NRS 210 Exam #3 Pearls of Knowledge PDF

NRS 210 Exam #3 Pearls of Knowledge Chapter 57 – Burns ~ Know the rule of nines BE ALERT: TOTAL ARM IS 9% - IF IT SAYS FRONT OF ARM THEN 4.5% or TOTAL LEG IS 18%, IF THE QUESTION STATES FRONT OF LEG THEN 9% READ CAREFULLY! ~ Know the Parkland Formula for fluid resuscitation of Ringers Lactate: 4ml X...

NRS 210 Exam #3 Pearls of Knowledge Chapter 57 – Burns ~ Know the rule of nines BE ALERT: TOTAL ARM IS 9% - IF IT SAYS FRONT OF ARM THEN 4.5% or TOTAL LEG IS 18%, IF THE QUESTION STATES FRONT OF LEG THEN 9% READ CAREFULLY! ~ Know the Parkland Formula for fluid resuscitation of Ringers Lactate: 4ml X % of burn X pts weight kg. So 70 kg patient with 40% burns = 4 X 40 X 70 = 11,200 ml of fluid over 24 hrs (half to be given in the first eight hours and the rest over 16 hours) ~ Understand the criteria for classification of burns, ie partial thickness and full thickness (skin, muscle and can or may include bone) ~ Refer to Brunner page 1877-1879 regarding emergent/resuscitative phase of a burn injury. Because of cellular damage, potassium comes out of the cell, thus hyperkalemia. The patient is fluid depleted initially, thus hypovolemia and high hematocrit levels are to be expected due to fluid loss. During the Emergent/Resuscitative stage ABC’s are a priority then fluid resuscitation. -In the early stage of burn care, after the ABC’s - fluid resuscitation is a priority. The fluid of choice is Ringers Lactate. The nurse assists with calculating the patient’s expected fluid requirement and monitoring the patient’s response to fluid resuscitation. Monitor hourly urinary output…. as blood pressure reading will not be accurate in the burn patient due to the inflammatory response. The myoglobin released from damaged tissues (especially in electrical burns) can cause kidney failure, thus urinary outputs and renal function tests, ie BUN, Creatinine are important. -In the Acute phase (48 hrs after burn injury,) which follows the Emergent/Resuscitative phase, kidney function and infection control is a priority. You may see hyponatremia and hypokalemia and pale urine during the acute phase due to fluid resuscitation during the Emergent/Resuscitative Phase. -Complications associated with burns in the Emergent/Resuscitative Phase include: Impaired gas exchange and impaired airway clearance Hypovolemia – increased capillary permeability, and evaporative losses Hypothermia * Pain Collaborative Problems: Acute Respiratory Failure, Distributive Shock, Acute Kidney Injury, Compartment Syndrome, Paralytic Ileus and Curling’s Ulcer (due to stress) -Compartment syndrome: decrease pulses, decrease capillary refill time, no ice, no elevation of extremity and must prepare for a fasciotomy as a treatment. -Smoke inhalation, burns to the face and chest, singed nasal hairs – look for airway compromise. May develop glottis edema and have to be intubated. -Care of the graft site: Protection and Immobility are the priorities- *Occlusive dressing for humid environment to support optimal healing *Splints to immobilize and position patient carefully * First dressing changed 3-5 days after surgery *Patient may begin to exercise the grafted area within 5-7 days after surgery. -Main goal for nursing care when the hands and feet of a patient are burned – preservation of limb function -Full thickness burns = monitor for pulses. May have to do escharotomy to increase blood supply to area -Pain management in the burn patient – additional pain medication may be needed because of the rapid body metabolism in a burn patient. Pain meds should be given before any procedures such as dressing changes, debridement and hydrotherapy. Patients with a history of drug/alcohol abuse usually require higher doses of pain medications. IV is the preferred method of administering pain medication to the burn patient. -Electrical burns = cardiac arrhythmias. Electrical burns release myoglobin from injured tissues thus renal failure ensues -Chemical burn = always neutralize the chemical first Chapter 66 -Doff – Gloves, Gown, Goggles and the Mask is always last -Legionnaires disease is not spread from person to person! No mask! No isolation! From Tara’s slides:  Clinical Manifestations: 2-10 days - Early: Malaise, Muscle aches, Dry cough. Progressive: Productive Cough, SOB, Chest Pain, High Fever. Diagnostics: Xrays, Cultures, Urinary Antigen test (most common) Medical Management: Azithromycin, Fluoroquinolones (moxifloxacin) Chapter 67 -Heat Stroke: dry, hyperthermia, tachycardia, NO SWEATING, confused and disoriented -Emergency nursing – A, B then C Airway, Breathing (give oxygen) then C Circulation (control bleeding) -Establishing an IV line in a critically ill patient is a priority -Snake bite: NO ICE, NO ELEVATION, NO TOURNIQUET !!!! – keep extremity below heart level Chapter 68 -Always know the hospital’s disaster or response plan for an emergent situation, mass casualty. “Doing the greatest good for the most amount of people” -Black Triage in a Disaster – Large burns of body > 60%, CPR in progress -Red Triage in a Disaster – The patient has a condition that can result in death, soon. For example: severe asthmatics, pulmonary embolism, pneumothorax, stridor when breathing Chapter 12 Palliative care, according to Brunner focuses on symptom management, psychological support and aims to improve the quality of life through management of pain. Palliative care is appropriate for patients at any stage of illness while pursuing disease directed treatments and curative therapies. Palliative care focuses on optimizing the quality of life. Whereas hospice care just focuses on comfort, not treatment or cures, for patients at the end of life. HPV vaccine is an example of primary prevention in a patient with an abnormal PAP smear. TNM system of cancer staging T=size of tumor 1,2,3 N=number of nodes 1,2,3 M=metastasis 0,1 - Dairy products may increase the risk of prostate cancer and alcohol and polys may increase the risk of colon cancer. Colon cancer presents with anorexia, rectal bleeding, and possible abdominal mass. -Colon Cancer – no high residue (irritant), assess patient for obstruction, pain meds, and emotional support. Monitor for bowel obstructions. -First sign of bladder cancer may be painless hematuria -Malignant melanoma – irregularly shaped border and asymmetrical -Stage III ovarian cancer would indicate that there is metastasis outside of the pelvic region -Stop chemo if no IV return, resistance to infusion, redness, swelling at site -Brachytherapy no children, no preg people/staff, wear dosimeter, 30 min for adults and a 6 ft distance and private room -Chemotherapy – causes myelosuppression of bone marrow – low WBC’s, platelets (thrombocytopenia), RBC’s -Exercise post breast cancer surgery = lifting an object over their head. Lymphedema, then take BP/ IV unaffected side. -DCIS does not usually metastasize, category is Stage 0, can develop into invasive cancer is not detected early. -Complications after brain tumor surgery: seizures, vision loss, cerebral edema, pituitary dysfunction, neurologic deficits -6 month prognosis but unable to be at home needs referral for hospice care. Central to hospice is that the client and family should be viewed as a single units of care -Radiation to pelvic area for a male – harvest sperm prior to treatment -After a tracheostomy the patient can suction with a suction catheter. -Myelosuppression : bleeding, people with attenuated or live vaccines stay away, wash hands, avoid crowded places, no fresh fruits or vegetables due to bacteria on raw fruits and vegetables. -Doxorubicin chemotherapy is cardiotoxic be sure to assess for CHF and check BNP levels >100 greater than 100 = CHF -Chemotherapy should be given through a CVAD such as an implanted port. If alopecia develops from chemo, suggest that patient buys a wig as there is a chance that hair will not grow back. -Lung cancer: assess lung sounds, monitor for fever, oxygen, small meals for feeding as they get short of breath -Resection of right lower lobe pt to lie on left side and an alternate to back in order to expand surgical lung -With a pneumonectomy lie on surgical side ie left pneumonectomy – lie on left side -After a lobectomy, there should be no more than 100 cc drainage an hour. If so, call MD -Surgical staging of tumors: assessment of tumor size, number of tumors, site of tumor and pattern of spread -Secondary prevention of cancer: mammograms, fecal occult blood testing, colonoscopy age 50 every 10 years -Tumor lysis syndrome (TLS) is a medical emergency that occurs when the body breaks down cancer cells too quickly, causing an imbalance of electrolytes and chemicals. Symptoms include: Gastrointestinal: Nausea, vomiting, diarrhea, lack of appetite, Musculoskeletal: Muscle cramps or twitches, weakness, numbness or tingling, Urinary: Decreased urination, dark urine, blood in the urine ,Neurological: Confusion, restlessness, irritability, delirium, hallucinations, seizures, Cardiac: Irregular heart rate, heart palpitations , fainting, low BP Chapter 13 Living Will = patient’s wishes for care Health Care Proxy = appoints person to act on their behalf Patient Self Determination Act = requires hospital to ask for advance directives Power of Attorney – makes decisions when patient cannot Chapter 32 -Goals of antiretroviral therapy is to: lower HIV viral load, prevent transmission of HIV, suppress viral replication of HIV, decrease HIV morbidity. -If healthcare worker is exposed to HIV FLUIDS (not a HIV patient), RN must report to supervisor, go to ER or EHC -Monitor CD4-t lymphocytes with HIV. Antiretroviral therapy should INCREASE CD4 number (normal 500-1500) -Opportunistic infection in the HIV patient is pneumocyctis pneumonia, there will be low CD4 count, an increase in WBCs. Give oxygen and antibiotics (trimethoprim-sulfamethoxazole) Chapter 19 – Respiratory When a patient is on PEEP, positive expiratory end pressure, it inflates the alveoli longer to enhance gas exchange, prevents collapse of alveoli. PEEP may cause barotrauma (rupture of alveoli) and PEEP, by causing an increased in intrathoracic pressure may lower the patient’s blood pressure. Chest tube – no bubbling in the water seal chamber – if present may indicate leak in system. There should be tidaling, ie fluid moves down during inspiration and up in exhalation. If chest tube drainage system breaks, cracks or leaks put chest tubing into a bottle of sterile water to prevent air from going into pleural space. Treatment of TB: Isoniazid (INH), Rifampin, Ethambutol. (all hepatotoxic, check liver enzymes) INH lowers B6 thus numbness and tingling results; Rifampin turns urine, eye secretions yellow red brown, tell patient not to wear contacts; Ethambutol may cause eye problems such as optic neuritis, color blindness. S/S of TB: Hemoptysis, fever, night sweats, cough, fatigue In order to decrease the development of atelectasis: Turn and position patient, incentive spirometer, chest PT and only suction when necessary. Never every hour if no adventitious sounds are auscultated. If a patient is intubated and develops a temperature, that is a RED FLAG as the patient may have developed aspiration pneumonia or HAP or VAP. Notify physician. Chest tube – tidaling in water seal OK- water level goes down during inspiration. There should be no bubbling in the water seal chamber as that indicates a link in the system. Patient with ARDS – prone position as often as possible. Turn and position every two hours at least. Never withhold nutrition – very important to feed sick people. Fluid support as needed. High peak pressures – suction patient, sedate patient, empty fluid in tubing, possible chest x- ray to evaluate tube placement If endotracheal tube is advanced too far, hitting the carina (where the R & L brochus splits into to right and left lung) the patient will “buck” the machine, cough, and be very anxious. X-ray to be done and ET tube to be 1 ½ inch to 2.5 inch from carina. Always auscultate both lungs after intubation, assess CO2 and O2 levels. To prevent VAP (ventilator acquired pneumonia) use aseptic technique always, sit patient up - keep the head of the bed elevated, check cuff pressure (20-30) every shift (to prevent aspiration and dislodgement of endotracheal tube, auscultate BS, if NGT feedings in place, check for residual to prevent aspiration. A venturi mask delivers precise oxygen amount depending on color of cone attachment and a non-rebreathing mask delivers 60%-80% oxygen. Weaning patient from ventilator – patient must be alert and oriented, adequate tidal volume, spontaneous ventilation on 40% or less, patient’s ABG at least 70. YOU GOT THIS! STUDY HARD!