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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
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
<100ml/24h
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
<60mL/min for 3m+ (normal 125), up to 80% GFR lots until symptoms. >90 kidney damage
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
<3 BM/wk, abd distention, decreased appetite, indigestion, sensation of incomplete evacuation, straining at stool, elimination of small-volume, hard, dry stools
Constipation Collaborative care
Meds: stepwise approach for laxative Hemorrhoids, perforation, fissures ###
Constipation Nutritional therapy
Dietary fiber and fluids Exercise, bowel routine