OK I know this sounds stupid but I have a friend that gets really freaked out before big tests like finals, HESI, NCLEX, and usually we get together and a few days before I start throwing out random facts at her. On 2 different tests she said the only way she got several questions was from the random facts that I threw at her that she never would have thought of!
SOOOOO..... I thought that if yall wanted to do this we could get a thread going and try to throw out 5 random facts or "things to remember". NCLEX is coming and the more I try to review content the more I realize that I have forgotten so......here are my 5 random facts for ya:
OH and BTW these came from rationales in Kaplan or Saunders no made up stuff:
1️⃣ A kid with Hepatitis A can return to school 1 week within the onset of jaundice.
2️⃣ After a patient has dialysis they may have a slight fever...this is normal due to the fact that the dialysis solution is warmed by the machine.
3️⃣ Hyperkalemia presents on an EKG as tall peaked T-waves
4️⃣ The antidote for Mag Sulfate toxicity is ---Calcium Gluconate
5️⃣ Impetigo is a CONTAGEOUS skin disorder and the person needs to wash ALL linens and dishes seperate from the family. They also need to wash their hands frequently and avoid contact.
Oh, ohh, one more...
? Vasopressin is also known as antidiuretic hormone
* An alteration in skin integrity resulting in tissue loss or injury caused by heat, chemicals, electricity, or radiation
* There are several types of burn injury: thermal, chemical, electrical, and radiation
* Thermal burn: results from dry heat (flames) or moist heat (steam or hot liq*uids); is most common type; causes cellular destruction that results in vascu*lar, bony, muscle, or nerve complications; thermal burns can also lead to inhalation injury if head and neck area is affected
* Chemical burn: caused by direct contact with either acidic or alkaline agents; alters tissue perfusion and leads to necrosis
* Electrical burn: severity depends on type and duration of current and amount of voltage; electricity follows path of least resistance (muscles, bone, blood vessels. and nerves); sources of electrical injury include direct current, alter*nating current, and lightning
* Radiation burn: usually associated with sunburn or radiation treatment for cancer; usually superficial; extensive exposure to radiation may lead to tissue damage and multisystem injury
o Nursing assessment: history of injury, estimate burn extent and depth, obtain past medical history and medication history including date of last tetorifice pro*phylaxis; assess for other concurrent injuries
o Systemic effects of severe burns include asphyxia from smoke inhalation that causes edema of respiratory passages; shock from fluid shifts; renal failure from shock; protein loss from open wound; potassium excess from tissue destruction and renal failure
o Diagnostic and laboratory test findings: may have elevated hematocrit (Hct) and decreased hemoglobin (Hgb) caused by fluid shift, decreased sodium (Nat) and increased potassium (K+) caused by damage to capillary and cell mem*branes, elevated BUN and creatinine caused by dehydration, myoglobin in urine, and possible deterioration of arterial blood gases (ABGs) and oxygen (02) saturation readings depending on respiratory status
o Therapeutic management
* First aid: douse flames with water or smother them with a blanket, coat, or other similar object; cool a scald burn with cool water; flush chemical burns copiously with water or other appropriate irrigant after dusting away any dry powder if present; remove client from contact with an electrical source only after current has been shut off
* Priority care is on ABCs: airway, breathing, and circulation; assess for smoke inhalation injury (singed nares, eyebrows or lashes; burns on face or neck; stridor, increasing dyspnea) and give 02 (up to 100% as prescribed), being prepared for possible intubation and mechanical ventilation if severe inhala*tion injury or carbon monoxide inhalation has occurred; assess for signs of shock caused by fluid shifts (increased pulse, falling BP and urine output, pal*lor, cool clammy skin, deteriorating level of consciousness [LOC])
* Fluid resuscitation: Brooke formula uses 2 mL/kg/% TBSA burned (3/4 crys*talloid plus 1/4 colloid) plus maintenance fluid of 2,000 mL D5W per
o Medication therapy: analgesics—usually morphine sulfate IV, tetorifice booster (> 5-10 years since last dose), topical antimicrobials, systemic antibiotics
o Acute phase of burn management: begins with start of diuresis (usually 48 to 72 hours postburn) and ends with closure of burn wound
o Therapeutic management
+ Wound care management includes debridement, dressing changes, hydrother*apy, and possible escharotomy,
+ Mafenide (Sulfamylon) may be applied in thin layer over open wound and covered with dressing
+ Sulfadiazine (Silvadene) may applied in thin layer over open wound and cov*ered with dressing; use with caution when impaired renal function exists; must be washed off and reapplied every 8 to 12 hours
+ Skin grafting may need to be done to achieve healing in full-thickness and large, deep partial-thickness burns
+ Nutritional therapies (high-calorie, high-protein diet with vitamins and min*erals) and continue to maintain hydration status
+ Infection control with strict sterile technique
+ Maintain heated environment to prevent chilling
+ Physical therapy as needed
+ Psychosocial support
# Rehabilitative phase of burn management: begins with wound closure and ends when client returns to highest level of health restoration
# Therapeutic management
* Prevent immobility contractures with exercises or ongoing physical therapy
* Assist in returning to work. family, and social life
* Client education
* Environmental safety: use low temperature setting for hot water heater, en*sure access to and adequate number of electrical cords/outlets, isolate house*hold chemicals, avoid smoking in bed
* Use of sunscreen to protect healing tissue and other protective skin; measures soft tissue injuries; or deep chemical or electrical
+ To prevent burns, hot water heaters should be set no higher that 120° Fahrenheit.
Burn Classifications
+ Pain medication is given intravenously to provide quick, optimal relief and to prevent overmedication as edema subsides and fluid shift is resolving.
+ The cardiac status of a client with electrical burns should be closely monitored for at least 24 hours following the injury to detect changes in electrical conduction of the heart.
+ Full thickness burns can damage muscles, leading to the development of myoglobinuria in which urinary output becomes burgundy in color. The client with myoglobinuria require hemodialysis to prevent tubular necrosis and acute renal failure.
Burn Measurement with TBSA
+ It will be beneficial to review your nursing textbooks for local and systematic reactions to burns because these injuries affect all body systems and cardiovascular and renal functions in particular.
Nursing Care for Burn Victims
+ The eyes should be irrigated with water immediately if a chemical burn occurs. Follow-up care with an ophthalmologists is important because burns of the eyes can result in corneal ulceration and blindness.
+ Important Steps in treating a burn client include the following:
* Treat airway and breathing – Traces of carbon around the mouth or nose, blisters in the roof of the mouth, or the presence of respiratory stridor, indicate the client has respiratory damage
* Ensure proper circulation – Compromised circulation is evident by a drop in normal blood pressure, slowed capillary refill, and decreased urinary output. These symptoms signal impending burn shock.
o It is important to remember that the actual burns might not be the biggest survival issue facing burn clients. Carbon monoxide from inhaled smoke can develop into a critical problem as well. Carbon monoxide combines with hemoglobin to form carboxyhemoglobin which binds to available hemoglobin 200 times more readily than with oxygen. Carbon monoxide poisoning causes a vasolidating effect causing the client to have a characteristic cherry red appearance. Interventions for carbon monoxide poisoning focus on early intubation and mechanical ventilation with 100% oxygen.
The Consensus Formula
o Fluid replacement formulas are calculated from the time of injury rather than from the time of arrival in the emergency room.
The Intermediate Phase
o Infections represent a major threat to the post-burn client. Bacterial infections (Staphylococcus, Proteus, pseudomonas, eshcerichia coil, and Klebsiella) are common due to optimal growth conditions posed by the burn wound; however, the primary source of infection appears to be the client’s own intestinal tract. As a rule, systemic antibiotics are avoided unless an actual infection exists,
o Enzymatic debridement should not be used for burns greater thatn 10% TBSA, for burns near the eyes, or for burns involving muscle.
Dressing for Burns
o Dressing for burns include standard wound dressings (sterile gauze) and biologic or biosynthetic dressings (grafts, amniotic membranes, cultured skin, and artificial skin)
o Biologic dressings are obtained from either human tissue (homograft or allograft) pr animal tissue (heterograft or xenograft). These dressing which are temporary are used for clients with partial thickness or granulating full thickness injuries.
o Hemografts and allografts are taken from cadaver donors and obtained through a skin bank. These grafts are expensive and there is a risk of blood-borne infection. Heterografts and xenografts are taken from animal sources. The most common heterograft is pig skin (porcine) because of its compatibility with human skin.
o Muslims and Orthodox Jews are two religious/ethnic groups who might be offended by the use of porcine grafts since the pig is considered an unclean animal. Christian groups such as Seventh Day Adventists might also reject the use of procine grafts.
* nose: filters, humidifies, and heats inspired air; nasal hairs trap airborne particles in mucus; olfactory nerve receptors allow for sense of smell
* paranasal sinuses: air-filled cavities in frontal, maxillary, ethmoid, and sphenoid bones that contribute to mucus production and voice resonance
* pharynx: nasopharynx, laryngopharynx, and oropharynx; adenoids in the nasopharynx and tonsils in oropharynx contain lymphatic tissue that contributes to immune function
* larynx: contains vocal cords that vibrate to produce voice; epiglottis closes during swallowing to prevent passage of food into trachea
* trachea: passageway between upper and lower respiratory tract; divides into-right and left mainstem bronchi
lower respiratory tract (conducting airways and gas exchange airways)
* bronchi: right and left mainstem bronchi (conducting airways) lead into smaller bronchioles that eventually terminate in alveoli; right mainstem bronchus curves less sharply than left, making it a more common passage for aspirated gastric contents and dislocated endotracheal tubes
* alveoli: air-filled sacs in lungs; oxygen (02) diffuses from alveoli (gas exchange airways) into blood across alveolar-capillary membrane (primary site of gas exchange); carbon dioxide (co2) diffuses back into alveoli; surfactant decreases surface tension
* lungs: right lung has three lobes—upper, middle, and lower; left lung has two lodes—upper and lower; upper area is called the apex; lower area is called base
* pleura: two-layer membrane covering lungs (visceral pleura) and thoracic cavity (parietal pleura); pleural fluid lubricates pleural layers and holds them together during inspiration and expiration
* pleural cavity: air-filled space of thoracic cavity housing structures of lower respiratory tract
accessory structures: contribute to the mechanics of breathing and/or pro support and protection
* rib cage: 12 pairs of ribs and sternum
* intercostal muscles: located between ribs
* diaphragm: separates thoracic cavity from abdominal cavity; flattens (contracts) during inspiration via phrenic nerve to allow greater chest expansion
respiratory system functions
1. primary function is gas exchange; process of respiration (process of 02 and co2
exchange) involves ventilation, perfusion, diffusion, and nervous system control
diagnostic test and assessment
pulse oximetry
* monitors arterial or venous oxygen saturation ([percentage of 02] bound to he*moglobin [hgb] compared to volume that hgb is capable of binding); normal is usually 95% or greater in a client with no lung disease; in clients with lung dis*ease, target oxygen saturation is 90% or greater; may be measured intermit*tently (such as with vital signs or ambulation) or continuously
* uses a light spectroscopy probe attached to a finger, earlobe, or nose
* accuracy is lower with diminished peripheral perfusion, brightly lit environ*ment, acrylic fingernails, and dark skin color
laboratory
sputum analysis: specimen obtained for microbiology (gram stain, culture and sensitivity) or cytology
* specimens for acid-fast bacilli (mycobacterium tuberculosis) may be collected
* on three different days; specimen collection following a long sleep period (early morning) is desirable because of greater concentration; if unable to ob*tain a sputum specimen for acid-fast bacilli, gastric specimen may be obtained because mycobacterium tuberculosis is not altered by acidic gastric contents
* specimen processing: collect specimens in appropriate container and send to laboratory promptly
skin testing: assesses for allergic reactions to specified antigens (type i hyper- sensitivity), exposure to tuberculosis-causing organisms (type iv hypersensiti vity), or fungi
* measure area of induration (if present), not reddened area; read result 48 to 72 hrs after placement; an uncertain reading at 48 hrs may be reread at 72
* positive result: individual has been exposed to antigen; does not mean that individual currently has active disease, only that there has been exposure/ infection
* when performing skin tests to assess for type i allergies, ensure that antihict*amines, which could interfere with test results, are discontinued 72 hours prior to testing
common nursing techniques and procedures
airway management: goal is to maintain patent airway
1. head and jaw position
* open airway by head tilt and anterior chin lift maneuver
* in individuals with suspected neck injury, open airway by anterior chin dis*placement and/or jaw thrust; do not perform head tilt
* limit suctioning to 10 seconds per catheter pass (5 in children) to reduce risk of inadequate oxygenation and cardiac dysrhythmias from hypoxia
body positioning
* acute respiratory failure
a. elevate head at least 45 decrees to increase chest exnansion
* unilateral lung disease a. position with unaffected lung in dependent position ("good lung down")
oxygen (02) administration
nasal cannula
* typical 02 flow of 1 to 6 l/min will provide 02 concentrations of 24% to 44%
* individuals with chronic obstructive pulmonary disease (copd) should re*ceive low flow oxygen, about 1 to 2 l/min, to prevent respiratory depression; these clients are used to high co2 levels and low 02 levels, so increased 02 (greater than 2 l/min) can cause a loss of respiratory drive
key ventilator settings
* rate: number of breaths per minute delivered by ventilator; is a number that is combined with the mode often in clinical practice (e.g., simv of 6/min)
* fio2: fraction of inspired 02 or 02%; amount of 02 in air inhaled via ventilator; is expressed as a decimal instead of a percentage (e.g., fi02 of .40 versus 40%)
* tidal volume (vt): amount of air delivered with each breath; often expressed in milliliters or liters (e.g., 700 ml or 0.7 l)
* peep: abbreviation for positive end-expiratory pressure; the amount of posi*tive-pressure set in system at end of exhalation; keeps alveoli open during ex*halation to increase gas exchange; is expressed in terms of centimeters of pressure (e.g., 5 cm)
nursing management
* position client for maximum alveolar ventilation and comfort; maintain soft restraints to avoid accidental extubation
* monitor for any changes in respiratory status or effort
* maintain ventilator settings as ordered and remain knowledgeable about how to troubleshoot ventilator alarms (high pressure frequently indicates need for suctioning or kinking/compression of et tube; low pressure indi*cates leak or disconnection); manually ventilate client if alarms sound with*out apparent cause
* in addition to standard precautions, persons should wear mask when near client who has known or suspected pathogen transmitted by droplet route
* limit client transport within facility; when transport is necessary, place mask on client
* limit contamination of equipment and/or environment
* place client in private room or with a cohort (client with same diagnosis)
nursing management of client having thoracic surgery
preoperative period
* reduce anxiety through preoperative teaching about procedure and postopera*tive course and care
* assess client's support systems and ability to care for self after surgery
* administer preoperative medications, such as antibiotics, opioid analgesics, and anti-anxiety agents, as ordered
* obtain baseline vital signs, oxygenation status, and cognitive status for compari*son postoperatively
postoperative period
* maintain patent airway
* position client for optimal ventilation and perfusion; note any specific surgeon-s orders for positioning; be prepared to initiate respiratory support (intubation. emergency tracheostomy, mechanical ventilation) as needed
* maintain client safety
* assess for and report possible surgical complications to maintain oxygenation
* change in level of consciousness (loc) ranging from restlessness and agitation to lethargy or unresponsiveness
* increase in respiratory rate, unequal chest expansion, decreased breath sounds, and/or use of accessory muscles for breathing
* loss of water seal drainage in closed chest drainage system
* greater than desired volume of chest drainage (75-100 ml drainage over 1 hour is an average acceptable upper limit); orders should specify volume acceptable chest tube drainage; should decrease over first 24 hours
positioning client after lung surgery: orders should specify turning parameters for indvidual client
* lobectomy: positioning includes lying on back or turned to either side
* segmental resection: positioning includes lying on back and turned onto nonl erative side; positioning on operative side may place tension on sutures and mote bleeding
* pneumonectomy
* positioning includes lying on back and turned toward operative side
* avoid complete lateral turning to either side, which changes pressure dynam*ics within chest and could lead to mediastinal shift
obstructive pulmonary diseases
emphysema
a. progressive destruction of alveoli related to chronic inflammation
assessment
* "pink puffer" is a classic clinical description characterized by barrel chest, pursed-lip breathing (caused by forced exhalation), obvious use of accessory muscles when breathing, and underweight appearance
* exertional dyspnea progresses with advancing disease
* persistent tachycardia is related to inadequate oxygenation
* overall diminished breath sounds, and possible wheezes or crackles
* abgs: slightly decreased p02; pco2 is not elevated until later stages
* chest x-ray: hyperinflated lungs with a flattened diaphragm; heart size is nor*mal or small
* pulmonary function tests: low vital capacity and forced expiratory volume (fevi)
therapeutic management
* goals are to improve ventilation and promote patent airway by removing se*cretions
* remove environmental pollutants and encourage smoking cessation
* prescribed treatments include bronchodilator therapy, beta-adrenergic ago*nists, corticosteroid therapy, oxygen and nebulization therapy, chest physio*therapy, intermittent positive-pressure breathing (ippb), possibly mechanical ventilation, and possible surgical procedures such as bullectomy, lung volume reduction surgery, or lung transplantation
* provide education and referrals for clients with behaviors (such as smoking) that increase risk for copd
* refer clients to a structured pulmonary conditioning program and provide reinforcement as appropriate
* teach clients to avoid pulmonary irritants
* assist clients to develop appropriate nutritional plans to provide ade*quate calories
chronic bronchitis
a disorder of chronic airway inflammation with a chronic productive cough lasting at least 3 months during 2 years; is a form of copd
assessment
* frequent cough, occurring during winter season, with foul-smelling sputum
* frequent pulmonary infections
* classic appearance of "blue bloater" includes tendency for obesity and bluish-red skin discoloration from cyanosis and polycythemia
* dyspnea and activity intolerance occurs as disease progresses
* increased anterior–posterior chest diameter
* elevated red blood cell count; hemoglobin and hematocrit elevated in later stages
* chest x-ray reveals enlarged heart, congested lung fields, and normal or flattened diaphragm
* pulmonary function indicates increased residual volume, decreased vital capacity, fevi, and fevi/fvc ratio
therapeutic management
* includes measures previously described in section on emphysema
* provide education or referrals to clients with behaviors that increase the risk of developing copd
* refer clients to a structured pulmonary conditioning program and provide reinforcement as appropriate
* teach clients how to avoid pulmonary irritants
* assist clients to develop appropriate nutritional plans that provide adequate calories but maintain ideal weight
* administer supplemental low-flow 02 as necessary; be prepared to initiate mechanical ventilation
* medication therapy includes immunization against pneumonia and influenza antibiotics, possible bronchodilators (beta-adrenergic agonists, anticholiner‑minimal client symptoms; air leak may progress until pressure between thoracic cavity and atmosphere equalizes and client is symptomatic.
* tension: disruption of chest wall or lungs causes air accumulation in pleural space; pressure on mediastinum causes pressure on other lung and interrupts venous return to heart; is a medical emergency that requires emergency placement of chest tube to relieve increasing pressure in thoracic cavity and restore adequate cardiac output
pneumothorax and hemothorax
assessment
* dyspnea
* tracheal deviation toward unaffected side
* diminished breath sounds on affected side
* percussion dullness on affected side
* unequal chest expansion (reduced on affected side)
* crepitus over chest
* chest x-ray reveals pneumothorax
* abg shows decreased p02
therapeutic management
* in mild cases, no chest tube is required; if pneumothorax is significant, a chest tube is inserted and attached to water seal drainage
* spontaneous pneumothorax: in otherwise healthy client, may resolve without in*vasive treatment
* if spontaneous pneumothorax occurs repeatedly, may require pleurodesis, an in*stillation of an agent (such as talc or tetracycline) in pleural spaces to allow pleura to adhere together; other procedures include partial pleurectomy, sta*pling, or laser pleurodesis for pleural sealing
* care of client with a chest tube:
* monitor respiratory and oxygenation status
* provide supplemental oxygen as indicated
* maintain infection control practices
* medication therapy: analgesics and antibiotics
atelectasis
* incomplete expansion or collapse of the lung resulting from obstruction of air*way by secretions or a foreign body
assessment
* low-grade fever
* breath sounds diminished or absent in affected area
* diminished rate and depth of respiration
pulmonary tuberculosis
* lung infection caused by mycobacterium tuberculosis
assessment
* frequent cough with copious frothy pink sputum; nonproductive cough devel*ops first as an early symptom (especially in early morning)
* night sweats
* anorexia
* weight loss
* history may indicate recent exposure to infected individual
* positive tuberculin skin test (indicates exposure)
* appearance of characteristic ghon tubercle on chest x-ray
* institute standard precautions (centers for disease control [cdc] tier 1) and airborne precautions (tier 2, transmission-based precautions
* use a private room with negative air pressure that has 6 to 12 full air exchanges per hour and is vented to the outside or has its own air filtration system
* wear specially fitted mask (n95 respirator) whenever entering client's room; fit-test the mask with each use
* provide visitors with appropriate masks
* wear gown and masks if client does not reliably cover mouth during cough*ing or sneezing to reduce risk of transmission to others
* provide client with a surgical mask if it is necessary to bring client to another department; choose shortest and least busy route and alert that department ahead of time about client's status; schedule tests for least busy times of day
* administer antimicrobial therapy as prescribed
* provide supplemental oxygen as indicated
* obtain periodic sputum cultures following onset of antimicrobial therapy
client education
* infection control measures, including handwashing, coughing into tissues disposing of them in a closed bag
* teach client, family, and close contacts about mechanisms of transmission antimicrobial therapy, including need to take medication for full course of apy to prevent recurrence and/or development of drug-resistant organisrm
pulmonary embolism
* emboli lodge in pulmonary vasculature and impede blood flow through pulmonary capillaries
* depends on stage of disease and general condition of client
* radiation therapy or brachytherapy (placement of a radioactive sow next to tumor)
* chemotherapy
* laryngectomy
* radical neck dissection
* maintain patent airway (tracheostomy performed with laryngectomy)
* pain management
* provide adequate hydration and nutrition (temporary or permanent alter route for nutrition)
* provide alternate means for communication and plan for permanent mea communication (artificial larynx or esophageal speech)
* monitor respiratory and oxygenation status
* provide oxygen supplementation as indicated
* medication therapy: opioid analgesics and antipyretics
thoracic trauma
* alteration of breathing mechanics and/or gas exchange caused by respiratory. system trauma
assessment
* chest pain, may be severe such as with flail chest
* shallow breathing with splinting
* possible unequal chest expansion
* tachycardia, tachypnea, hypotension
* crepitus over chest
* chest x-ray findings show white opacifications
* abgs reveal hypoxemia
therapeutic management: same as pneumothorax and hemothorax
* ventilation support
* be prepared to initiate mechanical ventilation
* maintain iv access
* possible placement of chest tube with water seal drainage
* medication therapy: opioid analgesics, patient-controlled or epidural analgesia may be appropriate
cystic fibrosis (cf)
* multisystem disorder of exocrine glands, leading to increased production of
thick mucus in bronchioles, small intestines, and pancreatic and bile ducts
assessment
* sweat test (pilocarpine iontophoresis) analyzes na+ and c1-- content in sw e chloride concentration greater than 60 meq/l is diagnostic of cystic fibrosis.. ents often report that infants taste salty when kissed
therapeutic management
* respiratory: ensure pulmonary hygiene is performed; auscultate breath sounds before and after treatments; encourage coughing and deep breath exercises and physical activity as tolerated; administer prescribed antibiotics and bronchodilator(s)
* digestive: provide high-calorie (150% above normal recommendations). high protein diet and snacks; give infants a predigested formula such as pregestnutramigen; administer pancreatic enzymes with all meals and snacks; indi ize to achieve stools as near normal as possible; administer fat-soluble vitamins determine food preferences to encourage acceptance of diet; weigh daily: avoid pulmonary treatments immediately after meals to decrease risk of vomiting
* medications: antibiotics for treatment of pulmonary infection and purulent cretions, pancreatic enzymes for fat absorption, vitamin supplementation. immucolytics to decrease viscosity of sputum, bronchodilators to improve lung function; see chapter 37 for overview of commonly ordered respiratory cardiac medications
* high-calorie, high-protein diet is essential; give pancreatic enzymes with all meals and snacks; may need extra salt in hot weather
bronchopulmonary dysplasia (bpd)
* a chronic obstructive pulmonary disorder occurring in infants as a sequela to prolonged 02 therapy and mechanical ventilation
assessment
* diagnosed by chest x-ray, which reveals lung changes and air trapping with or without hyperinflation
* blood gases reveal hypercapnia (increased co2) and respiratory acidosis
* respiratory observations include tachypnea (rapid respirations), tachycardia, in*creased work of breathing, retractions, wheezing, and barrel chest (rounding of chest caused by trapped air)
* pallor, activity intolerance, and poor feeding result from chronic hypoxia
therapeutic management
* infants with bpd are cared for in intensive care units and require an artificial airway; avoid pressure or trauma to et tube and infant's airway
* suctioning, turning, and weighing is done carefully to ensure adequate 02 sat*uration levels are maintained
* monitor respiratory status continuously; infant's condition can worsen in a short period of time
* monitor for fluid overload; infants are at increased risk for pulmonary edema; weigh daily; maintain strict i & 0
* strict handwashing; avoid exposure to respiratory infections
* cluster nursing care to minimize 02 requirements and caloric expenditure
* plan quiet stimulation and activities to foster normal infant development and parental bonding with extended and often repeated hospitalizations of in*fants with bpd
medications
* bronchodilators open airways and increase lung compliance
* corticosteroids reduce airway edema and inflammation
* diuretics remove excess fluid from lungs and help prevent pulmonary edema
* antibiotics may be given prophylactically
laryngotracheobronchitis (ltb)
* viral infection that causes inflammation, edema, and narrowing of chea, and bronchi; usually ltb is preceded by a recent upper respira% fection (uri)
assessment
* onset is gradual after uri
* child awakens with low-grade fever, barking cough, and acute stridor; noisy breathing and use of accessory muscles increase
* child is agitated, restless, has a frightened appearance, sore throat, and rhinorrhea
* pulse oximetry is used to detect hypoxemia; anteroposterior (ap) and lateral upper airway x-rays are ordered
therapeutic management
* monitor child's respiratory effort continuously to ensure a patent airway; ob*serve for diminished breath sounds, circumoral cyanosis, diminishing noisy breathing, and drooling
* quiet respiratory effort is a sign of physical exhaustion and impending respira*tory failure
* provide humidity and supplemental 02; iv fluids prevent dehydration and help liquefy secretions
* assist child to assume upright position or any position of comfort; promote a calm, quiet environment; keep parents nearby to decrease child's stress and to lessen crying
* keep emergency intubation equipment available at bedside; readily respond to call bell or requests for assistance
* assess parental and child's anxiety level; provide emotional support
* medications
* bronchodilators decrease mucosal constriction and laryngeal edema; nebu*lized racemic epinephrine has a rapid onset with improvement of symptoms, although relapse may occur within 2 hours
* corticosteroids decrease inflammation and edema
child and family education
* cool mist humidifier and parental presence can be initial treatment of crisis; comforting measures include cuddling, rocking, singing, and any calming mea*sures until breathing becomes easier
* instruct parents to seek medical attention immediately if breathing becomes la*bored, child seems exhausted or very agitated, or if symptoms do not improve after cool air humidity treatment
epiglottitis
inflammation and swelling of epiglottis. primarily affecting children ages 2 to 8
assessments
* child awakens with sudden onset of high fever (102°f), extremely sore and pain on swallowing
* child is very anxious, restless, looks ill, and insists on sitting upright legs and arms, with chin thrust out and mouth open (tripod position)
* dysphonia (muffled voice), dysphagia (difficulty swallowing), drooling and distressed respiratory effort are classic signs
* edematous, cherry-red epiglottis is most reliable diagnostic sign
* examination of throat is contraindicated, however, unless emergency equipment and trained personnel are available; physical manipulation of hypersensitive and irritated airway muscles may result in spasm and a obstruction
* lateral neck-x-ray confirms an enlarged epiglottis; portable x-rays are completed in examination room with child on parent's lap to minimize stress maximize child's comfort and calm behavior
* complete blood count (cbc) and blood cultures are taken once child is - stabilized
therapeutic management
* assess continuously for respiratory distress and decrease in respiratory report changes in status
* never leave child unattended; support child in position of comfort; encourage parents to hug and cuddle their child
* keep et and tracheotomy tubes and suction equipment at bedside; assist emergency ventilation if needed before child is taken to operating room for airway insertion
* child is usually intubated for 24 hours; restraints may be necessary to prevent tube dislodgment, because swelling of epiglottis may prohibit reintubation
* provide support for child and family and alleviate anxiety; explain all procedures clearly and calmly
* all invasive procedures, including starting an iv infusion, abgs, and blot surtures are performed in or
* keep child npo; iv fluids provide hydration; administer antipyretics and antibotics as prescribed
* after extubation, monitor child closely in intensive care unit to ensure ir*ate assessment if respiratory effort is compromised
* medications
* antibiotics treat bacterial infection (usually given for 7 to 10 days); discharged in about 3 days with oral antibiotics
* antipyretics treat fever and manage pain of sore throat
* corticosteroids may be given for 24 hours before extubation
assessment
* clinical manifestations include worsening of uri with tachypnea, retractions, low-grade fever, anorexia, thick nasal secretions, and increasingly labored breathing; older infants may have a frequent, dry cough
* auscultation of lungs reveal wheezing or crackles
* nasopharyngeal washing to obtain respiratory secretions identifies causative virus; chest x-ray may be normal or indicate hyperinflation or nonspecific inflammation
therapeutic management
* assess respiratory status hourly; provide humidified 02 to ease respiratory ef*fort; use pulse oximetry to assess 02 saturation
* clear nasal passages with bulb syringe; elevate head of bed
* cluster nursing care to allow for rest; assess anxiety level of parents and provide support; maintain a calm environment
* iv fluids may be needed if oral intake is compromised; monitor strict i & 0; weigh daily to assess fluid loss
* maintain strict handwashing and contact precautions; caregivers should not care for other high-risk children
* medications: bronchodilators and steroids are sometimes used; prevention of bronchiolitis in high-risk children under age 2 may be achieved with use of palivizumab (synagis) or iv rsv immunoglobulin
foreign body aspiration
* inhalation of an object into respiratory tract, intentional or otherwise
* the type and shape of object, as well as small diameter of an infant's airway, de*termines severity of problem; round objects such as hot dogs, round candy, nuts, and grapes do not break apart and are more likely to occlude airway; latex bal*loons are particularly hazardous; objects with irregular shapes may irritate air*way and partially obstruct airflow
assessment
* sudden coughing and gagging is first sign, and objects in upper airway may be expelled by coughing
* partial obstruction may cause symptoms of respiratory infection for days or even weeks; child may have hoorificeness, croupy cough, wheezing, and dyspnea
therapeutic management
* assess respiratory status to determine severity of problem and degree of ob*struction; continuously monitor and provide assistance if obstruction worse
* if total airway obstruction occurs, perform back blows and chest thrusts for infants and heimlich maneuver in children older than 1 year
* keep npo; foreign body is usually removed in surgery
* position for comfort and to optimize airway; provide emotional support to parents and child and alleviate anxiety
* after removal of object, assess for additional obstruction that may result from laryngeal edema and tissue swelling
asthma
* when both antibiotics and aminophylline are administered intravenously, the nurse should check for compatibility. if only one iv site is used, the nurse should use the sas procedure (saline, administer medication, saline) for administering medications. administer iv doses using a controller.
* clinets receiving aminophylline should be maintained or cardiorespiratory monitoring because aminophylline affects cardia and respiratory rates as well as blood pressure. because toxicity can occur rapidly the nurse should monitor the client’s aminophylline level. symptoms of toxicity are nausea, vomiting, tachycardia, palpitations, hypotension. in extreme cases, the client could progress to shock, coma and death.
* the therapeutic range for aminophylline is 10-20 mcg/ml.
pneumonia
* some medications used in the treatment of pneumonia require special attention:
* tetracycline should not be given to women who are pregnant or to small children because of the damage it can cause to developing teeth and bones
* garamycin, an aminoglycoside, is both ototoxic and nephrotoxic. it is important to monitor the client for signs of toxicity. serum peak and trough levels are obtained according to hospital protocol. peak levels for garamycin are drawn 30 minutes after the third or fourth iv or im dose. trough levels for garamycin are drawn 30 minutes before the third or fourth iv dose. the therapeutic range for garamycin is 4-10mcg/ml.
pulmonary embolus
* remember the three fs of fat emboli:
o fat
o femur
o football player
* most fat emboli come from fractured femurs; most fractured femurs occur in young men 18-25, the age of most football players.
* streptokinase is made from beta strep; therefore, clients with a history of strep infections might respond poorly to anticoagulant therapy with streptokinase because they might have formed antibodies.
* streptokinase is not clot specific; therefore, the client might develop a tendency to bleed from incision of injection sites.
Specializes in Medical and general practice now LTC.
Can I please remind members that posting should be their own notes and in their own words, anything to indicate copied from elsewhere and infringes copyright issues will be removed
please answer my question after these facts (below)
Transmission-based Precautions: ADC
A - Airborne
D - Droplet
C - Contact
AIRBORNE PRECAUTION (credit goes to the one who posted this on April thread, sorry can't remember your name)
My - Measles
Chicken - Chickenpox
Hez - Herpes Zoster (Disseminated)
TB - TB
Private room
Negative pressure with 6-12 air exchanges per hour
UV
Mask
N95 Mask for TB
DROPLET PRECAUTION
think of SPIDERMAN!
S - Sepsis
S - Scarlet fever
S - Streptococcal pharyngitis
P - Parvovirus B19
P - Pertussis
P - Pneumonia
I - Influenza
D - Diptheria (Pharyngeal)
E - Epiglottitis
R - Rubella
M - Mumps
M - Meningitis
M - Mycoplasma or meningeal pneumonia
An - Adenovirus
Private room
Mask
CONTACT PRECAUTION
MRS.WEE
M - Multidrug resistant organism
R - Respiratory infection - RSV
S - Skin infections
W - Wound infections
E - Enteric infections - clostridium defficile
E - Eye infections
Skin Infections:
V - Varicella zoster
C - Cutaneous diptheria
H - Herpes simplex
I - Impetigo
P - Pediculosis
S - Scabies, Staphylococcus
This post has helped many and so I am posting it because I caught something while studying and need some understanding!!!
So, chicken pox is "airbornes precautions" but under "contact precautions" with the pnuemonics "Mrs Wee we see "skin infections" and the person posted "vchips" and V being varicella zoster which is chicken pox??!!?? That could also turn into shingles. Please explain????
I had a question I was studying and the employee didn't have to go home after she told the nurse she had the description of what was shingles. The answer said she had to cover up the rash and use contact precautions and could not be assigned to a pregnant mom or immunocomprimised patient. I am totally confused, help moi!!!:heartbeat:heartbeat:nurse:
please answer my question after these facts (below)
Transmission-based Precautions: ADC
A - Airborne
D - Droplet
C - Contact
AIRBORNE PRECAUTION (credit goes to the one who posted this on April thread, sorry can't remember your name)
My - Measles
Chicken - Chickenpox
Hez - Herpes Zoster (Disseminated)
TB - TB
Private room
Negative pressure with 6-12 air exchanges per hour
UV
Mask
N95 Mask for TB
DROPLET PRECAUTION
think of SPIDERMAN!
S - Sepsis
S - Scarlet fever
S - Streptococcal pharyngitis
P - Parvovirus B19
P - Pertussis
P - Pneumonia
I - Influenza
D - Diptheria (Pharyngeal)
E - Epiglottitis
R - Rubella
M - Mumps
M - Meningitis
M - Mycoplasma or meningeal pneumonia
An - Adenovirus
Private room
Mask
CONTACT PRECAUTION
MRS.WEE
M - Multidrug resistant organism
R - Respiratory infection - RSV
S - Skin infections
W - Wound infections
E - Enteric infections - clostridium defficile
E - Eye infections
Skin Infections:
V - Varicella zoster
C - Cutaneous diptheria
H - Herpes simplex
I - Impetigo
P - Pediculosis
S - Scabies, Staphylococcus
This post has helped many and so I am posting it because I caught something while studying and need some understanding!!!
So, chicken pox is "airbornes precautions" but under "contact precautions" with the pnuemonics "Mrs Wee we see "skin infections" and the person posted "vchips" and V being varicella zoster which is chicken pox??!!?? That could also turn into shingles. Please explain????
I had a question I was studying and the employee didn't have to go home after she told the nurse she had the description of what was shingles. The answer said she had to cover up the rash and use contact precautions and could not be assigned to a pregnant mom or immunocomprimised patient. I am totally confused, help moi!!!
Thyroid storm is a crisis or life-threatening condition characterized by an exaggeration of the usual physiologic response seen in hyperthyroidism. Whereas hyperthyroidism can cause symptoms such as sweating, feeling hot, palpitations and weight loss - symptoms of thyroid storm are more severe, resulting in complications such as:
* fever
* rapid heart rate
* nausea/vomiting
* diarrhea
* irregular heart beat
* weakness
* heart failure
* confusion/disorientation
Fever tends to be one of the hallmarks of thyroid storm and can be as high as 105-106F. The actual diagnosis of thyroid storm is made on the basis of suspicion in patients with symptoms, and in the setting of elevated blood levels of thyroid hormones (T3 and T4). Conditions such as severe sepsis, pheochromocytoma, and malignant hyperthermia can mimic thyroid storm.
Causes of thyroid storm may include:
* discontinuing needed medications for hyperthyroidism
* over-replacement of thyroid hormone
* recent treatment with radioactive iodine
* severe infection or illness, usually in a patient with hyperthyroidism
* severe medical stressors, such as heart attack, in a patient with hyperthyroidism
Thyroid storm requires emergent treatment and hospitalization. The main treatment is to decrease the circulating thyroid hormone levels and decrease their formation. PTU and methimazole are two agents that decrease thyroid hormone synthesis and are usually prescribed in fairly high doses. To inhibit thyroid hormone release from the thyroid gland, sodium iodide, potassium iodide and/or Lugol's solution can be given. Beta blockers such as propranolol (Inderal, Inderal LA) can help to control the heart rate, and intravenous steroids may be used to help support the circulation.
Earlier in this century, the mortality of thyroid storm approached 100%. However, now, with the use of aggressive therapy as described above, the death rate from thyroid storm is less than 20%.
Does anyone have anything for thyroid storm? How to remember s/s?
Thyroid storm is an medical emergency (should be treated immediately to prevent stroke or heart attack). Thyroid storm means the over production of the thyroid hormone as in Grave's disease and hyperthyroidism.
Everything goes up: thyroid hormone, BP, temp, and HR. SOB, confusion, N/V, diarrhea, hyper reflexes, restlessness, sweating, dehydration are some of the other s/s.
diagnosis: LOW level of TSH
treatment:
mainly supportive care (control the temperature and CHF)
IV fluids (D51/2NS)
glucose
propranolol (beta-blockers)
tylenol for temperature
vitamin (esp B complexes)
potassium iodide or sodium iodide -remember to gradually withdraw
large dose of PTU (200 mg po/ng q4h)
corticosteriods (dexamethasone) -remember to gradually withdraw
So, chicken pox is "airbornes precautions" but under "contact precautions" with the pnuemonics "Mrs Wee we see "skin infections" and the person posted "vchips" and V being varicella zoster which is chicken pox??!!?? That could also turn into shingles. Please explain????
I had a question I was studying and the employee didn't have to go home after she told the nurse she had the description of what was shingles. The answer said she had to cover up the rash and use contact precautions and could not be assigned to a pregnant mom or immunocomprimised patient. I am totally confused, help moi!!!
okay according to the CDC website:
If it says VARICELLA ZOSTER virus: it is both chickenpox and shingles
If it says VariCella virus alone: it is Chickenpox
If it says Herpes ZOSTER: it is Shingles
From my understanding why one with these should not be assigned to a pregnant mom, immunocompromised, or an unvaccinated client is because close exposure can still pass the virus. Open lesions that have not crusted yet can still be transmitted. Open lesions can transmit the virus from hands, to eyes, to mucous membranes and so on and so forth.
Okay, I have a question if anyone could please help clarify something for me before I take my boards Monday morning...? When it comes to calculating gtts/min, let's say the answer I come up with ends up being 10.5 (gtts/min)...what answer do I actually need to put down--10.5 or do I round up to 11? The reason I'm asking is because in my nursing school, they taught us that gtts/min were ALWAYS rounded to the nearest whole number...however, on the computer test I took earlier--it counted my answer wrong when I put "11" because it said the the answer was, in fact, 10.5 (gtts/min)... So, I'm just wondering which answer NCLEX says is correct? Thanks, ya'll!!
okay, i have a question if anyone could please help clarify something for me before i take my boards monday morning...? when it comes to calculating gtts/min, let's say the answer i come up with ends up being 10.5 (gtts/min)...what answer do i actually need to put down--10.5 or do i round up to 11? the reason i'm asking is because in my nursing school, they taught us that gtts/min were always rounded to the nearest whole number...however, on the computer test i took earlier--it counted my answer wrong when i put "11" because it said the the answer was, in fact, 10.5 (gtts/min)... so, i'm just wondering which answer nclex says is correct? thanks, ya'll!!
:tinkbll:first, good luck as you take your exam on monday. on the nclex from my experience, the math problems will state whether they want a whole number answer or a decimal answer...just read the question very thoroughly....each math question will be different in regards to how the answer is to be written. they are fill in the blank, so be sure to see what your answer needs to be...a whole number or decimal number...so for example if the question asks for a decimal answer to the tenths place....10.45 is what you come up when working out the problem, i would round it up to 10.5...and that is what i would put in as the answer. same with whole number answers....say your worked out answer is 11.4 gtts and it asks for a whole number, i would just put 11 as the answer. i hope this helps....please feel free to correct me anyone!
Thanks, ya'll!!
lady_anne76
59 Posts
Client with Burns
BURN INJURY
* An alteration in skin integrity resulting in tissue loss or injury caused by heat, chemicals, electricity, or radiation
* There are several types of burn injury: thermal, chemical, electrical, and radiation
* Thermal burn: results from dry heat (flames) or moist heat (steam or hot liq*uids); is most common type; causes cellular destruction that results in vascu*lar, bony, muscle, or nerve complications; thermal burns can also lead to inhalation injury if head and neck area is affected
* Chemical burn: caused by direct contact with either acidic or alkaline agents; alters tissue perfusion and leads to necrosis
* Electrical burn: severity depends on type and duration of current and amount of voltage; electricity follows path of least resistance (muscles, bone, blood vessels. and nerves); sources of electrical injury include direct current, alter*nating current, and lightning
* Radiation burn: usually associated with sunburn or radiation treatment for cancer; usually superficial; extensive exposure to radiation may lead to tissue damage and multisystem injury
o Nursing assessment: history of injury, estimate burn extent and depth, obtain past medical history and medication history including date of last tetorifice pro*phylaxis; assess for other concurrent injuries
o Systemic effects of severe burns include asphyxia from smoke inhalation that causes edema of respiratory passages; shock from fluid shifts; renal failure from shock; protein loss from open wound; potassium excess from tissue destruction and renal failure
o Diagnostic and laboratory test findings: may have elevated hematocrit (Hct) and decreased hemoglobin (Hgb) caused by fluid shift, decreased sodium (Nat) and increased potassium (K+) caused by damage to capillary and cell mem*branes, elevated BUN and creatinine caused by dehydration, myoglobin in urine, and possible deterioration of arterial blood gases (ABGs) and oxygen (02) saturation readings depending on respiratory status
o Therapeutic management
* First aid: douse flames with water or smother them with a blanket, coat, or other similar object; cool a scald burn with cool water; flush chemical burns copiously with water or other appropriate irrigant after dusting away any dry powder if present; remove client from contact with an electrical source only after current has been shut off
* Priority care is on ABCs: airway, breathing, and circulation; assess for smoke inhalation injury (singed nares, eyebrows or lashes; burns on face or neck; stridor, increasing dyspnea) and give 02 (up to 100% as prescribed), being prepared for possible intubation and mechanical ventilation if severe inhala*tion injury or carbon monoxide inhalation has occurred; assess for signs of shock caused by fluid shifts (increased pulse, falling BP and urine output, pal*lor, cool clammy skin, deteriorating level of consciousness [LOC])
* Fluid resuscitation: Brooke formula uses 2 mL/kg/% TBSA burned (3/4 crys*talloid plus 1/4 colloid) plus maintenance fluid of 2,000 mL D5W per
o Medication therapy: analgesics—usually morphine sulfate IV, tetorifice booster (> 5-10 years since last dose), topical antimicrobials, systemic antibiotics
o Acute phase of burn management: begins with start of diuresis (usually 48 to 72 hours postburn) and ends with closure of burn wound
o Therapeutic management
+ Wound care management includes debridement, dressing changes, hydrother*apy, and possible escharotomy,
+ Mafenide (Sulfamylon) may be applied in thin layer over open wound and covered with dressing
+ Sulfadiazine (Silvadene) may applied in thin layer over open wound and cov*ered with dressing; use with caution when impaired renal function exists; must be washed off and reapplied every 8 to 12 hours
+ Skin grafting may need to be done to achieve healing in full-thickness and large, deep partial-thickness burns
+ Nutritional therapies (high-calorie, high-protein diet with vitamins and min*erals) and continue to maintain hydration status
+ Infection control with strict sterile technique
+ Maintain heated environment to prevent chilling
+ Physical therapy as needed
+ Psychosocial support
# Rehabilitative phase of burn management: begins with wound closure and ends when client returns to highest level of health restoration
# Therapeutic management
* Prevent immobility contractures with exercises or ongoing physical therapy
* Assist in returning to work. family, and social life
* Client education
* Environmental safety: use low temperature setting for hot water heater, en*sure access to and adequate number of electrical cords/outlets, isolate house*hold chemicals, avoid smoking in bed
* Use of sunscreen to protect healing tissue and other protective skin; measures soft tissue injuries; or deep chemical or electrical
+ To prevent burns, hot water heaters should be set no higher that 120° Fahrenheit.
Burn Classifications
+ Pain medication is given intravenously to provide quick, optimal relief and to prevent overmedication as edema subsides and fluid shift is resolving.
+ The cardiac status of a client with electrical burns should be closely monitored for at least 24 hours following the injury to detect changes in electrical conduction of the heart.
+ Full thickness burns can damage muscles, leading to the development of myoglobinuria in which urinary output becomes burgundy in color. The client with myoglobinuria require hemodialysis to prevent tubular necrosis and acute renal failure.
Burn Measurement with TBSA
+ It will be beneficial to review your nursing textbooks for local and systematic reactions to burns because these injuries affect all body systems and cardiovascular and renal functions in particular.
Nursing Care for Burn Victims
+ The eyes should be irrigated with water immediately if a chemical burn occurs. Follow-up care with an ophthalmologists is important because burns of the eyes can result in corneal ulceration and blindness.
+ Important Steps in treating a burn client include the following:
* Treat airway and breathing – Traces of carbon around the mouth or nose, blisters in the roof of the mouth, or the presence of respiratory stridor, indicate the client has respiratory damage
* Ensure proper circulation – Compromised circulation is evident by a drop in normal blood pressure, slowed capillary refill, and decreased urinary output. These symptoms signal impending burn shock.
o It is important to remember that the actual burns might not be the biggest survival issue facing burn clients. Carbon monoxide from inhaled smoke can develop into a critical problem as well. Carbon monoxide combines with hemoglobin to form carboxyhemoglobin which binds to available hemoglobin 200 times more readily than with oxygen. Carbon monoxide poisoning causes a vasolidating effect causing the client to have a characteristic cherry red appearance. Interventions for carbon monoxide poisoning focus on early intubation and mechanical ventilation with 100% oxygen.
The Consensus Formula
o Fluid replacement formulas are calculated from the time of injury rather than from the time of arrival in the emergency room.
The Intermediate Phase
o Infections represent a major threat to the post-burn client. Bacterial infections (Staphylococcus, Proteus, pseudomonas, eshcerichia coil, and Klebsiella) are common due to optimal growth conditions posed by the burn wound; however, the primary source of infection appears to be the client’s own intestinal tract. As a rule, systemic antibiotics are avoided unless an actual infection exists,
o Enzymatic debridement should not be used for burns greater thatn 10% TBSA, for burns near the eyes, or for burns involving muscle.
Dressing for Burns
o Dressing for burns include standard wound dressings (sterile gauze) and biologic or biosynthetic dressings (grafts, amniotic membranes, cultured skin, and artificial skin)
o Biologic dressings are obtained from either human tissue (homograft or allograft) pr animal tissue (heterograft or xenograft). These dressing which are temporary are used for clients with partial thickness or granulating full thickness injuries.
o Hemografts and allografts are taken from cadaver donors and obtained through a skin bank. These grafts are expensive and there is a risk of blood-borne infection. Heterografts and xenografts are taken from animal sources. The most common heterograft is pig skin (porcine) because of its compatibility with human skin.
o Muslims and Orthodox Jews are two religious/ethnic groups who might be offended by the use of porcine grafts since the pig is considered an unclean animal. Christian groups such as Seventh Day Adventists might also reject the use of procine grafts.