first degree burn
superficial, epidermis layer, skin is red and dry.
second degree burn
partial thickness, blistered, skin moist, pink or red, epidermis and dermis layer affected.
third degree burn
full thickness, charring, skin is black, brown or red, epidermis, dermis, and subcutaneous layers affected.
fourth degree burn
full thickness, charring, skin is white or black with networks of thrombosed capillaries, epidermis, dermis, subcutaneous, and muscle & bone affected.
burn care nursing interventions
maintaining patent airway and replacing body fluids and electrolytes, use of sterile gloves always.
IV solution used most for burns
Normal saline with lactated ringers.
Post op graft care
applications of pressure dressings, immobilize wound for 3-7 days post op.
rules of nines
head & neck 9%, anterior trunk 18%, posterior trunk 18%, arms 9% each (18%), legs 18% each (36%), and perineum is 1%
the introduction of microorganism to patient is great.
functions of the liver
produces heparin, emulsifies fat, converts glucose to glycogen, metabolizes hormones, turns amino acids into protein(albumin), filters blood, and produces fibrogen, and prothrombin.
indication of liver damage
decreased albumin, and delayed clotting factors.
complications of cirrhosis
portal hypertension that leads to esophageal varices.
distended engorged vessels resulting from increased portal pressure.
# 1 tx. for esophageal varices
caused by the decreased blood flow to the kidneys.
s/s of hepatorenal failure
asterixis is the first sign, then azotemia, oliguria, and ascites.
medications for hepatorenal failure
colac or laculose, attaches to the ammonia in the GI tract and removes it.
dx. test for colac
ph test of the stool, looking for acidic reading indicating that ammonia is being removed.
Medications for cirrhosis
aldactone, inderal, and vitamin K.
vitamin supplement, given PO, IM, and you must check color before giving, must be clear.
uses RNA to make copies of DNA that becomes genetic makeup of cells.
normal CD4 cell count
used to establish stage of HIV infection.
CD4 count <500, s/s fever, nightsweats, enlarged lymph nodes, and persistent infections.
full blown aids
CD4 count <200, s/s PCP, and esophageal candidas.
preliminary test or screening to detect HIV antibodies, if + retest.
Western Blot test
used to confirm HIV status.
most common opportunistic infection seen with HIV/AIDS.
s/s of PCP
fever, chest pain, dyspnea, cough.
meds. for PCP
Bactrim unless allergic, then pentnum is used.
fungal infection, usually inhaled.
dx. test for histoplasmosis
s/s of histoplasmosis
cough, increased temp., and malaise.
meds. for histoplasmosis
Amphotercin B, given IV, given first, then NIZORAL for maintenance therapy.
Side effects of AmpohotercinB
thrombocytopenia, agranulocytosis, and renal impairment.
NI for Amphotercin B
premedicate with benadryl as amphotercin causes anaphylatic shock, do not give with Foscavir, and it must be kept out of the light.
caused by organisms found in soil or water.
Dx. for MAC
s/s of MAC
meds. for MAC
biaxin, cipro, and zithromax.
caused by herpes virus
s/s of CMV
weight loss, fever, diarrhea.
Meds. for CMV
cytovene, and Foscavir. complication is retinitis.
Diet for HIV/AIDS
small frequent high calorie meals, fluids to be given in between meals not with them.
caused by contaminated food or water.
DX. test for cryptosporidiosis
s/s of cryptosporidosis
profuse watery diarrhea, weight loss, fever, anorexia, dehydration, and electrolyte imbalances.
Meds. for cryptosporidiosis
lomodil, and imodium
NI for cryptosporidiosis
proper hand washing is a must.
fungal infection found in bird droppings, soil, fruits, and fruit juices.
s/s of crypto meningitis
ha, mental status changes, fever, and stiff neck.
Meds. for crypto meningitis
diflucan, and amphotercin B
found in cats and raw meats.
s/s for toxoplasmosis
lethargy, ha, fever, and seizures
meds. for toxoplasmosis
daraprim, which is an antiprozoal, and must give with folic acid.