Unit 5
Patient risk assessment for heat related illnesses
-Older adults -Mentally ill -Outside workers -Homeless -Substance users -Athletes -Military -Obesity, CVD, Fever, infection, exercise, seizures, burns -Lithium, neuroleptics, beta adrenergic blockers, anticholinergics, ACE inhibitors, Diuretics,
Emergency patient assessment- priorities
ABCs- assess the scene for safety.
Plan of care- TB ER Presentation
Administer heated and humidified oxygen Isolate in private negative‑airflow room, and implement airborne precautions; n95, Have the client wear a surgical mask if transportation to another department
Gentamicin sulfate- used to treat what? Nursing considerations and assessments to make
Aminoglycoside anti-infective agent. Advantage: Bactericidal aminoglycoside Disadvantages: nephrotoxic: monitor kidney function; BUN, creatinine, urine output, I&O, weight Ototoxic: monitor for hearing loss weekly, tinnitus
HACE- high altitude cerebral edema nursing assessment and treatment
Cannot perform ADLs, ataxia, altered mental status w confusion & impaired judgment Cranial nerve dysfunction & seizures Stupor, coma, death Rapid descent Supp O2 IV Dexamethasone
Burn Patient- infection control strategies
Change gloves between carrying out wound care on different parts of the body Restrict plants and flowers d/t risk of contact with Pseudomonas aeruginosa, restrict consumption of fresh fruits and vegetables, limit visitors, use client dictated equipment such as BP cuffs and thermometers, administer tetanus toxoid, administer antibiotics to treat infection monitor peak and trough levels, use strict asepsis with wound care.
Burn patient- plan of care specific to nutrition
Daily weighs to ensure proper nutrition, 5,000 calories, albumin: 3.5-5, increase protein intake, carbs, calories Dietician- may need NG tube to prevent aspiration
Burn victim- self awareness and positive perspective
Dont make any off putting faces when performing dressing changes PROMOTE TRUTHFUL COMMUNICATION, ASSIST THE PATIENT IN PRACTICING APPROPRIATE STRATEGIES, GIVE POSITIVE REINFORCEMENT WHEN APPROPRIATE
Contamination risk reduction
Hand hygiene proper PPE
Hydrotherapy- task delegation
Hydrotherapy: assist client into warm tub of water or use warm running water to cleanse wound. Use mild soap or detergent to wash burns gently and then rinse with room temp. water, encourage client to exercise joints during treatment.
Shock symptoms and nursing priority management
Hyperthermia, tachycardia, thready pulse, hypotension, orthostatic hypotension, decreased CVP, tachypneic, hypoxia, Dizziness, syncope, confusion, weakness and fatigue. Oliguria, diminished capillary refill, cool clammy skin, diaphoresis, sunken eyeballs, flattened neck veins, poor skin turgor and tenting. Oxygen as prescribed. Monitor Vital signs and heart rhythm, auscultate lung sounds, initiate and maintain intravenous access, fluid therapy
Disaster Medical Assistant Team- requirements and licensure
Licensed health care providers such as nurses act as federal employees when they are deployed, their professional licenses are recognized and valid in all states
Goal of Triage
Organized system for sorting or classifying pt into priority levels depending on illness or injury severity. Highest acuity to lowest
Cimetidine- indications for use and patient education
Peptic ulcers, acid reflux, GERD resulting in decreased libido, gynecomastia, and impotence CNS Effects (lethargy, depression, confusion) These effects are seen more often in older adults who have kidney or liver dysfunction Avoid aspirin, NSAIDS, caffeine, chocolate, smoking, acidic foods, reduce stress, notify the provider for any indication of obvious or occult GI bleeding, such as coffee-ground emesis (vomit).
Lightning strike- priority actions
Priority: spinal stabilization w priority attention to maintenance of an adequate airway, effective breathing & circulation through standard basic & advanced life support measures CPR is performed immediately when a patient is in cardiac arrest If cardiopulmonary or CNS injury is present, skin burns are not the initial priority
Frostbite-nursing actions dependent on the level of injury (thickness)
Severe/deeper: aggressive management Partial thickness to full: rapid rewarming in water bath 99-102 Debridement of necrotic tissue Swirl part in water, do not let it touch sides Admin analgesics, IV opiates, IV rehydration Admin IBU to decrease thromboxane Do NOT use dry heat or massage After rewarming, handle injured area gently & elevate above heart level Splints are used to immobilize extremities during healing Assess qhr for compartment syndrome Assess pain, pallor, pulses, muscle weakness Tdap Apply loose non adherent sterile dressings Avoid compression on tissues Topical & systemic antibiotics
Thickness burn- determine based on description
Superficial -First degree: Above basal layer of epidermis, dry pink-red, no edema, no blistering, pain, no eschar -Second degree: into dermis, moistly red, blanching, blistering, mild to moderate edema, much pain, no eschar Deep -Deep second degree: deeper into dermis, less moist, less blanching, less painful, moderate edema, rare blistering, some pain, soft & dry eschar -Third degree: entire thickness of skin destroyed into fat, any color, severe edema, no blistering, no pain, hard & inelastic -Fourth degree: damage extends into muscle, tendon, bone, black, severe edema, no blistering, no pain, yes eschar full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain
Burn injury- risk for infection
When skin in intact, no risk for infection Risk for infection during resuscitation phase
ABC- management and assessment. Nursing priorities
assess, ensure airway
Heat Stroke assessment findings
core temperature above 104° F altered mentation absence of perspiration circulatory collapse skin is hot, dry, and ashen.
Suicidal precautions- nursing priorities
safety one-one, remove potentially dangerous items, remove all belongings
Black Widow spider bite- treatment
tetanus prophylaxis, diazepam, antivenin, muscle rigidity. Opioids, ice to bite site
Mass casualty classifications/stable/unstable
-Emergent or Class I -Identified with a red tag indicating an immediate threat to life, Red: Airway obstruction, shock -Urgent or Class II, Yellow: Major injuries that require treatment; can delay treatment one to two hours, Open fractures w distal pulses, large wounds that need tx within 30-2hrs -Nonurgent or Class III, Green: Minor injuries that do not require immediate treatment, can delay treatment two to four hours, closed fractures, sprains, strains, abrasions, contusions, walking wounded -Expectant or Class IV, Black: Expected and allowed to die, agonal breathing, cardiac arrest, massive head trauma, high cervical spinal cord injury, extensive full-thickness body burns, profound hemorrhage
Fire/burn victim- complications (recognizing and treating).
-Hypovolemia, pulmonary edema, infection -Change in resp pattern, drooling, diff swallowing, brassy cough, audible breath sounds on exhalation, indicates pulmonary injury & impairment of gas exchange -Listen for hoarseness, cough, wheezes, stridor, assess mouth and nares for black soot, burning odor to breath -Place upright, apply O2, report any signs immediately to provider or rapid response team -Immediate intubation: wheezes that disappear -Infection s/s- tachycardia, hypotension, fever, and purulent wound drainage, increasing redness, warmth to touch
Heat exhaustion nursing responses
-Tell client to stop physical activity and move to cool place -Use cooling measures such as placing cold packs on neck, chest, abdomen, groin -Soak individual in cool water or fan while spraying water on skin -Remove constrictive clothing -Sports drink or oral rehydration therapy solution can be provided -Do not drink plain water -Do not give salt tablets HOSPITAL: -Monitor VS -Rehydrate pt w IV -Draw blood for electrolyte analysis
Burn patient- assessment findings- concerns
-Na: decreased d/t third spacing, seizure precautions -K: increased d/t cell destruction (hyperkalemia), ECG, cardiac monitoring -BUN: elevated d/t fluid loss -Hct/Hgb: elevated (hemoconcentration) d/t the loss of fluid volume and the fluid shift into the interstitial space (third spacing) -Glucose: elevated d/t stress -Total protein and albumin: low d/t fluid loss
Burn patient- plan of care infection prevention
-Sterile technique to prevent infection, hand hygiene, screen visitors, take full course of antibiotics, tetanus vaccine Uncomplicated burns; topical antimicrobial w gauze -Infection s/s- tachycardia, hypotension, fever, and purulent wound drainage, increasing redness, warmth to touch
Burn patient- recognizing complications related to treatment
-assess for fluid overload: edema, engorged neck veins, lung crackles wheezes. -Daily weight, maintain urine output of 30ml/hr (o.5ml/kg/hr). -Monitor for manifestations of shock: alterations in sensorium (confusion), increased cap refill time, urine output less than 30ml/hr, rapid elevations of temperature, decreased bowel sounds, blood pressure average or low. -Maintain thermoregulation- Use warm, inspired air, a warm room, warming blankets, and warmers for infusing fluids.
Burn patient- pain management
-opioid analgesics such as morphine, hydromorphone, and fentanyl or anesthetics such as ketamine and nitrous oxide. -Monitor for respiratory depression, constipation -The use of PCA pump is appropriate to help manage pain. -Administer pain medication 30min prior to dressing changes and procedures. -Ambulatory basis: ibuprofen, acetaminophen
Mass Casualty- triage
1. Emergent: red tag, immediate threat to life or limb 2. Urgent: yellow tag, major injuries, needs immediate attention 3. Non-urgent: green tag, minor injuries, do not need immediate attention - Can walk away to seek medical care 4. Expectant: black tag, expected or allowed to die
Burn patient- fluid resuscitation expectations (Parkland formula)- cause for concern
4ml/kg/% burn, half in first 8hrs, then rest in 16hrs Under resuscitation with fluids can lead to unstable vital signs, acute renal failure, and further end-organ injury. Over-resuscitation has been shown to increase complications such as abdominal and extremity compartment syndromes, cerebral edema, acute respiratory distress syndrome, a higher risk of sepsis, and multi-organ dysfunction Fluid overload: Dyspnea, orthopnea, crackles, diminished breath sounds, pink frothy sputum; Elevate HOB 45, apply O2, report to provider Fluid volume deficit: Hyperthermia, tachycardia, weak thready pulse, hypotension, orthostatic hypotension, decreased central venous pressure, tachypneic, hypoxia HYPERKALEMIA, HYPONATREMIA, ELEVATED HEMATOCRIT AND METABOLIC ACIDOSIS
Autocontamination- prevention
Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, changing gloves between carrying out wound care on difference parts of the client's body can prevent autocontamination.
Lightning strike- first priority
Before hospital: Assess scene, seek shelter, stay in car Initial care: spinal stabilization w priority attention to maintenance of adequate airway, effective breathing, circulation CPR is performed immediately when in cardiac arrest If cardiopulmonary or CNS injury is present, skin burns are not priority At hospital: Cardiac monitoring, 12 lead ECG Mech vent CT scan CK Burn tx TDAP
Mass casualty classification/stable/unstable
DC early: admitted for observation & not bedridden, dx evaluations & not bedridden, soon as scheduled to be DC or could be cared for at home w support of fam, no critical change in condition for past 3 days, could be cared for in other facility (rehab or long term care)
Transfer Hand off report components
DOB, mechanism of injury, antibiotic information, name, allergies, diagnostic tests done, precaution, isolation precautions up-to-date information regarding patient care, treatment and service, condition, and any recent or anticipated changes. evaluations of the patient's response to nursing and medical interventions, the effectiveness of the patient-care plan, and the goals and outcomes for the patient I-PASS (I): illness severity (P): patient summary (A): action list (S): situational awareness and contingency plans (S): synthesis by the receiver
Burn victim complications: assessment and interventions
Drooling, s/s airway compromise; listen to lung sounds, may need intubation
Burn patient- assessment of fluid status, recognizing complications
Fluid & electrolyte imbalances: evaluation of urine output, I&O, BUN, Creatinine, cardiac output, blood pressure, status of electrolytes <30ml/hr: dehydration -Monitor for signs of fluid overload/ pulmonary edema: Dyspnea, orthopnea, crackles, diminished breath sounds, pink frothy sputum; Elevate HOB 45, apply O2, report to provider
Burn patient- emergent phase complications, assessment and treatment.
Emergent (resuscitation): begins at onset of injury and continues for about 24-48 hrs. During this phase, the injury is evaluated & priorities of care are determined based on extent and severity of the burn Priorities of care 1) Securing the airway 2) Supporting circulation perfusion 3) maintaining body temperature 4) Keeping the patient comfortable w/ analgesics 5) Providing emotional support Complications: compromised airway, infection, hypovolemia, hypothermia -Supporting circulation via fluid therapy. Rapid fluid replacement is needed during the emergent phase to maintain tissue perfusion and prevent hypovolemic (burn) shock. -Airway: be prepared to admin O2, keep emergency airway equipment near; masks, o2, cannulas, manual resuscitation bags, laryngoscope, endotracheal tube, emergency trach -Pulmonary edema: Raise HOB 45, apply O2, notify rapid response
Triage- "Urgent" Classification
Emergent: time-sensitive client, life or limb, critically injured w active hemorrhage Urgent: immediate threat to life does not exist at moment, ex: new onset of pneumonia, renal colic, complex lacerations. displaced fractures, dislocations, temp> 101 Non-urgent: Can wait long time to be seen: Sprains, strains, skin rashes, simple fractures, uncomplicated UTI
Triaging- industrial accident
Emergent: time-sensitive client, life or limb, critically injured w active hemorrhage Urgent: immediate threat to life does not exist at moment, ex: new onset of pneumonia, renal colic, complex lacerations. displaced fractures, dislocations, temp> 101 Non-urgent: Can wait long time to be seen: Sprains, strains, skin rashes, simple fractures, uncomplicated UTI
Critical Incident debriefing- communication
Ensure needs of hospital departments have been met and can resume normal operations -Formal systematic and analysis, first type: entails in crisis support teams to provide sessions for small groups of staff to promote effective coping skills -Second type: Administrative review of staff & system performance, determine whether opportunities for improvement in plan exist
Mass casualty- personnel role assignments
Incident commander: Physician or administrator who assumes overall leadership for implementing the emergency plan. Assist in organization of hospital services to rapidly expand capacity, recruit paid or volunteer staff, ensure availability of medical supplies. EX: dictate that all pt due to be dc from an impatient unit be moved to a lounge area asap, direct departments such as PT to cancel usual operations Command physician: physician who decides the number, acuity, resource needs of patients. Determining #, acuity, med resource needs of victims arriving from incident scene, id need for calling in specialty providers, who can be transferred to other facilities Triage officer: physician or nurse who rapidly evaluates each pt to determine priorities for tx Community relations or public information officer: Serves as liaison between health care facility and media
Airway management and assessment burn patient
Inspect mouth, nose, pharynx Continuous airway assessment is priority Change in resp pattern, drooling, diff swallowing, brassy cough, audible breath sounds on exhalation, indicates pulmonary injury & impairment of gas exchange Listen for hoarseness, cough, wheezes, stridor Place upright, apply O2, report any signs immediately to provider or rapid response team Immediate intubation: wheezes that disappear
Triage- "Non-urgent" Classification
Non-urgent: Can wait several hours to be seen: Sprains, strains, skin rashes, simple fractures, uncomplicated UTI
Resuscitation phase- nursing actions
Priority is airway and fluid resuscitation Edema & upper airway obstruction- upright, apply oxygen, report to rapid response Resuscitation- airway, iv access, fluid, hypothermia, oxygen, pain management, antibiotics- prophylaxis, tetanus shot IV fluid therapy, pain management, dressing changes -Intial fluid shift (occurs in the first 12hrs and continues for 24-36hrs) -Na: decreased d/t third spacing -K: increased d/t cell destruction (hyperkalemia) -BUN: elevated d/t fluid loss -Hct/Hgb: elevated (hemoconcentration) d/t the loss of fluid volume and the fluid shift into the interstitial space (third spacing) -Glucose: elevated d/t stress
Heat Stroke nursing interventions
Scene: -Ensure airway -Remove pt from hot environment -Contact EMS -Remove clothing -Pour or spray cold water on body & scalp -Fan -Place ice in cloth or bags & position on scalp, groin area, behind neck, in armpits -Immediate immersion in cold water -Do not give food or water Hospital: -Support Airway -Give O2 by mask or NC, prepare for intubation -Start at least 1 large bore IV -Admin fluids, using cooled solutions -Use cooling blanket -Shivering occus, use midazolam or propofol, caution risk for delirium & hypotension -Obtain baseline CBC, UA, electrolytes, Cardiac enzyme, liver enzyme -Do not admin aspirin or antipyretics -Insert rectal probe, assess q15min -Insert indwelling cath -Monitor VS -Assess ABG -Admin muscle relaxants or benzos -Measure or monitor UO & Specific gravity -Stop cooling interventions when core body temp 102
Burn phases
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 (ie, wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, 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
Anaphylaxis recognition and treatment
airway is priority, O2, epinephrine, recognition & treatment of anaphylaxis- call 911 -s/s-wheezing, facial swelling, respiratory distress, wheals/skin reactions, hives, itching, angioedema, bronchospasm, laryngeal edema, hypotension, loc change, cardia arrhythmias
Lightning strike nursing priorities
cardiac rhythm do ECG first. maintain patent airway and CPR if needed.
