NURS 3000 Midterm - Experiencing Acute Illness Solved 100% Correct!!

NURS 3000 Midterm - Experiencing Acute Illness Solved 100% Correct!! Acute Care -health acre to treat sudden, unexpected, urgent/emergent episodes of illness/injury that can lead to death/disability -can include care to promote health, prevent illness & rehabilitate Domains in Acute Care - emergency care, surgery care, urgent care, critical care, trauma care, pre-hospital care, short-term stabilization Multidisciplinary Team Includes but is not limited to Rn, RPN, PSW, pharmacist, dietician, physician, surgeon, PT/OT, psych, social worker (essentially all disciplines) Role of Med-Surg Nurse relational care, cultural care, inter-professional care Documents to Support Practice Pt. Safety, Workplace Violence, CNA documents, CNO documents, RNAO documents, Care Challenges/Considerations -aging population -innovative technology -expanded nursing role *all effect how we reason, analyze, synthesize info. & how we make decisions Pain -subjective (must collect all data) -age, culture, condition all play a role in perception -don't assume -#1 reason seek HC Nursing Process -Nursing Diagnosis (related to, evidenced by) -Planning (SMART goals) -Interventions (pharm/no pharm) -Evaluation (successful or not) Types of Pain nociceptive, persistent, breakthrough, neuropathic, chronic, acute, cancer Factors Influencing Pain Psychological, social, spiritual, cultural Physiological Response to Pain (mild - severe intensity) -stimulation of SNS -inc. RR, inc. bronchial dilation, diaphoresis, in. HR, inc. Blood glucose, pupil dilation, peripheral vasoconstriction, inc. muscle tension, dec. GI motility Physiological Response to Pain (severe - deep pain) -Stimulation of PNS -pallor, inc. muscle tension, dec. HR, dec. BP (stimulation of vagal nerve), inc. RR & irregular breathing, weakness/exhaustion Collecting Pain Data OPQRST: onset, palliation, quality, region, severity, timing, understanding, value P.A.I.N: pattern, area, intensity, nature Pain Scales: 0-10, faces, PIPP Burn Injury - injury to tissues caused by heat, chemicals, electric, radiation Types of Burns Thermal, Chemical, Smoke Inhalation, Electrical Thermal Burns -flame, flash, scald -most common type of burn Chemical Burns - acids, alkalis, organic compounds Smoke Inhalations Injury/Burn - inhalation of hot air/noxious chemical -causes damage to resp. tract - major predictor of mortality in burn victims - needs to be treated quickly Three types of smoke inhalation injuries -carbon monoxide poising -injury above glottis -injury below glottis Carbon Monoxide Poisoning - caused by incomplete combustion of burning materials -displaces oxygen & leads to hypoxia, carboxyhemoglobinemia, death -can occur in absence of burn to skin -skin can appear cherry-red ***treat w/ 100% humidified oxygen Inhalation Injury Above Glottis -thermally produced (hot air, steam, smoke) -mucosal, oropharynx & larynx burns -mechanical obstruction can occur quickly & can lead to a true medical emergency - reliable clues may be > facial burns, singed nose hair, hoarseness, painful swallowing, darkened oral/nasal membranes, carbonaceous sputum, burned clothes around neck/chest Inhalation Injury Below Glottis -injury related to exposure to smoke/toxic fumes - pulmonary edema may not appear until 12-24 hrs after injury - manifests as acute respiratory syndrome Electrical Burns - results from coagulation necrosis caused by intense heat generated from an electrical current - may result from direct damage to nerves/vessels causing tissue anoxia & death - severity of burn depends on voltage, duration, current pathway, surface area affected -passing through vital organs is more life-threatening -can ignite clothing & cause electrical & thermal injury - severity can be hard to assess (below skin) - Pt. at risk for dysrhythmias, severe metabolic acidosis, myoglobinuria Classification of Burn Injury - determined by depth, extent of TBSA affected, location, client risk factors -superficial thickness (epidermis), partial-thickness (epidermis & dermis), full-thickness (epidermis, dermis, fat, muscle, bone) Common Guides for Determining TBSA Affected by Burn - Lund-Browder Chart (more accurate) - Rule of Nines (adequate for initial assessment in adults) Location of Burn Determines Severity - face, neck, chest : respiratory obstruction -hands, feet, joints, eyes : self-care deficit - ears, nose, butt, perineum : infection Phases of Burn Management - pre-hospital care (extinguish causative factor) - emergent care (resuscitative) - acute (wound healing) - rehabilitation (restorative) Pre-Hospital Care (Burns) - remove person from source, stop burning process **rescuer must protect self Emergent Phase (Burns) - resolve immediate problems resulting form injury - can last up to 72 hours - primary concerns are onset of hypovolmeic shock & edema - phase begins w/ fluid loss & edema formation and continues until fluid mobilization & diuresis begins Emergent Phase (Burns) - Patho - F/E shift : greatest threat is hypovolemic shock caused by a massive shift of fluids out of blood vessels as a result of inc. capillary permeability - Shock : syndrome from dec. tissue perfusion & impaired cellular metabolism (imbalanced supply/demand for oxygen & nutrients) - hypovolmeic shock is classified as a low blood flow type of shock (loss of intravascular volume) Emergent Phase (Burns) - Clinical Manifestations - shock from pain & hypovolemia - blisters, adynamic ileus, shivering - altered mental status Emergent Phase (Burns) - Complications - dysrhythmias, hypovolemic shock, impaired circulation to extremities, tissue ischemia, necrosis Emergent Phase (Burns) - Nursing Management - airway management - fluid therapy -wound care - drug therapy - assess effectiveness of interventions - nutritional therapy Fluid Resuscitation - Parkland/Baxter Formula - colloid solutions - 4ml x Kg x TBSA given over 24 hrs - 50% fluids in first 8 hours - 25% fluids next 8 hours - 24% fluids final 8 hours Acute Phase (burns) - begins w/ mobilization of extracellular fluid & subsequent diuresis - concluded when burned area is completely covered by skin grafts/wounds have healed Acute Phase (Burns) - Patho - diuresis from fluid mobilization occurs & pt. is less edematous - bowel sounds return - healing begins when WBCs surround the burn wound & phagocytosis occurs, necrotic tissue begins to slough - granulation tissue forms - partial-thickness burn wound heals from the edges - full-thickness burns must be covered by skin grafts & require debridement Acute Phase (Burns) - Complications - Infection - CV & Resp. - Neuro - Muskoskeletal - GI - Endocrine Acute Phase (Burns) - Nursing Management - wound care - pain management - nutrition therapy (extremely important) - excision/grafting - physical & OT - Psychological care Acute Phase (Burns) - Wound Care Excision & grafting - eschar removed down to the subcutaneous tissue/fascia - graft is placed on clean, viable tissue - wound is covered w/autograft - donor skin is taken w/ a dermatome - choice of dressing varies Rehab Phase (Burns) -begins when wounds have healed - pt. able to resume some level of self-care - complications - contractures (most common complication - splints/exercise can minimize)