NUR 213 #4 septicemia, burns

Shock

Ineffective tissue perfusion

• impacts all body systems, can be sudden or happen over time

• Risks: trauma, burns, hemorrhage, dehydration, chronic disease, malnourishment, invasive procedures, emergent/multiple surgeries, old/young ppl

• Caused by hypoperfusion, hypermetabolism, activated inflammatory response

Distributive shock

Pooling in peripheral vessels (septic shock most common)

Septic shock

Caused by widespread infection

• early stages: normal BP, tachycardia, hyperthermia, fever, bounding pulses, tachypnea, normal urine output, N/V, diarrhea

• As it progresses: tissues become less perfused & acidotic, compensation fails, S/S of organ dysfunction

• Risks: SEPSIS- suppressed immune, extreme age, procured organs (transplant), surgery (emergent), indwelling devices, sickness

• Treat within 1 hour

Systemic inflammatory response syndrome (SIRS)

Type of cytokine release syndrome (cytokine storm)

• results from a clinical insult that initiates an inflammatory response (pooling in vessels)

• Temp >101/ <96.8, tachycardia >100, tachypnea >20, WBC >12,000/ <4,000 >10% bands

Sepsis patho

Microorganism (infection suspected, may not be found) → immune response (activation of cytokines) → inflammatory response (increased capillary permeability, SIRS, cytokine storm, hypercoagulation) → sepsis (organ dysfunction) → septic shock (vasodilation leading to critically decreased perfusion)

Sepsis steps

SIRS (at least 2 criteria), sepsis (2 criteria & confirmed or suspected infection), severe sepsis (sepsis, end stage organ damage, SBP <90 & unresponsive to fluids, elevated lactic acid), septic shock (severe sepsis, MODS, hypoperfusion)

Patho of gram negative infection

Microorganisms invade tissues → immune response → provoked the activation of biochemical cytokines & produces physiologic events that lead to poor perfusion → increased capillary permeability, results in fluid leaking (capillary instability = vasodilation, poor perfusion, 02, nutrients to tissues/cells)

Sepsis medical management

Focus on prevention & early detection, rapid identification

• fluid replacement (fluid challenge of crystalloids)

• No response to fluids → vasopressors (norepinephrine, dopamine) to improved tissue perfusion & increased MAP >65

• PRBCs to support 02

• Neuromuscular blockage agents & sedation to reduce metabolic demands

• Heparin for DVT prophylaxis

• H2 blocking agents (PPIs) for stress ulcer prophylaxis

Sepsis nursing management

• Recognize risks & S/S of infection, tx underlying cause, manage shock (respiratory, fluid replacement, promote perfusion, nutritional therapy)

• Hypothermia blanket

• Iv fluids & meds (antibiotics, vasoactive meds to restore vascular volume)

• Monitor labs & report (CRP BUN Cr WBC Hgb Hct platelets/ coagulation)

• Monitor hemodynamic status, I&Os, daily weight, nutritional status

Sepsis caring interventions

Education needs, anxiety, coping, disease process, end of life prep, grief process

Bactericidal

Kills bacteria

Bacteriostatic

Inhibits bacteria growth

Superinfection

Infections that occur when opportunistic pathogens have the opportunity to invade tissues & cause infections bc normal flora bacteria have been destroyed by antibiotics

Penicillin

“Cillin” amoxicillin, ampicillin

• bactericidal: kills bacteria by destroying the cell wall

• Broad spectrum, but focuses on gram positive

• MOA: inhibits bacterial cell wall synthesis

• IV, IM, PO (mainly absorbed in stomach so take PO on empty stomach)

• Contraindications: renal disease, cephalosporins, culture insensitivity test, pregnancy

• ASE: N/V, diarrhea, rash, abdominal pain, stomatitis, gastritis, sore mouth, fuzzy tongue, superinfection

• Drug interactions: aminoglycosides, aspirin, furosemide, thiazide diuretics, methotrexate, oral contraceptives

Aminoglycosides

“Mycin” “micin” “cin” gentamicin neomycin streptomycin

• bactericidal

• specific to gram negative

• MOA: inhibits protein synthesis by binding to the ribosomal subunit

• IM, Poorly absorbed in GI

• Contraindications: renal disease, hearing loss, Parkinsonism, pregnancy

• ASE: N/V diarrhea, weight loss, stomatitis, HTN, hypotension, palpitations

• Drug interactions: loop diuretics, vancomycin, neuromuscular blockers, cephalosporins

Carbapenems

“Enem” ertapenem, meropenem

• bactericidal

• Broad spectrum

• MOA: inhibits bacterial cell wall synthesis

• IV, IM

• Contraindications: pregnancy/ lactation, renal impairment

• ASE: N/V, c diff, dehydration, superinfection, electrolyte imbalance, mental status changes, seizures, GI issues

• Drug interactions: valproic acid, ganciclovir

Sulfonamides

“Azine”, “azole”, “mide” dorzolamide pediazole sulfadiazine

• bacteriostatic

• Broad spectrum

• MOA: inhibits folic acid synthesis required for bacterial growth

• PO, Absorbed in GI, metabolized in liver, excreted in urine

• Contraindications: allergy to thiazide/ loop diuretics, pregnancy/lactation(teratogenic) , renal disease, kidney stones, older adults

• ASE: N/V/D, hematuria, nephrotic syndrome, proteinuria, headache, dizziness, vertigo, bone marrow suppression, photo sensitivity

• Drug interactions: ACE inhibitors/ k sparing (hyperkalemia), antidiabetics (hypoglycemia), cyclosporines (nephrotoxicity)

Fluoroquinolones

“Floxacin” ciprofloxacin

• bactericidal

• Broad spectrum

• MOA: interferes w DNA replication in gram negative/ positive bacteria cell reproduction

• PO, IV, absorbed through GI tract, metabolized through liver, excreted in urine & feces

• Contraindications: <18 yo, uncomplicated infections, pregnancy/ lactation, renal dysfunction, seizure disorders

• ASE: N/V/D, dizziness, insomnia, depression, dry mouth, peripheral neuropathy, c diff, CNS effects, lover toxicity, bone marrow suppression, fever, rash, photosensitivity, torsades des pointes

• Drug interactions: iron salts, multivitamins, calcium, magnesium, antacids, theophylline, warfarin, NSAIDS

Cephalosporins

“Ceph” “cef” cefazolin, cefdinir, ceftraroline

• bactericidal & bacteriostatic

• Broad spectrum MOA

• MOA: interferes w the cell wall building ability of bacteria when they divide (prevents bacteria shnthesis)

• PO, IV, IM, metabolized through liver, excreted by liver

• ASE: N/V/D, anorexia, abdominal pain, bone marrow suppression, c diff, headache, dizziness, lethargy, parasthesia, nephrotoxicity, superinfection

• Contraindications: allergy to cephalosporins/ penicillins, hepatic/renal impairment, pregnancy/ lactation

Tetracyclines

“Cycline” doxycycline tetracycline

• bacteriostatic

• Broad

• MOA: inhibits bacterial RNA protein synthesis

• PO, IV, topical, absorbed in GI tract and metabolized in liver

• Contraindications: <8 yo, pregnancy

• ASE: growth inhibition in kids, tooth discoloration, delayed bone growth, hepatotoxic, N/V/D, abdominal pain, dysphagia, superinfection

• Drug interactions: digoxin, ca/mg/zinc/aluminium/bismuth salts/iron

Epidermis

Contains nerve endings

Dermis

Contains nerve endings, blood vessels, hair follicles, glands

Hypodermis

Contains blood vessels & adipose tissue (fat cells)

1st degree burn

Superficial

• Affects epidermis only

• Pink/red (erythema) & dry skin

• Tenderness or pain

• Blanching present

• No blisters or scarring

• Can recover within days

• Negative nikolskys sign

• Ex: sunburn

2nd degree burn

Partial thickness

• Affects epidermis & dermis

• Red, blistered & moist skin

• Painful

• Blanching present

• Shiny scars left behind

• Typically heal 2-3 weeks

• Ex: contact w hot water, oil, flame

3rd degree burn

Full thickness

• Affects epidermis, dermis, & hypodermis

• May look black, red, yellow, & hard

• Charred, dry, leathery skin (eschar)

• Bones, tendons, @ muscles may be visible

• Little to no pain (nerve damage)

• Skin won’t heal (needs skin grafting)

• Eschar must be removed

• Can take years to heal

4th degree burn

Deep burn necrosis

• damage to deep tissue, muscle, or bone

• Appears blacked, charred w eschar

• Nerve endings destroyed (all sensation of pain is gone)

• Watch for renal failure

• Surgery w skin grafts needed

• Long recovery

Thermal burn

From external heat source

• hot surface, steam or liquid, fire

• soak w cool water

Radiation burn

From radiation

• sun, radiation therapy, excessive x rays

• sun burn focus on pain management

• Treatment for cancer

Chemical burns

From contact w toxic agents

• bleach, gases, drain cleaner

• Alkali burns are harder to treat because they aren’t neutralized by the skin like acid burns

• Flush w constant stream of cool water, remove clothes

• Decontamination shower in ED for full body

Cold burns

From overexposure to cold

• frostbite

• feet, hands, nose & ears

• Goal: restore normal body temperature

• Remove wet clothes asap

• Controlled, rapid rewarming → after warming protect from further injury & elevate to control edema

• Gauze/cotton on extremities

Electric burn

From electrical current

• power lines, outlets, lighting

• Can also cause dysrhythmias & kidney injury if severe

• Risk for bone fractures (apply cervical collar first)

• Hemoglobin and myoglobin in urine

Friction burns

From skin being scraped off forcibly by object

• rug burn, rope burn

Emergent phase

Onset of injury up until capillary integrity restored 24-48 hours

• increased capillary permeability (leaky blood vessels) causes edema & fluid volume deficit (patient at high risk for hypovolemic shock, respiratory distress & compartment syndrome)

• High HR, low BP, low CO, high HCT/BUN/CR, low UO, high k+, low Na, low WB

• Priorities: fluid resuscitation (LRs), establish large bore IV (at least 2), strict I&Os (foley), closely monitor VS, EKG, & electrolytes

• Nursing: pain meds (morphine), attend psychosocial needs, accurate/frequent documentation, elevate extremities

Acute phase

Onset of diuresis up until wound closure 48-72 hours after burn until wound closes

• capillary permeability is restored & causes diuresis

• Primary focus: infection prevention, pain management, nutrition, wound care

• Priorities: infection prevention (clean sheets, monitor temp, broad spectrum antibiotics), monitor electrolytes (Na, K+, & glucose), nutrition (monitor bowel sounds- risk of ileus & ulcers (H2 blockers), high protein, carbs & calories)

• Wound care (premedicate before wound care, debridement or grafting)

Rehabilitative phase

From wound closure to optimal state of functioning (can last weeks-years)

• focuses on preventing scars/ contractures & psychosocial support

• ROM, PT, OT, avoid direct sunlight for at least 3 months

• Encourage ADLs, cosmetic consults

Parkland formula

Used to calculate fluid replacement for first 24 hours

• 2nd & 3rd degree burns only

• 4mL x body weight (kg) x TBSA %

• Give 1st half over first 8 hours

• Give 2nd half over next 16 hours

TBSA %

Total body surface area

• Head: 4.5%

• Arms (front & back): 4.5%

• Chest/ upper back: 9%

• Stomach/ lower back: 9%

• Groin: 1%

• Legs (front & back): 9%

Inhalation injury

Thermal & chemical

• upper/lower airway injury (airway priority concern)

• High cause of mortality

• Administer 100% O2

• Dx: bronchoscopy

Topical therapies for burns

Barrier against bacteria/fungi

• can penetrate eschar but not toxic to patient

• Antimicrobials: protects against bacteria & promotes moist environment

• Silver sulfadiazine: water soluble, bactericidal, broad, penetrates eschar

• Mafenide acetate: anti microbial, broad, can penetrate eschar & certain tissue

• Silver nitrate: works against staph & pseudomonas, specific to gram negative, can’t penetrate eschar

• Silver impregnated: broad, anti microbial, can be left in place for days

Hypertrophic abnormal wound healing

Contained within the site of injury and push outward on the perimeter of the wound

• red, raised, hard