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Types of Burns

Thermal, chemical, electrical, cold thermal, smoke inhalation

Why are chemical burns hard to manage

because they cause protein hydrolysis and liquefaction- damage continues after alkali neutralized (up to 72h), can injury liver/kidney

smoke inhalation majory predictor of mortality

1. Carbon monoxide poisoning, 2. Above glottis, 3. Below glottis

Carbon monoxide poisoning

inhaled CO displaces O2 leads to hypoxia, carboxyhemoglobinemia, death

CO treatment

100% humidified

Smoke above Glottis

thermally produced, hot air/steam/smoke, mucosal burns of oropharynx and larynx, mechanical obstruction can occur quickly,

Clues To smoke above glottis

facial burns, singed nasal hair, painful swallowing, hoarse, carbonaceous sputum, hx of burn in enclosed space, clothing burn around neck.

Consequences of smoke above glottis

Pulmonary edema 12-24h after\= acute resp distress syndrome.

Electrical burns

coagulation necrosis, direct damage to nerves and vessels, causing tissue anoxia/death.

Severity

amount of V, tissue resistance, current pathways, surface area, duration of flow, current can pass through organs\= death of organ, electrical sparks may ignite clothing\= thermal and electrical burns.

iceberg effect

Difficult to assess damage below skin for electrical below

Stage 1 Burns

Superficial partial thickness burn-epidermis

Stage 2 Burns

deep partial-thickness-dermis

Stage 3 Burns

Full-fat

Stage 4 Burns

muscle, bone

Phases of burn management resuscitative

lasts 72h, primary concern hypovolemic shock/edema. Fluid and electrolyte shift\= hypovolemic shock from shift of fluid out of blood vessel as a result of increased cap permeability,, decreases BP, elevated pulse

Sevre burns amt fluid lost

200-400mL/hr,

Manifestations emergent burns

shock, pain, hypovolemia, blisters, adynamic ileus, shiver, mental status.

Complications emergent burns

dysrhythmias, hypovelomeic shock, impaired circ, tissue ischemia, necrosis. Escharotomies.

Nursing management emergent burns

early endotracheal intubation, escharotomies, fiberoptic bronchoscopy, humid o2 100%. 2 large-bore IV

Parkland Formula

\>15% of TBSA. parkland (baxter) formula (FLUID REQ\= TBSA burned % x w (kg) x (4mL/Kg) of RL, ½ fluid in 1st 8h, 2nd ½ over next 16 h.

Wound care

delayed until ABC, fluid replacement established, cleansing, debridement.

Open method

topical antibiotic no drsg. Silver sulfadiazine to gauze. When open burns, staff wear hats, masks, gowns, gloves. Allograft or homograft hands/arms extended on pillows no pressure on ears, early ROM, routine Labs, tetanus routine, no systemic antibiotics only topical.

VTE prophylaxis

low heparin, compression devices. Early and aggressive nutritional support, hypermetabolic state\= increase 50-100%, 5000kcal/day, colloidal sol’n

Acute (wound healing) mobilization

of extracellular fluid and subsequent diuresis, acute phase done when all burn covered by skin grafts/healed.

Labs

hyponatremia and water intoxication, hyperkalemia, muscle weakness, ECG changes

Wound care- enzymatic debridement, grafts left open- complication blebs. Dermatome harvest skin for grafts.

Pain management

continuous background pain and treatment induced pain- tx

Complication

skin/joint contractures.

Brain death/Brain arrest

Irreversible loss of capacity for consciousness with the irreversible loss of all brainstem functions

Bereavement

Sense of deprivation or loss, Happens in conjugation with grief

Mourning

Social customs and cultural practices that follow a death

Palliative care

An approach that improves the QOL of individuals and their families facing life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other physical, psychological, and spiritual problems.

Goals of EOL

Provide comfort and supportive care during the dying process Improve the quality of remaining life Help ensure a dignified death

Hearing and Touch and Death

↓ Sensation ↓ Perception of pain and touch Hearing and touch are the last sensory system to disappear

Taste, Smell, and sight

↓ with disease progression
Blurring of vision
Sinking and glazing of eyes
Blink reflex absent
Eyelids remain half-open

Integument

Mottling on hands, feet, arms, and legs
Cold, clammy skin
Cyanosis on nose, nail beds, knees
“Waxlike” skin when very near death

Respiratory

↑ respiratory rate
Cheyne-Stokes respirations
Inability to cough or clear secretions
Grunting, gurgling, or noisy, congested breathing
Irregular breathing-Slowing down to terminal gasps

Urinary

Gradual ↓ in urinary output
Incontinent of urine
Unable to urinate

GI

Slowing of digestive tract and possible cessation of function
Accumulation of gas
Distension and nausea
Loss of sphincter control
Bowel movement may occur before imminent death or at the time of death

MSK

Gradual loss of ability to move
Sagging of jaw resulting from loss of facial muscle tone
Difficulty speaking
Swallowing can become more difficult
Difficulty maintaining body posture and alignment
Loss of gag reflex
Jerking seen in clients on large amounts of opioids (myoclonus)

Cardio

↑ Heart rate Later slowing and weakening of pulse
Irregular rhythm
Decrease in blood pressure
Delayed absorption of drugs administered intramuscularly or subcutaneously

Dying Meds

Opioids \= Dilauded/morphine
Midazolam and pain meds can be run slowly through PCA and SC set
Midazolam (versed)
Scopolamine

RENAL SYSTEM Subjective

pain, voiding, Gi, anemia, fever, chills, DM, HTN, prostate enlargemente

Kidney Pain

costovertebral angle, dull ache, if sudden distension- severe/sharp, N, V, diaphoresis, pallor, acute obstruction, pyelonephritis.

Bladder pain

suprapubic, dull continuous, intense w voiding, full bladder\= severe. Urgency, straining. Cystitis, tumour.

Urethral Pain

costovertebral angle, flank, lower abd. Severe sharp, N, V, ureteral stones, stricture, edema, blood clot.

Dysuria

pain difficult urination

Anuria

Upper

pyelonephritis

Lower

cystitis, urethritis

DX UTI

hx, exam, cystoscope, urinalysis, urine culture

Uncomplicated UTI

adequate fluids, antibiotic (1-3d), recurrence reduction

Complicated UTI

repeated urinalysis, antibiotic (3-5d), consider 3-6m suppressive antibiotics, adequate fluids

Renal Calculi

calcium oxalate stones

Renal Calculi DX

urinalysis, Urine culture, ultrasound, cystoscopy, BUN, Creatinine, WBC, Urine pH

Intervention

lithotripsy

Implementation

no obstruction

Acute kidney injury

varying degrees, changes occur in 48hr

Cause AKI

hypovolemia-decreased renal blood flow, tubule damage, ischemia, glomerular filtrate leaks decreased

CKD

anemia, PTH increase, small kidneys

GFR CKD

CKD S+S

headaches, decreased ability to concentrate urine, polyuria to oliguria, increased BUN/creatinine/bp, edema,

Chronic Uremia

nitrogen waste builds up

Hyponatremia

water retention\= edema, HTN, CHF. Metabolic acidosis, anemia, ecchymosis,

TX hyperkalemia

insulin+ Calcium gluconate

Musculoskeletal Subjective Data

Pmhx, meds, surgeries, important health info, questions about joints, muscle, bones, self-care etc.

Musculoskeletal Objective Data

Physical exam (inspection, palpation, motion, muscle-strength testing, measurement)

Musculoskeletal Aged related changes

Atrophy of muscles
Tendons shrink & harden
Reduction shrink & harden
Loss of height
Joint activity & motion

Musculoskeletal Diagnostic Studies

Radiological studies, bone mineral density, radioisotope studies, endoscopy, mineral metabolism, serological studies
Muscle enzymes, invasive procedures, miscellaneous

Osteoarthritis Risk Factors

Major-
Age \>65y
Family hx of osteoporotic fracture
Vertebral compression fracture
Crohn's disease
Primary hyperparathyroidism, tendency to fall, osteopenia apparent on radiograph, hypogonadism, early menopause
Minor-
Rheumatoid arthritis
Hyperthyroidism
Prolonged use of anticovulsants
Low calcium intake

Osteoarthritis Diagnostic studies

Bone scan, CT, MRI, x-rays, blood studies, synovial fluid analysis

Osteoarthritis Collaborative Care

Managing pain and inflammation
Preventing disability
Drug therapy
Managing and improving joint function

Osteoarthritis Nursing Management

Patients joint pain and stiffness (type, location, severity, frequency, duration)

Nursing Diagnosis

Acute & Chronic pain
Insomnia
Impaired physical mobility
Self-care deficits
Imbalanced nutrition

Osteoarthritis Collaborative Care

Maintain or improve joint function through a balance of rest and activity
Use joint protection measures to improve activity tolerance
Achieve independence in self-care and maintain optimal role
Pain control

Osteoarthritis Nursing implementation

Health promotion
Acute intervention
Frequent complaints of QA clients includes pain, stiffness, limitation of function

Osteoarthritis Evaluation

Experience adequate amounts of rest and activity, achieve pain management, joint flexibility

Rheumatoid Arthritis

Joint destruction begins as early as first year of disease without treatment
Flexion contractures and hand deformities
Nodular myositis and muscle fiber degeneration
Cataracts and loss of vision
Later, cardiopulmonary effects

Rheumatoid Arthritis Collaborative Care

Care begins with a comprehensive program of education and drug therapy
Physiotherapy helps maintain joint motion and muscle strength
Occupational therapy develops extremity function and encourages joint protection
A caring, long-term relationship with an arthritis health care team can increase client’s self-esteem and positive coping

Rheumatoid Arthritis Nursing Assessment

Important health information
Recent infections, presence of precipitating factors of remission & exacerbations
Use of aspirin, NSAIDs, corticosteroids, DMARDs
Integumentary (keratoconjunctivitis)
Cardiovascular (symmetric pallor and cyanosis of fingers, dysrhythmias, distant heart sounds, murmurs
Respiratory (chronic bronchitis, TB, histoplasmosis
GI (splenomegaly)
Musculoskeletal (symmetric joint involvement with swelling, erythema, heat, tenderness and deformities Lymphadenopathy, fever

Rheumatoid Arthritis Symptoms

Rheumatoid Arthritis Nursing Managment

Good pain relief
Min loss of functional ability of affected joints
Nursing Diagnosis
Chronic pain
Impaired physical mobility

Rheumatoid Arthritis Nursing implementation

Health promotion (education focuses on symptom recongiition)
Acute intervention (primary focus is reduction of inflammation, pain, maintenance of joint function)

Gout

Uric acid is the major end product of purine catabolism and is excreted primarily by the kidneys.
Hyperuricemia may result from prolonged fasting or excessive alcohol drinking because of the increased production of keto acids, which then inhibit uric acid excretion

Gout Manifestations

Acute- may occur in one or more joints
Chronic- multiple joint involvements

Gout Diagnostic studies

Serum uric acid levels

Gout Collaborative Care

Drug therapy
Weight reduction
Avoidance of alcohol and foods high in purine
Prevention of formation of uric acid kidney stones and development of associated conditions such as hypertriglyceridemia and hypertension

Gout Nursing Management

Nursing interventions for patients with acute gouty arthritis include supportive care for the inflamed joints
The nurse must avid causing pain to an inflamed joint by careless handling
Bed rest may be appropriate, with affected joints properly immobilized

Effects of Aging Mouth

Teeth loosen, reduced circulation to gums, teeth darken and fracture
Decreased output of salivary glands
Decreased stimulation of taste buds

Effects of Aging Stomach

Atrophy of gastric mucosa
Decreased secretion of hydrochloric acid
Decreased bile secretion
Decreased muscle tone and strength

Gastrointestinal Assessment Subjective data

Pmhx
Appetite, dysphagia, food intolerance, abd pain, nausea and vomiting, bowel habits, nutritional assessment
Meds
Surgery and other
Bowel patterns, diet
Lifestyle habits

Gastrointestinal Objective data

Physical exam (mouth, abd, IPPA, rectum and anus)
Vital signs
Height and weight
Emesis, amount, colour, consistency
Stool, amount, colour, consistency odor
Oral, abd, rectal assessment

Gastrointestinal Diagnostic Studies

Radiological Studies

Nausea and Vomiting Assessments

Determine underlying cause and treat
Careful history (when vomiting occurs, precipitating factors, contents of emesis)
Differentiate among vomiting, regurgitation, and projectile vomiting

N & V Clinical manifestations

Anorexia
Fluid and electrolyte imbalances (K+)
Metabolic
Colour of emesis

N & V Collaborative care

Determine underlying cause and treat
Careful history
When vomiting occurs, precipitating factors, contents of emesis
Drug therapy
Nutritional therapy
Non-drug precautions

Constipation

Decreased frequency of bowel movements
Insufficient dietary fibre, inadequate fluid intake, meds
Valsalva manoeuvres

Constipation Clinical Manifestations

Constipation Collaborative care

Meds: stepwise approach for laxative Hemorrhoids, perforation, fissures ###

Constipation Nutritional therapy

Dietary fiber and fluids Exercise, bowel routine