BSN EXAM III Study Guide ACUTE KIDNEY INJURY AND CHRONIC KIDNEY DISEASE, Exams of Nursing

Download BSN EXAM III Study Guide ACUTE KIDNEY INJURY AND CHRONIC KIDNEY DISEASE and more Exams Nursing in PDF only on Docsity! BSN EXAM III Study Guide ACUTE KIDNEY INJURY AND CHRONIC KIDNEY DISEASE 1.Identify factors that may contribute to the development of renal disorders. AKI causes: a. Hypovolemia / hypotension / dehydration / hemorrhage b. Cardiovascular issues: cardiogenic shock / heart failure / MI c. Sepsis ( peripheral vasodilation) d. DIC e. Acute Tubular Necrosis (ATN): from intrarenal damage i. Untreated pre-renal problems ii. Nephrotoxins iii. Myoglobin release (ex: crush injuries, myopathy, sepsis, transfusion rxn) f. Acute Glomerulonephritis (AGN) g. Sickle cell dz h. Systemic Lupus Erythematosus i. Bladder / ureteral / urethral obstructions CKD causes: a. Unresolved AKI b. DM c. HTN d. Chronic urinary obstruction e. Recurrent infections f. Renal artery occlusion g. Autoimmune disorders h. MOST @ risk: aging, obesity, DM, HTN 2. Compare the causes of prerenal, intrarenal, and postrenal acute kidney injury. a. Pre-renal:  impaired renal perfusion  GFR + reabsorption of Na/H2O i. Intravascular volume depletion 1. Dehydration 2. Burns 3. Trauma 4. Diuretic overdose 5. Hemorrhage 6. GI losses (V/D) 7. Major surgery ii. peripheral vascular resistance 1. Anti-HTN drugs 2. Sepsis 3. Neuro injury 4. Anaphylaxis iii. Pre-renal infection or obstruction 1. Arterial embolism 2. Arterial or venous thrombosis 3. Tumor iv. Cardiovascular issues: CO 1. Arrhythmias 2. Cardiac tamponade 3. Cardiogenic shock 4. MI 5. Heart failure v. Severe vasoconstriction: 1. DIC b. Intra-renal:  damage to kidney tissue i. Prolonged pre-renal ischemia ii. Acute tubular necrosis (ATN)  may follow nephrotoxicity or ischemia iii. Acute glomerulonephritis iv. Nephrotoxicity (aminoglycosides, contrast dye, heavy metals, analgesics) v. Myoglobin release (gets stuck in tubules) 1. Crush injuries 2. Myopathy 3. Sepsis vi. Hemolytic blood transfusion rxn vii. Systemic Lupus Erythematosus viii. Intra-renal infection or obstruction 1. Acute interstitial nephritis 2. Acute pyelonephritis 3. Sickle cell dz (hemolyzed RBCs clog kidney) c. Post-renal:  obstructed urine flow i. Bladder obstruction: 1. Anticholinergic drugs 2. Autonomic nerve dysfunction 3. Infection 4. Tumor ii. Bladder cancer iii. Calculi iv. Blood clots v. Uric acid crystals vi. Prostate enlargement (BPH or cancer) vii. Strictures viii. Trauma ix. Post-renal infection 3. Compare the oliguric and diuretic phases of acute kidney injury. a. Oliguric: i. Days 1-7 of injury   2wks ii. UO < 400 mL/day iii. Urinalysis may show: ix. Tx: a. Plan: estimate progression 3. Stage 3 = moderate GFR a. GFR 30 – 59 mL/min b. Plan: evaluate + treat complications 4. Stage 4 = severe GFR a. GFR 15 – 29 mL/min b. Plan: preparation for kidney replacement therapy 5. Stage 5 = kidney failure = end-stage renal dz (ESRD) a. GFR < 15 mL/min (or on dialysis ) b. Plan: kidney replacement (if uremia present & pt desires) 1. Correct extracellular fluid volume overload (or) deficit 2. Nutritional therapy (usually individualized) a. Protein not usually restricted when on dialysis, but should avoid high-protein diets & supplements (may over stress kidneys) b. Water/fluids generally NOT restricted in stages 1-4 (but diuretics may be used) c. On HD, fluid intake = 600 mL + last 24-hr UO d. Na should be restricted (including salt substitutes ) < 2g/day e. K+ restrictions... on HD i. Should avoid oranges, bananas, melons, tomatoes, prunes, raisins, deep green & yellow veges, beans, legumes f. K+ supplements may be given on PD d/t loss in dialysate g. ESRD… limit phosphates i. Should avoid dairy products (meat, milk, ice cream, cheese, yogurt, pudding) 3. Erythropoietin therapy 4. Calcium supplements  give on EMPTY STOMACH (but NOT w/iron) a. Kidney dz  activation VitD  impaired Ca absorption  pulls Ca out of bones/teeth  bone demineralization  osteomalacia 5. Iron supplements  give BETWEEN MEALS 6. Phosphate-binding agents (PhosLo or Caltrate)  give WITH meals 7. Anti-HTN therapy a. ACE inhibitors / ARBs 8. Treat hyperlipidemia 9. Measures to K+ (Kayexalate) 10. Adjust drug dosages to degree of renal function (many drugs cleared through kidneys  toxicity) 11. @ end-stage  need renal replacement therapy (dialysis or transplant) 12. Teach ways to thirst: suck on ice cubes/lemon/hard candy 13. Avoid antacids (containing magnesium & aluminum) 14. Avoid NSAIDs 15. Pt should report: a. Wt gain > 4 lb b. BP c. SOB d. Edema e. fatigue/weakness f. Confusion or lethargy x. Leading cause of death = CV dz 5. List effects of renal dysfunction on all of the body systems. a. Psychologic: i. Anxiety ii. Depression b. Neurologic: i. Fatigue ii. HA iii. Sleep disturbances iv. Encephalopathy v. Asterixis (hand-flapping) c. Eyes: i. Hypertensive retinopathy d. Cardiovascular: i. HTN ii. HF iii. CAD iv. Pericarditis v. PAD e. Pulmonary: i. Pulmonary edema ii. Uremic pleuritis iii. Pneumonia f. GI: i. Anorexia ii. Nausea iii. Vomiting iv. GI bleeding v. Gastritis vi. Stomatitis (oral inflammation) w/exudates & ulcerations + metallic taste in mouth + uremic fetor (urinous odor of breath) g. Integumentary: i. Pruritis ii. Ecchymosis iii. Dry, scaly skin h. Musculoskeletal: i. Vascular & soft tissue calcifications (Ca pulled out of bones  blood/tissues) ii. Osteomalacia (demineralization of bone) iii. Osteitis fibrosa (decalcification + replacement of bone tissue w/fibrous tissue) i. Peripheral neuropathy: i. Paresthesias ii. Restless leg syndrome j. Endocrine/Reproductive: i. Hyperparathyroidism ii. Thyroid abnormalities iii. Amenorrhea iv. Erectile dysfunction k. Metabolic: i. Carb intolerance ii. Hyperlipidemia l. Hematologic: i. Anemia (erythropoietin production) ii. Bleeding (impaired platelet aggregation) iii. Infection 6. Differentiate among hemodialysis, peritoneal dialysis, and hemofiltration. a. Hemodialysis: i. Artificial membrane (usually made of cellulose-based or synthetic materials) is used as semipermeable membrane ii. SubQ AV fistula is commonly created (usually in forearm)  provides arterial (rapid) blood flow thru vein  dilates + toughens vein 1. Venipuncture usually not done until 4-6 wks (preferably, at least 3 months) after creation of AV fistula 2. AVFs have best patency rates + least number of complications (thrombosis, infections) iii. AV grafts are made of synthetic materials & form “bridge” between arterial & venous blood supplies 1. Should let heal 2-4wks before use (some may use earlier) 2. More likely to become infected or to be thrombogenic iv. Temporary access may be obtained through percutaneous cannulation of internal jugular or femoral vein (subclavian vein = option of last resort) 1. Catheters have double lumen (blood insertion + blood drainage) 2. IJ/subclavian: can be left in place 1-3 wks (not to exceed 3wks) 3. Femoral: can leave in place up to 1wk v. Long-term cuffed catheters may be placed while awaiting fistula placement/development (or if other options fail) 1. Catheter tunneled through upper chest  internal or external jugular vein  tip rests in right atrium i. Give blood or fluid supplements (IV), as ordered k. Provide continuous EKG monitoring (arrhythmias can occur w/-lyte imbalances) l. Monitor ultrafiltrate during CRRT: should remain clear yellow (no gross blood) i. Blood = leak!  infection risk m. Monitor dialyzer blood lines (HD): make sure all connections secure + no clotting in line n. Monitor drainage lines for kinked tubing o. Monitor distal to insertion site for obstructed blood flow (cool, pallor, weak pulse, pain) p. During HD, monitor for disequilibrium syndrome (d/t rapid fluid removal + -lyte changes) i. HA ii. Muscle twitching iii. Backache iv. N/V v. Seizures vi. If occurs  notify physician  may blood flow rate or stop dialysis q. For PD, monitor for respiratory distress d/t fluid overload (or) leakage of solution into pleural space (or) pressure on diaphragm i. If severe, drain peritoneal cavity + call HCP r. Make sure arm used for vascular access is NOT used for BP, IV insertion, etc. ORGAN AND HEMATOPOIETIC STEM CELL TRANSPLANTATION (7 questions) 1. Identify the criteria used to evaluate and prepare patients for transplantation. a. Age: neonate  70yo (age not set) b. Absence of infection (or) infection being “adequately treated” c. Absence of general malignancy (or isolated cancer + under control) d. Assess whether pt can benefit + tolerate the rigor & toxicity of treatment e. Must have good support system f. Cannot have: i. Serious active infection or sepsis ii. Severe dz in other organs iii. Recent or disseminated cancer iv. Current substance abuse v. Severe cachexia (skin & bones) vi. Active peptic ulcer dz vii. Psychiatric disorders (can have mental illness, but move prove they are stable & compliant) viii. Repeated non-compliance 2. Discuss the principles of organ and hematopoietic stem cell compatibility and immunosuppression. a. Donors & recipients are matched by: i. ABO blood typing (if recipient is Rh+  can get Rh- but must have same A/B/O blood type) ii. Human leukocyte antigen (HLA) typing 1. 4 pt match (crossmatching)  especially for KIDNEYS & hematopoietic stem cells a. May not be done for lung, liver, and heart transplants 2. Tissue typing also involves testing for panel of reactive antibodies (PRA)  if recipient + for antibodies, then do crossmatch (to test for anti-HLA antibodies to the potential donor) a. PRA indicates recipient’s sensitivity to various HLAs b. May have been exposed to HLA antigens by previous blood transfusions, pregnancy, or previous organ transplant c. High % PRA = poor chance of finding crossmatch- negative donor 3. A + crossmatch = recipient has cytotoxic antibodies to donor = absolute contraindication!!! iii. Medical urgency (if pt will die soon  top of list) iv. Time on waiting list v. Geographic location (especially for heart transplant  can only last 4-6hrs) b. Immunosuppression requires balance b/t being able to prevent organ rejection, while maintaining adequate immune response to prevent overwhelming infection + development of malignancies i. Many immunosuppressive drugs have significant side effects (incl: nausea & HA) ii. Drugs must be taken FOR LIFE!!! iii. By using combination of agents that work during different phases of immune response, lower doses of each drug can be given iv. Major drugs include: 1. Cyclosporine 2. Calcineurin inhibitors 3. Sirolimus 4. Mycophenolate mofetil 5. Monoclonal antibodies 6. Polyclonal antibodies v. Corticosteroids (Prednisone, Solu-Medrol) may be weaned after a few years 1. Corticosteroids glucose levels + risk: joint deterioration vi. Suppresses immune system  must wear respiratory mask + limit travel (especially early in therapy) 3. List the complications of organ and hematopoietic stem cell transplantation. Rejection; GVHD, VOD a. Rejection: (normal immune response to foreign tissue) i. Manifests as HR / temp / WBCs (signs of infection) 1. Must biopsy to determine whether it’s infection or rejection ii. May be controlled by immunosuppression therapy, ABO & HLA matching & ensuring crossmatch is negative iii. Classified as hyperacute, acute, and chronic iv. Prevention, early diagnosis, and treatment are essential for long-term graft function b. GVHD: Graft vs. Host Disease i. Occurs when immunoincompetent (immunodeficient) pt is transfused or transplanted w/immunocompetent cells ii. In transplants, the graft rejects the recipient tissue iii. Once rxn starts, little can be done to modify its course iv. Involves donor T cells attacking & destroying vulnerable host cells v. Target organs are skin, liver & GI tract vi. Biggest problem = infection vii. No adequate treatment of GVHD c. VOD: Veno-Occlusive Disease i. Occurs in liver  microemboli form & clots  liver dies! 4. Describe the process of organ rejection (hyperacute/acute/chronic) and the interventions for each. a. Hyperacute: (rare) i. Occurs minutes – hours after transplantation ii. Blood vessels rapidly destroyed iii. Occurs b/c recipient had pre-existing antibodies against transplanted tissue/organ iv. Kidney most susceptible v. Usually from ABO incompatibility = wrong organ to wrong person! vi. Treatment: no treatment  organ must be removed b. Acute: i. Most commonly within 1st six months after transplantation (usually 2-3 months after transplant) ii. Usually mediated by recipient’s lymphocytes (activated against donated/foreign tissue/organ) iii. Common to have at least 1 rejection episode (usually w/organs from deceased donors) iv. Treatment: usually reversible w/additional immunosuppressive therapy 1. May include corticosteroid doses or polyclonal or monoclonal antibodies 2. Unfortunately, immunosuppressants risk for infection c. Chronic: i. Occurs over months – years ii. Irreversible iii. Can occur from unknown reasons (or) from repeated episodes of acute rejection iv. Transplanted organ is infiltrated w/large # T and B cells  characteristic of an ongoing, low-grade, immune-mediated injury v. Results in fibrosis & scarring vi. Treatment: no treatment available  primarily supportive 1. Patients should be put back on transplant list iii. Although procedure is lifesaving, long-term or delayed complications can affect quality of life iv. The goal for therapy is CURE… but even if cure is not achieved, transplantation can result in period of remission THE ELDERLY IN CRITICAL CARE (5 questions) 1. Discuss changes responsible for increased life span in the United States. a. Common diseases of the early 20th century that killed many older adults (flu, diarrhea) are now less common  people are living longer b. Drug therapies (ABX, chemo, etc.) + mechanical devices + health promotion + earlier detection of diseases  contributes to life span 2. Describe the normal physiological changes of aging and their implications for the patient in critical care: Physiologic Changes of Aging; Pain Management; Pharmacologic Management a. Physiologic Changes of Aging: i.  mortality rate r/t age-related deterioration ii.  stress tolerance iii.  physiologic reserve iv.  CO v.  complication risk vi. Pre-existing chronic diseases vii. Pre-existing nutritional deficits (may not take extra vitamins or may have difficulty chewing) viii. Cardiovascular changes = more atherosclerosis + BP + CO 1. Normal BP may be higher or lower 2. Need to monitor hemodynamic status continuously ix. Pulmonary changes = 1.  PaO2 (oxygen levels) 2.  pulmonary reserve 3. Kyphosis  can’t breathe in deep + lose cough reflex  risk of aspiration & pneumonia x. Neuro changes = 1.  cerebral blood flow 2.  functioning neurons 3. Dementia starts to occur 4. Have fears/anxiety r/t falling, becoming functionally limited 5. Have problems w/reaction in time + visual acuity + fine motor ability + physical strength + cognitive/functional motivations xi. Renal changes = 1.  kidney function 2.  GFR  can’t concentrate urine  risk hypovolemia 3.  BUN + creatinine 4. Must consider renal changes for certain meds and/or contrast media xii. Skin = 1. Paper thin! 2. Less cushion against mechanical forces 3. More susceptible to shearing forces 4. Skin has trouble to tamponade (stop) bleeding 5. Trouble adjusting to sudden shifts in temperature  tend to be hypothermic  can’t warm themselves a. If temp starts to , HR may  too b. Pain Management: i. Opioids: we don’t worry about addiction, when used for pain ii. Can have risk of adverse reactions (ex: narcotics), but still must treat pain iii. Pain can kill  rate of healing + contributes to life-threatening complications iv. Meds often given IV thru PCA  encourage family not to mess with it! v. NSAIDs often used to augment narcotics c. Pharmacologic Management: i. Need to monitor hemodynamic status continuously ii.  liver & renal function  may need doses  risk toxicity (body doesn’t clear drugs as fast  free drug in circulation iii. Antihistamines, anesthesia, TCA, benzo’s, steroids, B-blockers  risk for delirium!!! iv. START LOW & GO SLOW!!! v. Consider common causes of med errors: 1. Poor eyesight 2. Forgetting to take meds 3. Use of non-Rx OTC drugs 4. Use of meds prescribed for someone else 5. Lack of financial resources to obtain prescribed drugs 6. Failure to understand instructions or importance of drug treatment 7. Refusal to take meds d/t undesirable side effects (nausea, impotence) vi. Assess for constipation d/t narcotic meds 3. Discuss legal and ethical issues pertaining to the elderly: Advanced Treatment Directives; Ethical Issues; Use of Restraints; Informed Consent; Palliative Care; End-of- life Care. a. Advanced Treatment Directives: i. = written documents that can speak for the pt when no longer able to advocate for themselves ii. Documents may vary from state to state iii. DNR  more natural term = “allow natural death”  if heart stops: don’t do compressions + if stop breathing: we don’t breathe for them b. Ethical Issues: i. Use principles of beneficence & non-maleficence to guide care ii. Is ethically acceptable to give pain meds (even if it hastens their death  pain meds may relax them enough they stop breathing) c. Use of Restraints: i. Drugs + unfamiliar area  delirium  may need restraints (must document fully) ii. Document + assess + ROM q2hr iii. HCP must rewrite order for restraints q24hr iv. Always want to try other methods first  try to encourage family to stay with pt v. If using restraints, must monitor + maintain safety + prevent complications 1. Do more frequent skin care & extremity checks (monitor pulses, etc.) d. Informed Consent: must provide decisions and allow choices i. Have right to self-determination ii. Have right to know what’s in their best interest iii. However, may have altered decision-making ability (may be anxious about “unfinished business” or may suffer from depression) iv. Have right to know if benefits of treatment will/will not outweigh risks e. Palliative Care: active total care of pts not responsive to a cure i. Treat w/respect ii. Respect/accept practices & rituals associated w/life/dying  don’t be judgmental iii. Still need touch/care iv. Be available & present v. Use empathy & active listening vi. Allow pt & family to express feelings (encourage communication) vii. Support grieving process viii. Help w/cultural attitudes toward death/dying ix. Provide realistic hope x. Manage symptoms & provide physiological comfort & safety 1. Physiological needs: oxygen + nutrition (if feel hungry) f. End-of-life Care: full codes are NOT for all patients! i. Goal: provide comfort & supportive care during dying process  improve quality of remaining life  help ensure a dignified death 4. When giving medications to the elderly patient, what changes in their physiology do we need to take into consideration? a.  tissue perfusion  don’t want to give IM meds  IV best choice (especially for pain) b.  motility in GI tract (affects PO meds) c.  total body water & total body fat  may need to water-soluble meds + lipid-soluble drugs d.  plasma albumin  drug effectiveness + free drug in circulation  risk toxicity e.  hepatic blood flow + GFR  metabolism & excretion of drug occurs slower  need lower doses f. Co-morbidities  need to address all issues g. We don’t worry about narcotic addiction, when used for pain i. Encourage patients & caregivers to express concerns, ask questions, and state their needs ii. Include patient & caregiver in all conversations iii. Explain the purpose of equipment & procedures iv. Structure surrounding environment to anxiety v. May need to use anti-anxiety drugs (Ativan) or complementary therapies (guided imagery/massage) b. Anger  Allow the patient/family to talk c. Powerlessness  include patient/family in plan of care + give options/control d. Safety  keep informed + allow to voice feelings 2. Describe common problems of critical care patients: nutrition, anxiety, pain, impaired communication, sensory-perceptual problems; sleep issues. a. Nutrition i. Hyper-metabolic / catabolic / malnourished states ii. Inadequate nutrition linked to  mortality/morbidity rates iii. Underfeeding d/t frequent interruptions for medication administration + multiple tests/procedures iv. Primary goal = prevent or correct nutritional deficiencies v. Early enteral nutrition  fewer complications + shorter hospital stays vi. Parenteral nutrition used when enteral route unsuccessful in providing adequate nutrition, or is contraindicated (ex: paralytic ileus, diffuse peritonitis, intestinal obstruction, etc.) b. Anxiety (and fear) i. Includes perceived or anticipated threats to physical health + actual loss of control of body functions + environment is foreign ii. May be due to: 1. Complex equipment 2. High noise & light levels 3. Isolation from family 4. Intense pace of activity iii. Enhanced by: 1. Pain 2. Sleeplessness 3. Immobilization 4. Loss of control 5. Impaired communication c. Pain i. Linked to agitation & anxiety ii. Contributes to stress response iii. Most at risk include those who: 1. Have medical conditions that include ischemic, infectious, or inflammatory processes 2. Are immobilized 3. Have invasive monitoring devices (including ET tubes) 4. Require invasive or noninvasive procedures iv. Continuous IV sedation + analgesic may be required/effective 1. Daily “sedation vacation” should be implemented (to check neuro status) d. Impaired communication i. May be due to sedatives/paralyzing drugs or ET tube ii. Explanations should be given for all procedures, etc. iii. Explore alternative methods 1. Picture boards 2. Notepads 3. Magic slates 4. Computer keyboards iv. Non-verbal communication is also important (touch the patient!) e. Sensory-perceptual problems i. ICU delirium = alterations in: mentation + psychomotor behavior + sleep- wake cycle ii. Prevalence may be as high as 80% iii. Predisposing factors: 1. Advanced age 2. Preexisting cognitive impairment 3. Vision/hearing impairments 4. History of drug/alcohol abuse iv. Contributing environmental factors: 1. Sleep deprivation 2. Anxiety 3. Sensory overload 4. Immobilization v. Contributing physical conditions: 1. Hemodynamic instability 2. Hypoxemia 3. Hypercarbia 4. Electrolyte disturbances 5. Severe infections vi. Contributing drugs: 1. Sedatives (benzo’s) 2. Furosemide (Lasix) 3. Antimicrobials (aminoglycosides) f. Sleep problems (disturbances in sleep-wake cycle) i. May be due to: 1. Noise 2. Anxiety 3. Pain 4. Frequent monitoring 5. Treatment procedures 6. How can you ease the fears of the family members of a trauma patient in the ICU? a. Prepare them for the experience by briefly describing the patient’s appearance and the physical environment (equipment/noise/etc) b. Accompany caregivers as they enter room + observe responses of both patient & caregivers c. Invite them to participate in patient’s care (if they desire) d. Encourage them to touch the patient! e. Encourage visitation f. Provide reassurance with realistic hope g. Provide information in an honest manner h. Assess their understanding of patient’s status, treatment plan, and prognosis + provide information as appropriate BURNS (12 questions) 1. What are system complications with clinical manifestations that can occur with Burns: respiratory(what would indicate the patient may have inhalation injuries), cardiovascular – including peripheral pulses, renal, GI/nutritional, neurologic, integument? a. Respiratory: i. CO poisoning = “cherry red” skin color ii. Inhalation injury above glottis (upper airway) = redness, blistering & edema of oropharynx & larynx 1. Mechanical obstruction can occur quickly (from airway swelling) 2. Clues: presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral & nasal membranes, carbonaceous sputum, stridor, substernal & intercostal retractions, total airway obstruction, history of being burned in enclosed space, clothing burns around chest/neck iii. Inhalation injury below glottis (lower airway) = usually chemically produced 1.  direct insult at alveolar level (secondary to inhalation of toxic fumes or smoke)  interstitial edema (abnormal accumulation of liquid in lungs)  prevents diffusion of oxygen from alveoli to circulation 2. Pulmonary edema (may not appear until 12-24 hours after burn)  ARDS b. Cardiovascular: i. Electrical injury can cause dysrhythmias, cardiac arrest, cardiac standstill, or ventricular fibrillation 1. Delayed cardiac dysrhythmias or arrest may occur without warning during 1st 24 hrs after injury ii. Hypovolemic shock (may progress to irreversible shock) iii. Initially, blood viscosity  d/t fluid loss iv. Microcirculation is impaired d/t damage to skin structures that contain small capillary systems v.  blood viscosity + impaired microcirculation = “sludging” (can be corrected by adequate fluid replacement) 5. Appears dry (dermis gone  no fluid) 6. Edema under eschar 7. Rarely blanches 8. Sensation reduced or absent (nerve endings destroyed) 9. Healing depends on establishing adequate blood supply 10. Requires split- or full-thickness grafts 11. Scarring + wound contractures likely x. 4th degree = destruction of muscle & bone 1. Typically seen w/electrical injuries 2. Extremity probably NOT salvageable 3. Limbs may warp! xi. Full-thickness & deep partial-thickness burns: initially anesthetic (nerve endings destroyed) xii. Superficial to moderate partial-thickness burns: PAINFUL xiii. Partial-thickness burns: may form blisters w/fluid & protein xiv. Partial-thickness burns may convert to full-thickness wounds when organisms invade viable, adjacent unburned tissue! xv. Burn wound infection may progress to transient bacteremia + sepsis (d/t manipulation: e.g., after showering/debridement) xvi. During rehab phase, complications include skin/joint contractures + hypertrophic scarring 1. Patient often assumes position of flexion (d/t pain), which contributes to formation of contractures  encourage movement + extension 2. What type of electrolyte imbalances will you see with a burn patient? a. Na (along with water) moves out of cells  into interstitial spaces (2nd spacing) & into surrounding tissues (3rd spacing) i. Hyponatremia: excessive GI suctioning, diarrhea, water intake 1. Burn patient may develop dilutional hyponatremia = water intoxication  pt should drink fluids other than water (juice, soft drinks, or nutritional supplements) 2.  weakness / dizziness / muscle cramps / fatigue / HA / tachycardia / confusion ii. Hypernatremia: may follow successful fluid resuscitation if copious amounts hypertonic solutions were required 1. Could also be d/t tube feeding therapy or inappropriate fluid administration 2.  thirst / furry tongue / lethargy / confusion / (possibly) seizures b. K shift develops initially: injured cells & hemolyzed RBCs release K+ into circulation i. Hyperkalemia: noted w/renal failure, adrenocortical insufficiency, or massive deep muscle injury (lots of K+ released from damaged cells) 1.  cardiac dysrhythmias / ventricular failure / muscle weakness / ECG changes ii. Hypokalemia: V/D, prolonged GI suction, prolonged IV therapy w/out K+ supplementation 1. Constant K+ loss occurs through burn wound! 2.  fatigue / muscle weakness / leg cramps / paresthesias / reflexes 3. How do you use the Rule of Nines? To estimate total body surface area (TBSA) for burns a. Thorax = 18% b. Back = 18% c. Front of each leg = 9% d. Back of each leg = 9% e. Front & back of each arm = 9% f. Front & back of head = 9% g. Genitals = 1% h. ***for irregular/odd-shaped burns, patient’s hand = 1%*** i. 4. What is the Parkland Fluid Resuscitation Formula? How do you assess if your resuscitation is effective? a. LR: 4.0mL/kg/%TBSA = total fluid requirement for 1st 24 hours after burn b. ½ in 1st 8 hrs c. ¼ in 2nd 8 hrs d. ¼ in 3rd 8 hrs e. Effective: i. U/O (most commonly used): 0.5 – 1.0 mL/kg/hr 1. 75 – 100 mL/hr for electrical burn patient w/evidence of hemoglobinuria/myoglobinuria ii. Cardiac factors: 1. MAP > 65 mmHg 2. SBP > 90 mmHg 3. HR < 120 bpm 4. (MAP & BP most appropriately measured by art line – peripheral measurement often invalid d/t vasoconstriction & edema) 5. How are burns treated – immediate (what would you do if you see someone whose clothes are on fire or if electrical burn) acute and later? When does physical therapy/rehab start for a burned patient? a. Immediate (emergent/resuscitative): i. Priority is given to removing the person from the source of the burn & stopping the burning process 1. Assess ABCs 2. Stabilize c-spine 3. Assess for inhalation injury + provide supplemental 100% O2 as needed ii. Primary concerns are: onset of hypovolemic shock & edema formation iii. Collaborative management = airway management + fluid therapy + wound care iv. Fluid therapy: 1. If > 15% TBSA  need at least 2 large bore IV access routes (important to be large bore to accommodate large volumes of fluid) 2. If > 30% TBSA  central line (for fluid & drug administration + blood sampling) should be considered 3. Type of fluid replacement is determined by: a. Size & depth of burn b. Age of patient c. Individual considerations (such as preexisting chronic illness) 4. Fluids usually used = LR, colloids (albumin), or combination of both 5. Fluid replacement amounts are estimates & should be titrated based on patient’s physiologic response 6. Colloids (albumin) usually given after 12-24 hrs post-burn (when cap permeability returns to normal/near normal) v. Assess for other injuries that may take priority over burn wound vi. Small thermal burns ( 10% TBSA)  cover with clean, cool, tap water- dampened towel (for patient comfort + protection until definitive medical care is instituted) vii. Cooling of injured area (if small) within 1 minute  helps minimize depth of injury viii. Large burns (> 10% TBSA) / electrical burns / inhalation burns  focus attention first on ABCs 1. Airway: check for patency, soot around nares/on tongue, singed nasal hair, darkened oral/nasal membranes 2. Breathing: check for adequacy of ventilation 3. Circulation: check for presence & regularity of pulses + elevate burned limb(s) above heart (to  pain/swelling) i. Phase begins when wounds have healed + pt able to resume level of self- care activity ii. Goals of phase: 1. Assist pt in resuming functional role in society 2. Rehabilitate from functional & cosmetic reconstructive surgery iii. Focus: physical & occupational therapy iv. Continue to: 1. Counsel & teach 2. Encourage & assist patient in resuming self-care (including dressing changes + wound care) 3. Prevent or minimize contractures & assess likelihood for scarring a. Surgery, physical/occupational therapy, splinting, pressure garments v. Discuss possible reconstructive surgery vi. Provide reassurance that feelings during period of adjustment are normal (frustration is to be expected) vii. Prepare for discharge home or transfer to rehab hospital d. Physical therapy/rehab starts: i. Planning for rehab begins on the day of the burn injury or admission to the burn center ii. Formal rehab begins as soon as functional assessments can be performed TRAUMA (HEAD --8 questions and SPINAL CORD PATIENT --- 8 questions) 1. Assess the potential effects of injury to the head, neck, or spine. a. Scalp lacerations may bleed profusely b. Concussion  disruption of LOC + amnesia + HA c. Skull fx: may lead to cranial nerve deficits + leakage of CSF (rhinorrhea/otorrhea) i. Could  intracranial infections d. Head bleeds: neuro changes may be noticed w/in 1st few hours i. Epidural hematoma (usually arterial bleeding)  neurologic emergency! 1.  initial unconsciousness  brief lucid interval  LOC 2. Also: HA + N/V + focal findings ii. Subdural hematoma (usually venous bleeding) 1.  LOC + HA (usually w/in 1st 24-48 hrs) iii. Intra-cerebral: size of bleed determines outcome/presentation e. Head injuries could cause seizures f. Altered mental status/LOC g. Severe HA h. Impaired gag reflex / inability to maintain patent airway / altered or irregular RR, pattern i. Cushing’s triad : systolic HTN w/widening pulse pressure + bradycardia w/full & bounding pulses + irregular respirations j. Vomiting (may be projectile) k. Bowel/bladder incontinence l. Mood/behavioral changes m. Mentation changes n. Impaired judgment o. Aphasia / dysphasia p. Motor deficit/impairment, weakness, palmar drift, spasticity, flaccidity, ataxia q. Paralysis, decorticate/decerebrate posturing, muscular rigidity/increased tone r. Uninhibited sexual expression s. Fear / denial / anger / aggression / depression t. SCI  paraplegia / tetraplegia i. Spinal &/or neurogenic shock ii. Cervical injury above C4  total loss of respiratory muscle function iii. Below C4  diaphragmatic breathing (if phrenic nerve is functioning) iv. Even if below C4, edema & hemorrhage can affect function of phrenic nerve  respiratory insufficiency v. Cervical or thoracic injuries  paralysis of abdominal (and often intercostal) muscles  cough may not be effective  risk: atelectasis & pneumonia vi. Poikilothermism  unable to regulate body heat vii. Warm, dry skin below level of injury (neurogenic shock) viii. With lesions @ C1-3 = apnea, inability to cough ix. With lesions @ C4 = poor cough, diaphragmatic breathing, hypoventilation x. With lesions @ C5-T6 = respiratory reserve xi. Lesions above T5 = bradycardia, hypotension, postural hypotension, absence of vasomotor tone xii. May have decreased/absent bowel sounds, abdominal distention, constipation, fecal incontinence, fecal impaction xiii. Urinary retention (lesions @ T1 – L2), flaccid bladder, spasticity w/reflex bladder emptying xiv. May have priapism or loss of sexual function xv. Lesions above C8 = tetraplegia w/flaccid paralysis + anesthesia xvi. Lesions below C8 = paraplegia w/flaccid paralysis + anesthesia xvii. Muscle atony (in flaccid state) or contractures (in spastic state) 2. What are signs and symptoms of spinal shock vs. neurogenic shock? a. Spinal shock: temporary neurologic syndrome i.  reflexes + loss of sensation & movement ii. Flaccid paralysis below level of injury iii. Lasts days – months iv. May mask post-injury neurologic function b. Neurogenic shock: i. d/t loss of vasomotor tone ii. Hypotension + bradycardia iii. No loss of motor or sensory function! iv. Loss of SNS innervation  peripheral vasodilation, venous pooling, CO v. Generally associated w/cervical or high thoracic injury (T6 or higher) 3. Evaluate signs, symptoms, and implications of increasing intracranial pressure. a. S&S: i. Changes in LOC: 1. Ranges from flattened affect, attention, change in orientation  coma (corneal & pupillary reflexes absent, pt does not respond to painful stimuli, cannot swallow or cough, incontinent of urine/feces) ii. Changes in vitals: 1. Cushing’s triad (later sign): systolic HTN w/widening pulse pressure + bradycardia w/full & bounding pulses + irregular or slow respirations  medical EMERGENCY! 2. Change in body temp iii. Ocular signs: 1. Ipsilateral (same side) dilation of pupil  Neuro EMERGENCY! 2. Sluggish or no response to light 3. Inability to move eye upward 4. Ptosis of eyelid 5. Blurred vision 6. Diplopia 7. Changes in extra-ocular eye movements 8. Papilledema (edematous optic disc on retinal exam) iv.  motor function: 1. Contralateral (opposite side) hemiparesis or hemiplegia 2. Noxious stimuli may elicit decorticate (flexor) or decerebrate (extensor) posturing v. HA: 1. d/t compression of intracranial structures: walls of arteries/veins + cranial nerves) 2. HA often continuous, but usually WORSE in AM! 3. Straining, agitation, or movement may make worse vi. Vomiting: 1. Usually NOT preceded by nausea 2. May be projectile b. Implications: i. Potentially life-threatening ii. Diminishes CPP iii. risk: brain ischemia & infarction iv. Associated w/poor prognosis v. May result in: 1. Hypercapnia 2. Cerebral acidosis 3. Impaired autoregulation 4. Systemic HTN 5. (all promote formation & spread of cerebral edema) i. Life-threatening situation  requires immediate resolution ii. Could lead to: status epilepticus, stroke, MI, death iii. Most common precipitating cause: distended bladder or rectum b. Manifestations: i. HTN (up to 300 systolic) ii. Sudden throbbing HA iii. Marked diaphoresis (above level of SC lesion) iv. Bradycardia (30 – 40 bpm) v. Piloerection (body hair stands on end) vi. Flushing of skin (above level of SC lesion) vii. Pale extremities (below level of SC lesion) viii. Blurred vision or spots in visual field ix. Nasal congestion x. Anxiety xi. Nausea c. Assessment: i. Important to measure BP when SCI pt complains of HA!!!! ii. Assess for presenting S&S iii. Assess for cause (most commonly: bladder irritation) d. Treatment: i. Raise to sitting position (HOB  45*) ii. Remove noxious stimulus (fecal impaction, kinked urinary catheter, tight clothing) iii. Notify HCP (if above actions do not relieve S&S) iv. If immediate catheterization is required, Lidocaine jelly should be instilled in urethra before insertion v. If existing catheter is clogged/plugged, small-volume irrigation should be performed slowly & gently (or new catheter may need to be inserted) vi. Digital rectal exam only after application of anesthetic ointment to rectal stimulation (prevents  S&S) vii. Remove all skin stimuli (constrictive clothing & tight shoes) viii. Monitor BP frequently ix. If S&S persist after source removed, alpha blocker or arteriolar vasodilator (nifedipine/Procardia) should be given x. Monitor vitals until stabilized xi. Teach pt & caregiver to recognize S&S (must understand life- threatening nature) + be able to relieve the cause 8. What would you relay about the prognosis of a patient with a C5 vertebral fracture with paralysis to family members? a. Respiratory function could be impaired, if edema or hemorrhage interfere w/function of phrenic nerve  respiratory insufficiency possible b. influence of SNS  bradycardia + hypotension i. Cardiac monitoring is necessary ii. Drugs (atropine) may be needed to keep HR > 40 (prevent hypoxia) c. Patient will have tetraplegia d. Possible movement still remaining: i. Full neck movement ii. Partial shoulder, back, and biceps iii. Gross movement in elbow iv. Inability to roll over or use hands v.  respiratory reserve e. (Vagus nerve domination of heart, respirations, & all vessels and organs below injury) f. Pt may be able to (eventually) drive electric wheelchair (with mobile hand supports) i. May have indoor mobility in manual wheelchair ii. Able to feed self w/setup + adaptive equipment iii. Will probably require attendant care 10 hr/day g. During acute care: i. Will have: 1. Immobilization of vertebral column by skeletal traction 2. O2 by high-humidity mask 3. Foley catheter 4. IV fluids 5. Stress ulcer prophylaxis 6. DVT prophylaxis ii. Will need: 1. Maintenance of HR (atropine) + BP (dopamine) 2. Methylprednisolone high-dose therapy 3. Insertion of NG tube (attached to suction) 4. Bowel & bladder training iii. May be intubated (depending on ABGs & PFTs) h. Rehab & home care: i. Will need: 1. ROM exercises 2. Mobility training 3. Muscle strengthening 4. Occupational therapy (splints, ADL training) 5. Pressure ulcer prevention 6. Recreational therapy ii. Prevention of autonomic dysreflexia important iii. Patient & caregiver teaching will be provided TRAUMA PATIENT (14 questions) 1. As a triage nurse, how do you know who should be seen first, second, third… a. Use the Emergency Severity Index (ESI) Triage Algorithm (Fig. 69-1) b. ESI 1 = any threats to life (requires immediate life-saving intervention) i. Unstable ABCs ii. Obvious life or organ threat iii. Ex: cardiac arrest / intubated trauma patient / OD w/bradypnea / severe respiratory distress c. ESI 2 = high-risk situation (or) confused/lethargic/disoriented (or) severe pain/distress i. ABCs threatened ii. Live or organ threat likely, but not always obvious iii. Should be seen within 10 mins iv. May require multiple, often complex diagnostic studies v. Ex: chest pain probably resulting from ischemia / multiple trauma unless responsive d. ESI 3/4/5 = based on # of anticipated resources they may need i. ESI 3 = Many resources needed 1. Normal vitals  ESI 3 2. Abnormal vitals  ESI 2  reconsider severity! 3. ESI 3: should be seen w/in 1 hr 4. Ex: abdominal pain or gynecologic disorders unless in severe distress / hip fracture in elderly pt ii. ESI 4 = One resource needed 1. Can be delayed 2. Requires one simple diagnostic study (x-ray) or simple procedure (sutures) 3. Ex: closed extremity trauma, simple laceration, cystitis iii. ESI 5 = Zero resources needed 1. Can be delayed 2. Examination only 3. Ex: cold symptoms, minor burn, recheck (wound), prescription refill 2. What are the primary and secondary assessments – what is included in the assessment of each? a. Primary: i. Focuses on Airway, Breathing, Circulation, Disability, Exposure/Environmental control ii. Serves to identify life-threatening conditions so that appropriate interventions can be initiated 1. If encounter life-threatening conditions related to A/B/C/D  start interventions immediately (before moving to next step of survey) iii. A irway w/cervical spine stabilization &/or immobilization b. Serve as advocate c. Help remind healthcare team of their “personhood” d.  important to assign member of team to explain care delivered + answer questions by family v. G ive comfort measures 1. Pain = primary complaint  should be addressed pharmacologically (NSAIDs, IV opioids) + non- pharmacologically (imagery, distraction, positioning) a. Also assess/address anxiety 2. Other measures include: a. Verbal reassurance b. Listening c. Reducing stimuli (dim lights, limit noise) d. Develop trusting relationship e. Splint/elevate/ice injured extremities (as appropriate) vi. H istory + Head-to-toe assessment 1. H istory: provides clues to cause + suggests specific assessment/interventions a. Details of incident/injury/illness b. Mechanism & pattern of injury c. Length of time since incident occurred d. Injuries suspected e. Vitals (by pre-hospital personnel) f. Treatment provided + patient response g. LOC h. History should include questions: i. What is the chief complaint? What caused the patient to seek attention? ii. What are the patient’s subjective complaints? iii. What is the patient’s description of pain (location, duration, quality, character)? iv. What are witnesses’ (if any) descriptions of the patient’s behavior since the onset? v. What is the patient’s health history? (Use AMPLE) 1. Allergies to drugs/food/environment 2. Medication history 3. Past health history (preexisting medical and/or psychiatric conditions, previous hospitalizations/surgeries, smoking history, recent use of drugs/alcohol, tetanus immunization, last menstrual period, baseline mental status) 4. Last meal 5. Events/Environment leading to illness/injury 2. H ead-to-toe assessment: a. Head/neck/face: i. General appearance + skin color ii. Face & scalp  lacerations, bone or soft tissue deformity, tenderness, bleeding, foreign bodies iii. Eyes/ears/nose/mouth  bleeding, foreign bodies, drainage, pain, deformity, ecchymosis, lacerations, loose/missing teeth 1. Eyes: extra-ocular movements, disconjugate gaze (neuro damage), “raccoon eyes”/periorbital ecchymosis (fx of base of frontal portion) 2. Ears: Battle’s sign (basilar fx of posterior portion), blood or CSF 3. Do NOT block clear drainage from ear or nose 4. Mouth: ability to open + swallow iv. Head  depressions of cranial or facial bones, contusions, hematomas, areas of softness, bony crepitus v. Neck  stiffness or pain in cervical vertebrae (fx), tracheal deviation (tension pneumo), distended neck veins, bleeding, edema, difficulty swallowing, bruising, subQ emphysema (laryngotracheal disruption), bony crepitus 1. Protect c-spine w/rigid collar + supine position 2. Logroll if movement necessary (using 2-3 people) b. Chest: i. Rate/depth/effort of breathing (including chest wall movement + use of accessory muscles) 1. Paradoxic chest movements 2. Sucking chest wounds ii. Palpate (sternum/clavicles/ribs) for bony crepitus, subQ emphysema, deformity, point tenderness iii. Auscultate breath sounds + heart sounds (distant?) iv. 12-lead ECG (dysrhythmias + evidence of myocardial ischemia or infarction) v. External signs of injury: petechiae, bleeding, cyanosis, bruises, abrasions, lacerations, old scars c. Abdomen/flanks: i. Symmetry of external abdominal wall & bony structures ii. External signs of injury: bruises, abrasions, lacerations, punctures, old scars iii. Masses, guarding, femoral pulses iv. Type & location of pain, rigidity, distention of abdomen v. Auscultate bowel sounds (paralytic ileus?) 1. BS in chest (diaphragmatic rupture) vi. If suspect intra-abdominal hemorrhage, a focused abdominal sonography for trauma (FAST) determines presence of blood in peritoneal space (cannot rule out retroperitoneal bleed  CT scan) d. Pelvis/perineum: i. Gently palpate pelvis (do NOT rock)  pain (fx?) ii. Assess genitalia for blood at meatus, priapism, ecchymosis, rectal bleeding, anal sphincter tone iii. Ability to void? (bladder distention, hematuria, dysuria, inability to void) e. Extremities: i. Signs of external injury: deformity, ecchymosis, abrasions, lacerations, swelling ii. Quality & location of pain, tenderness iii. Movement, strength, sensation in arms/legs iv. Skin color + palpate skin for temp & crepitus v. Quality + symmetry of peripheral pulses vi. Splint injured extremities above & below injury ( further soft tissue injury + pain) 1. Check pulses before AND after movement or splinting 2. Pulseless extremity = time-critical vascular or orthopedic emergency! 3. Assess for compartment syndrome 4. Immobilize + elevate + apply ice 5. Open fx  prophylactic ABX vii. Inspect posterior surfaces: 1. Logroll  inspect + palpate back for deformity, bleeding, lacerations, bruises, abrasions, puncture wounds a. Palpate spine for misalignment, deformity, pain 3. Explain the pathophysiology, clinical manifestations and nursing and collaborative care for specific traumatic injuries: (pneumothorax; sucking chest wound; ruptured diaphragm; rib fractures; flailed chest; pulmonary contusions; blunt cardiac bruising; crush injury; stabbing; gunshot wounds; abdominal trauma: ruptured spleen, liver lacerations, renal trauma.)? a. Pneumothorax i. Patho: air in pleural space  partial or complete collapse of lung (should be suspected after any blunt trauma to chest wall) 1. Open: air enters pleural space through opening in chest wall a. Examples: i. Stabbing d. Rib fractures (most common chest injury from blunt trauma) i. Patho: ribs 5-10 most commonly fractured b/c least protected by chest muscles 1. If splintered or displaced, may damage pleura & lungs 2. Could  subQ emphysema ii. Manifestations: 1. Pain at site of injury (especially during inspiration & coughing) 2. Patient splints area + takes shallow breaths (to pain)  atelectasis & pneumonia may develop (d/t ventilation + retained secretions) iii. Care: 1. Main goal = pain (to breathe adequately & promote lung expansion) 2. Do NOT strap chest w/tape or binder  limits chest expansion 3. To reduce pain + aid in deep breathing & coughing, use: a. NSAIDs b. Opioids c. Nerve blocks 4. Teach pt deep breathing + coughing + use of I/S + pain meds e. Flailed chest i. Patho: fracture of 2 or more adjacent ribs in 2 or more places + loss of chest wall stability (unstable segment) ii. Manifestations: 1. Paradoxic movement of chest wall (opposite of rest of chest/ribs) a. During inspiration, segment sucked in b. During expiration, segment bulges out c. Prevents adequate ventilation of lung + WOB 2. Rapid, shallow respirations 3. Tachycardia 4. Respiratory distress 5. Crepitus near rib fractures 6. CXR reveals fractures 7. Abnormal ABGs 8. May not be initially apparent in conscious pt d/t splinting 9. May be associated w/hemothorax, pneumothorax, or pulmonary contusion iii. Care: 1. Manage airway & provide adequate ventilation 2. O2 as needed to maintain O2 sats 3. Analgesia 4. Stabilize flail segment w/positive pressure ventilation (CPAP, BiPAP) or mechanical ventilation 5. Treat associated injuries f. Pulmonary contusions i. Patho: bruised lung tissue  swells  pulmonary edema 1. May occur w/blunt steering-wheel injury to chest or shoulder- harness seat belt injury ii. Manifestations: oxygenation iii. Care: support breathing efforts + assist when needed g. Blunt cardiac bruising i. Patho: injury to heart tissue  contused 1. May occur w/blunt steering-wheel injury to chest or shoulder- harness seat belt injury ii. Manifestations: 1. Pericardial tamponade  outside of heart oozes fluid  pressure iii. Care: 1. Treat like MI 2. Monitor for dysrhythmias h. Crush injury i. Patho: may occur w/heavy equipment or some other force crushing thorax ii. Manifestations: 1. May lead to pneumothorax/hemopneumothorax, flail chest, great vessel tears/rupture, blood return to heart  CO iii. Care: (treat injuries as they present) i. Stabbing i. Patho: penetrating trauma ii. Manifestations: 1. May lead to open pneumothorax, tension pneumothorax, hemopneumothorax, cardiac tamponade, esophageal damage, tracheal tear, great vessel tears iii. Care: (treat injuries as they present) j. Gunshot wounds i. Patho: penetrating trauma ii. Manifestations: 1. May lead to open pneumothorax, tension pneumothorax, hemopneumothorax, cardiac tamponade, esophageal damage, tracheal tear, great vessel tears iii. Care: (treat injuries as they present) k. Abdominal trauma: ruptured spleen, liver lacerations, renal trauma i. Patho: usually from blunt trauma or penetration injuries 1. Often associated w/low rib fractures, fractured femur, fractured pelvis, or thoracic injury ii. Manifestations: 1. Solid organs (liver, spleen) bleed profusely when injured 2. Damage to hollow organs (bladder, stomach, intestines)  peritonitis when contents spill into peritoneal cavity 3. Injuries  massive blood loss  hypovolemic shock 4. Abdominal compartment syndrome can develop  organ dysfunction d/t intra-abdominal HTN 5.  peritonitis + sepsis (especially when bowel perforated) 6. Contusion or abrasion across lower abdomen may indicate internal organ trauma (d/t seat belt use) 7. Patient presents with: a. Guarding/splinting abdominal wall b. Hard, distended abdomen (indicating intra-abdominal bleeding) c. /absent bowel sounds d. Contusions, abrasions, or bruising over abdomen e. Abdominal pain f. Pain over scapula caused by irritation of phrenic nerve by free blood in abdomen g. Hematemesis h. Hematuria (damage to kidney or bladder) i. Signs of hypovolemic shock i. LOC / RR / HR / BP / pulse pressure j. Ecchymosis around umbilicus (Cullen’s sign) or flanks (Grey Turner’s sign)  may indicate retroperitoneal hemorrhage k. Auscultation of bruits  arterial or aortic damage iii. Care: 1. Establish patent airway & adequate breathing (O2 via non- rebreather) 2. Control external bleeding w/direct pressure or sterile pressure dressing a. Cover protruding organs w/sterile saline dressing 3. Fluid replacement (2 large-bore IV catheters + infuse warm NS or LR) 4. Prevent hypovolemic shock 5. Obtain blood for type & crossmatch + CBC 6. Remove clothing 7. Foley (if no blood at meatus / pelvic fx / boggy prostate) a. Obtain urine for urinalysis 8. NG tube (if no facial trauma) to decompress stomach + prevent aspiration 9. Do NOT remove impaled objects (stabilize w/bulky dressing) 10. Anticipate diagnostic peritoneal lavage 11. Surgery may need to be performed ASAP  repair damaged organ(s) + stop bleeding 12. Tx for renal trauma: