Adult Nursing 2 - Second Year Nursing Student PDF

Adult Nursing (2) For Second Year Nursing Student Second semester By Adult Nursing Department, Faculty of Nursing, South Valley University- Qina 2024 – 2025 1  Adult nursing...

Adult Nursing (2) For Second Year Nursing Student Second semester By Adult Nursing Department, Faculty of Nursing, South Valley University- Qina 2024 – 2025 1  Adult nursing (2) Unit Corse Contents Page I Nursing management for patient with neurological alteration: 6hrs. - Increased intracranial pressure management. - Intracranial surgery (craniotomy) management - Stroke management - Seizure disorders management. II Nursing management for patient with orthopedic alteration. - Orthopedic trauma patient. - Fracture management. - Methods of restriction movement. 9hrs - Traction. - Cast. - Methods of internal fixation. - Orthopedic infection and acute osteomyelitis. - Rheumatoid Arthritis. III Nursing management of patient with urological alterations: - Caring for patient with urinary disorders. - Urinary tract infection. - Cystitis. - Obstructive disordered and urolithiasis. - Renal failure. - Acute renal failure. 9hr - Chronic renal failure. - Dialysis. - Peritoneal dialysis. - Hemodialysis. IV Nursing management of patient with alterations in skin integrity(Burn): - Anatomy and physiology of the skin. - Pathology of burns. - First aid of burn. - Emergent phase of burn. - Acute phase of burn. 9hr - Wound dressing. - Hydrotherapy. - Wound debridement. - Infection control in burned patient. 2 - Nutritional support for burn patient. - Skin graft. - Rehabilitation phase of burn. 3 Nursing Management of patient with Neurological Alteration 4  The Nervous System Learning objectives: At the end of this lecture, the student should be able to: - Discuses anatomy and physiology of the nervous system - Understanding position and function of the cranial nerves - Identify lumber puncture 5  The Nervous System Anatomy and physiology of the nervous system: The nervous system is divided into central nervous system (CNS), and peripheral nervous system (PNS). -The central nervous system is divided into brain and spinal cord in which the brain divided into cerebrum, cerebellum and brain stem. The cerebrum consists of lobs which are (frontal, parietal, temporal and occipital) and diencephalon which are (thalamus, hypothalamus). While brain stem consists of midbrain, pons and medulla oblongata - The peripheral nervous system is divided into cranial nerves (12 pairs) and spinal nerves (31 pairs). -Autonomic nervous system divided into sympathetic and parasympathetic is also considered to be a part of the PNS and it controls the body's many vegetative (non-voluntary) functions. Basic structure of the nervous system is the nerve cell or neuron. Neurons are either sensory which transmit impulses to the CNS or motor which transmit impulses from the CNS, they are separated units but impulses 6 travel from one to another by the means of synapses. A neuron is composed of a cell body, a nucleus, dendrites and axons Anatomy of Neuron: (Fig. 1) The neurve cell Dendrites: Conducts impulses to the cell body (to or toward) nerve fibers and called afferent. Axon: Is a nerve fiber that projects and conducts impulses away from the cell body (away from) nerve fibers and called efferent it usually is larger than dendrites. Neurotransmitters (Neurohormones): Accomplish the transmission of an impulse from one neuron to the next which can excite or inhibit neurons. Myelin: Fatty substance covers some axons in CNS and PNS, axons that are covered by myelin called Myelinated (white matter or white nerve fibers). Axons that not covered with myelin called Unmyelinated (gray matter or gray nerve fibers). Myelin is insulating substance for the axon that confines the electrical conduction without allowing it to scatter. Neurilemma: Membranous sheath covers the myelin of axon in peripheral nerves. 7 Nodes of Ranvier: Myelinated nerves are segmented with periodic gaps when impulses travel along axons of myelinated nerves they leap from node to node by process called Saltatory conduction, which is much faster than impulses traveling along axons of unmyelinated nerves. The central nervous system: Brain: (Fig. 2) The brain If the brain is discussed anatomically, it is divided into three fossae are: Anterior: contains the frontal and cerebral hemispheres. Middle: contains the parietal, temporal and occipital lobes. Posterior: contains brain stem and medulla. The anterior and middle fossae sit above the tentorium which is a membranous structure that separated the cerebral hemispheres from the brain stem and cerebellum. The brain divided into three parts (cerebrum- cerebellum and brain stem). A- Cerebrum: consists of two hemispheres connected by Corpus Callosum, which is band of white fibers acts as bridge for transmitting impulses between left and right hemispheres. Each hemisphere has four lobes as: 1-Frontal: is the largest lobe controls an individual's affect judgment, personality, inhibitions and mental activities 8 2-Parietal: a pure sensory lobe except smell. Control sensation as pain, touch and temperature. 3-Temporal: integrates the sensations of taste, smell, hearing, and short term memory. 4-Occipita: the posterior lobe of cerebral hemisphere responsible for visual interpretation. Cerebral cortex :is the surface of the cerebrum contains motor neurons which responsible for movement and sensory neurons, it receives impulses from peripheral sensory neurons located throughout the body. Motor tracts: either pyramidal or extrapyramidal as, Pyramidal motor tract: motor pathways originate in the motor cortex of the cerebrum cross over the level of medulla and end in the brain stem and spinal cord. Extrapyramidal motor tract: Fibers originate in the motor cortex and project to the cerebellum and basal ganglia. They do not cross over as they connect to motor neurons in the spinal cord. B- Diencephalon: It is a deep area within the brain consists of 1- Thalamus: located in either side of the third ventricle, monitors sensory input and are lay station for sensation. 2- Hypothalamus: Small area making up the anterior wall of the third ventricle, control vital function as water balance, blood pressure, sleep, appetite and body temperature also affect some emotional responses e.g pleasure and fear. Cerebellum: located behind and below the cerebrum, separated from the cerebral hemisphere by a fold of dura mater. It has both excitatory and inhibitory actions and is largely responsible for coordinates muscle movements; controls fine movement, balance, position sense and integration of sensory input. Brain stem: Consist of midbrain, pons and medulla oblongata. 9 Midbrain: connects the pons and cerebellum with two cerebral hemispheres, origin of III and IV cranial nerves, conduct impulses from the lower centers of the brain to the cortex. (Fig. 3)Brain steem Pons: connects the two hemispheres of the cerebellum with brainstem, spinal cord and cerebrum, origin of V, VI, VII and VIII cranial nerves also control reticular formation which has to do with keeping us awake, it contain vital centers as respiration, heart beats, hiccoughing, blood pressure and vasomotor activity (smooth muscles activity in blood vessel walls) Medulla oblongata: transmits motor impulses from the brain to the spinal cord and sensory impulses from peripheral sensory neurons to the brain. Origin of IX, X, XI and XII cranial nerves. The brain is enclosed in a rigid bony compartment called the skull or cranium, at the base of it is the foramen magnum through which the spinal cord passes. Beneath the skull, the brain is covered by three membranes or meninges. Three meninges are: 1- Duramater: The tough out most covering. 2- Arachnoid: Middle lying directly below the duramater. 3- Piamater: A delicate layer adheres to the brain and spinal cord. Subarachnoid space: lies between the Piamater and the arachnoid membrane. 10  (Fig. 4) Meninges of the brain Ventricles: Within the brain there are four hollow irregularly spaces called ventricles which manufacture, circulating and absorb cerebrospinal fluid (CSF). (Fig.5) Brain ventricles for CSF production Cerebrospinal fluid (CSF): - It is clear and color less, odor less fluid hat looks like water a specific gravity 1.007, it is approximately 500ml produced dally in normal adult. - CSF is analyzed for protein, glucose chloride, and has a minimal number of WBC and no RBCs. - Constantly circulates in the subarachnoid space of the brain and spinal cord. It produced in the ventricles passes down into the subarachnoid space of the spinal cord then up through the basilar cisterns and over the cerebral hemispheres to the region of the dural sinuses where most of the 11 absorption occurs. It acts as a cushion, protects and supports the brain and spinal cord, carries nutrients to various areas of the brain and spinal cord and helps maintain constant intracranial pressure. Cerebral circulation: - Cerebral circulation receives about 20% of the cardiac output or 750 ml per minute. - The brain doesn't' store nutrients and has a high metabolic demand, so the high flow is necessary. - Arteries: Two internal carotid arteries and two vertebral arteries and their extensive system of branches provide the arterial blood supply to the brain. - Veins: Venous drainage for the brain doesn't accompany the arterial circulation as in other body structures. The network of the sinuses carries venous out flow for the brain and empty into the jugular vein which then returns the blood to the heart. Spinal cord: Contained within the vertebral canal, it is continuation of the medulla covered by the meninges as (H-shaped gray matter surrounded by white matter). Spinal cord ends between the first and second lumbar vertebrae where it divided into smaller sections called cauda equina. It functions are a passage for ascending sensory and descending motor neurons, provide centers for reflex action, serve as a pathway for impulses to and from the brain. (Fig. 6) Cross section in the spinal cord 12  (Fig. 7) pathway for impulses to and from the brain. Peripheral nervous system (PNS): Consists of all sensory (dorsal nerve fibers)and motor (ventral nerve fibers) nerves outside of CNS it include the cranial and spinal verves. The motor division is divided into somatic nervous system (control voluntary activity of skeletal muscles) and autonomic nervous system (control involuntary activity like heart respiration and digestion) which are either belonging sympathetic or parasympathetic division of autonomic nervous system. 13  Cranial nerves: are 12 pairs as: olfactory, optic, oculomotor, Trochlear, trigeminal, Abducens, facial, vestibulocochlear, Glossopharyngeal, vagus, accessory and hypoglossal. (Fig. 8) Position of the cranial nerves Cranial Nerve Type Function I- Olfactory Sensory Sense of smell. II-Optic Sensory Visual acuity. III- Oculomotor Motor Regulation of eye movement. IV- Trochlear Motor Regulation of eye movement. V- Trigeminal Mixed. Facial sensation, corneal reflex and mastication VI- Abducens Motor Regulation of eye movement. Mixed Facial muscle movement, facial VII- Facial expressions, tear and saliva secretion. Taste: anterior two thirds of tongue. VIII- Auditory Sensory Hearing and equilibrium. (vestibulocochlear) IX- Glossopharyngeal Mixed Taste: posterior third of tongues. X- Vagus Mixed - Pharyngeal contraction. - Symmetric movement of vocal cords. - Symmetric of soft palate XI- Spinal accessory Motor Movement of sternocleidomastiod and trapezes muscle XII- Hypoglossal Motor Movement of tongue. Spinal nerves: are 31 pairs as 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal. The spinal nerves have two roots dorsal and ventral nerve fibers. Peripheral sensory nerve fibers: in the various areas of the body it transmit impulses to the spinal nerves, which transmit impulses up to the spinal cord then to the brain. 14 Motor impulses: Traveling from the brain and down the spinal cord leave by the ventral root and travel to areas of the body. Each spinal nerve root innervates a specific area or dermatome of the body surface. Autonomic nervous system: It consists of sympathetic and parasympathetic. Sympathetic nervous system: - It regulates the expenditure of energy, Prepare the body to handle stressful situation. - The neurotransmitters for sympathetic NS called catecholamines are (epinephrine, nor-epinephrine which secreted by the adrenal medulla in addition nor-epinephrine produced also at sympathetic nerve endings and dopamine which is a neither precursor of nor- epinephrine also nor- epinephrine then becomes epinephrine. - Sympathetic neurons are located in the thoracic and the lumbar segments of spinal cord. Note: Stressful situations as (danger, intense emotion, and sever illness) result in the release of catecholamines. Parasympathetic nervous system: - Conserve body energy and partly responsible for slowing heart rate, digesting food and eliminating body wastes. - It located in two sections: one in the brain stem and other from spinal segments below L2 because of the location of these fibers. - The parasympathetic system is referred to as the craniosacral division. - Neurotransmitter of parasympathetic is called Acetylcholine enzyme it released at the nerve endings of parasympathetic nerve fibers, at some nerve endings in the sympathetic nervous system and at nerve ending of skeletal muscles. - It release allows passage of nerve impulse from the nerve fiber to the effectors organ or structure. Assessment of Nervous system: 1- History. 2- Physical examination. 3- Cranial nerves examination. 15 4- Motor function examination. 5- Sensory function examination 6- Level of consciousness (LOC) 7- Vital signs. Diagnostic investigations of CNS: I- Non- invasive studies as: 1- Skull and spinal plain X-ray, CT, MRI. 2- Electroencephalography (EEG). II- Invasive studies as: 1- Lumbar puncture: lumbar puncture is insertion of a needle into lumbar subarachnoid space to withdraw CSF for diagnostic and therapeutic purposes. Diagnostic uses: 1- To obtain a specimen of CSF for laboratory analysis. 2- To estimate CSF pressure normally (80-180 mm H2O). 3- To induce radio-opaque dye. Therapeutic uses: 1- To introduce therapeutic drugs (antibiotic) 2- To introduce epidural anesthesia. Contraindications related lumber puncture: 1- Increased intracranial pressure. 2- Spinal deformity makes lumbar puncture difficult. Nursing role for lumber puncture: Pre-procedure: 1- Explain the purpose of the test to the patient and his family. 2- An informed consent should be signed by the patient prior the test. 3- The bladder and bowel should be emptied as possible. 4- Prepare the needed equipments. 5- The patient lie on one side with the legs pulled into the abdomen and head tucked into the chest, in order to open the spaces between the vertebrae. 6- Sedation may be ordered before the test. 16  (Fig. 9) lumber puncture During procedure: 1- Assure the patient. 2- Assist the patient to maintain the position to avoid sudden movement. Post procedure: 1- Vital signs should be recorded. 2- Encourage increase fluid intake. 17  Increased Intracranial Pressure Management Learning objectives: At the end of the lecture the student will be able to: 1- Define intracranial pressure (ICP) and increased (ICP). 2- List causes if increased (ICP). 3- Identify signs and symptoms of increased (ICP). 4- Differentiate between the fifth grades of intracranial pressure. 5- Identify diagnostic finding for increased (ICP). 6- List complications if increased (ICP). 7- Discuss nursing management and education for patient with increased (ICP). 18  Increased Intracranial Pressure Management Introduction: Inside the cranium there are brain tissue, blood and (CSF). Brain tissue represents about 84% of the cranial contents, blood contributes 4% of the total and (CSF) provides 12%. If one or more of these increase significantly without a decrease in either or the other two, intracranial pressure becomes elevated. Definitions: Intracranial pressure (ICP): It is defined as the measure of cerebrospinal fluid pressure within the cranium. Normal (ICP) rages from 15-20 mmHg. Increased (ICP): It is defined as an increase in normal brain pressure due to an increase in cerebrospinal fluid pressure. Pathophysiology: Under normal circumstances, auto- regulatory mechanisms keep brain tissue perfused with adequate O2and glucose. Dilation or constriction of cerebral blood vessels in response to change in blood pressure, blood O2 levels, blood PH maintains constant of consistent tissue perfusion. Normally when (ICP) increased some compensation occurs as (CSF) production may decrease or displace at greater rate into venous circulation. Causes of increased ICP: - Severe head injury and hemorrhage - Subdural hematoma. - Hydrocephalus. - Brain tumor and infection. - Meningitis and encephalitis. - Aneurysm rupture and subarachnoid hemorrhage. - Status epilepticus and stroke. - Hypoxia and hypotension lead to vasodilatation which increase ICP 19 Signs and symptoms of increased (ICP): 1- Change in level of consciousness: - May occur over a period of minutes, hours or days. - Characterized by diminished response to environmental stimuli. - Responsiveness ranges from alert and oriented to no response to stimuli. - Confusion, restlessness, disorientation and drowsiness may be signs of an impending change. 2- Headache: Increases in severity with coughing sneezing or straining at defecation. 3- Vomiting. 4- Papilledema and pupil changes: - Edema and pressure of both the optic nerve and the Oculomotor nerve which caused by venous congestion resulting from increased ICP. - Pupil on the affected side may be dilated or non reactive. 5- Elevation of blood pressure with a widened pulse pressure. 6- Decreased pulse rate (may be increased initially). 7- Decreased respiratory rate (may be irregular). Diagnostic finding of increased ICP 1- Cerebral angiography. 2- CT scan and imaging (MRI). 3- Transcranial Doppler study to detect cerebral blood flow. 4- Lumber puncture is avoided in patients with increased ICP because the sudden release of pressure can cause the brain to herniate. Complications of increased ICP: 1- If (ICP) continues to rise auto- regulatory mechanisms can fail. 2- Compressing blood vessels lead to cerebral ischemia. 3- Brain stem herniation: if increased ICP not treated the contents of the cranium are compressed cases brain tissue to herniated through foramen magnum. 4- Brain stem herniation affects respiration, heart rate, Blood pressure and functions of descending and ascending nerve fibers. 5- Diabetes insipidus is the result of decreased secretion of anti-diuretic hormone. 6- Consequences of increased ICP impaired cellular activity, neurological dysfunction and death. 20 Nursing management for increased ICP: 1- Monitor vital signs closely. 2- Assess and document neurological status. 3- Evaluate level of consciousness. 4- Monitor increased ICP: Monitor increased ICP for the following purposes: - To identify increased pressure early. - To determine degree of elevation. - To initiate appropriate treatment. - To provide access to CSF for sampling and drainage. - To evaluate the effectiveness of treatment. 5- Maintain patient airway: - Intubations and hyperventilation may be indicated to provide adequate cerebral perfusion of oxygenated blood and decrease carbon dioxide induced vascular spasm. - If patient is not intubated, position the patient on his side to decrease the possibility of airway occlusion, use oral or nasopharyngeal airway. - Be aware that stimulation of coughing when suctioning increase ICP and may precipitate seizure activity. - Hyperventilating increase ICP and lead to brain injury from cerebral vasoconstriction and cellular necrosis. 6- Administer medications as ordered: - Mannitol (osmotic diuretic to decrease cerebral edema). - Corticosteroids (to reduce cerebral edema) - Dilantin (to prevent seizure activity). - Antibiotics. 7- Elevate head of bed (30o) to promote return of venous blood. 8- Administer hypertonic I.V solution as ordered. - For maintain cerebral tissue perfusion and BP the patient take isotonic normal saline 5%, Ringer's lactated or hypertonic 3% saline. - Do not give hypotonic solution and glucose because it increases ICP. - Give O2or mechanical ventilation to keep SaO2= 95% ,PaCo2between 35-45 mmHg and prevent hypoxia. - Oral fluids will be restricted to reduce ICP. - Accurate intake and output records must be kept. 9- Protect patient from injury (seizures may occur). - Pad side rails. 21 - Secure a tongue blade to the head of the bed for easy access. 10- Maintain normal body temperature: - Monitor temperature frequently. - Shivering may increases ICP, seizure and hyperactivity. - Intracranial bleeding is frequently accompanied by increase in body temperature that are resistant to antipyretic agents. Education for patient with increased ICP: Instruct the patient to return to the hospital if any of the following problems occur: 1- Fever greater than 100Fo 2- Pulse less than 50 beats per minute. 3- Vomiting, Slurred speech and dizziness. 4- Blurred or double vision. 5- Unequal pupil size. 6- Blood or fluid discharge from ears or nose. 7- Increased sleeping or inability to move extremities. 8- Convulsions or unconsciousness. 22  Stroke management Learning objectives: At the end of this Lecture student will be able to: 1- Define stroke. 2- List incidence of stroke. 3- Identify types of stroke. 4- Describe risk factors for stroke. 5- Explain clinical manifestation of stroke. 6- Identify diagnostic evaluation finding for stroke. 7- Identify effects of stroke. 8- Discuss medical and nursing management for patients with stroke. 23  Stroke management Definition: A stroke called brain attack or cerebrovascular accident(CVA); it define as when prolonged interruption in the blood flow to part of the brain occurs. So, if brain deprived of oxygen (3-7 minutes) during stroke the nerve cells die and irreversible. Incidence of stroke: - In the USA, stroke is the third largest cause of death, approximately 780000 Americans have a new or recurrent stroke. Pathophysiology and Etiology: There are two main types of stroke: 1- Ischemic strokes: - Occur when a thrombus or embolus obstructs an artery carrying blood to the brain. - When ischemic occur, glucose and O2 to brain cells are reduced. The reduced glucose quickly depletes the stores of adenosine triphosphate (ATP), resulting in anaerobic cellular metabolism and accumulation of toxic lactic acid. Although some cells die from anoxia. - The lack of oxygen destroys additional brain cells by secondary mechanism as it triggers the release of glutamate in addition to activates neuronal receptors known as (NMDA) which allow large amount of calcium followed by glutamate to enter the cells causing disordered enzyme activities that release toxic free radicals which destroy the cells. - This secondary assault extends the zone of cerebral infarction. 2- Hemorrhagic strokes: - Occur when a cerebral blood vessel ruptures and blood is released in brain tissue. - Blood leaks from intracerebral arteries; the collection of blood adds volume to the intracranial contents resulting in elevated pressure. - Hemorrhagic strokes are more common in particular areas of the brain as cerebellum and brain stem. 24  (Fig. 10) Area of Hemorrhagic and Ischemic stroke Risk factors for CVA: Uncontrollable: - Age: Risk of CVA increases with each decade beyond age 55 years. - Sex: Men have a slightly risk than women. - Race: African Americans experience more CVAs than do other groups. - Genetics: Those whose blood relatives have had a CVA are at increased risk. Controllable: - Hypertension: 40%- 90% of clients with CVA have previous hypertension. - Atrial fibrillation: 15% of those with atrial fibrillation, a dysrhythmia associated with thromboembolic complications, develop a CVA. - Hyperlipidemia: High blood cholesterol and low-density lipoprotein (LDL) levels increase the risk for atherosclerosis and CVA. - Diabetes:Elevated blood glucose level increases triglycerides and accelerates their conversion to LDLs. - History of TIA or CVA: 35% of clients who already have had a TIA will have a CVA within 5 years after one CVA, 42% of men and 24% of women have another. - Smoking: Nicotine is a vasoconstrictor. - Obesity: It contributes to hypertension, Hyperlipidemia and diabetes. - Thrombogenic substances: Stimulants as herbal products derived from ephedra plants, estrogens and oral contraceptives increases risk. - Valvular disease or replacement: Thrombi and emboli from and break free from vegetations or valve replacements. 25 Clinical manifestation for stroke: A stroke happens fast. Most people have two or more signs so the most common signs are: 1- Sudden numbness or weakness of face, arm or leg (mainly on one side of the body) - The loss of voluntary movement and/or sensation may be complete or partial. - There may also be an associated tingling sensation in the affected area. 2- Sudden trouble seeing in one or both eyes. 3- Sudden trouble walking, dizziness or loss of balance. 4- Sudden confusion or trouble talking or understanding speech. 5- Sudden severe headache with no known cause. Women may have unique symptoms: 1- Sudden face and arm or leg pain. 2- Sudden hiccups. 3- Sudden nausea. 4- Sudden tiredness. 5- Sudden chest pain. 6- Sudden shortness of breath (feeling like you can't get enough air) 7- Sudden pounding or racing heartbeat. (Fig. 11) Clinical manifestation for stroke 26 Diagnostic evaluation for stroke: 1- Neurological examination. 2- CT scans, MRI scans and Angiogram. 3- Doppler ultrasound and arteriography to detect carotid stenosis. 4- Blood tests to determine hypercholesterolemia. Effects of stroke: It depends on the type of stroke, where the stroke occurs and the extent of brain injury also mild stroke can cause little or no brain damage. Major stroke can cause severe brain damage and even death, it may occur in different parts of the brain. If stroke in the right half of the brain: 1- Problems judging distances: The stroke survivor may misjudge distances and fall or be unable to guide her hands to pick something up. 2- Short-term memory loss: The stroke survivor may be able to remember events from 30 years age, but not what she ate for breakfast that morning. If stroke in the left half of the brain: 1- Speech and language problems: The stroke survivor may have trouble speaking or understanding others. 2- Slow and cautious behavior: The stroke survivor may need a lot of help to complete tasks. 3- Memory problems: The stroke survivor may not remember what she did ten minutes ago or she may have a hard time learning new things. If stroke in thecerebellum: - Abnormal reflexes of the head and upper body. - Balance problems. - Dizziness, nausea and vomiting. 4- If strokes in the brain stem: - Patients with a brain stem stroke may also develop paralysis or not be able to move or feel on one or both sides of the body. - The brain stem controls all our body's functions that we don't have to think about, such as eye movements, breathing, hearing, speech and swallowing. - Since impulses that start in the brain must travel through the brain stem on their way to the arms and legs. 27 Medical management for stroke: 1- Pharmacological approach: A CVA is a medical emergency, treatment varies and is directed toward relieving the cause if known and aimed at rehabilitation and prevention of future CVAs. - Stroke caused by blood clots can be treated with clot-busting drugs as tissue plasminogen activator (TPA) is a thrombolytic agent.It must be given within three hours of the start of a stroke to work - This is why it is so important for a person having a stroke to get to a hospital fast for administer medications to decrease brain edema. - Other medications are used to treat and to prevent stroke anticoagulants as warfarin also antiplatelet agents as aspirin to prevent a stroke in patients with high risk. - Hypothermia also is being used to protect damaged cells by reducing their metabolic need for oxygen. 2- Surgical approach: If atherosclerosis of the carotid artery is the cause a carotid endarterectomy is considered. Nursing management for stroke:During acute phase (1st 24-48hrs). 1- Maintain patient airway: an air way, endotracheal or tracheostomy, may have been inserted, oxygen should be administered as ordered. 2- Position the patient on his side to prevent aspiration. 3- Remove secretion from airway. 4- Precaution should be taken to avoid prolonged suctioning which would increase intracranial pressure. 5- Monitor respiratory function by auscultation of chest, observing chest movement and arterial blood gases. 6- Monitor vital signs frequently. 7- Monitor neurological assessment frequently. 8- Monitor urinary function (a Foley catheter is usually inserted). 9- Maintain intake and output record. 10- Evaluate fluid and electrolyte balance. 11- Establish seizure precautions as necessary. 28 Post-acute phase and rehabilitation: 1- Provide routine hygienic care. 2- Monitor vital signs and neurological assessment. 3- Perform passive (ROM) exercises 4 times daily to all joints. 4- Apply change position every 2 hours. 5- Elevate the head of the bed 30 degree to control the increased ICP. 6- Apply elastic stocking. 7- Apply catheter care (if present). 8- Make sure that the patient is safe and prevent falls. 9- Encourage patient to independence as possible. 10- Feel hemiplegic's patients by placing the food on the good side of the mouth. 11- Provide good skin care. 12- Assist the patient with their assistive and supportive devices. 13- Follow the ordered bowel and bladder retraining program. 14- Help the person with their activities of daily living (both,get dressed and eat). 15- Assist the patient with mobility and ambulation. 16- Encourage and support the patient. - It is important for all health care providers to give the stroke's patient and their family member's encouragement and support. - This is a very difficult time for them. - Adjust communications to be appropriate for the patient's deficits. Transient ischemic attach (TIA): It is a sudden, brief attack of neurologic impairment caused by a temporary interruption in cerebral blood flow. - Symptoms may disappear within one hour and come continue for as long as one day. - TIA is a warning that CVA can occur in the near future. 29  Seizures and Epilepsy Learning objectives: At the end of lecture the student will be able to: 1- Define the seizures and epilepsy. 2- Differentiate between the three phases of grand mal seizure. 3- Describe diagnose, investigation for seizures and epilepsy. 4- Illustrate a teaching plan for patient and the family. 5- Develop nursing care during and after seizure. 6- List complications during and after seizure. 7- Discuss action patient before, during and after anticonvulsant therapy. 30  Seizures Disorders Management (Seizures and Epilepsy) Definitions: Seizure: it is a brief episode of abnormal electrical activity in the brain(abnormal motor, sensory, autonomic or psychic activity) resulting from sudden excessive discharge from cerebral neurons.. Convulsion: it is one manifestation of a seizure characterized by spasmodic contractions of muscles. Epilepsy: is an abnormal electrical disturbance in one or more areas of the brain,it is a group of syndromes characterized by chronic recurrent pattern of seizures. Aura: A sensation that occurs immediately before the seizure, it is sensory (hallucinatory odor or sound) or a sensation of weakness or numbness. N.B: - Most seizures last from 30 seconds to 2 minutes and do not cause harm. - It is a medical emergency if seizures last longer than 5 minutes or if a person has many seizures and does not wale up between them. - Having a seizure does not necessary mean that a person has epilepsy. Pathophysiology and Etiology: Seizure disorders are classified as idiopathic (no known cause) or acquired causes. Causes of acquired seizures: 1- High fever 2- Electrolyte imbalances. 3- Uremia, hypoglycemia and hypoxia. 4- Brain tumor. 5- Drug abuse and alcohol withdrawal. The known causes of epilepsy: Once the cause is removed the seizures cease, it includes: 1- Brain injury at birth. 2- Head injuries and inborn errors of metabolism. 31 Types of Seizures: Seizures are divided into two general categories: partial Seizure and generalized Seizure as the following: 1- Partial Seizures: Partial or focal seizures it begin in a specific area of the cerebral cortex, it can progress to generalized seizures and has two subcategories as the following: (Fig. 12) Types of seizures a- Partial Elementary with simple symptoms: - Usually does not lose consciousness. - The seizure lasts less than one minute. - Usually terms jacksonian, focal motor and focal sensory are used to describe it. - It is also divided into Partial elementary with motor symptoms: which usually companied by: Uncontrolled jerking movements of a body part as finger, mouth, hand or foot. Partial elementary with sensory symptoms: which usually companied by: hallucinatory sights, sounds and odors, mumbling and the use of nonsense words. 32  (Fig. 13) Partial motor and somatosensory seizures b- Partial Elementary with complex symptoms: - May have several sensory or motor manifestations. - It last less than one minute and after the seizure the client often is confused. - Manifested by automatic repetitive movement (automatisms) as smacking and picking at clothing or objects. - Usually terms psychomotor and psychosensory are used to describe it. (Fig. 14) complex partial seizures 33 Generalized Seizures: It involve the entire brain and characterized by loses consciousness, seizure may last from several seconds to several minutes. There are three types of generalized seizures as the following: a- Absence Seizures: - Referred to as petit mal seizures and more common in children, adolescent at the onset of puberty. - It characterized by a brief loss of consciousness during which physical activity ceases. - The patient stares by the eyelids flutter, lips move, and slight movement of the head, arms and legs. - It last for a few seconds and falls to the ground and it often go unnoticed. - People with absence seizures can have them many times a day. b- Myoclonic Seizures. - It characterized by sudden excessive jerking of the arms,leg or entire body. - These seizures are brief and the muscle activity is so severe that the client falls to the ground. c- Tonic-Clonic Seizures: - It referred to as grand mal seizures, characterized by a sequence of event that begins with a preictal (prodromal) phase. (Fig. 15) tonic – clonic seizures 34  Prodromal phase: It the time immediately before a seizure and consists of vague emotional changes as depression, anxiety and nervousness. It lasts for minutes or hours and followed by an aura which occurs a day before the attack. - The aura is followed by the epileptic cry The epileptic cry: It characterized by spasm of the respiratory, throat and glottis muscles. - It precedes loss of consciousness and the ensuing tonic and clonic phase resulting in jerking thrashing movement of the arms and legs. - Cyanoticpaleskin, spasmodic breathing, frothing saliva, tightly clenched jaws, may bite of tongue, lip and inner cheek. - Eyes are open, fixed dilate pupils for few seconds. - Urinary or fecal incontinence is common. - It lasts for one minute or more thin gradually subsides and followed by the postictal phase. Postictal phase:It characterized by headache, fatigue, deep sleep, confusion, and nausea and muscle soreness. - Fall into a deep sleep for several hours. Status epilepticus:Is relatively rare, it characterized by a series of tonic- clonic seizures in which the client dose not regain consciousness between seizures. - It is dangerous condition can lead to death. - It can occur spontaneously in acute neurologic disorders or for unknown or abrupt discontinuation of anticonvulsant medication. 35  (Fig. 16)Phases of epilepsy Nursing intervention during seizure: 1- Provide privacy. 2- Patient should be lowered to the floor and a soft object placed under his head to prevent injury. 3- If patient has fallen to the floor, at the onset of a seizure. He should not be moved during the attack. 4- Loosen constrictive clothing. 5- Push aside any furniture that may injured the patient during the seizure. 6- If the patient is in bed, remove pillows and raise side rails. 7- If an aura precedes the seizure, insert an oral airway to educe bite of tongue or cheek. 8- Do not try to pry open jaws that are clenched in a spasm to insert anything. This can lead to broken teeth and injury to the lips and tongue. 36 9- Do not attempt to restrain the patient during the seizure. It can produce injury. 10- If possible place the patient on one side with head flexed forward, which allow the tongue to fall forward and facilitates drainage of saliva and mucus. 11- Set up suction equipment at the patient's bedside. 12- Use during or after a seizure to clear the patient's airway. 13- Institute and reinforce the importance of anticonvulsant drug therapy: - Anticonvulsant drug therapy is a means of controlling the condition to establish and maintain an anticonvulsant level in the brain that suppresses seizures with minimal side effects, It is not a cure, it must be withdrawn gradually or patient may get status epilepticus. - Initially dosage will have to be monitored and altered to provide maximum control with minimum side effects. Observe and Report these items during seizures: - Kind of convulsion, duration of seizure, - Movement of eyes, pupils dilate or constrict - How pulse and respiration are affected - Changes in skin color. - Grinding or clenching of teeth. - Diaphoresis, urinary or fecal incontinence. Nursing intervention after seizure: 1- Keep bed flat and patient turned on his side until he is alert to maintain airway patent. 2- Room lighting should be dim and noise kept to a minimum. 3- Loosen restrictive clothing (if not done during seizure). 4- Check vital signs immediately following seizure and every 30 minutes (or as ordered) until patient is alert. 5- Check lips, tongue and inside of mouth for injuries. 6- If patient is incontinent, change clothing and bedding with as little disturbance as possible. 7- If the patient becomes agitated (postictal) use gentle restraint. 8- Convulsions should be described in details in the nurse's note, and reported to the physician. Documentation after seizure: - All precautions taken. 37 - All activity observed during a seizure, to include the time, location, circumstances, length of seizure activity and vital signs. - Any injury during a seizure. Patient teaching after seizure: 1- Give patient information about nature of his disorder, long term plan of treatment, side effects of medications. 2- Instruct patient to keep record of events surrounding his seizures (number, duration, time, sleep/eating patterns). 3- Avoid stimulation hat precipitate seizure activity: - Sudden loud noises. - Flickering lights. - Antihistaminic and sedative. - Fatigue, infections and emotional loss. 4- Make adjustments in life style to have a life as normal as possible. - Avoid activities as driving a car. - Swimming, diving skiing, horse riding. 5- Patient should carry an identification card include the following description for: - The seizure disorder. - Current therapeutic regimen. - Phone number of physicians. - Home phone number of patient. 6- Help family to accept disease and patient. Nutrition Notes: - Anticonvulsants impair vitamin D metabolism, leading to calcium imbalance, rickets, and osteomalacia if supplemental vitamin D is not given. - A high-fat diet (ketogenic nutrition) is used as part of treatment in children Medical intervention: Some types of medications are given to control seizures as: 1- Anticonvulsants: as phenytoin (Dilantin), carbamazepine (Tigretol), Valproic acid (Depakene, Depakote). But has side effects as: - Nystagmus, rash, sedation, gingival hyperplasia, liver toxicity - Dizziness, ataxia bone marrow suppression. 38 2- Barbiturates: a Phenobarbital (Luminal) with side effect as sedation, rash, hyperactivity, ataxia, respiratory depression. 3- Benzodiazepines: as diazepam (Valium) with side effect as sedation, respiratory depression and hypotension. Surgical intervention: - Seizures that are caused by brain tumor, brain abscess or other disorders often require surgical intervention. - Surgery for epilepsy is not considered unless the client dose not responds to drug therapy and seizures are frequent and severe. 39  Intracranial Surgery (Craniotomy) Management Learning objectives: At the end of this lecture student will be able to: 1- Define craniotomy. 2- Mention indications for craniotomy. 3- Identify types of craniotomy. 4- Describe pre and post-operative care for patient undergoing craniotomy. 5- List post-craniotomy complications. 40  Intracranial Surgery(Craniotomy) Management Definitions: Craniotomy: A craniotomy is a temporary surgical opening of part of the cranium or skull to gain access tostructures beneath the cranial bones. Craniectomy: It is removal of a portion of a cranial bone. Cranioplasty: It is the repair of a defect in a cranial bone, a metal or plastic plate or wire mesh is used to replace the removed bone or to reinforce a defect in a cranial bone. Tentorium: It is a double fold of dura mater that separates the cerebrum from the cerebellum. Indications for craniotomy: 1- Brain tumor. 2- Remove a blood clot and control hemorrhage. 3- Inspect the brain to repair damaged tissues or blood vessels. 4- Perform a biopsy. 5- Relive pressure inside the skull. Types of craniotomy: Two basic ways to open the skull: 1- Supratentorial approach: above the tentorium, curving incision from behind the hairline in front of the ear. 2- Infratentorial approach: below the tentorium, curving incision at the nape of the neck. (Fig 17) Supratentorial approach (Fig.18) Infratentorial approach 41 Preoperative care for craniotomy: Perform and record a preoperative neurological assessment that includes: 1- Level of consciousness (LOC) 2- Motor and sensory function. 3- Cranial nerve function. 4- Papillary reaction. 5- Abnormal behavior. Before the surgery: 1- Patients are usually given drugs to ease anxiety. 2- Other medications to reduce the risk of swelling, seizures and infection after the operation. 3- Fluids may be restricted and a diuretic may be given before and during surgery. 4- Prepare the head as ordered may include an antibacterial shampoo. - The scalp is shaved in the operating room right before surgery. - This is done so that any small nicks in the skin won't have a chance to become infected before the operation. 5- Preoperative teaching process should include reinforcement of information specific to the preoperative process, expectation for hospitalization and the initiation of discharge planning. 6- Teach the patient postoperative activities which include: - Diaphragmatic breathing for promotion of lung ventilation and blood oxygenation. - Coughing exercises which promotes the removal of chest secretions (vigorous coughing is contraindicated). - Foot and leg exercises for improving circulation and muscles ton and turning. Postoperative care for craniotomy: 1- Assessing respiratory function is essential because small degree of hypoxia can increase cerebral ischemia and neurologic checks are made frequently. - It is important to the patient to takes deep breath to allow the air sacs to expand. - This is important to reduce the risk of postoperative pneumonia. 42 2- In Supratentorial approach: - The head of the bed is elevated 30-45 degrees, pillow under head and shoulder, align neck and avoid positioning on operative side. 3- In Infratentorial approach: - Head of the bed must be flat, keep client off back, small pillow under head, neck alignment. 4- Continuous neurological assessment, especially for intracranial pressure (ICP). 5- Seizure precautions. 6- Body temperature regulation and hyperthermia. 7- Turning, deep breathing and leg exercises every two hours. 8- Reinforce dressing and check for cerebrospinal fluid (CSF) or drainage. 9- Give pain medication as prescribed. 10- Put cool saline solution-soaked gauze pads on the eyelids to reduce edema. - Leave in place for about 15 minutes each hour and then replace with new pads at the next application. - Bacteria will grow beneath saline-soaked pads if they are reused or left on the eye for extended periods. 11- IV fluids will be ordered during the initially recovery period. - IV fluids will be stopped when the patient can takes fluids and foods by mouth. - Fluid intake and output will be carefully monitored for the first 48 hours. 12- Initially a diet of clear liquids will be started and if this is tolerated the diet will be increased gradually to a regular diet. 13- Depending on the type of brain surgery, the patient will need to take medications. - Steroid medication (to control swelling) and anticonvulsant medication (to prevent seizures) are commonly prescribed following craniotomy. 14- Staying in hospital will be between five days and two weeks. - The length of stay depends on many factors, as the type of surgery and whether or not the patient experienced complications or required further operations. 15- Stitches (or staples) are usually removed about one week after surgery. 43 Post-craniotomy complications: 1- Bleeding. 2- Swelling of the brain. 3- Brain damage. 4- Excessive increase in intracranial pressure. 5- Infection. 6- Seizures. 7- Injury from the head pin fixing device. 8- Respiratory complications. 9- Urinary bladder disorder. Home recovery instructions after craniotomy: 1- Incision site should remain dry while the sutures or staples are still in place. The patient will be able to shower and wash head with a mild shampoo 24 hours after the sutures or staples are removed. The incision should be kept clean. 2- Do not place ointment or powders on the incision unless prescribed by physician. 3- Eating a well-balanced diet is important for proper wound healing. 4- Following craniotomy the patient may feel fatigued for a period of 2-6 weeks after surgery; this is a normal part of healing and is expected. - The patient must rest when feels tired and not to overextend him or herself. 5- Following craniotomy: - The wound may have a small pocket of fluid beneath it for a while; this is normal and should disappear with time. - The skin on one side of the wound may feel numb for some months. 6- Returning to work (for light duties only) after about six weeks and driving should be avoided before three months. 7- Walking is a recommended form of exercise. Patient information about craniotomy complications: - Patient should immediately return to hospital if the patient or his or her family notices the following: - Fluid and electrolyte imbalance. - Venous thrombosis especially in the arms and leg - A change in the skin around the incision as redness or swelling or any drainage from the incision line. 44 - The patient cannot walk, speaks or use hands like normally he or she can. - Severe headache that pain medicine does not relieve. - No improvement in the pain after surgery. - Faint or a seizure and increased ICP. - Leakage of CSF. - The patient become very sleepy and difficulty staying awake. - The patient has fever or chills. - The patient has nausea and vomiting that does not let up. - Stress ulcer and hemorrhage. 45  Unconscious Patient Management Learning objectives: At the end of the lecture the student will be able to: 1- Define level of consciousness, altered level of consciousness and unconscious patient. 2- Identify causes of unconscious patient. 3- List clinical manifestations of altered level of consciousness. 4- Identify diagnostic evaluation for unconscious patient. 5- Discuss appropriate nursing assessment of the unconscious patient. 6- Describe the multiple needs of the unconscious patient. 7- Discuss nursing management for unconscious patient. 46  Unconscious Patient Management Definitions: Level of consciousness: It is most critical clinical piece of data assessed in the comatose patient with decreasing level of consciousness. Conscious: The client responds immediately, fully and appropriately to visual, auditory and other stimulation. Somnolent or lethargic: The client is drowsy or sleepy at inappropriate times but can be aroused only to fall asleep again. Stuporous: The client is aroused only by vigorous and continuous, usually by manipulation or strong auditory or visual stimuli. Altered level of consciousness (LOC): It is a condition in which the patient is unresponsive to and unaware of environmental stimuli. Unconscious patient: It is a patient who is not oriented, does not follow commands, or needs persistent stimuli to achieve a state of alertness. Semi- comatose: The client is unresponsive except to superficial, relatively mild painful stimuli to which the client makes some purposeful motor response to evade stimulation. 47 Coma: Is a clinical state of unconsciousness in which the patient is unaware of self or the environment for prolonged periods (days to months or years), the client responds only to very painful stimuli by fragmentary, delayed reflex withdrawal. Causes of consciousness: 1- Neurological (head injury or stroke) 2- Toxicological (drug over dose or alcohol intoxication). 3- Metabolic (hepatic, renal failure and ketoacidosis). Clinical manifestations for consciousness: 1- Decrease he patient's state of alertness and consciousness. 2- Change in the following: - Papillary response. - Eye response. - Verbal response and motor response. Diagnostic evaluation for consciousness: 1- Scanning as (CT). 2- Imaging as (MRI). 3- Electroencephalography (EEG). 4- Laboratory tests include analysis of : - Blood glucose and electrolytes. - Serum ammonia. - Blood urea nitrogen. - Calcium level and prothrombin time. - Arterial blood gases levels. Nursing management for unconscious patient: Patient Assessment: Same as neurological assessment. 1- Ineffective air way clearance related to altered level of consciousness: Nursing interventions: 1- Maintain a patent airway by proper positioning of the patient, whenever possible; position the patient on his side with the chin extended. This prevents the tongue from obstructing the airway. 2- The patient requires frequent suctioning and oral hygiene. 3- Suctioning is performed to remove secretions from the posterior pharynx and upper trachea. 48 4- The chest is auscultated at least every 8 hours for adventitious breath sounds or absence of breath sounds. 5- Reposition the patient from side to side to prevent pooling of mucous and secretions in the lungs. 6- Chest physiotherapy and postural drainage are initiated to promote pulmonary hygiene, unless contraindicated by the patient's underlying condition. 7- Always have suction available to prevent aspiration of vomits. Nursing diagnosis: 2- Risk for fluid volume deficit related to inability to take in fluids by mouth: Nursing intervention: 1- IV solutions and blood transfusions for patient with intracranial conditions must be administered slowly. If given too rapidly, they may increase ICP. 2- The quantity of fluids administered may be restricted to minimize the possibility of producing cerebral edema. 3- When tube feeling an unconscious patient, it is best to place the patient in a sitting position (fowler's or semi-fowlers) and support with pillows. 4- This permits gravity to help move the feeding or medication, observe the patient for signs of dehydration or fluid overload. 5- Keep accurate records of intake and urine output. 3- Impaired oral mucous membrane related to mouth breathing and altered fluid intake: Nursing interventions: 1- Provide oral hygiene at least twice per shift. Include the tongue: all tooth surfaces and all soft tissue areas. 2- The unconscious patient is often a mouth breathing, this causes saliva to dry and adhere to the mouth and tooth surfaces so the mouth is cleansed and rinsed carefully to remove secretions and to keep the mucous membranes mist. 3- A thin coating of petrolatum on the lips prevent drying, cracking and encrustations. 4- If the patient has an endotracheal tube: the tube should be moved to the opposite side of the mouth daily to prevent ulceration of the mouth and lips. 49 4-Risk for impaired skin integrity related to immobility: Nursing interventions: 1- The unconscious patient should be given a complete bath every other day this prevents drying of the skin. 2- The patient's face and perineal area should be bathed daily. 3- The skin should be lubricated with moisturizing lotion after bathing. 4- The nails should be short as many patients will scratch themselves. 5- Apply petrolatum to the lips to prevent drying. 6- Keep the nostrils free of crusted secretions. Prevent drying with a light coat of lotion, petrolatum, or water-soluble lubricant. 7- Check the eyes frequently for signs of irritation or infection. 8- Use only cleansing solutions and eye drops ordered by the physician. 9- One such solution, methyl cellulose (referred to as artificial tears) may be ordered for instillation at frequent intervals to prevent irritation. 10- If the patient is incontinent, the perineal area must be washed and dried thoroughly after each incident. 11- Change the bed linen if damp or soiled. 12- Observe the skin for evidence of skin breakdown. 13- Regular schedule of turning to avoid pressure, which can cause breakdown and necrosis of the skin. 14- Maintaining correct body position is important equally important is passive exercise of the extremities so that contractures are prevented. 15- The use of foam boots aids in the prevention of foot drop and eliminates the pressure of bedding on the toes. 5- Impaired tissue integrity of cornea related to diminished or absent corneal reflex: Nursing intervention: 1- Protect the eyes from corneal irritation. 2- Make sure the patient's eye is not rubbing against bedding. 3- Inspect the size of the pupils and condition of eyes with a flashlight. 4- Irrigate eyes with sterile prescribed solution. 5- Instill prescribed ophthalmic ointment. 50 6-Ineffective thermoregulation related to damage to hypothalamic center: Nursing interventions: 1- Cool sponge baths and electric fan blowing over the patient to increase surface cooling may be helpful. 2- Frequent temperature monitoring is indicating to assess the patient's response to the therapy. 3- To prevent an excessive decrease in temperature and shivering my increase cellular oxygen demands and result in cellular hypoxia; it may also increase ICP by isometric muscle contraction. 7-Impaired urinary elimination (incontinence or retention) related to impaired in neurological sensing and control: Nursing intervention: 1- The unconscious patient is either incontinent or has urinary retention. 2- The bladder is palpated at intervals to determine whether urinary retention is present. 3- Insert an indwelling urethral catheter for short-term management. 4- Use intermittent bladder catheterization for retention as soon as possible. 5- Monitor for fever and cloudy urine, inspect the urethra for supportive drainage. 6- Initiate a bladder training program as soon as consciousness is regained. 8-Bowel incontinence related to impaired in neurological sensing, control and altered in nutrition: Nursing intervention: 1- The abdomen is assessed for distention by listening for bowel sounds and measuring the girth of abdomen with a tape measure. 2- There is a risk of diarrhea from infection, antibiotics and hyperosmolar fluids. 3- Immobility and lack of dietary fiber may cause constipation. 4- Rectal examination for signs of fecal impaction. 5- Stool softeners may be prescribed to facilitate bowel emptying, a glycerin suppository may be indicated. 51  9-Risk for injury related to decreased level of consciousness: Nursing intervention: 1- Keep side rails up. 2- Pad the rails with pillows or folded blankets. 3- Keep stray objects out the bed, use draw sheets for easier turning. 4- Use restraints only with physician's order. 5- Precautions to prevent restraint from becoming restricting. 6- Do not cut off circulation. Do not irritate the skin. Evaluation: Expected patient outcomes: 1- Maintain clean airway. 2- Maintain adequate fluids status. 3- No corneal irritation. 4- Maintain health oral mucous membrane. 5- Maintain normal skin integrity. 6- Effective thermoregulation. 7- Has no urinary retention. 8- Maintain effective bowel elimination. 9- Experience no injuries. 52  Unit IV Nursing Management of Patient with Alterations in Skin Integrity (Burn) 53  Burn Injury Learning objectives: At the end of lecture the student will be able to: - Discuses anatomy and physiology of the skin - Define of burn, causes and types of burn - Discuses effect of burn on the body systems - Discuses management of patient with burn 54 Introduction: As a burn is a traumatic injury the skin and underlying tissues burns is painful and disfiguring and may require long hospitalizations. Severe burns can be life threatening or fatal. Most burns occur in the home and can be preventable. Often the burn injury is the result of the individual's own action. Feelings of anger and guilt can complicate recovery and the individual may have self-image disturbances also family relationships can be strained. A burn injury can affect people of all age groups, in all socioeconomic groups. An estimated 500, 000 people are treated for minor burn injury annually. The number of patients who are hospitalized every year with burn injuries is more than 40, 000, including 25, 000 people who require hospitalization in specialized burn centers across the country. The remaining 5, 000 hospitals see an average of three burns per year. A nurse who cares for a patient with burn injury should be knowledgeable about the physiologic changes that occur after a burn, as well as astute assessment skills to detect subtle changes in the patient’s condition. Anatomy and physiology of the skin: Skin is the largest organ of the body; it composed of three layers as the following: 1- Epidermis: It is an epithelial structure where two layers types of cell are recognized namely: a- Keratinocytes: Is the main bulk of the skin responsible for prevent excessive fluid loss from the body and repel pathogens. b- Dendritic: - Are mainly melanocytes and Langerhans cells. - Melanin is response about color of skin and hair. - Production of melanin control by hormone (melanocytes) selected by hypothothalamus of the brain. c- Langerhans cell: play role in immune system. And transport the antigens to the lymph system to active the lymphocytes. 2- Dermis: Composed of the following layers: 55 - Papillary: Lies directly beneath epidermis and is composed fibroblast producing one form of collagen and connective fibers. - Reticular: lies the papillary layers also produce collagen and elastic bundles. - Skin gland: sebaceous glands, sweat glands. 3- Subcutaneous tissue: Is the most layer of the skin it is primarily adipose tissue, which provides a cushion between the skin layers, muscle and bones. Definition of burn: Burns are a form of traumatic injury caused by thermal, electrical, chemical or radioactive agents. Causes of burns: 1- Thermal burns: Are caused by exposure to contact with flame, hot liquids or stream. 2-Chemical burns: Are caused by tissue contact with strong acids, alkalis or organic compound. - Electrical burns: It is caused by intense heat generated by electrical energy as it passes through the body. 3- Radiation burn: Radiation burns are the least common type of burn injuries and are caused by exposure to a radioactive agent. Effect of burn on the body systems: 1- Systemic response: The initial systemic response following a major burn injury is homodynamic instability resulting from: - Loss of capillary integrity. - Subsequent shift of fluid from the intravascular space into the interstitial spaces. 2- Cardiovascular response: At onset of burn shock: - Cardiac output decrease. - Vascular volume decrease. - Decrease of blood pressure. The sympathetic nervous system releases catecholamine, which results in increase in peripheral resistance (vasoconstriction), increase in pulse rate. 56 3- Effects on fluids, electrolytes and blood volume: - Circulating blood volume decrease. - Massive cell destruction leads to hyperkalemia. -Fluid shifts and inadequate potassium intake lead to hypokalemia. - Hyponatremia common during the first week of the acute phase. 4- Pulmonary response: - Hyperventilation and increased oxygen consumption. - The majority of deaths from fire are due to smoke inhalation. - The effects of burn shock on cell membrane potential may cause pulmonary edema. - Restrictive defect due to burn of neck. - Initial respiratory alkalosis resulting from hyperventilation. - Respiratory acidosis associated with pulmonary insufficiency as a result of major burn. 5- Renal function response: - Destruction of red blood cells at the injury site results in free hemoglobin in the urine. - Release of antidiuretic hormone resulting in oliguria. - Blood urea nitrogen and creatinine level elevated. - Decrease cardiac output lead to decrease renal blood flow, resulting in acute renal failure. 6- Hematological response: - Red blood cells destroyed lead to anemia. - Hematocrite value may be elevated due to plasma loss. - Abnormalities in coagulation including decrease in platelets (thrombocytopenia). 7- Neuroendocrine system response: - Direct nerve injury may occur after electrical injury. - Encephalopathy. - Catecholamine (epinephrine and nor epinephrine) are released. - Epinephrine promotes hyperglycemia. - Nor epinephrine causes an initial vasoconstriction after the burn injury. - The adrenal cortex is stimulated to form cortisol stimulate aldosterone secretion in response to the decrease in intravascular sodium and hypovolemia. 8- Immune system response: Patient liable to infection due to: - Loss of skin barrier and presence of eschar. 57 - Hypoxia, acidosis and thrombosis of vessels in wound area. 9- Gastrointestinal response: - Peristalsis decreases. - Gastric distention. - Nausea and vomiting. - Paralytic ileus. - Ischemia of the gastric mucosa lead to risk for duodenal ulcer and gastric ulcer manifested by occult bleeding and in some cause life threatening hemorrhage. 10- Other systemic responses: - Loss of skin results in an inability to regulate body temperature lead to hypothermia in the early hours post burn. - Hyper metabolism. - Coronial abrasions may result after facial burns. - Chronic complications of electrical burns may involve cataracts or glaucoma. Classification of extent of burn injury: 1- Minor burn injury: - Second degree burn of < 15% total body surface area (TBSA) in adults or > 10% TBSA in children. - Third degree burn of < 2% TBSA not involving special care areas (eye, ears, face, hands, feet, perineum, joints). - Excludes all patients with electrical injury, inhalation injury or concurrent trauma and all poor risk patients (extremes of age, intercurrent disease). 2- Moderate, uncomplicated burn injury: - Second degree burns of 15-25% TBSA in adults or 10-20% in children. - Third degree burns of < 10% TBSA not involving special care areas. - Excludes electrical injury, inhalation injury or concurrent trauma and all poor risk patients. 3- Major burn injury: - Second degree burns > 25% TBSA in adults or > 20% in children. - All third degree burns > 10% TBSA. - All burns involving eyes, ears, face, hands, feet, perineum, joints. - All inhalation injury, electrical injury or concurrent trauma and all poor- risk patients. 58 Anatomical location: In determining the severity of burn injury, the location of injury is always taken in consideration, for example: - Burn of the eyes, face, hands and perineum are rarely considered to be minor or moderate burns, regardless of the estimated percentage. - Burns of the head, neck and chest frequently have associated pulmonary complication. - Burns involving the face often associated corneal abrasion. - Burns of ears are prone to auricular chondritis and are susceptible to infection. - Burns of the hands and joint often require intense physical and occupational therapy. - Burns involving the perineum area prone to infection due to auto- contamination by urine and feces. - Burn of extremities may produce a tourniquet like effect and lead to distal vascular and pulmonary insufficiency Burn depth: 1- First degree burns. 2- Second degree burns. 3- Third degree burn. 4- Fourth degree of burn 59 Classification Burns are classified according to the depth of tissue destruction as superficial partial-thickness injuries, deep partial thickness injuries, or full thickness injuries Burn depth characteristics: Skin Degree Depth Clinical finding Superficial First degree Epidermis Erythema, minor thickness involvement pain, lack of blisters Partial superficial Second degree Superficial Blisters, clear fluid thickness (papillary) dermis and pain Partial deep Second degree Deep (reticular) Wither appearance, thickness dermis with decreased pain. Difficult to distinguish for full thickness Full thickness Third degree Dermis and Hard, leather like underlying tissue and Escher, purple fluid, possibly fascia, bone no sensation or muscle (insensate) Nursing alert: The severity of injury is related to the burn's depth, extent and location and the length of exposure to the burn agent as well as the victim's age and health status at the time of injury Estimate the extent of burns 1- Rule of Nines: A common method, the rule of nines is a quick way to estimate the extent of burns in adults through dividing the body into multiples of nine and the sum total of these parts is equal to the total body surface area injured. 60 Lund and Browder Method: This method recognizes the percentage of surface area of various anatomic parts, especially the head and the legs, as it relates to the age of the patient. Palmer Method: The size of the patient’s palm, not including the surface area of the digits, is approximately 1% of the TBSA, and the patient’s palm without the fingers is equivalent to 0.5% TBSA and serves as a general measurement for all age groups. Associated injuries: - Smoke inhalation. - Hoarseness, cough, singed nasal hairs, oral burns, wheezing. - Carbon monoxide poisoning. - Fractures. - Trauma Management of patient with burn First aid of burn: 1- First aid for minor burns: if the skin not broken (1st degree): - Cool the area for 10 or more minutes or until the pain diminished (Do not) use ice. 61 - Use cool running not cold water or immerse burned area in cool water or cover area with mist cool compresses. - If the burn occurred in a cold environment, do not apply water just a clean, cold, wet towel will also help reduce pain - Cover the burn with sterile gauze, do wrap bandage loosely, non- adhesive because the area will swell, which can lead to pressure on skin. - Protect the burn from friction and pressure. - Don not uses fluffy materials which leaves behind lint and promotes infection. - Reassure the patient and keep them calm. - Do not break blisters which can lead to infection and promote scaring. 2- First aid for severe burns: (second and third degree): - Do not remove burn clothing (unless it comes off easily), but do ensure that the patient is not in contact with burning or smoldering materials. - Make sure the patient airway open. - Cover the burn with a cool moist sterile bandage or clean cloth, do not use a blanket or towel, a sheet is best for large burns. - Do not apply any ointments and avoid breaking blisters. - If fingers or toes have been burned, separate them with dry sterile, non- adhesive dressings. - Elevate the burned area and protect it from pressure or friction. - Take steps to prevent shock. Lay the patient flat elevate the feet about 12 inches, and cover the patient with a coat or blanket. Do not place the patient in the shock position if a head, neck, back or leg injury is suspected or if it makes the patient uncomfortable. - Continue to monitor the patient's vital signs (breathing, pulse, blood pressure). Do not: 62  - Do not apply ointment, butter, ice, medications, fluffy cotton dressing, adhesive bandages, cream, oil spray or any household to a burn. This can interfere with proper healing. - Do not allow the burn to become contaminated, avoid breathing or coughing on the burned area. - Do not apply cold compresses and do not immerse a severe burn in cold water. This can cause shock. - Do not place a pillow under the patient's head if there is an airway burn and they are lying down. This can close the airway. 1- Emergent phase: Begin from onset of injury to complete of fluid resuscitation. Fluid shifts: - Massive fluid shifts out of blood vessels as result of increase capillary permibility. - Water, sodium, plasma and protein moves into interstitial spaces. - The colloid osmitic pressure decrease with loss protein from the vascular space (second space). - Fluid goes into areas with no fluid third spacing e.g., exuded blister formation. - Decrease volume deplitation due to fluid shifts in edema, decrease blood pressure and increase pulse. - Fluid and electrolyte changes in the emergent/ resuscitative phase: Fluid accumulation phase (shock phase) Plasma →interstitial fluid (edema at burn site) Observation Explanation Generalized dehydration Plasma leaks through damaged capillaries. Reduction of blood volume Secondary to: plasma loss, fall of BP, and diminished cardiac output Decreased urinary output Secondary to: fluid loss, decreased renal blood flow, sodium and water retention caused by increased adrenocortical activity, hemolysis of red blood cells, causing hemoglobinuria and myonecrosis or myoglobinuria. Potassium (K+) excess Massive cellular trauma causes release of K+ into 63  extracellular fluid (ordinarily most K+ is intracellular) Sodium Na+ deficit Large amount of Na+ is lost in trapped edema fluid and exudate and by shift into cells as K+ is released from cells (ordinarily most Na+ is extracellular). Metabolic acidosis (base- Loss of bicarbonate ions accompanies sodium loss. bicarbonate deficit) Hemoconcentration (elevated Liquid blood component is lost into extravascular space. hematocrit) Acute Phase The acute or intermediate phase begins 48 to 72 hours after the burn injury. Burn wound care and pain control are priorities at this stage. Acute or intermediate phase begins 48 to 72 hours after the burn injury. - Focus on hemodynamic alterations, wound healing, pain and psychosocial responses, and early detection of complications - Measure vital signs frequently. Respiratory and fluid status remains highest priority. - Assess peripheral pulses frequently for first few days after the burn for restricted blood flow. - Closely observe hourly fluid intake and urinary output, as well as blood pressure and cardiac rhythm; changes should be reported to the burn surgeon promptly. - For patient with inhalation injury, regularly monitor level of consciousness, pulmonary function, and ability to ventilate; if patient is intubated and placed on a ventilator, frequent suctioning and assessment of the airway are priorities. Rehabilitation Phase Rehabilitation should begin immediately after the burn has occurred. Wound healing, psychosocial support, and restoring maximum functional activity remain priorities. Maintaining fluid and electrolyte balance and improving nutrition status continue to be important. - In early assessment, obtain information about patient’s educational level, occupation, leisure activities, cultural background, religion, and family interactions. 64 - Assess self-concept, mental status, emotional response to the injury and hospitalization, level of intellectual functioning, previous hospitalizations, response to pain and pain relief measures, and sleep pattern. - Perform ongoing assessments relative to rehabilitation goals, including range of motion of affected joints, functional abilities in ADLs, early signs of skin breakdown from splints or positioning devices, evidence of neuropathies (neurologic damage), activity tolerance, and quality or condition of healing skin. - Document participation and self-care abilities in ambulation, eating, wound cleaning, and applying pressure wraps. - Maintain comprehensive and continuous assessment for early detection of complications, with specific assessments as needed for specific treatments, such as postoperative assessment of patient undergoing primary excision Priorities in care: - First aid. - Prevention of shock. - Prevention of respiratory distress. - Detection and treatment of injuries. - Wound assessment and initial care Emergency medical management: 1- Suctioning in sever situation or give bronchodilators and monolithic agent. 2- Endotracheal intubations when present edema. 3- Removed immediately if chemicals have contracted the eyes. 4- Assess for cervical spinal injuries or head injury if the patient was involved electrical injury. 5- A history of preexisting disease, allergies and medications and the use of drugs, alcohol and tobacco. 6- Inserted I.V catheter in non-burned area. 7- Give patient large amount of I.V fluids quickly and central venous pressure can be monitored. 8- When patient nauseated, a nasogastric tube should be inserted and connected to suction to prevent paralytic illus. 65 9- An indwelling urinary catheter is inserted to accurate monitoring of urine output and renal function. 10- Basic height, weight, arterial blood gases, hematocrite, electrolyte, urine analysis and chest X- Rays are obtained. Give patients tetanus prophylaxis. Clinical Manifestations The changes that occur in burns include the following: Hypovolemia: This is the immediate consequence of fluid loss and results in decreased perfusion and oxygen delivery. Decreased cardiac output: Cardiac output decreases before any significant change in blood volume is evident. Edema: Edema forms rapidly after burn injury Circulating blood volume : Decreased circulating blood volume. Hyponatremia: Hyponatremia is common during the first week of the acute phase, as water shifts from the interstitial space to the vascular space. Hyperkalemia: Immediately after burn injury hyperkalemia results from massive cell destruction. Hypothermia: Loss of skin results in an inability to regulate body temperature. Prevention of burn injury To promote safety and avoid burns, the following must be done to prevent burns. - Advise that matches and lighters be kept out of reach of children. 66 - Emphasize the importance of never leaving children unattended around fire or in bathroom/bathtub. - Caution against smoking in bed, while using home oxygen, or against falling asleep while smoking. - Caution against throwing flammable liquids onto an already burning fire. - Caution against using flammable liquids to start fires.. - Recommend avoidance of overhead electrical wires and underground wires when working outside. - Advise that hot irons and curling irons be kept out of reach of children. - Caution against running an electrical cord under carpets or rugs - Advocate caution when cooking, being aware of loose clothing hanging over the stove top. - Recommend having a working fire extinguisher in the home and knowing how to use it. Complications of burn injury:- There are a lot of consequences involved in burn injuries that may progress without treatment. 1- Ischemia: As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow. 2- Tissue hypoxia: Tissue hypoxia is the result of carbon monoxide inhalation. 3- Respiratory failure. Pulmonary complications are secondary to inhalational injuries Medical Management:- Burn care is a delicate task any nurse can have and being knowledgeable in the proper sequencing of the interventions is very essential. 1- Transport:- The hospital and the physician are alerted that the patient is en route so that life-saving measures can be initiated immediately. 2- Priorities:- Initial priorities in the ED remain airway, breathing, and circulation. 3- Airway:- 100% humidified oxygen is administered and the patient is encouraged to cough so that secretions can be removed by coughing. 67 4- Chemical burns:- All clothing and jewelry are removed and chemical burns should be flushed. 5- Intravenous access:- A large bore (16 or 18 gauge) IV catheter is inserted in the non-burned area. 6- Gastrointestinal access: If the burn exceeds 20% to 25% TBSA, a nasogastric tube is inserted and connected to low intermittent suction because there are patients with large burns that become nauseated. 7- Clean beddings:- Clean sheets are placed over and under the patient to protect the burn wound from contamination, maintain body temperature, and reduce pain caused by air currents passing over exposed nerve endings. 8- Fluid replacement therapy:- The total volume and rate of IV fluid replacement is gauged by the patient’s response and guided by the resuscitation formula. Nursing Management:- Nursing management in burn care requires specific knowledge on burns so that there could be a provision of appropriate and effective interventions. 1- Nursing Assessment The nursing assessment focuses on the major priorities for any trauma patient; the burn wound is a secondary consideration. - Focus on the major priorities of any trauma patient. The burn wound is a secondary consideration, although aseptic management of the burn wounds and invasive lines continues. - Assess circumstances surrounding the injury. Time of injury, mechanism of burn, whether the burn occurred in a closed space, the possibility of inhalation of noxious chemicals, and any related trauma. - Monitor vital signs frequently. Monitor respiratory status closely; and evaluate apical, carotid, and femoral pulses particularly in areas of circumferential burn injury to an extremity. - Start cardiac monitoring if indicated. If patient has history of cardiac or respiratory problems, electrical injury. - Check peripheral pulses on burned extremities hourly; use Doppler as needed. 68 - Monitor fluid intake (IV fluids) and output (urinary catheter) and measure hourly. Note amount of urine obtained when catheter is inserted (indicates pre burn renal function and fluid status)) - Obtain history. Assess body temperature, body weight, history of pre burn weight, allergies, tetanus immunization, past medical surgical problems, current illnesses, and use of medications. - Arrange for patients with facial burns to be assessed for corneal injury. - Continue to assess the extent of the burn; assess depth of wound, and identify areas of full and partial thickness injury - Assess neurologic status: consciousness, psychological status, pain and anxiety levels, and behavior. - Assess patient’s and family’s understanding of injury and treatment. - Assess patient’s support system and coping skills. Definition of wound dressing: It's a clean of burned area and prescribed topical agent is applied and wound cover with several layers of dressing. Purpose of wound dressing: - To enhance absorption of topical medications. - To protect the wound from any infection. - Promote retention of moisture. - Prevent evaporation of medication. - reduce pain and itching. - To immobilized the wound. - To depride the wound from any dead tissues. - To inhabit or kill microorganism by using dressing with antiseptic properties. Types of wound dressing: there are two types of dressing as exposure method and occlusive method 1- Exposure method: Definition: The wound is treated by exposing it to air, but no dressing applied. Precaution of exposed method: - Keeping the immediate environment free from microorganisms. - Everything coming in contact with the patient must be sterile (line). 69 - Instruct visitors to wear operative gown and not touch the bed or hand the patient or any things. - The patient's room must be comfortable warm with 40%- 50% humidity to prevent excessive evaporative. Occlusive method: Proper application of a plastic wrap dressing includes washing the area, lightly patting it dry, applying the medication to moist skin, covering the medication area with plastic wrap, and covering with a dressing to seal the edges. Wet dressings and ointments should only be applied to affected areas, not to health intact skin, because this can cause maceration of good skin. Nursing care: Continued use of occlusive dressings can cause skin atrophy, folliculitis, maceration, erythema and systemic absorption of the medication. To prevent some of these complications, the dressing is removed for at least 12 out of every 24 hours. Technique of wound dressing changes: - The dressing changed in the patient's unit, hydrotherapy room or treatment area approximately 20 minutes after analgesic agent is administered. - A mask, hair cover, disposable plastic apron or cover gown and gloves are worn by health care personnel when removing the dressing. - The outer dressing are removed and disposed. - Dressing that adhere to the wound can be removed more comfortable if they are moistened with tap water or if the patient is allowed to soak for a few moment in the tub. - The dressing is carefully and gently removed. The wound then cleaned and debrided to remove debris, any remaining topical agent, exudates and dead skin. - During this procedure the wound and surrounding skin are carefully inspected. - Inspect the color, odor, size, exudates, signs of re-epithelization and eschar. - Topical agent is applied and wound cover with several layers of dressing. - Transfer the patient to his bed. 70 Hydrotherapy: Is the bathing of the burn patient in a tub of water or with a water shower to facilitate cleaning and debridement of the burned area. Advantages: - Topical medications, adherent dressing and eschar are more easily removed. - Provides an opportunity for the patient to practice ROM exercises. - Total assessment of the burn area is facilitated, total body cleansing can be achieved. Disadvantages: - Loss of body heat, and loss of sodium. - Uncomfortable and at time painful for patient. - Maintenance of IV lines and ventilator care may be difficult during tubing. - The patient's anxiety level often increases. Wound depridement: Definition: Is a removal of foreign material that surrounding health tissue. Goals of depridement: - To remove tissue contaminated by bacteria and foreign bodies thereby protecting the patient form invasion of bacteria - To remove devitalized tissue or burn eschar in preparation for grafting and wound healing. Types of depridement:There are three types as natural, mechanical and surgical. Natural depridement: The dead tissue separated from the underlying viable tissue spontaneously. Mechanical depridement: Using surgical scissors and forceps to separate and remove the eschar. This technique can be performed by skilled physicians, nurses or done with daily dressing changes and wound cleaning procedures. Surgical debridement: Is operative procedure involving either primary excision (surgical removal of tissue) of the full thickness of the skin down to the fascia or shaving the burned skin layers gradually down to freely bleeding viable tissue. 71 Disorders of wound healing: 1- Scaring: hypertrophy scars and wound contractures. 2- Keloids: A large heaped up maw of scar tissue, keloid may develop and extend the wound. 3- Contractors. Failure to heal related to many factors including: Infection, inadequate maturation and serum albumin level of less than 29/dl. Skin graft: Definition of skin graft: Skin graft is a surgical procedure in which a piece of skin is transplanted from one area to another. Often skin will be taken from unaffected area on the injured person and used to cover a defect often a burn. A skin graft means a healthy layer of replacement skin is transplanted into a skin wound site. Indication of skin graft: - Skin grafts are used to treat skin ulceration. - Burns. - Chronic skin wounds Purposes of skin grafting: - Reduce the course of treatment needed and time in the hospital. - Improve the function and appearance of the area of the body which receives the skin graft. (Fig. 92)Skin graft Types of skin graft: 1- Autograft: Patches of healthy skin taken from another location on a patient's body. 72 2- Allograft (homograft) : Skin taken from other human sources. 3- Xenograft (heterograft): Grafts made from the skin of other animal species. Graft application: - The physician first collects a graft from a donor site, usually with an instrument called a dermatome. - Which shaves very thin slices of skin. Note: If the area of the skin defect is especially large, the harvested skin may be meshed to stretch it into a larger patch. - To ensure that, the skin graft will adhere to the wound, the physician debrides the wound site, thoroughly cleaning it of bacteria, debris and dead skin cells so that the skin graft will adhere to the wound. - The physician then places the graft on the recipient site. The graft is then secured in place with sutures around the edge of the graft. - Ointment and mesh gauze that adheres to the healthy skin surrounding the graft site and places pressure on the graft itself may also be placed on the graft site. - Other support as bandages may be used to help keep the graft in place. - The graft begins to grow and adhere within 48 hours, at the end of four to five days the graft should be adherent. New skin will naturally grow to cover the wound made at donor site. - The donor site will heal in approximately two weeks. The grafted area and donor site may form scars. - If the skin graft is not successful or there is more dead tissue to be debrided the patient will return to operating room for further skin grafting until all wounds are covered. - The overall number of surgeries is determined by the extent of the injury. The skin graft may be rejected due to: 1- Movement. 2- Bleeding. 3- Infection. 4- Poor nutrition. Care of the patient with graft: 1- Occlusive dressings are commonly used initially after grafting to immobilize the graft. 73 2- The first dressing change is usually performed 3-5 days after surgery. 3- If the graft is dislodged, sterile saline compresses will help prevent drying of the graft. 4- The patient is positioned and turned carefully to avoid disturbing the graft or putting pressure on the graft site. 5- If an extremity has been grafted, it is elevated to minimize edema. 6- Assess for edema, hematoma formation, fluid collection and infection. Care of donor site: Donor site must remain clean, dry and free from pressure. Inspect the site daily and assess for bleeding, pain and infection. Possible complications: - Rejection of the skin graft. - Infections at donor or recipient sites. - Bleeding. - Fluid weeping from graft sites. - Scarring Infection control in burned patient 1- Monitoring for clinical manifestation of impending infection, and sepsis. 2- Maintenance of clean environment to reduce the reservoir of microorganisms, through: decrease number of visitors and avoid plant in patient room. 3- Use of aseptic technique for all invasive procedures and wound care. 4- Timely administration of prescribed antimicrobial agents systemic and topical. Universal precautions should be followed when caring all patients. The basic principles for infection control should be followed in burns unit: - Use antimicrobial agents at the wound. - Cap, gown, mask and gloves are worn while caring for the patient with open burn wounds. - Use clean technique when caring directly for burn wounds. Nutritional support for burn patient: Note: Nutritional support consists of three closely linked components: - Assessment of nutritional requirements. - Planning and implementation of dietary regimens. - Monitoring the adequacy of the nutrients provided. 74 Note: Maintenance of adequate nutrition during the acute phase is in promoting wound healing and preventing infection. Nursing diagnoses for burn injuries include - Impaired gas exchange related to carbon monoxide poisoning, smoke inhalation, and upper airway obstruction. - Ineffective airway clearance related to edema and effects of smoke inhalation. - Fluid volume deficit related to increased capillary permeability and evaporative losses from burn wound. - Hypothermia related to loss of skin microcirculation and open wounds. - Pain related to tissue and nerve injury. - Anxiety related to fear and the emotional impact of burn injury. Planning and Goals - To implement the plan of care for a burn injury patient effectively, there should be goals that should be set:- - Maintenance of adequate tissue oxygenation - Maintenance of patent airway and adequate airway clearance. - Restoration of optimal fluid and electrolyte balance and perfusion of vital organs. - Maintenance of adequate body temperature.. Control of pain: Minimization of patient’s and family’s anxiety Nursing Priorities: - Maintain patent airway/respiratory function. - Restore hemodynamic stability/circulating volume. - Alleviate pain. - Prevent complications. - Provide emotional support for patient/significant other - Provide information about condition, prognosis, and treatment. Nursing Interventions 75 Nursing care of a patient with burn injury needs to be precise and effective:- Promoting Gas Exchange and Airway Clearance - Provide humidified oxygen, and monitor arterial blood gases (ABGs), pulse oximetry, and carboxyhemoglobin levels - Assess breath sounds and respiratory rate, rhythm, depth, and symmetry; monitor for hypoxia - Observe for signs of inhalation injury: blistering of lips or buccal mucosa; singed nostrils; burns of face, neck, or chest; increasing hoarseness; or soot in sputum or respiratory secretions. - Report labored respirations, decreased depth of respirations, or signs of hypoxia to physician immediately; prepare to assist with intubation and escharotomies. - Monitor mechanically ventilated patient closely. - Institute aggressive pulmonary care measures: turning, coughing, deep breathing, periodic forceful inspiration using spirometry, and tracheal suctioning. - Maintain proper positioning to promote removal of secretions and patent airway and to promote optimal chest expansion; use artificial airway as needed. Restoring fluid and Electrolyte Balance - Monitor vital signs and urinary output (hourly), central venous pressure (CVP), pulmonary artery pressure, and cardiac output - Note and report signs of hypovolemia or fluid overload. - Maintain IV lines and regular fluids at appropriate rates, as prescribed. - Document intake, output, and daily weight - Elevate the head of bed and burned extremities. - Monitor serum electrolyte levels (eg, sodium, potassium, calcium, phosphorus, bicarbonate); recognize developing electrolyte imbalances. - Notify physician immediately of decreased urine output; blood pressure; central venous, pulmonary artery, or pulmonary artery wedge pressures; or increased pulse rate. Monitoring of nutritional support: 76 - Daily weight measurements. - Measurements of plasma proteins. - Anthropometric measurements. Calculation of nutritional requirements for adult: Kcal: (25xkg) + (40x % burn). Protein (g): (kg) + (3x % burn). Maintaining Normal Body Temperature - Provide warm environment: use heat shield, space blanket, heat lights, or blankets. - Assess core body temperature frequently. - Work quickly when wounds must be exposed to minimize heat loss from the wound. Minimizing Pain and Anxiety - Use a pain scale to assess pain level (1 to 10) differentiates between restlessness due to pain and restlessness due to hypoxia. - Administer IV opioid analgesics as prescribed, and assess response to medication; observe for respiratory depression in patient who is not mechanically ventilated. - Provide emotional support, reassurance, and simple explanations about procedures. - Assess patient and family understanding of burn injury, coping strategies, family dynamics, and anxiety levels. Provide individualized responses to support patient and family coping; explain all procedures in clear, simple terms - Provide pain relief, and give antianxiety medications if patient remains highly anxious and agitated after psychological interventions. Monitoring and Managing Potential Complications 1- Acute respiratory failure: Assess for increasing dyspnea, stridor, changes in respiratory patterns; monitor pulse oximetry and ABG values to detect problematic oxygen 77 saturation and increasing CO2; monitor chest xrays; assess for cerebral hypoxia (eg, restlessness, confusion); report deteriorating respiratory status immediately to physician; and assist as needed with intubation or escharotomy. 2- Distributive shock: Monitor for early signs of shock (decreased urine output, cardiac output, pulmonary artery pressure, pulmonary capillary wedge pressure, blood pressure, or increasing pulse) or progressive edema. Administer fluid resuscitation as ordered in response to physical findings; continue monitoring fluid status. 3- Acute renal failure: Monitor and report abnormal urine output and quality, blood urea nitrogen (BUN) and creatinine levels; assess for urine hemoglobin or myoglobin; administer increased fluids as prescribed. 4- Compartment syndrome: Assess peripheral pulses hourly with Doppler; assess neurovascular status of extremities hourly (warmth, capillary refill, sen