Lecture Notes 1 (NSC 315) PDF

LECTURE NOTES 1 (NSC 315) Unit I: Concepts and Terms in Medical Surgical Nursing Terminologies used in medical and surgical conditions: The surgical team is usually grouped into sterile and unsterile members: I. Sterile members: they perform surgical hand scrubbing, wear sterile gown and gloves and...

LECTURE NOTES 1 (NSC 315) Unit I: Concepts and Terms in Medical Surgical Nursing Terminologies used in medical and surgical conditions: The surgical team is usually grouped into sterile and unsterile members: I. Sterile members: they perform surgical hand scrubbing, wear sterile gown and gloves and work within the sterile field during surgery, they consists of the surgeon, his assistants and the scrub nurse The surgeon: is a physician with specific training and qualifications, who is responsible for determining the surgical procedure required, obtaining the client’s consent, performing the procedure, and following the client after surgery. The assistants: Surgical assistants are classified as either first, second, or third assistants. The first assistant assists in the surgical procedure and may be involved with the client’s preoperative and postoperative care. The assistant may be another physician, a surgical resident, or an RN who has appropriate approval and endorsement to perform surgeries. Second or third assistants are RNs, licensed practical or vocational nurses (LPNs/LVNs), or surgical technologists who assist the surgeon and first assistant. The scrub nurse: is a registered nurse who has completed and passed additional training on surgical procedures. The scrub nurse performs surgical hand scrub, wears a sterile gown and gloves and sets up the sterile tables; preparing sutures, ligatures, and special equipment (such as a laparoscope), and assisting the surgeon and the surgical assistants during the procedure by anticipating the instruments that will be required, such as sponges, drains, and other equipment. The scrub nurse is also responsible for receiving specimens for laboratory examination, counting sponges and needles used during surgeries. II. The unsterile members: are not requested to perform surgical hand scrubbing and are not expected to move closer to sterile field. They include the anesthesiologist who can either be a Physician, anesthetist, registered nurse and a circulating nurse. A Physician is a person who has completed residency training in anesthesia. This person is responsible for administering anesthesia to the client and for monitoring the client during and after the surgical procedure. The anesthesiologist assesses the client before surgery, prescribed preoperative medications, informs the client of the options for anesthesia, and explains the risks involved; The anesthetist may be a medical doctor who administers anesthesia but has not completed a residency in anesthesia, a dentist who administers limited types of anesthesia; and A registered nurse (RN) is the person who has completed an accredited nurse anesthesia program and passed the certification examination (Certified Registered Nurse Anesthetist [CRNA]). The anesthesiologist supervises the anesthetist. The anesthetist may assess the client before surgery, discuss options for anesthesia, preoperative medication orders, administer anesthesia, and monitor the client during and after surgery. The anesthesiologist and anesthetist are not sterile members of the surgical team, they wear theatre (operating room) attire but they do not wear sterile gowns or work within the sterile field. Anesthesiologists or anesthetists classify clients according to their general physical status and assign a risk potential. The circulating nurse: she/he wears operating room (OR) attire but not a sterile gown, his/her responsibilities include obtaining and opening wrapped sterile equipment and supplies before and during surgery, keeping records, adjusting lights, receiving specimens for laboratory examination, and coordinating activities of other personnel, such as the pathologist and radiology technician. Phases of Perioperative Nursing care There are three phases or stages in the surgical process; Preoperative phase: Begins with decision for surgery and ends with transfer to the operating room; Intraoperative phase Begins with transfer to operating room and ends with admission to post anaesthesia care unit (PACU). Postoperative phase: Begins with admission to post anaesthesia Care Unit (recovery room) and continues until the patient is discharged to surgical clinic. Nursing care of surgical patients is directed toward meeting the psychological and physical needs of the patients and this depends on nature and type of the surgery. To achieve this, nursing process approach should be used in rendering such care. Preoperative nursing care: Preoperative care requires a complete assessment of the client. The assessment varies, depending on the: urgency of the surgery and whether the client is admitted the same day of the surgery or earlier. For any preoperative client, however, the nurse must make every effort to gather as much data as possible. Nursing Assessment of the Preoperative Patient On admission, the nurse reviews preoperative instructions, such as diet restrictions and skin preparations, to ensure the client has followed them. If the client has not carried out a specific portion of the instructions, such as withholding foods and fluids, the nurse immediately notifies the surgeon. He or she identifies the client’s needs to determine if the client is at risk for complications during or after the surgery. General risk factors are related to age; nutritional status; use of alcohol, tobacco, and other substances; and physical condition. When surgery is not an emergency, the nurse performs a thorough history taking and physical examination. He or she assesses the client’s understanding of the surgical procedure, postoperative expectations, and ability to participate in recovery. The nurse also considers the client’s cultural needs, specifically as they relate to beliefs about surgery, personal privacy, and disposal of body parts, blood transfusions, and the presence of family members during the preoperative and postoperative phases. If the surgical procedure is an emergency, the nurse may have to omit some tasks because of the client’s condition or need for rapid preparation. There may not be time to perform a thorough assessment or write a complete care plan. Assessment of the client for surgery is essential, but the situation dictates the extent of this process. For a surgical patient, the following data should be collected as these will help in preparing for the needs of the patient: Subjective Data: Health History Questions Demographic information: Name, age, marital status, occupation, religion and tribe? History of condition for which surgery is scheduled: Why are you having surgery? Medical history: Any allergies, acute or chronic conditions, current medications, pain, or prior hospitalizations? Surgical history: Any reactions or problems with anesthesia? Previous surgeries? Tobacco use: How much do you smoke? Pack-year history (number of packs per day per number of years)? Alcohol use: How often do you drink alcohol and what quantity? Coping techniques: How do you usually cope with stressful situations and where do you seek support? Family history: Hereditary conditions, diabetes, cardiovascular, anesthesia problems? Female patients: Date of last menses and obstetrical information? Objective Data: Body System Review Vital signs; TPR and BP, oxygen saturation, Height and weight Emotional status: calm, anxious, tearful, etc. Neurological status: ability to follow instructions Skin: color, warmth, bruises, lesions, turgor, dryness, mucous membranes. Respiratory: infection: cough; breath sounds; chronic obstructive pulmonary disease; respiratory rate, pattern, and effort; barrel chest. Cardiovascular: angina, myocardial infarction, heart failure, hypertension, valvular heart disease, mitral valve prolapse, heart rate and rhythm, peripheral pulses, edema, jugular vein distention Gastrointestinal: bowel sounds, date of last bowel movement, abdominal distention, firmness, ostomy (surgical creation of an opening from inside to outside the body for pee or poop) Musculoskeletal: deformities, weakness, decreased range of motion, crepitation, gait, artificial limbs, and prostheses. The physical and psychological needs of surgical patients Identification of specific needs of a particular patient undergoing surgery can only be achieved when the nurse carried out comprehensive assessment on the patients using the guideline above but generally during the preoperative phase, their psychological needs include: Reduction of fear, anxiety reduction, and respect for spiritual and cultural believes. Informed consent: the client must sign a surgical consent form or operative permit. When signed, this form indicates that the client consents to the procedure and understands its risks and benefits as explained by the surgeon. If the client has not understood the explanations, it is the duty of the nurse to notify the surgeon before the client signs the consent form. Clients must sign a consent form for any invasive procedure that requires anesthesia and has risks of complications. The physical needs of surgical patients are:  Bowel preparation  Management of valuables  Skin preparation and shaving  Preoperative teaching  Pre medication Physical and Psychological preparation of surgical patients Physical Preparation: Preparing a client for surgery is an essential element of preoperative care. Depending on the time of admission to the hospital or surgical facility, the nurse may perform some of the physical preparation, which includes the following: i. Skin preparation: Skin preparation depends on the surgical procedure and the policies of the surgeon or institution. The goal is to decrease bacteria without compromising skin integrity. For planned surgery, the client may be asked to clean the particular area with detergent germicidal soap for several days before surgery. Hair usually is not removed before surgery unless it is likely to interfere with the incision, in this case, the hair is removed with a blade at the time of surgery. ii. Elimination: The nurse may need to insert an indwelling urinary catheter preoperatively for some surgeries, particularly of the lower abdomen. A distended bladder increases the risk of bladder trauma and difficulty in performing the procedure. The catheter keeps the bladder empty during surgery. If a catheter is not inserted, the nurse instructs the client to void immediately before receiving preoperative medication. Enemas or laxatives may be ordered to clean out the lower bowel if the client is having abdominal or pelvic surgery. A clean bowel allows for accurate visualization of the surgical site and prevents trauma to the intestine or accidental contamination by feces to the peritoneum. A cleansing enema or laxative is prescribed the evening before surgery and may be repeated the morning of surgery. iii. Food and fluids: The physician gives specific instructions about how long before surgery food and fluids are to be withheld, often at least 8 to 10 hours before surgery. After midnight the night before surgery, the client usually is not allowed to have anything by mouth (NPO). Many ambulatory surgical centers, however, allow clear fluids up to 3 or 4 hours before surgery. Before these times, the nurse encourages the client to maintain good nutrition to help meet the body’s increased need for nutrients during the healing process. Adequate intake of protein and ascorbic acid (vitamin C) is especially important in wound healing. iv. Care of valuables: The nurse encourages the client to give valuables to a family member to take home. If this is not possible, however, the nurse itemizes the valuables, places them in an envelope, and locks them in a designated area. The client signs a receipt, and the nurse notes their deposition on the client’s chart. If the client is reluctant to remove a wedding band, the nurse may slip gauze under the ring, then loop the gauze around the finger and wrist or apply adhesive tape over a plain wedding band. The client also removes eyeglasses and contact lenses, which the nurse places in a safe location or gives to a family member. v. Attire/grooming: Usually clients wear a hospital gown and a surgical cap in the OR. Hair ornaments and all makeup and nail polish must be removed. If the client is having minor surgery performed under local anesthesia in a room separate from the general surgical suites, the nurse instructs the client on what clothing and cosmetics to remove and provides appropriate hospital attire. The physician may order thigh-high or knee-high anti embolism stockings or order the client’s legs to be wrapped in elastic bandages before surgery to help prevent venous stasis during and after the surgery. Removal of cosmetics assists the surgical team to observe the client’s lips, face, and nail beds for cyanosis, pallor, or other signs of decreased oxygenation. If a client has acrylic nails, one usually is removed to attach a pulse oximeter, which measures blood oxygen saturation level. vi. Prostheses: Depending on agency policy and physician preference, the client removes full or partial dentures. Doing so prevents the dentures from becoming dislodged or causing airway obstruction during administration of a general anesthetic. Some anesthesiologists prefer that well- fitting dentures be left in place to preserve facial contours. If dentures are removed, the nurse usually places them in a denture container and leaves them at the client’s bedside or places them with the client’s belongings. Other prostheses like artificial limbs, are also removed, unless otherwise ordered. Preoperative Medications The anesthesiologist frequently orders preoperative medications, commonly prescribed preoperative medications include: Anticholinergics, which decrease respiratory tract secretions, dry mucous membranes, and interrupt vagal stimulation Histamine2-receptor antagonists, which decrease gastric acidity and volume Opioids which decrease the amount of anesthesia needed, help reduce anxiety and pain, and promote sleep Sedatives, which promote sleep, decrease anxiety, and reduce the amount of anesthesia needed Tranquilizers, which reduce nausea, prevent emesis, enhance preoperative sedation, preoperative anxiety, slow motor activity, and promote induction of anesthesia. Prior to administering preoperative medications, the nurse checks the client’s identification bracelet, asks about drug allergies, checks BP, pulse and respiratory rates, ask the client to void, and makes sure the surgical consent form has been signed. The nurse also reviews with the client what to expect after receiving the medications. Immediately after giving the medications, the nurse instructs the client to remain in bed, places side rails in the up position and ensures that the call button is within easy reach. Preoperative teaching: Teaching clients about their surgical procedure and expectations before and after surgery is best done during the preoperative period. Clients are more alert and free of pain at this time. Clients and family members can better participate in recovery if they know what to expect. The nurse adjust instructions and explanations to the client’s ability to understand. When clients understand what they can do to help themselves recover, they are more likely to follow the preoperative instructions and work with healthcare team members. Information to include in a preoperative teaching plan varies with the type of surgery and the length. The following are examples of information to include in preoperative teaching:  1. Postoperative pain control 2. Explanation and description of the post anesthesia recovery room or post-surgical area. 3. Preoperative medications; when and why they are given and their effects 4. Discussion of the frequency of assessing vital signs and use of monitoring equipment The nurse also explains and demonstrates deep-breathing and coughing exercises, use of incentive spirometry, how to splint the incision for breathing exercises and moving, position changes, and feet and leg exercises. In addition, the nurse must inform the client about intravenous (IV) fluids and other lines and tubes. Sometimes IV fluids are initiated before surgery, along with indwelling catheters or nasogastric tubes. When clients receive demonstrations, it is important that they practice these skills and provide an opportunity for the nurse to assess whether they understood the instructions. Preoperative teaching time also gives clients the chance to express any anxieties and fears and for the nurse to provide explanations that will help alleviate those fears. When clients are admitted for emergency surgery, time for detailed explanations of preoperative preparations and the postoperative period is unavailable. If the client is alert, however, the nurse provides brief explanations. During the postoperative period, explanations will be more complete. Family members require as many preoperative explanations as possible. The purpose of adequate preoperative teaching/learning is for the client to have an uncomplicated and shorter recovery period. He or she will be more likely to deep breath and cough, move as directed, and require less pain medication. The client and family members will demonstrate sufficient knowledge of the surgical procedure (preoperative preparations, and postoperative procedures) and will be able to participate fully in the client’s care. Components of a preoperative teaching plan Information to include in a preoperative teaching plan varies with the type of surgery and the length of the hospitalization. The examples of preoperative teaching include: 1. Psychological preparation of patients Surgical Consent: before surgery, clients must sign a consent form before receiving any preoperative sedatives. When the client or designated person has signed the permit, an adult witness also signs it to indicate that the client or designee signed voluntarily. If an adult client is confused, unconscious, or not mentally competent, a family member or guardian must sign the consent form. If the client is younger than 18 years of age, a parent or legal guardian must sign the consent form. Persons younger than age 18 years of age, living away from home and supporting themselves, are regarded as emancipated minors and sign their own consent forms. In an emergency, the surgeon may have to operate without consent. Each nurse must be familiar with agency policies and state laws regarding surgical consent forms. This witness usually is a member of the healthcare team or an employee in the admissions department. The nurse is responsible for ensuring that all necessary parties have signed the consent form and that it is in the client’s chart before the client goes to the operating room (OR). Criteria for valid informed consent: Voluntary Consent Valid consent must be freely given, without coercion. Incompetent Client Legal definition: Individuals who are not autonomous and cannot give or withhold consent (individuals who are cognitively impaired, mentally ill, or neurologically incapacitated). Informed Subject Informed consent should be in writing. The content should contain the following: a. Explanation of procedure and its risks b. Descriptions of benefits and alternatives c. An offer to answer questions about procedure d. Instructions that the client may withdraw consent e. A statement informing the client if the protocol differs from customary procedure. Client Able to Comprehend Information must be written and delivered in language understandable to the client. Questions must be answered to facilitate comprehension if material is confusing. Transfer to Surgery When the surgery department is ready, the patient is taken to the surgical holding area on a stretcher. The patient’s chart, inhaler medications for those with asthma, and glasses or hearing aids also go to the surgical holding area. The patient can be accompanied by family members. During surgery, the family waits in the surgical waiting area, which is a communication center where the family is kept informed regarding the patient’s status. The physician calls the family there when surgery is over. Families may be given beepers so that they can walk outside or to other areas of the hospital and still be reached. After transfer After the patient goes to surgery, prepare the patient’s room and necessary equipment so it is ready for the patient’s return. Table 1: Preoperative Diagnostic Tests Diagnostic Test Purpose Chest x-ray Detect pulmonary and cardiac abnormalities Oxygen saturation Obtain baseline level and detect abnormality Serum Tests Obtain baseline levels and detect pH and Arterial blood gases oxygenation abnormalities Bleeding time Detect prolonged bleeding problem Blood urea nitrogen Creatinine Detect kidney problem Complete blood cell count Detect anemia, infection, clotting problem Electrolytes Detect potassium, sodium, chloride imbalances Fasting blood glucose Detect abnormalities, monitor diabetes control Pregnancy Detect early, unknown pregnancy Partial thromboplastin & Time prothrombin Detect clotting problem & monitor warfarin time therapy Type and cross match Identify blood type to match blood for possible transfusion Urine Test: Pregnancy Detect early, unknown pregnancy Urinalysis Detect infection, abnormalities Suture Materials Sutures are surgical materials used during operative procedures as ligatures to tie off blood vessels and control bleeding. It is also used to hold a wound together in good apposition until such time as the natural healing process is sufficiently well established to make the support from the suture material unnecessary. The ideal suture material should include:  Have good handling characteristics like not inducing a significant tissue reaction, Have adequate tensile strength, not cut through tissue, be non-electrolytic, be non-allergenic, should be cheap and sterile, Highly uniform tensile strength, permitting use of finer sizes, High tensile strength retention in vivo, holding the wound securely throughout the critical healing period, Consistent uniform diameter and Predictable performance, not predisposed to bacterial growth, as well as rapid absorption potentials.  Easy to handle and ties down well, provides optimum knot security, Minimally reactive in tissue and Capable of holding tissue layers throughout the critical wound healing period securely when, knotted without fraying or cutting, non-carcinogenic,  Absorbed completely with minimal tissue reaction after serving its purpose, non-resistant to shrinking in tissues. Classification of sutures: they are classified according to: Number of strands: Sutures are classified according to the number or strands of which they are comprised. a. Monofilament sutures are made of a single strand of material. Because of their simplified structure, they encounter less resistance as they pass through tissues than multifilament suture material. They also resist harboring organisms which may cause suture line infection. These characteristics make monofilament sutures well-suited to vascular surgeries e.g. Polyamide (Nylon), Polypropylene. b. Multifilament sutures consist of several filaments, or strands, twisted or braided together. This affords greater tensile strength, pliability, and flexibility. Multifilament sutures may also be coated to help them pass relatively smoothly through tissues and enhance handling characteristic e.g. Polyglycolic Acid (PGA), Silk, Polyester. Basis of Absorption: Absorbable sutures are those that will get absorbed to the body and this may be used to hold wound edges in approximation temporarily, until they have healed sufficiently to withstand normal stress or to secure haemostasis. It may be naturally absorbable and these sutures are prepared from the collagen of healthy mammals. Some are absorbed rapidly, while others are treated or chemically structured to lengthen absorption time (Chromic). Absorbed/ digested by body enzymes which attack and break down the suture strand. Plain sutures are absorbed in 70 days with measurable tensile strength for 7-10 days. Chromic sutures are absorbed in over 90 days with measurable tensile strength for 14-21 days. Synthetic Absorbable sutures: They are made of polymer strands which are braided and impregnated or coated with agents that improve their handling properties and colored with an FDA approved dyes to increase visibility in tissue. Synthetic absorbable sutures are hydrolyzed, a process by which water is gradually allowed to penetrate the suture filaments and causing the breakdown of the suture's polymer chain. Absorption normally completes in 60-90 days. Compared to the enzymatic action of naturally absorbable, hydrolyzation results in a lesser degree of tissue reaction following implantation. Varieties of Synthetic Absorbable sutures: Polyglycolic Acid (PGA) Fast Absorbing (Surucryl suture), Polyglycolic Acid (PGA) (Surucryl®), Polyglactin 910 (PLA) Suture (Surucryl 910TM), Monofilament Poliglecaprone 25 Suture, Monofilament Polydioxanone Suture. Non absorbable Materials: Non-absorbable sutures are those, which are not digested by the body enzymes or hydrolyzed in the body tissue. They may be used in a variety of applications: Exterior skin closure; to be removed after sufficient healing has occurred. Within the body cavity, where they will remain permanently encapsulated in the tissue, where lifelong support is required like in cardiovascular surgeries. These sutures may be uncoated or coated, un-coloured or naturally coloured or dyed with FDA approved dyes to enhance visibility. Nature of production Sutures are classified according to mode of production: Natural and Synthetic materials. Natural suture materials can either be absorbable or non-absorbable: These are called catgut and can be plain of chromic (soaked in chromium solution). Was made from the submucosa of sheep gastrointestinal tract, broken down within about one week. Chromic acid delays hydrolysis and catgut has been replaced by synthetic absorbable polymers Non-Absorbable: Silk are strong and handles well but induces strong tissue reaction and its capillarity encourages infection causing suture sinuses and abscesses. Others are Linen and Stainless Steel Wire Synthetic suture materials: These are made from synthetic materials and may be absorbable or non-absorbable Absorbable: Polyglycolic Acid (Dexon). Polyglactin (Vicryl), Polydioxone (PDS). Polyglyconate (Maxon). Non-Absorbable: Polyamide (Nylon), Polyester (Dacron), and Polypropylene (Prolene). Suture sizes Sutures are sized by the USP (United States Pharmacopoeia) scale The available sizes and diameters are: 6-0 = 0.07 mm, 5-0 = 0.10 mm, 4-0 = 0.15 mm, 3-0 = 0.20 mm, 2-0 = 0.30 mm, 0 = 0.35 mm, 1 = 0.40 mm , 2 = 0.5 mm. Needle points: There are five types of needle points that are in common use: Conventional cutting needle Reverse cutting needle Round-body taper-point needle Taper cutting needle Blunt point needle. Prevention of immediate Postoperative Complications Hemorrhage: Hemorrhage can be internal or external. If the client loses a lot of blood, he or she will exhibit signs and symptoms of shock. The nurse inspects dressings frequently for signs of bleeding and checks the bedding under the client, because blood may pool under the body and be evident on the bedding. If bleeding is internal, the client may need to return to surgery for ligation of the bleeding vessels. Blood transfusions may be necessary to replace lost blood. When bleeding occurs, the nurse notes the amount and color on the chart. Bright red blood signifies fresh bleeding; dark, brownish blood indicates older blood. The nurse may need to reinforce soiled or saturated dressings. A written order is needed to change dressings. The nurse also must be aware of any wound drains and the type and amount of drainage expected. If such drainage is expected, the nurse explains to the client that the drainage is normal and does not indicate a complication. Shock: Fluid and electrolyte loss, trauma (both physical and psychological), anesthetics, and preoperative medications all may contribute to shock. Signs and symptoms include pallor, fall in BP, weak and rapid pulse rate, restlessness, and cool, moist skin. Shock must be detected early and treated promptly because it can irreversibly damage vital organs such as the brain, kidneys, and heart. Hypoxia: Factors such as residual drug effects or overdose, pain, poor positioning, accumulation of secretions in the lungs, or obstructed airway predispose the client to hypoxia (decreased oxygen). Oxygen and suction equipment must be available for immediate use. The nurse observes the client closely for signs of cyanosis and dyspnea. Breathing may be obstructed if the tongue falls back and blocks the nasopharynx. If this occurs, the nurse pulls the lower jaw and inserts an oropharyngeal airway. Positioning the client on his or her side also may relieve nasopharyngeal obstruction. Restlessness, crowing or grunting respirations, diaphoresis, bounding pulse, and rising BP may indicate respiratory obstruction. If a client cannot breathe effectively, mechanical ventilation is used. Aspiration: Danger of aspiration from saliva, mucus, vomitus, or blood exists until the client is fully awake and can swallow without difficulty. Suction equipment must be kept at the client’s bedside until the danger of aspiration no longer exists. The nurse closely observes the client for difficulty swallowing or handling of oral secretions. Unless contraindicated, the nurse places the client in a side-lying position until the client can swallow oral secretions. Later Postoperative Period The later postoperative period begins when the client arrives in the hospital room or postsurgical care unit. Because the nurse can anticipate, prevent, or minimize many postoperative problems, he or she must approach the care of the client systematically. Later management of surgical patient in the ward: This period includes respiratory function, general condition, vital signs, cardiovascular function and fluid status, pain level, bowel and urinary elimination, and dressings, tubes, drains, and IV lines. Respiration: The nurse focuses on promoting gas exchange and preventing atelectasis, hypoventilation related to anesthesia, postoperative positioning, and pain is a common problem. Preoperative and postoperative instructions include teaching the client how to take deep breath and cough, and how to splint the incision to minimize it. Clients who have abdominal or thoracic surgery have greater difficulty taking deep breaths and coughing. Some clients require supplemental oxygen. Nursing management to prevent postoperative respiratory problems includes early ambulation, frequent position changing, deep breathing and coughing exercises, and use of incentive spirometer. Hiccups (singultus) may also interfere with breathing. Singultus result from intermittent spasms of the diaphragm and may occur after surgery, especially abdominal surgery. They may be mild and last for only a few minutes. Prolonged hiccups not only are unpleasant but also may cause pain or discomfort. They may result in wound dehiscence or evisceration, inability to eat, nausea and vomiting, exhaustion, and fluid, electrolyte, and acid- base imbalances. If hiccups persist, the nurse needs to notify the physician. Circulation: The nurse must assess the client’s BP and circulatory status frequently. Although problems with postoperative bleeding decrease as the recovery time advances, the client is still at risk for bleeding. Some clients experience syncope when moving to an upright position. To prevent this, and the danger of falling, the nurse helps the client to move slowly to an upright or standing position. The client also is at risk for impaired venous circulation related to immobility. When clients lie still for long periods without moving their legs, blood may flow sluggishly through the veins (venous stasis). Venous stasis predisposes the client to venous inflammation and clot formation in the veins (thrombophlebitis), or clot formation with minimal or absent inflammation (phlebothrombosis). These two conditions are most common in the lower extremities. If the clot travels in the bloodstream (an embolus), it may obstruct circulation to a vital organ, such as the lungs, and causes severe symptoms and possibly death. To prevent venous stasis and other circulatory complications, the nurse encourages the client to move his or her legs frequently and do leg exercises. The nurse also does not place pillows under the client’s knees or calves unless ordered. He or she avoids placing pressure on the client’s lower extremities, applies elastic bandages or anti-embolism stockings as ordered, ambulates the client as ordered, and administers low-dose subcutaneous heparin every 12 hours as ordered. Pain Management: Most clients experience pain after an operation, and a range of postoperative analgesics usually are ordered. Postoperative pain reaches its peak between 12 and 36 hours after surgery and diminishes significantly after 48 hours. Pain creates varying degrees of anxiety and emotions. If accompanied by great fear, the degree of pain can increase. Patients must receive pain and discomfort relief. When patient-controlled analgesia (PCA) is used, clients administer their own analgesic. The nurse assesses for adverse effects of analgesics, timing of the medication in relation to other activities, effects of other comfort measures, contraindications, and source of the pain. The need for pain relief depends on the type and extent of the surgery, and the client. Pain unrelieved by medication may signal a developing complication, which underscores the need for a thorough assessment of the cause of pain Fluids and Nutrition: IV fluids usually are administered after surgery, the length of administration depends on the type of surgery and the client’s ability to take oral fluids. The nurse monitors the IV fluid flow rate and adjusts it as needed while assessing for signs of fluid excess or deficit and notifies the physician of any such signs. Many clients complain of thirst in the early postoperative recovery period, but because anesthesia slows peristalsis, ingesting liquids before bowel activity resumes can lead to nausea and vomiting. Note that, pain medications may also cause nausea and vomiting but once peristalsis has returned and the client is tolerating clear liquids, the nurse helps the client to increase dietary intake. Dietary progression (from clear liquids to a full, solid diet) often depends on the type of surgery, the client’s progress, and physician preference. IV fluids usually are discontinued when the client can take oral fluids and food, and nutritional needs are met Skin Integrity/Wound Healing: A surgical incision is a deliberate cut (wound or injury) which interrupt the continuity of the skin integrity. Initially the client may have a wound or incisional drain, which is a tube that exits from the peri-incisional area into either a dressing or portable wound suction device When assessing the wound, the nurse inspects for approximation of the wound edges, intactness of staples or sutures, redness, warmth, swelling, tenderness, discoloration, or drainage. He or she also notes any reactions to the tape or dressings. The first phase of wound healing is the inflammatory stage, which is when a blood clot forms, swelling occurs, and phagocytes ingest the debris from damaged tissue and the blood clot. This phase lasts 1 to 4 days. The second phase is the proliferative phase, in which collagen is produced and granulation tissue forms. It occurs over 5 to 20 days. The last phase is referred to as the maturation or remodeling phase and lasts from 21 days to several months and even 1 to 2 years. During this phase, the tensile strength of the wound increases through synthesis of collagen by fibroblasts and lysis by collagenase enzymes. In addition, surgical wounds are formed aseptically, depending on the nature of the incision and the underlying condition. There are three modes of wound healing: Primary intention: The wound layers are sutured together so that wound edges are well approximated. This type of incision usually heals in 8 to 10 days, with minimal scarring. Secondary intention: Granulating tissue fills in the wound for the healing process. The skin edges are not approximated. This method is used for ulcers and infected wounds. This type of wound healing is slow, although new products, such as antimicrobial under dressings or calcium alginate dressings, promote healing. Tertiary intention: The approximation of wound edges is delayed secondary to infection. When the wound is drained and cleaned of infection, the wound edges are sutured together. The resulting scar is wider than that with primary intention. TRAUMA Trauma is an unintentional or intentional wound or injury inflicted on the body from a mechanism against which the body cannot protect itself and mostly a leading cause of death in children and in adults younger than 44 years of age. The incidence is increasing in adults older than 44 years of age. Alcohol and drug abuse are leading factors in both blunt and penetrating trauma. Trauma occurs when an individual is subjected to physical or psychological injury or threat of injury. Traumatic events are not only by the nature of the event but also the individual’s perception of it as overwhelming especially when cases of abuse, assault, serious medical illness, natural disaster and neglect are experienced. A person does not need to experience a traumatic event directly in order to feel its effects. Events that threaten an individual’s safety, such as witnessing domestic violence, can also cause significant trauma to an individual. Classification of Trauma Injury that can results from trauma can be classified in two, blunt and penetrating trauma. 1. Blunt Trauma: Mostly results from accidents, but it may occur in assaults, serious medical illness, natural disaster, neglect, falls from heights, and sports related injuries 2. Penetrating Trauma: Results from foreign objects that enter into the body, the open wound injury is an obvious sign e.g. gun short and stab wounds. Injuries sustained from penetrating objects must be assessed for the potential for infection from the debris carried by the penetrating object. Most severe injuries in mass trauma events are fractures, burns, lacerations, and crush injuries. While common injuries are eye injuries, sprains, strains, minor wounds and ear damage. Management of Specific Traumatic Injuries Contusion: This is a soft tissue injury produced by blunt trauma, such as a blow, kick, or fall. Many small blood vessels rupture and bleed into soft tissues (ecchymosis, or bruising). A haematoma develops when the bleeding is sufficient to cause an appreciable collection of blood. Local symptoms (pain, swelling, and discoloration) are controlled with intermittent application of cold. Most contusions resolve in 1 to 2 weeks. Strain is a “muscle pull” caused by overuse, overstretching, or excessive stress. Strains are microscopic, incomplete muscle tears with some bleeding into the tissue. The patient experiences soreness or sudden pain, with local tenderness on muscle use and isometric contraction. Sprains: are injuries to the ligaments surrounding a joint that is caused by a wrenching or twisting motion. The function of a ligament is to maintain stability while permitting mobility, when the ligament torn, it loses its stabilizing ability. The surrounding blood vessels rupture and oedema occurs and the joint becomes tender, and movement of the joint becomes painful. The degree of disability and pain increases during the first 2 to 3 hours after the injury because of the associated swelling and bleeding. An x-ray should be obtained to rule out bone injury. Avulsion fracture (in which a bone fragment is pulled away by a ligament or tendon) may be associated with a sprain. Management Treatment of contusions, strains, and sprains consists of resting and elevating the affected part, applying cold, and using a compression bandage. (The acronym RICE (Rest, Ice, Compression, and Elevation) is helpful for remembering treatment interventions.) Rest prevents additional injury and promotes healing. Moist or dry cold applied intermittently for 20 to 30 minutes during the first 24 to 48 hours after injury produces vasoconstriction, which decreases bleeding, edema, and discomfort. Care must be taken to avoid skin and tissue damage from excessive cold. An elastic compression bandage controls bleeding, reduces edema, and provides support for the injured tissues. Elevation controls the swelling. If the sprain is severe (torn muscle fibers and disrupted), surgical repair or cast immobilization may be necessary so that the joint will not lose its stability. The neurovascular status (circulation, motion, sensation) of the injured extremity is monitored frequently. After the acute inflammatory stage (24 to 48 hours after injury), heat may be applied intermittently (for 15 to 30 minutes, four times a day) to relieve muscle spasm and to promote vasodilation, absorption, and repair. Depending on the severity of injury, progressive passive and active exercises may begin in 2 to 5 days. Severe sprains may require 1 to 3 weeks of immobilization before protected exercises are initiated. Excessive exercise early in the course of treatment delays recovery. Strains and sprains take weeks or months to heal. Splinting may be used to prevent re injury. Hip Dislocation: A dislocation of a joint is a condition in which the articular surfaces of the bones forming the joint are no longer in anatomic contact. The bones are literally “out of joint.” A subluxation is a partial dislocation of the articulating surfaces. Traumatic dislocations are orthopedic emergencies because the associated joint structures, blood supply, and nerves are distorted and severely stressed. If the dislocation is not treated promptly, avascular necrosis (tissue death due to anoxia and diminished blood supply) and nerve palsy may occur. Dislocations may be congenital, or present at birth (most often the hip); spontaneous or pathologic, caused by disease of the articular or periarticular structures; or traumatic, resulting from injury in which the joint is disrupted by force. Signs and symptoms of a traumatic dislocation are pain, change in contour of the joint, change in the length of the extremity, loss of normal mobility, and change in the axis of the dislocated bones. X-rays confirm the diagnosis and demonstrate any associated fracture. Medical Management The affected joint needs to be immobilized while the patient is transported to the hospital. The dislocation is promptly reduced (ie, displaced parts are brought into normal position) to preserve joint function. Analgesia, muscle relaxants, and possibly anesthesia are used to facilitate closed reduction. The joint is immobilized by bandages, splints, casts, or traction and is maintained in a stable position. Neurovascular status is monitored. After reduction, if the joint is stable, gentle, progressive, active and passive movement is begun to preserve range of motion (ROM) and restore strength. The joint is supported between exercise sessions. Nursing Management Nursing care is directed at providing comfort, evaluating the patient’s neurovascular status, and protecting the joint during healing. The nurse teaches the patient how to manage the immobilizing devices and how to protect the joint from re injury. Fracture A fracture is a break in the continuity of a bone which may affect tissues or organs near the bones. Fractures occur when the bone is subjected to stress greater than it can absorb and are caused by direct blows, crushing forces, sudden twisting motions, and even extreme muscle contractions. When the bone is broken, adjacent structures are also affected, resulting in soft tissue oedema, haemorrhage into the muscles and joints, joint dislocations, ruptured tendons, severed nerves, and damaged blood vessels. Body organs may be injured by the force that caused the fracture or by the fractured fragments. Types of Fractures Complete fracture: A complete fracture involves a break across the entire cross-section of the bone and is frequently displaced (removed from normal position). In an incomplete fracture (e.g., greenstick fracture), the break occurs through only part of the cross-section of the bone. Comminuted: A comminuted fracture is one that produces several bone fragments. Closed fracture (simple fracture): is a fracture that does not cause a break in the skin. Open fracture (compound, or complex, fracture): An open fracture is one in which the skin or mucous membrane wound extends to the fractured bone. Open fractures are graded according to the following criteria: Grade I is a clean wound less than 1 cm long. Grade II is a larger wound without extensive soft tissue damage. Grade III is highly contaminated, has extensive soft tissue damage, and is the most severe. Fractures may also be described according to the anatomic placement of fragments, particularly if they are displaced or not displaced. Clinical Manifestations The clinical manifestations of a fracture are pain, loss of function, deformity, shortening of the extremity, crepitus, and local swelling and discoloration. Not all of these clinical manifestations are present in every fracture. For example, many are not present with linear or fissure fractures or with impacted fractures. The diagnosis of a fracture is based on the patient’s symptoms, the physical signs, and the x-ray findings. Usually, the patient reports having sustained an injury to the area. Pain: The pain is continuous and increases in severity until the bone fragments are immobilized. The muscle spasm that accompanies fracture is a type of natural splinting designed to minimize further movement of the fracture fragments. Loss of Function: After a fracture, the extremity cannot function properly, because normal function of the muscles depends on the integrity of the bones to which they are attached. Pain contributes to the loss of function. In addition, abnormal movement (false motion) may be present. Deformity: Displacement, angulation, or rotation of the fragments in a fracture of the arm or leg causes a deformity as the bone assume an unusual position resulting from soft tissue swelling. Shortening: In fractures of long bones, there is actual shortening of the extremity because of the contraction of the muscles that are attached above and below the site of the fracture. The fragments often overlap by as much as 2.5 to 5 cm (1 to 2 inches). Crepitus: When the extremity is examined with the hands, a grating sensation, called crepitus, can be felt. It is caused by the rubbing of the bone fragments against each other. Swelling and Discoloration: Localized swelling and discoloration of the skin (ecchymosis) occurs after a fracture as a result of trauma and bleeding into the tissues. These signs may not develop for several hours after the injury. Emergency Management of Fractures Immediately after injury, whenever a fracture is suspected, it is important to immobilize the body part before the patient is moved. If an injured patient must be removed from a vehicle before splints can be applied, the extremity is supported above and below the fracture site to prevent rotation as well as angular motion. Adequate splinting, including joints adjacent to the fracture, is essential. Movement of fracture fragments causes additional pain, soft tissue damage, and bleeding. Temporary, well-padded splints, firmly bandaged over clothing, serve to immobilize the fracture. Immobilization of the long bones of the lower extremities may be accomplished by bandaging the legs together, with the unaffected extremity serving as a splint for the injured one. In an upper extremity injury, the arm may be bandaged to the chest, or an injured forearm may be placed in a sling. The neurovascular status distal to the injury should be assessed to determine adequacy of peripheral tissue perfusion and nerve function. With an open fracture, the wound is covered with a clean (sterile) dressing to prevent contamination of deeper tissues. No attempt is made to reduce the fracture, even if one of the bone fragments is protruding through the wound. Splints are applied for immobilization. In the emergency department, the patient is evaluated completely. The clothes are gently removed, first from the uninjured side of the body and then from the injured side. The patient’s clothing may be cut away. The fractured extremity is moved as little as possible to avoid more damage. Medical Management of Fractures The principles of fracture treatment include reduction, immobilization, and regaining of normal function and strength through rehabilitation. iii. Reduction: Reduction of a fracture (“setting” the bone) refers to restoration of the fracture fragments to anatomic alignment and rotation. Either closed reduction or open reduction may be used to reduce a fracture. However, he specific method selected depends on the nature of the fracture and the underlying principles are the same. Usually, the physician reduces a fracture as soon as possible to prevent loss of elasticity from the tissues through infiltration by oedema or haemorrhage. In most cases, fracture reduction becomes more difficult as the injury begins healing. Before fracture reduction and immobilization, the patient is prepared for the procedure; permission for the procedure is obtained, and an analgesic is administered as prescribed. Anesthesia may be administered. The injured extremity must be handled gently to avoid additional damage. i. Closed Reduction: In most instances, closed reduction is accomplished by bringing the bone fragments into apposition (i.e., placing the ends in contact) through manipulation and manual traction. The extremity is held in the desired position while the physician applies a cast, splint, or other device. Reduction under anesthesia with percutaneous pinning may be used. The immobilizing device maintains the reduction and stabilizes the extremity for bone healing. X-rays are obtained to verify that the bone fragments are correctly aligned. Traction (skin or skeletal) may be used to effect fracture reduction and immobilization. Traction may be used until the patient is physiologically stable and able to withstand surgical fixation. ii. Open Reduction. Some fractures require open reduction. Through a surgical approach, the fracture fragments are reduced. Internal fixation devices (metallic pins, wires, screws, plates, nails, or rods) may be used to hold the bone fragments in position until solid bone healing occurs. These devices may be attached to the sides of bone, or they may be inserted through the bony fragments or directly into the medullary cavity of the bone. Internal fixation devices ensure firm approximation and fixation of the bony fragments. iv. Immobilization: After the fracture has been reduced, the bone fragments must be immobilized, or held in correct position and alignment, until union occurs. Immobilization may be accomplished by external or internal fixation. Methods of external fixation include bandages, casts, splints, continuous traction, and external fixators. Metal implants used for internal fixation serve as internal splints to immobilize the fracture. Nursing Management of Patients with Closed Fractures The nurse encourages patients with closed (simple) fractures to return to their usual activities as rapidly as possible, but teaches them how to control swelling and pain associated with fracture and with soft tissue trauma, and encourages them to be active within the limits of the fracture immobilization. It is important to teach exercises to maintain the health of unaffected limb. The Process of Bone Healing The process of Fracture healing restores the tissue to its original physical and mechanical properties and is influenced by a variety of systemic and local factors. Healing occurs in three distinct but overlapping stages: The early inflammatory stage; The repair stage; The late remodeling stage. Inflammatory stage: Here hematoma develops within the fracture site during the first few hours and days. Inflammatory cells (macrophages, monocytes, lymphocytes, and polymorpho nuclear cells) and fibroblasts infiltrate the bone under prostaglandin mediation. This results in the formation of granulation tissue, in growth of vascular tissue, and migration of mesenchymal cells. The primary nutrient and oxygen supply of this early process is provided by the exposed cancellous bone and muscle. The use of anti-inflammatory or cytotoxic medication during this 1st week may alter the inflammatory response and inhibit bone healing. Repair stage: In this stage, fibroblasts begin to lay down a stroma that helps support vascular in growth. It is during this stage that the presence of nicotine in the system can inhibit this capillary in growth. A significantly decreased union rate had been consistently demonstrated in tobacco abusers. As vascular in growth progresses, a collagen matrix is laid down while osteoid is secreted and subsequently mineralized, which leads to the formation of a soft callus around the repair site. In terms of resistance to movement, this callus is very weak in the first 4 to 6 weeks of the healing process and requires adequate protection in the form of bracing or internal fixation. Eventually, the callus ossifies, forming a bridge of woven bone between the fracture fragments. Alternatively, if proper immobilization is not used, ossification of the callus may not occur, and an unstable fibrous union may develop instead. Remodeling stage: during this stage, fracture healing is completed. The healing bone is restored to its original shape, structure, and mechanical strength. Remodeling of the bone occurs slowly over months to years and is facilitated by mechanical stress placed on the bone. As the fracture site is exposed to an axial loading force, bone is generally laid down where it is needed and resorbed from where it is not needed. Adequate strength is typically achieved in 3 to 6 months. The most critical period of bone healing is the first 2 weeks, when inflammation and revascularization occur. A variety of systemic factors can inhibit bone healing, e.g. cigarette smoking, malnutrition, diabetes, rheumatoid arthritis, and osteoporosis. During the 1st week of bone healing, steroid medications, cytotoxic agents, and non-steroidal anti-inflammatory drugs can have harmful effects. Irradiation of the fusion site within the first 2-3 weeks can inhibit cell proliferation and induce an acute vasculitis that significantly compromises bone healing BURNS A burn is and injury to the skin or tissues due to heat from too much sun, hot liquids, flames, chemicals, electricity, steam and other sources. Burns can be minor medical problems or life- threatening emergencies and the treatment depends on where they are on the body and how bad they are. Burns can be classified into first degree, second degree, and third degree, depending on how deep and severe the burns penetrate the skin. First-degree burns are superficial and causes local inflammation of the skin e.g. sunburns. The inflammation is characterized by pain redness, and a mild amount of swelling. The skin may be very tender to the touch. Second-degree burns are deeper and is usually characterized by pain, inflammation redness, and blistering of the skin may occurs. Third-degree burns are deeper, involving all layers of the skin and in effect, killing that area of skin. Because the nerves and blood vessels are damaged, third-degree burns appear white and leathery and tend to be relatively painless. Fourth-degree burns are the most severe burns with the maximum amount of damage to tissue by heat where all the layers of the epidermis, dermis, and subcutaneous tissue, along with the underlying bones and muscles, are affected. This type of burn is painless because all the nerve fibers are destroyed; thus, they are not able to carry pain. Common causes of Burns Flame: House fire is a common cause. It is usually associated with an inhalation injury. Flash injury occurs from a sudden ignition or explosion. Contact: Hot tar, hot metals, or hot grease produce a full-thickness injury on contact. Scald: A burn from hot liquid. This is common among children less than 5 years and adults older than 65 years. With an immersion scald, there are usually no splash marks; usually involves lower regions of body. Chemical: Usually occurs in an industrial setting. Extent and depth of injury are directly proportional to concentration and quantity of agent, duration of contact, and chemical activity and penetrability of agent. Electrical: It is one of the most serious types of burn injury; can be full thickness with possible loss of limbs, as well as cause internal injuries. Entry wound is usually ischemic, charred, and depressed. Exit wound may have an explosive appearance. Extent of injury depends on voltage, resistance of body, type of current, amperage, pathway of current, and duration of contact. Bones offer greatest resistance to the current; can have much damage. Tissue fluid, blood, and nerves offer least resistance; therefore, the current travels this path follows an undetermined course from entrance to exit, causing major damage in its path. Radiation: This usually occurs in an industrial setting, due to treatment of diseases, or from ultraviolet light (sun or tanning salons). Severity depends on type of radiation, duration of exposure, depth of penetration, distance from source, and absorbed dose. Pathophysiology The cause of cell damage in burns is heat, the severity of the burn is related to the temperature of the heat source, its duration of contact, and the thickness of the tissue exposed to the heat source, and the location of the burn. Burns in the perineal area are at increased risk for infection from organisms in the stool. Burns of the face, neck, or chest have the potential to impair ventilation. Burns involving the hands or major joints can affect dexterity and mobility. Thermal (burns) injuries cause the protein in cells to coagulate, chemicals like strong acids, bases, and organic compounds yield heat during a reaction with substances in cells and tissue. They subsequently liquefy tissue and loosen the attachment to nutritive sub layers in the skin. Electrical burns and lightning also produce heat, which is greatest at the points of entry to and exit from the body. Because deep tissues cool more slowly than those at the surface, it is difficult initially to determine the extent of internal damage. Cardiac dysrhythmias and central nervous system complications are common among victims of electrical burns. The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury. Protease enzymes and chemical oxidants are proteolytic, causing additional injury to healing tissue and deactivation of tissue growth factors. Neutrophils, whose mission is to phagocytize debris, consume available oxygen at the wound site, contributing to tissue hypoxia. Injured capillaries thrombose, causing localized ischemia and tissue necrosis. Bacterial colonization, mechanical trauma, and even topically applied antimicrobial agents further damage viable tissue. Serious burns cause various neuroendocrine changes within the first 24 hours. Adrenocorticotropic hormone (ACTH) and antidiuretic hormone (ADH) are released in response to stress and hypovolemia. When the adrenal cortex is stimulated, it releases glucocorticoids, which cause hyperglycemia, and aldosterone which is a mineralocorticoid, causes sodium retention. Sodium retention leads to peripheral edema as a result of fluid shifts and oliguria. The patient eventually enters a hyper-metabolic state that requires increased oxygen and nutrition to compensate for the accelerated tissue catabolism. After a burn, fluid from the body moves toward the burned area, which accounts for edema at the burn site. Some of the fluid is then trapped in the area and rendered unavailable for use by the body, leading to intravascular fluid deficit. Fluid is also lost from the burned area in extremely large amounts in the forms of water vapor and seepage. Decreased blood pressure follows, and if physiologic changes are not immediately recognized and corrected, irreversible shock is imminent. These changes usually happen rapidly and the client’s status may change from hour to hour, requiring that patients with burns receive intensive care by skilled personnel. Fluid shifts, electrolyte deficits, and loss of extracellular proteins such as albumin from the burn wound affect fluid and electrolyte status. Anemia develops because the heat literally destroys erythrocytes. Patients with a burn experiences haemo-concentration when the plasma component of blood is lost or trapped. The sluggish flow of blood cells through blood vessels results in inadequate nutrition to healthy body cells and organs. Myoglobin and hemoglobin are transported to the kidneys, where they may cause tubular necrosis and acute renal failure. The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to developing gastric ulcers. Inhalation of hot air, smoke, or toxic chemicals, accompanying injuries such as fractures, concurrent medical problems, and the client’s age, increase the mortality rate from burn injuries. Burn Assessment Tools There are two major charts that can be used to calculate the total body surface area of burnt patient. These are: i. Wallace Rule of Nines-Adults Only: It is a chart that can be used to determine the percentage of total body surface area (TBSA) that has been burnt. The chart divides the body into sections that represent 9 percent of the body surface area. It is inaccurate for children, and should be used in adults only. SN Wallace Rule-of- Nine Total Subdivisions 1 Head and neck 9% Anterior = 4.5% posterior = 4.5% 2 Each arm 9% Anterior, 4.5% posterior, 4.5% 3 Anterior Trunk 18 % Thorax, 9, abdomen 9 4 Posterior Trunk 18 % Upper = 9, lower = 9 5 Each leg 18 % Anterior = 9 % posterior = 9 % 6 Perineum 1% 7 Total body surface 100 % With pediatric patients, the head is a proportionally larger contributor to body surface area (BSA), while the upper legs contribute less. ii. A standard Lund-Browder chart is an assessment tool that is usually available in most emergency departments for a quick assessment of total body surface area burns. Depth of Burn Injury One method for determining the extent of injury is to assess the depth of the burn. Burn depth is classified as follows: 1. Superficial (first degree) 2. Superficial partial thickness and deep partial thickness (second degree) 3. Full thickness (third and fourth degree) Burn depth is determined by assessing the color, characteristics of the skin, and sensation in the area of the burn injury. A superficial burn is similar to a sun burn. The epidermis is injured, but the dermis is unaffected. Although the burn is red and painful, it heals in less than 5 days, usually spontaneously with symptomatic treatment. Infection, increased metabolism, and scarring do not occur. A partial-thickness burn is classified as either superficial or deep partial thickness, depending on how much dermis is damaged. A superficial partial-thickness burn heals within 14 days, with possibly some pigmentary changes but no scarring; it requires no surgical intervention. A deep partial-thickness burn takes more than 3 weeks to heal, may need debridement, is subject to hypertrophic scarring, and may require skin grafts. A full-thickness burn destroys all layers of the skin and consequently is painless. The tissue appears charred or lifeless. If not debrided, this type of burn injury leads to sepsis, extensive scarring, and contractures. Skin grafts are necessary for a full-thickness burn because the skin cells no longer are alive to regenerate. The most serious burn can involve muscle and bone. CARE OF PATIENTS WITH BURNS Pre Hospital Care of Major Burns a. Remove victim from source of burn and Stop the burning process. b. If it is a chemical burn, carefully remove clothing and irrigate wound with water. c. If it is electrical burn and victim is still in contact with source, do not touch victim. Remove electrical source with dry non-conductive object. d. Establish patent airway and assess for inhalation injury. Give oxygen if available. e. Start two large bore IV lines or intra-osseous’ (IO) with normal saline or Ringer’s lactate. f. Check peripheral pulse to assess circulatory status. g. Assess and initiate treatment for injuries requiring immediate attention. h. Remove tight-fitting jewelry and clothing. i. Cover burn with dry sterile or clean cover and Control pain. j. Cover victim with warm, dry cover to prevent heat loss. k. Transport victim to nearest acute care facility. Diagnostic investigations: various diagnostic tests are performed for systemic reactions, infection, and other complications. Common tests for systemic reactions include complete blood cell count (CBC) and differential, blood urea nitrogen (BUN), serum glucose and electrolytes, arterial blood gases, serum protein and albumin, urine cultures, urinalysis, clotting studies, cervical spine series, electrocardiogram, wound cultures, and, if there is a suspected inhalation injury, arterial blood gases, bronchoscopy and carboxyhaemoglobin levels. Medical Management The objective of burn management is to prevent infection, decrease inflammation and pain, and promote healing of the areas. Treatment choices depend on the degree of burn and the amount of body surface area that was burned. Any second-degree burn greater than 5 to 10 percent of surface area and all third-degree burns should be managed in a hospital, preferably within a specialized burn unit. All electrical burns and burns of the ears, eyes, face, hands, feet, and perineum require hospital care, as do chemical burns and burns in infants or the elderly. The outcome of a burn injury depends on the initial first aid provided and the subsequent treatment in the hospital or burn center. Any one of three complications e.g. inhalation injury, hypovolemic shock, and infection can be life-threatening. Patients with major burns are referred to a hospital where there is reconstructive and burn specialist. Care during Emergent Stage At the time of injury, the burning process must be stopped. The clothes are removed, and the wound is cooled with tepid water and covered with clean sheets to decrease shivering and contamination. The burn wound itself takes a lower priority to the ABCs (airway, breathing, circulation) of trauma resuscitation. The patient should be stabilized in terms of fractures, hemorrhage, spine immobilization, and other injuries. Inhalation injury is suspected if the patient sustained a burn from a fire in an enclosed space or was exposed to smoldering materials, if the face and neck were burned, if there are vocal changes, and if the patient is coughing up carbon particles. Intravenous fluids are given to prevent and treat hypovolemic shock. The patient is treated for pain with appropriate IV opioid analgesics. Patient-controlled analgesia (PCA) is very effective. An accurate history of the injury is obtained to determine severity, probable complications, and any associated trauma. The patient’s medical history is also obtained. Admission to the facility and burn care treatment are explained to the patient and family. Care at the Acute Stage If the patient is in a facility with a special burn unit, multidisciplinary care from a burn team is provided during the acute stage. Management goals include wound closure with no infection, minimum scarring, maximum function, maintenance of comfort as much as possible, adequate nutritional support, and maintenance of fluid, electrolyte, and acid-base. Showering using a shower trolley or shower chair, and bedside care should be given. Debridement, or the removal of non-viable tissue (eschar), can be mechanical, chemical, surgical, or a combination of these methods. Mechanical debridement can involve the use of scissors and forceps to manually excise loose, nonviable tissue, or the use of wet-to-moist or wet-to-dry fine mesh gauze. Chemical debridement involves the use of a proteolytic enzymatic debriding agent that digests necrotic tissue. Surgical debridement is the excision of full thickness and deep partial thickness burns. This method is followed by an application of a skin graft. If the patient has a circumferential burn (one that surrounds an extremity or area), an increase in tissue pressure secondary to tissue edema occurs. The burn then acts like a tourniquet, impeding arterial and venous flow. Common sites for these burns are the extremities, trunk, and chest. If this occurs on the chest and trunk, respiratory insufficiency can occur as a result of restricted chest expansion. An escharotomy is immediately necessary to relieve this pressure. An escharotomy is a linear excision through the eschar to the superficial fat that allows for expansion of the skin and return of blood flow. Use of an occlusive dressing over the wound is thus necessary. General principles for dressing burns injury include the following: 1. Limit the bulk of the dressing to facilitate range of motion. 2. Never wrap skin-to-skin surfaces (e.g., wrap fingers or toes separately; place a donut gauze dressing around the ear). 3. Base dressings on the size of wounds, absorption, protection, and type of debridement. 4. Wrap extremities distal to proximal to promote venous return. 5. Elevate affected extremities. Biological dressing: refers to tissue from living or deceased humans (cadaver skin), deceased animals (pigskin), or cellular dressings that may use animal tissue, human tissue, and synthetics. Biological dressings assist with wound healing and stimulate epithelialization. These dressings may be used as donor site dressings, to manage a partial- thickness burn, and to cover the clean, excised wound before auto-grafting. Some of the cellular wound dressings have varied layers that form a matrix onto which the patient’s own cells migrate over a few weeks and form a new dermis. A very thin layer of the person’s own skin is then grafted onto this new dermis. Synthetic dressings are used in the management of partial-thickness burns and donor sites. These dressings are more readily available, less costly, and easier to store than biological dressings. They are made from a variety of materials and come in many different sizes and shapes. Most of these dressings contain no antimicrobial agents. Biological and synthetic dressings are used as temporary coverings over clean partial- and full-thickness injuries. They act as skin substitutes to help maintain the wound surface until healing occurs, a donor site becomes available, or the wound is ready for auto grafting. Skin Grafts Skin graft involves taking a section of epidermis and dermis which has been completely separated from its blood supply in one part of the body (uninjured area of the body), the donor site, before being transplanted to another area of the body, its recipient site and using it to provide coverage for an open wound. When primary closure is impossible because of soft tissue loss and closure by secondary intention is contraindicated, a skin graft is the next rung on the reconstructive ladder. It is not a technically difficult procedure but does require some surgical skills. The type of skin graft most commonly used is the auto-graft, when the donor and recipient of the skin graft is the same person, for example when a patient has a skin graft taken from their thigh and applied to a wound on their lower leg. Classification of skin grafts Skin grafts may be classified as partial or full-thickness grafts, depending on how much of the dermis is harvested by the surgeon. 1. Split-thickness Skin Graft A split-thickness skin graft (STSG) is composed of the top layers of skin and involves excision of the epidermis and part of the dermis but leaves behind sufficient reticular (deep) dermis in the wound bed to enable the skin to regenerate itself. The graft is placed over an open wound to provide coverage and promote healing. The STSG donor site is essentially a second-degree burn because only part of the dermis is included in the graft. An STSG (0.006 to 0.016 inch) may be applied as a sheet graft or a meshed graft. A sheet graft is used for cosmetic effect, such as for a face, neck, upper chest, breast, or hand burn. It is placed on the area as a full sheet. A meshed graft is passed through a mesher that produces tiny splits in the skin, similar to a fishnet, with openings in the shape of diamonds to permit the skin to expand one and a half to nine times its original size. The meshing allows for coverage of a large burn area with a small piece of skin by stretching it and securing it with sutures or staples. A mesh graft is especially useful when there are extensive burns resulting in few available donor sites. Graft “take,” or vascularization, is complete in about 3 to 5 days. The donor site will heal on its own because some dermal elements remain. The most common donor site areas for split-skin grafts include the thigh, buttock, back, upper arm, forearm and abdominal wall. Indications of split-thickness skin graft (STSG) A split-thickness skin graft (STSG) is indicated in most wounds that cannot be closed primarily and when closure by secondary intention is contraindicated. It is also indicated for a relatively large wound (> 5–6 cm in diameter) that would take many weeks to heal secondarily. A skin graft provides more stable coverage for large wounds than the scar that result from secondary closure. A large wound also heals more quickly with a skin graft than with dressing changes alone. The wound must be clean, all necrotic tissue removed before skin grafting, and there should be no signs of infection in the surrounding tissues. Full-thickness Skin Graft A full thickness skin graft (FTSG) consists of the epidermis and the full thickness of the dermis but no subcutaneous fat. Since none of the reticular dermis remains to allow spontaneous regeneration of skin, the wound must be directly closed to heal by primary intention. Consequently, the surgeon must select a donor site where a small area of skin may be excised and the wound sutured to leave minimal scarring. Full-thickness skin grafts (0.035 to 0.040 inch) can be sheet grafts or pedicle flaps. FTSGs are used over areas of muscle mass, soft tissue loss, hands, feet, and eyelids. They are not used for extensive wounds because the donor sites usually require an STSG for closure, or closure from the wound edges. A pedicle graft or flap includes the skin flap and subcutaneous tissue that is attached by its pedicle to a blood supply (artery and vein); it is then attached to the area in need of grafting. Once the distal part of the graft takes, it remains in place and the flap is divided, with the remainder returning to the original site. Pedicle flaps are not as popular as free skin flaps because they require more than one surgery and take longer for the graft site and donor site to heal. Common donor site areas for full-thickness skin grafts include the pre- and post-auricular (ear), supraclavicular and antecubital inner elbow) areas, the upper eyelid, scalp, groin and areola Full- thickness skin grafts do not contract as much as split-skin-grafts, so are used to cover exposed areas of the body, usually the face or neck. FTSGs are rarely done, because the wound must be very clean for the graft to survive. Most often they are used for a small wound, usually one created surgically (such as a wound on the face created by excision of a malignant skin lesion). The other common use is for open wounds on the palmar surface of the hands and fingers. These areas may scar too tightly if the thinner STSG is used. Factors Inhibiting Graft “Take” The following factors will not allow graft to take:  Infection  Mechanical trauma  Bleeding  Necrotic skin (tissue)  Buttocks  Poor nutritional status  Perineum  Poor-quality donor skin  Axillae  Anatomic location of graft  Shock Factors Promoting Graft “Take”  Adequate haemostasis and Good nutritional status  Graft well secured and Smooth contour  Non joint areas and Anatomical location of graft  Immobilization of graft area The therapy started during the acute phase continues in the rehabilitation phase. There is wound closure, and the goal is to return the patient to an optimum level of physical and psychosocial function. This may take months to years to accomplish, depending on the extent of the injury. Reconstructive surgery can be ongoing for many years. Two things to keep in mind when caring for the patient with a major burn are that The most comfortable position (flexion) is the position of contracture The burn wound will shorten until it meets an opposing force. To avoid contractures, a specific exercise program is begun 24 to 48 hours after injury, along with the use of splinting devices to maintain proper positioning and stretching. Hypertrophic scarring, or a proliferation of scar tissue can be minimized or prevented through the use of a pressure garment. The burn affects the patient’s psychosocial status in many ways. The magnitude of these effects are related to the age of the patient, location of the burn (face, hands), cause of the injury (especially if related to negligence or a deliberate act). The patient may experience a disruption of role function and general health and coping ability. Treatment involves the patient and significant others. Support groups, counselors, and psychiatrists should be utilized appropriately. Nursing management (Nursing process) Assessment  Determine the type of burn (thermal, chemical, electrical) and when it occurred.  Assess vital signs and evidence of inhalation injury.  Determine the oxygen saturation and respiratory effort.  Evaluate pain intensity and auscultate bowel sound.  Determine the volume and characteristics of urine.  Note the percentage and depth of burn.  Assess for concurrent medical problems, and review the results of laboratory tests. Nursing Diagnoses 1. Impaired gas exchange related to upper airway edema, carbon monoxide poisoning, and oedema of alveolar capillary membranes Interventions i Assess respiratory status: auscultate breath sounds every 15 minutes or as necessary, note any breath sounds, observe for chest excursion and monitor the ability to cough. ii Monitor arterial blood gases and CO level. iii Monitor for nasal flaring, retractions, wheezing, and stridor. iv Administer humidified 100% oxygen by tight-fitting face mask and Suction as needed. v Elevate head of bed (if no cervical spine injuries or no history of multiple trauma). vi Provide appropriate pulmonary care: turn, cough, and deep breathe every 2–4 hours. vii Provide incentive spirometer every 2–4 hours 2. Impaired skin integrity related to thermal injury Interventions  1. Assess burning process, if heat is felt on wound, cool with tepid tap water or sterile water. 2. Assist physician to assess the burn area for extent (percentage) and depth (partial thickness, full thickness) of injury. Then obtain history of burning agent. 3. Remove patient’s clothing and jewelry then cover patient with clean sheet or blanket. 4. Do not apply ice, but irrigate with tepid water for 20 minutes for all chemical burns, do not neutralize chemical because this takes too much time and the resulting reaction may generate heat and cause further skin injury, removal of contaminated clothing. 5. Brush off dry chemicals before irrigation. 6. Use heavy rubber gloves or thick gauze for removal of contaminated clothing. 7. Cleanse wound via tubbing or showers. 8. Assist physician with debriding wound via surgical, chemical, or mechanical means. 9. Apply topical agent and dressing as prescribed. 3. Deficient fluid volume related to evaporative losses from wound, capillary leak, and decreased fluid intake. Interventions 1. Obtain admission weight and monitor weight daily. 2. Record fluid intake and output hourly. 3. Assess for signs and symptoms of hypovolemia (hypotension, tachycardia, tachypnea extreme thirst, restlessness, disorientation). 4. Monitor electrolytes, complete blood count (CBC). 5. Administer IV fluids as ordered via large bore IV catheter. 6. Insert indwelling urinary catheter. 7. Monitor urine for amount, specific gravity, and haemochromogens. 8. Administer osmotic diuretics as ordered; monitor response to therapy. 9. Assess gastrointestinal function for of bowel sounds and maintain nasogastric tube. 4. Pain related to burns or graft donor sites Interventions 1. Assess level of pain (the nature, location, intensity, and duration at various times during procedures and at rest). 2. Ask the patient to rate pain on visual analog scale. 3. Observe for responses to pain, increase in blood pressure, pulse, respiration; increased restlessness and irritability; increased muscle tension; facial grimaces; guarding. 4. Acknowledge presence of pain and explain the causes of pain. 5. Administer narcotics IV. Utilize patient controlled analgesia (PCA) as appropriate. 6. Offer diversional therapy (music, TV, books, games, relaxation techniques). 7. Properly position patient and elevate burned extremities. 8. Maintain comfortable environment (bed cradle; comfortable environmental temperature, 86–91.4_F [30–33°C]; quiet environment). 9. 5. Risk for sepsis related to wound infection Interventions  1. During wound care ensure isolation, regular hand-washing and sterile technique 2. Administer immune supportive medications as prescribed: tetanus and gamma globulin. 3. Perform wound care as prescribed, (inspect and debride wounds daily, culture wound three times a week or at sign of infection; shave hair at least 1 inch around burn areas excluding eyebrows, inspect invasive line sites for inflammation if line is through a burn area). 4. Continually assess for and report signs and symptoms of sepsis (temperature rise, change in sensorium; changes in vital signs and bowel sounds; decreased output; positive blood/wound cultures. 5. Administer systemic antibiotics and topical agents as prescribed. Complications of burns i. Shock ii. Wound infection iii. Death SUMMARY In this unit you have been taken through likely causes of burns injury, its Pathophysiology and how to estimate the percentage of total body surface area burnt. Different medical treatments modalities’ and nursing process for burns patients were also discussed. SHOCK Shock is a critical condition resulting from a sudden drop in blood flow through the body due to trauma, heat-stroke, blood loss, severe infection, severe burns, poison and allergic reactions. It is a medical emergency that can cause hypoxia, heart attack or cardiac arrest which leads to systemic hypo-perfusion owing to reduction either in cardiac output or in the effective circulating blood volume leading to hypotension and subsequent reduction in blood supply to most vital structures in the body (impaired tissue perfusion) and cellular hypoxia. When this occurs, the condition is referred to as shock. Shock affects all body systems. It may develop rapidly or slowly, depending on the underlying cause. During shock, the body struggles to survive, calling on all its homeostatic mechanisms to restore blood flow and tissue perfusion. If prolonged will lead to generalized impairment of cellular function, leading to tissue hypoxia and altered cellular metabolism Types of Shock Shock can be grouped into three general categories v. Hypovolemic shock, vi. Cardiogenic shock, vii. Anaphylactic shock viii. Septic shock ix. Neurogenic shock x. Circulatory Shock Pathophysiology of shock In shock, the cells lack an adequate blood supply and are deprived of oxygen and nutrients; therefore, they must produce energy through anaerobic metabolism. This results in low energy yields from nutrients and an acidic intracellular environment. Because of these changes, normal cell function ceases.The cell swells and the cell membrane becomes more permeable, allowing electrolytes and fluids to seep out of and into the cell. The sodium-potassium pump becomes impaired; cell structures, primarily the mitochondria, are damaged; and death of the cell results. Stages of Shock i. Compensatory Stage In the compensatory stage of shock, the patient’s blood pressure remains within normal limits. Vasoconstriction, increased heart rate, and increased contractility of the heart contribute to maintaining adequate cardiac output. This results from stimulation of the sympathetic nervous system and subsequent release of catecholamines (epinephrine and norepinephrine) , activation of rennin-angiotensin axis , and antidiuretic hormone release. The patient displays the often- described “fight or flight” response. The body shunts blood from organs such as the skin, kidneys, and gastrointestinal tract to the brain and heart to ensure adequate blood supply to these vital organs. As a result, the patient’s skin is cold and clammy, bowel sounds are hypoactive, and urine output decreases in response to the release of aldosterone and ADH. ii. Progressive Stage If the underlying causes are not corrected, shock passes on to the progressive phase with a serious sign of widespread tissue hypoxia as oxygen deficit persist. During this period, intracellular aerobic respiration is replaced by anaerobic activities, with excessive production of lactic acid which further lowers the tissue PH. iii. Irreversible (refractory) Stage Unless there is intervention, the process eventually enters an irreversible stage when the organs become severely damaged to the point where the patient does not respond to treatment and cannot survive. The blood pressure remains low despite treatment, with complete renal and liver failures compounded by the release of necrotic issue toxins which creates an overwhelming metabolic acidosis. i. Hypovolemic Shock This occurs due to loss of intravascular fluid which may be caused by haemorrhage, dehydration, vomiting, diarrhea, loss of plasma in burns, inadequate fluid intake and excessive use of diuretics, which decreased venous return of blood to the heart and subsequently decreases ventricular filling. A decreased ventricular filling results in decreased stroke volume (amount of blood ejected from the heart) and decreased cardiac output. When cardiac output drops, blood pressure drops and tissues cannot be adequately perfused. ii. Cardiogenic Shock Cardiogenic shock occurs when the heart’s ability to contract and to pump blood is impaired and the supply of oxygen is inadequate for the heart and tissues. This is often associated with acute myocardial infarction which usually involves the left ventricle. The vascular system and circulating volume are intact but the pumps action is inadequate to maintain tissue perfusion. The causes of cardiogenic shock are known as either coronary or non-coronary. Coronary cardiogenic shock is more common than non-coronary cardiogenic shock and is seen most often in patients with myocardial infarction. Coronary cardiogenic shock occurs when a significant amount of the left ventricular myocardium has been destroyed. Non-coronary causes can be related to severe metabolic problems (severe hypoxemia, acidosis, hypoglycemia, and hypocalcemia) and tension pneumothorax. Pathophysiology: In cardiogenic shock, cardiac output, which is a function of both stroke volume and heart rate, is compromised. When stroke volume and heart rate decrease or become erratic, blood pressure drops and tissue perfusion is compromised. Along with other tissues and organs being deprived of adequate blood supply, the heart muscle itself receives inadequate blood. The result is impaired tissue perfusion. Because impaired tissue perfusion weakens the heart and impairs its ability to pump blood forward, the ventricle does not fully eject its volume of blood at systole. As a result, fluid accumulates in the lungs. This sequence of events can occur rapidly or over a period of days. Patients with this condition may experience angina pain and develop dysrhythmias and hemodynamic instability. Management The goals of medical management are to: 1. Limit further myocardial damage and preserve the healthy myocardium 2. Improve the cardiac function by increasing cardiac contractility, decreasing ventricular after load and also increase oxygen supply to the heart muscle is the ultimate goal. The following can be done for patients with cardiogenic shock. Oxygen Supply: In the early stages of shock, supplemental oxygen is administered by nasal cannula at a rate of 2 to 6 L/min to achieve an oxygen saturation exceeding 90%. Monitoring arterial blood gas values and pulse oximetry values helps to indicate whether the patient requires a more aggressive method of oxygen delivery. Pain Relief: Analgesics can be given such as morphine sulfate, administered intravenously for pain relief. In addition to relieving pain, morphine dilates the blood vessels , reduces the workload of the heart by both decreasing the cardiac filling pressure (preload) and reducing the pressure against which the heart muscle has to eject blood (afterload) and at the same time relieves the patient’s anxiety. Fluid Therapy: In addition to medications, appropriate fluid is necessary in treating cardiogenic shock. Administration of fluids must be monitored closely to detect signs of fluid overload. Incremental intravenous fluid boluses are cautiously administered to determine optimal filling pressures for improving cardiac output. Note: A fluid bolus should never be given quickly because rapid fluid administration in patients with cardiac failure may result in acute pulmonary edema. The nurse has a critical role in safe and accurate administration of intravenous fluids. Fluid overload and pulmonary edema are risks because of ineffective cardiac function and accumulation of blood and fluid in the pulmonary tissues. The nurse documents and records fluid intake and output. Pharmacologic Therapy Vasoactive medication like dobutamine, dopamine, and nitroglycerin can be administered in coronary cardiogenic shock. Two classification of drugs are usually administered, sympathomimetic agents and vasodilators. The aims of vasoactive medication therapy is to improved cardiac contractility, decreased preload and afterload, or stabilize heart rate. Sympathomimetic medications increase cardiac output by mimicking the action of the sympathetic nervous system through vasoconstriction, resulting in increased preload, and by increasing myocardial contractility (inotropic action) or increasing the heart rate (chronotropic action). While Vasodilators are used to decrease preload and afterload, thus reducing the workload of the heart and the oxygen demand. For example Dobutamine (Dobutrex) produces inotropic effects by stimulating myocardial beta receptors, increasing the strength of myocardial activity and improving cardiac output. It enhances the strength of cardiac contraction, improving stroke volume ejection and overall cardiac output. Other vasoactive medications include: norepinephrine (Levophed), epinephrine (Adrenalin), milrinone (Primacor), amrinone (Inocor), vasopressin (Pitressin), and phenylephrine (Neo- Synephrine). Each of these medications stimulates different receptors of the sympathetic nervous system. A combination of these medications may be prescribed, depending on the patient’s response to treatment. Diuretics such as furosemide (Lasix) may be administered to reduce the workload of the heart by reducing fluid accumulation. Antiarrhythmic medication is also part of the medication regimen in cardiogenic shock, which are used to stabilize heart rate. The nurse is expected to give patient the right dosage, right drug at the right time and via the right route to the right patient and document. The nurse needs to be knowledgeable about the desired effects as well as the side effects of medications and report if it occurs to the physician.. For example, it is important for the nurse to monitor the patient for decreased blood pressure after administering morphine or nitroglycerin. The patient receiving thrombolytic therapy must be monitored for bleeding. a. Assess the neurologic status after administration of thrombolytic therapy to assess for the potential complication of cerebral haemorrhage associated with the therapy. b. Intravenous infusions must be observed closely because tissue necrosis and sloughing may occur if vasopressor medications infiltrate the tissues. c. Monitoring of urine output, BUN, and serum creatinine levels to detect decreased renal function secondary to the effects of cardiogenic shock or its treatment. d. The nurse must ensure safety; enhance comfort, and reducing anxiety by administering medication to relieve chest pain, preventing infection at the multiple arterial and venous line insertion sites, protecting the skin, and monitoring respiratory function. e. Ensure proper positioning of the patient promotes effective breathing without decreasing blood pressure and may also increase the patient’s comfort while reducing anxiety. III. Anaphylactic Shock Anaphylactic shock is caused by a severe allergic reaction (to drugs, insect, food or pollens etc) when a patient who has already produced antibodies to a foreign substance (antigen) develops a systemic antigen– antibody reaction. Initial introduction of an antigen into the body results in the production of an antibody specific to that antigen. Subsequent presentations of the antigen may induce the physiological reactions that characterize anaphylaxis. Antibody response releases histamines, bradykinins and other vasoactive substances. In combination, these substances produce vasodilation, increased capillary permeability and sever bronchoconstriction. Because anaphylactic shock occurs in patients already exposed to an antigen who have developed antibodies to it, it can often be prevented. Therefore, patients with known allergies need to understand the consequences of subsequent exposure to the antigen and should wear medical identification that lists their sensitivities. This could prevent inadvertent administration of a medication that would lead to anaphylactic shock. Medical Management Treatment of anaphylactic shock requires removing the causative antigen (e.g., discontinuing an antibiotic agent), administering medications that restore vascular tone, and providing emergency support of basic life functions. Epinephrine is given for its vaso-constrictive action. Diphenhydramine (Benadryl) is administered to reverse the effects of histamine, thereby reducing capillary permeability. These medications are given intravenously. Nebulized medications, such as albuterol (Proventil), may be given to reverse histamine-induced bronchospasm. If cardiac arrest and respiratory arrest are imminent or have occurred, cardiopulmonary resuscitation is performed. Endotracheal intubation or tracheotomy may be necessary to establish an airway. Intravenous lines are inserted to provide access for administering fluids and medications. Nursing Management The nurse has an important role in preventing anaphylactic shock: assessing all patients for allergies or previous reactions to antigens (e.g., medications, blood products, foods, contrast agents, latex) and communicating the existence of these allergies or reactions to other healthcare team. Additionally, the nurse assesses the patient’s understanding of previous reactions and steps taken by the patient and family to prevent further exposure to antigens. When new allergies are identified, the nurse advises the patient to wear or carry identification that names the specific allergen or antigen. When administering any new medication, the nurse observes the patient for an allergic reaction. This is especially important with intravenous medications. If the elderly patient reports an allergy to a medication, the nurse must be aware of the risks involved in the administration of similar medications. In the hospital and outpatient diagnostic testing sites, the nurse must identify patients at risk for anaphylactic reactions to contrast agents (radiopaque, dye-like substances that may contain iodine) used for diagnostic tests. These include patients with a known allergy to iodine or fish or those who have had previous allergic reactions to contrast agents. This information must be conveyed to the staff at the diagnostic testing site, including x-ray personnel. The nurse must be knowledgeable about the clinical signs of anaphylaxis, must take immediate action if signs and symptoms occur, and must be prepared to begin cardiopulmonary resuscitation if cardiorespiratory arrest occurs. In addition to monitoring the patient’s response to treatment, the nurse assists with intubation if needed, monitors the