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Exam 5 -304- study cards

Terms in this set (56)

Define Thermal Burns
Exposure to heat caused by fire/flame or scalding from hot liquids or steam
Treatment of Thermal Burns
1) Soak victim & Adherent clothing with cool water briefly.
2) Restore Normal Skin Temperature
3) Cover Burns quickly with clean or sterile dressings & Keep Pt warm
4) Transport Patient
Define Electrical Burns
Coagulation necrosis cused by intense heat generated from electrical current
Treatment of Electrical burn
1) Do not touch patient until power is turned off.
2) Assess ABCs
3) If person is not breathing or pulseless, start CPR
4) C-Spine immobilization with airway
5) Continuous Cardiac monitoring
6) Frequent ABG Analysis
7) Aggressive infusion of LR to flush myoglobin & HgB out of kidneys
8) Mannito as diuretic
9) BiCarb added to IVF
Electrical burn Meds
Lactated ringers, Mannito, Bicarb
Treatment of Chemical Burns
1) decontaminate pt prior to transport/transfer -remove clothing, brush off powder, rinse with water for 30 minutes.
2) Keep Patient Warm
Treatment of Frostbite
1) Submerse in circulating water bath
2) Analgesia and tentanus required if Frostbite is deep
3) Treat with topical antimicrobial/antibiotics
4) Amputation may be required if frostbite is deep
Greater risks for Elderly getting burned because of:
Reduced mobility
Vision/hearing changes
Decreased sensation
Living in older homes
Using older appliances
Not having operational smoke alarms.
Elderly have more severe burns because:
Difficulty extinguishing fire.
Difficulty removing selves from source
Thinning skin
Small margin of difference between dehydration & Hypovolemia
Inability to withstand metabolic stressors
Loss of skin elasticity
Chronic Illness
Suppressed immune system
Malnutrition
Delay seeking treatment
Inhalation injuries occurring above the glottis are:
True medical emergencies requiring early intubation.
Changes in Sensorium after a burn may indicate:
Hypoxia
Pulmonary Edema may develop up to _____ days after smoke inhalation injury.
7 days
Respiratory distress can occur ______ after smoke inhalation.
anytime
Manifestations associated with occur typically 24 - 48 hours after the burn.
smoke inhalation
Carbon Monoxide Toxicity
CO binds with Hgb and shifts OxyHgb dissociation curve to the left, decreasing ability of RBC to release oxygen to body tissues. Results in severe Anoxia and brain injury.
S/S of Carbon Monoxide Toxicity
Similar to hypoxia and impaired cerebral oxygenation
Management of Carbon Monoxide Toxicity
1) Remove source of CO
2) Rapid displacement of CO w/O2
3) Serial ABGs and COHgB levels
4) Early intubation and hyperbaric oxygen therapy
Pulse Oximetry is inaccurate when:
HgB is bound with CO
Resuscitative/emergent burn phase
1) IVF resuscitations for PTs with burns greater than 20%

2) Maintain uop in adults of 30 - 70 mL/hr (0.5 cc/kg/hr)

3) Systemic responses: Acute renal failure (give adequate fluids); GI, paralytic ileus and gastric ulcer; Metabolic, risk for decreased wound healing and Muscle mass. Need for increased nutrition
Reparative/acute Burn Phase
Onset of diuresis to near completion of wound closure.
Rehabilitative Burn Phase
Major wound closure to return to PTs optimal level of adjustment
Escharotomy
Excision of the eschar of a circumferential burn mimicking compartment syndrome.
Indications that a Eschorotomy may be needed:
1) Circumferential FT extremity burns with threatened distal tissue. (diminished /absent distal pulses via doppler & S/S of compartment syndrome)

2) Circumferential FT THoracic burn (elevated peak pressure or worsening oxygenation or ventilation)

3) Nearly impossible to resuscitate a PT with restrictive eschar.
Escharotomy procedure
PT lays in anatomical position. non-sterile field. Cut through eschar with scalpel or electrocautery.
Mng. Fluid Loss
Day 1 First half given in 8 hours second half in next 16.

Day 2 varies; addition of colloid.
Fluid loss resuscitation considerations
More is not bettter.
Cystalloids vs Colloids
Only lactated ringers
Given 2-4 cc LR/kg/%TBSA
Care of PT with autograft
1) Maintain Occlusive dressing to immobilize graft site with turning and repositioning
2) Bedrest
3) Moisten autograft site with NSS or antibiotic solution Q6H X 3 days
4) Keep donor site clean and pressure free
5) pulse checks distal to dressings Q2H X 24h
Resp. Considerations (C1-C4)
Total loss of respiratory FX
Resp. Considerations C1-C7
Accessory Muscles
Resp. Considerations C3-C5
Diaphragm
Resp . Considerations t1-t11
intercostals
Resp. Considerations t6-L1
abdominal muscles
Resp Considerations C5 - Ty:
Hypoventilation, impairment of intercostal muscles, need O2 and may require additional Respiratory Support
Artificial Airways related to:
Respiratory Compromise (loss of innervation of diaphragm, fatigue, hypoventilation, secretion retention, associated injuries)
With injury to respiratory system observe for:
Ascending edema.
Complications of Respiratory injury
1) Hypoxemia
2) Atelectasis
3) Pulmonary Edema
4) Pneumonia
5) Pneumothorx
6) Respiratory Arrest
Assessing Resp. System.
Lab data, Chest x-ray, ABG/CBC/Sputum cultures, Bronch, BAL
NI - Resp:
1) monitoring of ventilatory support or supplemental O2
2) turning and positioning, elevate HOB
3) ETT & Trach care
4) Oral care, suction as needed
5) Chest PT
6) pulmonary toileting: incentive spirometry, quad coughing, percussion vest.
Cardiovascular considerations with Spinal injury
1) Loss of sympathetic input from higher brain centers results in bradycardia and vasomotor paralysis
2) Vasodilation of blood vessels below level of lesion leeds to hypotension
3) hypotension and decreased blood flow back to the heart
4) pooling of blood coupled with immobility
5) Increased risk of vascular stasis (DVT/PE)
6) Orthostatic Hypotension
Assess Cardiovascular system after S.I.
1) monitor for signs, cardiac Monitoring, EKG
2) monitor response to elevation of head; orthostatic hypotension
3) observe for signs of DVT and PE
4) Lab data
N.I. Cardiovascular system after S.I.
1) Constant Cardiac monitoring
2) Hemodynamic Monitoring
3) Treat Arrhythmias
4) IV fluid Management
5) Apply SCDs
6) Prophylactic heparin
7) Vasopressors as indicated.
Neurological Considerations with S.I.
1) the level and pattern of the neurological loss depends in the level of the injury
2) As a result of spinal shock, many motor, sensory, and reflex functions are lost
3) Hypothermia and orthostatic hypotension are often seen in the acute phase of care
Neuro Complications associated with S.I.
1) Self care deficit
2) sensory/perceptual awareness
3) Sexual Dysfunction
4) Sleep pattern disturbances
5) Impaired Swallowing
Assessment of Neuro after S.I.
1) Assess baseline & monitor highest level of sensory, motor function, & reflexes
2) Monitor Vital Signs
3) Assess baseline & monitor routine neurological signs
4) Laboratory data
5) CT head, MRI, C-spine Xrays
N.I. Neuro S.I.
1) Initial and ongoing assessments
2) frequent neuro assessments.
3) Complete or incomplete injury? (monitor for spinal/neurogenic shock, assess for resolution)
4) Provide Pt and family info/teaching
Clinical triggers for organ donation
1) Immanent death of ventilated patient (irreversible brain damage, brain death protocol being considered)
2) Call within one hour of meeting clinical triggers (death expected within 48 hours, end of life comfort measures being considered, Call into CORE before discontinuing mechanical or pharmacological support)
3) determination of death in donor (irreversible cessation of all brian activity including brain stem, heart and lungs functioning by mechanical support)
Brain death testing Criteria:
1) coma
2) absence of motor responses
3) absence of pupil & corneal responses
4) absence of cough and gag reflexes

5) absence of confounding factors:
a. no CNS depressanfs or neuromuscular blockade agents
b. temperature > 32 C
c. SBP >90 or no lowerthan 11mmHg below pt normal blood pressure

6) oculocephalic reflex (Doll's eyes)
a. normal response: eyes movefrom side fo sde when head istumed
b. abnormal response eyes remain in fixed position when head is turned

7) oculovestibular reflex (ice caloics)
a. normalresponse; eyes move towards ice water application
b. abnormal response eyes do not deviate
Apnea Test protocol
Vent PT to 100% with rate of 0 for 8-10 minutes.
Observe for spontaneous breathing.
No breaths, obtain ABG. If PaCO2 Exceeds 60 PT has failed.
Terminate test, PT passes if breaths observed, if PT becomes extremely hypoxic, or PT becomes hemodynamically unstable.
Test to confirm Brain Death
1) Cerebral Angiography
2) EEG
3) Transcranial Dopplers
4) Nuclear Scan
Organ Donor Care: Hemodynamics and Perfusion
Q1H VS
Vasopressors: Dopamine, norepiephrine, vasopressin
Care of Organ Donor Oxygenation
ABG Q30min after each ventilator Chnage
Care of Organ Donor Fluids and Electrolytes
1) K, Hct, Glucose, Q2H replacement coverage protocols
2) Q1H intake and output, Monitor for DI
3) Iv fluid replacement to increas uop >250/hr
Care of Organ Donors: Hormone Replacement
T4
Care of Organ Donor: Physologic endpoints
1) SBP 90 - 100
2) MAP 60-65
3) CVP < or = 12
4) UOP 0.5
5) Core Temp > 35
6) Hemocrit 25- 30%
7) O2 Saturation > 95%
8) pH 7.4 - 7.45
Care of Organ Donor: Organ Evaluation
1) EKG, ECHO, Cardiac Cath.
2) CXR, O2 Challenge, Bronchoscopy, LFTs, Glucose, UOP
Nursing Considerations for transplant patients:
1) constant hand washing
2) monitor Vital signs
3) Isolation and neutropenic precautions
4) optimal nutritional support
5) prophylactic antibiotic therapy
6) treatment: antibiotic
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