Exam 3 Flashcards

Question

AKI: Meds for Treatment - IV fluids (3) - Sodium bicarb (2) - RBC production (2) - Acetylcysteine

Answer 1

IV Fluids - Crystalloids (NS, ½NS, LR) – to increase renal perfusion and output - avoid LR b-c has potassium) - Colloids (Albumin) – volume expanders to maintain hemodynamic stability Sodium Bicarbonate - For Metabolic acidosis - must be in separate line, no y-site connections Red blood cell production stimulation/production - Give iron, PRBCs, erythropoietin (epoetin alfa), vitamin B12, B6, folate - stress ulcer prophylaxis to prevent GI bleed Acetylcysteine (Mucomyst) - Used to reduce contrast-dye induced AKI

Answer 2

Purpose: stimulate UOP if fluid overload and functioning kidneys Loop (budesonide, furosemide) - Caution if sulfa allergy - Furosemide is ototoxic Thiazide (Hydrochlorothiazide) - Caution if sulfa allergy - Ineffective if GFR < 10 Carbonic anhydrase inhibitor - for metabolic alkalosis after aggressive diuresis to increase release of bicarb Potassium-sparing (spironolactone) - Weak diuretic - No potassium supplements

Answer 3

- Use: cerebral edema, excretion of toxins, increased ICP Action - Increases UOP and GFR via high plasma osmolality and water flow - increase cerebral blood flow by pulling water out of intracellular space but causes cerebral vasoconstriction as part of autoregulation Care - need filter - risk for hypernatremia, hypokalemia - need CVP to prevent hypovolemia

Answer 4

A = Acidosis (metabolic <7.1) or Azotemia E = Electrolyte Imbalance (hyperkalemia) I = Intoxication/Toxins (drug or alcohol) O = Oliguria or Overload of Fluid U = Uremia (azotemia with symptoms i.e. metallic taste in mouth, anorexia, muscle cramps, dyspnea, hiccups, uremic frost on skin, change in mentation, pericarditis (pericardial friction rub), neuropathy (paresthesia)) = Elevated BUN

Answer 5

- Separates and removes excess electrolytes, fluids, and toxins from blood - Loss of fluid over short period of time (3-4 hrs) Disadvantages - Needs Anticoagulation (heparin) - needs special nurse - Risks of hypotension, infection, graft-clotting, hemorrhage, and embolism - Contraindicated in hemodynamically unstable patient

Answer 6

Temporary vascular access - Only for dialysis (Not for meds, blood samples, or monitor CVP) - Assess for s/s of infection, perfusion, bleeding Permanent - not used in AKI - Fill the thrill, hear the bruit - No BP measures, IV infusions, phlebotomy in arm of fistula

Answer 7

- Uremic toxins and fluids are removed, while acid–base status and electrolytes adjusted slowly and continuously - Blood filtered and cleansed with dialysate solution - Venous blood circulated via porous hemofilter back into body - continuous over several days (large volume over long period)

Answer 8

- Monitor ultrafiltration hourly - add replacement fluid if large volume removed - Hemofilter change q24-48 hours - Anticoagulation (heparin) is required - Only in ICU - contraindicated if Hct > 45% or terminal illness

Answer 9

- hemodynamically unstable pt who requires removal of large volumes of fluid - Hypervolemic or edematous pts. unresponsive to diuretic therapy - Pts. with MODS (multi-organ dysfunction syndrome) - Ease of fluid management in pts requiring large daily fluid volume - Replacement for oliguria - Admin of TPN - Inability to be anticoagulated

Answer 10

- decreased ultrafiltration rate (risk for clotting) - place pt supine, lower container - filter clotting - reset up system and use anticoagulant - hypotension - clamp line - f/e imbalance - bleeding (hemorrhage) - Access dislodgement or infection - sterile dressing changes - EKG interference - assess pt - Air embolus - prime tube properly

Answer 11

Use - acute HF - unresponsive to diuretics - when azotemia or uremia not a concern b-c only fluid loss (no electrolyte loss) Notes * No replacement fluid added * Rate: 100 to 300 ml/ hour (slow) * Requires both arterial and venous access * Clots easily

Answer 12

Use: fluid and moderate solute removal via convection (urea, creatinine, and other small non-protein toxins) Notes * Must have MAP of 60 (BP driving force) * Rate: 5 -20 mL/min or up to 7- 30 L/24 hr * Replacement fluid is added

Answer 13

Use - fluid and max solute removal via diffusion (dialysate pumped concurrent to blood) - resistance to diuretics - severe uremia or critical acid-base problems Notes * most like traditional HD *Must have MAP of 70 (BP is driving force) *Rate: 500-800 mL/hr (more effective over days) *Replacement fluid added * Ideal for hemodynamically unstable in ICU b-c do experience abrupt fluid and solute changes

Answer 14

Use - max fluid and max solute removal via convection and diffusion - Combines CVVH and CVVHD - most complex Notes - Requires a MAP of at least 60 (BP driving force) - Replacement fluid is added

Answer 15

- Drugs (anticholinergics, diuretics, CNS depressants) - Diseases (Depression, Arthritis, Parkinson, Dementia) - Inadequate Resources (lack of support, lack of assistive devices, high cost of products) - Nocturia - urinary retention from age or drugs - weakened urinary sphincter - decreased bladder capacity

Answer 16

CNS - Confusion due to infection and delirium often seen - Neurodegeneration (Reduced brain volume and weight, blood flow) - Decrease in neurotransmitters (Ach, dopamine, serotonin, glutamate) - altered sleep-wake cycle (increases risk for delirium and dementia) - Increased blood brain barrier permeability (increased drug effects) - slower processing times and memory loss) Sensory - Decreased pupil size and reactivity (vision) - Decreased touch sensation (falls) - Reduced reflexes r/t neuronal loss (falls) - decreased taste, hearing, and smell

Answer 17

- LOC (earliest indicator of change in neuro status) - Motor function - pupillary function - respiratory function - vital signs

Answer 18

- Alert - Confused - Delirious (disoriented to time, patient, place and may have hallucinations) - Lethargic - Obtundent (dull indifference to any stimuli) - Stuporous (only respond to continuous stimuli) - Comatose (no response to any stimulus)

Answer 19

Arousal - ability to respond to verbal or noxious stimulus. (Verbal (calm then loud), sternal rub, trapezius muscle pinch) - Central stimulation preferred (trapezius muscle pinch or sternal rub) over Peripheral stimulation (nailbed pinch) for overall body response. - no need for noxious stimuli if follows commands Alert (LOC) Awareness (orientation to person, place, time, situation) if arousable

Answer 20

- Highest = 15 & lowest = 3. - < 7 = comatose i.e. “Less than 8, intubate”. - Never use GCS in place of complete neurologic assessment - does not account for patients with aphasia or mechanically ventilated. - Change in 2 or more points is significant

Answer 21

Eye opening (4-1) - spontaneously - to speech - to pain - none Verbal Response (5-1) - oriented - confused (appropriate language but disoriented) - inappropriate - incomprehensible (mumbles, moans, groans) - none Motor response (6-1) - obeys commands - localizes pain (spontaneous w/ purpose away from noxious stimuli) - withdraws from pain (does not cross midline but moves away) - flexion to pain (Decorticate) - extension to pain (decerebrate) - brainstem dysfunction - none

Answer 22

Posturing - denote decorticate (flexion), decerebrate (extension), or flaccid after peripheral noxious stimuli Reflexes - DTRs (achilles, quadriceps, biceps, triceps) should be present - corneal (CN 5 and CN7) should be present - pharyngeal/gag (CNIX and CNX) should be present - Babinski, grasping, rooting if > 2 yrs = brainstem lesion or herniation

Answer 23

Muscle size and shape - any atrophy Muscle tone - via passive movement - flaccid, hypotonia, hypertonia Muscle strength - via active movement - graded 0 to 5 - pronator drift (arm held out and pronated then drops due to weakness)

Answer 24

Size, shape, symmetry - pupils should be equal b/w 2-5 mm - any new discrepancy = significant b-c may be herniation or increased ICP) Reaction to light - should be direct and consensual response - Dilated, nonreactive or oval shape= CN III (oculomotor compression) - Pinpoint & fixed = brainstem dysfunction/ loss of sympathetic control from opioid - Asymmetric, loss of reaction, unilateral/bilaterally dilated = brain herniation Eye movement - use H test if conscious - If unconscious, use doll’s eye reflex or ice caloric text

Answer 25

”Doll’s eyes” - Action: turn head side to side quickly while someone holds eyes open (DO NOT DO IF CERVICAL INJURY) - positive = eyes move in opposite direction of head movement = intact brainstem. - Negative = eyes stay fixed and midline or move in same direction as head movement = significant brainstem injury Cold caloric test” - Action: place 20-100 ml of ice water in ear while head raised to 30 degrees (HCP ensures tympanic membrane is intact first)- very NOXIOUS - Positive: eyes turn toward ear with water in it - Negative: disconjugate/abnormal or absent reflex = degree of brainstem injury

Answer 26

Initial - increased BP - Increased HR and CO - Decreased RR (hypoventilation i.e. hypoxemia and hypercapnia lead to cerebral vasodilation = increased ICP - Temp (hypo or hyperthermia b-c unable to regulate) Late (Cushing's Triad- opposite of shock) - Increased SBP (widened pulse pressure - Abnormal respirations/Airway status (Cheyne stokes, cluster breathing, apnea) - Bradycardia

Answer 27

Use: gold standard rapid noninvasive test for TBI, vascularity, mass lesions Care - Serial CT to detect changes (increased ICP or midline shifts) - May be w/ or w/o contrast dye (need contrast dye care i.e. hydration, allergy check, kidney check, previous reactions (antihistamine or corticosteroids if mild reactions previously)) - Stay w/ patient during procedure to monitor neuro, VS, and ICP - keep patient flat

Answer 28

- LP (definitive diagnosis) - CT/MRI – identify increased ICP, hydrocephalus or brain abscess - XRAY – determine if infection present - Culture & sensitivity - identify causative agent if LP delayed CSF - cloudy - increased protein, WBC, lactate, specific gravity - decreased glucose CBC- WBC (elevated b-c infection)

Answer 29

Use: Allows visualization of lumen of vessels to provide info on patency, size (narrowing or dilation), irregularities, occlusion (thrombosis) i.e. aneurysm, vasospasm, AV malformation, carotid artery disease, vascular tumor, stroke Contraindications: renal insufficiency, bleeding, cardiac instability Care - NPO for 4 hrs prior b-c sedated - Uses contrast dye (check for allergies and check kidney function; enhance hydration) - Bedrest for 8-12 hrs after - Care similar to cardiac cath (Keep patient flat and leg straight for 2-6 hrs, monitor puncture site and pulses after procedure) - Monitor: VS, Neuro and neurovascular q15 for 1 h

Answer 30

MRI - more detail than CT to show subtle details (small tumors, cerebral infarct, CNS infections and inflammation, malignancy, metastatic lesions, spinal cord injury - Requires patient to be motionless in tight space for long time (blindfold, music, or light sedation may be needed) - Remove all metal from pt body and clothing (do not use if ICP monitoring) EEG - Looks at electrical impulses to view seizure activity, cerebral infarct, metabolic encephalopathies, alt LOC, infectious disease, head injury, confirm brain death X-ray - Identify fractures (except basilar), anomalies, or possible tumors - may be unnecessary if CT

Answer 31

Use: visualize CSF and analyze to diagnose meningitis Contraindications - increased ICP associated with space-occupying lesion, mass or trauma b-c risk of brain herniation - increased bleeding risk (anticoagulants, thrombocytopenia, coagulopathies) Care - Monitor for changes in neuro or breathing pattern - properly align patient (flexed lateral) - Do CT first to rule out mass, lesion, or trauma prior to LP if increased ICP suspected

Answer 32

Management: Cerebral Autoregulation (ability of cerebral vessels to maintain cerebral blood flow regardless of body’s blood pressure) Notes - corresponds w/ metabolic demands of body - MAP of 50-150 = okay if autoregulation working but not okay if impaired autoregulation - If impaired autoregulation, maintain SBP > 90

Answer 33

Increased = increased ICP to compensate which worsens ischemia - Acidosis (hypoxia, hypercapnia, ischemia,) -> vasodilation - Increased metabolic demand (hyperthermia) Decreased - Alkalosis (hypocapnia) -> vasoconstriction -> ischemia due to decreased cerebral blood volume - Reduced metabolic demand (hypothermia or barbiturates) Disorders - CSF Space (meningitis, Pseudotumor Cerebri, hydrocephalus) - Intracranial Blood Flow - Brain Substance (brain tumors)

Answer 34

Goal: reduce ICP by decreasing volume of blood, brain, or CSF in cranial vault General Management - Elevate HOB to improve perfusion pressure. - Oxygen therapy to prevent hypoxia for patients with O2 less than 95% - Hyperoxygenate the patient before and after suctioning to avoid transient hypoxemia - quiet environment w/ low lights - frequent neuro exam and GCS to find changes early

Answer 35

- AEDs to prevent seizures - Antipyretics and cooling blankets to decrease metabolic demand. - sedation and antihypertensives to reduce CPP - hypertonic saline (keep Na on high side of normal and reduce cerebral edema) - Steroids (decrease cerebral edema and inflammation) - Diuretics (mannitol or furosemide) - Opioids (fentanyl, morphine) and sedatives (propofol)- smallest amount b-c interferes w/ neuro exam - Neuromuscular blocking agents – must use ICP monitor b-c not able to get neuro exam w/ these

Answer 36

- head, hip or neck flexion - clustering of nursing procedures - unnecessary suctioning - PEEP > 20 cm H2) - vomiting (antiemetics) - Constipation and straining (stool softeners) - Coughing (lidocaine)

Answer 37

Early - Decreased LOC (earliest) - behavior changes (restlessness, irritability, confusion) - speech changes (aphasia - sensorimotor changes (CN dysfunction, ataxia, motor dysfunction, change in muscle tone) Late - Severe headache - Nausea and vomiting (may be projectile) - Seizures (usually within first 24 hours after stroke) - Cushing triad (very late sign): - Abnormal posturing (very late sign): Decerebrate or Decorticate - Pupillary changes: fixed, constricted, dilated - Papilledema (edema and hyperemia due to increased blood flow to eye)

Answer 38

- pressure needed to ensure blood flow to brain - MAP - ICP = CPP Normal range: 50-70 ( CPP < 30 = neuronal hypoxia and cellular death) Notes - Increased ICP -> decreased CPP and causes cytotoxic edema - maintain SBP > 90

Answer 39

Use: monitoring or treatment via draining CSF in EVD (external ventricular drain) for TBI, ICH, stroke, meningitis, hepatic encephalopathy, Normal range ICP: 5-15 mmHG (Persistent elevation > 20 remains most significant factor associated with fatal outcomes Care for device - Need waveform (3 notches) along w. numeric value - Zero device once per shift - Check for catheter dislodgement or kinks in tubing - Transducer must be leveled w/ ear (external auditory meatus) once a shift - Do not move HOB b-c misaligns transducer and changes drainage - reinforce but do not change cranial dressings

Answer 40

Contraindication: coagulopathy Complications: - Ventriculitis (decrease risk w/ antibiotic impregnated catheter) - Meningitis - Post-op hemorrhage, - Decreased drainage (increases ICP)

Answer 41

Uses: cerebral decompression, resection of tumor, clipping to remove hematoma or aneurysm Types of craniotomy - Transcranial approach: Scalp incision w/ series of Burr holes and remove bone flap - Transsphenoidal approach (MIS): Create entrance into cranium via nasal cavity to remove pituitary tumors

Answer 42

- Halo sign (place fluid on absorbent pad (see serosanguineous in middle and CSF forms yellow or clear halo around fluid) - test clear drainage for Test for glucose ( ≧ 30) - otorrhea/rhinorrhea

Answer 43

- Periorbital edema and ecchymosis (common and need need cold compress and eye drops - Intracranial HTN (Increased ICP and cerebral edema) - Surgical hemorrhage (If transsphenoidal, frequent swallowing, postnasal drip (pt complaint), or external drainage OR loss of vision after pituitary) - Fluid imbalance (self-limiting DI/SIADH) – fluid management/restriction - CSF leak (rhinorrhea, otorrhea, sweet/salty taste, headache, Halo sign, persistent postnasal drip/excessive swallowing) – from subarachnoid space - DVT (focus on prevention i.e. SCD, subQ heparin or enoxaparin (unless active hemorrhage), early ambulation)-- s/s: leg or calf pain, erythema, warmth, selling - Infections (meningitis, cerebral abscesses, bone flap infections, subdural emphema)

Answer 44

Preserve adequate CPP (> 70) - Monitor neuro and VS q15-30 min for first 4-6 hrs then hourly - Increased ICP prevention (neutral head, no hip/neck flexion, raise HOB, pharmacologics) - Fluid mgmt (hourly I & Os, monitor sodium) Promote arterial oxygenation - Mechanical ventilation for 24-48 hrs (no PEEP > 20) - Sedation (propofol or benzos) for pain and anxiety if breathing over ventilator rate - Maintain airway clearance via Suction PRN & proper technique (pre-oxygenate and no more than 2 passes) - Early rehabilitation (deep breathing and repositioning q2h Enteral nutrition - OG or NGT within 24 hrs post-op - Stress ulcer prophylaxis (PPI, H2A)

Answer 45

- infection of meninges of brain and spinal cord i.e pia mater and arachnoid where organism enters via blood stream Types - Sterile (Cancer, NSAIDs, antibiotics, IV Igs) - Viral (aseptic i.e HSV2, varizella, mumps, HIV) - Bacterial (Meningococcal meningitis = emergency) --contagious and life-threatening in first 24 hrs - Fungal (cryptococcus neoformans) - Protozoal

Answer 46

Risk factors - trauma (head, neck, basilar fracture - Surgical procedures to brain or spine - infection (ear, nose, mouth, eye, otitis media, sinus infection, brain abscess - Immunocompromised (asplenia, immunosuppressant drugs, older adults) Prevention - Vaccination (meningococcal and all vaccines (hib, pneumococcal, mumphs, varicella)) esp if high pop density area (college dorm, military barracks, crowded living area) - prophylaxis antibiotics for those in close contact)

Answer 47

Care - frequent neuro and neurovascular assessments q2h - CN assessment (CN VI deficit: inability to move eyes laterally (may indicate hydrocephalus same if increased ICP or incontinence)) - Pain management (opioids and nonopioids) - Isolation precautions (droplet if bacterial; standard if others) - IV Broad spectrum Antibiotic administration ASAP (may discontinue or change after culture results are in; needed for 2 weeks ) - Pharmacologic interventions to decrease ICP or manage seizure activity (Mannitol, hypertonic saline, AEDs)

Answer 48

- Nuchal rigidity - Positive Kernig (leg extension) & Brudzinski (neck flexion) signs - Pupils (photophobia, nystagmus) - Severe headache - Motor (CN dysfunction (II, IV, VI, VII, VIII), Myalgia; Hemiparesis, hemiplegia, decreased muscle tone - Fever/chills (may be absent in older adults, immunocompromised or those on antibiotics) - Tachycardia - Red macular rash (only bacterial) - Memory problems (short attention span; personality and behavior changeS) - increased ICP and hydrocephalus

Answer 49

- Increased ICP - Vascular dysfunction and coagulation disorders (risk for gangrene (thrombotic complications seen in hands i.e. cap refill, temp of extremities, pulses, color) - f/e imbalance (i.e. SIADH)- get I & O - Seizures - Sepsis (shock and arthritis) - ARDS

Answer 50

Primary TBI (mild to severe) - during trauma and at moment of impact due to mechanical forces to head - can be open (dura mater torn) or closed (dura mater not closed) Secondary TBI - after initial injury from cellular response that exacerbates primary TBI and causes add’l damage and impairment in brain - due to 4 things: ischemia (r/t hypotension (MAP <70) or hypoxia (PaO2 <80) and hypercapnia), intracranial HTN, cerebral edema, initial cerebral vasodilation

Answer 51

S/s - CSF leak (otorrhea, rhinorrhea) - Battles sign (ecchymosis behind the ear over mastoid process) - Raccoon eyes (purplish discoloration around eyes) - Palsy of CN VII Care - detect w/ CT - NO NGT for this client! (rule out basilar fracture b-c can accidentally insert into brain)

Answer 52

Mild brain injury (GCS 13-15 and d/c home) w/ brief loss of neurologic function, particularly loss of consciousness. Diagnostic: based on hx S/s - Loss of consciousness (few minutes to hour) -> anterograde or retrograde amnesia - confusion/disorientation/dizziness - irritability/headache - NV - ringing in ear - may have long term secondary effects (CTE or post concussion syndrome)

Answer 53

- bruising of brain (blood collects) due to acceleration-deceleration injuries - coup (at point of impact) or contrecoup (secondary opposite point of impact) Diagnostic: CT S/s - inability to concentrate - numbness and tingling - issues speaking - risk for intracerebral hematoma or hemorrhage - risk for cerebral edema - may need surgery

Answer 54

- Arterial Bleeding (FAST) into the space between the skull and outermost layer of the dura mater S/s - Severe, localized headache (sleepy) - Dilated and fixed pupil on impact side - Brief loss of consciousness followed by a period of lucidity then rapid deterioration of LOC (Walk – Talk – Die phenomenon) Care: Requires EMERGENCY surgical evacuation to remove blood and cauterize vessels

Answer 55

- Venous bleeding (SLOW) into the space between the dura and above the arachnoid space. - Most frequently seen intracranial hemorrhage Risk factors: - Coordination or balance disturbance - Anticoagulants Care: craniectomy or craniotomy

Answer 56

- ABCs = priority (b-c risk for Hypoxia, hypercapnia; Hypertension/Hypotension, fever) - need controlled hyperventilation and hypothermia - Continuous and Frequent Neurologic Assessment and GCS q1h for early detection and treatment - Assess electrolytes q6h if diuretics used - Spine precautions (cervical collar, supine, neutral, log roll) until cervical injury ruled out) - Seizure precautions - Use Foley and PEG/ NG for strict I & O measurement - Avoid noxious stimuli (excess suctioning, coughing, irritation, clustering care) - Early consults: OT/PT/SLP/social work/organ donation

Answer 57

- Decrease in lean body mass - Increase in body fat - Decline in muscle strength (osteoporosis, fractures, immobility) - Decreased sensation - polypharmacy (fall risk w/ benzos, SSRIs, TCA, neuroleptics, and AEDs = highest risk of falls) - frailty (decreased muscle mass, poor nutrition, diminished cognition)

Answer 58

- autoimmune disease - demyelination of peripheral nerves causes inflammatory peripheral neuropathy - TEMPORARY

Answer 59

- Men - vaccines (flu, swine flu, tetanus) - prior respiratory and intestinal infection - trauma (surgery lymphoma)

Answer 60

-Initial muscle weakness and pain - bilateral paresthesia, ataxia -> paralysis - Ascending paralysis (flaccidity to respiratory paralysis) over 2-3 weeks then plateaus - No effect on LOC or cerebral function (may have CN dysfunction) - Decreased DTR Complications - Pulmonary (atelectasis, pneumonia, pneumothorax) - Autonomic dysfunction (HTN, Tachycardia -> beta blocker needed)

Answer 61

- autoimmune antibodies - CSF analysis (Elevated CSF protein with normal cell count) - Nerve conduction studies (Reduced conduction in GBS)

Answer 62

- sensory and neuro assessment q1h - no cure but hasten recovery w/ Plasmapheresis, IVIG, and steroids for inflammation - Respiratory care (may need ventilatory support)- admitted to ICU if requires respiratory support - Pain management (opioids) - Nutritional management (NG or OG tube if swallowing difficulties) - Communication boards or writing if on ventilator and has strength - Initiating OT and PT rehabilitation

Answer 63

Use: GBS, MG Action: Removes circulating antibodies assumed to cause disease from blood then reinfuse blood (similar to dialysis) Pre-procedure - place vascular Cath - need informed consent Contraindications: sepsis, hemodynamic and venous access complications

Answer 64

Use: GBS Minor discomforts ( mild fever/chills, myalgia, and headache) Major complications (anaphylaxis, retinal necrosis, AKI) Contraindications: hypercoagulable states, renal failure, hypersensitivity

Answer 65

- Chronic autoimmune disease - Destruction of myelin (fatty and protein materials) sheath that cover certain fibers in the brain and spinal cord - Slows or stops impulse transmission via neuronal injury and muscle atrophy - Periods of remission and exacerbation

Answer 66

- More common in women, northern European - Increased risk w/ first degree relative - Onset b/w 20-50s - exacerbated by metabolic demands (fatigue, stress, exertion, hot temp) - Infection, genetic, or immune factors

Answer 67

Musculoskeletal/mobility - Muscle weakness and spasticity (paresthesia, flexor spasms) -> paralysis - Intention tremors (when doing activities) i.e. dysmetria - Ataxia Visual - Nystagmus - Diplopia - Decreased acuity (blurry) - Scotoma (change in peripheral vision) Audio - Decreased hearing acuity - Tinnitus - Vertigo (dizziness)

Answer 68

Speech - Dysarthria (difficulty speaking) - Dysphagia (difficulty swallowing) Cognitive changes - memory loss, impaired judgment, inattention - Mood swings (euphoria; depression) - Pain -> hypoalgesia (decreased pain sensation) Elimination/repro - Urinary retention (Spastic bladder) - Constipation - Decreased sexual function (sensation, interest, erection)

Answer 69

- CSF: elevated proteins and increased WBC count - CSF electrophoresis: increased myelin basic protein and presence of increased IgG - MRI (shows at least two areas of diffuse random or patchy areas of plaque in white matter of CNS ) = definitive finding - Evoked potential testing (Visual evoked response (VER)): identify impaired transmission along optic nerve pathway

Answer 70

- ABCs (promote mobility) - collab w/ PT, OT, SLP - reorient if cognitive deficits - eye patch and scanning techniques for visual problems

Answer 71

- Immunosuppressive therapy (Cyclophosphamide (Cytoxan); methylprednisolone (Solu-Medrol)) - Anticholinergic agents for overactive bladder - Antispasmodics (baclofen or tizanidine) for muscle spasticity which cause pain - Antiepileptics (carbamazepine) and TCA for paresthesia - Analgesics-- pain

Answer 72

- Autoantibody attack on the acetylcholine receptor sites (AChRs) in the muscle end plate membranes - Inadequate ACh = result which prevents muscle contraction - exacerbations and remissions

Answer 73

- thymus dysfunction ( Size decreases w/ age but large in MG) - infections (pneumonia, bronchitis, UTI, C.diff, bacteremia) - hypo/hyperthyroidism - increased metabolic demand (exertion, pregnancy, emotions, fever)

Answer 74

- Fatigue/extremity weakness -> Respiratory muscle compromise - Poor posture - Ptosis/ diplopia - Dysarthria (difficulty speaking) - Dysphagia (difficulty swallowing) --Risk for aspiration - Loss of bowel and bladder control

Answer 75

Procedure: patient in controlled environment and given acetylcholine or edrophonium (acetylcholinerase inhibitor) Result (observe or take before and after pics of ptosis) Symptoms improve = MG crisis Symptoms worsen = cholinergic crisis Risks - cardiac dysrhythmias and cardiac arrest (bradycardia, hypotension, bronchospasm, syncope) - Ach Toxicity: lacrimation, salivation, hyperhidrosis, abdominal cramping, diarrhea Care - Antidote = atropine - Have continuous BP, O2, and cardiac monitoring - contraindicated w/ asthma or cardiac diseases

Answer 76

- Ice pack test (Procedure: place ice pack for 2 min and see if ptosis improves) - Thyroid function - CT: show thymus gland abnormalities or confirm presence of thymoma (tumor outside thymus) - Antibodies to acetylcholine receptor antibody (AChRs) - Repetitive nerve stimulation (RNS) or Electromyography (EMG): show impaired neuromuscular transmission - Tensilon test Note: MRI not used b-c contrast can worsen weakness

Answer 77

Myasthenic crisis - Acute exacerbation of MG from enough anticholinesterase drugs (too little Ach) - s/s: dysphagia, nasal regurgitation, nasal speech, jaw or tongue weakness, decreased facial sensation, dyspnea, acute respiratory failure - Treat: Mestinon (pyridostigmine);IVIG or plasmapheresis; respiratory support w/ artificial airway Cholinergic crisis - Acute exacerbation of muscle weakness caused by too much anticholinesterase drugs (too much Ach) - Treat: atropine

Answer 78

Non-surgical Management - Ventilator support (ETT or noninvasive) - Pulmonary support (CPT, vibration, airway clearance; adequate nutrition, f/e balance) - Promote mobility to prevent DVT and other immobility complications Surgical Management - Thymectomy (take thymus out)-

Answer 79

Mestinon (pyridostigmine) (Cholinesterase (ChE) inhibitor drug) - Gold standard for MG (no impact on autoimmune response) - enhances functional AChRs by increasing ACh release Immunosuppressants (steroids, cyclosporin, methotrexate) - reduce autoimmune process and progression - avoid crowds and report s/s of infection; don’t stop steroids abruptly b-c adrenal insufficiency IVIG or Plasmapheresis - If severe w/ bulbar dysfunction or respiratory insufficiency

Answer 80

Description (Lou Gehrig’s disease) - Upper and lower motor neurons degenerate and leave dead tissue until entire body involved - Progressive and neurodegenerative - No cure (life expectancy = 3 yrs. after diagnosis) Care (all treatment is support) - ABCs (trach and vent, perfusion) to treat/prevent respiratory failure - Riluzole - FDA approved to slow progression (not a cure)

Answer 81

S/s - Severe Weakness and fatigue (muscle atrophy) -> respiratory failure - Stiff and clumsy gait - Abnormal reflexes (facial twitching) - Dysphagia (Difficulty swallowing) - Dysarthria(Slurred speech) - Psychosis (late) Diagnostics - Muscle biopsy – atrophy fibers - EMG – fibrillation of muscle

Answer 82

Cervical (8) - control diaphragm, chest wall muscles, arms, shoulders - If C4 and up leads to paralysis of respiratory muscles and all four extremities (tetraplegia) or quadriparesis (weakness) Thoracic (12) - control upper body, GI function i.e. paraplegia (lower extremity paralysis) or paraparesis (lower extremity weakness) Lumbar (5) and Sacral (5) - controls lower body, bowel, bladder

Answer 83

- Complete (Total loss of motor and sensory below level of injury) - Incomplete (more common w/ some sensation and motor activity below level of injury)

Answer 84

- Hyperflexion (esp Cervical area (level of C5/C6 b-c most mobile from head on collision) - Hyperextension (whiplash from rear end accidents OR falls onto chin) - Axial loading, or vertical compression (From falls landing on feet or butt; diving) - Excessive rotation - Penetrating injuries to the spinal cord (i.e. knife or gunshot)

Answer 85

- inflammation (cytokine release) - Hemorrhage (contusion or internal CNS petechial leaking) - Ischemia ( lack of oxygen r/t reduced blood flow) - Hypovolemia - Local edema -> capillary compression and cord ischemia

Answer 86

- secondary mechanism of spinal cord injury - medical emergency - Loss of vasomotor tone -> systemic vasodilation -> hypotension and hypoperfusion (give fluids) - Bradycardia (give atropine and norepinephrine)

Answer 87

- Temporary (Happens immediately and usually lasts 48h but can Last up to 4-12 weeks) - complete paralysis/weakness below injury (may lack reflexes and have priapism) - Decreased bowel sounds and gastric distention -> hypotonic bowel - must resolve before level of injury can be determined

Answer 88

- assess neurological status ( GCS <8 = intubate) q1h for 4-6h - Assess for hemorrhage (internal bleeding; may need blood) - Determine level of injury based on ROM, paralysis, DTRs, weakness Nonsurgical management - ABCs (evaluation respirations and perfusion) q2-4h - spinal precautions (collar, bed rest, log roll, jaw thrust) - ventilation ( no nerve blocking agents; often difficulty weaning) - pulmonary support (suctioning, chest percussion, incentive spirometer) - Traction (skeletal, halo fixation)- assess for infection and bleeding; do not adjust - Prevent complications (musculoskeletal, integumentary, elimination)

Answer 89

- X-rays of spine to identify vertebral fractures, subluxation, or dislocation - CT and MRI to rule out cervicothoracic injury or determine degree and extent of damage to spinal AND determine if blood or bone in spinal column

Answer 90

- Shock (hypovolemic, spinal, neurogenic) - Cardiac (Dysrhythmias esp. if C3-C5 level, symptomatic bradyarrhythmias, treated w/ atropine or inotropic meds then pacemaker; DVT; orthostatic hypotension) - Pulmonary complications (O2 < 92%, atelectasis, pneumonia, respiratory paralysis) - Musculoskeletal complications ( contractures, osteopenia, osteoporosis, heterotopic ossification (bony overgrowth onto muscle) ---Care: PT/OT for ROM exercises, foot drop splints, hand splints, celecoxib to prevent heterotopic ossification - Integumentary complications (Risk for pressure ulcers, temp dysregulation, VTE) -- use cooling blanket prior to antipyretics - Elimination complications (Risk for abdominal distention, constipation, fecal impaction; Spastic bladder if upper SCI; flaccid bladder if lower SCI) -- care: Foley and stool softeners; bowel program (Fluids, fiber, proper position, physical activity, reflex stimulation) - Autonomic dysreflexia (EMERGENCY)

Answer 91

- Methylprednisolone (Medrol) for edema and inflammation - Baclofen for spasms (risk for CNS depression, hypotension; OR Hallucination and seizures if sudden withdrawal) - Stress ulcer prophylaxis (PPI) - IV fluids and vasopressor support to keep SBP > 90 and MAP > 85-90 to prevent hypotension - Dextran (plasma expander) to increase capillary blood flow in spinal cord and prevent/treat hypotension - Atropine sulfate to treat bradycardia if pulse < 50-60 beats/min

Answer 92

(within 24 hrs to stabilize if needed to remove bone fragments, hematomas, or penetrating objects) - Laminectomy (lamina removed from posterior spine to provide decompression - Spinal fusion (fusion of 2 to 6 vertebral bodies to provide stability and prevent motion) - Pedicle screw fixation (for thoracic and lumbar fracture) - Vertical plates and bone grafting

Answer 93

- Restrictive clothing - Pressure area (Epididymitis or scrotal compression; Sheet wrinkles or hard objects) - UTI - Irritation of hemorrhoids - Pain - Distended bladder (Areflexic (neurogenic) bladder) - Constipation (fecal impaction)

Answer 94

S/s - Vasodilation above level of injury (Severe HTN, severe headache, nasal stuffiness, blurred vision, spots in visual field, Flushing, Diaphoresis, goosebumps, JVD, apprehension) - Bradycardia - Vasoconstriction below level of injury (Pale, Cool, No sweating) Risks - cerebral hemorrhage - seizures - stroke

Answer 95

Basics - Exaggerated sympathetic response to stimuli in people w/ high level SCI (T6 or higher) Care - Raise HOB to reduce BP - Treat the cause i.e. remove impact, check catheter, loosen clothes, identify UTI, examine for pressure ulcer - Notify MRT - Monitor BP q10-15 min - Give nifedipine or nitrate to lower BP

Answer 96

- Immunologic mechanism - Bactrim (trimethoprim-sulfamethoxazole) - Allopurinol - AEDs (Carbamazepine, Lamotrigine, phenytoin) - Phenobarbital - sulfasalazine

Answer 97

Mild - Skin lesions widely distributed and bilateral - Rash Severe - Fever (sepsis risk) - Aching joints and muscles - Excessive fluid loss (risk for dehydration) - Renal failure and renal problems - Blindness - Oral and respiratory mucous membranes involvement - Vesicles, erosions and crusts (epidermal detachment) -> Permanent skin damage (necrosis)

Answer 98

- Mild forms self limiting (10-14 days) - Removal of offending drug - Antibiotics to prevent infection - Steroids to suppress immune and inflammatory response - Fluid replacement - Mechanical ventilation if respiratory problems - Supportive (skin, CRT for renal)

Answer 99

General - Severe pain - Swelling (vesicles or bullae) - Redness or ecchymosis - Minty, rubbery, or metallic taste in mouth - Muscle paresthesia (twitch or tingling of face and head) and weakness - NV Later developments - Seizures - Hypotension - subQ ecchymosis - DIC (bleeding and depletion of coagulation factors)

Answer 100

- reduced pain perception (mild abdominal and site pain) - ascending paralysis -> respiratory paralysis and cardiac collapse - Mental status change (headache) - CN deficits (ptosis, diplopia, difficulty swallowing, speaking) - N/V - Pallor - Paresthesia, Numbness

Answer 101

- Move to safe place away from snake - continuous cardiac, blood pressure and pulse oximetry monitoring - Assess distal circulation q1hr - Measure and record the circumference of the bitten extremity every 15- 30 min with skin marker - Oxygen - Give IV fluids - Pain management - give tetanus shot - give Antivenom (Crotalidae Polyvalent Immune Fab (CroFab) for pit vipers; Antivenin (Micrurus fulvius) for coral snakes)

Answer 102

- Coagulation studies (b-c DIC risk w/ pit viper - UA (b-c myoglobinuria w/ coral) - CBC - BMP - CK (b-c increased in coral) - EKG to assess for myocardial ischemia or other abnormalities

Answer 103

- Remove jewelry and constrictive clothing (no tourniquets) - Immobilize affected extremity at level of heart (do not elevate) - Encourage rest - No alcohol - No sucking or cutting the wound - No ice

Answer 104

- Xerosis (dry, cracked, itchy skin) --Worsened by inadequate water intake or environmental conditions; interventions: moisturizers, natural oils - Seborrheic keratosis (Noncancerous growths) - Cancer (skin cancer)-- avoid hot day, protective clothes, sunscreen, check sin - Skin tears (wound from shear, friction, and or blunt force which separates skin layers) - Pressure ulcers --assess w/ Braden Scale

Answer 105

- Less elastic r/t collagen depletion - Drier ((less moisture) so prone to dermal-epidermal separation, reduced subQ blood flow, decreased dermal lymphatic drainage - More fragile b-c epidermis thins, BVs break easy - Decreased wound healing r/t decreased cytokine and growth factor production; diminished inflammatory response and reduced cell proliferation - increased breakdown r/t incontinence, immobility, diarrhea

Answer 106

- Anytime there is injury to the tissues of the body caused by heat, chemicals, electrical current, cold, or radiation Classification - Size of Burn Injury - Depth of Burn Injury - Type of Burn Injury - Location of Burn Injury - Patient Age and History

Answer 107

- partial thickness of 10% TBSA - Any full thickness/ 3rd degree - Burn to face, genitals, major joints, perineum, hands, feet - special Injuries (electrical, inhalation, chemical, frostbite) - Burn w/ preexisting conditions (DM, pulmonary, cardiac, kidney, or CNS disorders) that increase risk of mortality - Burn injury + former trauma (fracture)

Answer 108

Components - chest (18%) - back (18%) - genitals (1%) - Each leg (18%- one side = 9%) - Each arm (9%- one side = 4.5%) - Head (9%- face = 4.5%) Tidbits - Circumferential from shoulder to elbow = 4.5% - Palmar surface of hand = 1%

Answer 109

- Must be accurate for burn shock interventions, calculation of TBSA, and caloric needs - Quickest way to calculate size of burn injury in adults - Do not include first degree burns in rule of nines

Answer 110

- how much of two skin layers involved - impacted by location (thinner skin on eye vs arm) - impacted by age (thinner in child vs adult)

Answer 111

Epidermal burn (not included in rule of nines) s/s - Red, erythema - Painful, Tender which resolves in 48-72 hrs - Possible swelling Care - Heals in 2-7 days - Pain relief - Anti-Pruritics - Oral fluids

Answer 112

- involves all of epidermis and part of underlying dermis S/s - Light to bright red or mottled appearance - Blanch w/ pressure due to inadequate perfusion - Bullae OR wet and weeping blisters due to microvessel injury increasing permeability and causing leakage of plasma into interstitium - Extremely painful - sensitive to air currents Care - Uncomplicated heals in 7-21 days w/ minimal scarring - IV fluids

Answer 113

Burn involving entire epidermal layer and deeper layers of the dermis w/ Severe blood supply impairment S/s - Red with patchy white areas that blanch with pressure - Turns from white to yellow due to dermal necrosis and surface coagulated protein - NO blister formation Care - Extensive healing time (up to 6 weeks) -- full-thickness if infected, inadequate perfusion, or more trauma - Spontaneous healing (hypertrophic scarring and contractures due to unstable epithelium) - Surgical excision - Skin grafting

Answer 114

- All 3 layers of skin involved so skin does not grow back on its own S/s - Pale white or charred, red or brown - Leathery and dry - bleed from vessel damage - Painless (May have background or procedural pain) - Insensitive to palpitation - systemic effects on f/e balance, infection, metabolism, thermoregulation Treatment - Does not heal by epithelialization or on its own - Skin grafting

Answer 115

- Most common type of burn - Most at risk: <2 yrs. (scalds) AND > 60 yrs. - Temperature and duration of contact determine extent and depth of injury

Answer 116

Notes - Highest incidence in children - risk for tissue destruction, contracture formation, acid-base balance. Rhabdomyolysis Amount of damage determined by - Type and voltage of circuit - Resistance (insulation) - Pathway of transmission through body (More serious than outside appearance due to current traveling inside the body and damaging inner tissues) - Duration of contact

Answer 117

- Usually localized from high dose radiation (accelerators, cyclotrons, medical treatment) or prolonged sun - Appearance similar to thermal injury (Differentiate based on timing of injury and clinical manifestations) - Care: not extensive (may need fluids and anti-pruritic)

Answer 118

Amount of injury determined by - Concentration of chemical - duration of contact - chemical action (alkaline more severe than acid) - amount of tissue Care - Remove contacts prior to flushing eye - Remove contaminated clothing and shoes - Flush area w/ large amounts of water for hours after injury - Neutralization can worsen injury

Answer 119

Resuscitation/Emergent - Begins at the time of injury and continues for about 48 hrs - ends when capillary integrity restored and plasma volume repleted - 1st hour after injury is crucial Acute - begins after resuscitation (36-48 hr) w/ diuresis (end of edema) - lasts until complete wound closure is achieved - Early eschar excision and grafting = early resolution of inflammation and better healing Rehabilitative - Begins with major wound closure to return to optimum level of health (independence and maximum function) - Usually about 6 months to 2 yrs but may take a lifetime b-c ends when highest level of functioning reached.

Answer 120

- Save patient's life (maintain vital organ function and perfusion) - Minimize complications and disability (wound healing and prevention of infection) - Prepare for rehabilitation and definitive care

Answer 121

- Age (higher risk if <2 or > 60) - How did it happen? (mechanism of injury) - rule out trauma, fractures, abuse - Assess source and cause - Where did it happen? (time and place; think CO poisoning if in confined space) - Assess for known allergies - Assess status of tetanus immunizations - significant medical history (preexisting conditions, current meds)

Answer 122

- Maintain adequate oxygenation (airway) - Maintain adequate fluid balance (circulation to prevent hypovolemic shock from fluid shift) - Promote adequate tissue perfusion (may need w/ art line or CVP; remove watches/jewelry which can have tourniquet effect) - Maintain body temperature (risk for hypothermia via evaporation and radiation) - Prevent infection - Keep patient comfortable w/ analgesics and emotional support

Answer 123

- Toxic mediators of inflammatory process - Infection (endogenous or exogenous flora; eschar or exudate) - Inappropriate volume resuscitation - Malnutrition - Chronic illness (steroid therapy, diabetes, extreme obesity) - Age - Impaired perfusion (inappropriate resuscitation) - Trauma from daily dressing changes

Answer 124

- Ventilator support (100% oxygen, (low tidal volume, high PEEP, permissive hypercarbia) - HOB elevated - Early intubation - Mobilize and remove secretions (cough, deep breathing, suctioning, bronchodilators, early mobility, elevate HOB) - Careful fluid resuscitation to prevent pulmonary edema - Cervical precautions if possibility of instability - Nebulized heparin (increase airway clearance of debris)

Answer 125

Goal: avoid ARDS, pneumonia, pulmonary edema s/s of airway damage - Assess ( singed nasal hairs or eyebrows, hoarseness, facial burn carbonaceous sputum, drooling) - Sudden stop of stridor or wheezing = unable to breath (EMERGENCY) - Facial edema = intubate prior to airway closing - Hypoxemia (tachypnea, agitation, anxiety, upper airway obstruction)

Answer 126

Smoke-related - s/s: coughing, SOB, hoarseness, orofacial burns, black carbon particles in nose, mouth, sputum; smoky breath smell Upper airway injury (pharynx, larynx, glottis, trachea, large bronchie)- most common - Due to direct heat or chemical inflammation and necrosis Lower airway injury – usually r/t chemical damage to mucosa (chemical pneumonitis - s/s: tracheobronchitis (severe spasm and wheezing) - Diagnosis: chest x-ray and CT

Answer 127

S/s - Early: tachycardia, tachypnea, confusion, lightheadedness, - Late: decreased level of responsiveness, pale to reddish purple skin, ST depression, hypotension, dysrhythmia Care - Obtain HbCO level (binding of CO to hemoglobin which prevents binding of O2 to hemoglobin)- normal < 2% O2 sat will be normal - Start 100% oxygen via ETT or nonrebreather

Answer 128

Concerns - chest restriction (reduced expansion and compliance) w/ circumferential full thickness chest burns Care - Escharotomy to chest wall ASAP - Monitor ABGs and O2 sat (Respiratory acidosis -> respiratory alkalosis) - Monitor respiratory rate and effort - Monitor for cyanosis (late sign)

Answer 129

Goal: maintain end organ perfusion and avoid fluid overload Concerns - Under resuscitation = inadequate cardiac output = inadequate perfusion and wound conversion (AKI, cardiovascular collapse, death from shock) - Over resuscitation = excess wound edema -> moderate to severe pulmonary edema -> decreased perfusion of unburned tissue Care - Requires accurate fluid resuscitation - No diuretics - Assess HR, BP, pulses, cap. Refill, I & Os, LOC (perfusion to brain) - Continuous EKG (May need nontraditional placement of leads due to burn locations)- initial if electrical wound or preexisting hear condition

Answer 130

- common cause of death in the emergent phase (Higher TBSA (>20%) = higher chance of shock) - Loss of fluid from vascular compartment to area of injury - Leads to blisters and edema from damaged blood vessels increasing permeability to protein and water Effects - hypovolemic shock - tissue trauma - increased PVR (leads to pulmonary edema) - decreased myocardial contractility and cardiac output b-c increased SVR

Answer 131

Parkland Formula - 4cc LR * body weight in Kg* % TBSA burned - ½ given over first 8 hours post-injury - ½ given over the following 16 hours post-injury Tips - LR via large bore (18 G or 20 G) IV - LR > NS b-c matches ECF - Plasma replacement and isotonic fluids used after 24 hours to increase circulating volume

Answer 132

- urine (hemoglobinuria, myoglobinuria) - inadequate fluid replacement (hypoperfusion, hypovolemia) - inadequate UOP (edema, elevated BP) - Change in LOC (lethargy, confusion) Care - Monitor labs (BUN, Crt, GFR, K/Na), PO4 - Assess urine (color, bloody, myoglobin, odor, particles, foamy) - Monitor UOP and specific gravity - May need dialysis (hemodialysis or CRT) - Place foley (if TBSA > 20% or perineum burn)

Answer 133

Effects of stress response - Paralytic Ileus and gastric dilation (also due to burn shock, hypokalemia, SNS response to trauma) - stress ulcer (Curling’s ulcer) - Decreased GI activity (also due to hypovolemia and neurologic injury) Care - Initial NPO - Abdominal exam q2h then q4h (incl. eval for abdominal compartment syndrome) - Place NGT or OGT to low intermittent suction (Prevention of aspiration, distention, emesis) - Administer GI prophylaxis (PPI, H2A, sucralfate, antacids) - Enteral nutrition (Purpose: increase intestinal flow, intestinal blood flow, and GI motility)

Answer 134

Clinical manifestations - arterial insufficiency due to wound edema, circumferential burns (leads to ischemia and necrosis) - Diminished to absent peripheral pulses - Loss of muscle function Care - Assess neurovascular integrity q6h ( Pulselessness, pallor, pain, paresthesia, paralysis, poikilothermy) - Doppler flow probe (evaluate arterial pulses) - escharotomy if circumferential burn to restore circulation and allow swelling - Extend and elevate extremities to decrease peripheral edema and enhance venous return - Avoid crossed legs, dependent positions, pillows behind knees

Answer 135

Effects due to stress response - Overwhelming stress leads to bone marrow suppression, anemia, and infection Care - IV antibiotics - Meticulous wound care (hand hygiene) - Wound monitoring ( for exudate, odor, warmth, fever, and color) - Supportive care (isolation techniques w/ dedicated equipment) - Blood transfusions b-c prone to anemia

Answer 136

- Hgb, Hct, & BUN HIGH (Due to fluid volume loss) - Glucose HIGH (Due to stess response - Na+ LOW (Due to trapped in wound edema, fluid loss, vomiting, NGT drainage, diarrhea) - K+ HIGH or LOW (High due to release from damaged cells, metabolic acidosis, impaired kidney function (hemoglobinuria, myoglobinuria, decreased renal perfusion) --> Care: correct acidosis (no DICK) OR Low due to massive fluid loss or hemodilution) - pH LOW (Due to metabolic acidosis - Total protein & albumin LOW (Due to loss via burn wound) - WBC initial rise then drop as immune system unable to sustain its defenses. (may be sepsis)

Answer 137

Types - background (physiological including damage and exposure of nerve endings) r/t ROM, routine activities - Breakthrough which is not relieved by routine pain meds - Procedural (PT, OT, dressing changes, splints) When to manage pain - Only after IV fluid resuscitation is underway - Not initial priority b-c pain sensation diminished if well oxygenated and wound covered - Premedicated prior to procedural care

Answer 138

- Reduce BMR via preventing catecholamine release i.e. from pain, fear, anxiety, cold - use IV in resuscitation phase (no subQ or IM b-c unpredictable absorption - use nonpharmacological (imagery, hypnosis, virtual reality, distraction) - use opioids (NSAIDs and acetaminophen only if no risk for bleeding)

Answer 139

Contracture: shortening of scar over joint and causes functional deficit Prevention - Physical and occupational therapy - Passive and active ROM to prevent complications - Splint (Keep joints fully extended in anatomical position on pillows) - no pillow behind head if face burn to prevent flexion of neck

Answer 140

- Daily observation and assessment - Multiple dressing changes (application and reapplication of clean, dry dressing. - skin graft must be placed on clean, viable, tissue - Analgesics and sedatives (morphine, midazolam (versed), hydromorphone) to prevent procedural pain - Topical antibiotics (silver sulfadiazine, mafenide acetate cream, bacitracin, silver) to control/decrease bacterial colonization - Refer to Burn Center (delivers all therapy incl. rehabilitation and can perform personnel training and burn research)

Answer 141

Goal: maintain moist environment while limiting exposure to prevent hypothermia and bacteria exposure Notes - Done in a hydrotherapy tub, cart shower, shower, or bedside - Hydrotherapy limited to 30 min to prevent hypokalemia

Answer 142

- Early continuous enteral feeds - Caloric needs are about 5000 kcal/day due to high BMR - High-protein, high-carbohydrate foods - May need supplmental albumin, iron, zinc, calcium, phosphate, potassium

Answer 143

Goal: remove devitalized (nonviable) tissue down to bleeding stable tissue to control inflammation and remove contaminated tissue to prepare for grafting Types - Mechanical (via scissors or forceps) - Enzymatic (via topical substance to loosen and dissolve eschar) - Surgical (gold standard in OR once hemodynamically stable)

Answer 144

Autograft - Patient’s own skin (abdomen, thigh, back) - Provides permanent coverage - Donor site must be treated as partial thickness wound and needs wound care Homografts (allografts) - From cadaver or living donor - high cost and risk for infection - Temporary (Rejected 2 weeks after application) Heterografts (xenografts) - From another species (pig) - Must assess daily for adherence b-c can be rejected Synthetic skin - very expensive (Integra, cultured epithelial autograft)

Answer 145

Skin care - Discoloration of scar fades with time but not invisible and may not fully go away - Newly healed areas can be hypersensitive or hyposensitive to cold, heat, and touch - Healed areas must be protected from direct sunlight for 1 year - use lotion for itching Mobility - Engage in PT, OT - exercise important Emotional - praise minor and major accomplishment - use group therapy

Answer 146

- pressure garments which reduce scar blood flow, help organize collagen, prevent venous stasis and edema - Scar massage via providing moisture, stretching scar, and preventing contracture - High SPF sun protection via preventing long term pigment change - Silicone gel sheeting via maintaining scar hydration and reduce tension - Laser therapy - Steroids for hypertrophic scars via inhibiting fibroblast growth

Exam 3 Flashcards

(170 cards)