NSG 252 Exam 4
underlying cause of seizures
electrical disturbance (dysrhythmia) in the nerve cells in one section of the brain; these cells emit abnormal, recurring, uncontrolled electrical discharges
treatments for edema with burns
elevation of the extremity removal of eschar via escharotomy decompression of edema formation via fasciotomy
skin involvement first degree burns
epidermis
skin involvement of third degree burns
epidermis dermis sometimes subcutaneous tissue may involve connective tissue & muscle
skin involvement 2nd degree burns
epidermis, portion of dermis
recuperative course & tx 3rd degree burns
eschar may slough grafting necessary scarring/loss of contour/function
most common etiology of burns in the older adult
fire/flame
causes of third degree burns (full thickness)
flame prolonged exposure to hot liquids electric current chemical contact
things that contribute to survivability and recovery from burn injuries
fluid resuscitation, infection control, nutrition delivery, early burn excision (surgical removal of tissue), wound closure
three main seizure types
focal, generalized, and unknown
tonic-clonic seizure
generalized seizure in which the patient loses consciousness and has jerking movements of paired muscle groups
autograft
graft derived from one part of a patient's body and used on another part of that same patient's body
The percentages of the "Rule of Nines"
head 9% each arm 9% each leg 18% anterior 18% posterior 18% pelvic region 1%
what is one of the main causes of epilepsy that can be prevented?
head injury
Here are more indications of possible pulmonary damage after a burn injury. SATA 1. Labored respirations 2. Voice change, stridor 3. Tachycardia 4. Soot-tinged sputum
1, 2, 4
A 35-year-old client is brought to the emergency department with second- and third-degree burns over 15% of the body. Admission vital signs are blood pressure 100/50 mm Hg, heart rate 130 beats/minute, and respiratory rate 26 breaths/minute. Which nursing interventions are appropriate for this client? Select all that apply. Administer 6 mg of IV morphine. Begin an intravenous (I.V.) infusion of lactated Ringer's solution. Place ice directly on the burn areas. Cover the burns with saline-soaked towels. Administer tetanus prophylaxis, as ordered. Clean the burns with hydrogen peroxide.
1, 2, 5
After sustaining a closed head injury, a client is prescribed phenytoin 100 mg intravenously every 8 hours for seizure prophylaxis. Which nursing interventions are necessary when administering phenytoin? Select all that apply. 1. Monitor the client for signs of early toxicity, such as drowsiness, nystagmus, ataxia, dysarthria, tremor, and slurred speech. 2. Administer phenytoin slowly, diluted in 250 cc. 3. Mix intravenous doses in solutions containing dextrose 5% in water. 4. Administer an intravenous bolus no faster than 50 mg/minute. 5. Do not use an in-line filter when administering the drug. 6. Monitor electrocardiogram (ECG), blood pressure, and respiratory status continuously when administering phenytoin intravenous.
1, 4, 6 Explanation: Administer an intravenous bolus by slow (50 mg/minute) intravenous push method; too rapid an injection may cause hypotension and circulatory collapse. Continuous monitoring of ECG, blood pressure, and respiratory status is essential when administering phenytoin intravenously. A dilution of 250 cc is not required. Early toxicity may cause drowsiness, nausea, vomiting, nystagmus, ataxia, dysarthria, tremor, and slurred speech. Later effects may include hypotension, arrhythmias, respiratory depression, and coma. Death may result from respiratory and circulatory depression. Phenytoin would not be administered by intravenous push in veins on the back of the hand; larger veins are needed to prevent discoloration associated with purple glove syndrome. Mix intravenous doses in normal saline solution and use the solution within 30 minutes; doses mixed in dextrose 5% in water will precipitate. Use of an inline filter is recommended.
An explosion at a chemical plant produces flames and smoke. More than 20 persons have burn injuries. Which victims, all adults, should be transported to a burn center? Select all that apply. The victim who has: inhaled smoke first-degree burns of both hands chemical spills on both arms third-degree burns of both legs respiratory distress
1,2,4,5 (Victims with chemical burns, 2nd and 3rd degree burns over more than 20% of the BSA and those with inhalation injury should be transported to a burn center The victim with 1st degree burn of the hands can be treated on scene and referred to health care facility)
stages of burn care
1. Emergent/resuscitative - from onset to completion of fluid resuscitation; 48-72 hours; hypovolemic shock; need IV fluids 2. Acute - from the start of diuresis to near completion of wound closure 3. Rehabilitation - from wound closure to return of optimal level of physical/psychosocial function
treatment for carboxyhemoglobin
100% O2, hyperbaric O2
Which of the following are indications of possible pulmonary damage after a burn injury? SATA 1. hypotension 2. singed nasal hair 3. incident occurred in an enclosed space 4. facial and/or neck burns
2, 3, 4
status epilepticus
A condition in which seizures recur every few minutes or last more than 30 minutes.
immediately after burn injury, what may result from massive cell destruction?
hyperkalemia possible hyponatremia due to plasma loss anemia due to RBC damaged hematocrit elevated due to plasma loss thrombocytopenia
rule of nines
A system that assigns percentages to sections of the body, allowing calculation of the amount of skin surface involved in the burn area.
A school nurse is called to the playground where a 6-year-old girl has been found sitting unresponsive and "staring into space," according to the playground supervisor. How would the nurse document the girl's activity in her chart at school?
Absence seizure
1st degree burn would appearance
reddened blanches with pressure & dry minimal or no edema possible blisters
signs of skin breakdown
redness, poor skin turgor, bleeding, pain
The school nurse notes a 6-year-old running across the playground with friends. The child stops in mid-stride, freezing for a few seconds. Then the child resumes their progress across the playground. The school nurse suspects what in this child? a) A tonic-clonic seizure b) A complex seizure c) A partial seizure d) An absence seizure
An absence seizure Absence seizures, formerly referred to as petit mal seizures, are more common in children. They are characterized by a brief loss of consciousness, during which physical activity ceases. The person stares blankly; the eyelids flutter; the lips move; and slight movement of the head, arms, and legs occurs. These seizures typically last for a few seconds, and the person seldom falls to the ground. Because of their brief duration and relative lack of prominent movements, these seizures often go unnoticed. People with absence seizures can have them many times a day. Partial, or focal, seizures begin in a specific area of the cerebral cortex. A generalized seizure involves the whole brain
Which medication classification is used preoperatively to decrease the risk of postoperative seizures?
Anticonvulsants
A client is admitted to an acute care facility after an episode of status epilepticus. After the client is stabilized, which factor is most beneficial in determining the potential cause of the episode? A. Recent stress level B. Compliance w/prescribed med regimen C. Recent weight gain and loss D. Type of anticonvulsant prescribed to manage the epileptic condition
B The most common cause of status epilepticus is sudden withdraw of anticonvulsant therapy. The type of medication prescribed, the client's stress level, and weight change don't contribute to this condition.
The nurses teaches the parent of a child with severe burns about the importance of specific nutritional support in burn management. The nurse recognizes the need for more teaching if the parents select which food for their child? cheeseburger, cottage cheese and pineapple salad, chocolate milk, and a brownie beef, bean, and cheese burrito; a banana; fruit-flavored yogurt; and skim milk chicken nuggets, orange and grapefruit sections, and a vanilla milkshake bacon, lettuce, and tomato sandwich; milk; and celery and carrot sticks
D
Nikolsky sign
Diagnostic sign whereby the superficial epithelium separates easily from the basal layer on exertion of firm, sliding manual pressure with the fingers
some anticonvulsant medications
Carbamazepine Clonazepam Ethosuximide felbamate Gabapentin Lamotrigine Levetiracetam Oxcarbazepine Phenobarbital Phenytoin Primidone Tiagabine Topiramate Valproate Zonisamide
Carboxyhemoglobin
Carbon monoxide bound with hemoglobin
While completing a health history on a client who has recently experienced a seizure, the nurse would assess for what characteristic associated with the postictal state?
Confusion
seizure precautions
reduce environmental stimuli identify triggers pad side rails bed lowest position O2 and suction available
skin breakdown interventions
reposition q 2 hrs pressure relief maintain clean and dry skin adequate nutrition and hydration
causes of second degree burns (partial thickness)
scalds flash flame contact
The clinic nurse caring for a patient with Parkinson's disease notes that the patient has been taking levodopa and carbidopa (Sinemet) for 7 years. What common side effects of Sinemet would the nurse assess this patient for?
Dyskinesia
most common type of seizure seen in children less than 5 years old
Febrile
main causes of burns
Flame related Scalds Direct source contact Electrical Chemical contact Inhalation Miscellaneous
A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure? a) Absence b) Generalized c) Jacksonian d) Sensory
Generalized A generalized seizure causes generalized electrical abnormality in the brain. The client typically falls to the ground, losing consciousness. The body stiffens (tonic phase) and then alternates between episodes of muscle spasm and relaxation (clonic phase). Tongue biting, incontinence, labored breathing, apnea, and cyanosis may also occur. A Jacksonian seizure begins as a localized motor seizure. The client experiences a stiffening or jerking in one extremity, accompanied by a tingling sensation in the same area. Absence seizures occur most commonly in children. They usually begin with a brief change in the level of consciousness, signaled by blinking or rolling of the eyes, a blank stare, and slight mouth movements. Symptoms of a sensory seizure include hallucinations, flashing lights, tingling sensations, vertigo, déjà vu, and smelling a foul odor.
A client has experienced a seizure in which she became rigid and then experienced alternating muscle relaxation and contraction. What type of seizure does the nurse recognize?
Generalized seizure
side effect of long-term use of Phenytoin
Gingival Hyperplasia (Swollen and tender gums)
The nurse is educating a patient with a seizure disorder. What nutritional approach for seizure management would be beneficial for this patient?
High in protein and low in carbohydrate
Following a major burn injury, what is the recommended route for opioid administration?
IV
The nurse is caring for a client who is in status epilepticus. What medication should the nurse anticipate administering to halt the seizure immediately?
Intravenous diazepam
Which IV solution is appropriate to administer during the first 24 hours of fluid resuscitation following a burn injury?
Lactated Ringer's [[LR is an Isotonic IV solution]]
A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate?
Loosen the client's restrictive clothing.
burn prevention
Minimize sun exposure Never leave children unattended around fire Education about installation of smoke & carbon monoxide detectors Educate about smoking near oxygen
When educating a patient about the use of antiseizure medication, what should the nurse inform the patient is a result of long-term use of the medication in women? a) Obesity b) Osteoarthritis c) Anemia d) Osteoporosis
Osteoporosis Because of bone loss associated with the long-term use of antiseizure medications, patients receiving antiseizure agents should be assessed for low bone mass and osteoporosis. They should be instructed about strategies to reduce their risks of osteoporosis (AANN, 2009).
A patient is admitted to the hospital for management of an extrapyramidal disorder. Included in the physician's admitting orders are the medications levodopa, benztropine, and selegiline. The nurse knows that most likely, the client has a diagnosis of:
Parkinson's disease.
The nurse is caring for a client who has undergone supratentorial removal of a pituitary mass. What medication would the nurse expect to administer prophylactically to prevent seizures in this client?
Phenytoin
A hospital client has experienced a seizure. In the immediate recovery period, what action best protects the client's safety?
Place the client in a side-lying position.
methods to estimate TBSA affected by burns
Rule of nines Lund and Browder method palmer method
febrile seizure
Seizure activity brought on by an excessively high fever (102.2 or higher) in a young child or an infant.
A patient with Parkinson's disease is undergoing a swallowing assessment because she is experiencing difficulties when swallowing. What consistency is most appropriate for this patient, to reduce the risk of aspiration?
Semisolid food with thick liquids
diagnostics for seizures
Stat accu-check CBC, CMP CT or MRI EEG (Electroencephalogram) +/- LP Medication and Substance history
The nurse is providing care for a client who is withdrawing from heavy alcohol use. The nurse and other members of the care team are present at the bedside when the client has a seizure. In preparation for documenting this clinical event, the nurse should note which of the following?
The client's activities immediately prior to the seizure.
clinical manifestations of 4th degree burns
shock myoglobinuria possible hemolysis
how should a pt with a seizure be placed?
side-lying position to prevent aspiration
A 70-year-old woman is being treated at home for Parkinson's disease (PD), a health problem that she was diagnosed with 18 months ago. The nurse who is participating in the woman's care should be aware that her initial symptoms most likely consisted of:
Tremors and muscle rigidity
Atonic seizures
sudden loss of muscle tone
what do seizures result from?
sudden, excessive discharge from cerebral neurons
causes of first degree burns (superficial)
sunburn low-intensity flash superficial scald
Palmer method
Used with scattered burns Size of pts hand including fingers is approximately 1%
cardiovascular alterations from burns
decrease in CO workload of heart & O2 demand increase due to vasoconstrictive compensatory responses hypovolemia is immediate As fluid loss continues due to capillary leakage, and vascular volume decreases, cardiac output continues to decrease and the blood pressure drops the sympathetic nervous system releases catecholamines, resulting in an increase in peripheral resistance (vasoconstriction) and an increase in pulse rate that further decreases tissue perfusion
skin involvement 4th degree burns
deep tissue muscle bone
wound appearance 3rd degree burns
dry, pale white, red, brown leathery/charred coagulated vessels may be visible edema
generalized seizures
a seizure that affects both sides of the brain
recuperative course & tx 4th degree burns
amputations likely grafting of no benefit, given depth & severity of wound (s)
epilepsy
at least 2 unprovoked seizures occuring more than 24 hrs apart
would appearance of second degree burns
blistered, mottled red base disrupted epidermis weeping surface edema
Myoclonic seizures
brief, jerky, may or my not loss consciousness, loss of tone
standard test for definitive diagnosis of inhalation injury
bronchoscopy
physiologic changes with severe burns
cardiac depression edema hypovolemia vasoconstriction impaired motility/absorption
A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to:
carefully move the client to a flat surface and turn him on his side.
causes of seizures
cerebrovascular disease fever (childhood) hypoxemia of any cause head injury HTN CNS infections metabolic & toxic conditions brain tumor drug and ETOH withdrawal allergies
wound appearance 4th degree burns
charred
clinical manifestations of 3rd degree burns
insensate shock myoglobinuria (red pigment in urine) possible hemolysis possible contact points (entrance/exit wounds in electrical burns)
How to respond when your child has a seizure
instruct parents and caregivers: -remain calm -if child is standing or sitting, ease child to ground -time seizure episode -tight clothing and jewelry around neck should be removed or loosened -place child on one side, and open airway -do not restrain child -remove hazards from area -do not forcibly open jaw with tongue blade or fingers -document length of seizure and movements noted, loss of bladder control -remain with child until full conscious -call EMS if: child stops breathing injury has occurred seizure lasts more than 5 min this is the childs first seizure child is unresponsive to painful stimuli afterwards
Nursing care after a seizure
keep the pt on its side make sure airway is patent on awakening, reorient pt to environment
patients with burn injuries may exhibit low what in the early hours after injury due to thermoregulatory alterations?
low body temperatures
focalized seizures
originate within one hemisphere in the brain
clinical manifestations of second degree burns
pain hyperesthesia sensitive to air currents
three of the most common GI alterations in patients with burns
paralytic ileus curling's ulcer (gastric or duodenal erosion) translocation of bacteria
A client with epilepsy is having a seizure. During the active seizure phase, the nurse should:
place the client on his side, remove dangerous objects, and protect his head.
most common complication of burns of older adults
pneumonia followed by UTIs
causes of fourth degree burns (full thickness that includes fat, fascia, muscle, and/or bone)
prolonged exposure or high voltage electrical injury
nursing care during a seizure
provide privacy ease patient to floor protect the head with a pad to prevent injury loosen constrictive clothing and remove eyeglasses if pt is in bed, remove pillows and raise side rails do not put anything in pts mouth*** if possible, place pt on side with head flexed forward
recuperative course & tx for second degree burns
recovery in 2-3 weeks some scarring/depigmentation possible may require grafting
recuperative course & tx for 1st degree burns
recovery within a few days oral pain meds cool compresses skin lubricants topical antimicrobial agents not indicated
skin functions
thermoregulation protection innate immune protection synthesize vitamin D water & salt excretion dilated capillaries are a blood reservoir
postictal
time after a seizure
clinical manifestations of 1st degree burns
tingling hyperesthesia pain that is soothed by cooling peeling itching
During a seizure the nurse should document
types of movements involved area of body involve first thing the pt does in a seizure size of both pupils incontinence of urine or stool
patho of seizures
uncontrolled, abnormal discharges of neurons occur repeatedly
Absence seizures (petit mal)
usually include a loss of consciousness and unresponsiveness for short periods without muscle involvement.
age groups with highest mortality with burns
young children and older adults due to thinner skin
The nurse is called to attend to a patient having a seizure in the waiting area. What nursing care is provided for a patient who is experiencing a convulsive seizure? (Select all that apply.) a) Loosening constrictive clothing b) Providing for privacy c) Restraining the patient to avoid self injury d) Positioning the patient on his or her side with head flexed forward e) Opening the patient's jaw and inserting a mouth gag
• Loosening constrictive clothing • Positioning the patient on his or her side with the head flexed forward • Providing for privacy During a patient's seizure, the nurse should do the following. Loosen constrictive clothing. If possible, place the patient on one side with the head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus. If suction is available, use it if necessary to clear secretions. Provide privacy, and protect the patient from curious onlookers. (The patient who has an aura [warning of an impending seizure] may have time to seek a safe, private place.) The nurse should not attempt to pry open jaws that are clenched in a spasm or attempt to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. No attempt should be made to restrain the patient during the seizure, because muscular contractions are strong and restraint can produce injury.
