital signs b) Comparing the patient's palm with the size of the burn wound c) Observing the patient's level of consciousness d) Observing the color of the patient's wound
b
Pathogenesis of ascites
cirrhosis with portal hypertension-- splanchich arterial vasodilation--decrease in arterial blood volume-- Activation of renin-angiotensin and sympathetic nervous systems and ADH.---Kidney retains sodium---Hypervolemia-- Persistent activation of systems for retention of sodium and water; ascites and edema formation.-- continued arterial underfilling; cycle repeats.
management of hemorrhage?
control bleeding and replace fluids, RBC's. Monitor: EKG, ultrasound, accult stool samples
s/s of airway obstruction?
can't breath/talk/cough, clutch neck or chest, scared, stridor, dyspnea, confusion, cyanosis, LOC
who gets a resuscitation status?
cardiac arrest and pt's without airway or using another airway
hepatic encephalopathy
central nervous system dysfunction frequently associated with elevated ammonia levels that produce changes in mental status, altered level of consciousness and coma
define hypothermia?
core temperature is 95 degrees or less
trauma is either
unintentional or intentional
multiple trauma is defined as? what is the management for this condition?
damage to at least two organ systems. team approach, determine extent
key to treat food poisoning?
determine source and type
Portal hypertension
elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver.
urban hypothermia is defined as? who is more at risk?
exposure to cold in urban setting At risk- elderly, infants, ill and homeless
frostbite most frequently seen
feet, hands, noes and ears
emergant?
fractures, pregnant women with abdominal pain. pregnant women with bleeding.
Orthopic liver transplantation (OLT)
grafting of a donor liver into the normal anatomic location, with removal of the diseased native liver.
s/s of intra-abdominal injures
guarding, hypoactive or absent bowel sounds, distended, firm and rigid, pain, blood in vomit
Which of the following is the key sign of onset of ARDS? a) Tachypnea b) Stridor c) Hypoxemia d) Chest pain
hypoxemia Explanation: The key sign of the onset of ARDS is hypoxemia while receiving 100% oxygen, with decreased lung compliance and significant shunting. The physician should be notified immediately of deteriorating respiratory status.
causes of carbon monoxide poisoning?
industrial, household incident, attempted suicide
Astererixis
involuntary flapping movements of the hands
Airway Obstructions
life-threatening. partial or complete: partial can become a complete at any moment
hypothermia causes____, which may lead to?
low bp and hr pulses may become undetectable dysrhythmias
Contact thermal burns-
may result from irons, ovens and fire grills with upper limbs mostly effected.
substance abuse
misuse of drugs and/or alcohol to alter mood or behavior drug abuse- use of drugs other than legitimate medical purposes accidental or intentional natural or synthetic
heat stroke is either
non-exertional or exertional
most common cause of heat stroke
non-exertional, prolonged exposure of temp greater than 102.5
Splash
occur when the scalding agent is thrown on to the victim. These are difficult to distinguish from accidental splash burns.
intra-abdominal injuries are either? what are some examples of each?
penetrating: stab wound, GSW or impalement or blunt: falls, sports injuries
nonurgent?
pt's without primary care providers. suture removal, urinary drugs screens, not complaining of an illness
s/e of stimulants (cocaine)
rapid HR, Increased BP, muscle cramps, vomiting, hyperthermia, panic attack, seizures
goal of frostbite management?
restore temperatire, prevent tissue loss
major blood loss may cause?
shock or cardiac arrest
urgent?
sick but they can wait a little bit, stomach viruses, laceration but not hemorrhaging
what medications are used for intra-abdominal injures? and what are the rules following this?
small doses of opiods. bc we want them to be able to tell us our pain & if it is moving
less urgent?
sore throat, ear aches, simple lacerations
intra-abdominal assessment?
start with ABCDE then more to abdominal assessment
what is food poisoning?
sudden illness after ingestion of contaminated food/ drink
fetor hepaticus
sweet, slightly fecal odor to the breath, presumed to be of intestinal origin; prevalent with the extensive portal circulation in chronic liver disease.
prevention for heat stroke?
teach them to avoid midday sun, drink lots, AC use
Scald induced-porcelain contact sparing/immersions-
that are deliberate incur burns of uniform depth with distinct borders with skin-fold sparing
s/s of heat exhaustion
thirst, profuse diaphoresis, muscle cramps Headache Anxiety Syncope Gooseflesh Orthostatic
xenograft
transplantation of organs from one species to another.
principles of emergency care? modifications on? takes?
triage. modifications depending on size, staff and department flow. takes advance skill and experience
HDL
Male: 35-70 mg/dL; Female: 35-85 mg/dL Cholesterol levels are elevated in biliary obstruction and decreased in parenchymal liver disease.
33. A patient with Cushing syndrome has been hospitalized after a fall. The dietician consulted works with the patient to improve the patients nutritional intake. What foods should a patient with Cushing syndrome eat to optimize health? Select all that apply. A) Foods high in vitamin D B) Foods high in calories C) Foods high in protein D) Foods high in calcium E) Foods high in sodium
A, C, D Feedback: Foods high in vitamin D, protein, and calcium are recommended to minimize muscle wasting and osteoporosis. Referral to a dietitian may assist the patient in selecting appropriate foods that are also low in sodium and calories.
11. The nurse is performing a shift assessment of a patient with aldosteronism. What assessments should the nurse include? Select all that apply. A) Urine output B) Signs or symptoms of venous thromboembolism C) Peripheral pulses D) Blood pressure E) Skin integrity
A, D Feedback: The principal action of aldosterone is to conserve body sodium. Alterations in aldosterone levels consequently affect urine output and BP. The patients peripheral pulses, risk of VTE, and skin integrity are not typically affected by aldosteronism.
A nurse on a solid organ transplant unit is planning the care of a patient who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority? A. Implementation of infection-control measures B. Close monitoring of skin integrity and color C. Frequent assessment of the patient's psychosocial status D. Administration of antiretroviral medications
A. Implementation of infection-control measures Rationale: Infection control is paramount following liver transplantation. This is a priority over skin integrity and psychosocial status, even though these are valid areas of assessment and intervention. Antiretrovirals are not indicated.
A patient is being discharged after a liver transplant and the nurse is performing discharge education. When planning the patient's continuing care, the nurse should prioritize which of the following risk diagnoses? A. Risk for infection related to immunosuppressant use B. Risk for injury related to decreased hemostasis C. Risk for unstable blood glucose related to impaired gluconeogensis D. Risk for contamination related to accumulation of ammonia
A. Risk for infection related to immunosuppressant use Rationale: Infection is the leading cause of death after liver transplantation. Pulmonary and fungal infections are common; susceptibility to infection is increased by the immunosuppressive therapy that is needed to prevent rejection. This risk exceeds the threats of injury and unstable blood glucose. The diagnosis of risk for contamination related to environmental toxin exposure.
exopthalamos
Abnormal protrusion of one or both eyeballs.
17. The nurse is planning the care of a patient with hyperthyroidism. What should the nurse specify in the patients meal plan? A) A clear liquid diet, high in nutrients B) Small, frequent meals, high in protein and calories C) Three large, bland meals a day D) A diet high in fiber and plant-sourced fat
B Feedback: A patient with hyperthyroidism has an increased appetite. The patient should be counseled to consume several small, well-balanced meals. High-calorie, high-protein foods are encouraged. A clear liquid diet would not satisfy the patients caloric or hunger needs. A diet rich in fiber and fat should be avoided because these foods may lead to GI upset or increase peristalsis.
37. The nurse is caring for a patient at risk for an addisonian crisis. For what associated signs and symptoms should the nurse monitor the patient? Select all that apply. A) Epistaxis B) Pallor C) Rapid respiratory rate D) Bounding pulse E) Hypotension
B, C, E Feedback: The patient at risk is monitored for signs and symptoms indicative of addisonian crisis, which can include shock; hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness. Epistaxis and a bounding pulse are not symptoms or signs of an addisonian crisis.
A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patient's plan of care? A. Measurement of abdominal girth and body weight B. Assessment for variceal bleeding C. Assessment for signs and symptoms of jaundice D. Monitoring of results of liver function testing
B. Assessment of variceal bleeding Rationale: Esophageal varices are a major cause of mortality in patients with uncompensated cirrhosis. Consequently, this should be a focus of the nurse's assessments and should be prioritized over the other listed assessments, even though each should be performed.
38. A patient has been assessed for aldosteronism and has recently begun treatment. What are priority areas for assessment that the nurse should frequently address? Select all that apply. A) Pupillary response B) Creatinine and BUN levels C) Potassium level D) Peripheral pulses E) BP
C, E Feedback: Patients with aldosteronism exhibit a profound decline in the serum levels of potassium, and hypertension is the most prominent and almost universal sign of aldosteronism. Pupillary response, peripheral pulses, and renal function are not directly affected.
Addison's Disease
Chronic adrenocortical insufficiency due to inadequate adrenal cortex function.
D.I
Condition in which abnormally large volumes of dilute urine are excreted as a result of deficient production of vasopressin.
27. A patient has been taking prednisone for several weeks after experiencing a hypersensitivity reaction. To prevent adrenal insufficiency, the nurse should ensure that the patient knows to do which of the following? A) Take the drug concurrent with levothyroxine (Synthroid). B) Take each dose of prednisone with a dose of calcium chloride. C) Gradually replace the prednisone with an OTC alternative. D) Slowly taper down the dose of prednisone, as ordered.
D Feedback: Corticosteroid dosages are reduced gradually (tapered) to allow normal adrenal function to return and to prevent steroid-induced adrenal insufficiency. There are no OTC substitutes for prednisone and neither calcium chloride nor levothyroxine addresses the risk of adrenal insufficiency.
A nurse is performing an admission assessment for an 81-year-old patient who generally enjoys good health. When considering normal, age-related changes to hepatic function, the nurse should anticipate what finding? A. Similar liver size and texture as in younger adults B. A nonpalpable liver C. A slightly enlarged liver with palpably hard edges D. A slightly decreased size of the liver
D. A slightly decreased size of the liver Rationale: The most common age-related change in the liver is a decrease in size and weight. The liver is usually still palpable, however, it is not expected to have hardened edges.
corticosteriods
Hormones produced by the adrenal cortex or their synthetic equivalents; also referred to as adrenalcorticol hormone & adrenalcorticosteroids; CONSISTS of: Glucocorticoids, Mineralocorticoids, & Androgens
androgens
Male Sex Hormones
adrenogenital syndrome
Masculinization in women, feminization in men, or premature sexual development in children. Result of abnormal secretion of adrenocortical hormones (esp. ANDROGENS)
Chvostek's Sign
Spasm of facial muscles produced by sharply tapping over the facial nerve in front of the parotid gland & anterior to the ear; suggestive of latent tetany in pts with hypocalcemia.
euthyroid
State of Normal Thyroid Hormone production.
Glucocorticoids
Steroid Hormones secreted by the adrenal cortex in response to adrenocorticotropic hormone; produce a rise of liver glycogen and blood glucose.
adrenalectomy
Surgical removal of one or both adrenal glands.
Nonviral Hepatitis
-Toxic: inhaled, taken orally or injected (bad chemicals/ minerals) -Drug-induced: acetaminophen, methyldopa, antibiotics, antimetabolites and anesthetic agents (no cure except for liver transplant)
21. A patient with suspected adrenal insufficiency has been ordered an adrenocorticotropic hormone (ACTH) stimulation test. Administration of ACTH caused a marked increase in cortisol levels. How should the nurse interpret this finding? A) The patients pituitary function is compromised. B) The patients adrenal insufficiency is not treatable. C) The patient has insufficient hypothalamic function. D) The patient would benefit from surgery
A Feedback: An adrenal response to the administration of a stimulating hormone suggests inadequate production of the stimulating hormone. In this case, ACTH is produced by the pituitary and, consequently, pituitary hypofunction is suggested. Hypothalamic function is not relevant to the physiology of this problem. Treatment exists, although surgery is not likely indicated.
3. A patient with thyroid cancer has undergone surgery and a significant amount of parathyroid tissue has been removed. The nurse caring for the patient should prioritize what question when addressing potential complications? A) Do you feel any muscle twitches or spasms? B) Do you feel flushed or sweaty? C) Are you experiencing any dizziness or lightheadedness? D) Are you having any pain that seems to be radiating from your bones?
A Feedback: As the blood calcium level falls, hyperirritability of the nerves occurs, with spasms of the hands and feet and muscle twitching. This is characteristic of hypoparathyroidism. Flushing, diaphoresis, dizziness, and pain are atypical signs of the resulting hypocalcemia.
35. A patient with Cushing syndrome as a result of a pituitary tumor has been admitted for a transsphenoidal hypophysectomy. What would be most important for the nurse to monitor before, during, and after surgery? A) Blood glucose B) Assessment of urine for blood C) Weight D) Oral temperature
A Feedback: Before, during, and after this surgery, blood glucose monitoring and assessment of stools for blood are carried out. The patients blood sugar is more likely to be volatile than body weight or temperature. Hematuria is not a common complication.
28. Following an addisonian crisis, a patients adrenal function has been gradually regained. The nurse should ensure that the patient knows about the need for supplementary glucocorticoid therapy in which of the following circumstances? A) Episodes of high psychosocial stress B) Periods of dehydration C) Episodes of physical exertion D) Administration of a vaccine
A Feedback: During stressful procedures or significant illnesses, additional supplementary therapy with glucocorticoids is required to prevent addisonian crisis. Physical activity, dehydration and vaccine administration would not normally be sufficiently demanding such to require glucocorticoids.
23. A nurse works in a walk-in clinic. The nurse recognizes that certain patients are at higher risk for different disorders than other patients. What patient is at a greater risk for the development of hypothyroidism? A) A 75-year-old female patient with osteoporosis B) A 50-year-old male patient who is obese C) A 45-year-old female patient who used oral contraceptives D) A 25-year-old male patient who uses recreational drugs
A Feedback: Even though osteoporosis is not a risk factor for hypothyroidism, the condition occurs most frequently in older women.
1. The nurse is caring for a patient diagnosed with hypothyroidism secondary to Hashimotos thyroiditis. When assessing this patient, what sign or symptom would the nurse expect? A)Fatigue B) Bulging eyes C) Palpitations D) Flushed skin
A Feedback: Symptoms of hypothyroidism include extreme fatigue, hair loss, brittle nails, dry skin, voice huskiness or hoarseness, menstrual disturbance, and numbness and tingling of the fingers. Bulging eyes, palpitations, and flushed skin would be signs and symptoms of hyperthyroidism.
32. The nurse providing care for a patient with Cushing syndrome has identified the nursing diagnosis of risk for injury related to weakness. How should the nurse best reduce this risk? A) Establish falls prevention measures. B) Encourage bed rest whenever possible. C) Encourage the use of assistive devices. D) Provide constant supervision.
A Feedback: The nurse should take action to prevent the patients risk for falls. Bed rest carries too many harmful effects, however, and assistive devices may or may not be necessary. Constant supervision is not normally required or practicable.
10. You are developing a care plan for a patient with Cushing syndrome. What nursing diagnosis would have the highest priority in this care plan? A) Risk for injury related to weakness B) Ineffective breathing pattern related to muscle weakness C) Risk for loneliness related to disturbed body image D) Autonomic dysreflexia related to neurologic changes
A Feedback: The nursing priority is to decrease the risk of injury by establishing a protective environment. The patient who is weak may require assistance from the nurse in ambulating to prevent falls or bumping corners or furniture. The patients breathing will not be affected and autonomic dysreflexia is not a plausible risk. Loneliness may or may not be an issue for the patient, but safety is a priority.
31. A patient is undergoing testing for suspected adrenocortical insufficiency. The care team should ensure that the patient has been assessed for the most common cause of adrenocortical insufficiency. What is the most common cause of this health problem? A) Therapeutic use of corticosteroids B) Pheochromocytoma C) Inadequate secretion of ACTH D) Adrenal tumor
A Feedback: Therapeutic use of corticosteroids is the most common cause of adrenocortical insufficiency. The other options also cause adrenocortical insufficiency, but they are not the most common causes.
A patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patient's fluid volume excess? Select all that apply. A. Administering diuretics B. Administering calcium channel blockers C. Implementing fluid restrictions D. Implementing a 1500 kcal/day restriction E. Enhancing patient positioning
A. Administering diuretics B. Administering calcium channel blockers E. Enhancing patient positioning Rationale: Administering diuretics, implementing fluid restrictions, and enhancing patient positioning can optimize the management of fluid volume excess. Calcium channel blockers and calorie restriction do not address this problem.
A nurse is caring for a patient with hepatic encephalopathy. While making the initial shift assessment, the nurse notes that the patient has a flapping tremor of the hands. The nurse should document the presence of what sign of liver disease? A. Asterixis B. Constructional apraxia C. Fector hepaticus D. Palmar erythema
A. Asterixis Rationale: The nurse will document that a patient exhibiting a flapping tremor of the hands is demonstrating asterixis. While constructional apraxia is a motor disturbance, it is the inability to reproduce a simple figure. Fector hepaticus is a sweet, slightly fecal odor to the breath and not associated with a motor disturbance. Skin changes associated with liver dysfunction may include palmar erythema, which is a reddening of the palms, but is not a flapping tremor.
A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patient's presentation? A. How many alcoholic drinks do you typically consume in a week? B. To the best of your knowledge, are your immunizations up to date? C. Have you ever worked in an occupation where you might have been exposed to toxins? D. Has anyone in your family ever experienced symptoms similar to yours?
A. How many alcoholic drinks do you typically consume in a week? Rationale: Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol use. Immunization status, occupational risks, and family history are also relevant considerations, but alcohol use is a more common etiologic factor in liver disease.
A nurse educate is teaching a group of recent nursing graduates about their occupational risks for contracting hepatitis B. What preventative measures should the educator promote? Select all that apply. A. Immunizations B. Use of standard precautions C. Consumption of vitamin-rich diet D. Annual vitamin K injections E. Annual vitamin B12 injections
A. Immunizations B. Use of standard precautions Rationale: People who are at high risk, including nurses and other health care personnel exposed to blood or blood products, should receive active immunization. The consistent use of standard precautions is also highly beneficial. Vitamin supplementation is unrelated to an individual's risk of HBV.
A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patient's current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A. Two to 3 soft bowel movements daily B. Significant increase in appetite and food intake C. Absence of nausea and vomiting D. Absence of blood or mucus in stool
A. Two to 3 soft bowel movements daily Rationale: Lactulose (Cephulac) is administered to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the patient's appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool.
s/e of hallucinogens/psychedelics (LSD, PCP, marijuana, special k)
ABC's Mild hypertension, confusion, withdrawn, hallucinations, seizures
s/e of sedation and seditory drugs diazepam (Valium), lorazepam (Ativan), midazolam (Versed)
ABC's- respiratory depression/circulatory collapse Decreased LOC flumazenil (Romazicon)
Following a burn injury, which of the following areas is the priority for nursing assessment? a) Pulmonary system b) Cardiovascular system c) Nutrition d) Pain
Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs.
what is poisoning?
Any substance that, when ingested, inhaled, absorbed, applied to the skin, or produced within the body in relatively small amounts, injures the body by its chemical action.
5. The nurse is caring for a patient with Addisons disease who is scheduled for discharge. When teaching the patient about hormone replacement therapy, the nurse should address what topic? A) The possibility of precipitous weight gain B) The need for lifelong steroid replacement C) The need to match the daily steroid dose to immediate symptoms D) The importance of monitoring liver function
B Feedback: Because of the need for lifelong replacement of adrenal cortex hormones to prevent addisonian crises, the patient and family members receive explicit education about the rationale for replacement therapy and proper dosage. Doses are not adjusted on a short-term basis. Weight gain and hepatotoxicity are not common adverse effects.
15. While assisting with the surgical removal of an adrenal tumor, the OR nurse is aware that the patients vital signs may change upon manipulation of the tumor. What vital sign changes would the nurse expect to see? A) Hyperthermia and tachypnea B) Hypertension and heart rate changes C) Hypotension and hypothermia D) Hyperthermia and bradycardia
B Feedback: Manipulation of the tumor during surgical excision may cause release of stored epinephrine and norepinephrine, with marked increases in BP and changes in heart rate. The use of sodium nitroprusside and alpha-adrenergic blocking agents may be required during and after surgery. While other vital sign changes may occur related to surgical complications, the most common changes are related to hypertension and changes in the heart rate.
26. The nurses assessment of a patient with thyroidectomy suggests tetany and a review of the most recent blood work corroborate this finding. The nurse should prepare to administer what intervention? A) Oral calcium chloride and vitamin D B) IV calcium gluconate C) STAT levothyroxine D) Administration of parathyroid hormone (PTH)
B Feedback: When hypocalcemia and tetany occur after a thyroidectomy, the immediate treatment is administration of IV calcium gluconate. This has a much faster therapeutic effect than PO calcium or vitamin D supplements. PTH and levothyroxine are not used to treat this complication.
25. A patient has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in this patients immediate care? Select all that apply. A) Administering diuretics to prevent fluid overload B) Administering beta blockers to reduce heart rate C) Administering insulin to reduce blood glucose levels D) Applying interventions to reduce the patients temperature E) Administering corticosteroids
B, D Feedback: Thyroid storm necessitates interventions to reduce heart rate and temperature. Diuretics, insulin, and steroids are not indicated to address the manifestations of this health problem.
A patient with a history of injection drug use has been diagnosed with Hepatitis C. When collaborating with the care team to plan this patient's treatment, the nurse should anticipate what intervention? A. Administration of immune globulins B. A regimen of antiviral medications C. Rest and watchful waiting D. Administration of fresh-frozen plasma (FFP)
B. A regimen of antiviral medications Rationale: There is no benefit from rest, diet, or vitamin supplements in HCV treatment. Studies have demonstrated that a combination of two antiviral agents, Peg-interferon and ribavirin (Rebetol), is effective in producing improvement in patients with hepatitis C and in treating relapses. Immune globulins and FFP are not indicated.
A patient has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the patient may have developed liver metastases? A. Persistent fever and cognitive changes B. Abdominal pain and hepatomegaly C. Peripheral edema unresponsive to diuresis D. Spontaneous bleeding and jaundice
B. Abdominal pain and hepatomegaly Rationale: The early manifestations of malignancy of the liver include pain, a continuous dull ache in the right upper quadrant, epigastrium, or back. Weight loss, loss of strength, anorexia, and anemia may also occur. The liver may be enlarged and irregular on palpation. Jaundice is present only if the larger bile ducts are occluded by the pressure of malignant nodules in the hilum of the liver. Fever, cognitive changes, peripheral edema, and bleeding are atypical signs.
A participant in a health fair has asked the nurse about the role of drugs in liver disease. What health promotion teaching has the most potential to prevent drug-induced hepatitis? A. Finish all prescribed courses of antibiotics, regardless of symptoms resolution. B. Adhere to dosing recommendations of OTC analgesics. C. Ensure that expired medications are disposed of safely. D. Ensure that pharmacists regularly review drug regimens for potential interactions.
B. Adhere to dosing recommendations of OTC analgesics. Rationale: Although any medication can affect liver function, use of acetaminophen (found in many OTC medications used to treat fever and pain) has been identified as the leading cause of acute liver failure. Finishing prescribed antibiotics and avoiding expired medications are unrelated to this disease. Drug interactions are rarely the cause of drug-induced hepatitis.
A patient with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the patient's prioritization for receiving a donor liver be determined? A. By considering that patient's age and prognosis B. By objectively determining the patient's medical need C. By objectively assessing the patient's willingness to adhere to post-transplantation care D. By systematically ruling out alternative treatment options
B. By objectively determining the patient's medical need Rationale: The patient would undergo a classification of the degree of medical need through an objective determination known as the Model of End-Stage Liver Disease (MELD) classification, which stratifies the level of illness of those awaiting a liver transplant. This algorithm considers multiple variables, not solely age, prognosis, potential for adherence and the rejection of alternative options.
A patient with a diagnosis of esophageal varices has undergone endoscopy to gauge the progression of this complication of liver disease. Following the completion of this diagnostic test, what nursing intervention should the nurse perform? A. Keep patient NPO until the results of test are known B. Keep patient NPO until the patient's gag reflex returns C. Administer analgesia until post-procedure tenderness is relieved D. Give the patient a cold beverage to promote swallowing ability
B. Keep patient NPO until the patient's gag reflex returns Rationale: After the examination, fluids are not given until the patient's gag reflex returns. Lozenges and gargles may be used to relieve throat discomfort if the patient's physical condition and mental status permit. The result of the test is known immediately. Food and fluids are contraindicated until the gag reflex returns.
20. The nurse is assessing a patient diagnosed with Graves disease. What physical characteristics of Graves disease would the nurse expect to find? A) Hair loss B) Moon face C) Bulging eyes D) Fatigue
C Feedback: Clinical manifestations of the endocrine disorder Graves disease include exophthalmos (bulging eyes) and fine tremor in the hands. Graves disease is not associated with hair loss, a moon face, or fatigue.
A patient with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the patient's treatment? A. Decisional Conflict B. Deficient Knowledge C. Death Anxiety D. Disturbed Thought Processes
C. Death Anxiety Rationale: The sudden hemorrhage that accompanies variceal bleeding is intensely anxiety-provoking. The nurse must address the patient's likely fear of death, which is a realistic possibility. For most patients, anxiety is likely to be a more acute concern than lack of knowledge or decisional conflict. The patient may or may not experience disturbances in thought processes.
A nurse has entered the room of a patient with cirrhosis and found the patient on the floor. The patient stated that she fell when transferring to the commode. The patient's vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurse's most appropriate action? A. Remove the patient's commode and supply a bedpan B. Complete an incident report and submit it to the unit supervisor C. Have the patient assessed by the physician due to the risk of internal bleeding D. Perform a focused abdominal assessment in order to rule out injury.
C. Have the patient assessed by the physician due to the risk of internal bleeding Rationale: A fall would necessitate thorough medical assessment due to the patient's risk of bleeding. The nurse's abdominal assessment is an appropriate action, but is not wholly sufficient to rule out internal injury. Medical assessment is a priority over removing the commode or filling out an incident report, even though these actions are appropriate.
A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this patient is what? A. IV administration of immune globulins B. Transfusion of packed red blood cells and fresh-frozen plasma (FFP) C. Liver transplantation D. Lobectomy
C. Liver transplantation Rationale: Liver transplantation carries the highest potential for the resolution of fulminant hepatic failure. This is preferred over other interventions, such as pharmacologic treatments, transfusions, and surgery
A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient's liver? A. Place hand under the right lower abdominal quadrant and press down lightly with the other hand. B. Place the left hand over the abdomen and behind the left side at the 11th rib. C. Place hand under right lower rib cage and press down lightly with the other hand. D. Hold hand 90 degree to right side of the abdomen and push down firmly.
C. Place hand under right lower rib cage and press down lightly with the other hand. Rationale: To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. The liver is not on the left side or in the right lower abdominal quadrant.
A patient with liver disease has developed jaundice; the nurse is collaborating with the patient to develop a nutritional plan. The nurse should prioritize which of the following in the patient's plan? A. Increased potassium intake B. Fluid restriction to 2L per day C. Reduction in sodium intake D. High-protein, low-fat diet
C. Reduction in sodium intake Rationale: Patient with ascites require a sharp reduction in sodium intake. Potassium intake should not be correspondingly increased. There is no need for fluid restriction or increased protein intake.
A patient who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? A. The patient will obtain measurement of drainage from the T-tube. B. The patient will exercise three times a week. C. The patient will take immunosuppressive agents as required. D. The patient will monitor for signs of liver dysfunction.
C. The patient will take immunosuppressive agents as required. Rationale: The patient is given written and verbal instructions about immunosuppressive agent doses and dosing schedules. The patient is also instructed on steps to follow to ensure that an adequate supply of medication is available so that there is no change of running out of the medication or skipping a dose. Failure to take medications as instructed may precipitate rejection. The nurse would not teach the patient to measure drainage from a T-tube as the patient would;t go home with a T-tube. The nurse may teach the patient about the need to exercise or what the signs of liver dysfunction are, but the nurse would not stress these topics over the immunosuppressive drug regimen.
s/s of carbon monoxide poisioning?
CNS symptoms predominate- may appear drunk, muscle weakness, dizzy, headache, pink, cherry-colored skin
s/e of barbituates (nembutal, GHB)
Can mimic ETOH intoxication, respiratory depression, flushed face, decreased HR/BP, agitated, decreased LOC
Which of the following complications is common for victims of electrical burns? a) Inhalation injury b) Infection c) Hypovolemic shock d) Cardiac dysrhythmia
Cardiac dysrhythmia Correct Explanation: Cardiac dysrhythmias are common for victims of electrical burns. If the patient has an electrical burn, a baseline electrocardiogram (ECG) is obtained and continuous monitoring is initiated. Any burn injury can lead to complications, such as inhalation injury, infection, and hypovolemic shock.
Which of the following solutions should the nurse anticipate for fluid replacement in the male patient? Dextrose 5% in water Type O negative blood Hypertonic saline Lactated Ringer's solution
Correct response: Lactated Ringer's solution Explanation: Replacement fluids may include isotonic electrolyte solutions and blood component therapy. O negative blood is prepared for emergency use in women of childbearing age.Dextrose 5% in water should not be used to replace fluids in hypovolemic patients. Hypertonic saline is used only to treat severe symptomatic hyponatremia and should be used only in intensive care units.
30. A patient with pheochromocytoma has been admitted for an adrenalectomy to be performed the following day. To prevent complications, the nurse should anticipate preoperative administration of which of the following? A) IV antibiotics B) Oral antihypertensives C) Parenteral nutrition D) IV corticosteroids
D Feedback: IV administration of corticosteroids (methylprednisolone sodium succinate [Solu-Medrol]) may begin on the evening before surgery and continue during the early postoperative period to prevent adrenal insufficiency. Antibiotics, antihypertensives, and parenteral nutrition do not prevent adrenal insufficiency or other common complications of adrenalectomy.
24. A patient with a recent diagnosis of hypothyroidism is being treated for an unrelated injury. When administering medications to the patient, the nurse should know that the patients diminished thyroid function may have what effect? A) Anaphylaxis B) Nausea and vomiting C) Increased risk of drug interactions D) Prolonged duration of effect
D Feedback: In all patients with hypothyroidism, the effects of analgesic agents, sedatives, and anesthetic agents are prolonged. There is no direct increase in the risk of anaphylaxis, nausea, or drug interactions, although these may potentially result from the prolonged half-life of drugs.
12. The home care nurse is conducting patient teaching with a patient on corticosteroid therapy. To achieve consistency with the bodys natural secretion of cortisol, when would the home care nurse instruct the patient to take his or her corticosteroids? A) In the evening between 4 PM and 6 PM B) Prior to going to sleep at night C) At noon every day D) In the morning between 7 AM and 8 AM
D Feedback: In keeping with the natural secretion of cortisol, the best time of day for the total corticosteroid dose is in the morning from 7 to 8 AM. Large-dose therapy at 8 AM, when the adrenal gland is most active, produces maximal suppression of the gland. Also, a large 8 AM dose is more physiologic because it allows the body to escape effects of the steroids from 4 PM to 6 AM, when serum levels are normally low, thus minimizing cushingoid effects.
A nurse is amending a patient's plan of care in light of the fact that the patient has recently developed ascites. What should the nurse include in this patient's care plan? A. Mobilization with assistance at least 4 times daily B. Administration of beta-adrenergic blockers as ordered C. Vitamin B12 injections as ordered D. Administration of diuretics as ordered
D. Administration of diuretics as ordered Rationale: Use of diuretics along with sodium restriction is successful in 90% of patients with ascites. Beta-blockers are not used to treat ascites and bed rest is often more beneficial than increased mobility. Vitamin B23 injections are not necessary.
A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine? A. The hepatitis A vaccine B. Albumin infusion C. The hepatitis A and B vaccines D. An immune globulin injection
D. An immune globulin injection Rationale: For people who have not been previously vaccinated, hepatitis A can be prevented by the intramuscular administration of immune globulin during the incubation period, if given within 2 weeks of exposure. Administration of the hepatitis A vaccine will not protect the patient exposed to hepatitis A, as protection will take a few weeks to develop after the first dose of the vaccine. The hepatitis B vaccine provides protection against the hepatitis B virus, but plays no role in protection for the patient exposed to hepatitis A. Albumin confers no therapeutic benefit.
A patient with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the patient's family how to safely perform which of the following actions? A. Aspirating bile from the catheter using a syringe B. Removing the catheter when output is 15 mL in 24 hours C. Instilling antibiotics into the catheter D. Assessing the patency of the drainage catheter
D. Assessing the patency of the drainage catheter Rationale: Families should be taught to provide basic catheter care, including assessment of patency. Antibiotics are not instilled into the catheter and aspiration using a syringe is contraindicated. The family would not independently remove the catheter; this would be done by a member of the care team when deemed necessary.
A nurse is participating in the emergency care of a patient who has just developed variceal bleeding. What intervention should the nurse anticipate? A. Infusion of intravenous heparin B. IV administration of albumin C. STAT administration of vitamin K by the intramuscular route D. IV administration of octreotide (Sandostatin)
D. IV administration of octreotide (Sandostation) Rationale: Octreotide (Sandostatin) a synthetic analog of the hormone somatostatin is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and albumin are not administered and heparin would exacerbate, not alleviate, bleeding.
A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patient's increased risk of bleeding. The nurse recognizes that this risk is related to the patient's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A. Alterations in glucose metabolism B. Retention of bile salts C. Inadequate production of albumin by hepatocytes D. Inability of the liver to use vitamin K.
D. Inability of the liver to use vitamin K. Rationale: Decreased production of several clotting factors may be partially due to deficient absorption of vitamin K from the GI tract. This probably is caused by the inability of liver cells to use vitamin K to make prothrombin. This bleeding risk is unrelated to the roles of glucose, bile salts, or albumin.
The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to promote which of the following? a) Increased metabolic rate b) Increased skeletal muscle breakdown c) Decreased catabolism d) Increased glucose demands
Decreased catabolism Correct Explanation: Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to the injury. The body's response has been classified as hyperdynamic, hypermetabolic, and hypercatabolic. The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism.
how to stop external bleeding?
Direct firm pressure, tourniquets are the last resort: causes tissue damage below that area. because you decrease bloodflow to other systems
sexual assault
Don't make the patient wait in the lobby or room Crisis intervention starts immediately Sexual assault nurse examiner (SANE) Goal of treatment is to provide support, not judge, reduce emotional trauma, gather evidence Give the patient control of decision-making regarding treatment Give something to help calm anxiety Don't bath or clean assaulted areas till evidence collected Hospital policy
violence, abuse and neglect
ED is often the first place people go to seek help Types of violence Intimate Partner Violence (IPV) Family Violence Elder abuse/neglect Disabled at higher risk Emotional, physical, verbal, neglect, violation of personal rights and/or financial Chart 72-8 p. 2146 Story inconsistent with injuries, injuries in various stages of healing Partner answering questions for the patient Most common signs of neglect = malnutrition and dehydration
Thermal
Flame, Scald (from steam, hot or molten liquid), Contact (from a hot object, such as a hot cooking pan)
Acute or intermediate phase=
From beginning of diuresis to wound closure
Rehabilitation phase=
From wound closure to return to optimal physical and psychosocial adjustment
A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following? a) Superficial partial-thickness b) Superficial c) Full-thickness d) Deep partial-thickness
Full-thickness Correct Explanation: A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish froma full-thickness burn. It is red or white, mottled, and can be moist or fairly dry
management for snake bites
Get the when/how/what/timeline Poison control information and antivenin Measure and photograph ABC's Remove constrictive clothing Immobilize below chest level VS, Labs (CBC, UA, PT/aPTT) Mark the area No ice, suction, or tourniquet (causes more damage) Tetanus/pain medication No specific protocol, treat symptoms Observe closely for changes
Wound Debridement
Goal: -Removal of devitalized tissue or eschar -Removal of contaminated tissue -Natural debridement -Mechanical debridement -Chemical debridement -Surgical debridement
Assessment for food poisioning?
How long after eating did symptoms occur? Wat was eaten I the previous meal? Did you notice a taste or odor Did you vomit, what did it look like? Did diarrhea occur? (Absent with botulism) Are neurologic symptoms present? (Occurs with botulism) Does the patient have a fever? (Occurs with salmonella)
Systemic Effects
Immediate systemic event= hemodynamic instability r/t loss of capillary integrity resulting in fluid shift, sodium, and protein from intravascular space to interstitial space= hypovolemic shock
management for carbon monoxide poison?
Immediate treatment (reverse hypoxia and remove CO2) Rapid progression to coma or death Fresh air and remove tight clothes ABC's/ CPR- 100% oxygen Monitor continuously- carboxyhemoglobin < 5%
e of the Nursing Process in the Care of the Patient in the Emergent Phase of Burn Care—Diagnoses
Impaired gas exchange Ineffective airway clearance Fluid volume deficit Hypothermia Acute pain Anxiety
types of wounds
Laceration- skin tear with irregular edges and vein bridging Avulsion- tearing away of tissue from supporting structures Abrasion- denuded skin Ecchymosis/contusion- blood rapped under the surface of the skin Hematoma- tumor like mass of blood trapped under the skin Stab- incision of skin with well defined edges, usually cause by sharp instrument, typically deeper than it is long Cut- incision of the skin with well defined edges, usually longer than deep Patterned- wound representing the outline of the object causing the wound.
Which of the following is the preferred IV fluid for burn resuscitation? a) Lactated Ringer's (LR) b) D5W c) Total parenteral nutrition (TPN) d) Normal saline (NS)
Lactated Ringer's (LR) Correct Explanation: LR is the preferred IV fluid for burn resuscitation because the sodium concentration and potassium are similar to normal intravascular levels. NS, D5W, and TPN are not the IV of choice for burn resuscitation.
trauma is the what?
Leading cause of death in children/adults younger than 44 years
management for intra-abdominal injures?
Mechanism of injury/Document damage NPO/ NG tube to decompress stomach and prevent aspiration Tetanus and broad spectrum ABX [abx give to prevent infection from any spillage of bowel contents] If abdomen open, place sterile, saline soaked dressings assess continually for internal hemorrhage
Rule of Nines
Most commonly used for adults Divides anatomic regions
The nurse is caring for a patient in the burn unit. Which of the following may be an early sign of sepsis in the patient with burn injury? a) Clammy skin b) Decreased pulse rate c) Hyperthermia d) Narrowing pulse pressure
Narrowing pulse pressure Explanation: Patients with burns are hypermetabolic. This results in tachycardia, tachypnea, and elevated body temperature. These physiological norms in patients 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 patient's status. Early signs of sepsis may include increased temperature, increased pulse rate, widened pulse pressure, and flushed dry skin in unburned areas.
Emergent or resuscitative phase=
Onset of injury to completion of fluid resuscitation
psychiatric emergencies
Overactive, underactive, depressed or suicidal patients or those with violent behavior Management SAFETY!!! Injury themselves? Non-judgmental History of psychiatric disorder Crisis intervention Specific treatment based on type of psychiatric emergency
Common signs of significant smoke inhalation injury and the potential need for intubation include
Persistent cough, stridor, or wheezing -Hoarseness -Deep facial or circumferential neck burns -Nares with inflammation or singed hair -Carbonaceous sputum or burnt matter in the mouth or nose -Blistering or edema of the oropharynx -Depressed mental status, including evidence of drug or alcohol use -Respiratory distress -Hypoxia or hypercapnia -Elevated carbon monoxide and/or cyanide levels -Renal Alterations -GI alterations -Immunologic alterations -Effect on thermoregulation
Assisting with Paracentesis
Preprocedure: 1. Check for consent form 2. Provide education 3. Instruct pt to void (prevent bladder puncture) 4. Gather appropriate sterile equipment and collection receptacles. 5. Upright position or Fowler's if bed confined (movement of peritoneal fluid makes easier puncture and fluid removal) 6. BP cuff Procedure: 1. Asceptic technique, trocar/needle below umbilicus. 2. Maintain upright position 3. Measure BP throughout procedure 4. Monitor for pallor, increased pulse rate, decreased BP Post Procedure: 1. Return pt to bed/sitting position 2. Measure/describe fluid collected 3. Label samples and send to lab 4. Monitor VS q 15 mins for 1 hr, q 30 mins after 2 hours, q hour for 2 hrs, the q 4 5. Take temp 6. Assess for hypovolemia, electrolyte shifts, changes in mental status, and encephalopathy 7. Check puncture site for drainage/bleeding 8. Provide pt teaching-avoid heavy lifting
management for frostbite?
Rewarming, CONTROLLED, 37-40 degrees C for 30-40 minutes intervals Remove constrictive/wet clothing and jewelry Lower extremity injury- DON'T WALK (more tissue damage) Pain meds, NEVER massage Once rewarmed, elevate and protect Hemorrhagic blebs-leave intact Nonhemorrhagic blisters- debride (inflammatory mediators) Whirlpool, escharotomy, and fasciotomy Discharge instructions- NO caffeine, tobacco (restricts blood flow) or ETOH (desensitizes)
Thyroid Storm
SEVERE-LIFE THREATENING HYPERTHYROIDISM!!! Precipitated by stress; Sx: HIGH fever, Extreme TachyCardia, Altered Mental State
endocrine
Secreting internally; hormonal secretion of a ductless gland.
A patient has been prescribed mafenide acetate (Sulfamylon) cream for burn treatment. The nurse should educate the patient regarding which of the following? a) Stains clothing b) Severe burning pain for up to 20 minutes c) Blood levels of sodium and potassium will be monitored. d) Can be left in place for 3 to 5 days
Severe burning pain for up to 20 minutes Explanation: The patient should be premedicated with analgesic before applying mafenide acetate because this agent causes severe burning pain for up to 20 minutes after application. Silver nitrate stains everything it touches black. Acticoat dressings can be left in place for 3 to 5 days. Silver nitrate solution acts as a wick for sodium and potassium; serum levels of these electrolytes need to be monitored
what is emergency nursing?
Specialized education/training: CEN certification, know police, EMT's and press well. Experience Ability to assess and identify patients' health problems in a crisis situation Monitor, prioritize, delegate, monitor, continuously assess for changes in patient status and department flow
Thyroidectomy
Surgical Removal of all or part of the Thyroid Gland.
All of the following are antimicrobials commonly used to treat burns except: a) Tetracycline b) Silver sulfadiazine (Silvadene) c) Mafenide (Sulfamylon) d) Silver nitrate (AgNO3) 0.5% solution
Tetracycline Correct Explanation: Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns.
Sclerotherapy
The injection of substances into or around esophagogastric varices to cause constriction, thickening and hardening of the vessel and stop bleeding.
Thyroxine (T4)
Thyroid Hormone Active Iodine compound formed & stored in the thyroid. Deiodiniated in peripheral tissues to form Triiodothyronine;; maintains body metabolism in a steady state.
Triiodotyronine (T3)
Thyroid Hormone; Formed & stored in the thyroid. Released in smaller quantities, biologically more active, and with faster onset of action than T4' Widespread effect on cellular metabolism
TSH
Thyroid-Stimulating Hormone Released from the Pituitary Gland; Causes stimulation of the Thyroid: Resulting in release of T3/T4
The nurse is caring for a patient with superficial partial-thickness burn injuries to the lower extremities. The patient is ordered IV morphine for pain. The nurse understands narcotics are given IV to manage pain during the initial management of pain because of which of the following? a) Tissue edema may interfere with drug absorption via other routes. b) The patient can experience nausea and emesis when given oral medications. c) Bleeding may occur at injection sites when the intramuscular route is used. d) Pain resulting from a burn injury requires relief by the fastest route available.
Tissue edema may interfere with drug absorption via other routes. Explanation: IV administration is necessary because of altered tissue perfusion from the burn injury.
Viral Hepatitis
Types: A, B, C, D, E
Serum Alkaline Phosphatase
Varies with method: Adults 30- 120 U/L Serum alkaline phosphatase is manufactured in bones, liver, kidneys, and intestine and excreted through biliary tract. In the abscence of bone disease, it is a sensitive measure of the biliary tract obstruction. Results may vary because the test is temp and lab method dependent.
Wound Care/Dressing
Wound cleaning -Hydrotherapy - the use of warm water, both during immersion in a tub, and in showers with running water, provided these procedures contribute to the healing process of burn injury. -Encourage pt. participation -Use of topical agents -Appropriate dressings as ordered -Documentation
The nurse is caring for a patient with extensive burn injuries. Which of the following parameters would the nurse evaluate to determine if the patient is receiving adequate fluid resuscitation? Select all that apply. a) Heart rate b) Urine output c) Oxygen saturation d) Blood pressure
• Blood pressure • Heart rate • Urine output Explanation: Fluid resuscitation is administered to maintain adequate cardiac output and tissue perfusion. If adequate fluid is administered, tachycardia, hypotension, and oliguria will resolve. Expected outcomes of fluid resuscitation specifically include the following: urine output between 0.5 and 1.0 mL/kg/hr (30-50 mL/hr; 75 to 100 mL/hr if electrical burn injury), mean arterial pressure (MAP) pressure > 60 mm Hg, voids clear yellow urine with specific gravity within normal limits, and serum electrolytes are within normal limits
dwarfism
generalized limited growth resulting from insufficient secretion of growth hormone during childhood.
acromegaly
progressive enlargement of peripheral body parts resulting from X-Cessive secretion of growth hormone.
A 42-year-old client suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. Which of the following conditions create the need for intensive care by specifically trained personnel? a) Fluid shift b) Fluid loss c) All options are correct. d) Hypotension
• All options are correct. • Fluid shift • Fluid loss • Hypotension Explanation: Fluid shift, fluid loss, and hypotension can lead to irreversible shock. These changes usually happen rapidly and the client's status may change from hour to hour, requiring that clients with burns receive intensive care by skilled personnel.
A patient is being cared for in a burn unit after suffering partial-thickness burns. The patient's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine (Silvadene) to be applied to the patient's burns. The nurse provides information to the patient about the medication. Which of the following statements made by the patient indicates an understanding about this treatment? Select all that apply. a) "This medication is an antibacterial." b) "This medication will stain my skin permanently." c) "This medication will help my burn heal." d) "This medication will be applied directly to the wound."
"This medication is an antibacterial." • "This medication will help my burn heal." • "This medication will be applied directly to the wound." Correct Explanation: This medication is an antibacterial, which has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to the wound. This medication will not stain the patient's skin, but it will help heal the patient's burned areas.
Severity of Burns
-Age of pt. -Depth -TBSA -Inhalation? -Other injuries? -Location of burn -PMH
Homecare
-Mental health -Skin and wound care -Exercise and activity -Nutrition -Pain management -Thermoregulation and clothing -Sexual issues
Hepatitis A (Infectious)
-Transmission: Fecal-oral (poor sanitation, contact, waterborne, foodborne) -Incubation: 4 weeks -Lasts: 4-8 weeks, worse >40 yo -Not chronic -Causes immunity to itself, not other hepatitis infections -Initial S/S: mild, flu-like, URI -Later S/S: dark urine, jaundice, indigestion Tx: rest, nutrition
13. A patient presents at the walk-in clinic complaining of diarrhea and vomiting. The patient has a documented history of adrenal insufficiency. Considering the patients history and current symptoms, the nurse should anticipate that the patient will be instructed to do which of the following? A) Increase his intake of sodium until the GI symptoms improve. B) Increase his intake of potassium until the GI symptoms improve. C) Increase his intake of glucose until the GI symptoms improve. D) Increase his intake of calcium until the GI symptoms improve.
A Feedback: The patient will need to supplement dietary intake with added salt during episodes of GI losses of fluid through vomiting and diarrhea to prevent the onset of addisonian crisis. While the patient may experience the loss of other electrolytes, the major concern is the replacement of lost sodium.
A patient's physician has ordered a liver panel in response to the patient's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply. A. Alanine aminotransferase (ALT) B. C-reactive protein (CRP) C. Gamma-glutamyl transferase (GGT) D. Aspartate aminotransferase (AST) E. B-type natriuretic peptide (BNP)
A. Alanine aminotransferase (ALT) B. C-reactive protein (CRP) D. Aspartate aminotransferase (AST) Rationale: Liver function testing includes GGT, ALT, and AST. CRP addresses the presence of generalized inflammation and BNP is relevant to heart failure; neither is included in a liver panel.
A 55-year-old female patient with hepatocellular carcinoma (HCC) is undergoing radiofrequency ablation. The nurse should recognize what goal of this treatment? A. Destruction of the patient's liver tumor B. Restoration of portal vein patency C. Destruction of a liver abscess D. Reversal of metastasis
A. Destruction of the patient's liver tumor Rationale: Using radiofrequency ablation, a tumor up to 5 cm in size can be destroyed in one treatment session. This technique does not address circulatory function or abscess formation. It does not allow for the reversal of metastasis.
A group of nurses have attended an inservice on the prevention of occupationally acquired diseases that affect healthcare providers. What action has the greatest potential to reduce a nurse's risk of acquiring hepatitis C in the workplace? A. Disposing of sharps appropriately and not recapping needles B. Performing meticulous hand hygiene at the appropriate moments in care C. Adhering to the recommended schedule of immunizations D. Wearing an N95 mask when providing care for patients on airborne precautions
A. Disposing of sharps appropriately and not recapping needles Rationale: HCV is blood-borne. Consequently, prevention of needle stick injuries are paramount. Hand hygiene, immunizations and appropriate use of masks are important aspects of overall infection control, but these actions do not directly mitigate the risk of HCV.
A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurse's most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurse's best response to this assessment finding? A. Document the presence of normal bile output. B. Irrigate the drainage system with normal saline as ordered. C. Aspirate a sample of the drainage for culture. D. Promptly report this assessment finding to the primary care provider.
A. Document the presence of normal bile output. Rationale: Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment finding, with no other action necessary.
During a health education session, a participant has asked about the hepatitis E virus. What prevention measure should the nurse recommend for preventing infection with this virus? A. Following proper hand-washing techniques B. Avoiding chemicals that are toxic to the liver C. Wearing a condom during sexual contact D. Limiting alcohol intake
A. Following proper hand-washing techniques Rationale: Avoiding contact with the hepatitis E virus through good hygiene, including hand-washing, is the major method of prevention. Hepatitis E is transmitted by the fecaloral route, principally through contaminated water in areas with poor sanitation. Consequently, none of the other listed preventative measure is indicated.
A patient with a liver mass is undergoing a percutaneous liver biopsy. What action should the nurse perform when assisting with this procedure? A. Position the patient on the right side with a pillow under the costal margin after the procedure B. Administer 1 unit of albumin 90 minutes before the procedure as ordered C. Administer at least 1 unit of packed red blood cells as ordered the day before the scheduled procedure D. Confirm that the patient's electrolyte levels have been assessed prior to the procedure
A. Position the patient on the right side with a pillow under the costal margin after the procedure. Rationale: Immediately after a percutaneous liver biopsy, assist the patient to turn onto the right side and place a pillow under the costal margin. Prior administration of albumin or PRBC's is unnecessary. Coagulation tests should be performed, but electrolyte analysis is not necessary.
management for food poisoning
ABC's - BP/ RR/ LOC monitored Collect any expelled contents to assess Baseline weight, Monitor F/E status d/t vomit/diarrhea Control N/V to prevent alkalosis or acidosis Assess for hypovolemic shock NPO-Clear liquids, progress slowly
management for heat stroke
Cooling blankets- core temperature < 102 F w/in 1 hour ABC's monitor- VS- EKG- CVP- Ventilation Fluids- NS/ LR, monitor i& o's Labs- Liver, CBC, myoglobin, Trop Medications- Anti-seizure, K+, Bicarb, Benzos
animal & human bites
All bites reported to PHA Rabies vaccine if no documentation * series of immunoglobulins plus vaccine. Human bite higher chance of infection Usually not closed up * want to drain infectionus material Tetanus and ABX given, bites close to joints can cause serious infection Photographs/measuring tape for evidence
s/e of amphetamine (crystal meth, ecstasy, ritalin)
N/V, tachycardia, increased BP/RR, irritable, agitation, fear, decreased inhibition Airway support and cardiac status Keep calm, quiet and cool Small doses of Valium and Haldol
Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Select the graft described as the following: a biologic source of skin similar to that of the client. a) Autograft b) Allograft c) Xenograft d) Slit graft
Allograft Explanation: Allograft or homograft is a biologic source of skin similar to that of the client. A xenograft or heterograft is obtained from animals, principally pigs or cows. An autograft uses the client's own skin, transplanted from one part of the body to another. A slit graft is a type of autograft.
Topical Antibacterial Therapy
Alteration of therapy is necessary : refer to Table 62-4 General -Antimicrobial ointment Specific -Silver Sulfadiazine -Mafenide Acetate (severe side effects if impaired renal function)) -Silver nitrate -Silver impregnated dressings
22. The physician has ordered a fluid deprivation test for a patient suspected of having diabetes insipidus. During the test, the nurse should prioritize what assessments? A) Temperature and oxygen saturation B) Heart rate and BP C) Breath sounds and bowel sounds D) Color, warmth, movement, and sensation of extremities
B Feedback: The fluid deprivation test is carried out by withholding fluids for 8 to 12 hours or until 3% to 5% of the body weight is lost. The patients condition needs to be monitored frequently during the test, and the test is terminated if tachycardia, excessive weight loss, or hypotension develops. Consequently, BP and heart rate monitoring are priorities over the other listed assessments.
36. What should the nurse teach a patient on corticosteroid therapy in order to reduce the patients risk of adrenal insufficiency? A) Take the medication late in the day to mimic the bodys natural rhythms. B) Always have enough medication on hand to avoid running out. C) Skip up to 2 doses in cases of illness involving nausea. D) Take up to 1 extra dose per day during times of stress.
B Feedback: The patient and family should be informed that acute adrenal insufficiency and underlying symptoms will recur if corticosteroid therapy is stopped abruptly without medical supervision. The patient should be instructed to have an adequate supply of the corticosteroid medication always available to avoid running out. Doses should not be skipped or added without explicit instructions to do so. Corticosteroids should normally be taken in the morning to mimic natural rhythms.
18. A patient with a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH) is being cared for on the critical care unit. The priority nursing diagnosis for a patient with this condition is what? A) Risk for peripheral neurovascular dysfunction B) Excess fluid volume C) Hypothermia D) Ineffective airway clearance
B Feedback: The priority nursing diagnosis for a patient with SIADH is excess fluid volume, as the patient retains fluids and develops a sodium deficiency. Restricting fluid intake is a typical intervention for managing this syndrome. Temperature imbalances are not associated with SIADH. The patient is not at risk for neurovascular dysfunction or a compromised airway.
A patient has been admitted to the critical care unit with a diagnosis of toxic hepatitis. When planning the patient's care, the nurse should be aware of what potential clinical course of this health problem? Place the following events in the correct sequence. 1. Fever rises 2. Hematemesis 3. Clotting abnormalities 4. Vascular collapse 5. Coma A. 1,2,5,4,3 B. 1,2,3,4,5 C. 2,3,1,4,5 D. 3,1,2,5,4
B. 1,2,3,4,5 Rationale: Recovery from acute toxic hepatitis is rapid if the hepatotoxin is identified early and removed or if exposure to the agent has been limited. Recovery is unlikely if there is a prolonged period between exposure and onset of symptoms. There are no effective antidotes. The fever rises; the patient becomes toxic and prostrated. Vomiting may be persistent, with the emesis containing blood. Clotting abnormalities may be severe, and hemorrhages may appear under the skin. The severe GI symptoms may lead to vascular collapse. Delirium, coma, and seizures develop, and within a few days the patient may die of fulminant hepatic failure unless he or she receives a liver transplant.
A nurse is caring for a patient with a blocked bile duct from a tumor. What manifestation of obstructive jaundice should the nurse anticipate? A. Watery, blood-streaked diarrhea B. Orange and foamy urine C. Increased abdominal girth D. Decreased cognition
B. Orange and foamy urine Rationale: If the bile duct is obstructed, the bile will be reabsorbed into the blood and carried throughout the entire body. It is excreted in the urine, which becomes deep orange and foamy. Bloody diarrhea, ascites, and cognitive changes are not associated with obstructive jaundice.
A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the patient's cognition and behavior. What is the nurse's most appropriate response? A. Ensure that the patient's sodium intake does not exceed recommended levels B. Report this finding to the primary care provider due to the possibility of hepatic encephalopathy C. Inform the primary care provider that the patient should be assessed for alcoholic hepatitis. D. Implement interventions aimed at ensuring a calm and therapeutic care environment.
B. Report this finding to the primary care provider due to the possibility of hepatic encephalopathy Rationale: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patient's mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. This change in status is likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive care environment is beneficial, but does not address the patient's physiologic deterioration.
29. A 30 year-old female patient has been diagnosed with Cushing syndrome. What psychosocial nursing diagnosis should the nurse most likely prioritize when planning the patients care? A) Decisional conflict related to treatment options B) Spiritual distress related to changes in cognitive function C) Disturbed body image related to changes in physical appearance D) Powerlessness related to disease progression
C Feedback: Cushing syndrome causes characteristic physical changes that are likely to result in disturbed body image. Decisional conflict and powerless may exist, but disturbed body image is more likely to be present. Cognitive changes take place in patients with Cushing syndrome, but these may or may not cause spiritual distress.
9. The nurse caring for a patient with Cushing syndrome is describing the dexamethasone suppression test scheduled for tomorrow. What does the nurse explain that this test will involve? A) Administration of dexamethasone orally, followed by a plasma cortisol level every hour for 3 hours B) Administration of dexamethasone IV, followed by an x-ray of the adrenal glands C) Administration of dexamethasone orally at 11 PM, and a plasma cortisol level at 8 AM the next morning D) Administration of dexamethasone intravenously, followed by a plasma cortisol level 3 hours after the drug is administered
C Feedback: Dexamethasone (1 mg) is administered orally at 11 PM, and a plasma cortisol level is obtained at 8 AM the next morning. This test can be performed on an outpatient basis and is the most widely used and sensitive screening test for diagnosis of pituitary and adrenal causes of Cushing syndrome.
4. The nurse is caring for a patient with a diagnosis of Addisons disease. What sign or symptom is most closely associated with this health problem? A) Truncal obesity B) Hypertension C) Muscle weakness D) Moon face
C Feedback: Patients with Addisons disease demonstrate muscular weakness, anorexia, gastrointestinal symptoms, fatigue, emaciation, dark pigmentation of the skin, and hypotension. Patients with Cushing syndrome demonstrate truncal obesity, moon face, acne, abdominal striae, and hypertension.
7. A patient is prescribed corticosteroid therapy. What would be priority information for the nurse to give the patient who is prescribed long-term corticosteroid therapy? A) The patients diet should be low protein with ample fat. B) The patient may experience short-term changes in cognition. C) The patient is at an increased risk for developing infection. D) The patient is at a decreased risk for development of thrombophlebitis and thromboembolism.
C Feedback: The patient is at increased risk of infection and masking of signs of infection. The cardiovascular effects of corticosteroid therapy may result in development of thrombophlebitis or thromboembolism. Diet should be high in protein with limited fat. Changes in appearance usually disappear when therapy is no longer necessary. Cognitive changes are not common adverse effects.
2. A patient has been admitted to the post-surgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the patient? A) Side-lying (lateral) with one pillow under the head B) Head of the bed elevated 30 degrees and no pillows placed under the head C) Semi-Fowlers with the head supported on two pillows D) Supine, with a small roll supporting the neck
C Feedback: When moving and turning the patient, the nurse carefully supports the patients head and avoids tension on the sutures. The most comfortable position is the semi-Fowlers position, with the head elevated and supported by pillows.
A nurse is caring for a patient with severe hemolytic jaundice. Laboratory tests show free bilirubin to be 24 mg/dL. For what complication is this patient at risk? A. Chronic jaundice B. Pigment stones in portal circulation C. Central nervous system damage D. Hepatomegaly
C. Central nervous system damage Rationale: Prolonged jaundice, even if mild, predisposes to the formation of pigment stones in the gallbladder, and extremely severe jaundice (levels of free bilirubin exceeding 20 to 25 mg/dL) poses a risk for CNS damage. There are not specific risks of hepatomegaly or chronic jaundice resulting from high bilirubin
A patient with portal hypertension has been admitted to the medical floor. The nurse should prioritize which of the following assessments related to the manifestations of this health problem? A. Assessment of blood pressure and assessment for headaches and visual changes. B. Assessments for signs and symptoms of venous thromboembolism. C. Daily weights and abdominal girth measurement. D. Blood glucose monitoring q4h.
C. Daily weights and abdominal girth measurement Rationale: Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose of VTE.
Hep B
Cause: -Parenterally -Sexual and Oral -Perinatal S/S: -Asymptomatic - arthralgias, rash Outcome: -may be fatal -Increased risk cirrhosis, other hep, hep CA
Diagnostic testing has revealed that a patient's hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patient's plan of care will focus on what intervention? A. Cryosurgery B. Liver transplantation C. Lobectomy D. Laser hyperthermia
C. Lobectomy Rationale: Surgical resection is the treatment of choice when HCC is confined to one lobe of the liver and the function of the remaining liver is considered adequate for postoperative recovery. Removal of a lobe of the liver (lobectomy) is the most common surgical procedure for excising a liver tumor. While cryosurgery and liver transplantation are other surgical options for management of liver cancer, these procedures are not performed at the same frequency as a lobectomy. Laser hyperthermia is a nonsurgical treatment for liver cancer.
Hep D
Cause: -Same as HBV S/S: -Same a HBV Outcome: Same as HBV, but greater carrier state
A nurse is caring for a patient with hepatic encephalopathy. The nurse's assessment reveals that the patient exhibits episodes of confusion, is difficult to arouse from sleep and has rigid extremities. Based on these clinical findings, the nurse should document what stage of hepatic encephalopathy? A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4
C. Stage 3 Rationale: Patients in the third stage of hepatic encephalopathy exhibit the following symptoms: stuporous, difficult to arouse, sleeps most of the time, exhibits marked confusion, incoherent in speech, asterixis, increased deep tendon reflexes, rigidity of extremities, marked EEG abnormalities. Patients in stages 1 and 2 exhibit clinical symptoms that are not as advanced as found in stage 3, and patients in stage 4 are comatose. In stage 4, there is an absence of asterixis, absence of deep tendon reflexes, flaccidity of extremities, and EEG abnormalities.
Trousseau's Sign
Carpopedal Spasm induced when blood flow to the arm is occluded using a BP cuff or Tourniquet, causing ischemia to the distal nerves. Suggestive sign for latent tetany in HYPOCALCEMIA.
Hep C
Cause -Blood/Blood productus -Sexual transmission S/S: -Similiar to HBV Outcome: -Chronic liver disease, Hep CA
Hep E
Cause: -Fecal Oral S/S: -Similiar to Hep A, very severe in pregnancy tho Outcome: -Same as Hep A
Hep A
Cause: -Fecal Oral route -Waterborne/Foodborne - Oral/Anal Sexual contact S/S; -Asymptomatic -Flu like symptoms Outcome: Not fatal
management of chemical burns?
Challenging =large number of possible offending agents with diverse actions and metabolic effects Determine severity:Mechanism of action, Penetrating strength and concentration, Amount and duration of skin exposure Management- drench with tepid water immediately after exposure EXCEPT for lye or white phosphorus (wipe those off) Determine chemical agent for treatment Standard treatment- antimicrobial, tetanus, debridement Plastic surgery is possible recheck 24-72 hrs then 1 week later
management for hypothermia?
Core body temperature monitoring Vitals, CVP, urine output, ABG, Chemistry levels, continuous ECG monitoring Remove wet clothing and rewarm Internal (moderate-severe)- Warm fluids and O2, bypass, peritoneal lavage External-Heaters, warm air blankets Frequently monitor to prevent burns Ventricular fibrillation may occur during re-warming Bicarb, anti-arrthymics
A patient has undergone a diagnostic peritoneal lavage. The nurse interprets which result as indicating a positive test? Red blood cell count of 50,000/mm3 Evidence of feces Absence of bile White blood cell count of 300/mm3
Correct answer: Evidence of feces
A client arrives at the emergency department and is experiencing a severe allergic reacton to a bee sting. The client received treatment and is being discharged. Which client statement indicates that additional teaching about exposure prevention is needed? "I need to avoid using perfumes and scented soaps when I'm going outside." "I should always wear something on my feet when I'm outside." "Brightly colored clothes help to ward off bees." "If a bee comes near me, I should stay still."
Correct response: "Brightly colored clothes help to ward off bees." Explanation: To prevent insect stings, the client should avoid wearing brightly colored clothing because it attracts bees. The client should wear covering on the feet and avoid going barefoot because yellow jackets nest and pollinate on the ground. Staying still or motionless reduces the likelihood of being stung. Perfumes and scented soaps attract bees and should be avoided.
A patient with frostbite to both lower extremities from exposure to the elements is preparing to have rewarming of the extremities. What intervention should the nurse provide prior to the procedure? Apply a heat lamp. Administer an analgesic as ordered. Massage the extremities. Elevate the legs.
Correct response: Administer an analgesic as ordered. Explanation: During rewarming, an analgesic for pain is administered as prescribed, because the rewarming process may be very painful. To avoid further mechanical injury, the body part is not handled. Massage is contraindicated.
A patient has experienced blunt abdominal trauma from a motor vehicle crash. The nurse assesses the patient, knowing that which organ is the most frequently injured solid abdominal organ? Duodenum Pancreas Large bowel Liver
Correct response: Liver Explanation: The most frequently injured solid organ in a penetrating trauma is the liver.
When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind? Most multiple trauma victims exhibit evidence of the trauma. The most lethal injuries are often the most readily apparent. The client is assumed to have a spinal cord injury until proven otherwise. Injuries have occurred to at least three distinct organ systems.
Correct response: The client is assumed to have a spinal cord injury until proven otherwise. Explanation: With clients experiencing multiple trauma, the nurse must assume that the client has a spinal cord injury until proven otherwise. Multiple trauma cleints experience life-threatening injuries to at least two distinct organs or organ systems. Evidence of the trauma may be sparse or absent. Additionally, the injury that may seem the least significant may be the most lethal.
A patient presents to the ED with serious health problems that are not immediately life threatening. The nurse will correctly triage the patient into which of the following categories? Psychological support Emergent Urgent Nonurgent
Correct response: Urgent Explanation: Patients triaged have serious health problems that are not immediately life threatening. They must be seen within 1 hour. The emergent category is for patients who have the highest priority conditions that are life-threatening and they must be seen immediately. Nonurgent is for patients who have episodic illness that can be addressed within 24 hours without increased morbidity. Patients in the less urgent category must be reassessed at least every 60 minutes and do not have serious health problems.
14. The nurse is caring for a patient with hyperparathyroidism. What level of activity would the nurse expect to promote? A) Complete bed rest B) Bed rest with bathroom privileges C) Out of bed (OOB) to the chair twice a day D) Ambulation and activity as tolerated
D Feedback: Mobility, with walking or use of a rocking chair for those with limited mobility, is encouraged as much as possible because bones subjected to normal stress give up less calcium. Best rest should be discouraged because it increases calcium excretion and the risk of renal calculi. Limiting the patient to getting out of bed only a few times a day also increases calcium excretion and the associated risks.
40. The nurse is providing care for an older adult patient whose current medication regimen includes levothyroxine (Synthroid). As a result, the nurse should be aware of the heightened risk of adverse effects when administering an IV dose of what medication? A) A fluoroquinalone antibiotic B) A loop diuretic C) A proton pump inhibitor (PPI) D) A benzodiazepine
D Feedback: Oral thyroid hormones interact with many other medications.Even in small IV doses, hypnotic and sedative agents may induce profound somnolence, lasting far longer than anticipated and leading to narcosis (stupor like condition). Furthermore, they are likely to cause respiratory depression, which can easily be fatal because of decreased respiratory reserve and alveolar hypoventilation. Antibiotics, PPIs and diuretics do not cause the same risk.
34. A patient on corticosteroid therapy needs to be taught that a course of corticosteroids of 2 weeks duration can suppress the adrenal cortex for how long? A) Up to 4 weeks B) Up to 3 months C) Up to 9 months D) Up to 1 year
D Feedback: Suppression of the adrenal cortex may persist up to 1 year after a course of corticosteroids of only 2 weeks duration.
A patient with liver cancer is being discharged home with a hepatic artery catheter in place. The nurse should be aware that this catheter will facilitate which of the following? A. Continuous monitoring for portal hypertension B. Administration of immunosuppressive drugs during the first weeks after transplantation C. Real-time monitoring of vascular changes in the hepatic system D. Delivery of a continuous chemotherapeutic dose
D. Delivery of a continuous chemotherapeutic dose Rationale: In most cases, the hepatic artery catheter has been inserted surgically and has a prefilled infusion pump that delivers a continuous chemotherapeutic dose until completed. The hepatic artery catheter dose not monitor portal hypertension, deliver immunosuppressive drugs, or monitor vascular changes in the hepatic system
A patient with esophageal varices is being cared for in the ICU. The varices have begun to bleed and the patient is at risk for hypovolemia. The patient has Ringer's Lactate at 150 cc/hr infusing. What else might the nurse expect to have ordered to maintain volume for this patient? A. Arterial line B. Diuretics C. Foley catheter D. Volume expanders
D. Volume expanders Rationale: Because patients with bleeding esophageal varices have intravascular volume depletion and are subject to electrolyte imbalance, IV fluids with electrolytes and volume expanders are provided to restore fluid volume and replace electrolytes. Diuretics would reduce vascular volume. An arterial line and Foley catheter are likely to be ordered, but neither actively maintains the patient's volume.
Which type of burn injury involves destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis? a) Fourth degree b) Full-thickness c) Deep partial-thickness d) Superficial partial-thickness
Deep partial-thickness Correct Explanation: A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis. In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, destruction of underlying tissue, muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs with prolonged flame contact or high voltage injury that destroys all layers of the skin and damages tendons and muscles.
Molly Baker has a third-degree burn on her leg from a house fire. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to her leg. What procedure would be done to relieve pressure on the affected area? a) Allograft b) Escharotomy c) Silvadene application d) Debridement
Escharotomy Correct Explanation: Debridement is the removal of necrotic tissue. An escharotomy is an incision into the eschar to relieve pressure on the affected area. An allograft would not be the treatment. Silvadene may be part of the treatment regimen but not specifically for this situation.
Nursing Assessment for Genetic Hepatic Disorders
Family History: - Collect family hx for 3 generations. Maternal and paternal. -Assess for family members with early onset hepatic disease. Patient assessment: -Assess for indigestion, reflux, hemorrhoids, gallstones, intolerance to fatty foods, intolerance to alcohol, n/v, abdominal bloating, and constipation. -Assess for nervous system. Depression, mood changes esp. irritability and anger. -Assess for blood sugar problems like hypoglycemia. -Inquire if family has had genetic testing -Offer info, resources, and support to newly diagnosed -Refer to Merck Manual
Cushing Syndrome
Group of symptoms produced by an OVERSECRETION of adrenocorticotropic hormone; Signs: TRUNCAL OBESITY.. "MOON-FACE".. Acne, ABD Striae, HTN!
Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar? a) Chemical debridement b) Mechanical debridement c) Natural debridement d) Surgical debridement
Mechanical debridement Explanation: Mechanical debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar. Topical enzymatic debridement agents are available to promote debridement of the burn wounds. With natural debridement, the dead tissue separates from the underlying viable tissue spontaneously. Surgical debridement is an operative procedure involving either primary excision (surgical removal of tissue) of the full thickness of the skin down to the fascia (tangential excision) or shaving of the burned skin layers gradually down to freely bleeding, viable tiss
snake bites snakes native to TN? affects? s/s?
N/S Copperhead, Western Cottonmouth, Timer and Western Pigmy Rattlesnake. affects neuro, cv, and respiratory systems N/ V, edema/ecchymosis to necrosis at site, hypotension and seizures
what is the management for an airway obstruction?
PRIORITY: establish an airway [can't hold their own airway, ET intubation, confirmed w/ x-ray] never put them in someone conscious it stimulates the gag reflex always measure before you put in, from mouth to ear for orophranygeal tube: upside down or sideways to flip over tongue. always measure before you put in from nose tip to ear for nasal trumpets: lots of lubrication it hurts alot
A patient with a burn wound is prescribed mafenide acetate 5% (Sulfamylon) twice daily. Nursing implications associated with this medication include which of the following? a) Premedicating the patient with an analgesic prior to application b) Monitoring the patient's Na+ and K+ serum levels and replace as prescribed c) Monitoring the patient for the development of respiratory acidosis d) Protecting the bed linens and patient's clothing from contact to prevent staining
Premedicating the patient with an analgesic prior to application Correct Explanation: Mafenide is a strong carbonic anhydrase inhibitor and may cause metabolic acidosis. Application may cause considerable pain initially, thus premedicating the patient is an appropriate intervention. The other nursing implications are not associated with mafenide.
the levels of triage " to sort"
RESUSCITATION EMERGENT URGENT LESS URGENT NONURGENT
Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? a) Reduction in blood volume b) Sodium excess c) Increased urinary output d) Potassium deficit
Reduction in blood volume Correct Explanation: A reduction in blood volume occurs secondary to plasma loss. Sodium deficit, potassium excess, and decreased urinary output occurs in this phase.
hyophysectomy
Removal or destruction of all or part of the pituitary gland.
frostbite define as?
Trauma from freezing temperature and actual freezing of fluid in the intracellular and intercellular spaces
what is the lab/ scans work needed for intra-abdominal injuries?
UA, H/H, WBC, amylase/ lipase CT and US
Which of the following is to be expected soon after a major burn? Select all that apply. a) Bradycardia b) Anxiety c) Hypertension d) Hypotension e) Tachycardia
• Anxiety • Hypotension • Tachycardia Correct Explanation: Tachycardia, slight hypotension, and anxiety are expected soon after the burn.
The nurse is providing care for a patent with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the patient is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. The nurse's best response based on the clinical findings is which of the following? a) Apply an elastic stocking to the extremity and administer SQ heparin per order. b) Document the findings and instruct the patient to report numbness of the extremity. c) Contact the primary care provider and prepare for an escharotomy. d) Elevate the leg on pillows and reassess the leg in 1 hour.
You selected: Contact the primary care provider and prepare for an escharotomy. Correct Explanation: The nurse assesses peripheral pulses frequently with a Doppler ultrasound device, if needed. Frequent assessment also includes warmth, capillary refill, sensation, and movement of extremity. It is necessary for the nurse to report loss of pulse or sensation or presence of pain to the physician immediately and to prepare to assist with an escharotomy. The other interventions are inappropriate when the nurse has detected a loss of peripheral pulses.
The nurse understands that during the emergent/resuscitative phase of burn injury, hemoconcentration is due to which of the following? a) Liquid blood component is lost into extravascular space b) Fluid loss c) Decreased renal blood flow d) Sodium and water retention caused by increase adrenocortical activity
You selected: Liquid blood component is lost into extravascular space Correct Explanation: Hemoconcentration is due to the blood component being lost into the extravascular space. Decreased urinary output occurs secondary to fluid loss, decreased renal blood flow, and sodium and water retention caused by increased adrenocortical activity.
Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The following describes one of the injury zones: the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. What is the name of that zone? a) Zone of stasis b) Zone of coagulation c) Zone of hyperemia d) Zone of hypotension
Zone of stasis Explanation: The zone of stasis is the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. The zone of coagulation is at the center of the injury, and it is the area where the injury is most severe and usually deepest. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. This is not the name of one of the zones.
At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Choose all that apply. a) Open door and encourage air in an enclosed space. b) Place the client in a horizontal position. c) Place the client in a vertical position. d) Roll the client in a blanket to smother the fire.
• Place the client in a horizontal position. • Roll the client in a blanket to smother the fire. Explanation: If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire.
Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply. a) Facial burns b) Yellow sputum c) Hoarseness d) Singed nasal hair e) Bradypnea
• Singed nasal hair • Hoarseness • Facial burns Explanation: Indicators of possible pulmonary damage include singed nasal hair, hoarseness, voice change, stridor, burns of the face or neck, sooty or bloody sputum, and tachypnea.
Thyrotoxicosis
Condition produced by X-Cessive Endogenous -or- Exogenous thyroid storm
Jaundice
Condition where the body tissues, including the sclerae and the skin, become tinged yellow or greenish yellow due to high bilirubin levels.
s/s of heat stroke
Confusion Delirium Coma Seizures Hot, dry skin (anhidrosis) Tachypnea, hypotension, tachycardia Low sodium and potassium Body temp 105 F (40.6 C)
The nurse is caring for a patient in the ED following a sexual assault. The patient is hysterical and crying. The patient states, "I know I'm pregnant now, maybe I have HIV; why did this happen to me?" The nurse's best response is which of the following? "Do you want to discuss antipregnancy measures?" "Let's talk about this; do you want me to call a support person?" "Do you want the phone number for the National Sexual Assault Hotline?" "Would you like us to complete HIV testing?"
Correct response: "Let's talk about this; do you want me to call a support person?" Explanation: The patient should be reassured that anxiety is natural and asked whether a support person may be called. The goals of management are to provide support, reduce the patient's emotional trauma, and gather available evidence for possible legal proceedings. Throughout the patient's stay in the ED, the patient's privacy and sensitivity must be respected. The patient may exhibit a wide range of emotional reactions, such as hysteria, stoicism, or feelings of being overwhelmed. Support and caring are crucial.
Hep B Risk Factors
- Freq exposure to blood/body fluids -Hemodialysis -Male homosexual/bisexual - IV drug use -carrier of Hep B virus - Mother to child transmission -travel to unsanitary conditions - Multiple sexual partners - Recent hx of STI -Receipt of blood/blood products -Tattooing
Hep A Prevention
- Proper community and home sanitation - enc individual hygiene -support community health programs - enc manadatory reporting of virus - reccommend vaccines
Age-related changes in Hepatobiliary System
- Steady decrease in size and weight of the liver, particularly women. - Decrease in blood flow -Decrease in replacement/repair of liver cells after injury -Reduced drug metabolism -Slow clearance in hep B surface antigen -More rapid progression of hep C infection and lower response rate to therapy -Decline in drug clearance capability - Increased prevelance of gallstones due to the increase in cholesterol secretion in bile -Decreased gallbladder contraction after a meal - Atypical clinical presentation of biliary disease. -More severe complications of biliary tract disease
Radiation burns
- UV rays from the sun or tanning booths x-rays - certain types of radiation therapy for the treatment of cancer - radio frequency energy and thermal radiation -The effects of radiation burns depend on the energy of the radiation as well as the intensity of exposure
Management of Ascites
- make appropriate diet choices. -state importance of dialy weights - record daily weights - list and report weight changes to PCP - Monitor I&O - Fluid rx if needed - No NSAIDS, alcohol, abt, salt containing antacids -Stop all alcohol intake -Give AA contact info -Pt teaching of skin care - ID early signs: encephalopathy, spontaneous bacterial peritonitis, dehydration, electolyte abnormalites, azotemia.
Esophageal Varices
-30% compensated cirrhosis -60% decompensated cirrhosis -Due to elevated pressure in the veins that drain into the portal system -Often source of hemorrhages from upper GI tract -High mortality rate
Acute/Intermediate Phase
-48 to 72 hours after injury -Continue assessment and maintain respiratory and circulatory support -Prevention of infection, wound care, pain management, and nutritional support are priorities in this stage
Hep C Prevention
-Advise against high risk behaviors (IV drug use) -use barrier precautions when in contact with blood/body fluids - Monitor sanitation -Avoid Multidose vials -Standard Precautions
Managing Pain-
-Analgesics -IV use during emergent and acute phases -Morphine -Fentanyl Other -Role of anxiety in pain -Effect of sleep derivation on pain -Non-pharmacologic measures
Major burn-
-Any burn involving the respiratory tract or involving other major traumatic injury (i.e. broken bones, large lacerations, etc.) -2nd or 3rd degree burns involving the face, hands, feet, genitalia, or respiratory tract -Any 3rd degree burn covering more than 10% BSA -Any 2nd degree burn covering more than 30% BSA -Any 2nd or 3rd degree circumferential burn to any extremity -Any moderately classed burn in children less than 5 years or older than 55 years of age
Post-procedure Nursing Interventions for PerQ Liver Biopsy
-Assist pt turning to right side and have them remain in (recumbent, immobile) position for several hours (compressed liver capsule to prevent blood or bile leakage) -Remeasure vitals q10-15 min for 1 hour followed by q30 min for 1-2 hours -Watch for most common complications: bleeding @ site, severe hemorrhage, bile peritonitis -Instruct to avoid heavy lifting/strenuous activity for 1 week after to reduce risk of bleeding at site
Hypermetabolism/Nutritional Support
-Burn injuries produce profound metabolic abnormalities, and patient with burns have great nutritional needs related to stress response, hypermetabolism, wound healing. hypermetabolism - ↑ risk of infection and slows healing -Goal of nutritional support - promote a state of nitrogen balance and match nutrient utilization. Nutritional support - based on patient pre-burn status and % of TBSA burned. -Enteral route is preferred. Jejunal feedings are frequently used to maintain nutritional status with a lower risk of aspiration in a patient with poor appetite, weakness, or other problems.
Burns are caused by a transfer of energy from a heat source to the body Thermal Radiation Chemical Electrical
-Burns less than 25% TBSA produce primarily a local response. -Burns more than 33% produce a local and systemic response and are considered major burns. -Systemic response includes release of cytokines and other mediators into systemic circulation. -Fluid shifts and shock result in tissue hypo-perfusion and organ hypo-function.
Effects of Major Burn Injury
-Cardiovascular effects-cardiac depression, stress ↑'s cardiac workload -Fluid and electrolyte shift-immediately after hyperkalemia, hyponatremia. > fluid leak 24-48 hrs.
Cirrhosis
-Chronic liver disease -Causes fibrotic changes, formation of dense tissue in the liver, degenerative changes and loss of functional tissue -Types: alcoholic, postnecrotic and biliary -Manifestations: liver enlargement, portal obstruction, ascites, infection, GI varices, edema, vitamin deficiency, anemia, mental deterioration
Pre-procedure Nursing Interventions for PerQ Liver Biopsy
-Coagulation test results (liver disease pts often also have clotting defects + at risk for bleeding) -Check for consent -Measure and record vitals before biopsy for baseline -Describe steps to patient in advance (allay fears and ensures cooperation)
Ascites
-Collection of 20 L or more albumin rich fluid in the peritoneal cavity -Result of liver damage, cancer, renal disease, HF) -S/S: fluid wave (ballottement assessment), rapid weight gain, abdominal girth -Tx: Paracentesis, nutrition (low sodium), diuretics, bedrest with upright position, shunt for obstruction
Burns /Child
-Common and preventable -Young children ↑st risk -Mortality ↑st in younger than 6 yrs -3rd leading cause of death b/t 1 and 4 yrs
Age-Related Changes to Hepatobiliary System
-Decrease in size and weight of liver (esp women) -Decrease in blood flow -Decrease in replacement/repair of cells after injury -Reduced drug metabolism -Slow clearance of hepatitis B surface antigen -More rapid progression of hep C and lower response to therapy -Decline in drug clearance -Increased gallstones (inc cholesterol secretion in bile) -Decreased gallbladder contraction after meals -Atypical clinical presentation of biliary disease -Worse complications with biliary tract disease
Fluid and Electrolyte Shifts—Emergent Phase
-Decreased urine output-oliguria -Release of potassium into extracellular fluid: d/t massive tissue destruction : hyperkalemia (hypokalemia later) -Edema in 4 hrs up to 18 hrs -Plasma loss: hyponatremia (seizures, coma, cardiac arrest) -Metabolic acidosis
Manifestations of Liver Disease
-Edema and bleeding (decreased albumin & clotting factor production) -Vitamin A, C, K deficiencies -Thiamine, riboflavin, pyroxidine and folic acid deficiencies -Metabolic abnormalities (high serum glucose) -Pruritus and skin changes
Risks for Liver Disease
-Exposure to hepatotoxins -Drug use (Illegal drugs versus prescribed meds like Tylenol) -Alcohol consumption (60-80 g/day men, 40-60 g/day women) -Family history (genetic) -Overweight, obese -DM
Full thickness including fat, fascia, muscle, and /or bone (Fourth Degree)
-Extend into deep tissue, muscle or bone -Hair follicles, sweat glands destroyed -Prolonged exposure or high voltage electrical injury -Shock, myogloboniuria and hemolysis -Charred -Loss of extremities likely -Grafting is no benefit r/t depth and severity of wounds
Obstructive Jaundice
-Extrahepatic obstruction -Occlusion of bile duct by gall stone, inflammatory process, tumor or enlarged organ, meds causing inflammation -S/S: orange/foamy urine, light/clay colored stool, dyspepsia, only mod rise of LFTs -Can eventually cause cell damage and hepatocellular jaundice
Decompensated Cirrhosis
-Failure to synthesis proteins, clotting factors -Symptoms similar to portal HTN -S/S: ascites, jaundice, weakness, weight loss, clubbing fingers, purpura, easy bruising, epistaxis, hypotension, sparse body hair, white nails, gonadal atrophy
Degree of burn
-First degree= Superficial -Second degree= Partial thickness -Third degree= Full thickness (deep dermal) -Fourth degree= Full thickness that includes fat, fascia, muscle and /or bone
Nursing Interventions for Hepatic Encephalopathy
-Frequent neuro assessment -Monitor mental status -I&O -Daily weight -Serum ammonia lab -Protein intake restriction (comatose, refractory, not long term) -Enteric feeding PRN
Collaborative Problems and Potential Complications
-Heart failure and pulmonary edema -Sepsis -Acute respiratory failure -Visceral damage (electrical burns)
Factors to Consider in Determining Burn Depth/Classification
-How the injury occurred -Causative agent -Temperature of agent -Duration of contact with the agent -Thickness of the skin
Complications of Esophageal Varices Treatment
-Hypovolemia -Hemorrhagic shock -Hepatic encephalopathy -Electrolyte imbalance -Alkalosis -Alcohol withdrawal -Seizures
Fluid and Electrolyte Shifts—Emergent Phase
-Hypovolemia-Intravascular volume is lost (capillary leaking) -Reduced blood volume and hemo-concentration (increase in the proportion of formed elements in the blood, as a result of a decrease in its fluid content)
Hepatocellular Jaundice
-Inability of damaged liver cells to clear normal amounts of bilirubin from the blood -Hep virus or other viruses, chemical toxins, alcohol, cirrhosis -S/S: mildly or severely ill (infection) -Serum and urine bilirubin elevation, AST and ALT levels increased -May be reversible
Jaundice
-Increase in bilirubin concentration causing skin and sclerae yellowing -Due to bile obstruction (obstructive), liver dysfunction (hepatocellular), excessive destruction of RBCs (hemolytic)
Hemolytic Jaundice
-Increased destruction of RBCs, liver can't keep up -Hemolytic transfusion rxn or disorder -Increased fecal and urine bilirubin levels -Unless severe, no s/s (gallstones, CNS effects)
Superficial (First Degree)
-Involves Epidermis (possibly dermis) -Sunburn, superficial scald -Pain soothed by cooling -Minimal or no edema -Complete recovery within a few days -Oral pain meds , cool compresses
Compensated Cirrhosis
-Less severe, more vague symptoms -May be discovered through routine physical -S/S: mild fever, vascular spiders, red palms, epistaxis, ankle edema, vague morning indigestion, gas, firm/enlarged liver, enlarged spleen
Hepatic Encephalopathy (portosystemic)
-Life-threatening -Due to profound liver failure -Dx: neuropsychopathic testing -Reversible metabolic form of encephalopathy -TOO MUCH AMMONIA, NOT ENOUGH LIVER FILTRATION -4 stages (less alert, more sleeping, mental changes)
Ascites Teaching
-Low sodium diet -Daily weights -Output trends to report -Avoid NSAIDs, alcohol intake -Diuretic therapy -Skin care -Edema management strategies (position) -S/S complications
Management of Burn Shock—Fluid Resuscitation/ Burns 20% or > TBSA
-Maintain blood pressure of greater than 100 mm Hg systolic and urine output of 30 to 50 mL/hr; maintain serum sodium at near-normal levels -Consensus formula -Evans formula -Brooke Army formula -Parkland Baxter formula (4ml x wt in kg x %TBSA) Hypertonic saline formula (all use different formulas)
Nutritional Management of Hepatic Encephalopathy
-Minimize ammonia absorption and formation of toxins -Restrict protein <1.2 - 1.5 g/kg/day -Avoid protein restriction when possible -Small, frequent meals with snacks -Monitor electrolyte levels -Discontinue sedatives, transquilizers and analgesic meds -Benzodiazipine antagonists
Gerontologic Considerations
-Mortality rates increase r/t age related changes -Fire/flame most common -Males 60% (60 years and older) -Complications- Pneumonia, UTI, Resp failure -↓ kidney and hepatic function -Malnutrition prior to injury -Dementia
Paracentesis
-Patient in upright position at the end of the bed or in a chair with feet on a stool (best possible position for fluid) -Monitor for hypovolemia, electrolyte shifts, changes in mental status, encephalopathy, infection
Emergent/Resuscitative Phase
-Patient is transported to emergency department -ABC's -Fluid resuscitation is begun in burns > 20% TBSA -Foley catheter is inserted -Patient with burns exceeding 20% to 25% should have an Ng tube inserted and placed to suction -Patient is stabilized and condition is continually monitored -Patients with electrical burns should have ECG -Address pain; only IV medication should be administered -Psychosocial consideration and emotional support should be given to patient and family- may be abuse, neglect, suicide attempt
Burn Goals
-Prevention (Chart 62-1) -Life saving measures for severely burned clients -Prevention of disability and disfigurement -Rehabilitation
Major Burns= One Third of TBSA
-Produce Local and Systemic response -Characterized by burn wound edema, generalized edema in good tissue, c/v function alteration, impaired organ perfusion
Hep B Prevention
-Recommend Vaccines -Advise against high risk behaviors - Standard Precautions - Use needleless injections and IVs -barrier precautions -Monitor sanitation - Avoid multidose vials
Rehabilitation Phase
-Rehabilitation is begun as early as possible in the emergent phase and extends for a long period after the injury. -Focus is on wound healing, psychosocial support, self-image, lifestyle, and restoring maximal functional abilities so the patient can have the best quality life, both personally and socially. -The patient may need reconstructive surgery to improve function and appearance. -Vocational counseling and support groups may assist the patient. -May be complications.
Emergent or Resuscitative Phase— On-the-Scene Care
-Remove pt from source of injury and Prevent injury to rescuer -Stop injury: extinguish flames, soak clothing, cool the burn -Rescue workers-ABCs: Establish airway, breathing, and circulation -Start oxygen and large-bore IVs -Remove restrictive objects and cover the wound -Irrigate chemical burns -Do assessment surveying all body systems and obtain a history of the incident and pertinent patient history --Note: Treat patient with falls and electrical injuries as for potential cervical spine injury.
Biliary Cirrhosis
-Scarring around bile ducts -Usually from biliary obstruction and infection -Much less common
Prevention
-Signs of child abuse induced burns -Our most defenseless children are the most likely to be burned intentionally. Child abuse burn victims are almost always under the age of 10 with the majority under the age of 2.
Fulminant Hepatic Failure
-Sudden and severely impaired liver function in previously healthy person -Onset w/in 8 weeks of initial jaundice -Tx: rapid recognitition and intensive intervention, liver transplant
Liver Tenderness
-Suggests recent enlargement with stretching of the liver capsule (viral hepatitis) -Non-tender implies long-standing duration (alcoholism)
Emergent Phase
-The burn patient has a number of complex injuries that must be taken care of: in addition, the patient's condition changes substantially during the burn disease's evolution. -The initial post-burn period is characterized by cardiopulmonary instability (caused by- significant fluid shifts between compartments) and in many cases by direct injuries to the airways. -With the onset of wound inflammation. immunosuppression, and infection the physiological and metabolic parameters change from those seen initially.
Hepatitis B (Serum)
-Transmission: bodily fluids (mainly blood, mother/infant possible) -Long incubation period (1-6 m) -Progression: most develop antibodies and spontaneously recover in 6 months -Can progress to carrier state, cirrhosis, cancer -Dx: antibodies in circulation -Tx: interferon, antiviral agents, rest, nutrition
Hepatitis C (Chronic)
-Transmission: body fluids (parenterally) -Clinical course: similar to Hep B -S/S: mild -Chronic carrier state frequent with increased risk of chronic liver disease and cancer -Relapses occur -No benefit from diet, rest or vitamin supplements -Tx: antiviral agents -Most common bloodborne infection, most common reason for liver transplant
Urine bilirubin
<0.25 mg/24h These studies measure the ability of the liver to conjugate and excrete bilirubin. Results are abnormal in the liver and biliary tract disease and are associated with jaundice clinically.
Chemical burns
-caused by industrial or household chemicals that are corrosive and abrasive to the skin. -may occur from chemicals in solid, liquid, or gas form. -caused by direct contact with a strong acid or base.
Serum bilirubin, direct
0.1-0.4 mg/dL These studies measure the ability of the liver to conjugate and excrete bilirubin. Results are abnormal in the liver and biliary tract disease and are associated with jaundice clinically.
ALT
8-40 U/mL These studies are based on release on enzymes from damaged liver cells. These enzymes are elevated in liver cell damage. Normal values differ in men and women.
39. A patient who has been taking corticosteroids for several months has been experiencing muscle wasting. The patient has asked the nurse for suggestions to address this adverse effect. What should the nurse recommend? A) Activity limitation to conserve energy B) Consumption of a high-protein diet C) Use of OTC vitamin D and calcium supplements D) Passive range-of-motion exercises
B Feedback: Muscle wasting can be partly addressed through increased protein intake. Passive ROM exercises maintain flexibility, but do not build muscle mass. Vitamin D and calcium supplements do not decrease muscle wasting. Activity limitation would exacerbate the problem.
16. A patient has returned to the floor after having a thyroidectomy for thyroid cancer. The nurse knows that sometimes during thyroid surgery the parathyroid glands can be injured or removed. What laboratory finding may be an early indication of parathyroid gland injury or removal? A) Hyponatremia B) Hypophosphatemia C) Hypocalcemia D) Hypokalemia
C Feedback: Injury or removal of the parathyroid glands may produce a disturbance in calcium metabolism and result in a decline of calcium levels (hypocalcemia). As the blood calcium levels fall, hyperirritability of the nerves occurs, with spasms of the hands and feet and muscle twitching. This group of symptoms is known as tetany and must be reported to the physician immediately, because laryngospasm may occur and obstruct the airway. Hypophosphatemia, hyponatremia, and hypokalemia are not expected responses to parathyroid injury or removal. In fact, parathyroid removal or injury that results in hypocalcemia may lead to hyperphosphatemia.
8. A nurse caring for a patient with diabetes insipidus is reviewing laboratory results. What is an expected urinalysis finding? A) Glucose in the urine B) Albumin in the urine C) Highly dilute urine D) Leukocytes in the urine
C Feedback: Patients with diabetes insipidus produce an enormous daily output of very dilute, water-like urine with a specific gravity of 1.001 to 1.005. The urine contains no abnormal substances such as glucose or albumin. Leukocytes in the urine are not related to the condition of diabetes insipidus, but would indicate a urinary tract infection, if present in the urine.
6. The nurse is teaching a patient that the body needs iodine for the thyroid to function. What food would be the best source of iodine for the body? A) Eggs B) Shellfish C) Table salt D) Red meat
C Feedback: The major use of iodine in the body is by the thyroid. Iodized table salt is the best source of iodine.
A patient is brought to the ED by a friend, who states that a tree fell on the patient's leg and crushed it while they were cutting firewood. What priority actions should the nurse perform? (Select all that apply.) Performing a fasciotomy Splinting the wound in a position of rest to prevent motion Inserting an indwelling catheter Elevating the site to limit the accumulation of fluid in the interstitial spaces Applying a clean dressing to protect the wound
Correct response: Applying a clean dressing to protect the wound Elevating the site to limit the accumulation of fluid in the interstitial spaces Splinting the wound in a position of rest to prevent motion Explanation: Major soft tissue injuries are dressed and splinted promptly to control bleeding and pain. If an extremity is injured, it is elevated to relieve swelling and pressure.
A female patient was sexually assaulted when leaving work. When assisting with the physical examination, what nursing interventions should be provided? (Select all that apply.) Assess and document any bruises and lacerations. Ensure that the police are present when the examination is performed. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. Have the patient shower or wash the perineal area before the examination. Record a history of the event, using the patient's own words.
Correct response: Assess and document any bruises and lacerations. Record a history of the event, using the patient's own words. Label all torn or bloody clothes and place each item in a separate brown bag so that any evidence can be given to the police. Explanation: A history is obtained only if the patient has not already talked to a police officer, social worker, or crisis intervention worker. The patient should not be asked to repeat the history. Any history of the event that is obtained should be recorded in the patient's own words. The patient is asked whether he or she has bathed, douched, brushed his or her teeth, changed clothes, urinated, or defecated since the attack, because these actions may alter interpretation of subsequent findings. Each item of clothing is placed in a separate paper bag. The bags are labeled and given to appropriate law enforcement authorities. The patient is examined (from head to toe) for injuries, especially injuries to the head, neck, breasts, thighs, back, and buttocks. The exam focuses on external evidence of trauma (bruises, contusions, lacerations, stab wounds).
A client has a gaping wound on his forearm that is bleeding profusely. Applying pressure to which pressure point would be most helpful? Femoral Brachial Radial Subclavian
Correct response: Brachial Explanation: The pressure point at the brachial artery would be most appropriate because this site is proximal to the bleeding site. The femoral pressure point would be useful for bleeding in the lower extremities. The radial pressure point would be appropriate for bleeding in the wrist and hands. The subclavian pressure point would be used for bleeding in the upper anterior chest area.
A patient presents to the ED following a motor vehicle collision. The patient is suspected of having internal hemorrhage. The nurse assesses the patient for signs and symptoms of shock. Signs and symptoms of shock include which of the following? Select all that apply. Increasing urine volume Decreasing blood pressure Increasing heart rate Delayed capillary refill Cool, moist skin
Correct response: Cool, moist skin Decreasing blood pressure Increasing heart rate Delayed capillary refill Explanation: Signs and symptoms of shock include cool, moist skin (resulting from poor peripheral perfusion), decreasing blood pressure, increasing heart rate, delayed capillary refill, and decreasing urine volume.
The nurse is conducting a secondary survey on a patient in the ED. Which of the following is completed during the secondary survey? Diagnostic and laboratory testing Undressing the patient Establishing a patent airway Assessment of peripheral pulses
Correct response: Delayed capillary refill Explanation: If a client exhibits tachycardia, falling blood pressure, thirst, apprehension, cool moist skin, or delayed capillary refill, internal bleeding should be suspected.
A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following? Working in a chemical plant Swimming in a lake Running a race in hot humid weather Diving in an ocean
Correct response: Diving in an ocean Explanation: Decompression sickness occurs when patients have engaged in diving in a lake or ocean or high-altitude flying or flying in a commercial aircraft within 24 hours of diving. Swimming in a lake could lead to a near-drowing episode. Running a race in hot humid weather would increase a person's risk for heat stroke. Working in a chemical plant would increase the risk for chemical burns.
A client is brought to the emergency department by ambulance. The client is seriously ill and unconscious. No family or friends are present. Which of the following would be most appropriate to do? Ask the ambulance team for information about the client's family to ensure informed consent. Document the client's condition and absence of friends or family for obtaining consent to treatment. Check the client's record for the name of a family member to call to allow care to be provided. Explain to the client that care is going to be provided because he is seriously ill.
Correct response: Document the client's condition and absence of friends or family for obtaining consent to treatment. Explanation: Consent is needed to examine and treat a client unless he or she is unconscious or in critical condition and unable to make decisions. In this situation, the client is unconscious and no friends or family are around to provide consent to treatment. The nurse should document this fact and provide care. Checking the client's record and asking the ambulance team for information would waste valuable time. Explaining to the client that care will be provided is appropriate even though the client is unconscious, but documentation is essential.
A patient brought to the ED by the rescue squad after getting off a plane at the airport is complaining of severe joint pain, numbness, and an inability to move the arms. The patient was on a diving vacation and went for a last dive this morning before flying home. What is a priority action by the nurse? Send the patient to the hyperbaric chamber. Send the patient for a chest x-ray. Ensure a patent airway and that the patient is receiving 100% oxygen. Draw labs for a chemistry panel.
Correct response: Ensure a patent airway and that the patient is receiving 100% oxygen. Explanation: Decompression sickness, also known as "the bends," occurs in patients who have engaged in diving (lake/ocean diving), high-altitude flying, or flying in commercial aircraft within 24 hours after diving. Signs and symptoms include joint or extremity pain, numbness, hypesthesia, and loss of range of motion. A patent airway and adequate ventilation are established before all other interventions, as described previously, and 100% oxygen is administered throughout treatment and transport.
The nurse in the ED is triaging patients during the shift. What does the nurse know is the first priority in treating any patient in the ED? Controlling hemorrhage. Establishing an airway. Obtaining consent for treatment. Restoring cardiac output.
Correct response: Establishing an airway. Explanation: The primary survey focuses on stabilizing life-threatening conditions. The ED staff work collaboratively and follow the ABCDE (airway, breathing, circulation, disability, exposure) method. The first priority is always to establish a patent airway.
Nursing students are reviewing the categories of intra-abdominal injuries. The students demonstrate understanding of the information when they identify which of the following as examples of penetrating trauma? Select all that apply. Gunshot wound Knife-stab wound Fall from a roof Being struck with a baseball bat Motor-vehicle crash
Correct response: Gunshot wound Knife-stab wound Explanation: Examples of penetrating trauma include gunshot wounds and stab wounds. Motor vehicle crashes, falls, and being struck with a baseball bat are examples of blunt trauma.
Which of the following phases of psychological reaction to rape is characterized by fear and flashbacks? Heightened anxiety phase Denial phase Reorganization phase Acute disorganization phase
Correct response: Heightened anxiety phase Explanation: During the heightened anxiety phase, the patient demonstrates anxiety, hyperalertness, and psychosomatic reactions, in addition to fear and flashbacks. The acute disorganization phase is characterized by shock, disbelief, guilt, humiliation, and anger. The denial phase is characterized by an unwillingness to talk. The reorganization phase occurs when the incident is put into perspective. Some patients never fully recover from rape trauma.
A client comes to the emergency department with a suspected airway obstruction. The emergency department team prepares to manage the client as if he has a complete airway obstruction based on which of the following? Wheezing between coughs Forceful coughing High-pitched noise on inhalation Refusal to lie flat
Correct response: High-pitched noise on inhalation Explanation: A client who demonstrates a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, or cyanosis should be managed as if he or she has a complete airway obstruction. Forceful coughing, wheezing between coughs, and a refusal to lie flat suggest a partial airway obstruction that can be managed as such.
A nurse is caring for a client who has arrived at the emergency department in shock. The nurse intervenes based on the knowledge that which of the following is the most common cause of shock? Hypovolemia Sepsis Cardiac dysfunction Anaphylaxis
Correct response: Hypovolemia Explanation: Types of shock include cardiogenic, neurogenic, anaphylactic, and septic. Of these, the most common cause is hypovolemia.
An 85-year-old patient is admitted to the ED. Heat stroke is suspected. The patient's core temperature is 106.2°F (41.2°C), blood pressure (BP) 90/60 mm Hg, and pulse 102 bpm. The nurse understands that the primary treatment measure for the patient will include which of the following? Immersion of the patient in a cold-water bath IV hydration with normal saline solution Endotracheal intubation with mechanical ventilation Administration of sodium supplements
Correct response: Immersion of the patient in a cold-water bath Explanation: For the patient with heat stroke, simultaneous treatment focuses on stabilizing oxygenation using the CABs (circulation, airway, and breathing) (formerly called the ABCs) of basic life support. This includes establishing IV access for fluid administration. After the patient's clothing is removed, the core (internal) temperature is reduced to 39°C (102°F) as rapidly as possible, preferably within 1 hour. One or more of the following methods may be used as prescribed: Cool sheets and towels or continuous sponging with cool water; ice applied to the neck, groin, chest, and axillae while spraying with tepid water; and cooling blankets. Immersion of the patient in a cold-water bath is the optimal method for cooling (if available). Hydration would be with lactated Ringer's solution. There is no indication for intubation. Administration of sodium supplements is indicated for the treatment of heat cramps.
A patient who has accidentally ingested toilet bowel cleaner is brought to the emergency department. Which action would NOT be appropriate for the nurse to implement? Induced vomiting Gastric lavage Dilution with water or milk Administration of activated charcoal
Correct response: Induced vomiting Explanation: Vomiting is never induced after ingestion of caustic substances (acid or alkaline) such as toilet bowl cleaner because the substance is corrosive to the tissues. Appropriate actions include dilution with milk or water, gastric lavage, and administration of activated charcoal.
A nurse is completing her annual cardiopulmonary resuscitation training. The class instructor tells her that a client has fallen off a ladder and is lying on his back; he is unconscious and isn't breathing. What maneuver should the nurse use to open his airway? Abdominal thrust Head tilt-chin lift Jaw-thrust Seldinger
Correct response: Jaw-thrust Explanation: If a neck or spine injury is suspected, the jaw-thrust maneuver should be used to open the client's airway. To perform this maneuver, the nurse should position herself at the client's head and rest her thumbs on his lower jaw, near the corners of his mouth. She should then grasp the angles of his lower jaw with her fingers and lift the jaw forward. The head tilt-chin lift maneuver is used to open the airway when a neck or spine injury isn't suspected. To perform this maneuver the nurse places two fingers on the chin and lifts while pushing down on the forehead with the other hand. The abdominal thrust is used to relieve severe or complete airway obstruction caused by a foreign body. The Seldinger maneuver is a method of percutaneous introduction of a catheter into a vessel.
What is the most frequently injured solid organ in a penetrating trauma? Brain Lungs Liver Pancreas
Correct response: Liver Explanation: The most frequently injured solid organ in a penetrating trauma is the liver.
A nurse is providing care to an older adult client who has frostbite of the feet. Which action would be least appropriate? Massaging the feet Placing sterile cotton between the toes after rewarming Providing an analgesic for pain Restricting ambulation
Correct response: Massaging the feet Explanation: For a client with frostbite, massaging the affected body part is contraindicated. Analgesia is given for pain during the rewarming process because it can be very painful. Ambulation would be restricted. Once rewarmed, sterile gauze or cotton is placed between the affected toes to prevent maceration.
The nurse is administering antivenin to a patient who was bitten on the arm by a poisonous snake. What intervention provided by the nurse is required prior to the procedure and every 15 minutes after? Measure the circumference of the arm. Administer cimetidine (Tagamet). Administer diphenhydramine (Benadryl). Assess peripheral pulses.
Correct response: Measure the circumference of the arm. Explanation: Before administering antivenin and every 15 minutes thereafter, the circumference of the affected part is measured. Premedication with diphenhydramine (Benadryl) or cimetidine (Tagamet) may be indicated, because these antihistamines may decrease the allergic response to antivenin. Antivenin is administered as an IV infusion whenever possible, although intramuscular administration can be used.
Acetaminophen overdose is treated with the administration of which of the following medications? Diazepam (Valium) N-acetylcysteine (Mucomyst) Naloxone (Narcan) Flumazenil (Romazicon)
Correct response: N-acetylcysteine (Mucomyst) Explanation: Treatment of acetaminophen overdose includes administration of N-acetylcysteine (Mucomyst). Flumazenil is administered in the treatment of nonbarbiturate sedative overdoses. Naloxone (Narcan) is administered in the treatment of narcotic overdoses. Diazepam (Valium) may be administered to treat uncontrolled hyperactivity in the patient with a hallucinogen overdose.
A family member brings a patient to the emergency department. The family member states, "I think he overdosed on heroin." Which of the following would the nurse expect to assess? Flushed face Pinpoint pupils Hypertension Hyperventilation
Correct response: Pinpoint pupils Explanation: Signs of an acute overdose of heroin, an opioid, include pinpoint pupils, marked respiratory depression, descreased blood pressure, stupor progressing to coma, seizures, and pulmonary edema. Flushed face typically reflects a barbiturate overdose.
When preparing to perform abdominal thrusts on a client with an airway obstruction, which of the following would be most appropriate? Using a sequence of four thrusts, each progressing in intensity Placing the thumb side of one hand at the xiphoid process Having the conscious client lie down Positioning the hands in the midline slightly above the umbilicus
Correct response: Positioning the hands in the midline slightly above the umbilicus Explanation: When performing abdominal thrusts, the nurse would place the thumb side of one fist against the client's abdomen in the midline slighlty above the umbilicus and well below the xiphoid process, grasping the fist with the other hand. Then the nurse would press the fist into the client's abdomen with a quick inward and upward thrust such that each new thrust should be a separate and distinct maneuver. The unconscious client is positioned on the back. The client who is conscious should be standing or sitting.
A nurse is providing care to a client in the emergency department and walks into the hallway to get equipment. All of a sudden, gunshots are heard. Which of the following would be the nurse's priority? Gaining control of the situation Protecting himself or herself Providing care to the injured Securing the area
Correct response: Protecting himself or herself Explanation: If gunfire occurs in the emergency department, self-protection is the priority. Security officers and police must gain control of the situation first and then care is provided to the injured.
A patient is admitted to the ED after a near-drowning accident. The patient is diagnosed with saltwater aspiration. The nurse will observe the patient for several hours to monitor for symptoms of which of the following? Pulmonary edema Head injury Hyponatremia Hypothermia
Correct response: Pulmonary edema Explanation: Resultant pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Freshwater aspiration results in a loss of surfactant and, therefore, an inability to expand the lungs. Saltwater aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. If a person survives submersion, acute respiratory distress syndrome (ARDS), resulting in hypoxia, hypercarbia, and respiratory or metabolic acidosis, can occur. The patient would experience hypernatremia. Hypothermia and head injury may be associated with near drowning, but would be apparent at the time of admission and would not develop after several hours.
A home health nurse is visiting a 74-year-old client with Alzheimer's disease. During the visit, the nurse notes bruising on the client's upper arms, and the client is more withdrawn than normal. The client is unable to communicate effectively because of his disease progression. The nurse suspects elder abuse. What is the nurse's responsibility in this situation? Do nothing because the nurse has no proof of wrongdoing. Try to convince the client to report the problem. Monitor the situation during subsequent visits. Report the suspicion to the local agency on aging within 24 hours of the visit.
Correct response: Report the suspicion to the local agency on aging within 24 hours of the visit. Explanation: The nurse must report the suspicion to the local agency on aging within 24 hours of the visit. Doing nothing and monitoring the situation during subsequent visits go against the nurse's legal and professional obligation, which is to report suspected abuse when it occurs. The client's disease process prevents him from reporting the problem.
A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn? Rinsing the area with copious amounts of water Administering tetanus prophylaxis Covering the area with a sterile dressing Applying antimicrobial ointment
Correct response: Rinsing the area with copious amounts of water Explanation: The priority for any chemical burn is to immediately drench the area with running water, unless the chemical is lye or white phosphorus, which should be brushed off the patient. Antimicrobial ointments, sterile dressings, and tetanus prophylaxis are measures instituted later in the course of treatment, depending on the characteristics of the chemical agent and the size and location of the burn.
Which of the following guidelines is appropriate to helping family members cope with sudden death? Inform the family that the patient has passed on Obtain orders for sedation for family members Show acceptance of the body by touching it, giving the family permission to touch Provide details of the factors attendant to the sudden death
Correct response: Show acceptance of the body by touching it, giving the family permission to touch Explanation: The nurse should encourage the family to view and touch the body if they wish, since this action helps the family to integrate the loss. The nurse should avoid using euphemisms such as passed on. The nurse should avoid giving sedation to family members, since this may mask or delay the grieving process. The nurse should avoid volunteering unnecessary information (eg, patient was drinking at the time of the accident).
Following a motor vehicle collision, a patient is brought to the ED for evaluation and treatment. The patient is being assessed for intra-abdominal injuries. The patient states severe left shoulder pain (pain score of 10 on a 1 to 10 pain scale). The nurse suspects injury to which of the following? Gallbladder Large intestines Liver Spleen
Correct response: Spleen Explanation: The location of pain can indicate certain types of intra-abdominal injuries. Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen, whereas pain in the right shoulder can result from laceration of the liver.
A client comes to the emergency department after experiencing a wound. Inspection reveals an opening in the skin with distinct edges and whose depth is greater than the length of the wound. The nurse documents this as which type of wound? Laceration Patterned Stab Avulsion
Correct response: Stab Explanation: A stab wound is an incision of the skin with well-defined edges and is typically deeper than long. It is usually caused by a sharp instrument. A laceration is a tear in the skin with irregular edges and vein bridging. An avulsion is manifested as a tearing away of tissue from the supporting structures. A patterned wound takes on the outline of the object causing the wound.
A client is admitted to the emergency department after sustaining a penetrating injury to the abdomen. Which of the following would the nurse identify as a possible cause? Concrete debris from an explosion Stabbing with a knife Impact of a steering wheel Fall to the ground from a ladder
Correct response: Stabbing with a knife Explanation: Penetrating abdominal injuries are ones involving an opening into the abdomen, such as those that occur with a gunshot or stabbing. Blunt injuries usually occur with motor vehicle crashes, falls, and explosions.
A patient was bitten by a tick 3 months ago and is now having muscle aches as well as joint pain and swelling. The patient is having difficulty with self care and requires assistance with activities of daily living (ADLs). What stage of Lyme disease does the nurse recognize the patient is in? Stage II Stage IV Stage I Stage III
Correct response: Stage III Explanation: Lyme disease has three stages. Stage I presents with a classic "bull's-eye" rash (i.e., erythema migrans) and flulike signs and symptoms that may include chills, fever, myalgia, fatigue, and headache. If antibiotics are not administered, stage II Lyme disease may present within 4 to 10 weeks following the tick bite and may manifest with joint pain, memory loss, poor motor coordination, and meningitis. Stage III can begin anywhere from weeks to more than a year after the bite and has serious long-term chronic sequelae, including arthritis, neuropathy, myalgia, and myocarditis.
A nurse is providing inservice education for staff members about evidence collection after sexual assault. The educational session is successful when staff members focus their initial care on which step? Collecting semen Performing the pelvic examination Supporting the client's emotional status Obtaining consent for examination
Correct response: Supporting the client's emotional status Explanation: The teaching session is successful when staff members focus first on supporting the client's emotional status. Next, staff members should gain consent to perform the pelvic examination, perform the examination, and collect evidence, such as semen if present.
A patient present to the ED following a work-related injury to the left hand. The patient has an avulsion of the left ring finger. Which of the following correctly describes an avulsion? Tearing away of tissue from supporting structures Skin tear with irregular edges and vein bridging Incision of the skin with well-defined edges, usually longer than deep Denuded skin
Correct response: Tearing away of tissue from supporting structures Explanation: An avulsion is described as a tearing away of tissue from supporting structures. A laceration is a skin tear with irregular edges and vein bridging. Abrasion is denuded skin. A cut is an incision of the skin with well-defined edges, usually longer than deep.
19. A patient with hypofunction of the adrenal cortex has been admitted to the medical unit. What would the nurse most likely find when assessing this patient? A) Increased body temperature B) Jaundice C) Copious urine output D) Decreased BP
D Feedback: Decreased BP may occur with hypofunction of the adrenal cortex. Decreased function of the adrenal cortex does not affect the patients body temperature, urine output, or skin tone.
Tom Benson, a 42-year-old electrical lineman, suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. What occurrence makes it difficult to assess internal burn damage in electrical burns? a) Protein cell coagulation b) All options are correct. c) Continuing inflammatory process d) Deep tissue cooling
Deep tissue cooling Explanation: Because deep tissues cool more slowly than those at the surface, it is difficult initially to determine the extent of internal damage.
Bill Jenkins has suffered from a burn on his leg related to an engine fire. Burn depth is determined by assessing the color, characteristics of the skin, and sensation in the area. When the burn area was assessed, it was determined that he felt no pain in the area and that it appeared charred. What depth of burn injury would he be said to have? a) Fourth degree b) Superficial (first degree) c) Full thickness (third degree) d) Superficial partial-thickness and deep partial-thickness (second degree)
Full thickness (third degree) Explanation: Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appears charred or lifeless. Superficial (first degree) burn is similar to a sunburn. The epidermis is injured, but the dermis is unaffected. Superficial partial-thickness burn heals within 14 days, with possibly some pigmentary changes but no scarring. The deep partial-thickness (second degree) burn takes more than 3 weeks to heal, may need debridement, and is subject to hypertrophic scarring. A fourth-degree burn can involve ligaments, tendons, muscles, nerves, and bone.
A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat? a) Moisten with sterile water only. b) Moisten with saline. c) Keep Acticoat saturated. d) Use topical antimicrobials with Acticoat burn dressing.
Moisten with sterile water only. Explanation: Acticoat is moistened with sterile water only; never use normal saline. Do not use topical antimicrobials with Acticoat burn dressing. Keep Acticoat moist, not saturated.
Assisting with Liver Bx
Preprocedure: 1. Look at labs (PT, PTT, and platelets) make sure donor and blood available. 2. Check for signed consent 3. Do VS 4. Explain procedure to pt During Procedure 1. Support pt. 2. Expose right upper abd 3. Instruct pt to inhale/exhale deeply. (penetration of diaphragm avoided) 4. Have pt resume breathing (relieves anxiety) Post procedure 1. Keep pt to right side, place pillow under back, and no coughing/straining. 2. Do VS 3. D/C Instructions: Avoid heavy lifting for 1 wk.
acute alcohol intoxication
Psychotropic drug that affects mood, judgment, behavior, concentration and consciousness Alcohol poisoning may result in death CNS depression and hypotension Maintain airway Labs- BAL Elimination at 10-20% per hour Most hospitals have protocol for patients with ETOH intoxication EKG, seizures, aspiration Oxazepam (Serax) or lorazepam (Ativan)
Hemorrhage
assess the level of bleeding major or minor
The nurse is caring for a 30-year-old female patient who suffered severe head and facial burn injuries. Which of the following actions, if completed by the patient, indicates she is adapting to her altered body image? Select all that apply. a) Reports absence of sleep disturbance b) Wears hats and wigs c) Covers her face with a scarf d) Participates actively in daily activities
• Wears hats and wigs • Participates actively in daily activities Correct Explanation: The following are indicators that a patient is adapting to altered body image: verbalizes accurate description of alterations in body image and accepts physical appearance, demonstrates interest in resources that may improve function and perception of body appearance (e.g., uses cosmetics, wigs, and prostheses, as appropriate); socializes with significant others, peers, and usual social group; and seeks and achieves return to role in family, school, and community as a contributing member. Covering the face with a scarf indicates the patient is not adapting to the alteration in body image; absence of sleep disturbances is expected by the burn-injured patient but is not related to body image disturbance.
