Burn Care and Complications: Wound Healing, Lab Values, Shock, and Sepsis, Exams of Nursing

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. -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 shock medications - ans-Vasoconstrictors(dopamine, norepinephrine, phenylephrine): improve MAP by increasing peripheral resistance, venous return, and myocardial contractility. -Inotropic agents(dobutamine, milrinone): stimulate receptors on the heart muscle, improving contractility. -Agents enhancing myocardial perfusion( nitropress/nipride): improve myocardial perfusion by dilating coronary arteries rapidly for a short time. skeletal muscle assmt (shock) - ansduring shock it include weakness and pain in response to tissue hypoxia and anaerobic metabolism, which are later manifestations. DTR are decreased or absent. Assess muscle strength by having pt squeeze your hand and assess DTR by lightly tapping the patellar tendons and Achilles tendons with reflex hammer and observing the degree of responsive movement. skin assmt (shock) - ansskin blood vessel constriction, which reduces skin perfusion, cool. Skin feels clammy or moist to the touch. As shock progesses, skin becomes mottled. Evaluate cap refill, with shock, cap refill is slow or may be absent. Cap refill not a reliable indicator. stages of shock - ans1. inital stage 2. nonprogressive stage 3. progressive stage 4. refactory stage Standard wound dressings - ansdressing changed and reapplied every 12-24 hrs. after thoroughly cleaning the areas. Synthetic dressing: - ansmade up of solid silicone and plastic membranes. Pain is reduced because it prevents contact of wound nerve endings with air. This dressing promotes faster healing with low infection rates, minimal pain, and reduced cost. The bundle ( within the first 3 hrs) - ans-Measure serum lactate levels -Obtain blood cultures before administering antibiotics -Administer broad spectrum antibiotics (vanco/zosyn) -If either hypotension or serum lactate level greater then 4 mmol is present, administer 30 ml/kg crystalloids IV. The bundle (within the 6 hr) - ans-Administer vasopressors for hypotension that does not respond to fluid resuscitation measures to maintain MAP > 65 mmhg -If arterial hypotension persists despites fluid volume resuscitation or lactic acid remains > 4 mmol measure CVP and central venous oxygen saturation -Remeasure lactic acid level What to monitor during fluid resuscitation - ans-Monitor VS hourly, monitor urine output ( the amount of fluid given depends on how much IV fluid per hour is needed to maintain 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.