Tissue Integrity and Mental Health

Most burn deaths occur during _____ or ____

initial transport, at the scene

Burn mortality process

immediate smoke inhalation or incineration, 24 hrs hypovolemia, sepsis later

Pt burn extent is reassessed within ___ bc there are more clear demarcations and depths at this time

72 hrs

Rule of the palm

Pt’s hand including fingers is equal to 1% of body

Thermal burns are due to

external heat source

Bathing water should be under ___ degrees, water heater shouldn’t be higher than ___ for 5 mins

100, 120

Thermal burns types

flame, scald, contact

Radiation burn dt

prolonged exposure to UV or other radiation sources

Chemical burns dt

strong acids, alkalis, detergents, solvents

chemical burns are usually ____ or 2/2 ___

occupational, assault

the most dangerous chemical is

alkali

tx for chemical burns

remove clothes, flush eyes with water, neutralizing agent just wastes time

initial nursing assessment for burns

time and cause, first aid, past medical hx, meds, age, body weight

burns tx

stop burn process, abc assess, tx life threatening injuries, extent and deph of burn eval

abcde

airway, breathing, circulation, disability, environment

airway intervention

intubate

breathing intervention

100% o2 and continuous pulse ox

circulation interventions

LR start, insert foley

inhalation injury interventions

cyanide kit for chemicals, intubation, bronchoscopy in 6 hrs, nebs

cyanide kit is a ____ reconstituted to drip via __

powder, IV

Parkland formula for LR

4ml/kg/tbsa in first 24 hrs

For parkland formula give half of total in ___ hours, and give ___x in the next ___ hours

8, 2.5, 16

parkland formula fluid resuscitation includes fluids given by

ems

for kids under 5, instead of LR give

d5lr

Titrate fluids ____ based on ____

hourly, uop

If uop under goal increase fluids by ___, if over goal decrease by the same amount

10%

Adults uop goal

0.5ml/kg/hr or 30-50ml/hr

children uop goal

1ml/kg/hr

heparin neb role in inhalation burn injuries

prevents clots from forming in airway from sloughing and damage in airway

mucomyst/acetylcysteine role in inhalation injury

inactivates reactive substances from inhalation injury

albuterol role in inhalation injury

inflammation tx

in the initial emergent phase want to look for

edema

in acute phase fluids shift ____ from intravascular so there will be x3 issues

out, K, Na, coag

hematuria is bc hemochromogens signals damage to ___ and ___ in the muscle

rbc, myoglobin

glycosuria

release of glycogen in response to stress from the liver

burn victims dont use

diuretics

biggest cause of death is

hypovolemic shock

escharotomies def

majro burn of an extremity/torso swells

escharotomies happen when ____ burned skin becomes rigid and hard

full thickness

escharotomy process/patho

fluid resuscitation causes swelling, circulation compromised, loss of pulses, motor and nerve function + cyanosis

escharotomy need clinical

tightness, loss of peripheral pulse, numbness and tingling, deep throbbing pain,

pain mgmt in burn

consistent measurement tool, medicate before procedures, give prescribed meds, explain procedures and discomfort levels, verabalize pain experience

if on pca need to regularly assess

loc and rr

infection control in burns considerations

pnemonia, uti, wbcs daily, tetanus shot, high calories, culture wounds and secretions, antimicrobials

wound care is not started until patient is

stable

wound dressings common

xeroform, silver sulfadiazine, kerlix, bacitracin, dermex, adaptic

biosynthetic graft has inner layer of matrix of fibers and outer layer of

silicone

biosynthetic allows for regrowth of ___ skin layer, and once it grows the silicone and removed and replaced with ____ skin graft

dermal, epidermal

allograft is from ___ and used to promote ____ healing prior to autograft

person, wound bed

xeroraft is from ___ and is temporary to ____ and ____ control for ___ burns

animals, cover and pain, superficial

isograft is between

twins

skin gun uses ____ and healing is days instead of weeks-months

stem cells

physical mobility interventions for burns

active/passive rom, splints, alignment, pain meds

delirium tremens happens in 5% cases of withdrawal in 12-24 hrs. S/s include

hallucinations, hyperthermia, htn, tachycardia, disorientation, agitation, diaphoresis

physical assessment for withdrawal

vs, ciwa-ar (higher score means need more benzos), skin/musculoskeletal for falls/accidents, tremors, tongue fasciculations

the s/s of withdrawal that is hard to replicate is

tongue fasciculations

history assessment for withdrawal

bac, how long and how muhc, is pt honest, do they want to quit, how long since last use

meds for normie alcohol withdrawal

diazepam/lorazepam or other benzos

why are benzos used to tx alcohol withdrawal?

alcohol desensitized to gaba, when alcohol stopped body has gaba overload. benaos kill off gaba

alc withdrawal severe cases tx

phenobarbital or propofol

phenobarbital role

barbituate that decrease seizure and symptoms

propofol role

intubated and sedated to prevent seizures

alcoholism causes ___ issues bc GI can’t absorb nutrients, even if they are eating the right foods

gi

alcohol withdrawal nutrition txs

thiamine, mg, phosphate, K, folate, vitamins

why give thiamine for withdrawal?

wernicke’s encephalopathy prevention

nursing tx for alc withdrawal

vs and ciwa q2-4hrs, seizure precautions, meds, limit setting, reality orientation dont go w them in delusion, family support

suicide top 3 questions

suicide is ___ leading cause of death ages 10-34 after trauma and firearms are most common method

2nd

nursing assessment questions for suicide

do you want to kys, if yes plan, plan yes what is the plan, previous attempts

main assessment physical for suicide is

skin

medical tx for suicidality

ssri, snri, benzos, hydroxyzine, quetiapine

anxiety meds

benzos and hydroxyzine

quetiapine indications

bpd, schizoaffective, depression

quetiapine moa

blocks serotonin, dope, and histamine receptors

suiciders can still od on their ___ so don’t give too much of their prescription

antidepressants

suicide remove stuff

cords, call lights, shower curtains, garbage bags, pillows, hand sani

beta blockers moa

block catecholamines centrally and peripherally. For BP, HR, and anxiety attacks

beta blockers od symtpoms

bradycardia, arrhythmias, hypothermia, ams, resp depression, hypoglycemia

assessment for beta blocker od

vs, renal uop, ams, resp statuss

med tx for beta blocker od

vasopressors, fluids

Ca channel blocker od symtpoms

hyperglycemia

Serotonin syndrome SS

acetaminophen OD assessment findings

resp, diarrhea from lactulose, uop, fluids, bleeding, ams, jaundice

Acetaminophen toxicity leads to

fulminant hepatic failure, AKI, metabolic acidosis, cerebral edema, death

ODs can be cleaned out with

gastric lavage

opioids make up ___ of ods

70%

opioids od nursing assessment

bradypnea, o2 down, ams, myois small pupils

72 hrs is for ___ ill or ___ dependent

mentally, chemically

72 hr hold rules

clinician ordered, written not verbal or phone, needs clear documented reason

nurse role in 72 hr hold

document progress note, provide rights in written form, cont assessment to see if hold is needed, comm with provider to get rid of it faster, secure pt room and belongings, call behavioral emergency if pt attempts to leave or combative

restraint image

restraints risk

increased confusion/agitation, fear, anger, loss of dignity, depression, pressure ulcers, incontinence, ptsd

chemical restraints common

haloperidol, olanzapine

nonviolent pt restraint methods

pt safety, all four rails raised, posy vest

nonviolent restraint nursing role

document q2h, circulation, rom, reposition, offer foods and fluids and elimination

violant restraint nurse role

document q15min, circulation, rom, skin, foods and fluids and elimination q2h

nonviolent renewed every ___ hrs, violent renewed every __ hrs

24, 4

Nonviolent can be removed when

pt reorients and keeps lines/tubes/drains safe

violent restraints removed if

no aggression within 1 hours, demonstrate control over behavior

if restraints are removed need

a new order