Final Exam Advance Med Surg PDF

**Final Exam Advance Med Surg** **ICU Management, Codes, and Mechanical Ventilation** Rapid Response - Details: - Utilized in many acute care settings to bring a team of critical care clinicians to a deteriorating patient's bedside - Designed to improve the safety of hospi...

**Final Exam Advance Med Surg** **ICU Management, Codes, and Mechanical Ventilation** Rapid Response - Details: - Utilized in many acute care settings to bring a team of critical care clinicians to a deteriorating patient's bedside - Designed to improve the safety of hospitalized patients - Can occur anywhere within the facility - Medical/surgical floors - Radiology - Hemodialysis units - \*indications - Sudden change in heart rate of rhythm - Sudden change in respiratory status - Acute active bleeding - Hyper- or hypotension - Acute change in mental status or level of consciousness - New or prolonged seizure activity - Signs and symptoms of a myocardial infarction - Suspected sepsis - Family concerns - Staff assessment Code Blue - What is a Code Blue? - Medical emergency! - Cardiopulmonary resuscitation or immediate intubation needed - Patient is: - Pulseless - Apneic - Agonal breathing - Unable to protect the airway - Confirm code status - \*nursing management - - \*capnography -- end tidal CO2 monitoring - confirm ET tube placement - Monitor ET tube position - Assess ventilation and treatments - Evaluate resuscitative measures during cardiopulmonary resuscitation Mechanical Ventilation - Modes - Continuous mandatory ventilation (CMV) Also known as assist-control (A/C) ventilation - Intermittent mandatory ventilation (IMV) - Synchronized intermittent mandatory ventilation (SIMV) - Pressure support ventilation (PSV) - Airway pressure release ventilation (APRV) - Proportional assist ventilation (PAV) - Continuous positive airway pressure (CPAP) - Positive end-expiratory pressure (PEEP) - setting changes - Set the machine to deliver the tidal volume required - 6 to 10 mL/kg of ideal body weight - Adjust the machine to deliver the lowest concentration of oxygen to maintain PaO2 or SpO2\>= 92% - Record peak inspiratory pressure - Set ventilator mode - Set PEEP and pressure support - Set high settings - Adjust sensitivity - Record minute volume - Obtain ABGs after 20 minutes - Adjust settings based on ABG results - weaning indications/contraindications - Criteria - Hemodynamically stable - Demonstrates spontaneous breathing capability - Recovering from the acute stage of disease process - Cause of respiratory failure is reversed - Collaboration - Respiratory - Monitor - Vital signs - Oxygen saturation - Electrocardiogram - Respiratory pattern - Terminate if adverse reactions occur Endotracheal Intubation - What is it? - Passing of an endotracheal tube through the nose or the mouth into the trachea - Provides: patent airway, access for mechanical ventilation, and easier removal of secretions - Maintain cuff pressure 20-25 mm Hg - In place no longer than 14-21 days. Patient may require tracheostomy for chronic mechanical ventilation - \*injury prevention - Administer adequately warmed humidity - Maintain adequate cuff pressure - Suction as needed - Maintain skin integrity - Auscultate lung sounds - Monitor for signs and symptoms of infection - Administer prescribed oxygen and monitor SpO2 - Monitor for cyanosis - Maintaining adequate hydration - Use sterile technique when suctioning - \*placement confirmation - Chest Xray to verify proper tube placement - capnography - Check cuff pressure every 6-8 hours Chest Tube - nursing management - promote drainage - maintain water seal **Structural, Infectious and Inflammatory Cardiac Disorders** Mitral Stenosis - Assessment - Valve does not completely open, and blood flow is reduced through. (Narrowed valve orifice) - Decreased ventricular filling and decreased cardiac output - Causes right ventricle hypertrophy - \*Low-pitched rumbling diastolic murmur and loud S1 Sound - Echocardiogram - clinical manifestations - dyspnea on exertion - decreased exercise tolerance - dry cough or wheezing - significant pulmonary congestion Mitral Regurgitation - Causes - Blood backflows back into left atrium from left ventricle during systole. - Mitral regurgitation may result from problems with one or more leaflets, chordae tendineae, the annulus, or the papillary muscles. - Conditions that can cause secondary mitral regurgitation: ineffective endocarditis, collagen vascular diseases, and cardiomyopathy. - Excess blood in atrium causes stretching then hypertrophy then dilation. - Assessment - Systolic murmur of mitral regurgitation is a blowing sound best heard at the apex of the heart. It may radiate to the left axilla. - Pulse irregular, or regular - Echocardiography extrasystole beats or atrial fibrillation - clinical manifestations - chronic is often asymptomatic - acute manifests as severe or sudden congestive heart failure - systolic murmur at the apex Mitral Prolapse - clinical manifestations - \*no symptoms - A small amount of people will experience fatigue, shortness of breath, lightheadedness, dizziness, syncope, palpitations, chest pain, or anxiety. - occurs twice as often in women than men - no clear cause - mitral click Aortic Stenosis -- teaching - Education - Echocardiograms every 2-5 years. - Prevention of aortic stenosis is primarily focused on controlling risk factors for proliferative and inflammatory responses---namely, through treating diabetes, hypertension, hypercholesterolemia, and elevated triglycerides, and avoiding tobacco product Valvuloplasty - Contraindications - Balloon Valvuloplasty: The procedure is contraindicated for patients with left atrial or ventricular thrombus, severe aortic root dilation, significant mitral valve regurgitation, and severe valvular calcification. - Complications - All patients will have some degree of mitral regurgitation following mitral balloon valvuloplasty. - bleeding from the catheter insertion sites, emboli resulting in complications such as strokes, and, rarely, left-to-right atrial shunts through the atrial septal defect created during the procedure. - Aortic ballon valvuloplasty: Possible complications include aortic regurgitation, emboli, ventricular perforation, rupture of the aortic valve annulus, ventricular arrhythmia, mitral valve damage, and bleeding from the catheter insertion sites. - medical management - Balloon valvuloplasty, Leaflet repair, valve replacement- mechanical or tissue - TAVR Transcatheter aortic valve replacement - a minimally invasive aortic valve replacement procedure - a balloon valvuloplasty is performed. Then, a bioprosthetic (tissue) replacement valve attached to a catheter is inserted percutaneously, positioned at the aortic valve, and implanted. - Commissurotomy - A commissurotomy is performed to separate the fused leaflets. - Commissurotomy is usually used for mitral valve stenosis. - patients with congenital mitral stenosis, severe calcified mitral stenosis, left atrial thrombus, moderate to severe coexisting mitral regurgitation, or in patients with coexisting moderate to severe tricuspid regurgitation who would also benefit from tricuspid valve repair - annuloplasty - The junction at which valve leaflets connect to the heart wall is an annulus. Annuloplasty refers to repair of the valve annulus, resulting in narrowing of the valve orifice. - - nursing management - hemodynamic stability - recovery from anesthesia - frequent assessments, cardiovascular neurological and respiratory - patient education - anticoagulant therapy - preventative of infective endocarditis - Follow up appointments - echocardiogram Endocarditis - risk factors; medical management; teaching Rheumatic Endocarditis - occurs after rheumatic fever. Group A beta-hemolytic streptococcal pharyngitis. - Risk factors: Malnutrition, overcrowding, poor hygiene, and low socioeconomic status. - Need to promptly recognize and treat strep throat for prevention. - Risk factors: Prosthetic heart valves, IV drug users, and chronic CVAD. - Insidious onset of symptoms: fever, new murmur, Osler nodes, Janeway lesions, Roth spots, splinter hemorrhages - Most frequent complication is heart failure - Medical Management: - Blood cultures - Echocardiogram - Long term Iv antibiotics, surgery - Nursing Management: - Temperature monitoring, antimicrobial medication administration, heart sounds, and CVAD monitoring - Prevention: - Antibiotic prophylaxis before certain procedures - Ongoing oral hygiene - Meticulous care should be taken in patients at risk with catheters - Catheters should be removed as soon as they are no longer needed Pericarditis Inflammation of the pericardium - Clinical manifestations - Many causes - Chest pain - Creaky or scratchy friction rub - - Medical management - Echocardiogram - Determine the cause - NSAIDS/corticosteroids - Colchicine - Pericardiocentesis - Pericardial window - Nursing management: pain management Myocarditis Inflammatory process involving the myocardium - Assessment - Clinical manifestations - Most commonly viral (most common are flu like symptoms!) - Asymptomatic to sudden cardiac death - Endometrial biopsy provides definitive diagnosis - Medical Management - Treat underlying cause - Bed rest, limit activities - Nursing management: monitor HR and temperature, focused cardiovascular assessment and VTE prophylaxis Dilated Cardiomyopathy - Medical management - Echocardiogram, chest Xray - Cardiac catheterization - Endomyocardial biopsy - Identify and manage underlying or precipitating causes - Correct heart failure - Controlling arrhythmias - Biventricular pacing (DCM) - Genetic counselor referral - Surgical management - Morrow procedure (myectomy) - Heart transplant - Ventricular assist device (VAD) - Total artificial heart Hypertrophic Cardiomyopathy Autosomal dominant genetic disorder Leading cause of sudden death in adolescents and young adults - Clinical manifestations - Complications - Heart failure - Ventricular arrhythmias - Atrial arrhythmias - Cardiac conduction defects - Pulmonary or cerebral embolism - Valvular dysfunction **Arrhythmias & Acute Coronary Syndrome** EKG Components - normal measurements - **Time & rate** are measured on the horizontal axis of the graph - **Amplitude or voltage** is measured on the vertical axis - **Positive deflection**: when an ECG waveform moves toward the top of the paper - **Negative deflection**: when it moves toward the bottom of the paper - **P wave**: represents the electrical impulse starting in the SA node and spreading through the atria - Atrial depolarization - Normally 2.5 mm or less in height - 0.11 seconds or less in duration - **QRS Complex**: represents ventricular depolarization - **Q wave**: first negative deflection after the p wave - Normally less than 0.04 seconds in duration and less than 25% of the R-wave amplitude - **R wave**: first positive deflection after the P wave - **S wave**: first negative deflection after the R wave - **QRS Complex**: normally less than 0.12 seconds in duration - **T wave**: represents ventricular repolarization (when the cells regain a negative charge; also called the resting state) - **U wave**: is rare but represents repolarization of the Purkinje fibers - Appears in patients with hypokalemia, hypertension, or heart disease - **PR interval**: measured from the beginning of the P wave to the beginning of the QRS complex and represents the time needed for sinus node stimulation, atrial depolarization, and conduction through the AV node before ventricular depolarization - Ranges from 0.12 to 0.20 seconds in duration - **ST segment**: represents early ventricular repolarization, lasts from the end of the QRS complex to the beginning of the T wave - **QT interval**: represents the total time for ventricular depolarization and repolarization - Measured from the beginning of the QRS complex to the end of the T wave - **TP interval**: measured from the end of the T wave to the beginning of the next P wave - An isoelectric period Sinus Bradycardia -- identification  - medical management - removal of causative factor - atropine - increase HR - transcutaneous pacing - other medications: - dopamine, epinephrine, isoproterenol Atrial Fibrillation - identification - Abnormal impulse formation from altered atrial tissue - Causes a rapid, disorganized, and uncoordinated twitching of the atrial musculature - The atrial rhythm is unmeasurable, and all atrial activity is chaotic. Ventricular rhythm is grossly irregular - Identification "The atria is quivering!" - Grossly irregular pulse usually over 100 BPM - Rhythm is irregular - P wave is none, or irregular, fibrillary waves. - Manifestations: Confusion, syncope. And dizziness - Severe hypoxia - medical management - Antithrombotic - CHA2DS-VASc - Anticoagulated to prevent clots - Medications to control the heart rate - Drug therapy: beta blockers, calcium channel blockers, digoxin, amiodarone, - Medications to convert or prevent atrial fibrillation - \*Unstable patient: Electrical cardioversion to synch shock with QRS wave - Other: - Catheter ablation therapy - Maze/Mini Maze procedure - Convergent procedure - Left atrial appendage occlusion - Wolff-Parkinson-White syndrome Atrial Flutter  - Identification - Rapid regular atrial impulse between 240 and 400 beats/min - Therapeutic block at the AV node - "Sawtooth" shape Asystole - identification; A graph with a line drawn on it Description automatically generated - medical management - high quality CPR and rapid assessment of cause - Hs and Ts; hypoxia, hypovolemia, hydrogen ion (acid--base imbalance), hypo- or hyperglycemia, hypo- or hyperkalemia, hypothermia, trauma, toxins, tamponade (cardiac), tension pneumothorax, or thrombus (coronary or pulmonary) - intubation - establishment of IV access Ventricular Tachycardia -- identification  - medical management - Factors to determine treatment - Type of VT - Presence of prolonged QT - Heart function - Antiarrhythmic - Procainamide - Amiodarone - Sotalol - Lidocaine - Stabilize a patient with a pulse - Oxygen - Antiarrhythmics such as AMIODARONE - Synchronized cardioversion, with QRS wave - Stabilize a patient without a pulse - Pulseless v-tach - Defibrillation per ACLS code - Drug therapy: epinephrine, vasopressin, amiodarone. Supraventricular Tachycardia - Identification - P wave cannot be identified - Abrupt onset - Narrow QRS- ventricle. - Nursing Management - \*Cough- bear down - Medication - \*Prepare for cardioversion - Medical Management - Alleviate symptoms and improve quality of life - Initial therapy immediately - Monitor and self treat with few symptoms present - Catheter ablation to break reentry of impulse - Vagal maneuvers - These techniques increase parasympathetic stimulation, causing slower conduction through the AV node and blocking the reentry of the rerouted impulse. - Pharmacological treatment - \*\*Bolus of adenosine to correct rhythm - Calcium channel blockers - Beta blockers - Digoxin Premature Atrial Contractions (PAC) - Causes - Ectopic focus within one of the atria fires prematurely - Normal phenomenon in some but may be cause by emotional disturbances fatigue, tobacco, and caffeine. - Other known causes include hypokalemia, stretched atrial myocardium, hypermetabolic states and atrial ischemia. - May be a sign of abnormal electrical activity associated with organic heart disease - Education - Correcting of hypokalemia - Reduction of caffeine intake, smoking, alcohol - Stress and anxiety management Premature Ventricular Contractions (PVC) - Causes - Premature ventricular response - May decrease the efficiency of the hearts pumping action - Palpitations, a feeling of irregular heart beat, or a lump in the throat - Other causes: - Ischemia due to a MI - Infection, mechanical damage due to pump failure - Electrolyte imbalance - Nicotine, coffee, tea, caffeine, medications such as digitalis - Acute and chronic lung disease - Medical management - Amiodarone or beta blockers (but long term therapy is not indicated) - Evaluate for underlying cause 3rd Degree AV Block  - Medical management - Increase heart rate to maintain a normal cardiac output - Pacemaker may be indicated - Remove medication possible causing problem -- like beta blockers. Acute Coronary Syndrome - Assessment - "coronary occlusion" "Heart attack" - Myocardial infarction - Emergent situation - Acute onset of myocardial ischemia that results in myocardial death - Cardiovascular assessment- chest pain, not relieved by rest or nitro, increase JVD, BP elevated, irregular pulse - ST segment and T wave changes - Respiratory assessment shortness of breath, dyspnea, tachypnea, and crackles - GI nausea, indigestion and vomiting - GI, skin, neurological anxiety and restlessness, and psychological FEAR or FEELING OF IMPENDING DOOM - Diagnostics - 12 lead ECG - Q wave abnormal - ST-segment elevation is measured 0.06 to 0.08 seconds after the J point. An elevation of more than 1 mm in contiguous leads is indicative of acute MI. - Patient history and identifying the timing - Serial cardiac biomarkers - Troponin, creatine kinase and - Myoglobin - medical management - minimize myocardial damage, preserve myocardial function, and prevent complications - immediate intervention of MONA - to minimize myocardial damage by reducing myocardial oxygen demand and increasing oxygen supply with medications, oxygen administration, and bed rest. - Emergent percutaneous coronary intervention - Thrombolytics - STEMI - Identification - The patient has ECG evidence of acute MI with characteristic changes in two contiguous leads on a 12-lead ECG. In this type of MI, there is a significant damage to the myocardium. - medical management - immediate cardiac catheterization lab for percutaneous coronary intervention - The procedure is used to open the occluded coronary artery and promote reperfusion to the area that has been deprived of oxygen. - **Acute Respiratory Failure & Acute Respiratory Distress Syndrome** ABG Interpretation - 7.35-7.45 pH - 22-26 HCO3 - 45-35 CO2 **Acute Respiratory Failure (ARF!)** - clinical manifestations - Early signs - Restlessness (hypoxia) - Tachycardia (hypoxia) - Hypertension (hypoxia) - Fatigue - Headache - Late Signs (usually VERY obvious) - Confusion - \*Lethargy and LOC\* - Central cyanosis - Diaphoresis - Respiratory arrest - Decreased breath sounds - Pain to breathe cough - risk factors - COPD and neuromuscular diseases - Atelectasis - Pneumonia - Pulmonary embolisms - characteristics - Tissue hypoxemia, with a decrease in PAO2 to less than 60 mmHg, hypercapnia an increase in PaCO2 to greater than 50 mmHg, and acidosis pH less than 7.35 **ARDS** - risk factors - \*Sepsis - \*Shock - Trauma - \*Aspiration - \*Covid 19 and pneumonia\* - Drug ingestion. Overdose - Fat or air embolism - Hematological disorders - \*Acute pancreatitis- high risk for development of ARDS. Accidental release of active pancreatic enzymes and cytokines into the bloodstream -- which get sucked into the lungs causing inflammation. - Localized infections - Major surgery - \*Inhalation of O2 prolonged. Smoke exposure or corrosive substance - Hydrocarbons - Near drowning event - Metabolic disorders (Uremia) - Sepsis Shock or Trauma - Fractures head injuries - Assessment - Intercostal retractions - Crackles - diagnostics - \*Chest Xray reveals bilateral infiltrates. White out infiltrates. - Hallmark sign or manifestations - \*\*\*\*Refractory hypoxemia - Retractive breathing - Horowitz Index PaO2/FiO2 - Mild \>200 mmHg - Moderate \>100 mm Hg - Severe \ 7.45 - \*Brain natriuretic peptide BNP level - Differentiate between ARDS and cariogenic pulmonary edema - Higher levels of BNP are associated with a decreased odds for ARDS - A normal BNP is \ - P/F ratio calculation - PaO2/FiO2 is the equation - \*Horowitz Index PaO2/FiO2 - Mild \200 mmHg - Moderate \>100 mm Hg - Severe \ - PEEP - Anxiety causes: - Tube blockage - Decreased oxygen level - Ventilator malfunction - Sedatives - Lorazepam / Midazolam - Dexmedetomidine - Propofol - Short-acting barbiturates - Neuromuscular blocking agents - Reduce anxiety - Promote rest - Vecuronium / Rocuronium - "Train-of-four" test - Analgesia - medical management - identification and treatment of underlying cause - supportive measures: - Supplemental oxygen - Intubation - Mechanical ventilation with PEEP - Circulatory support - Prone positioning - Sedation - Paralysis - Nutritional therapy - Frequent repositioning - COVID considerations - Ards is most serious and most frequent cause of death - Atypical clinical manifestations - Same classification system - Low dose corticosteroids \*\*\*\* - Prone position for 12-16 hours a day \* - Neurological assessment - Increased sedative requirements - Airbourne isolations Neuromuscular Blockades -- assessment \*Examples - Used for the shortest time possible - Vented more easily and may appear unconscious/appear they lost motor function but \*they are awake can feel and hear. - Vecuronium - Pancuronium - Rocuronium - Atracurium \*Nursing Management - Train of Four Test: assess neuromuscular blockade. - Four consecutive stimuli being conducted along the nerves and the response of muscle is measured in order to evaluate whether or not the stimuli is effectively being blocked. - No blockage: muscle twitches - Blockage present: loss of twitch and number will indicate degree of blockage - Reassurance: this is due to medication and is only temporary. Vent and patient alarms on at all times - Eye care, because pt cannot blink - Predispose pt to VTE, muscle atrophy, foot drop, stress ulcers, and skin breakdown. Mechanical Ventilation - patient/ventilator dyssynchrony management **Neurological Trauma** Concussion - Education - Encephalopathy - Worsening signs of neurological deficits Traumatic Brain Injury - Pathophysiology - - Posturing - Abnormal posturing response to stimuli - Decorticate reflection - Decerebrate posturing - medical management - depends on injury - elevation of skull -- surgical intervention - observation Skull Fractures - Types - Linear (simple) a break in the continuity of the bone - Comminuted: a splintered or multiple fracture line - Depressed skull fracture: occurs when the bones of the skill are forcefully displaced downward and can vary from a slight to splintered and embedded in the skull fracture. - clinical manifestations - Spinal Cord Injury - spinal shock: sudden depression of reflex activity in the spinal cord called areflexia - Occurs: after injury. IF complete spinal cord injury, it does usually occur - loss of function of the autonomic nervous system - muscle innervated; bp decreased and \*\*bradycardia - reflexes that initiate bladder and bowel are affected - takes 4-6 weeks to resolve Subdural Hematoma - clinical manifestations; assessment; diagnostics - - - - - - - clinical manifestations - (acute vs. chronic) - An SDH frequently venous in origin and is caused by a rupture of small vessels that bridge the subdural space. - Acute s/s: change in LOC, pupillary signs and hemiparesis. - Coma, increasing blood pressure, decreasing heart rate, and slowing respiratory rate are all signs of a rapidly expanding mass requiring immediate intervention. - Chronic: can resemble other conditions such as stroke, classical s/s fluctuate due to clot break down and calcification and ossification of the clot in the brain, alternation in focal neurological signs, personality changes, mental deterioration, and focal seizures. Diagnostics - CT and MRI change - PET SCAN Epidural Hematoma - clinical manifestations - brief LOC and patient will have lucid interval where patient interacts - increased ICP - restlessness agitation, confusion - progresses to coma - focal neurologic deficits - nursing management - Increase HOB - Monitor ICP - Prevent spinal injury - Seizure precautions - And maintain oxygenation and patent airway Brain Death - Criteria - COMA, absence of brain stem reflexes (corneal reflex, gag reflex), apnea - Diagnostics - To confirm brain death: EEG - Transcranial doppler - Cerebral blood flow studies - Brain stem auditory-evoked potentials BAEP **Sepsis, Shock, & Multiple Organ Dysfunction Syndrome (MODS)** Stages of Shock - pathophysiology; clinical manifestations; cardiac effects; nursing management Cardiogenic Shock - causes; medical management Hypovolemic Shock - causes; nursing management; medical management Anaphylactic Shock - causes; medical management Sepsis - medical management MODS - pathophysiology; clinical manifestations Vasoactive Medications - Goals - nursing management **Burn Injuries** Burn Prevention Emergent Phase - Stop the injury - Prevent injury to rescuer - ABCs - Supplemental oxygen, large bore IV lines - Remove restrictive objects and cover wounds with clean gauze - Fluids given - Disconnect source of electrical burn - Assessment - Survey all body parts - History of incident - Pertinent patient history - COOL ok- never ice! Hypothermia risk - No ointments at this time Acute Phase -complications - Priorities - Begins 48-72 hours after initial injury - Assessment and maintenance: respiratory status, circulatory status, fluid and electrolyte balance, GI function, and kidney function. - Burn Wound Care - Wound cleaning- hydrotherapy (hypothermia risk) - Topical agents (chart 57-4) - Wound dressings and dressing changes. Performed distal to proximal - Pain Management - Analgesics - IV during emergent and acute phases. PCA pumps. Oral used after acute phases. - Morphine, hydromorphone, fentanyl - Role of anxiety in pain. Benzodiazepines - Procedural pain - Non pharmacologic measures- relaxation. Music, meditation, touch and humor - Early positioning and mobility - Prevent contractures - Turning and moving 1^st^ year - Complications - ARF and ARDS - Heart failure - Pulmonary edema - Sepsis - Delirium Degrees of Burns - identification; priorities of care; nursing management - Superficial -- First Degree Burn - Superficial injuries that involve the outermost layer of the skin - Wound appearance: reddened, blanches with pressure, dry. Minimal or no edema. - Sun burn, low intensity flash and superficial scald - Clinical manifestations: tingling, painful, hypersensitivity, peeling, itching - Complete recovery within a few days. Oral pain medications, cool compresses, and skin lubricants are all forms of treatment. - Topical antimicrobial agents are not indicated - Partial Thickness Burn -- Second Degree - Involves the entire epidermis and varying portions of the dermis - Wound appearance: blistered, mottled red base with disrupted epidermis, weeping surface. Edema - Scalds, flash flame, and contact burns - Clinical manifestations: painful, hypersensitive, sensitive to air currents - Recovery in 2-3 weeks, some scarring and pigmentation may need grafting. - Full Thickness Burn- Third Degree - Total destruction of the dermis and underlying tissue - Wound appearance: dry, color changes, pale white red brown leathery, or charred. Coagulated vessels may be visible. Edema - Flame, prolonged exposure to hot liquids, electric current, and chemical contact - Involves epidermis, dermis and sometimes subcutaneous tissue. May involve connective tissues and muscle. - Clinical manifestations: insensate, shock, myoglobinuria, possible contact points like entrance and exit wounds. - Recovery: eschar may slough, grafting necessary, and scarring loss of contour and function. - Fourth Degree - Deep burn necrosis - Wound appearance: Charred - Prolonged exposed to high voltage electrical injury - Involves deep tissue muscle and bone - Clinical manifestations: shock, myoglobinuria - Amputation likely. Grafting of no benefit given depth and severity. Fluid Resuscitation preferred fluid is NS and LR - ABA formula - These formulas are only guidelines. It is imperative that the rate of infusion be titrated hourly as indicated by physiologic monitoring of the patient's response - Parkland formula First 8 hours, first half of dose, then 16 hours 2^nd^ half of dose. - Thermal or Chemical burns 2 mL LR x patient weight in kg x TBSA - Electrical: 4 mL LR x patient weight kg x TBSA Rule of Nines -- calculation **Organ Transplantation** Kidney Transplant - Contraindications - Must evaluate compatibility of doner and recipient - Recipient: recent malignancy, active or chronic infection, BMI \35 kg, current substance use disorder, active psychiatric disease, and history of nonadherence - Donor: same as recipient contraindications, hypertension and diabetes - medical management - - Teaching - Immunosuppressant therapy - The patient and family are educated about the need to report signs and symptoms of rejection Lung Transplant - medical management Liver Transplant - Education - Immunosuppressant therapy to prevent rejection - Heart Transplant - considerations - No nerve connections -- vagus nerve not intact - Extended warm up and cool down periods -- exercise - Atropine and digoxin will not decrease or increase heart rate - No anginal pain with ischemia Immunosuppressants - Teaching **Emergency & Disaster Nursing - 10** Emergency Operations Plan Components - Activation response: The EOP activation response of a health care facility defines where, how, and when the response is initiated. - Internal/external communication plan: Communication is critical for all parties involved, including communication to and from the prehospital arena. - Plan for coordinated patient care: A response is planned for organized patient care into and out of the facility, including transfers from within the hospital to other facilities. The site of the disaster can determine where the greater number of patients may self-refer. - Security plans: A coordinated security plan involving facility and community agencies is key to the control of an otherwise chaotic situation. - Identification of external resources: Resources outside the facility are identified, including local, state, and federal resources and information about how to activate these resources. - Plan for people management and traffic flow: "People management" includes strategies to manage the patients, the public, the media, and the personnel. Specific areas are assigned, and a designated person is delegated to manage each of these groups. - Data management strategy: A data management plan for every aspect of the disaster will save time at every step. A backup system for documenting, tracking, and staffing is developed if the facility utilizes an electronic health record. - Demobilization response: Deactivation of the response is as important as activation; resources should not be unnecessarily exhausted. The person who decides when the facility resumes daily activities is clearly identified. Any possible residual effects of a disaster must be considered before this decision is made. - After action report or corrective plan: Facilities often see increased volumes of patients 3 months or more after an incident. Postincident response must include a critique and a debriefing for all parties involved, immediately and again at a later date. - Plan for practice drills: Practice drills that include community participation allow for troubleshooting any issues before a real-life incident occurs. - Anticipated resources: Food and water must be available for staff, families, and others who may be at the facility for an extended period. - MCI planning: MCI planning includes such issues as planning for mass fatalities and morgue readiness. - Education plan for all of the above: A strong education plan for all personnel regarding each step of the plan allows for improved readiness and additional input for fine-tuning the EOP. Emergency Triage - ESI levels and typical injuries - ESI Levels - \*ESI levels and typical injuries Emergency service index levels 1-5 with most urgent to least urgent - Emergent - Urgent- serious/ not life threatening to life or limb - Non-urgent- episodic illness Based on acuity and anticipated resource needs. - ESI-1 Unstable vital functions, Obvious life threat or organ threat, patient should be seen immediately, high resource intensity/staff at beside continuously/often mobilization of team response Examples include: cardiac arrest, intubated trauma patient, overdose with bradypnea, severe respiratory distress - ESI-2 Threatening stability of vital signs, likely threat to life but not always obvious, patient should be seen within 10 minutes, high resource intensity/multiple often complex diagnostic studies/frequent consultation/continuous monitoring Examples include: chest pain probably resulting from ischemia, multiple trauma unless responsive - ESI-3 Stable vital functions, like threat or organ threat is unlikely but possible, medium to high resource intensity/multiple diagnostic studies/complex procedure Examples include: abdominal pain or gynecological disorders, hip fracture in older patients - ESI-4 No threat to vital functions, no threat to organ or life, treatment can be delayed, low resources intensity/one simple diagnostic study to be done Examples include closed extremity trauma, simple laceration and cystitis - ESI-5 No threat to vital functions, no threat to organ or life, treatment can be delayed, low resources intensity/one examination only examples include: cold symptoms, minor burns, recheck, prescription refill. Carbon Monoxide Poisoning - Assessment/Diagnostics - Carboxyhemoglobin (Blood work diagnostics) - Pulse oximetry is not reliable; nor is skin color - Clinical manifestations include: Because the CNS has a critical need for oxygen, CNS symptoms predominate with carbon monoxide toxicity. - Confusion - Palpitations - Dizziness - Drunk appearance - Headache and weakness - medical management - fresh air - CPR as needed - 100% oxygen or oxygen under hyperbaric pressure until carboxyhemoglobin levels are less than 4% - Continuous monitoring Multiple Trauma - nursing management - ABCS! Establish airway and ventilation - As soon as the patient is resuscitated, clothes are removed or cut off and a rapid physical assessment is performed. - Control hemorrhage - Prevent and treat hypovolemic shock - Large volumes of IV crystalloids might need to be infused to manage the effects of hypovolemia - Asses for head and neck injuries - Splint fractures reassess pulses and neurovascular status - Perform thorough head-to-toe assessment and diagnostic studies - The trauma emergency nurse must implement interventions that can mitigate the effects of hypothermia. - The ambient temperature in the trauma bay where the patient with major trauma is treated is kept higher than normal - Any wet clothing is removed, and warm blankets may be applied. IV fluids may be warmed while they are infusing. Alcohol Withdrawal clinical manifestations - Nausea or vomiting - Tremor - Paroxysmal sweats - Anxiety - Agitation - Tactile disturbances - Auditory disturbances - Visual disturbances - Headache - Orientation/clouding of sensorium Benzodiazepine Overdose - Endotracheal tube is inserted as a precaution; use assisted ventilation to stabilize and correct respiratory depression. Observe for sudden apnea and laryngeal spasm. - Assess for hypotension. - Evacuate stomach contents; lavage (if within 1 h of ingestion); activated charcoal. - Start ECG monitoring. Observe for arrhythmias. - Administer flumazenil, a benzodiazepine antagonist (reversal agent). - Refer patient for psychiatric evaluation (potential suicide intent). Sexual Assault nursing management - Goals: provide support, reduce emotional trauma, and gather available evidence for possible legal proceedings - SANE certification - Physical Exam, specimen collection. - Treating consequences- STI, pregnancy - Encourage follow up care. Provide hotline number. Wound - Definitions of Terms: - Abrasion: denuded skin - Avulsion: tearing away of tissue from supporting structures - Cut: incision of the skin within well defined edges, usually longer than deep - Ecchymosis/contusion: blood trapped under the surface of the skin - Hematoma - Laceration: skin tear with irregular edges and vein bridging - Patterned: wound representing the outline of the object causing the wound - Stab" incision of the skin with well defined edges usually caused by a sharp object. Typically deeper than long - nursing management - Goal is to restore skin integrity and function while minimizing scarring and preventing infection - Proper documentation - Determine when and how - Aseptic technique - medical management - wound cleansing: normal saline solution, povidone-iodine - primary closure: sutures and staples - delayed primary closure: gauze and occlusive dressing, antibiotic agents, tetanus booster. Disaster Triage - \*categories (title, color, priority) and typical conditions - Immediate: Injuries are life-threatening but survivable with minimal intervention. Individuals in this group can progress rapidly to expectant if treatment is delayed. - Color: Red - Priority: 1 - Typical conditions: Sucking chest wound, airway obstruction secondary to mechanical cause, shock, hemothorax, tension pneumothorax, asphyxia, unstable chest and abdominal wounds, incomplete amputations, open fractures of long bones, and second/third-degree burns of 15--40% total body surface area - Delayed: Injuries are significant and require medical care but can wait hours without threat to life or limb. Individuals in this group receive treatment only after immediate casualties are treated. - Color: yellow - Priority: 2 - Typical conditions: Stable abdominal wounds without evidence of significant hemorrhage; soft tissue injuries; maxillofacial wounds without airway compromise; vascular injuries with adequate collateral circulation; genitourinary tract disruption; fractures requiring open reduction, débridement, and external fixation; most eye and central nervous system injuries - Minimal: Injuries are minor, and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area. - Color: Green - Priority: 3 - Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding, behavioral disorders or psychological disturbances - Expectant: Injuries are extensive, and chances of survival are unlikely even with definitive care. Persons in this group should be separated from other casualties, but not abandoned. Comfort measures should be provided when possible. - Color: black - Priority: 4 - Patients who are unresponsive with penetrating head wounds, high spinal cord injuries, wounds involving multiple anatomic sites and organs, second/third-degree burns in excess of 60% of body surface area, seizures or vomiting within 24 h after radiation exposure, profound shock with multiple injuries, agonal respirations, no pulse, no blood pressure, pupils fixed and dilated - \*nurse's role - Mitigation -- preparedness -- response -- recovery - role varies during a disaster - may be asked to perform duties outside of expertise or usual scope of practice: intubation, chest tube insertion, and suture - may serve as triage officer - maximization of patient safety - be aware of state regulation