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Unit Four Exam Study Guide

Terms in this set (114)

At the Scene (pre-hospital)-
•Ensure a patent airway.
•Remove the patient from the hot environment (into air-conditioning or into the shade).
•Remove the pt's clothing.
•Pour or spray water on the pt's body and scalp.
•Fan the pt (not only the person providing care, but all surrounding people should fan the patient with newspapers or whatever is available).
•If ice is available, place ice in cloth or bags and position the packs on the patient's scalp, in the groin area, behind the neck, and in the armpits.
•Get the pt to the nearest ED!

Hospital care-
•The first priority for collaborative care is to monitor and support ABC's.
•Provide high-concentration O2 therapy, start several IV lines with 0.9% saline solution, and insert a urinary catheter.
•Continue aggressive interventions to cool the patient until the rectal temperature is 100° F (37.8° C)
•Obtain baseline laboratory tests as quickly as possible: serum electrolytes, cardiac enzymes, liver enzymes, and complete blood count (CBC).
•Obtain urinalysis, and monitor urine output.
•Assess arterial blood gases.
•Administer muscle relaxants (benzodiazepines) if the patient begins to shiver.
•Measure urine output and specific gravity to determine fluid needs.
•Slow cooling interventions when core body temperature is reduced to 102° F (39° C); stop cooling when rectal temperature is 100° F (37.8° C).

*If shivering occurs during the cooling process, give a parenteral benzodiazepine- (Valium) or (Thorazine) is an alternative agent.

Because seizure activity can further elevate body temp, have an IV benzo immediately available.
General management principles apply to both moderate and severe hypothermia:
•Protect from further heat loss and handle gently to prevent ventricular fibrillation.
•Positioning the patient in the supine position prevents orthostatic changes in BP from cardiovascular instability.
•Follow standard resuscitation efforts with special attention to maintenance of ABCs
•Admin drugs with caution and/or spaced at longer intervals because metabolism is unpredictable in hypothermic conditions.
•Remember that drugs can accumulate without obvious therapeutic effect while the patient is cold but may become active and potentially lead to drug toxicity as effective rewarming is underway.
•Consider withholding IV drugs until the core temperature is above 86° F (30° C).
•Initiate CPR for patients without spontaneous circulation.
•Be aware that defibrillation attempts may be ineffective until the core temperature is above 86° F (30° C).


Treatment of moderate hypothermia:
•Active external and core rewarming methods.
•Applying external heat with heating blankets can promote core temp "after-drop" by producing peripheral vasodilation.
•"After-drop" is the continued decrease in core body temp after being removed from the cold environment; it is caused by the return of cold blood from the periphery to the central circulation.
•Therefore the pt's trunk should be actively rewarmed before the extremities.
•Core rewarming methods for moderate hypothermia include administration of warm IV fluids, heated oxygen or inspired gas to prevent further heat loss via the respiratory tract, and heated peritoneal, pleural, gastric, or bladder lavage.

**Nursing Safety Priority- Critical Rescue:
Pts who are severely hypothermic are at high risk for cardiac arrest. Avoid using active external rewarming with heating devices because it is dangerous and contraindicated in this population due to rapid vasodilation.

Treatment for severe hypothermia is:
•use internal rewarming methods such as cardiopulmonary bypass, hemodialysis, venovenous or arteriovenous rewarming, or intravascular rewarming via a closed-loop indwelling catheter
•Cardiopulmonary bypass is the fastest core rewarming technique. .
Key Features for both: weakness, nausea, vomiting, hypotension, seizures, coagulopathy, severe pain, localized tissue swelling or redness.

1. Pit vipers S/S include:
* Severe pain, swelling, and redness or ecchymosis around bite
* Hrs later, vesicles or hemorrhagic bullae may form.
* Systemic responses include a minty, rubbery, or metallic taste paresthesias of the scalp, face, and lips.
*Muscle fasciculations (twitching) and weakness, nausea, vomiting, hypotension, seizures, and coagulopathy (clotting abnormalities) or DIC.
*If the bite site does not show evidence of local tissue swelling or redness within 8 hours, systemic effects less likely to develop.

TABLE 11-1 GRADES OF PIT VIPER ENVENOMATION
None- Fang marks, but no local or systemic reactions
Minimal- Fang marks, local swelling/pain, no systemic reactions
Moderate- Fang marks and swelling progressing beyond the site of the bite; systemic s/s such as N/V, paresthesias, & hypotension
Severe- Fang marks with swelling of the extremity, subcutaneous ecchymosis, severe symptoms, including manifestations of coagulopathy

2. Coral Snakes S/S include:
The effect is to block neurotransmission, producing
*ascending paralysis, reduced perception of pain, and, ultimately, respiratory paralysis

*Unlike the pain from pit viper bites, pain at site may be only mild
*The venom is spread via the lymphatic system, but swelling is unlikely.
*Fang marks may be difficult to find because of small teeth.
*The toxic effects of venom may be delayed up to 12-18hrs, but then produce rapid clinical deterioration.

**Early signs and symptoms are nausea, vomiting, headache, pallor, and abdominal pain.

*Assess for neurologic manifestations; paresthesias, numbness, and mental status changes, as well as cranial nerve and peripheral nerve deficits.

*Total flaccid paralysis may occur later, and may have difficulty speaking, swallowing, and breathing.
*Clotting changes do not occur.
*Respiratory problems and cardiovascular collapse can occur in severe cases

*ABGs reveal respiratory insufficiency.
*The muscle toxin in the venom can cause an elevation in (CK) from muscle breakdown and produce myoglobinuria (release of muscle myoglobulin into the urine).

Despite these clinical effects, death is rare if the patient receives timely management
Urinalysis is a part of any complete physical examination and is especially useful for patients with suspected kidney or urologic disorders


Color- Pale yellow
Dark amber indicates concentrated urine.
Very pale yellow indicates dilute urine.
Dark red or brown indicates blood in the urine. Brown also may indicate increased urinary bilirubin level. Red also may indicate the presence of myoglobin.


Odor- Specific aroma, similar to ammonia
Foul smell indicates possible infection, dehydration, or ingestion of certain foods or drugs.


Turbidity- Clear
Cloudy urine indicates infection, sediment, or high levels of urinary protein.


Specific gravity
Usually 1.005-1.030; possible range 1.000-1.040 (after 12-hr fluid restriction, >1.025)

Increased in decreased kidney perfusion, inappropriate antidiuretic hormone secretion, or congestive heart failure.

Decreased in chronic kidney disease, diabetes insipidus, malignant hypertension, diuretic administration, and lithium toxicity.
Older adult:
Decreased because of decreased concentrating ability



pH- Average: 6; possible range: 4.6-8
Changes are caused by diet, the administration of drugs, infection, freshness of the specimen, acid-base imbalance, and altered renal function.


Glucose <0.5 g/day
Presence reflects hyperglycemia or a decrease in the renal threshold for glucose.


Ketones- None
Presence reflects incomplete metabolism of fatty acids, as in diabetic ketoacidosis, prolonged fasting, anorexia nervosa.


Protein- 0.8 mg/dL
Increased amounts may indicate stress, infection, recent strenuous exercise, or glomerular disorders.


Bilirubin (urobilinogen)- None
Presence suggests liver or biliary disease or obstruction.


Red blood cells (RBCs)- 0-2 per high-power field
Increased amounts are normal with indwelling or intermittent catheterization or menses but may reflect tumor, stones, trauma, glomerular disorders, cystitis, or bleeding disorders.


White blood cells (WBCs)- Males: 0-3 Females: 0-5
Increased amounts may indicate an infectious or inflammatory process anywhere in the renal/urinary tract, renal transplant rejection, fever, or exercise.


Casts
A few or none, composed of RBC, WBC, protein, or tubular cell casts
Increased amounts indicate the presence of bacteria or protein, which is seen in severe kidney disease and could also indicate urinary calculi.


Crystals- None
Presence of normal or abnormal crystals may indicate that the specimen has been allowed to stand.


Bacteria <1000 colonies/mL
Increased amounts indicate the need for urine culture to determine the presence of urinary tract infection.


Parasites- None
Presence of Trichomonas vaginalis indicates infection, usually of the urethra, prostate, or vagina.


Leukoesterase- None
Presence suggests urinary tract infection.


Nitrites- None
Presence suggests urinary Escherichia coli.