Advanced Medical-Surgical Exam 1

Burns: First Action

Minor: first aid, cool water 3-5 min, do not use ice water or ice packs, avoid hypothermia (impede healing), burns with chemicals or tar require longer cooling time, clean with mild soap and water, cover with antimicrobial ointment + absorbent dressing, and comfort with OTC pain med

Ensure airway is patent and breathing is adequate in rate and depth, then determine if fluid resuscitation is needed

• Adults older than 14: 500 mL of LR/hr

Severe: urinary catheter, gastric decompression w/ NG or OG tube, monitor perfusion (compartment syndrome), HOB elevation, may require debridement or excision of nonviable tissue

Regular dressing changes

Active range of motion exercise (some with skin grafts may have movement restrictions)

Burns: Hydration

Burns: Rule of Nines

Common areas of the body are approximately 9% of the body

Front leg: 9% Only the thigh: 4.5%

Entire arm: 9%

Chest: 18%

Palm: 1%

Burns: Surgical Escharotomy

Necessary to relieve the tension caused by nonviable stiff eschar

Cuts through the eschar, stiff dead skin, to allow the tissues below to expand

Eschar tissue that surrounds and extremity or torso can cause constriction, resulting in compartment syndrome

Burns: Non-emergent

Burns: Smoke Inhalation Risk

Highest risk with a house fire

Respiratory status takes priority over other injuries

Impending loss of airway: hoarseness, drooling, audible wheezing or stridor, and/or difficulty swallowing

Burns: Electrical

Can burn from the inside out, skin over bones may initially appear non-burned & within a few days appear as a full-thickness injury

Do not touch the client until electrical source has been removed

Consultation for follow-up in burn center to screen for delayed manifestation onset and vision issues

Will need electrocardiogram

Burns: Chemical

Treatment: apply a topical enzyme after daily dressing change to break down and remove dead tissue

Interventions:

• Never try to neutralize

• Remove contaminated clothing

• Flush with water for 20-30 min, up to hrs for alkali burns

Burns: Opioid Administration

Adverse Effects: respiratory depression, drug tolerance, drug dependence, use smaller doses with older adult client

Client Teaching: dependence can occur, avoid prolonged use, assess pain before and after use, and may cause drowsiness

Benner’s Stages

Novice: no previous experience, cannot draw on their own judgment, struggles to decide which tasks are most relevant

Advanced Beginner: can recognize patterns and recurrent situations, issue with remembering and following the rules and guidelines, needs clinical support to set priorities

Competent: able to prioritize based on past experience, may not function at the same speed or ease of change as proficient, can recognize patterns more quickly and accurately

Proficient: can understand the bigger picture or desired outcomes, improved decision making, able to respond to changing situations and modify plans in diff events

Expert: extensive experience and knowledge in complex client conditions, must have self-confidence and trust their intuitive sense, knows what needs to be done and perform it well

Code Team Roles & Room Placement

Following the code: team organizes transfer to a critical care unit, CCU will continue interventions to stabilize client

One-three nurses

1: Client’s nurse; manages the environment and communicates with family if present

2: Recorder of events

3: Ensure IV access and administer medications

• A nurse and other members of the team will rotate to perform chest compressions

Respiratory therapist or anesthesia provider: ventilation

Medical provider (anesthesiologist, an intensivist, a hospitalist, or a surgical resident): extras will act as helpers or runners to obtain equipment or carry lab specimens

NCLEX Prioritization frameworks: Maslow

Five categories of needs that motivation human beings:

• Physiological: needs required for survival; food, water, air, shelter, sleep, clothing, warmth + rest, and reproduction; more than one unmet needs = person will likely try to meet physiological need before fulfilling other needs

• Safety: individuals like order, certainty, and having control in their lives

• Love and belonging: behavior is motivated by the need for social relationships and sense of connection; met through interactions

• Self-esteem: desire to feel good about self and having respect of others; may develop sense of uselessness leading the feelings of inferiority

• Self-actualization: all deficiencies are met, humans attempt to reach their full potential; may be restless or unhappy if goal is not met

Base of pyramid: basic needs

Middle: psychological needs

Peak: self-fufillment

Needs located lower in the pyramid must be met first

Nurse priority is to address client’s fundamental physiological needs

Mechanical Ventilation Weaning Criteria

Spontaneous Awakening Trials

For clients who are receiving mechanical ventilation

Daily stopping of sedatives and opioids if possible

Depends on the client’s assessed pain scale

Found to decrease the time a client requires mechanical ventilation

Spontaneous Breathing Trial (SBT)

The stopping of mechanical ventilation to allow the client to breathe spontaneously

Help predict whether the client will be able to breathe on their own without the assistance of the mechanical ventilator

Ordered by the provider, completed and documented by nurse and/or RT

If an oral odor is noted or suction secretions demonstrate a change in color or quality, notify the provider

Failure:

• Increase in RR to 35/min +

• Increase in HR 140/min +

• Cardiac dysrhythmia

• Oxygen saturation of 89% or less

Main Modes & Strategies of Mechanical Ventilation

Assist-control (ACV): each patient or time-triggered breath received a set tidal volume or pressure, with a backup rate

SIMV/IMV: set number of mandatory breathing + spontaneous breaths between, optionally with pressure support; synchronization improves comfort and limits dynamic hyperinflation

Pressure-support ventilation (PSV): fully patient initiated; each effort is assisted by a preset pressure until flow cycles off; unsuitable with unstable drive

CPAP/PEEP: continuous positive pressure to maintain FRC, recruit alveoli, and improve oxygenation; essential in ARDS/ALI and peds hypoxemic failure

Pain in Critical Care

Pain comes from:

• Suctioning

• Turning

• Wound care

Scale:

• 0 to 10 numerical

• Behavioral Pain Scale (BPS)

• Critical-Care Pain Observational Tool (CPOT)

Nurses must advocate for appropriate pain management and relaxation

Sedative Therapy

To counter-act fear, anxiety, and pain

Benzodiazepines:

• Midazolam (Versed) to reduce anxiety

Opioids:

• Morphine

Paralytic Therapy

Used when complete control of ventilation is required

Acute lung injury or ARSD

Med:

• Rocuronium (Zemuron)

Triage Categories

Emergent (life-threatening: cardiac arrest, severe respiratory distress, major trauma, active seizures, or anaphylaxis)

Urgent (treat within 2 hr: chest pain suggestive of MI, severe fractures, high fever, or deep wounds)

Non-urgent (can delay: minor rashes, small sprains, mild earaches, or basic medical questions)

Mass Casualty Categories: Color Coding

Red: high priority treatment or transfer (massive hemorrhage, tension pneumothorax, etc.)

Yellow: medium priority (isolated simple femur fracture, etc.)

Green: ambulatory patients (isolated abrasions, contusions, sprains, etc.)

Black: dead or minimal chance of survival (massive head injuries, 95% coverage with third degree burns, etc.)

Mass Casualty Categories: Urgent/Emergent

Emergent: higher priority; patient must be seen within minutes

• Immediate threat to life, limb, or organ function if treatment is delayed

Urgent: lower priority; condition is painful or distressing and could possible worsen, but there is no immediate danger of death

• Stable

• Can wait 1-2 hr

Mass Casualty Categories: Number of Services

1: limited to physician and nursing care

2: limited to physician and one other

3: physician and several other services (pharm and lab)

4: extensive time and services required

Nurse Practice Act

A body of state laws enacted by each individual state’s legislature that establishes the legal scope of practice for nurses within that state’s jurisdiction

Scope: defines what RNs, LPNs, and APRNs can and cannot legally do

Board of Nursing Authority: grant’s the state’s Board of Nursing the power to make administrative rules, issue licenses, and enforce the law

Licensure requirements: outlines the qualifications needed to obtain, renew, or maintain a nursing license

Disciplinary grounds: defines what constitutes professional misconduct, negligence, or incompetence, and establishes the process for suspending or revoking a license

Health Insurance Portability and Accountability Act (HIPAA)

Focus: protects individual health insurance coverage and private information of clients, deter inappropriate use of client health care information

Purpose: protect client’s privacy and personal health information from security breaches

The Emergency Medical Treatment and Active Labor Act (EMTALA)

Focus: prevent refusal of care to uninsured clients, ensures any client who has a medical or psychiatric condition who brings themselves in or is brought in must be evaluated or stabilized before discharge or transfer

Hospitals can lose Medicare funding if violated

COVID Impact: allows for the ability to send clients to an alternative location for required screenings and permits the transfer of clients who are not totally stable

Primary Survey in the ED

ABCDE assessment performed in the ED to assess for life-threatening injuries

Airway

Breathing

Circulation

DIsability

Exposure/Environment

Secondary Survey in the ED

A methodical head-to-toe assessment performed to discover any additional injuries not addressed in the primary survey; for severe trauma

Chest Trauma

High number from MVA and falls

Blunt: injury to thoracic cavity without penetration (ball, bat, club, MVC), vascular/cardiac/or pleural space injury must be present

• Diagnostic: CT (detect more subtle change)

Penetrating: open injury to the cardiothoracic region that may affect the cardiopulmonary system

• High velocity: rifle

• Medium velocity: handgun

• Low velocity: knives

Chest Flail

Cause: multiple rib fractures (usually neighboring), ribcage not able to maintain bellows action

Care: monitor ABGs, mechanical ventilation

Manifestation: pleuritic pain, tracheal deviation, reduced or absent breath sounds, dull percussion

Chest Tube

Used to drain fluid or remove air from the intrapleural space (between the lungs and chest wall)

Indicated for clients who have pneumothorax, lung infections with fluid accumulation, or after heart and lung surgeries

RN can delegate monitoring and dressing change to another RN or LPN, not an UAP

Chest Tube Air Leak

Can be indicated by continuous bubbling in the water seal, can originate from the client’s pleural space or from an external mechanical issue (loose connection or poor insertion-site)

Chest Tube Water-Seal

Allows air to exit from the pleural space of exhalation and stops air from entering the lungs with inhalation

• Tidaling is expected, cessation signals lung re-expansion or an obstruction

• Continuous bubbling indicates an air leak

• Check water-seal level every 2 hr

Chest Tube Tidaling

Water level responds to changes in pressure caused by respirations; indicates a good seal

Tension Pneumothorax

Air collects between the parietal and visceral pleura, resulting in a collapsed lung and a mediastinal shift; air is pushed outside of the lung but remains in the thoracic cavity — leads to compromise of cardiopulmonary function, life-threatening

Risks: iatrogenic procedures (lung biopsy, tracheostomy, bronchoscopy, intercostal nerve blocks, pacemaker placement, and cardiopulmonary resuscitation), and positive pressure mechanical ventilation (causes high volumes of oxygen and overexpansion of the lungs)

Clinical presentation: sharp pleuritic pain that radiates to the back or shoulder (key manifestation), increased HR, decreased BP, JVD, dyspnea, cyanosis

Pulmonary Embolism

Occurs when a substance (solid, gaseous, or liquid) enters venous circulation and forms a blockage in the pulmonary vasculature

More common in women than men

Expected findings: anxiety, feelings of impending doom, sudden onset of chest pressure, pain upon inspiration and chest wall tenderness, and/or air hunger

Interventions: assess resp. status every 30 min, compare BP in both arms, monitor for LOC change

Meds: anticoagulants (warfarin, LMP, enoxaparin)

Wound Care: Evisceration Dehiscence

Dehiscence: the partial or total separation of surgical wound layers

Evisceration: total separation of wound layers PLUS the protrusion of internal organs through the open wound (SEVERE MED EMERGENCY)

Interventions:

• Call for help immediately

• Position the patient in low fowlers

• Protect the organs with sterile dressings moistened with sterile NS

Prevention:

• Splinting: firmly hold a pillow against their abdomen when coughing, deep breathing, or moving

• Abdominal binders: use supportive binders as ordered

• Stool softeners: administer softeners to prevent straining during bowel movements

Wound Care: Pressure Injuries & Staging

Stage 1: erythema of intact that does not blanch

Stage 2: partial thickness loss with exposed dermis

Stage 3: full-thickness loss involving damage to the epidermis, dermis, and subcutaneous tissue, but not the muscle or bone

Stage 4: full-thickness skin and tissue loss, only it involves deep tissue necrosis of muscle, fascia, tendon, joint capsule, and sometimes bone

Unstageable: involve full-thickness loss but are impossible to accurately stage because the wound bed being obscured by eschar or excessive slough

Deep Tissue: may be intact or non-intact, deep red, maroon, or purple, does not blanch, blood-filled blister, thin blister that overlies a dark wound bed, eschar under blisters

Wound Care: Phases of Wound Healing

Inflammatory: wound is fresh and includes both hemostasis and phagocytosis

Reconstruction “Proliferation”: wound begins to heal and lasts about 21 days after injury

Maturation “Remodeling”: wound contracts, scar strengthens

Wound Care: Types of Wound Closures

Primary: clean, with little tissue loss (example: surgical incision) edges are approximated, wound is sutured, glued, stapled, or stitched closed

Secondary: greater tissue loss, wound edges irregular, edges cannot be brought together

Tertiary: wound left open for time to allow granulation tissue to form, then will be sutured closed

Wound Care: Shear Injuries

Occurs when the patient’s skin moves in opposite directions than items the patient is on

Prevention: remove linens from underneath a patient by rolling them to one side and folding the linens to the center of the bed, then roll the patient to the other side and remove linen completely

Wound Care: Factors Affecting Wound Healing

Age: wound contracts more slowly, strength of scarred area decreased, skin less elastic, collagen replacement impaired

Chronic Illness

Diabetes Mellitus: decreased circulation due to narrowed peripheral blood vessels, increased blood glucose interferes

Hypoxemia: decreased oxygen delivered to the wound by the bloodstream, oxygen necessary for wounds to heal

Lifestyle Choices: smoking decreases the oxygen content of blood and constricts blood vessels, excessive alcohol intake = poor nutrition, obesity increases risk of infection and dehiscence

Lymphedema: circulation to and from the wound is impaired

Medications: delays healing and can mask symptoms of inflammation and infection

Multiple Wounds: each wound competes for available protein and substrates for repair

Nutrition and hydration: lack of calories and protein impairs tissue growth, vitamin A, C and zinc deficiency, inadequate fluid intake causes wound to dry = restricting granulation of tissue

Radiation Exposure: breakdowns underlying connective tissue

Wound Tension: can lead to ischemia and necrosis

Wound Care: Wound Vac

Used to assist in wound contraction, decreasing edema, increasing vascularization and provide debridement and removal of exudate; applies (negative pressure) suction

• Removes drainage

• Reduces bacterial counts

• Promotes granulation

• Helps speed up wound-healing time

DO NOT USE:

• In an area with skin cancer

• Clients on anticoagulant therapy

• Have poor tissue health

• Clients with exposed vessels, nerves, or organs within the wound

Wound Care: Documenting & Measuring Wounds

Site: anatomical location

Type: open or closed

Closure: sutures, staples, Steri-Strips, approximation

Size: width, length, and depth

Wound bed condition: color, texture, eschar, sloughing, presence of granulation tissue, undermining, sinus tracts

Surrounding skin: color, texture, maceration

Pain: rate discomfort/tenderness

Drainage: amount, type/color, odor

Violence

Contributing factors: emergent situations, stress, anxiety, substances, mental illness, long wait times, fear of diagnosis/outcome, crowded waiting rooms

Care of Violence Victim:

• Provide emotional support

• Evaluate injuries

• Carries out forensics exam (SA)

• Collects evidence using a SA evidence kit

Infectious Disasters

Endemic: disease is constantly present at a steady, predictable rate within a specific region/group of people

• Malaria in certain parts of Africa

• Seasonal flu

Epidemic: a sudden, unexpected jump in the number of disease cases above what is normal in specific community

• Unexpected local spike of Ebola

• Severe regional measles outbreak

Pandemic: an epidemic that has spread across multiple countries or continents, affecting massive numbers of people worldwide

• COVID-19

• 1918 influenza

Nurses Role in Disasters

Apply the nursing process through clinical judgment function

Prepare ahead for disaster response

Use the triage system caring for clients

Use effective communication

ARDS Prone

Modify the distribution of transpulmonary pressure and improve gas exchange

Ventilation + perfusion matching improve because the prior dependent lung receives most of the blood flow and alveoli reopen

ARDS Supine

Worsens lung injury and impairs oxygenation due to gravitational and mechanical forces