N434 Shock & Tissue Integrity Flashcards

What is the progression of shock?Shock --> SIRS --> MODSWhat occurs when <15% fluid is lost during shock? 15-30%? >40%?<15% = body adapts 15-30% = SNS mediation >40% = irreversible damageWhat are the 4 stages of shock?1. Initial 2. Compensatory 3. Progressive 4. Refractory (Irreversible)What happens during the initial stage of shock?- Asymptomatic - Lactic acid accumulation (no O2 --> anaerobic metabolism)What happens during the compensatory stage of shock?Body tries to maintain homeostasis --> continued accum. of lactic acid --> stimulation of SNS --> blood flow shunted to vital organs --> multi-system response Respiratory acidosis from lactic acid accumulationWhat happens during the progressive stage of shock?Compensatory mechanisms fail --> further decrease to CO, BP, & perfusion Systemic inflammatory response syndrome (SIRS)What are triggers of SIRS?- Trauma - Abscess formation - Necrotic tissue - Microbial invasion - Endotoxin release - Perfusion deficitsWhat happens during the refractory (irreversible) stage of shock?Peripheral vasoconstriction --> decreased perfusion --> further lactic acid accumulation Multiple organ dysfunction syndrome (MODS)What is the diagnostic test for shock?There is none!! Only assessment measures to provide insight into its possible existence (e.g. EKG, chest x-ray, art line, pulse ox, skin assessments)How does albumin treat shock?Supports BP (pulls fluid back into intravascular space instead of 3rd space)Intervention is needed for what values of SBP, MAP, & lactate?SBP < 90 MAP < 65 Lactate > 4What medications are used to treat shock?- Vasopressors (e.g. norepinephrine, vasopressin, epinephrine, dopamine, phenylephrine) - Inotropes (e.g. dobutamine) - Corticosteroids - AnticoagulantsWhat are the 4 phases of wound healing?1. Hemostasis 2. Inflammatory 3. Proliferation/Granulation 4. Remodeling/MaturationWhat are the 6 types of burns?1. Thermal 2. Chemical 3. Smoke/Inhalation 4. Electrical 5. Radiation 6. Cold ThermalWhat is the most common type of burn injury?Thermal (flame, flash, scald, contact with hot objects)A majority of deaths at the fire scene occur from what?Metabolic asphyxiation (smoke inhalation injury)Carboxyhemoglobin levels greater than __% will result in death.20%What does the presentation of an inhalation injury look like?- Confined spaces - Burns on palate & mucosa - Loss of nose hair - Burns around nose & mouth - Wheeze, crackles - Hoarseness & stridor = LATE symptomsWhat are side effects of carbon monoxide?- Dull headaches - Weakness - Dizziness - Confusion - Blurred vision - Loss of consciousnessWhat is a major concern with electrical burns?Cardiac dysrhythmiasWhat is a urinary manifestation of electrical burns? Why does this occur?Myoglobinuria -- smoky dark urine --> myoglobin from injured muscle & hemoglobin from damaged RBCs are released into circulation --> can travel to kidneys & block renal tubules (ATN & AKI)What are the 3 types of burns?1. Superficial (1st degree) 2. Deep (2nd degree) 3. Full-thickness (3rd & 4th degree)What does a superficial (1st degree) burn look like?- Erythema/redness - Blanching on pressure - Pain & mild swelling - No vesicles or blistersWhat does a deep (2nd degree) burn look like?- Fluid-filled vesicles - Shiny/red/wet - SEVERE pain from nerve injury - Mild to moderate edemaWhat does a full-thickness burn look like?- Dry, waxy white, leathery, hard skin - No pain (nerve destruction) - Involvement of muscles, tendons, bonesWhat is the most accurate tool for measuring extent of burns?Lund Browder chart (considers patient's age in proportion to relative body-area size)What tool is used for INITIAL assessment of determining severity of burns?Rule of NinesDescribe the Rule of Nines.Divides body into 11 portions - Anterior trunk = 18% - Posterior trunk = 18% - Each entire leg = 18% - Each entire arm = 9% - Head = 4.5% - Genital area = 1%What are nursing interventions for immediate management of skin during the emergent burn phase?- Remove clothing & particles in chemical burns - Cool wound if small (<10% TBSA) within 1 min - DON'T cool wound if large (risk for hypothermia) - Wrap wound with cling film or dry/clean blanket - ElevationWhat is a major initial threat during the emergent burn phase?Hypovolemic shockWhat electrolyte shifts occur during the emergent burn phase?Capillary seal is lost --> interstitial edema Cellular integrity is altered - Na+ goes INTO cell (hyponatremia) - K+ goes OUT of cell (hyperkalemia) State of DEHYDRATIONWhat treatments are needed for burns >15% TBSA?IV fluid resuscitation with 2 large-bore catheters Foley catheter placementWhat 3 major organ systems are at risk during the emergent burn phase?1. Cardiovascular --> dysrhythmias, hypovolemic shock, blood "sludging", risk for VTE 2. Respiratory --> upper or lower airway burns/injuries 3. Urinary --> ATN, hypovolemia (renal ischemia)How are suspected inhalation injuries confirmed?Fiberoptic bronchoscopy & carboxyhemoglobin blood levelsWhat is the leading cause of death in patients with inhalation injury?PneumoniaWhat is the Parkland formula for fluid replacement therapy?4 mL * weight (kg) * TBSA Total volume of fluid needed in first 24 hours - First 8 hours = 1/2 - Next 8 hours = 1/4 - Last 8 hours = 1/4What should hourly urine output, MAP, systolic BP, & HR be to maintain perfusion?Urine = 0.5-1 mL/kg/hour MAP > 65 mmHg Systolic BP > 90 mmHg HR < 120 bpmWhat is an escharotomy? What type of wound is it used in?Incision through full thickness eschar to restore circulation to compromised extremities Used in circumferential burnsNon-intubated patients with __% TBSA can eat orally.<20%What is the site used for intraosseous (IO) access?TibiaHow long does the emergent burn phase last?Up to 72 hoursWhat two major electrolyte problems can occur during the burn phase?Hyponatremia HyperkalemiaWhat does the acute phase start with?Diuresis (mobilization of ECF)What treatments are done for 1st degree burns? 2nd degree? Deep 2nd degree or 3rd degree?1st = self healing 2nd = cleansing & dressing (silver sulfadiazine, vaseline gauze) 3rd = debridement, grafting/reconstruction, hydrotherapyWhat is the only permanent graft?AutograftWhat is a split thickness skin graft?Graft taken from patient's healthy skin -- meshed to cover a large wound From thigh, scalp, scrotum Higher success rateWhen does the rehabilitation phase begin? How long does it take?Begins when wounds have healed Can take 6-12 months or moreWhat are two major manifestations that can occur during the rehabilitation phase?Scarring & contracturesWhat are treatments for scarring after burn healing?- Water-based moisturizers - Jobst stockingsWhat are Jobst stockings? How long can they be worn?Keep pressure on & flatten scar -- only over HEALED skin Wear up to 24 hours a day & up to 12-18 monthsWhat are nursing interventions to prevent contractures after burn healing?Adequate ROM, Jobst or ace wraps, splintsWhat should wounds be cleansed with?Soap & water or NS-moistened gauze