Download Burn Care and Complications: Wound Healing, Lab Values, Shock, and Sepsis and more Exams Nursing in PDF only on Docsity!
NURS 480 exam 2
Artificial skin: - ansmade from beef collagen and shark cartilage. The artificial dermis slowly dissolves and replaced with blood vessels and connective tissue. Autolysis - ansthe disintegration of tissue by the action of the patient's own cellular enzymes. This is slow and prolongs hospital stay and increases the risk of infection. Biosynthetic wound dressing: - ansused for superficial partial thickness burns for scalds. Blood sugar - ansBlood glucose levels go high due to stress. Liver releases extra glucagon. Burn discharge - ans-Daily wound care, physical therapy, nutrition support, symptom management, drug therapy -Evaluate the home for cleanliness, access to bathing facilities, electricity, and running water, stairways, and number of occupants, temperature control, and safety. -Explain indications of infections, drug regimens, proper use of prosthetic and positioning devices, correct application and care of pressure garments, dates for follow up appts. -Address and resolve transportation problems for daily physical therapy and rehabilitation sessions. Burn hx - ansask about time and place of injury of injury and source of injury and cause of injury. Demographic data-age, weight, height and health history, drug use, pain, additional injuries Burns ABGs - anspaO2: 80-100 = low paCo2: 35-45 = high pH: 7.35-7.45 =low carboxyhemoglobin: 0-10% = high protein: 6.4- 8.3 =low albumin: 3.5-5.0= low Burns lab values - ansHemoglobin: 12-16 women+ 12-18 men = high Hematocrit:37-47% women +42-52% men = high BUN: 10-20 = high glucose: 70-110 = high Na: 135-145 =low Cl: 98-106 =high K: 3.5-5.0 = high
Carbon Monoxide 1-10 % (normal): - ansincreased threshold to visual stimuli, increased blood flow to vital organs, Carbon Monoxide 11-20% (mild poisoning): - ansHA, decreased cerebral function, decreased visual acuity, slight breathlessness Carbon Monoxide 21-40% (moderate poisoning): - ansHA, tinnitus, nausea, drowsiness, AMS and vertigo, AMS, confusion, stupor, irritability, decrease blood pressure, increased and irregular heart rate, depressed ST segment and dysrhythmias, pale to reddish purple skin Carbon. Monoxide 41-60% (severe poisoning): - anscoma, convulsions, cardiopulmonary instability cardio assmt (burns) - anshypovolemia and decreased cardiac output. At first, patient has tachycardia, decreased BP, and decreased RR, slow/absent cap refill. With fluid resuscitation, peripheral edema increases + increase patient weight. cause and risk factors of hypovolemic shock - anshemorrhage, trauma, GI ulcer, surgery , inadequate clotting ( hemophilia, liver disease, cancer therapy, anticoagulation therapy), dehydration (vomiting, diarrhea, heavy diaphoresis, diuretic therapy, NG suction, diabetes inspidious) circulatory overload - ansmay cause congestive heart failure: this creates high pressure within pulmonary blood vessels that pushes fluid into the lung tissue. The pt is short of breath and has dyspnea in the supine position, crackles on auscultation. CNS assmt (shock) - anschanges with shock, first manifestation is thirst and assess pt's LOC and orientation. In initial stage, patients may be restless, agitated, anxious, or have an impending doom. As hypoxia progress, confusion and lethargy occur. Lethargy progresses to somnolence and loss of consciousness. Cultured skin - anscan be grown from a small specimen of epidermal cells from an unburned area of the patient's body. Grown in lab Debridement: - ansremoval of cellular debris from the burn wound. Priority care: assessing the wound, providing wound care, and preventing infection. Fluid Resuscitation stages - ansIt is recommended that half of the calculated fluid volume for 24 hrs be given in the first 8 hrs after injury. The other half is given over the next 16 hrs for a total of 24 hrs. Fluid boluses avoided because they increase cap pressure and worsen edema. In the second 24 hour period after brun injury, the volume and the content of IV fluids based on patients fluid and electrolyte balances needs and his/her response to treatment. This resuscitation involves hourly infusion volumes that are greater the 125-150 ml per hour common infusion rates.
Parkland formula - ans-4ml/kg/% TBSA burn of crystalloid solution Physical assmt (shock) - ansINCREASED HR IS THE FIRST MANIFESTATION OF SHOCK! Progressive stage: - ansconfusion, rapid/weak pulse, low BP, pallor to cyanosis of oral mucosa and nail beds, cool and moist skin, anuria, 5-20% decrease in oxygen saturation, acidosis, increase lactic acid and hyperkalemia. psychosocial of burns - ansProblems include PTSD, sexual dysfunction, and severe depression. Address with patient reaction of others to the sight of healing wounds and disfiguring scars. Visits from friends and short public appearances before discharge may help patient begin to adjust to this problem. Community reintegration programs can assist the psychosocial and physical recovery of the patient with serious burns. Pulmonary fluid overload - anslung capillaries leak fluid into the pulmonary tissue spaces. When manifestations of pulmonary edema are present, elevate the head of bed to at least 45o degrees, apply oxygen , and notify rapid response team. Reducing risk of shock - ans-Evaluate all patients for the their risk for sepsis, especially older adults -Use aspectic technique during invasive procedures and when working with nonintact skin and mucous membranes in immunocompromised patients -Remove indwelling cathethers and IV access lines as soon as they are no longer needed -Ensure patients receieving mechanical vential are weaned from ventilator as ASAP -Early detection of sepsis before the progression of shock refactory stage - ansrapid loss of consciousness, nonpalpable pulse, cold/dusky extremities, slow, shallow respirations, and unmeasurable oxygen saturation. Resp assmt (burns) - anshoarseness, brassy cough, drooling, difficulty swallowing, produce sounds on exhalation (audible wheezes, crowing, stridor) Respiratory complications - ans- pulmonary fluid overload -circulatory overload Inspect the pts chest hourly for ease of respiration, amount of chest movement, rate of breathing, and effort. If pt is being mechanically ventilated, increased airway pressures may indicate the need for an escharotomy. Need to use continuous pulse ox responses to burn injury - ans-Increased thirst -Rapid respirations -Slow or no gastric motility, decreased bowel sounds, abdominal distention, N/V, ulceration of GI mucosa -Increased catecholamine secretion, increased metabolic and caloric needs, increased secretion of aldosterone
-Fluid retention, generalized edema, weight gain -Increased HR -Increased release of glycogen and increased blood sugar level -Vasoconstricted skin, pale and cool extremities, slow cap refill -Decreased urine output and increased specific gravity -Hemooccult positive stools Rule of nines - anshead: 4.5% (anterior +posterior) chest: 18% (anterior) arms: 4.5% (anterior + posterior) legs: 9% (anterior +posterior below chest area: 4.5% (anterior + posterior) Sepsis risk factors - ans-Malnutrition -Immunosuppression -Open wounds -Mucous membrane fissures -GI ischemia -Exposure to invasive procedures -Older then 80 yrs -Infection with resistant microorganism -Chemotherapy -Alcoholism -DB -Chronic kidney disease -Transplant -Hepatitis -HIV/Aids Shock history - ansask about age (shock from trauma is more common in young adults), ask about recent illness, trauma, procedures, chronic health problems that lead to shock (GI ulcers, general surgery, hemophilia, liver disorders, prolonged vomiting or diarrhea). Ask about the use of drugs (NSAIDS/Diuretics), ask about fluid intake and output (esp urine output; urine output is reduced during the first stages of shock, even when fluid intake is normal), assess for poor clotting and hemorrhage (gums, wounds, site of dressings, drains, vascular access. Check under the patient for blood. Observe any swelling or skin discoloration that may indicated an internal hemorrhage. shock lab values - ans➢ pH: decreased ➢ PaO2: decreased ➢ PaCo2: increased ➢ Lactic acid: 3-7 mg (increased) ➢ H+H: increased ➢ Potassium: increased
the hourly urine output at 0.5 ml/kg [30 ml/hr]), assess for fluid overload (dependent edema, JVD, rapid thread pulse, lung crackles or wheezing) -in burns larger than 35% TBSA, the use of invasive cardiac and pulmonary function monitoring may be needed. -Burn patients can develop severe hypovolemic shock need invasive cardiac monitoring.
