Exam 3: Shock, SIRS, Sepsis, MODS, Burns, & MSK

Risk factors for SIRS, sepsis, & MODS:

- Age >80 or <1 -Recent trauma or surgery -Indwelling devices --> urinary catheters, central lines, ET tube, NG/G tube -Immunosuppression -Cancer -Open wounds -Malnutrition -Infection

S/S of burns:

-ABC's --> 1st priority -burn characteristics, depth, TBSA, type -singed facial hair, eyebrows, and lashed -sooty face, sputum, black flecks (black sputum indicates the airway has been impacted -hoarse voice or stridor -hypothermia, low body temp (we need to keep these patients warm) -decreased sensation -severe pain or lack of pain based on the depth of the burn -tachypnea, increased O2 demand -shock if >35% TBSA (tachycardia, hypotension, decreased cardiac output; it is not a systemic inflammatory response and we will have significant hypovolemia) -edema --> 3rd spacing resulting from fluid depletion

S/S of DIC:

-Bleeding -Petechiae (non-blanchable) -Purpura

Nursing interventions for burns: rehabilitation

-rehab should begin immediately after the burn has occurred when VS are stable -wound healing -the priority of rehab is to restore maximum functional activity to remain priorities -assess patients response to pain and sleep alterations -patients with partial or full thickness burns who has unknown or inadequate immunization status should be vaccinated and given tetanus immune globin

Potential complications for burns:

-respiratory failure -hypothermia -hypovolemia -infection -acute compartment syndrome -ischemia -tissue hypoxia -pruritus -hypertrophic scarring -permanent hyperpigmentation -disfiguration -body image alterations -limited ROM and tightening of tissue

*1 hour bundle for sepsis:*

1. Measure lactate level 2. Obtain blood cultures before administering antibiotics 3. Admin broad-spectrum antibiotics 4. Begin rapid administration of 30 mL/kg for hypotension or lactate >4 5. Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a MAP >60

The nurse is caring for a client with hypovolemic shock. which new assessment finding indicated that interventions are currently effective? a. oxygen saturation remains unchanged b. core body temperature has increased to 99 degrees c. the client correctly states the moth and year d. serum lactate and serum potassium levels are declining

d. serum lactate and serum potassium levels are declining

Which pathophysiological risk is increased in a client who sustained burn injuries due to a fire and an explosion and has carbon monoxide level of 14%? a. stupor b. vertigo c. convulsions d. slight breathlessness

d. slight breathlessness

Why are the clinical s/s of most types of shock the same regardless of what specific events or conditions caused the shock to occur? a. the blood, blood vessels, and heart rate are directly connected to each other so that when one is affected, all three are affected b. because blood loss occurs with most types of shock, the most common first manifestation is hypotension c. every type of shock interferes with oxygenation and metabolism of all cells in the same sequence d. the sympathetic nervous system is triggered by any type of shock and initiates the stress response

d. the sympathetic nervous system is triggered by any type of shock and initiates the stress response

Caring for patients requiring traction:

-check the order (the order will tell sue what type of traction and how much weight is needed) -inspect all ropes, pulleys, and weights q 8 hrs -*monitor circulation* -monitor skin integrity (for an external fixator pin site care) -monitor for infection -pain management (these patients are good candidates for a PCA pump)

Medication induced risk factors for rhabdomylosis:

-drugs of abuse such as alcohol (ethanol), heroin, or cocaine -antibiotics (amphotericin B, ampicillin) -anesthetics -antidepressants -antihistamines -aspirin -corticosteroids -lidocaine -lithium -*statins --> if they feel fatigued and have weakness in the arms and legs its a red flag they may be developing rhabdo) -theophylline

Potential complications of amputations:

-infection -hemorrhage -hypovolemic shock -flexion contractures -falls and injury -impaired self image -loss of autonomy

Non-physical risk factors for rhabdomyolosis:

-infection -septic shock -electrolyte imbalances -snake venom -medication induced

Nursing interventions for fractures:

-monitor for potential complications -advocate for VTE prophylaxis d/t impaired mobility Neurovascular assessment: -q 1 hr for the 1st 24 hrs of a traumatic break -pulses -cap refill -ROM -sensation -monitor CSM's -elevation --> for all fractures (swelling and edema can come 48 hrs after the fracture) -Ice for 1st 24-48 hrs -cast care -crutch training -pain management

Hypovolemic Shock:

-occurs d/t a fluid deficit resulting in a decreased MAP -there is inadequate perfusion and gas exchange

When sepsis is diagnosed in a client, when will the nurse initiate the prescribed antibiotic therapy? a. within the 1st hr after diagnosis b. within the first 24 hrs after diagnosis c. after the results of blood cultures are known d. when blood lactate levels has increased to 9 mg/dL

a. within the 1st hr after diagnosis

Obstructive shock:

something is obstructing the return of blood to the heart -obstructs the heart muscles from pumping effectively ex: cardiac tamponade, tension pneumothorax, TAA/AAA

*Fat embolism syndrome:*

*Yellow marrow* from long bone enters the vasculature and travels to the lungs and gets stuck imitating a pulmonary embolism -occurs within 48 hrs of injury -priority assessment --> ABCs S/S: -SOB -anxiety -chest pain -decreased SaO2 -increased RR -altered mental status (early sign) -tachycardia -crackles in the lungs -*petechiae* Treatment: -bed rest -oxygen -fracture immobilization -IV fluids anticoagulants will not help with a fat embolism patients will present with all the s/s of a PE but the key indicator is that they have a long bone fracture Most common in long bone (femur) fractures

Non-surgical treatment for Sepsis:

-*Vasopressors --> maintain MAP >60) -*Fluid resuscitation* -*Antibiotics* -Corticosteroids -Insulin IV --> because they will be hyperglycemic -Heparin --> for DIC -FFP/ PRCs -Foley catheter with urometer (consider temperature control) -Central line -Consider transfer to ICU level care -Consider mechanical ventilation --> if ARDs develops

S/S of Rhabdomyolysis:

-*muscle pain/ weakness* -*tea colored urine* -swelling/ edema -stiffness/ cramping -presence of a pressure injury -reduced urine output -malaise -fever -nausea/ vomiting -abdominal pain -palpations

Potential complications for rhabdomylosis:

-AKI -electrolyte imbalances (hyperkalemia and hypercalcemia) -DIC -compartment syndrome -if left untreated can be fatal

Nursing interventions for sepsis:

-Act quickly upon sepsis and septic shock recognition -Minimize time to treatment -Monitor closely for response to intervention -Communicate sepsis status in hand off report

*Early s/s of sepsis:*

-Mild hypotension -Increased RR -Decreased urine output -Temp high or low -*Microthrombi clotting* -Hypoxia -Elevated WBC or less -Subtle changes in a short duration of time

Distributive shock:

-blood is distributed d/t vasodilation into interstitial tissues --> unable to perfuse organs -BP will drop, venous polling and capillary leak occur Septic shock: -subset of sepsis with severe circulatory, cellular and metabolic abnormalities Neurogenic shock: -occurs d/t trauma/ injury to the spinal cord or pain -disrupts autonomic pathway resulting in a decreased vascular resistance and changes in vagal tone Anaphylactic shock: -severe hypersensitivity reaction mediated by immunoglobulin E (Ig-E) --> causes cardiovascular collapse

Nursing interventions for burns emergent/ resuscitation:

-occurs in 1st 48hrs after a burn has occurred -a focused assessment needs to be preformed as a priority; the burn wound is a secondary consideration *Initial priorities:* -100% humidified oxygen -encourage patient to cough up secretions -if the airway is compromised --> intubate -support circulation/ perfusion For chemical burns: -all clothing and jewelry must be removed and burns should be flushed IV access: -large bore IV 16 or 18G --> inserted into a NON-burned area GI for burns >20% TBSA: -insert a nasogastric tube and connect it to low intermittent suction to reduce nausea Clean bedding: -clean sheets need to be placed over and under the patient to protect the burn wound from contamination, maintain their body temp, and reduce pain Fluid replacement therapy: -total volume and rate of fluid is gauged by the patient response and guided by the resuscitation formula

Non-surgical treatment for fractures:

-pain control -NSAIDs -reduction --> putting bone ends back together (if they are aligned together they will heal) -immobilization (for at least 4-6 wks) -casting -splints/boots

Prosthetics:

-swelling and edema has to be gone -pt has to be at a stable weight -compression bandage on the stump to help keep the stump from swelling -adjustments are made as the limb changes

Risk factors for fractures:

-trauma -fall -MVC -sports injury -malnutrition --> because it can make the bones more brittle -osteoporosis -age --> older adults -genetic disorders

Which clinical manifestation would the nurse associate with successful fluid replacement therapy? a. a trended urinary output of at least 30 mL/hr b. central venous pressure reading of 1.5 mmHg c. baseline pulse of 120 beats/min decreasing to 110 beats/min within a 15 min protocol d. baseline BP of 50/30 increasing to 70/40 within a 30 min period

a. a trended urinary output of at least 30 mL/hr

Which intervention would the nurse include when developing a plan of care for a client with compartment syndrome? select all a. bivalve the cast b. apply cold compress c. loosen the bandage applied d. evaluate the clients level of pain e. elevate the extremity above the heart level

a. bivalve the cast c. loosen the bandage applied d. evaluate the clients level of pain

Which dietary plan will the nurse follow while caring for a client 4 days after being admitted to the hospital with burns on the trunk and arms in collaboration with the dietician? a. high caloric intake, liberal potassium intake, and 3 g protein/ kg per day b. high caloric intake, restricted potassium intake, and 2 g protein/ kg per day c. moderate caloric intake, liberal potassium intake, and 3g protein/ kg per day d. moderate caloric intake, restricted potassium intake, and 1 g protein/ kg per day

a. high caloric intake, liberal potassium intake, and 3 g protein/ kg per day

Which action will the nurse anticipate when planning care for a client with an above-the-knee amputation who, two days after beginning to use a prosthesis, develops a small blister on the residual limb near the healed incision? a. remeasuring the residual limb for correct prosthesis sizing b. increasing the frequency of limb-toughening exercises c. changing the type of covering used to avoid irritation d. placing a bandage on the blister before putting the prosthesis back on

a. remeasuring the residual limb for correct prosthesis sizing

The nurse plans to administer an antibiotic to a client newly admitted with septic shock. what action will the nurse take first? a. take the clients VS b. ensure that blood cultures were drawn c. insert an IV line d. administer the antibiotic

b. ensure that blood cultures were drawn

a client in progressive stage of hypovolemic shock has all of the following signs, symptoms, or changes. Which signs will the nurse attribute to ongoing compensatory mechanisms? select all a. increasing pallor b. increasing thirst c. increasing confusion d. increasing HR e. increasing respiratory rate f. decreasing systolic BP g. decreasing blood pH h. decreasing urine output

b. increasing thirst c. increasing confusion e. increasing respiratory rate f. decreasing systolic BP

Which complication would a nurse be concerned about in a client in the acute phase of burns who has eaten only a small portion of each meal? a. dehydration b. dry, brittle hair c. prolonged wound healing d. clubbing of fingers

c. prolonged wound healing

Which action would the nurse use to increase the counteraction for a client who is in traction to reduce a hip fracture? a. elevate the HOB b. ass more weight to the traction c. raise the foot of the bed slightly d. tie a chest restraint around the client

c. raise the foot of the bed slightly

Which client demonstrates highest risk for hypovolemic shock? a. client receiving a blood transfusion b. client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion c. client with MI d. client with severe ascites

d. client with severe ascites

Nursing interventions for acute burns:

-49-72 hrs after the burn injury -burn wound care and pain control are priorities -we need to focus on hemodynamic alterations, wound healing, pain and psychological response and early detection of complications -frequent VS -*respiratory and fluid status remains the highest priority* -assess peripheral pulses frequently for the first few days after the burn for restricted blood flow -closely observe hourly fluid intake and urinary output, as well as BP and cardiac rhythm -for patients with inhalation injuries regularly monitor levels of consciousness, pulmonary function, and ability to ventilate -daily wt, initial wt gain from fluid resuscitation will decrease as fluid shifts -Nutrition --> these patients require 3,000-5,000 calories per/day to meet metabolic demands; diet high in protein

Nursing interventions for rhabdomylsois:

-strict I & O (d/t all the fluids we are giving them) -VS -IV access/ fluid resuscitation -assess for fluid volume overload --> heart and LS often -assess cardiac function with continuous ECG monitoring

A client has an open reduction internal fixation (ORIF) of the right wrist. What health teaching is appropriate for the nurse to proved for this client before returning home? select all a. keep you right arm below the level of your heart as often as possible b. use an ice pack for the first 24 hrs to decrease tissue swelling c. report coolness or discoloration of your right hand to your doctor d. dont place any device under the cast to scratch the skin if it itches e. move the fingers of the right hand frequently to promote blood flow

a. keep you right arm below the level of your heart as often as possible b. use an ice pack for the first 24 hrs to decrease tissue swelling d. dont place any device under the cast to scratch the skin if it itches e. move the fingers of the right hand frequently to promote blood flow

Which conditions will the nurse consider as increasing any client's risk for hypovolemic shock? select all a. hypoglycemia b. diuretic therapy c. severe head injury d. prolonged diarrhea e. liver failure with ascites f. continuous nasogastric suctioning g. large draining abdominal wound

b. diuretic therapy d. prolonged diarrhea f. continuous nasogastric suctioning g. large draining abdominal wound

Which prescribed action will the nurse take first when a client is admitted to the ED with DIC caused by sepsis? a. apply antiembolism stockings b. draw blood for culture and sensitivity c. administer vancomycin 1 g intravenously d. transfer the client the to ICU

b. draw blood for culture and sensitivity

Which actions are most appropriate for the nurse to take first when a client with blunt trauma to the abdomen who has been NPO for several hours now reports thirst and anxiety? select all a. obtain an order for a stat H & H b. get the client a few ice chips or moistened swab c. compare current VS to baseline d. check for obvious blood in the urine e. measure abdominal girth f. increase the IV rate

c. compare current VS to baseline e. measure abdominal girth

Which VS change in a client with hypovolemic shock indicates to the nurse that the therapy is effective? a. urine output increases from 5 mL/hr to 25 mL/hr b. pulse pressure decreases from 35 mmHg to 28 mmHg c. respiratory rate increases from 22 to 26 d. core body temp increases from 98.2 to 98.8

a. urine output increases from 5 mL/hr to 25 mL/hr

Which clinical finding would the nurse anticipate during the acute phase of burn recovery? a. unstable VS b. decreased urinary output c. high serum potassium levels d. reduced intravascular fluid volume

a. unstable VS

Which complication will the nurse remain alert for in a client who has septic shock? a. psychosis b. skin necrosis c. febrile seizures d. acute respiratory distress syndrome (ARDs)

d. acute respiratory distress syndrome (ARDs)

Cardiogenic shock:

*heart muscle* has inadequate pumping --> which decreases cardiac output

Carbon monoxide:

-Colorless, odorless, tasteless, gas release in the process of combustion (fire) -binds to hemoglobin in place of oxygen leading to impaired gas exchange -causes vasodilation "cherry red" facial appearance -O2 sat monitoring provides false values --> we must clinically assess the patient S/S: -decreased LOC -headache -tinnitus -N/V -confusion *administer high flow oxygen x 6 hrs at a minimum because oxygen is the treatment for carbon monoxide poisoning*

Non-surgical treatment for burns:

-First aid initially -*ABCs --> the priority treatment is airway followed by fluid volume status* -wound care and dressing changes (we need to premedicate before bandage changes)

Indications for amputations:

-peripheral arterial disease with complications -full thickness integumentary system --> extensive pressure injureis or non healing diabetic wounds, burns, frostbite -trauma -cancer/ tumors

Nursing interventions for amputations:

-prevent contractures (* 1st 24 hrs after surgery only elevate the limb, clients who have had a BKA or AKA assist with prone positioning*) -transfer and independence changes -pain management --> phantom limb pain -monitor for complications -prosthetics -psychosocial support

Physical risk factors for rhabdomyolosis:

-prolonged physical pressure placed on blood vessels, leading to tissue ischemia -prolonged immobilization -crush injuries -prolonged use of tourniquets -strenuous exercise -status epilepticus --> can deplete muscles of ATP -high voltage injuries

The 3 layers of the skin:

1. Epidermis --> no blood vessels; the top layer of the skin 2. Dermis --> below the epidermis, contains sweat and oil glands, connective tissue, nerve endings, and blood vessels 3. Subcutaneous tissue --> bottom layer of this skin,

Lab testing for DIC:

Decreased fibrinogen, hematocrit and platelets -Normal hematocrit: female: 37-47% male:42-52% Increased PT & PTT: -Normal PTT: 60-70 seconds

Dx testing for rhabdo:

EKG and telemetry monitoring for arrhythmias assess the underlying cause: -X-ray -CT/ MRI

Electrical burns:

Electrical current entry and wound exit (iceberg effect) -severity varies based on current type, duration, and pathway -the exit is usually to a grounded surface (usually the bottom of someones foot) -electrical burns occur all the way from the entry point to the exit point through the body

*SIRS criteria:*

Any of theses 2 -Temp: >100.4 or <95 -RR: >20 or PaCO2 <32 -HR: >90 -WBC: >12,000 or < 4,000

Factures:

Break of disruption on the continuity of a bone -fractures heal within stages -4-6 wks for healthy adults

Which clinical manifestation would the nurse observe in a client experiencing anaphylactic shock from a type I latex allergy reaction? select all a. stridor b. fissuring c. hypotension d. dyspnea e. cracking of the skin

a. stridor c. hypotension d. dyspnea

*Superficial partial thickness burns:*

Can extend into the dermis -pale, pink/red -painful -blistering -moist and soft -blanches when touched -do not pop the blisters but when the deroof (pop on their own) the skin will be moist red and hypersensitive

Risk factors for obstructive shock:

Caused by a non cardiac muscle issue -Cardiac tamponade -Pericarditis -Tension pneumothorax -PE

Risk factors for cardiogenic shock:

Caused by cardiac muscle issues -MI -Valve dz -Arrhythmia -Pump failure

Sepsis:

Extreme response to infection causing tissue damage and organ failure -Systemic inflammation causes impaired gas exchange and tissue perfusion -Progression in severity is quickly (within hrs) -The goal is to identify and treat early to stop the progression -The greater progression the greater the risk for mortality SIRS + infection = sepsis Sepsis + hypotension (that doesn't respond to a fluid bolus = septic shock Septic shock + evidence of multi organ failure = MODS

Non-surgical treatment for DIC:

Find and treat underlying cause -Sepsis -Placental abruption -Trauma Plasma or platelet transfusions may be needed and heparin for excessive clotting

*Parkland formula:*

Fluid replacement for burned patients within the 1st 24 hrs 4 mL x TBSA (%) x body wt (kg) -half is given within the 1st 8 hrs -half is given in 16hrs

*Compartment syndrome:*

Serious, limb threatening increased pressure on one or more of the compartments Common complaint: "cast feels tight", "my cast is so tight and painful" *Assess the 6 P's:* -pain -pulselessness (distal pulse will not be there and cap refill will be reduced, numbness and tingling) -pallor (extremity will feel *cold*) -paresthesia -paralysis -pressure Treatment: -*priority action is to remove the cast* -may progress to fasciotomy (patient will need a skin graft after)

The nurse is assessing a client with septic shock. what assessment data indicates a progression of shock? select all a. BP change from 86/50 to 100/64 b. HR change from 98 to 76 beats/min c. cool and clammy skin d. petechiae along the gum line e. urine output 45 mL/hr

a. BP change from 86/50 to 100/64 c. cool and clammy skin d. petechiae along the gum line

The nurse is caring for a patient in the initial stage of hypovolemic shock. what assessment data will the nurse anticipate? a. HR 118 beats/ min b. 2 + pedal pulses c. bilateral fine crackles in the lung bases d. BP changes from 100/60 to 100/40 mmHg

a. HR 118 beats/ min

Which client has a risk for hypovolemic shock? a. a client with esophageal varices b. a client with kidney failure c. a client with arthritis taking daily acetaminophen d. a client with pain from a kidney stone

a. a client with esophageal varices

Which statements about shock are true? select all a. affects all body organs b. occurs only in the acute care setting c. Is a whole body response to tissue hypoxia d. results from widespread abnormal cellular metabolism e. is classified as a disease rather than a discreet disorder f. may occur in older client in response to UTIs

a. affects all body organs c. Is a whole body response to tissue hypoxia d. results from widespread abnormal cellular metabolism f. may occur in older client in response to UTIs

Which specific drug therapy will the nurse anticipate for management of a client who has septic shock? a. antibiotics b. inotropics c. crystalloids d. antidysrhythmics

a. antibiotics

Which laboratory values in a client with hypovolemic shock will the nurse associated with the progressive stage of shock? select all a. arterial blood pH 7.32 b. serum lactate 9 c. sodium 147 d. BUN 15 e. potassium 6.3 f. neutrophil count 5,000

a. arterial blood pH 7.32 b. serum lactate 9 e. potassium 6.3

A client develops peritonitis and sepsis after the surgical repair of ruptured diverticulum. which signs would the nurse expect when assessing the client? select all a. fever b. tachypnea c. HTN d. abdominal rigidity e. increased bowel sounds

a. fever b. tachypnea d. abdominal rigidity

Which position would the nurse encourage for the client who has an above-the-knee amputation? a. functional alignment b. extended and abducted c. flexed and externally rotated d. hip raised when moving

a. functional alignment

Which changes in vital signs of a client in the early postoperative period indicates to the nurse that the client may be in the initial stage of hypovolemic shock? select all a. increased HR b. increased RR c. decreased systolic BP d. decreased urine output e. increased diastolic BP f. increased pulse pressure

a. increased HR b. increased RR e. increased diastolic BP

Which response would the nurse give to a client with full-thickness burn who several days after receiving an allograft points out that the graft is coming off the edges? a. it is a temporary graft; it is supposed to fall off b. you must have pulled it loose; ill notify your primary HCP c. An infection may be starting; I anticipate that antibiotics will be prescribed d. it is a permanent graft; it is likely that it will need to be replaced

a. it is a temporary graft; it is supposed to fall off

Which intervention would the nurse use for a client with full-thickness burns to the chest and anterior right arm? select all a. monitoring VS b. cutting off the clothing c. inserting a urinary catheter d. removing the clients jewelery e. establishing an intravenous line

a. monitoring VS b. cutting off the clothing c. inserting a urinary catheter d. removing the clients jewelery e. establishing an intravenous line

Which likely cause would the nurse suspect is responsible for a drop in BP after a client sustains multiple internal injuries in a MVA and the BP suddenly drops from 134/90 to 80/60? a. reduction in the circulating blood volume b. diminished vasomotor stimulation to the arterial wall c. vasodilation resulting from diminished vasconstrictor tone d. cardiac decompensation resulting from electrolyte imbalance

a. reduction in the circulating blood volume

Which newly admitted client does the nurse consider to be at highest risk for development of sepsis? a. 75 yr old with HTN and early Alzheimer dz b. 68 yr old who is 2 day post op from bowel surgery c. 54 yr old with moderate asthma and severe degenerative joint dz of the right knee d. 80 yr old community dweller with no other health problems undergoing cataract surgery

b. 68 yr old who is 2 day post op from bowel surgery

Which initial physiological change will the nurse expect in a client rescued from a burning building who has partial-and full-thickness burns over 40% of the body? a. an increase in blood volume b. an increase in serum potassium c. a decrease in capillary permeability d. a decreased in urinary specific gravity

b. an increase in serum potassium

for which client problems associated with hypovolemic shock will the nurse specifically prepare to administer a blood product rather than IV crystalloid? select all a. acidosis b. hypoxemia c. dehydration d. hypotension e. hyponatremia f. low hematocrit and hemoglobin levels

b. hypoxemia f. low hematocrit and hemoglobin levels

Which type of medication will the nurse anticipate the need to administer a client with cardiogenic shock who has an increased pulmonary artery pressure reading of 30mmHg? a. vasopressor b. loop diuretic c. antidysrhythmic d. beta-adrenergic blocker

b. loop diuretic

Which clinical symptom is a postoperative client indicate early sepsis with an excellent recovery if treated? a. reduced urinary output and increased respiratory rate b. low-grade fever and mild hypotension c. low oxygen saturation rate and decreased cognition d. localized erythema and edema

b. low-grade fever and mild hypotension

Which complication will the nurse anticipate when caring for a client in hypovolemic shock? a. hypokalemia b. metabolic acidosis c. respiratory alkalosis d. decreased PCO2 levels

b. metabolic acidosis

After an AKA of the right leg, a client reports pain in the right foot. which reason would the nurse explain to the patient for the phantom limb pain? a. tactile illusions are associated with severed blood vessels b. nerve endings in the limb are still intact and react to stimuli c. an unconscious phenomenon aids with grieving over the lost body part d. hallucinations are secondary to the emotional distress of the amputation

b. nerve endings in the limb are still intact and react to stimuli

Which information would the nurse recall when caring for a client who has a diagnosis of partial-thickness burns? a. partial -thickness burns requires grafting before they can heal b. partial-thickness burns are often painful, reddened, and have blisters c. Partial-thickness burns cause destruction of both the epidermis and dermis d. partial-thickness burns often take months of extensive treatment before healing

b. partial-thickness burns are often painful, reddened, and have blisters

Which clinical manifestation is associated with hypernatremia in burns? a. fatigue b. seizures c. paresthesias d. cardiac dysrhythmias

b. seizures

The nurse is teaching a clients family regarding the diagnosis of septic shock. which teaching will the nurse include? select all a. the blood cultures will tell us for sure if your loved one has septic shock b. the clients change in behavior and lethargy may be associated with septic shock c. antibiotics, as prescribed, will be started within the hour to treat sepsis d. an insulin drip has been started to keep the clients glucose as low as possible e. septic shock is easily treated with multiple antibiotics

b. the clients change in behavior and lethargy may be associated with septic shock c. antibiotics, as prescribed, will be started within the hour to treat sepsis

Which response would the nurse provide a client when asked the purpose of using buck traction before surgery? a. to reduce the fracture b. to immobilize the fracture c. to maintain abduction of the leg d. to eliminate rotation of the femur

b. to immobilize the fracture

A client returns from surgery, after a right below-the-knee amputation, with the residual limb straight, but elevated on a pillow to prevent edema. In which position would the nurse place the client after the first postoperative day? a. any position, as long as the residual limb remains immobilized b. turn client to the prone position for 15-20 minutes at least 3 x a day c. for short periods, position the client in the right side-lying position d. maintain elevation of the residual limb for a total of 3 days

b. turn client to the prone position for 15-20 minutes at least 3 x a day

When would the nurse begin ROM exercises when planning care to prevent deformities and contractures in a client with burns? a. when pain has lessened b. when VS are stable c. when skin grafts are healed d. when emotional status stabilizes

b. when VS are stable

*Full thickness deep burn:*

burns extend into the muscle and the bone -involves the muscle, tendon and bone S/S: -no pain -can be white, brown, or charred -*no blisters*

Which statement made by a client at high risk for hypovolemic shock is of greatest concern to the nurse? a. "I live alone in my house and my family lives in a different state" b. "Do you have any idea when I might go home? No one is feeding my cat" c. "Something feels wrong, but I'm not sure what is causing me to feel this way" d. "I would usually go golfing with my friends today. I hope they're not worried about me"

c. "Something feels wrong, but I'm not sure what is causing me to feel this way"

After a fire a client in the ED is diagnosed with smoke inhalation and has arterial blood gases that demonstrate an oxygen saturation of 91%, PaO2 of 75, PaCO2 of 45 and a pH of 7.35. which intervention would the nurse anticipate implementing? a. oral and tracheal suctioning b. intubation and mechanical ventilation c. oxygen admin by nasal cannula d. discharge teaching and follow up instructions

c. oxygen admin by nasal cannula

Which assessment has the highest priority for the nurse to preform to prevent harm when caring for a client in hypovolemic shock who is receiving IV sodium nitroprusside? a. asking about chest pain b. determining mental status c. checking BP q 15 min d. checking extremities for color and perfusion

c. checking BP q 15 min

Which complication would the nurse consider in a client who just has a hip replacement and is experiencing restlessness and changes in mentation? a. bladder spasms b. polycythemia vera c. hypovolemic shock d. pulmonary HTN

c. hypovolemic shock

A postoperative client is admitted to the ICU with hypovolemic shock. Which nursing action will the nurse delegate to an experienced assistive personal (AP)? a. assess level of alertness b. obtain vital sings every 15 min c. measure hourly urine output d. check oxygen saturation

c. measure hourly urine output

What is the nurse's best first action when a client who has sepsis is found to have a blood glucose level of 310 mg/dL? a. check the electronic health record to determine when the last dose fo antidiabetic drug was given b. ask the family member how long the client has had diabetes c. notify the primary HCP d. document the findings as the only action

c. notify the primary HCP

Which problem places a client at highest risk for sepsis? a. client owns an iguana b. pericarditis c. post kidney transplant d. pernicious anemia

c. post kidney transplant

A client has a new synthetic leg cast for a right fractured tibia. what health teaching will the nurse include before discharge to home? select all a. elevate your right leg as often as possible to reduce swelling b. report increased pain or burning sensation under your cast c. use use on the affected leg for the first 24-36 hrs d. do not bear weight on the affected leg until instructed to do so e. do not cover the cast when you are in bed; keep it open to air to dry

c. use use on the affected leg for the first 24-36 hrs d. do not bear weight on the affected leg until instructed to do so

Which percentage of TBSA would the nurse calculate for a burn victim who has waxy white areas interspersed with pink and red areas on the anterior trunk and all of both arms? a. 20 b. 25 c. 30 d. 36

d. 36

A client with a fractures head of the right femur is placed in Buck tension. which action would the nurse take? a. remove the weights from the traction every 2 hrs to promote comfort b. turn the client from side to side every 2 hrs to prevent pressure on the coccyx c. raise the knee gatch on the bed every 2 hrs to limit the shearing force of traction d. assess the affected leg every 2 hrs to ensure adequate tissue perfusion

d. assess the affected leg every 2 hrs to ensure adequate tissue perfusion

Which specific client symptom indicates to the nurse that septic shock may be present? a. hypotension b. pale, clammy skin c. anxiety and confusion d. oozing of blood at the IV site

d. oozing of blood at the IV site

Which assessment finding after an open reduction and internal fixation (ORIF) of a fractured hip would cause the nurse to suspect and monitor s/s of a fat embolism? a. fever and chest pain b. positive Homans sign c. loss of sensation in the operative leg d. tachycardia and petechiae over the chest

d. tachycardia and petechiae over the chest

MEWS:

Modified early warning system -An increased score = an increased risk for sepsis

Chemical burns:

-Occurs d/t exposure to corrosive acid-alkaline solutions -Severity is based on the kind of chemical and are of exposure Types of chemicals that can cause burns: -bleach -ammonia -mold and mildew cleaner -draino -other drain cleaners -furniture polish -laundry detergent -toilet cleaners

Dx for burns:

-Ophthalmic consult is the burn has affected the eyes -chest x-ray -CT scan/ MRI after acute stage to guide rehabilitation

Which type of burn injury should be followed up by scheduling the client for an electrocardiogram (ECG)? a. flame burn b. chemical burn c. electrical burn d. radiation burn

c. electrical burn

Which nursing action would be included in the plan of care to promote nutritional status of a client during the acute phase of treatment for extensive burns? a. provide a diet high in sodium b. limit caloric intake to decrease the work of the body c. reduce protein intake to avoid overtaxing the kidneys d. administer the prescribed IV fluid with the added vitamin C

d. administer the prescribed IV fluid with the added vitamin C vitamin C is essential for wound healing

*Lab testing for burns:*

-CMP -CBC -ABG's -ongoing monitoring for electrolyte imbalances, signs of infection, and fluid volume status -*hyponatremia --> happens because water is shifting out of interstitial space* -*hyperkalemia --> will happen immediately after burn because massive cell damage potassium leaks out (within 3 days they will become hypokalemic) -*hyperglycemia --> glucose stores are exhausted to meet demand; the liver increases gluconeogenesis* -*elevated hematocrit --> because burns impair microcirculation, capillary stasis occurs leading to ischemia and necrosis *

*Middle s/s of sepsis:*

-Cardiac output increases as compensation for capillary leakage -BP & RR improves -No cyanosis, extremities pink and warm -WBC values decrease -Underlying cellular changes -*Subtle decrease in O2 stat* -*Decreased to absent urine output* -Slight changes in mental status

Potential complications of shock:

-MODs -Anoxic encephalopathy -ARDs (because theres an inadequate V/Q perfusion) -Myocardial pump failure (myocardial depressants are released from the pancreas) -Acute tubular necrosis (results from decreased renal perfusion) -DIC (platelet consumption) -Rhabdomyolysis (skeletal muscle breakdown) -Profound sepsis (from decreased macrophage effectiveness) -Paralytic ileus (from decreased peristalsis) -Liver failure

*Labs for rhabdomylosis*

*Creatinine kinase:* -highly sensitive to muscle injury -will begin to rise within 2012 hrs of onset of injury and will reach its max in 4-72 hrs *Myoglobin:* -has a short half life so it needs to be caught quickly -will begin to rise before CK and return to baseline while CK is still continuing to increase -when plasma myoglobin levels exceed 1.5 mg/dL youll see *tea colored urine* -25-77 ng/mL CBC --> WBC and monocytes will be elevated CMP --> electrolyte imbalances *(Hyperkalemia and hypercalcemia)* BUN/ Cr --> for AKI (creatinine will be elevated) Uric acid --> will be elevated if rhabdo ESR & CRP --> for inflammation Urinalysis Toxicology PT/ PPT --> rhabdo can progress to DIC

Surgical treatment for Burns:

*Escharotomy* -edema resulting from a burn causing compartment syndrome -eschar is stiff, dead skin tissue caused by deep 2nd or 3rd degree burns -eschar on a limb constricts distal circulation -eschar on the thorax constricts respiration -a surgical incision is made through the eschar to relieve the constriction Debridement: -as the body begins to heal the burn we have to remove the eschar tissue or else it will lead to tissue necrosis Skin grafting: -may need skin grafts depending on the burn Reconstructive surgery

*Treatment for rhabdomylosis:*

Goal --> prevent continuous release of myglobin and preserve renal function *fluid resuscitation --> isotonic NS, up to 10L of fluid/ day to maintain urine output 200-300 mL/hr until CK levels stabalize

Flap vs. guillotine amputations:

Guillotine: -done emergently a straight cut -need skin graft to cover the stump Flap: -some of the skin and tissue is preserved to flap over the stump and suture

Recognizing and responding to anaphylaxis:

If any of these symptoms occur give an epi pen subcut or IM -The dose can be repeated after 5 minutes if symptoms continue or rebound -SOB, wheezing, or repetitive cough -pale/ bluish skin, faintness, weak pulse, or dizziness -Tight or hoarse throat, trouble breathing/ swallowing -Hives/ widespread redness -Repetitive vomiting or severe diarrhea

Surgical treatment for fractures:

Internal fixation: -can have allergic response, rejection response, and increased risk for infection because a foreign object is being placed into the body -oped reduction internal fixation (ORIF) External fixation: -temporary Hardware: -pins or rods Closed reduction with sedation Traction: -uses weight to help pull the bone ends together to *prevent muscle spasms* Bucks traction: -common in hip and femur fractures -pre-op to reduce spasms and prevent complications -velcro boot with 5-10Ibs -weight needs to be hanging freely Russels traction: -common in hip and femur fractures -pre op to reduce spasms and prevent complications -uses a sling under the back or pelvis area and a sling under the knee -up at an angle

Labs for shock:

Labs will reflect the underlying causes but there are no specific lab values for diagnosis CBC: -dehydration --> look at H&H -sepsis --> WBC Chem panel: -for dehydration look at electrolytes Lactate ABGs

Risk factors for distributive shock:

Look at the underlying cause -Neurogenic --> spinal cord injury or head trauma -Septic --> chemical induced (bacterial toxins) & sepsis -Anaphylaxis --> allergy

Dx testing for shock:

Look for the underlying cause -CT -MRI -Ultrasound -Chest X-ray

Serum lactate:

Measures aerobic and anaerobic metabolism -Lactate is a byproduct of anaerobic metabolism -Lactic acidosis = metabolic acidosis = high anion gap Normal --> 0.6- 1.8 *Hyperlactemia --> >2* (if they have sepsis) -A decrease in lactate over the 1st 5 days of admission is a good prognosis marker of survival

MODs:

Multiple organ dysfunction syndrome There are 6 organ systems that characterize mods: -Respiratory -Renal -Cardiovascular -Neurological -Hepatic -Hematologic --> DIC

*Types of fractures:*

Normal Transverse: -straight across; a clean break Oblique: -diagonal clean break Spiral: -the break is twisted and looks spiraled (an indication of child or elderly abuse) Communicated: -typically requires surgical repair -can happen from a compression fracture Avulsion: -the end tip of the bone comes off; common place for this to happen is the radial styloid on the wrist -will cause lots of pain and decreased ROM Impacted: -happens from compression; the bone breaks in half and is compressed causes striated breakage Fissure: -cracks in the middle of the bone Greenstick: -happens in pediatric patients because their bones are soft

*Late S/S of sepsis:*

Septic shock --> to MODS -Rapid decline (minutes to hrs) -Hypotension MAP <60 -Decreased cardiac output -Widespread microthrombi, clotting/ bleeding cascade -Anaerobic metabolism state, lactic acidosis (getting a lactic acid is our best indicator of anaerobic metabolism) -Increased oxygen demand -Stress response --> glucose liver reserves, hyperglycemia -DIC --> bleeding a clotting cascade (petechiae, purpura, bleeding from mucus membranes) -Respiratory distress --> ARDs -Shock --> hypotension, pallor, cyanosis, decreased cardiac output

*Superficial burns:*

Similar to a 1st degree burn (top layer involving the epidermis) S/S: -Red -Painful -Warm -*No blistering* -Will blanch -Typically will heal on its own

*Deep partial thickness burns:*

Similar to a 2nd degree burn --> the burn goes through the dermis S/S: -mottled or cherry red -can blister but is less likely -wound surface is mottled pink immediately after the injury -blanching is minimal or nonexistent d/t capillary damage -reduced sensation and minimal pain

*Full thickness burn:*

Similar to a 3rd degree burn --> goes through the dermis and subcutaneous tissue -involves the epidermis, dermis, and subcutaneous tissue S/S: -white leathery or black eschar, charred -*NO blanching, blisters, or pain*

Phantom limb pain:

The pain is real --> TREAT IT -*opioids are not effective* -IV calcitonin 1 wk post op (thought to sooth the neuro pathway and decrease the amount of pain) -beta blockers --> for dull burning pain -gabapentin --> knifelike sharp pain -baclofen --> for cramping muscle spasms -antidepressants -TENS (transcutaneous electrical nerve stimulation) therapy

Smoke related burns:

These burns are significant -exposure to smoke created injury to the upper airways or chemical injury to the airways -airway management is the priority action for a patient with a smoke related injury -we cannot rely on O2 sat is we suspect carbon monoxide poisoning because % will probably be normal (known as utilization)

Burns:

Tissue deconstruction results for coagulation, protein denaturation, or ionization -Localized burn --> <20% of TBSA -Systemic burn --> >20% TBSA -causes tissue edema, infection, and can progress to burn injury -fluid resuscitation is needed for treating burns because it can cause hypovolemic shock

*Rule of 9's:*

Used to estimate TBSA (total body surface area) of a burn -typically used for partial thickness and full thickness burns Purpose of the rule of 9's: -guide patient care -estimate fluid resucitation -determine if the patient requires care at a specialized burn center *Adult percentages:* -Anterior and posterior head and neck: 9% -Posterior head and neck: 4.5% -Anterior head and neck: 4.5 % - Anterior torso: 18% -Posterior torso: 18% -Upper extremities: 9% for each arm -Anterior arm: 4.5% -Posterior arm: 4.5% -Lower extremity: 18% for each leg -Anterior leg: 9% -Posterior leg: 9% -Perineum: 1%

Which client will the nurse recognize as having a higher risk for obstructive shock? a. 32 yr old with pulmonary embolus b. 42 yr old with stable angina c. 52 yr old with chronic afib d. 72 yr old with hx of heart failure

a. 32 yr old with pulmonary embolus

Which changes in condition will the nurse teach a client who is being discharge after successful management of sepsis to check daily as an indicator of a new or ongoing infection? select all a. SOB b. temperature elevation c. cloudy, foul-smelling urine d. new onset of productive cough e. paleness or blue tinge to mouth membrane f. redness and tenderness of an open skin lesion

a. SOB b. temperature elevation c. cloudy, foul-smelling urine d. new onset of productive cough e. paleness or blue tinge to mouth membrane f. redness and tenderness of an open skin lesion

Which GI changes may be found in the client with burn injuries? a. abdominal distention b. increased peristalsis c. activation of GI motility d. Increased blood flow to the GI area

a. abdominal distention

Which clinical manifestation would the nurse expect when assessing a client who is diagnosed with cardiogenic shock? select all a. tachycardia b. restlessness c. warm, moist skin d. decreased urinary output e. bradypnea

a. tachycardia b. restlessness d. decreased urinary output

Which information will the nurse share with a client who sustained a burn and asks, "what is the difference between by full-thickness and deep partial thickness burns?" a. full-thickness burns extend into the subcutaneous tissue; deep partial-thickness burns affect only the epidermis b. full-thickness burns involve superficial layers of the epidermis; deep partial-thickness burns extend through the epidermis c. full-thickness burns extend through the epidermis and only part of the dermis; deep partial-thickness burns extend into the subcutaneous tissue d. full-thickness burns extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve parts of the dermis

d. full-thickness burns extend into the subcutaneous tissue; deep partial-thickness burns extend through the epidermis and involve parts of the dermis

Which blood product type does the nurse anticipate will be ordered to infuse first in a client who has septic shock with poor clotting and hemorrhage? a. packed red blood cells (PRBCs) b. fresh frozen plasma (FFP) c. clotting factors d. platelets

d. platelets

For which change in condition will the nurse teach a client who is discharged and continued risk for fluid loss, to check for daily at home? a. elevated temp and itchiness b. loss of taste and sensation and appetite c. numbness of the fingers and toes d. reduced urine output and light headedness

d. reduced urine output and light headedness

Which statement reflects understanding of sepsis screening requirements by the nurse? a. blood cultures are required to diagnosis sepsis and begin sepsis protocols b. an oral temp of 96.4 is not an indicator of sepsis c. a primary HCPs prescription is required to screen for sepsis d. sepsis mortality is affected greatly by treatments preformed in the 1st 6 hrs

d. sepsis mortality is affected greatly by treatments preformed in the 1st 6 hrs

Non-surgical treatment for shock:

*For all causes --> 1st line treatment hemodynamic stabilization* -fluid restriction -vasopressor--> norepinephrine 1st line vasopressor for septic shock -inotropes Treat the underlying cause: Hypovolemic shock: -Blood transfusion --> for hemorrhage -Antiemetics --> for vomiting -Antidiarrheals --> for diarrhea -Fluid replacement Obstructive shock: -Chest tube -Pericardiocentesis -Thoracentesis --> for pleural effusion -Pericardial window -Surgical thoracotomy --> if theres a large volume of blood -TAA/ AAA --> if causes by aneurysm Cardiogenic shock: -Cardiac stent -CABG -Valve repair -antiarrhythmics --> for dysrhythmias Septic shock: -Antibiotics Neurogenic shock: -C-spine -Immobilization -Surgical decompression -Have pt lay supine with the legs elevated

Risk factors for hypovolemic shock:

-Hemorrhage -GI bleed -Trauma -Surgery -Dehydration -Vomiting -Diarrhea -Diuretics -Diabetes insipidus --> results in large amts of urine output and leaves the pt dehydrated

Potential complications for DIC:

-Hypovolemic shock -MODS -Thrombosis -Bleeding

Nursing interventions for shock:

-Maintain hemodynamic stability -Oxygen therapy -Obtain/ maintain IV access -Monitor I & O (will help us determine if the kidneys are being perfused)

Stages of shock:

1. Initial --> no visible changes in the client status, changes are occurring at the cellar level only 2. Compensatory --> body is trying to compensate to increase cardiac output and restore tissue perfusion and oxygenation (increased HR and RR) 3. Progressive --> compensatory mechanisms begin to fall -BP decreased -HR increases -decreased urine output -changes in LOC 4. Refractory --> IRREVERSIBLE, total body failure -multi organ failure that can progress to death

S/S shock:

Varies according to the type and stage of shock -Hypotension -Tachycardia -Tachypnea -Obtundation or abnormal mental status -Cold, clammy extremities, mottled skin -Oliguria Hypovolemic shock: -Pallor, skin tenting, bleeding (high HR is most concerning VS for these pts) Obstructive Shock: -Pleuritic chest pain -Absent/ diminished breath sounds -Tracheal deviation -Beck's triad --> JVD, hypotension, muffled heart sounds Cardiogenic shock: -Chest pain -Lung crackles -Significant arrhythmias Septic shock: -Infection -SIRS Anaphylactic shock: -Flushing -Urticaria -Hoarse voice -Oral and facial edema -Wheeze -Inspiratory stridor Neurogenic shock: -Head or spinal trauma -Guillian Barre syndrome -Spinal anesthesia

DIC:

Widespread (systemic) hypercoagulable state that can lead to both microvascular and macrovascular clotting and compromised blood flow -consumption of clotting factors in a positive feedback loop causing hemorrhage and thrombosis cocurrently

Shock:

a *syndrome* not a disease -body tissues are not sufficiently perfused -oxygen demands exceed availability -the initial response is organ compensation --> without oxygenation shock progresses to MODS (multi organ dysfunction syndrome) & death

Which type of burn would the nurse suspect in a client admitted with a burn injury that has erythema and mild swelling? a. 1st degree burn b. 2rd degree burn c. 4th degree burn d. 2nd degree burn

a. 1st degree burn

Which information would the nurse need to consider about electrical burns when assessing the entrance and exit wounds of a client admitted after occurring electrical burns to both hans while playing golf during a lightning storm? a. cause severe nervous tissue destruction along a path of least resistance b. result in severe destruction when the burn is incurred by direct current c. cause a line of destruction beginning at the grounding point to the point of contact d. result in visible dermal wounds that denote the internal electrical current destruction

a. cause severe nervous tissue destruction along a path of least resistance

Which point would the nurse include in a teaching plan to help manage pain during dressing changes if a client has burns over 18% of body surface? a. deep breathing exercises b. progressice muscle relaxation c. active ROM d. important elements of wound care

a. deep breathing exercises

Which physiological response occurs first when a client experiences sudden hypovolemia caused by hemorrhage? a. peripheral vasoconstriction b. elevation of serum cortisol level c. release of immature erythrocytes d. increased antidiuretic hormone (ADH)

a. peripheral vasoconstriction

Which condition would the nurse determine the client is likely developing when exhibiting restlessness two days after being admitted to the hospital for a severe burn? a. renal failure b. hypervolemia c. cerebral hypoxia d. metabolic acidosis

c. cerebral hypoxia

Which finding by the nurse who is caring for a client after major abdominal surgery may indicate impending hypovolemic shock? a. urine output 1000 mL in 8 hrs b. oral temp 101 c. client report of feeling very thirsty d. bounding radial and femoral pulses

c. client report of feeling very thirsty

The nurse is caring for a client who has an above-the-knee amputation a week ago. Which action would the nurse take to control edema of the residual limb? a. admin diuretic as needed b. restrict the clients oral fluid intake c. rewrap the elastic bandage as necessary d. keep the residual limb elevated on a pillow

c. rewrap the elastic bandage as necessary

Which assessment finding supports the nurse's conclusion that a prosthesis for a client with an above-the-knee amputation fits correctly? a. skin that is cool to the touch b. shrinking of the residual limb c. absence of phantom limb pain d. evenly darkened skin of the residual limb

d. evenly darkened skin of the residual limb

The nurse is caring for a postoperative client at risk for hypovolemic shock. which assessment indicates an early sign of shock? a. first-degree heart block b. blood pressure 100/48 c. respiratory rate 12 breaths/min d. heart rate 120 beats/min

d. heart rate 120 beats/min

Which type of shock is associated with a ruptured abdominal aneurysm? a. vasogenic shock b. neurogenic shock c. cardiogenic shock d. hypovolemic shock

d. hypovolemic shock

Which is the best response by the nurse when a carpenter with full-thickness burns of the entire right arm confides, "I'll never be able to use my arm again and I'll be scared forever?" a. the staff is taking steps to minimize scaring b. think about how lucky you are. you are alive c. try not to worry for now. concentrate on your ROM exercises d. i know you're worried, but it is too early to tell how much scarring will occur

d. i know you're worried, but it is too early to tell how much scarring will occur

*Trauma: Rhabdomyolysis:*

*trauma (direct physical damage to the muscle itself) leaking the contents into the extracellular space and bloodstream* *fluid shift creates cellular edema (influx of sodium and calcium into the cell wall)* *when the cell dies it breaks apart sending potassium, calcium, myoglobin, uric acid, creatinine kinase, and other materials into circulation*

Facture complications:

-Pressure necrosis (occurs when the cast is too tight; will develop a hot spot and will be painful in a specific area from cast compression; can lead to necrosis if not taken off and changed) -*Infection --> warm to touch, malodorous, avoid scratching under the cast* -infection can progress to cellulitis and osteomyelitis -peripheral nerve damage -decreased mobility -joint contractures -osteoarthritis -osteoporosis -muscle atrophy -hemorrhage (can have bleeding within the bone or within the soft tissue around it) -DVT & PE

Potential complications for sepsis:

-Progression to MODs -Death -Some individuals may have life long lasting effects like amputations or organ dysfunction Post sepsis syndrome: -Insomnia, difficulty getting to sleep or staying asleep -Nightmares, vivid hallucinations and panic attacks -Disabling muscle and joint pain -Extreme fatigue -Poor concentration -Decreased mental function -Loss of self-esteem and self-belief

Nursing interventions for DIC:

-Reposition -Therapeutic communication -Oxygen -IV fluids -Blood products -Gental oral care -Relieve pressure points -Frequent assessments (thrombosis, bleeding, hemodynamics)

Lab testing for SIRS, MODs, & sepsis:

-WBC --> can be elevated >12,000 or <4,000 -Elevated prolactonin -*Elevated glucose* -*Elevated serum lactate* -Elevated anion gap -Urinalysis -Cultures (urine, *blood*, sputum, and wounds) -ABGs --> if respiratory is involved Late findings in labs: -Renal failure --> creatinine and BUN -Liver failure --> AST & ALT -DIC --> H&H, platelets, INR, PTT -Electrolyte imbalances

S/S of a fracture:

-pain -decreased mobility -muscle spasms -ecchymosis -edema (depends on the amount of impaired tissue) -impaired perfusion (biggest concern) -visual deformity

*Classification of burns; degrees and thickness: 1st, 2nd, 3rd, and 4th degree*

1st degree: only the epidermis is damaged (the top layer of the skin), *no blisters* 2nd degree: burn extends to the dermis, red mottled areas with possible pale, immediate blistering 3rd degree burn: epidermis, dermis and subcutaneous tissue damage, white, red or black with leathery areas, painless d/t nerve damage, will require skin grafting , *no blisters* 4th degree burn: burn destroys epidermis, dermis, subcutaneous tissue, tendons, muscle, and bone, black with charred areas, painless, requires skin grafting

Which finding indicated that a client with 35% of total body surface area burned in a fire and now 48 hrs postburn is moving from the emergent to the acute phase of burn management? a. hypokalemia b. hypoglycemia c. decreased BP d. increased urine specific gravity

a. hypokalemia

Which action will the nurse take to promote comfort in a client with burns over 35% of the body who reports chills? a. limit room drafts b. place a sterile top sheet over the client c. decrease the room humidity to less than 10% d. maintain an 80 degree room temp

a. limit room drafts

SIRS:

Systemic inflammatory response syndrome (anything thats a syndrome is a sequence of events) -Inflammation at the site if injury/ infection (a localized response is a good thing but when the inflammation becomes too much for the body to handle, it becomes systemic and inflammation enters the bloodstream) -Systemic inflammation in the blood stream causes extensive tissue and vascular changes throughout the body -*Harmful and deadly* -W/ or w/out infection (sepsis) can lead to MODs Causes of SIRS: -Infection -Inflammatory dz -Massive tissue injury and ischemia --> trauma -Multiple transfusions -Burns -Neoplasia --> cancers

Which body area on a client with darker skin who is at high risk for shock will the nurse examine for indications of pallor and cyanosis? a. oral mucous membranes b. soles of hands and feet c. earlobes and bridge of the nose d. sclera closest to the inner corner of the eye

a. oral mucous membranes

Which clinical finding would the nurse expect when assessing a client who has cardiogenic shock? select all a. pallor b. agitation c. tachycardia d. narrow pule pressure e. decreased respirations

a. pallor b. agitation c. tachycardia d. narrow pule pressure

Which subjective symptom will the nurse expect to find in the compensatory stage of hypovolemic shock? a. thirst b. hunger c. headache d. numbness in fingers and toes

a. thirst

Which actions are priorities for the nurse to preform to prevent harm for a client with hypovolemic shock who is receiving an infusion of dobutamine? select all a. assessing hourly urine output b. assessing for chest pain throughout the infusion c. covering the infusion bag to protect it from light d. measuring BP at least q 15 min e. ensuring the drug is infused only with lactated ringers f. checking the infusion site q 30 min for extravasation

b. assessing for chest pain throughout the infusion d. measuring BP at least q 15 min f. checking the infusion site q 30 min for extravasation

Which assessment finding would the nurse expect to see in a client admitted to the hospital because of electrical burns? select all a. coughing b. burn odor c. smoky breath d. leathery skin e. cardiac arrest

b. burn odor d. leathery skin e. cardiac arrest

Which finding will the nurse expect when caring for a client who is in hypovolemic shock? a. slow HR b. cool skin temp c. bounding radial pulses d. increased urine output

b. cool skin temp

Which change in laboratory values or clinical symptoms in a client with hypovolemic shock indicates to the nurse that current therapy may need to be changed? a. urine output increases from 5 mL/hr to 6 mL/hr b. pulse pressure decreases from 28 mmHg to 22 mmHg c. serum potassium level increases from 3.6 to 3.9 d. core body temperature increases from 98.2 to 98.8

b. pulse pressure decreases from 28 mmHg to 22 mmHg

Which psychological factor helps maintain BP in the client with hypovolemia? select all a. arteriolar dilation b. release of aldosterone c. activation of angiotensin II d. sympathetic nervous system activation e. stimulation of the vagus nerve

b. release of aldosterone c. activation of angiotensin II d. sympathetic nervous system activation

Which area is most important for the nurse to assess for fluid balance in a client with full-thickness burns on the anterior trunk and thigh when monitoring fluid balance during the first 2-3 days after the burn? a. weight every day b. urinary output q hr c. BP q 15 min d,. extent of peripheral edema q 4 hrs

b. urinary output q hr

Which client does the nurse consider to be at highest risk for neural-induced distributive shock? a. 25 yr old receiving 500 mg of penicillin IV b. 47 yr old with sudden-onset severe chest pain and dyspnea c. 21 yr old who has received 4 mg of morphine IV for acute pain d. 82 yr old who has had severe vomiting and diarrhea for 2 days

c. 21 yr old who has received 4 mg of morphine IV for acute pain

Which fluid therapy will the nurse prepare to infuse when a client with hypovolemic shock has a hematocrit of 25%? a. lactated ringer solution b. human serum albumin 5% c. packed RBCs d. high molecular weight dextran

c. packed RBCs

Which complication is the client at high risk for when sepsis has developed after severe burn injuries? a. diarrhea b. constipation c. paralytic ileus d. malabsorption syndrome

c. paralytic ileus

Which distinguished sign unique to a fat embolism will a nurse monitor for in a client with a distal femoral shaft fracture who is at risk for developing a fat embolus? a. oliguria b. dyspnea c. petechiae d. confusion

c. petechiae

Which symptom in a client with sepsis does the nurse consider a late indication of septic shock? a. warm skin b. bounding pulse c. severe hypotension d. decreased urine output

c. severe hypotension

Which sign indicates to the nurse that fluid replacement therapy is adequate when assessing a client during the first 24 hrs after a burn injury? a. decreasing central venous pressure (CVP) reading b. hematocrit increasing from 50% to 55% c. slowing of a previously rapid pulse d. urinary output of 15-20 mL/hr

c. slowing of a previously rapid pulse

The nurse is caring for a client with hypovolemic shock that is bleeding from a traumatic injury to the chest wall. what is the priority nursing action? a. Insert a large bore IV catheter b. administer supplemental oxygen c. elevate the clients feet, keeping the head flat d. apply direct pressure to the area of overt bleeding

d. apply direct pressure to the area of overt bleeding

When caring for a client who is obtunded and admitted with shock of unknown origin, which action will the nurse take first? a. obtain IV access and hang prescribed fluids b. assess level of consciousness and pupil reaction to light c. apply the automatic blood pressure cuff d. check the airway and respiratory status

d. check the airway and respiratory status