medical emergencies ICP and burns
____ occurs when the brain's ability to autoregulate become ineffective and decompensation (ischemia and infarction) begins. what is this composed of?
-Cushing's triad (are the three signs and this is a late sign of increased ICP) -Signs: significant mental status changes and vital signs; bradycardia, hypertension (elevated diastolic), and bradypnea (on ppt also has irregular respirations and widening pulse pressure which is the difference between systolic and diastolic)
______ posture is an abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backward. The muscles are tightened and held rigidly. This type of posturing usually means there has been severe damage to the brain. (sign of what?)
-Decerebrate -symptom before death with increased ICP
_____ posture is an abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight. The arms are bent in toward the body and the wrists and fingers are bent and held on the chest. This type of posturing is a sign of severe damage in the brain. (sign of what?)
-Decorticate -symptom before death with increased ICP
describe the rule of nines with burns? (each %)
-Head: 9% -Anterior abdomen: 18% -Posterior abdomen: 18% -Each arm: 9% -Peri: 1% -Each leg: 18%
what are the symptoms before death, that are associated with increased ICP?
-decorticate -decerebrate -fixed dilated pupils
the setting of the water heater temperature should be no higher than _____
120 degree F (48.9 degree C)
the exposure to a temp. of 130 degree F for ____ will result in a burn
30 secs
The nurse is caring for a patient who sustained a moderate head injury following a bicycle accident. The nurses most recent assessment reveals that the patients respiratory effort has increased. What is the nurses most appropriate response? A) Inform the care team and assess for further signs of possible increased ICP. B) Administer bronchodilators as ordered and monitor the patients LOC. C) Increase the patients bed height and reassess in 30 minutes. D) Administer a bolus of normal saline as ordered.
Ans: A Feedback: Increased respiratory effort can be suggestive of increasing ICP, and the care team should be promptly informed. A bolus of IV fluid will not address the problem. Repositioning the patient and administering bronchodilators are insufficient responses, even though these actions may later be ordered.
The current phase of a patients treatment for a burn injury prioritizes wound care, nutritional support, and prevention of complications such as infection. Based on these care priorities, the patient is in what phase of burn care? A) Emergent B) Immediate resuscitative C) Acute D) Rehabilitation
Ans: C Feedback: The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care (i.e., wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound dbridement, and wound grafting), pain management, and nutritional support are priorities at this stage. Priorities during the emergent or immediate resuscitative phase include first aid, prevention of shock and respiratory distress, detection and treatment of concomitant injuries, and initial wound assessment and care. The priorities during the rehabilitation phase include prevention of scars and contractures, rehabilitation, functional and cosmetic reconstruction, and psychosocial counseling.
changes in ICP are closely linked with _____
CPP (cerebral perfusion pressure)
____ states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others
Monro-Kellie hypothesis
_____ is the brain's ability to change the diameter of its blood vessels to maintain a constant cerebral flow during alterations in systemic blood pressure
autoregulation
how could decreased venous outflow increase ICP?
because if there is decreased venous outflow then most of the outflow that is actually happening is going to be shunted from all the other organs just to the heart, brain, and lungs. This increases cerebral blood volume with increased ICP
what would be the characteristics of second-degree burns?
blisters, mottled red base, weeping, disrupted epidermis, edema
how do you calculate CPP (cerebral perfusion pressure?)
by subtracting the ICP from the MAP (mean arterial pressure) (ex.: if the MAP is 100 and ICP is 15 then the CPP is 85)
since there is limited space to expand in brain tissue, displacing or shifting _____, increasing the absorption or diminishing the production of ______ , or decreasing cerebral blood volume are used to accomplish compensation, and without these ICP begins to rise
cerebral spinal fluid
what is the earliest sign of increasing ICP?
change in LOC (agitation, slowing speech, and delay in response to verbal suggestions are other early indicators)
_____ is a clinical phenomenon and is seen when cerebral blood flow decreases significantly
cushing's response
fourth-degree burns are also known as _____
deep burn necrosis
what are the characteristics of a third-degree burn?
dry, pale white, red brown, leathery, or charred, edema, and coagulated blood vessels may be present
_____ is the term for surgical removal of tissue
excision
what happens in the early stages of cerebral ischemia due to decreased cerebral blood flow because of ICP?
the systemic pressure rises to maintain cerebral blood flow and is usually accompanied by a slow bounding pulse and respiratory irregularities
with which type of burns is there no pain because the burned area lacks sensation since the nerve fibers are damaged?
third and fourth degree
_____ burns involve total destruction of the epidermis and dermis and, in some cases, destruction of the underlying tissue
third-degree
what is the important goal of nurses in the community and home on prevention of burns?
to provide education about the prevention of burn injuries, especially with older adults (chart 62-1 pg 1807)
what would be known as a negative Nikolsky's sign?
with a burn, when the epidermis is rubbed the burned tissue does not separate from the underlying dermis (this is with first-degree)
_____ continue to have an increased morbidity (illness) and mortality (death) when compared to other age groups with similar injuries
young children and older adults
what is the medical management of increased ICP?
-administering osmotic diuretics -restricting fluids -draining CSF -controlling fever -maintaining systemic blood pressure and oxygenation -reducing cellular metabolic demands
what compensatory mechanisms are used when there is ICP due to cerebral edema?
-autoregulation (the brain's ability to change the diameter of its blood vessels to maintain a constant cerebral flow during alterations in systemic blood pressure) -decreased production and flow of CSF
Intracranial pressure is usually measured in the _____, with the normal pressure being _____
-lateral ventricles -0 to 10 mm Hg
the brain can maintain a steady perfusion pressure if the arterial systolic pressure is ______ and the ICP is _____
-systolic is 50-150 -if the ICP is less that 40
what factors contribute to the severity of a burn? (7)
1.) age of the patient 2.) depth of the burn 3.) amount of surface area of the body that is burned 4.) the presence of inhalation injury 5.) presence of other injuries 6.) location of injury in areas such as the face, the perineum, hands, or feet 7.) the presence of past medical history
what can increased ICP cause? (3)
1.) decreases cerebral perfusion 2.) stimulates further swelling (edema) 3.) and may shift brain tissue resulting in herniation
the exposure to a temp. of 140 degree F for ____ will result in a burn
5 secs (this is what most hot water heater are set on, but should be set on 120 F)
A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort? A) Education about home safety B) Education about safe storage of chemicals C) Education about workplace health threats D) Education about safe driving
Ans: A Feedback: A large majority of burns occur in the home setting; educational interventions should address this epidemiologic trend
A nurse on a burn unit is caring for a patient in the acute phase of burn care. While performing an assessment during this phase of burn care, the nurse recognizes that airway obstruction related to upper airway edema may occur up to how long after the burn injury? A) 2 days B) 3 days C) 5 days D) 1 week
Ans: A Feedback: Airway obstruction caused by upper airway edema can take as long as 48 hours to develop. Changes detected by x-ray and arterial blood gases may occur as the effects of resuscitative fluid and the chemical reaction of smoke ingredients with lung tissues become apparent.
A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurses immediate, priority concern when planning this patients care? A) Fluid status B) Risk of infection C) Nutritional status D) Psychosocial coping
Ans: A Feedback: During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.
The nurse has created a plan of care for a patient who is at risk for increased ICP. The patients care plan should specify monitoring for what early sign of increased ICP? A) Disorientation and restlessness B) Decreased pulse and respirations C) Projectile vomiting D) Loss of corneal reflex
Ans: A Feedback: Early indicators of ICP include disorientation and restlessness. Later signs include decreased pulse and respirations, projectile vomiting, and loss of brain stem reflexes, such as the corneal reflex.
A patient in the emergent/resuscitative phase of a burn injury has had blood work and arterial blood gases drawn. Upon analysis of the patients laboratory studies, the nurse will expect the results to indicate what? A) Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis B) Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis C) Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis D) Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis
Ans: A Feedback: Fluid and electrolyte changes in the emergent/resuscitative phase of a burn injury include hyperkalemia related to the release of potassium into the extracellular fluid, hyponatremia from large amounts of sodium lost in trapped edema fluid, hemoconcentration that leads to an increased hematocrit, and loss of bicarbonate ions that results in metabolic acidosis.
When caring for a patient with increased ICP the nurse knows the importance of monitoring for possible secondary complications, including syndrome of inappropriate antidiuretic hormone (SIADH). What nursing interventions would the nurse most likely initiate if the patient developed SIADH? A) Fluid restriction B) Transfusion of platelets C) Transfusion of fresh frozen plasma (FFP) D) Electrolyte restriction
Ans: A Feedback: The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH. SIADH requires fluid restriction and monitoring of serum electrolyte levels. Transfusions are unnecessary
A nurse has reported for a shift at a busy burns and plastics unit in a large university hospital. Which patient is most likely to have life-threatening complications? A) A 4-year-old scald victim burned over 24% of the body B) A 27-year-old male burned over 36% of his body in a car accident C) A 39-year-old female patient burned over 18% of her body D) A 60-year-old male burned over 16% of his body in a brush fire
Ans: A Feedback: Young children and the elderly continue to have increased morbidity and mortality when compared to other age groups with similar injuries and present a challenge for burn care. This is an important factor when determining the severity of injury and possible outcome for the patient.
The nurse is participating in the care of a patient with increased ICP. What diagnostic test is contraindicated in this patients treatment? A) Computed tomography (CT) scan B) Lumbar puncture C) Magnetic resonance imaging (MRI) D) Venous Doppler studies
Ans: B Feedback: A lumbar puncture in a patient with increased ICP may cause the brain to herniate from the withdrawal of fluid and change in pressure during the lumbar puncture. Herniation of the brain is a dire and frequently fatal event. CT, MRI, and venous Doppler are considered noninvasive procedures and they would not affect the ICP itself.
A patient exhibiting an altered level of consciousness (LOC) due to blunt-force trauma to the head is admitted to the ED. The physician determines the patients injury is causing increased intracranial pressure (ICP). The nurse should gauge the patients LOC on the results of what diagnostic tool? A) Monro-Kellie hypothesis B) Glasgow Coma Scale C) Cranial nerve function D) Mental status examination
Ans: B Feedback: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response. The Monro-Kellie hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the components (blood, brain tissue, cerebrospinal fluid) causes a change in the volume of the others. Cranial nerve function and the mental status examination would be part of the neurologic examination for this patient, but would not be the priority in evaluating LOC.
A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound? A) Silver sulfadiazine 1% (Silvadene) water-soluble cream B) Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream C) Silver nitrate 0.5% aqueous solution D) Acticoat
Ans: B Feedback: Mafenide acetate 10% hydrophilic-based cream is the agent of choice when there is a need to penetrate thick eschar. Silver products do not penetrate eschar; Acticoat is a type of silver dressing.
The nurse is providing care for a patient who is unconscious. What nursing intervention takes highest priority? A) Maintaining accurate records of intake and output B) Maintaining a patent airway C) Inserting a nasogastric (NG) tube as ordered D) Providing appropriate pain control
Ans: B Feedback: Maintaining a patent airway always takes top priority, even though each of the other listed actions is necessary and appropriate.
A nurse who provides care on a burn unit is preparing to apply a patients ordered topical antibiotic ointment. What action should the nurse perform when administering this medication? A) Apply the new ointment without disturbing the existing layer of ointment. B) Apply the ointment using a sterile tongue depressor. C) Apply a layer of ointment approximately 1/16 inch thick. D) Gently irrigate the wound bed after applying the antibiotic ointment.
Ans: C Feedback: After removing the old ointment from the wound bed, the nurse should apply a layer of ointment 1/16-inch thick using clean gloves. The wound would not be irrigated after application of new ointment.
Following a traumatic brain injury, a patient has been in a coma for several days. Which of the following statements is true of this patients current LOC? A) The patient occasionally makes incomprehensible sounds. B) The patients current LOC will likely become a permanent state. C) The patient may occasionally make nonpurposeful movements. D) The patient is incapable of spontaneous respirations.
Ans: C Feedback: Coma is a clinical state of unarousable unresponsiveness in which no purposeful responses to internal or external stimuli occur, although nonpurposeful responses to painful stimuli and brain stem reflexes may be present. Verbal sounds, however, are atypical. Ventilator support may or may not be necessary. Comas are not permanent states.
The nurse is caring for a patient in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the patients mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurses most appropriate action? A) Position the patient in the high Fowlers position as tolerated. B) Administer osmotic diuretics as ordered.C) Participate in interventions to increase cerebral perfusion pressure. D) Prepare the patient for craniotomy.
Ans: C Feedback: The cerebral perfusion pressure (CPP) is 55 mm Hg, which is considered low. The normal CPP is 70 to 100 mm Hg. Patients with a CPP of less than 50 mm Hg experience irreversible neurologic damage. As a result, interventions are necessary. A craniotomy is not directly indicated. Diuretics and increased height of bed would exacerbate the patients condition.
The nurse is caring for a patient with increased intracranial pressure (ICP). The patient has a nursing diagnosis of ineffective cerebral tissue perfusion. What would be an expected outcome that the nurse would document for this diagnosis? A) Copes with sensory deprivation. B) Registers normal body temperature. C) Pays attention to grooming. D) Obeys commands with appropriate motor responses.
Ans: D Feedback: An expected outcome of the diagnosis of ineffective cerebral tissue perfusion in a patient with increased intracranial pressure (ICP) would include obeying commands with appropriate motor responses. Vitals signs and neurologic status are assessed every 15 minutes to every hour. Coping with sensory deprivation would relate to the nursing diagnosis of disturbed sensory perception. The outcome of registers normal body temperature relates to the diagnosis of potential for ineffective thermoregulation. Body image disturbance would have a potential outcome of pays attention to grooming.
A patients burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid? A) 0.45% NaCl with 20 mEq/L KCl B) 0.45% NaCl with 40 mEq/L KCl C) Normal saline D) Lactated Ringers
Ans: D Feedback: Fluid resuscitation with lactated Ringers (LR) should be initiated using the American Burn Associations (ABA) fluid resuscitation formulas. LR is the crystalloid of choice because its composition and osmolality most closely resemble plasma and because use of normal saline is associated with hyperchloremic acidosis. Potassium chloride solutions would exacerbate the hyperkalemia that occurs following burn injuries.
A patient has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the patients ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? A) Hemiplegia B) Dry mucous membranes C) Signs of internal bleeding D) Loss of brain stem reflexes
Ans: D Feedback: Loss of brain stem reflexes, including pupillary, corneal, gag, and swallowing reflexes, is an ominous sign of approaching death. Dry mucous membranes, hemiplegia, and bleeding must be promptly addressed, but none of these is a common sign of impending death.
During the examination of an unconscious patient, the nurse observes that the patients pupils are fixed and dilated. What is the most plausible clinical significance of the nurses finding? A) It suggests onset of metabolic problems. B) It indicates paralysis on the right side of the body. C) It indicates paralysis of cranial nerve X. D) It indicates an injury at the midbrain level.
Ans: D Feedback: Pupils that are fixed and dilated indicate injury at the midbrain level. This finding is not suggestive of unilateral paralysis, metabolic deficits, or damage to CN X.
An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury? A) The length of time since the burn B) The location of burned skin surfaces C) The source of the burn D) The total body surface area (TBSA) affected by the burn
Ans: D Feedback: Systemic effects are a result of several variables. However, TBSA and wound severity are considered the major factors that affect the presence or absence of systemic effects.
the concentration of which ABG plays a role in regulation of cerebral blood flow, affecting ICP?
PaCO2 (an increase or decrease in this can cause increased ICP) (hypoxia or hypercapnia)
_____ burns are superficial injuries that involve only the outermost layer of skin
first-degree (epidermis is still intact, ex. sunburn or superficial scald)
with ____ burns, amputations are likely, grafting has no benefit given the depth and severity of wound
fourth degree
____ burns are those injuries that extend into deep tissue, muscle, or bone
fourth-degree burns
third-degree burn is also known as _____
full-thickness
Because _____ puts extreme pressure on parts of the brain and thereby cuts off the blood supply to various parts of the brain, it is often fatal
herniation
____ refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure
herniation
it is important to emphasize that a child should never be left unattended around fire or _____
in a bathroom/bathtub (because of hot water burns)
what needs to be done if there is suspicious sooty sputum, soot around the mouth, or respiratory difficulty? (burns)
intubation before laryngeal edema takes place
pts with a CPP (cerebral perfusion pressure) of ______ experience irreversible neurological damage
less than 50
what does your body do when there are alterations in intrathoracic pressure (these are normal circumstances such as sneezing, coughing, straining)?
minor changes in blood volume and CSF volume occur
any sudden change in a pt's condition, such as restlessness (without apparent cause), confusion, or increasing drowsiness, has _____
neurological significance
what is normal CPP (cerebral perfusion pressure)?
normal is 70 to 100 (but is best for it to be maintained at 70-80 to ensure adequate blood flow to the brain)
common age-related changes, such as diminished mobility, postural stability, strength, coordination, sensation, visual acuity, as well as declining memory, predispose ______ to burn injury
older adults
second-degree burn is also known as _____
partial-thickness
what is the most common complication of burn injuries with older adults?
pneumonia
what would be the characteristics of a first-degree burn?
reddened, blanches with pressure, dry, minimal or no edema, possible blisters
_____ burn involves the entire epidermis and varying portions of the dermis
second-degree (usually takes 2-3 weeks to heal)
what are the most common sites of tissue destruction with burns?
skin and mucosa of the upper airways
as ICP increases the pt becomes ____
stuporous, reacting only to loud or painful stimuli (as it progresses further they will become comatose and exhibits abnormal motor responses of decortication, decerebration, or flaccidity)
how do you calculate the MAP (mean arterial pressure)?
systolic + (x2 diastolic) / 3
why is it that burns on an older adult are more extensive? (skin)
the skin of an older adult is thinner and less elastic, which affects the depth of injury and its ability to heal