unit 6 AN
1) Because of her significant burn injury, AN is at high risk for infection. What measures will you institute to prevent this?
- Skin and wound care (sterile) - glucose management - Nutritional support (initially enteral or g tube; if that doesn't work add TPN) -prophylactic atb - protective isolations - need 4-5,000 calories/ day
Stages of Shock
Initial Compensatory Progressive Refractory
BURNS body percentage
Rule of 9's: Head 9%, Each arm 9%, Chest 9%, Abdomen 9%, Each anterior leg 9%, Each posterior leg 9%, Upper back 9%, Lower back 9%, Genitals 1% Palmar method: Patient's palm equates to 1%
Causes of hypercalcemia include:
prolonged immobility osteoporosis excess calcium or vitamin D intake indiscriminate use of antacids containing calcium bone tumors and tumors of the lung, stomach, and kidney hyperparathyroidism alkalosis thyrotoxicosis (hyperactivity of the thyroid ) Addison's disease (adrenal insufficiency) acute renal failure prolonged use of thiazide diuretics
irreversible stage of shock patho
tissue and cellular death becomes so widespread treatment cant reverse it.
causes of circulatory shock
-large-scale blood or fluid loss due to hemorrhage, vomiting, diarrhea, or extensive burns -poor circulation due to extreme vasodilation -loss of vasomotor tone due to anaphylaxis -failure of autonomic nervous system regulation -septicemia -pump failure due to myocardial damage from heart attacks
tx for hypokalemia
1. Give K+ 2. Aldactone makes them retain K+ 3. Eat more potassium
what does MAP need to maintain above
65
hypovolemic shock tx and nursing management
•Treatment of underlying cause •Fluid, blood replacement •Redistribution of fluid -Pharmacologic therapy (think about causes •Administering blood, fluids safely •Implementing other measures
signs of hypernatremia (FRIED)
FRIED Fever Restless Increased BP Edema Decreased urinary output
Signs of hypermagnesemia
Facial flushing Decreased HR Decreased BP Arrhythmia Decreased DTRs Weakness Wide QRS Increased PR N/V Drowsiness Respiratory depression Cardiac arrest
Causes of hypocalcemia include:
Hypoparathyroidism Malabsorption syndrome Deficient serum albumin Increased serum pH level Renal failure
tx for hyponatremia
give the patient sodium, and replacing fluids
compensatory stage of shock
normal bp HR >100 rr >20 breaths/min, PaCO2 <32 mm cold and clammy decreased uo confusion and agitation respiratory alkalosis
pharmacological management of cardiogenic shock
•Dobutamine •Nitroglycerin •Dopamine •Other vasoactive medications •Antiarrhythmic medications
1) Describe the interventions needed to care for AN on her arrival to the ED for burn victim
- Airway patency; check for singed hairs, sut (look in airway), hear wheezing in lungs and stridor - Start a large bore IV (2) - Pain medication administration - Decrease anxiety - Foley catheter - Fluid resuscitation - Calculate burn percentile using rule of 9 - Remove all contaminated clothing - Dry sterile gauze over burns - CNS checks - Assess for other injuries - Protect c spine if injuries - Tele - NG - Labs: CBC, chem, (would show hemoconcentration so high h&h)
what occurs during compensatory stage of shock
- Blood Shifted to Major Organs - Hyperventilation (counteract acidosis) - HR Increased
The client is ordered a special burn diet. She has always gained weight easily and is concerned about portion sizes. What diet-related teaching will you provide?
- Body needs an increase in nutritional support to help with healing of tissues and muscles damaged d/t burns, your body is burning through everything being given
1) How will you know that fluid resuscitation is benefitting the client with burns
- Improvement in vitals (BP up and HR down) - Not exhibiting signs of dehydration - Increased urine output (0.5-1 mL/kg/hr) - Expect hemodilution
parkland formula
4 mL x BSA x wt in (kg) = total volume in mL/24 hrs split total volume into 8 hrs and 16 hrs (divide in half) pump rate you would divide by 8 and 16
Parkland formula
4 mL x TBSA x kg 1st 8 hrs get half next 16 hrs get other half
primary survey
ABC's (airway, breathing, circulation) stabilize pt
Causes of neurogenic shock
Acute injury to spinal cord
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement? A Blood pressure 89/50 B Heart rate 98 C Urine output 20mL/hr D Weight increased by 5kg overnight
Correct Answer: Heart rate 98 Explanation: When a client's circulating fluid volume is low, the heart rate increases to maintain adequate blood pressure. Therefore, the nurse should identify a decrease in heart rate as an indication of adequate fluid replacement.
complications of MODS or multiple organ failure
DIC ART
causes of hypomagnesemia
Insufficient magnesium intake ~Malnutrition and starvation ~Vomiting diarrhea ~Malabsorption syndrome ~Celiac disease ~Crohn's disease Increased magnesium secretion ~Meds such as diuretics ~Chronic alcoholism Intracellular movement of magnesium ~Hyperglycemia ~Insulin administration ~Sepsis
cardiogenic shock medical and nursing tx
Medical management: Correction of underlying causes Initiation of first-line treatment •Oxygenation •Pain control •Hemodynamic monitoring •Laboratory marker monitoring •Fluid therapy •Mechanical assistive devices •Preventing cardiogenic shock •Monitoring hemodynamic status •Administering medications, IV fluids •Maintaining intra-aortic balloon counter pulsation •Ensuring safety, comfort
A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect? AMetabolic alkalosis BHypervolemia CHyperkalemia DLow hemoglobin
Correct Answer: Hyperkalemia Explanation: The nurse should expect a client who has a burn injury to experience hyperkalemia due to the release of potassium from damaged cells.
causes of hypernatremia
Decreased sodium excretion (corticosteroids, Cushing's Syndrome, Renal failure, Hyperaldosterone) Increased sodium intake (excessive oral soidium ingestion or administration of sodium containing IV fluids) Decreased water intake (NPO) Increased water loss (increased rate of metabolism, fever, hyperventilation, infection, excessive diaphoresis, watery diarrhea, diabetes insipidus)
Multiple Organ Dysfunction Syndrome (MODS) from irreversible shock
•Multiple Organ Dysfunction Syndrome (MODS)= Presence of altered function of two or more organs in acutely ill patient such that interventions are necessary to support continued organ function
types of circulatory shock
•Septic shock •Neurogenic shock •Anaphylactic shock
The nurse should be aware that formulas are only a guide for burn care fluid resuscitation. How often must the client's response to fluid therapy (heart rate, blood pressure, and urine output) be evaluated? AEvery hour BEvery 2 hours CEvery 3 hours DEvery 4 hours
a
client 1 day post op abdominal surgery w bp of 88/60 and apical pulse of 122. client is diaphoretic and has a pale, cold and clammy skin. which int should u do first A) increase clients iv fluid rate b) adm an intravenous dopamine drip c) obtain an arterial blood gas d) assess the client's abdominal dressing
a
irreversible stage of shock
require mechanical or pharmalogic support for bp erratic HR intubated and mechanical vent and oxygenation jaundice anuria, require dialysis unconscious profound acidosis
1) Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply a. Singed nasal hair b. Hoarseness c. Difficulty swallowing d. Stridor e. Bradypnea
abcd
A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? Select all that apply. ALimit visitors in the client's room BEncourage fresh vegetables in the diet CIncrease protein intake DInstruct the client to consume 2,000 calories a day ERestrict fresh flowers in the room
ace
TX for Hypokalemia includes
administering potassium. Oral potassium given in a cup of juice to mask the taste, IV potassium may be administered
tx for hypocalcemia
administration of calcium and vitamin D IV calcium gluconate
what do you give to a burn victim to pull fluid back into interstitial space?
albumin
The nurse is caring for a burn patient that has arrived to the emergency room. The nurse should choose which of the following as the priority of care? Afluid replacement Bestablishing a patent airway CAdministering pain medication DInsertion of an IV line
b
The nurse is educating a group of new nurses about burns. How should the nurse describe a full-thickness burn? AFull-thickness burns are classified by the appearance of blisters. BFull-thickness burns are identified by the destruction of the dermis and epidermis. CFull-thickness burns are not associated with edema formation. DFull-thickness burns are very painful because of exposed nerve endings
b
client w shock brought on by hemorrhage has a temp of 97.6, hr of 140 bpm, rr of 28, SPO2 92% and a blood pressure of 60/30. for this client the nurse should question which provider order? a)monitor uo at least hourly b) infuse normal saline at 50ml/hr via IV c) titrate o2 to keep sats over 92% d) draw samples for H&H q6h
b
progressive stage of shock
body no longer compensates vasoconstriction continues compromising perfusion decrease cerebral perfusion
A nurse is caring for a client who has sustained burns over 35% of his total body surface area. Of this total, 20% are full-thickness burns on the arms, face, neck, and shoulders. The client's voice has become hoarse. He has a brassy cough and is drooling. The nurse should identify these findings as indications that the client has which of the following? APulmonary edema Bbacterial pneumonia Cinhalation injury Dcarbon monoxide poisoning
c
client admitted to ER after na accident w a chain saw. the client is exhibiting s/s of acute hypovolemic anemia from severe blood loss. what s/s would you assess for first? A) fatigue B) postural hypotension c) reduced urine output d) hyperthermia
c
secondary survey
urine output medication hx health hx alcohol level allergy hx head to toe assessment
1) The client has a circumferential burn on her right lower leg. What complication is she in danger of developing? How will you monitor for it? What will they do if this complication occurs?
compartment syndrome -neurovascular assessments
tx of MODS
control initiating event promoting adequate organ perfusion providing nutritional support
Signs of hypocalcemia CATS
convulsions, Chovstek's (facial twitching) arrhythmias Trousseau's (carpal spasm), tetany, stridor+ spasms
1) By the end of the shift, which of the following assessment findings would best indicate that the client is responding to therapy? a. Respiratory rate 22, BP 120/74 b. Heart rate 110, urine output 20 mL/hr for last 4 hours c. Blood pressure 120/70, urine output 25mL/ hr for past 4 hours d. Blood pressure 104/64, urine output 40 mL/hr for past 4 hours.
d
Causes of hypokalemia
vomitting, NG suction (we have lots of K+ in our stomach), diuretics, Not eating (pg 13)
carbon monoxide poisoning
· Confusion · Red cherry lips · h/a
Causes of hyponatremia include
diarrhea, vomiting, excess sweating, burns, wounds, gastric lavage
tx for compartment syndrome d/t burns
escharotomy (through initial tissue) then fasciotomy if to thick (cuts through all layers)
1) 18 hours after the injury, the UAP reports vitals as BP 90/50, P 130., Resp 24, Temp 99F and states the urine output for the past hour was 20 mL. What do you suspect is occurring and why does this concern you? What treatment do you anticipate?
fluid loss -lost body's ability to regulate temp and regulate fluids -isotonic fluids
vasoactive medications are used when
fluid therapy alone does not maintain MAP
shock tx
fluids, blood, albumin, vasoactive meds -caution use of bolus if it is cardiogenic shock -monitor for fluid overload atb if sepsis suspected tx cause: -obstructive shock w cardiac tamponade, remove fluid around heart hemodynamic monitoring monitor labs -abg -cardiac markers -cbc -chem panel
1) The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury predispose the client to electrolyte imbalances. What electrolyte imbalances should the nurse monitor for?
high sodium and potassium
nurse is caring for a client who is being treated on oncology unit w dx of breast cancer w bone metastases. during assessment the nurse notes the client complains of a new onset of weakness and abdominal pain what electrolyte imbalance does the nurse suspect is occurring
hypercalcemia
caring for a client admitted w paralytic ileus a ng tube placed and has been on low intermittent suction for 3 days. upon review of morning abgs the nurse notices metabolic alkalosis which electrolyte imbalance does the nurse suspect is occurring
hypokalemia
Causes of septic shock
infection
Hypokalemia S/S
A SIC WALT Alkalosis Shallow respiration Irritability Confusion and drowsiness Weakness and fatigue Arrhythmias- irregular heart rate, tachycardia Lethargy Thready pulse decrease intestinal mobility, nausea and vomiting
causes of anaphylactic shock
Allergen exposure; drug, vaccine, food, serum, insect venom, chemical
Stages of Shock: Progressive
Compensatory mechanisms fail Tissues become hypoxic, cells switch to anaerobic metabolism, lactic acid builds up, and metabolic acidosis develops HR >150 systolic <90, MAP <65 (requires fluids to support bp) rapid, shallow resp., crackles, PAO2 <80 and PaCO2 >45 mottles and petechiae UO <0.5 ml/kg/hr lethargic metabolic acidosis
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? A"Large incisions will be made in the eschar to improve circulation." B"This procedure involves placing the client into a shower and removing the dead tissue." C"A piece of healthy skin will be removed from an unburned area and grafted over the burned area." D"Dead tissue will be non-surgically removed."
Correct Answer: "Large incisions will be made in the eschar to improve circulation." Explanation: An escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that encircle a body part, such as an arm or the chest, can cause swelling and tightness in the affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue allows the skin to expand, reduces tightness and pressure, and improves circulation.
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? AAirway obstruction BInfection CFluid imbalance DParalytic ileus
Correct Answer: Airway obstruction Explanation: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority risk is airway obstruction. Burns of the head, neck, and chest often involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care.
A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take? AInsert an indwelling urinary catheter. BInspect the mouth for signs of inhalation injuries. CAdminister intravenous pain medication. DDraw blood for a complete blood cell (CBC) count.
Correct Answer: Inspect the mouth for signs of inhalation injuries. Explanation: Since the client sustained burns to the chest and face, there is a possibility that flames and smoke from the client's burning clothes could have caused an inhalation injury. The nurse should inspect the mouth and throat for soot and swelling. Using the airway, breathing, circulation (ABC) priority-setting framework, is the priority concern at this time.
A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet. The nurse should recommend which of the following foods as the best source of protein to promote wound healing? AOne cup of brown rice BOne cup of orange juice COne cup of pureed avocado DOne cup of lentils
Correct Answer: One cup of lentils Explanation: The nurse should determine that nuts and legumes, such as lentils, are the best foods to recommend for protein intake for this client. One cup of lentils contains 17.86 g of protein. A diet high in protein and calories is required to promote wound healing. Nuts and legumes are good sources of protein to include in a plant based diet such as a vegan diet.
A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support? AAssign assistive personnel to keep his room neat and clean. BRotate the nursing staff so he can have varied interactions. CTalk with the client during wound care. DKeep family members aware of his condition.
Correct Answer: Talk with the client during wound care. Explanation: Talking with the client while providing care assists in the development of the nurse-client relationship and demonstrates caring.
A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn? AThe burned area is black in color and pain is absent. BThe burned area is pink in color with blisters present. CThe burned area is red in color with eschar present. DThe burned area is yellow in color with severe edema.
Correct Answer: The burned area is red in color with eschar present. Explanation: This finding indicates a deep partial-thickness burn. Additional findings may include moderate edema and reports of pain. At this stage, the eschar that is present is soft and dry.
A nurse is preparing to start an IV infusion of lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hr. How many mL/hr should the nurse set the pump to infuse for the first 8 hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ____mL/hr
Correct Answers 325mL/hr 325 325 mL Explanation: 325
A nurse is assessing a client who has sustained deep partial-thickness and full-thickness burns over 40% of their body 24 hours ago. Which of the following findings should the nurse expect? Select all that apply. ADyspnea BBradycardia CHyperkalemia DHyponatremia EDecreased hematocrit
Correct Answers Dyspnea Hyperkalemia Hyponatremia
Tx for hypernatremia
IV normal saline, diuretics, and decrease salt in the diet
signs of hypomagnesemia
Increased HR Increased BP Arrhythmia Increased DTR Tetany Confusion Agitation Wide QRS Decreased ST Insulin Resistance chvostek and trousseaus
Hyperkalemia S/S
M.U.R.D.E.R. M - Muscle weakness U - Urine, oliguria, anuria R- Respiratory distress D - Decreased cardiac contractility E - ECG changes R - Reflexes, hyperreflexia, or areflexia (flaccid)
Causes of hyperkalemia: MACHINE
M: meds (ACE inhibitors, steroids, beta blockers A: acidosis C: cellular destruction H: hypoaldosteronism, hemolysis I: intake excessive N: nephrons (renal) failure E: excretion impaired
if dextran is administered for shock what may it interfere with
platelet aggregation
Fasciotomy nursing care
Pack and dress wound Monitor for infection Continue to monitor CMS checks (circulation, motion, sensation)
MODS
presence of altered funciton of 2 or more organs in an acutely ill pt such as interventions necessary to support continued organ function primary or secondary high mortality rate; 75%
causes of hypermagnesiumia
eating too many tums, renal failure, ketoacidosis
on assessment nurse notes lethargic, weak, and confused with 3+ edema. what electrolyte imbalance is the most plausible cause of this clients s/s
hyponatremia
Tx for hypomagnesemia
increasing magnesium and calcium in the patient's diet, administer magnesium sulfate as ordered, usually given by IV
what fluids are you giving burn pt
isotonic
1) The client is in severe pain. What is the drug of choice for pain relief after the burn injury and how should it be given for burn victim
iv opioids (morphine, fentanyl, hydromorphone)
signs of hyponatremia
lethargy, headache, confusion, apprehension, seizures, coma
Signs of hypercalcemia are
lethargy, headache, weakness, muscle flaccidity, heart block, anorexia, nausea, and vomiting.
nurse is caring for pt undergoing alcohol withdrawal. which of the following serum labs should nurse monitor closely
magnesium
Tx for hypermagnesemia
monitor the patient's LOC, administer Ca gluconate to decrease magnesium
