Advanced Med Surg - Exam 2 Module 4&5

nerve injury

compression of nerve tracts causing paresthesia and edema with face and eye changes

Types of burns

electrical, thermal, chemical, radiation, smoke or inhalation, frostbite

What to monitor in burns

type, location/appearance (head and neck increased risk), size/depth, age (elderly/child increased risk), medical hx, %TBSA

Classifications of burns

superficial, superficial partial thickness, deep partial thickness, full thickness, deep full thickness

s/s of superficial burn

Tingling, hyperesthesia (supersensitivity), pain soothed by cooling, skin blanching with pressure, swelling

s/s of superficial partial thickness burn

Pain, hyperesthesia, sensitive to cold air, edema, fluid filled vesicles

s/s deep partial thickness burn

drier, red, pain to pressure

s/s of full thickness burn

Pain free, shock, hematuria/hemolysis, possible entrance and exit wounds, thrombosed vessles, nerve damage, SQ fat, dry white or leathery skin

s/s of deep full thickness

Muscle, tendon, bone involvement, black, eschar, no pain

Complications of burns

compartment syndrome, impaired chest wall expansion/pulmonary injury, pulmonary complications, corneal abrasions, auricular chondritis, autocontamination by urine and feces

How to identify signs of complications

inhalation injury - facial burns, hoarseness, soot in nose or mouth, eyebrow swelling

compartment syndrome - increase in cap refill time, decrease in pulse, change in sensation, swelling

sepsis

What distinguishes the different phases of burn management

Emergent (24-48 hrs) - fluid loss edema/diuresis

Acute (48-72 hrs) - capillary permeability returns to normal, ends with wound closure

Rehabilitative (restorative)

Clinical management of burns

Fluid resuscitation with LR, diet or tube feeding to meet calorie needs, warm room temp, protective isolation

What to monitor to determine if fluid resuscitation is adequate

for burns >20% TBSA, monitor urine output (0.5-1 ml/kg/hr), VS, and hemodynamics (MAP >65, SBP >90, HR <120)

How to calculate %TBSA using rule of nines

Head 9% (4.5/side), arms 9% (4.5/side), legs 18% (9/side), front 18%, back 18%, scrotum 1%

How to calculate %TBSA using LB chart

more accurate, add up percent of burn per portion of body

Parkland formula

4 mL LR x Kg body wt. x %BSA burn = 24 hr fluids

1/2 fluids first 8 hrs, 1/2 fluids second 16 hrs

Burn shock

decrease in circulating blood volume with edema, increased WBC and platelets slowing cap circulation, inflammatory markers decrease heart contractility

Stages of sepsis

SIRS>Sepsis>Severe sepsis>septic shock>MODS

How to differentiate between stages of sepsis

SIRS- slightly abnormal VS, no infection determined

Sepsis- Worsening vs, infection found

Severe sepsis-involves multiple organs/body systems

Septic shock-multiple organs/body systems and treatment has not improved condition

MODS - breakdown or muscle tissue and organs caused by septic shock (renal, respiratory, cardiac)

Labs for sepsis

lactate >4, WBC >12000/<4000, high creatinine, blood culturs, CBC, PTT, PT, platelets

Nursing care for sepsis

prevent progression/infection, initiate antibiotics, fluids/vasopressors, glucocorticoids with glucose control, draw blood cultures

Clinical manifestations of sepsis

Abnormal VS, high or low WBC, low PCO2, infection, symptoms dependent on type of infection

Distributive shock

septic, anaphylactic, neurogenic

increased capillary permeability with decreased perfusion leading to third spacing

Anaphylactic shock

severe allergic reaction

high or low RR

Neurogenic shock

severe central nervous system damage

low HR, high or low temp

hypovolemic shock

loss of 15-30% of intravascular volume

hemorrhagic shock (blood loss)

cardiogenic shock

hypoperfusion due to decreased cardiac output from failure of heart pump

obstructive shock

blocked blood flow disrupting circulation from tension pneumo, PE, aortic dissection

initial shock stage

increased lactic acid from lack of oxygen in the blood leading to anaerobic metabolism

Compensatory Shock Stage

vasoconstriction with increased HR/RR to compensate for low O2 and BP

Progressive shock stage (uncompensated)

oliguria, altered LOC, pallor/cool clammy skin, electrolyte imbalance, hypotension

Refractory shock stage

irreversible cellular and organ failure and impending death