Med surg Test 3

  1. Responsibilities of Critical Care Nurse
    • Nursing concerns
    • Nursing competencies
    • Comprehensive assessment skills
    • Standards of Care
    • -Assessment
    • -Diagnosis
    • -Outcome Identification
    • -Planning
    • -Implementation
    • Standard of Professional Practice
    • Quality of Care - Evidence-based practice – based on scientific research to ensure improved outcomes –cost-effective, efficient, quality of life, patient satisfaction.
    • Individual Practice Education
    • Education – practice alerts, infection control, technology
    • Collegiality - contributes to professional development
    • of peers and other health care providers
    • Ethics - advocate for patients
    • Collaboration - Ensure no compromise to patient outcomes
    • and safety – ancillary personnel
    • Research - Evidence-based practice
    • Resource - Cost effective care
    • Evaluation

    Holistic care – focuses on human integrity and stresses of the body, mind, and spirit
  2. AACN Synergy Model Nurse
    • Clinical judgment
    • Advocacy and moral agency
    • Caring practices
    • Collaboration
    • Systems thinking
    • Response to diversity
    • Facilitation of learning
    • Clinical inquiry
  3. AACN Synergy Model
    Patient Characteristics
    • Resiliency
    • Vulnerability
    • Stability
    • Complexity
    • Resource availability
    • Participation in care
    • Participation in decision making
    • Predictability
  4. Perceptions of Critical
    • Student – out of comfort zone, very technical, very sick
    • patients
    • Nurse – fast pace, lower nurse to patient ratio, more
    • frequent patient contact, collaboration with patient, family, physician, and axillary personnel
    • Patient - anxious, afraid, vulnerable, loud, powerless, restrained.
    • *Wants to feel safe, competent nurses, informed,
    • respected as a person (many times depersonalize pts), family near by.

    • Family– limited access to loved one, powerless, afraid, uninformed, want to be near by
    • • Family responsibilities, finances, caring for themselves
  5. Critical Care
    • Stressful– critical condition, life-threatening
    • Loss of privacy – lots of people working same time, curtains instead of doors, all rooms easy to visualize, wards (infection, anxiety, hostility)
    • Artificial lighting 24 hours per day – windows
    • Constant noise – over stimulated
    • Isolated from family - Lack of meaningful stimuli
    • Pain or discomfort – procedures, injury or illness
    • Nursing influences – what affects the way nurses respond - safety
    • Staffing levels
    • Nurse-physician collaboration
    • Type of critical care area
    • Unit culture mood, climate – noise (>70 decibels
    • hearing loss), EPA recommends < 45 dB, tempo, design – size, break room, culture
  6. Modification of Environment in critical care
    • -Noise reduction
    • -Acoustical tiles/designs
    • -Provide soothing music
    • -Private areas for communication between caregivers and with family members
    • -Adequate lighting
    • -Natural lighting
    • -Night-day synchronization
    • -Design of new units to promote health and safety
  7. Uveitis
    • is an inflammation ot the middle layer of the eye and accounts
    • for 10% of blindness in the US.
    • * one of the classifications of juvenile arthritis was enthesitis-related arthritis which was associated with acute
    • anterior uveitis
  8. fluid resuscitation
    • is for the first 24 hours. So the intial half of the fluids should be given within the first 8 hours following injury and the other half over the next 16 hours (1/4 over 8 hours and the other 1/4 over 8 hours).
    • *For a 70-kg patient with a 50% TBSA burn:
    • 4 ml x 70 x 50 = 14,000 ml in 24 hours
    • 1/2 1st 8 hours = 7000 ml (875 ml/hr)
    • 1/4 2nd 8 hours = 3500 ml (436 ml/hr)
    • 1/4 3rd 8 hours = 3500 ml (436 Ml/hr)
  9. Critical Care Environment:
    Many factors influence nurses’ ability to provide care

    • -Nurse-physician interactions
    • -Type of clinical area
    • -Culture of organization and unit
    • -Tempo, mood, climate, and design
    • -Family friendly versus family restraint
  10. Healthy Work Environment
    • -Promote safe, healing, and humane work
    • setting
    • -Components:
    • Skilled communication
    • True collaboration
    • Effective decision making
    • Appropriate staffing
    • Meaningful recognition
    • Authentic leadership
  11. The Critically Ill Patient:
    Patient responses vary according to:

    • Age
    • Prior illness or hospitalization experience
    • Family relationships and social support
    • Coping mechanisms
    • Beliefs about life and death
    • Spirituality
    • Cultural considerations
  12. Patients’ Recall About Critical Care
    • Difficult communication
    • Pain
    • Thirst
    • Difficult swallowing
    • Anxiety
    • Lack of control
    • Depression
    • Fear
    • Lack of family
    • Feelings of dread
    • Discomfort
    • Difficulty sleeping
    • Loneliness
    • Thoughts of dying
    • Physical restraint
  13. Psychosocial Support for Critical care patients
    • Assure safety
    • Reduce sleep deprivation
    • Reduce noxious sensory overload
    • Increase pleasant sensory input
    • Provide reorientation
  14. What are strategies to achieve Psychosocial Support for critical care patients goals?
    • -Outcome– Separation – Powerlessness
    • -Fear/Anxiety- apprehension and autonomic arousal
    • -Body Image – Disability - Death
    • -Sensory Overload
    • -Sensory Deprivation - Need to talk and explain things to patient even if unconscious –frequently orient them
    • -Sleep Deprivation
    • -Agitation/Delirium
    • -Agitation – increased motor activity – pain primary cause
    • -Delirium (ICU psychosis, ICU syndrome) – Many different
    • causes –metabolic, intracranial, endocrine, organ failure, drug-related - acute reversible disorientation when treat cause or in 1-2 days after leave unit -impaired short-term memory, hallucinations, abnormal thought processes,
    • inappropriate behavior
    • Three forms of delirium – hyperactive, hypoactive, mixed

    • *Haldol:drug of choice with scheduled dosing
    • *Nurses must keep these patients safe and try to prevent sleep deprivation and sensory overload – cluster activities or procedures to avoid interrupting sleep
    • * Nurses should attempt to increase positive sensory input – family, day-night cycle, position near window, reorient (Not questions just general conversation, don’t talk to others in room (step beyond pts hearing), personal items
    • -Dementia is different – chronic condition
    • -Cultural Beliefs - Culture – health and healing beliefs, space and touch, family organization (traditional folk medicine or faith healer, herbal medicine,minimal contact or comfortable with touch
    • -Spiritual Distress
  15. Perceptions of Caring Practices:
    Critical care patients need to feel safe &
    Nursing interventions
    • Technical competence
    • Vigilant response
    • Family at bedside
    • Information
    • Orientation of patient
  16. Quality of Life After Critical Care:
    Post critical care symptoms
    • Fatigue, sleep disturbance
    • Pain, muscle weaknes
    • Poor concentration, impaired memory
    • Poor appetite
    • * Post-traumatic stress disorder may develop in patients or families
    • *Discharge from critical care can be difficult for patients and families
    • *Relocation stress: Fear of abandonment, Learn new routines,Learn new staff, New roommates
    • *Prepare patients and family members for
    • transfer from the unit
  17. Geriatric Concerns in critical care
    • -Diminished ability to adapt or cope to stressors of critical illness
    • -At greater risk for negative outcomes
  18. Family Members of patient in critical care
    • -Critical illness/injury affects the whole family
    • -Emotional distress
    • -Financial bankruptcy
    • -Others?
    • -Family also influences the patient’s recovery
  19. Calgary Family Assessment
    • Structural:
    • -Internal – who is the family
    • -External – extended family or larger system
    • -Family context – ethnicity, race, social class, religion and spirituality, and environment
    • Developmental – family’s developmental stages, tasks, and attachments

    • Functional – how family members function and behave in relation to each other
    • -Instrumental – ADLs – sleep, eat,cook
    • -Expressive – communication patterns, problem-solving ability, beliefs, roles, and alliances within the family

  20. Family Needs of a patient in critical care
    • -Receiving assurance
    • -Remaining near the patient
    • -Receiving information
    • -Being comfortable
    • -Having support available
  21. Family visitation for a patient in critical care
    • Nurses restrict visitation to protect patient and to allow time to perform procedures. AACN supports open visitation but realizes one size doesn’t fit all.
    • •Flexible – mutual decision between family and staff
    • •Contract – written agreement with family, patient, and
    • staff
    • •Patient-controlled – Patient has signal to use when
    • wants or doesn’t want visitors.
    • •Structured – Periodic visitation by 2 people for longer
    • periods
    • •Inclusive – Open visitation except for specific time
    • periods decided by staff
    • •Open – no restrictions – number of visitors may be
    • restricted – AACN supports
  22. Management of Discomfort in Critical Care
    • -First want to make sure not other cause for discomfort
    • -Can use other nonpharmacological treatment.
    • -Assess pain scale if possible – provide pain meds if needed
    • -Use sedation scale: Table 9-1 page 100 – to assess for agitation/anxiety
    • -Some hospitals are using continuous EEG monitoring to monitor sedation
    • -Bispectral Index (BIS) or Patient State Index (PSI) – scale from 0-100

    Ø> 95 – awake

    • Ø< 50 – unconscious
    • or heavy sedated

    • Ø< 20 – extremely
    • deep sedation – brain-wave suppression – not desirable

    • *Oversedation and undersedation can both be
    • hazardous

    • *Antidote for benzodiazepines is Romazicon (flumazenil) unless benzo dependent then can cause seizures
    • *Assess for delirium – Haldol – delirium difficult to assess – drugs for sedation can make worse – sudden onset with
    • disorientation – is reversible – also may have short-term memory problems, hallucinations, inappropriate behavior.
    • *Sudden onset with mental changes
    • *Inattention
    • *Disorganized thinking
    • *Altered LOC
    • *Tools for assessing delirium in ICU patients are the CAM-ICU and ICDSC.
    • *The Confusion Assessment Method for the ICU (CAM-ICU) was adapted for use in nonverbal ICU patients and was designed to be a serial assessment tool.
    • *The Intensive Care Delirium Screening Checklist is an eight item delirium checklist completed based on data from the previous 24 hours. The eight items are scored
    • 1 (present) or 0 (absent), for a total of 8 points. A score of 4 or greater is a positive screen for delirium.
  23. Medications for Sedation
    • Midazolam (Versed):IV
    • 2-5 minute onset
    • Active metabolites

    • Lorazepam (Ativan):IV
    • 5-20 minute onset
    • No active metabolites
    • Propofol (Diprivan):IV
    • 1-2 minute onset
    • No active metabolites

    • *Active metabolites prolong sedation if used longer than 24 hours continuously.
    • *Valium not used as much because of slow elimination 20-120 hours.
    • *Slow onset of lorazepam makes it not suitable for acute agitation
    • *Important to select sedative by how long sedation will be needed and how long it will take to recover
    • *Propofol – sedative-hypnotic– works well with brain injury patients – decreases ICP – rapid elimination –
    • once stopped pt can be awake in 30 minutes – not reliable amnesia – may need to give opiate – emulsified in soybean intralipid can increase triglycerides and cause pancreatitis –
    • need dedicated line and tubing change every 12 hours because of medium for bacteria.
    • *Rare propofol infusion syndrome (PIS) – high-dose – cardiac arrest, myocardial failure, metabolic acidosis, rhabdomyolysis, an hyperkalemia in day 4 or 5 –
    • should not administer dosages above 5 mg/kg/hr for longer than 48 hours.
  24. Autism
    • -Autism spectrum disorders (ASDs) are complex neurodevelopmental disorders of brain function:
    • -Autistic disorder
    • -Asperger syndrome
    • -Pervasive developmental disorder not otherwise specified
    • -Range from mild to severe
  25. Causes of ASD
    • -Currently recognized as genetic disorder of prenatal and postnatal brain development
    • -Immune and environmental factors may increase ASD incidence
    • -High risk of recurrence in families
    • -Not apparently caused by MMR or thimerosal-containing
    • vaccines
  26. Diagnostic Criteria for
    • -Qualitative impairment in social interaction
    • -Qualitative impairment in communication
    • -Restricted repetitive and stereotyped patterns of behavior, interests, and activities
    • -Delays or abnormal functioning with onset before 3 years
    • -American Psychiatric Association DSM-IV-TR
  27. Nursing Considerations for ASD
    • Wide variation in individual client response to treatment efforts
    • No cure for ASD, but many therapies
    • Most promising results seem to be through highly structured routines and intensive behavior modification programs
  28. Family Support for ASD
    • -ASD often becomes a “family disease”
    • -Help alleviate parents’ unwarranted feelings guilt and shame
    • -Stress importance of family counseling
    • -Autism Society of America (ASA) is good source of information
    • -Encouraging home care for children; assisting with long-term placement later in life
  29. Retinoblastoma
    • -Congenital malignant tumor, arising from theretina
    • -60% are nonhereditary and unilateral
    • -15% are hereditary and unilateral
    • -25% are hereditary and bilateral
  30. Diagnostic Evaluation of Retinoblastoma
    • -Cat’s eye reflex—most common sign
    • -Strabismus—second most common sign
    • -Red, painful eye, often with glaucoma
    • -Blindness—late sign
  31. Therapeutic Management of Retinoblastoma
    • Early stage unilateral:
    • Irradiation, cryotherapy
    • Attempt to preserve useful vision in affected eye

    • Bilateral disease:
    • Attempt to preserve useful vision in least affected eye

    • Advanced tumor:
    • Enucleation
    • Chemotherapy—some controversy

    • *Survival rate of nearly 90%
    • -Tumor may spontaneously regress
    • -Concern with development of secondary tumors, especially osteogenic sarcoma
  32. Nursing Considerations for Retinoblastoma
    • Elicit parental concerns
    • Preparation for surgery
    • Postoperative care
    • Family support
  33. Macular Degeneration
    • -Age-degeneration of the macula – may be some genetic component
    • • Long-term exposure to UV light, hyperopia, smoking, light-colored eyes
    • -Most common cause of irreversible vision loss over 60 years
    • Two forms:
    • Dry - First notice close vision
    • becomes more difficult. Slow and painless progression.
    • Wet – more severe – most become
    • functionally blind – more rapid onset – abnormal blood vessels
    • Symptoms:
    • -Blurred/darkened vision
    • -Scotomas
    • -Metamorphopsia

    *Vitamin C & E, betacarotene, zinc may help development of advancing AMD

    • *Dark green leafy vegetables may
    • reduce risk
    • -Scotomas – blind spots

    • -Metamorphosia – distortion of vision
    • Diagnosis:
    • Ophthalmoscopy – fundus changes
    • Amsler grid test – pt looks at grid of lines focusing on center point and records abnormalities seen
    • -Fundus photography & IV
    • -angiography – compare changes
  34. Macular Degeneration: Treatment
    • Injections:
    • -Ranibizumab (Lucentis)
    • -Bevacizumab (Avastin)
    • -Pegaptanib (Macugen)
    • *Wet- Injections directly into eye to decrease endothelial growth factor to slow loss at 4-6 week intervals
    • SE: blurred vision, eye irritation, eye pain, photosensitivity.

    • Photodynamic therapy – cold laser excites dye - destroys abnormal vessels without other damage.
    • *Can also be activated by other high-intensity light –
    • sunlight, halogen – should avoid direct exposure for 5 days
    • *Must be completely covered – exposure to light on skin can lead to thermal burns.
    • Preventative Measures
    • -Vitamins
    • -Stop smoking
    • -Corticosteroid injection – clinical trials to reduce progression
    • -Need psychosocial support
    • -May still be able to drive slower during day only or not drive at all.
  35. Visual Impairment
    • Blindness:
    • -Partially sighted
    • -No useful vision
    • -Levels:
    • Total – no light perception and no useful vision
    • Functional – has some light perception but no useful vision
    • *Both LEGALLY BLIND – may need canes or dogs – vision enhancements not helpful
    • Causes:cataracts, macular degeneration, glaucoma, diabetic retinopathy, small percentage from injury
    • Nursing Concerns
    • Assessment
    • Successful adjustment
    • Verbalize feelings
    • Identify strengths and support systems
    • Coping strategies
  36. Visual Impairment
    • Partially sighted:
    • Acuity of 20/70-20/200
    • Education usually in public school system
    • Legal blindness:
    • Acuity of 20/200 or less
    • Legal as well as medical term
  37. Etiology of Visual
    • Perinatal or postnatal infections:
    • Gonorrhea, chlamydia, rubella, syphilis, toxoplasmosis
    • Retinopathy of prematurity
    • Perinatal or postnatal trauma
    • Other disorders
    • Unknown causes
  38. Infections
    • Conjunctivitis:
    • Ophthalmic antibiotics
    • Systemic antibiotics in some cases
    • Caution with use of steroids—mayexacerbate viral infections
    • Infection control concerns
  39. Nursing Assessment of Vision
    • Infancy:
    • -Response to visual stimuli
    • -Parental observations and concerns
    • -Expect binocularity by age 6 months
    • Childhood:
    • Visual acuity testing
  40. Necrotizing Fasciitis
    • Necrotizing soft tissue infections include:
    • -Necrotizing fasciitis
    • -Gas gangrene
    • -Hemolytic streptococcal gangrene
    • -Necrotizing cellulitis

    • Caused by:
    • -toxin-producing organisms introduced by minor skin disruptions – insect bite or cut
    • -Leads to widespread fascial and muscle necrosis
    • Risk factors:
    • Diabetes, obesity, hypertension
    • Symptoms:
    • -Initial – localized, painful edematous area
    • -Erythema and crepitus as increases
    • -Severe pain which seems out of proportion to outward appearance

    • Treatment:
    • -Early diagnosis
    • -Aggressive surgical excision and wound care
    • -Antibiotic therapy
  41. Herpes
    • Herpes is a Viral infection of the skin
    • •Herpes Simplex Virus (HSV) •Type 1 & Type 2
    • Lifelong viral infections exacerbated by:
    • -Sunlight
    • -Trauma
    • -Stress
    • -Menses
    • -Systemic Infections

    • *Contagious to those not previously infected
    • Transmission by:
    • -Respiratory droplets or virus-containing fluid (saliva, cervical secretions)
    • -Can be transmitted from one site to another by contact

    • Clinical manifestations;
    • First episode – symptoms occur 3-7 days or more
    • after contact – painful local reaction, single or grouped vesicles
    • *Systemic symptoms – fever, malaise or asymptomatic
    • Recurrent episodes – small, recurrence in similar spot,
    • grouped vesicles

    • Treatment – (symptomatic)
    • Soothing, moist compresses
    • White petroleum to lesions
    • Antiviral agents – Zovirax, Valtrex
  42. Shingles
    • *Herpes Zoster
    • *Contagious
    • *Linear distribution of groups vesicles and pustules along a dermatome – usually on one side of trunk, face, and lumbosacral areas
    • *Looks like chickenpox
    • *Activation of vericella-zoster virus – increases with age
    • *Potentially contagious for anyone who has not had varicella or who is immunocompromised

    • Symptoms:
    • Burning, pain, and neuralgia prior to outbreak
    • Mild to severe pain during outbreak

    • Treatment: Symptomatic
    • – antiviral agents – acyclovir, famciclovir, and valacyclovir within 24 hours to prevent postherpetic neuralgia
    • -Wet compresses
    • -Silvadene to ruptured vesicles
    • -Analgesia
    • -Mild sedation at bedtime
    • -Gabapentin (Neurontin) – postherpetic neuralgia
    • -Vaccine to prevent occurrence is available for adults > 60 years old who have had chickenpox
  43. Human Immunodeficiency Virus: HIV and Transmission
    • *Ribonucleic Acid –retrovirus (Develops backwards from RNA to DNA)
    • *The higher the viral load the higher the risk
    • *25% of infants born to untreated women become infected can be decreased to 2% with antivirals
    • *HIV destroys CD4 T helper cells – key cells in immune response to recognize and defend against pathogens.
    • *When CD4 T cells < 500 immune problems
    • CD4 T cells < 200 severe problems
    • *Opportunistic infections occur when so many CD4 T cells are destroyed that cannot regulate immune response – main cause of disease, disability, and death.
    • -Transmission:
    • -Sexual intercourse
    • -Infected blood or blood products
    • -Perinatal transmission
    • : breastfeeding, vaginal birth,during pregnancy
  44. HIV clinical manifestations
    Acute infection – seroconversion – mononucleosis-like syndrome – fever, swollen lymph glands, sore throat, headache, malaise, nausea, muscle and joint pain

    • Early chronic infection - asymptomatic disease – generalized symptoms – if untreated can last up to 11 years before becoming AIDS
    • *CD4 T cell count > 500, viral load
    • low
    • *Fatigue, headache, low-grade fever, night sweats, persistent generalized lymphadenopathy

    • *Intermediate chronic infection – CD4 T cell count
    • 200-500, increased viral load. More active stage

    • *Symptoms become worse – persistent fever, frequent
    • drenching night sweats, chronic diarrhea, recurrent headaches, severe fatigue, localized infections – most common oral Candida or thrush (vaginal), shingles
    • or genital herpes, Kaposi sarcoma, oral hairy leukoplakia(indicates disease progression), lymphadenopathy, nervous system manifestations.

    • *Late chronic infection or AIDS – HIV-infected pt
    • must meet CDC criteria for diagnosis of AIDS
    • 1) CD4 T cell count < 200,
    • 2)at least one opportunistic infection,
    • 3) at least one opportunistic cancer,
    • 4)wasting syndrome,
    • 5) AIDS dementia complex

    • *People with intact immune system do not usually get
    • opportunistic infections

    • *Medications have improved ability to maintain immune
    • response to some degree
  45. HIV diagnoses and treatment
    • *Diagnosis made based on presence of HIV antibodies or antigen
    • *Window period– time between infection and development of antibodies – up to 2 months
    • *Transmission can occur during window period
    • *Positive antibody test must be confirmed with the Western blot test
    • *HIV progression followed with CD4 T cell counts (marker of immune function – normal 800-1200) and viral load (assessment of disease progression) – undetectable is
    • lower than the test can report does not mean virus is gone or than cannot be transmitted
    • *Testing helps decide on treatment
    • *Other testing assist with identifying opportunistic infections or other problems Or which type
    • drug to use – genotype assay detects drug-resistant viral mutations, phenotype assay measures growth of HIV in concentrations of antiretroviral drugs (sensitivity test)
    • TREATMENT:ART – Antiretroviral Therapy
  46. HIV collaborative care
    • • Monitor progression
    • • Monitor immune function
    • • Initiate and monitor ART
    • • Prevent opportunistic diseases
    • • Manage symptoms
    • • Prevent or decrease complications of treatment
    • • Prevent further transmission
    • Education and support
  47. Drug Therapy for HIV: Indications for initiation of antiretroviral therapy
    • (Table 15-12 page 247 Lewis)
    • Clinical Category : TREAT CD4+ T Cell count:
    • -History of AIDS- defining illness Any
    • -Aysmptomatic <350 cells/microliter
    • -Pregnany Any
    • -HIV associated nephropathy Any
    • -Hep B virus co infection
    • when treatment of HBV is indicated Any
    • * Asymptomatic 350-500CELLS/uL RECOMMENDED
    • *Asymptomatic >500 cells/uL Recommend versus optional
  48. HIV drug therapy goals
    • -Decrease viral load
    • -Maintain or raise CD4 T-cell count
    • -Delay onset of symptoms or opportunistic infections
  49. HIV treatment guidelines
    • -Individualized to risk for disease progression and pt’s
    • desire
    • -Combination ART – suppresses HIV replication and limits
    • potential for resistance - at 3 ARTs from at least 2 different classes at full dosages.
    • -Women should get optimal ART
    • -Should avoid behaviors of transmission
    • *If taken correctly ART can decrease viral replication and reduce viral loads 90-99%
    • Drug Therapy for Infections
    • -Delay or prevent with ART
    • -Vaccines
    • -Prophylactic medications
  50. Systemic Lupus Erythematosus
    • *Multisystem inflammatory autoimmune disease – production of antibodies against nucleic acids directed at cell
    • nucleus, erythrocytes, coagulation proteins, lymphocytes, platelets
    • *Etiology unknown

    • Causes – interactions among genetic, hormonal, environmental, and immunologic factors.
    • Manifestations:*Manifests in skin, joints, serous membranes (pleura, pericardium), renal, hematologic, and neurologic systems – depends on which cell types or organs are involved.
    • *Generalized complaints – fever, weight loss, arthralgia, excessive fatigue
    • Skin – cutaneous vascular lesions – sun exposed areas – butterfly rash (50%)
    • Oral or nasopharyngeal ulcers
    • Transient hair loss – scalp dry, scaly, and atrophied
    • Musculoskeletal- polyarthralgia – morning stiffness – swelling of joints, muscle pain, increased risk of bone loss and fracture
    • -Heart & lungs – tachypnea, cough – restrictive lung disease, pleurisy, pleural effusion, dysrythmias – fibrous SA and AV nodes – pericarditis, hypertension, hypercholesterolemia,
    • Kidney – lupus nephritis (50%) – mild proteinuria to progressive glomerulonephritis
    • Nervous system – generalized or focal seizures, peripheral neuropathy – sensory and motor deficits – cognitive dysfunction –disordered thought processes, disorientation, memory deficits, severe depression, psychosis, headaches are common.
    • Blood – anemia, mild leukopenia, thrombocytopenia,
    • coagulation disorder – clots in arteries and veins
    • Infection – increased susceptibility
    • *Usually in women of childbearing age
  51. Systemic Lupus Erythematosus: diagnoses and drug therapy
    • Diagnosis:
    • History
    • Physical exam:rash, photosensitivity, oral ulcers. Arthritis, serositis
    • Lab findings: proteinuria or casts in urine, hemolytic anemia, leukopenia, lymphopenia, or thrombocytopenia
    • Post LE: preparation, anti-DNA antibody (high levels rare in other conditions) or anit-Smith antibody (exclusive for SLE),
    • false positive syphilis test, ANA -established autoimmune disease
    • •Drug therapy
    • -NSAIDs
    • -Hydroxychloroquine (Plaquenil)
    • -Immunosuppressants
    • -Anticoagulation

    • *NSAIDs – monitor for GI bleeding
    • *Plaquenil – antimalarial drug – treats fatigue, moderate skin and joint problems,prevent flares – may take several months for results. Must monitor visual field with opthamlamic exam every 6-12 months. Retinopathy can develop – reversed when discontinued.If unable to tolerate Plaquenil:Dapsone may be used – antiepilepsy med
    • *Avoid corticosteroids – may be used for acute exacerbations or for pts with severe cutaneous SLE
    • *Use steroid-sparing immunosuppressant – methotrexate and folic acid
    • *Imuran or cyclophosphamide may be used for immunosuppression therapy
    • *Coumadin may be needed to prevent life-threatening blood clots.
    • *Monitor serial anti-DNA levels, ESR and CRP are used to
    • evaluate effectiveness of treatment
  52. Systemic Lupus Erythematosus: nursing considerations
    • •Assess severity of symptoms (table 65-16 page 1668 Lewis) :SUBJECTIVE DATA:Past health history: Exposure to UV radiation, drugs, chemicals, viral infections, physical or pysch stress, states of increased estrogen activity( early onset of menarche, pregnancy and postpartum period) pattern of remissions and exacerbations.
    • Medications: oral contraceptives, procainamide( Pronestyl), hydralazine( apresoline), isoniazid ( INH), antiseizure drugs, antibiotics, corticosteroids, NSAIDS.
    • /functional health patterns: Family history, frequent infections, malaise, weight loss, oral nasal ulcers, nausea vomitting, salivary gland dryness, dysphagia, photosensitivy with rash, decreased urination, diarrhea, constipation stiff and swollen SOB, dyspnea, insomnia, visual disturbances, vertigo, headache, chest pain, abdominal pain, joint pain, throbbing, cold or numb fingers, amennorhea, iregular periods, depression, withdrawal.
    • OBJECTIVE DATA: GENERAL:fever, lyphadenopathy, periorbital edema, INTEGUMENTARY:alopecia, dry, scaly scalp, keratoconjunctivitis, malar "butterfly" rash, palmar or discoid erythema, uticaria, periungual erythema, purpura or petechiae, leg ulcers. RESPIRATORY: pleural friction rub, decreased breath sounds CARDIO: Vasculitis, pericardial friction rub, HTN, edema dysryhtmias, murmurs bilateral, systemic pallor and cyanosis of fingers( Raynaud's phenomenon) GI: oral and pharyngeal ulcers; splenomegaly NEURO:facial weakness, peripheral neuropathies, paplledema, dysarthia, confusion, hallucination, disoriented, psychosis, aphasia, hemiparesis. MUSCULO: myopathy, myositis, arthritis. URINARY: proteinuria
    • Assess response to therapy
    • •Monitor weight, I & O
    • Observe for bleeding
    • •Assess for neurological status and presence of pyschosis
    • •Educate (Table 65-17 page 1668 Lewis) :
    • -Disease process
    • -Names of drugs
    • -pain strategies
    • -energy conservation
    • -exercise
    • -Avoid stress
    • -Avoid those with illenesses
    • - Avoid powders, soaps, chemicals
    • -Use sunscreen and preotective clothing with minimun sun exposure (11am - 3pm)
    • -medical and lab follow ups
    • -marital and pregnancy couseling
    • -community resources nad health care agencies
    • •Support
  53. Scleroderma
    • Systemic Sclerosis
    • •Limited cutaneous disease (80%)
    • •Diffuse cutaneous disease
    • *Connective tissue disorder characterized byfibrotic, degenerative, and occasionally inflammatory changes of the skin, blood vessels, synovium, skeletal muscle, and internal organs.
    • *Collagen is overproduced – cause unknown–environmental factors may play a role – coal, plastics, or silica dust
    • *2 types – limited and diffuse – both systemic
    • *Occurs in females more than males, usually diagnosed between 30-50 years
    • •Manifestations
    • *Diffuse – cutaneous thickening with rapid progressive and widespread organ involvement – trunk and extremities
    • *Limited – benign limited cutaneous thickening – face and hands
    • *CREST:
    • Calcinosis – painful red deposits of calcium
    • in the skin
    • Raynaud’s phenomenon – abnormal blood flow in response to cold or sweat
    • Esophageal dysfunction – difficulty swallowing due to internal scarring – gastric reflux – weight loss, malnutrition
    • * Other GI effects hypomotility –constipation or diarrhea from malabsorption from bacterial overgrowth
    • Sclerodactyly – tightening of skin on fingers and toes
    • Telangiectasia – red spots on hands, forearms, palms, face, and lips
    • *20% will developsecondary Sjorgren’s syndrome –
    • dry eyes and mouth
    • *Lung involvement – pulmonary fibrosis, pulmonary artery
    • hypertension – treat with nifedipine, bosentan, ambrisentan
    • *Heart – pericarditis, pericardial effusion, cardiac dysrythmias, myocaridal fibrosis resulting in HF
    • *Renal disease – major cause of death – malignant hypertension leads to irreversible renal insufficiency – treat with ACE-inhibitors, dialysis, nephrectomy, kidney transplant,

    • •Diagnosis:
    • No clear testing ANA means autoimmune.
    • If x-ray evidence of subcutaneous calcifications, esophageal hypomotility, and bilateral pulmonary fibrosis is present then
    • Supportive care to prevent or treat complications
    • Physical therapy, occupational therapy
    • •Supportive care:
    • •Drug therapy
    • Improve blood flow to digits
    • Improve exercise capacity
    • Decrease diarrhea
    • Ulcer prevention
    • Hypertension
    • Immunosuppression
    • *vasoactive drugs – ACE inhibitors, calcium channel blockers,
    • -Raynaud’s – to improve blood flow – prevent ulcers
    • -Heart and lungs – improve exercise capacity
    • -Tetracycline – decrease diarrhea
    • -Topical creams
    • -H2 blockers or proton pump inhibitors – prevent ulcers
    • -assumeScleroderma
  54. Scleroderma: Nursing considerations
    • -Emotional stress and cold temperatures can aggravate -Raynaud’s
    • -Compromised circulation and poor healing of fingers – no finger sticks
    • -Poor self-image
    • -Loss of mobility and function – therapeutic exercises to prevent skin retractions and promote vascularization
    • -Moist heat can promote flexibility
    • -May need assistive devices
    • -Report signs of infection promptly.
    • -Lotions for dryness and cracking – must be rubbed in for long time due to thick skin
    • -Dysphagia causes eating difficulty – small frequent meals
    • -Anatacids prior to meals to decrease heartburn – sit up for at least 2 hours after eating
    • -May have problems with job – modifications may be necessary
    • -Sexual dysfunction – need counseling
  55. Sjogren's Syndrome
    • -Autoimmune disease which targets moisture-producing glands
    • -Primary – dry eyes and dry mouth
    • -Dry eyes – keratoconjunctivitis sicca
    • -Dry mouth – xerostomia
    • -Secondary – had another autoimmune disease before Siogren’s
    • *Nose, throat, airways, and skin can also be dry.
    • *Genetic and environmental factors
    • *Trigger may be viral or bacterial infection that adversely stimulates the immune system
    • *Lymphocytes attack and damage the lacrimal and salivary glands.
    • Symptoms:
    • -Dry eyes – decreased tearing causing gritty sensation, burning, blurred vision, and photosensitivity
    • -Dry mouth – buccal membrane fissures, altered sense of
    • taste, dyspahgia, and increased frequesncy of mouth
    • infections and caries.
    • -Dry skin an rashes, joint and muscle pain, thyroid problems (Grave’s disease or Hashimoto’s thryoiditis)
    • *Disease may become more generalized and involve lymph nodes, bone marrow, and visceral organs – risk for developing lymphoma

    • Diagnosis – ophthalmologic exam for tear production, measure for salivary gland function, and lower lip biopsy of minor salivary glands.
    • Treatment
    • 1)preservative-free artificial tears or antiinflammatory drops, 2) surgical punctual occlusion,
    • 3) increased fluids and meals.
    • *Dental hygiene is important - Meds for dry mouth (pilocarpine)
    • *Increased humidity to prevent infections
  56. Juvenile Idiopathic
    • *Chronic autoimmune inflammatory disease causing inflammation of joints and other tissue with an unknown cause
    • *Before age 16 – peak between 1 and 3
    • *Affects girls more than boys

    • Cause unknown
    • – possible immunogenic susceptibility and environmental or external trigger – Epsein- Barr virus, parvovirus B19
    • Symptoms:
    • Varies and unpredictable
    • Rarely life-threatening but disabling
    • Periods of exacerbation and improvement – 70% become inactive but may still have severe or minimal joint damage
    • 30% have progressive arthritis into adulthood – significant joint deformity andfunctional disability
    • Systemic – one or more joints associated with at least 2
    • weeks of fever, rash, lymphadenopathy, hepatosplenomegaly, and serositis.
    • Oligoarthritis – 1-4 joints for 1st 6 months of disease
    • Persistent oligoarthritis – remains in 4 joints
    • Extended oligoarhritis – more than 4 joints
    • Polyarthritisneg rheumatoid – 5 or morejoints with negative rheumatoid- positive rheumatoid –5 or more and positive rheumatoid factor
    • Psoriatic –arthritis with psoriasis or associated dactylitis, nail pitting, or onycholysis
    • Enthesitis-related – associated with at least 2 of the following:sacroiliac or lumbosacral pain, HLA-B27 atigen, arthritis in male > 6 years, acute anterior uveitis, inflammatory bowel disease, Reiter syndrome
  57. Juvenile Arthritis:diagnosis, meds, labs, therapy
    • Diagnosis based on clinical criteria
    • -Age of onsetbefore 16
    • -Arthritis in one or more joints for 6 weeks or more
    • -Exclusion of other causes
    • -Labs: Elevated sed rate
    • Antinuclear bodies but not specific
    • X-rays show soft tissue swelling and wider joint space due to increased fluid
    • Slit lamp eye exam to diagnose uveitis – inflammation of anterior chamber of the eye
    • Pain – NSAIDs,
    • Methotrexate if have failed NSAIDs alone – given in combination
    • Tumor necrosisfactor inhibition (Etanercept) – if unresponsive to Methotrexate
    • Physical and occupational therapy – individualized therapy to preserve function and prevent deformity
    • -Exercise pools, hot pack or warm bath beforetherapy
    • -Nighttime splinting – knees, wrists, hands
  58. Burns
    • *Initial management affects long-term outcome
    • Burn centers
    • Multidisciplinary team approach
    • Highest morbidity
    • Burns covering more than 50% of body surface area
    • Older patient
    • Younger patient
    • *For adults major causes involve cigarette smoking and alcohol; for childrenscalding
    • * Most victims of fires die from smoke or toxic gases, not from burns (Hall 2001).
    • *Major burn injury: treat in specialized burn center *Moderate burn injury: treat in hospital with expertise in burn treatment
    • * Minor burn injury: treat in outpatient setting
  59. Burns: Children
    • -Toddlers: hot water scalds
    • -Older children: flame-related burns

    * Child abuse: suspect if suspicious burns, scalds with clear line of demarcation, other wounds, fractures, bruises, or malnutrition, or inappropriate parent-child interactions.DOCUMENTATION REQUIRED.

    *Child with matches or lighters accounts for 1 in 10 house fires
  60. Integumentary System
    • Skin is to:
    • Protect from infection
    • Prevent loss of body fluids
    • Thermoregulation
    • Produce vitamin D
    • Excrete
    • Identity
    • Sensation reception

    • *Skin composed of two layers: Epidermis and Dermis
    • *Subcutaneous fat tissue layer
  61. Effects of Aging on skin
    • Flattened dermal-epidermal junction
    • Dermal and subcutaneous atrophy
    • Reduced microcirculation
    • Thinned skin - predisposition to deeper burns, and delayed or poor healing
    • Decreased ability to tolerate burn stress
  62. Mechanisms of Burn Injury
    • Thermal
    • Chemical
    • Electrical
    • Inhalation injury in 20% to 50%
  63. Thermal Injury
    • *Skin damaged by contact with heat:
    • Flame
    • Scalding liquids
    • Heat source
    • *Severity of injuries
    • Duration of contact
    • Temperature of agent
    • Amount of tissue exposed
    • Age of patient (skin changes)
  64. Chemical Injury
    • Methods of injury
    • Contact
    • Inhalation of fumes
    • Ingestion or injection
    • *Systemic and local effects
    • *Must be completely removed or neutralized or damage continues
    • *Material safety data sheets (MSDS)-are useful in neutralizing chemicals.
    • Severity of injuries
    • Type of agent
    • Volume of agent
    • Duration of contact
    • Concentration of agent
    • Types
    • Alkalis-are worse than acids.Cause liquefaction necrosis allowing deeper penetration
    • Acids-cause coagulation necrosis
    • Organic compounds
  65. Electrical Injuries
    • High versus low voltage
    • High >1000 volts
    • Low < 1000 volts
    • Energy is converted into heat
    • AC versus DC
    • AC higher probability of producing cardiac arrest

    • *DC – direct current – batteries or generators
    • AC – Alternate current – more severe and faster effects – more severe muscle contractions, produces sweat which decreases resistance.
    • Electrical energy converted to heat in direct proportion to resistance of tissue •Takes path of least resistance in order of increasing magnitude: Nerve – blood vessels – muscle – skin – tendon – fat – thin bone

    • Factors
    • -Type and path of current
    • -Duration of contact
    • -Environmental
    • -Tissue resistance
  66. Inhalation Injury
    • Three types:
    • -Carbon monoxide poisoning (majority of deaths need rapid assessment – cherry red – CO displaces O2 on hgb)
    • -Above the glottis(hot air, heat or steam – thermal – mucosal burns – redness, blistering, edema.Mechanical obstruction can occur usually singed nasal hair, facial burns, hoarseness, painful swallowing)
    • -Below the glottis(usually chemical – damage tissues of respiratory tract – causes redness and edema – pulmonary edema may not occur for 12-24 hours after – may manifest as ARDS)
  67. Burn Classification and Severity
    • Type of burn injury
    • Burn wound characteristics
    • -Depth (Superficial, Partial thickness,Full thickness)
    • -Extent
    • -Body part burned
    • Concomitant injuries
    • Patient age
    • Preexisting health status
  68. BURN: Superficial (first degree)
    • Epidermis only or small depth of dermis
    • Heals in 3 to 5 days without treatment
    • Erythema
    • Not calculated for fluid resuscitation
  69. BURN: Partial thickness (second degree) and
    • Partial thickness (second degree)
    • Epidermis and most of dermis

    • Sub-classification:
    • Superficial partial thickness:
    • -Epidermis and limited portion of the dermis
    • -Heals in 10 to 21 days

    • Deep partial thickness
    • -Epidermis and most of dermis
    • -Heals within 3 to 6 weeks
  70. Full thickness (third and fourth degree)
    • -Destruction of all layers down to or past fat, fascia, muscle, or bone
    • -Thick, dry, leathery appearance
    • -Insensate (no pain)
  71. Escharotomy
    • -Full thickness, circumferential burns
    • -Loss of circulation
    • -Loss of movement
    • -Performed medial and lateral sides
    • -Relieves pressure

    • *Circumfrential burns: Edema and Eschar
    • Shock
    • Myoglobin
    • Positioning - bed cradle

    • *Restores circulation to compromised extremities to prevent ischemia, paresthesias, necrosis, gangrene
    • *Use scapel or electrocautery incision through full-thickness eschar.
  72. Image Upload 1
    • Zone of hyperemia(outter) :Minimal injury
    • Zone of stasis(middle): Potentially reversible damage
    • Zone of coagulation(inner) Greatest injury
    • *Complications Burns cause both systemic and local complications.
    • The major factors contributing to systemic complications are breakdown of skin integrity and fluid loss. Local complications include eschars and contractures and scarring.
    • *Systemic: The greater the percentage of BSA involved, the greater the risk of developing systemic complications.
    • Risk factors for severe systemic complications and mortality include all of the following:
    • Burns of > 40% of BSA
    • Age > 60 yr or < 2 yr
    • Presence of simultaneous major trauma or smoke inhalation
    • The most common systemic complications are hypovolemia and infection.
  73. Extent of Injury
    • Expressed as total body surface area percent (%TBSA)
    • Methods for estimating
    • -Rule of nines
    • -Lund-Browder chart
    • Differences between adults and children
  74. Rule of nines for child
    Image Upload 2
  75. Rule of nines adult
    Image Upload 3
  76. Systemic Response to Burns
    • Cardiovascular -Loss of intravascular volume
    • -Decreased cardiac output
    • -Tachycardia and vasoconstriction

    • Host defense mechanisms-Immune suppression
    • -Increased risk of infection

    • Pulmonary -Pulmonary hypertension
    • -Effect of direct injury

    • Renal -Sensitive to decreased cardiac output
    • -Initial decrease in urine output related to decreased glomerular filtration rate
    • -Followed by diuresis as fluids shift

    • Gastrointestinal-Ischemia due to redistribution of blood to brain and heart
    • -Paralytic ileus
    • -Curling’s ulcers

    • Metabolic -Hyper state
    • -Lasts up to 9 to 12 months after burn
  77. Phases of Burn Care
    • Resuscitative phase
    • Acute phase
    • Rehabilitative phase
  78. Resuscitative Phase of burn care (emergent)
    • First 48 hours
    • ABCs
    • Includes prehospital time
    • Fluid management to prevent shock
    • Assessment of Respiratory :-Assess for hypoxemia
    • -Carbon monoxide poisoning
    • -Assess for direct injury
    • -Maintain cervical spine precautions
    • -High risk for impaired gas exchange:
    • -Alteration in breathing patterns
    • Ineffective airway clearance
    • -CO suspected : 100% oxygen for 2 hours (if wounds allow – may use hyperbaric chamber)
    • -If breathing difficulty occurs - intubate early (nasal preferred)

    • Cardiovascular
    • -Assess for fluid volume status, Vital signs, Hemodynamics, Carbon monoxide

    Neurologic 0 Changes in level of consciousness

    Renal - Urine output (decreased)

    GI - Assess for occult bleeding, Bowel sounds (ileus)(ischemia)

    Integumentary - Document extent of injury, Measure severity of burn (rule of nines, patient’s palm method, or Lund-Browder chart)

    Psychosocial - Assess response to injury, Pain assessment
  79. The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer?

    a.A 22-guage intravenous line with normal saline infusing.

    b.Wounds covered with moist sterile dressings.

    c.No intravenous pain medication.

    d.Adequate peripheral circulation to both feet ensured.
    • D. The client’s legs should have pedal pulses and be
    • warm to the touch, and the client must be able to move the toes.
    • - An 18-gauge catheter with LactatedRingers should be initiated to keep UO at > 30 ml/hr
    • - Wounds should be covered with a clean, dry sheet.
    • - The client should be transferred with adequate pain
    • relief which requires IV morphine
  80. Emergency Department Interventions
    • -ABCs; C-spine evaluation
    • -Circulation checks: assess need for escharotomy or fasciotomy
    • -Calculation of fluid requirements
    • -Administration of fluids: Ringer’s lactate
    • -Chest x-ray
    • -Nasogastric tube
    • -Pain management
  81. Fluid Guidelines: Electrical
    • -Electrical injury need higher volumes of fluid
    • -Keep urine output at 75 to 100 ml/hr
    • -Rationale: electrical injury results in the release of myoglobin, which can cause acute renal failure.

    • *Transfer patient to burn center early, according to criteria
    • -Partial thickness > 10% TBSA
    • -Full-thickness burns
    • -Burns face, hands, feet, genitalia, perineum, and joints
    • -Chemical and electrical
    • -Inhalation
    • -Co-morbidities
    • -Associated trauma
  82. Acute phase
    • Onset of diuresis to wound closure.
    • Continue with assessments performed during resuscitative phase
    • Respiratory system: Signs of respiratory compromise, Chest x-rays, Fever,WBC
    • Respirations and secretions

    Cardiovascular: Maintain fluid requirement, Monitor I & O, weight

    Neurologic:Changes in level of consciousness

    Renal: Urine output

    • GI system: Stress ulcer
    • Nutritional considerations: Consult fornutritional support
    • Daily caloric needs: (24 kcal X Kg usual wt.) + (40 kcal X % TBSA) Need includes 1.5-3 gm/Kg protein

    Integumentary system - Infection

    Blood and electrolytes - Fluid shift, Electrolyte imbalances
  83. Rehabilitative
    Restore to functional status
  84. Impaired skin integrity and High risk for infection
    • -Cleanse wounds daily or bid
    • -Clean in tank, whirlpool, or at bedside with sterile technique and sterile saline
    • -Isolation
  85. Initial wound care( burns)
    –Isolation or universal precautions

    –Clean wounds – blisters debrided

    –Shave hair for prevention of infection
  86. Dily Wound care (burns)
    -Pain med as needed

    –Dressings soaked off

    • –Remove old topical and gently wash wounds. Debride
    • loose tissue.

    –Reapply topicals and dressings as ordered
  87. Debridement
    – Remove dead tissue to get between dead and viable tissue

    –Not so aggressive as to cause bleeding

    –Some removed with coarse mesh gauze

    – Debrided with sedation /analgesic / conscious sedation or general anesthesia
  88. excision may invovle
    • Tangential excision – shaving layer by layer until a bleeding
    • [viable] bed is produced

    • Primary or fascial excision – separate tissue at fascial layer to minimize blood loss
    • – Fascia is the band or sheet of tissue investing or
    • connecting muscles
  89. Flaps and amputation
    of non-viable limb are generally referred to Plastic’s Service for further reconstruction
  90. acute care interventions for burns
    Facial burns: risk of respiratory injury; oral hygiene; promote healing

    Ears:prevent breakdown

    Eyes: ophthalmology consult as needed, keep moist

    • Hands and feet or major joints: adequate circulation;
    • maintain function

    • Genitalia and perineum: meticulous wound care to prevent
    • infection
  91. Types of grafts

    Allograft (homograft)

    Xenograft (heterograft)

    Artificial skin and cultured skin
  92. Autograft
    takenfrom unburned area of patient's own skin (donor site); thighs, buttocks and trunk are most common
  93. Allograft(homograft_
    • skin comes from another person, usually a cadaver;
    • patient may need immunosuppressive drugs
  94. Xenograft (heterograft)
    skincomes from another species, usually porcine
  95. artificial or cultured skin graft
    • useful when not enough viable skin is available for grafting
    • -Partial thickness: most common to allow for healing and reuse of donor sites if needed.
    • sheet: used as harvested
    • mesh: cut to cover more area (can cover three times the site of donor site)

    Full thickness - used in small areas for face, neck, and flexor surfaces for increased mobility
    - areas of harvested skinfor autografting
  97. Dressings
    used: for skin grafts


    Beta Glucan




    Sulfamylon Solution

    • *Pressure dressing for first 6-12 hrs to minimize bleeding then OTA [open to air] to dry out and heal.
    • *As donor site heals, dressing lifts and is trimmed off.
    • *Donor sites are 2nd degree and heal in 10-14 days; may be re-cropped once healed
  98. Conformant 2
    • is non-adherent and saves nursing time. Because it is permeable and flexible, can be used over
    • most wound sites under an absorbent outer dressing. is made entirely from high-density polyethylene, it tears easily and uniformly in the direction of the grain for dressing customization. is compatible with most topical agents, liquids and creams.Protects the wound and allows removal with less disturbance to granulation tissue. Transparency allows easy monitoring of a wound or graft.
  99. Glucan dressing
    is a highly advanced carbohydrate dressing with Beta-Glucan. an excellent hoice for donor sites, partial thickness skin loss, acute or chronic wounds, and for dermabrasion and surgical wounds. Patients appreciate the soft, pliable nature of the dressing and the pain relief.
  100. Imparied skin integrity and risk for infection
    Topical antibiotics:Silver sulfadiazine and sulfamylon most popular

    Culture major wounds routine and prn

    Dressings: open or occlusive?

    Assess for infection [Sepsis]-Disorientation, decreased UO, metabolic acidosis, tachypnea, tachycardia, paralytic ileus, hyperglycemia, hyper[hypo]thermia

    • • Assessing bacterial loads
    • –Isolation
    • –Clinical signs:a. gram + colonization – sources, cellulitis, ‘melting graft’ syndrome
    • b.gram – colonization – sources, clinical signs, gram – shock
    • –Culture wounds by swab, punch biopsy, lab tests

    • *TOPICAL AGENTS - most topicals are dressed with coarse mesh gauze and dry [kerlex] wrap unless specifically ordered to have moist dressings
    • SSD [Silvadene - silver sulfadiazine cream]: – For unexcised burns and donor sites
    • –Water soluble & non-toxic, pain-free –
    • Bacterial spectrum against wide range of gram + / - organisms and candida albicans – Softens the eschar; may combine with exudate to form gelatinous layer – Applied 1 or 2 x/day with few side effects
    • •Mafenide acetate cream – Sulfamylon:– Water soluble
    • cream, actively diffusible into avascular
    • tissue [well-absorbed]– Bacterial spectrum against gram + / - and some anaerobes, painful on application
    • –Strong anhydrase inhibitor - can cause metabolic acidosis
    • – Can cause hypersensitivity reactions [rashes] to sulfa
    • – Cream or mixed in Sterile H2O as topical solution for specific dressings
    • • Bacitracin or Petroleum ointments: – For shallow, partial thickness burns - to lips and face
    • – Against gram + organisms
    • – Sometimes used when MRSA discovered in wounds
    • Silver Nitrate [bulky wet dressings]: – Less frequently
    • used secondary to staining and newer agents
    • Dakin's Solution [0.025% sodium hypchlorite]: –Bactericidal without being tissue toxic – Effective against Pseudomonas - not an antibiotic
    • • Bactroban [Mupericin] ointment:– For shallow,
    • partial-thickness burns or donor sites
    • – Used for 'melting graft syndrome‘
    • – Effective against gram +, used when MRSA cultured
  101. The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, “What is a xenograft?”
    Which statement by the nurse would be the best response?

    a.“The doctor will graft skin from your back to your leg.”

    b.“The skin from a donor will be used to cover your burn.”

    c.“The graft will come from an animal, probably a pig.”

    d.“Ithink you should ask your doctor about the graft.”
    C. A xenogrft or heterograft consists of skin taken from animals, usually porcine.

    • a.This is the explanation for autograft.
    • b.This is description of homograft.
    • d. This is “passing the buck”, the nurse can and should
    • answer the question with factual information.
  102. Sheet Graft
    • Whole graft laid intact on wound
    • Used in cosmetic areas of body [face, neck, hands]
    • Requires meticulous care to prevent accumulation of fluid beneath which can impede vascularization
  103. Meshed Graft
    • Skin passed thru machine which creates slits
    • Can be expanded to cover larger wound
    • Often wrapped and protected 3-5 days while becomes vascularized
  104. Alloderm( NEW)
    • Donated human skin (decellularized dermal tissue)used in conjunction with autograft on areas where trying to achieve greater flexibility … areas of release of contracture or
    • adhesions AND areas involving joints
  105. Autograft Care
    • *Autografts – cultured epithelial autografts grown from
    • biopsy of unburned skin – takes 18-25 days – use adherent or staples

    • -Dressing plans
    • -Deblebbing - pressure dressings to prevent blisters – promotesvenous return, decreases pain and itching
    • -Use ofsplints /compression
    • -Staple removal [5-10 days]
    • -Specialty bed requirements and mobility/ immobility orders
    • -Protection from movement, pressure and shear.
  106. Post-surgical Healing Issues
    • -Shearing blisters
    • – Itching
    • – Contractures / Adhesions - secondary to
    • the pliability and mobility of tissues of joints
    • – Hypertrophic scarring - a raised, angry red mass which can contract and distort surrounding skin*Not a KELOID which is a scar that invades normal tissue
    • – Webbing - build up of scar tissue between
    • digits if burn dressings not applied appropriately to
    • maintain spacing
  107. High risk for scarring and loss of functional mobility of
    joints: nursing responsibilities and other interventions
    • -Positioning- position of function.all involved extremities be elevated at all times. When ambulating legs should be ace wrapped.
    • -Splints- when immobilization warranted after grafting; to prevent deformity; for stretching soft tissue - Continue Splints at night
    • -Pressure Garments - used to flatten hypertrophic areas and provide vascularsupport to newly healed wounds, donor sites and grafted areas. minimize over-repair. specially measured and custom-made to exert equally 25 mm Hg pressure on recovering skin.Must be worn 23 hours per day; only taken off for bathing. available for any body part with delivery of custom garment in 24-48; Jobst and others make
    • garments
    • –Exercise Regimens
  108. Cold Injury
    • Frostbite:Tissue damage due to ice crystals in tissues
    • -Blisters appear 24-48 hours after rewarming
    • -Treatment of blisters similar to burn treatment

    • Chilblain:Redness and swelling, especially of hands
    • -Vasodilation, edema, bluish patches, itching and burning
    • -Symptoms continue after rewarming; usually resolve in few days
    • •Toxic epidermal necrolysis - mimics partial thickness thermal injury
    • • Clinical symptoms are fever, systemic toxicity and cutaneous lesions
    • • Result of allergic reaction to a drug
    • *Due to reaction to medications – very painful
    • *Most commonly caused by sulfa drugs, phenobarbital, and phenytoin.
    • *Flu-like symptoms, fever, erythema and blisters
    • *Use care when handling patients
    • *Pigskin used for large open wounds and controls bacterial growth
    • *Effective barrier for treatment of SJS
  110. Botulism
    • *Most serious type of food poisoning with neurotoxin clostridium botulinum – formed from spores in soil – improper canning most common cause.
    • *Can also be contracted throughinfected wounds or nasal inhalation – potential bioterrorism agent
    • -Neurotoxin destroys or inhibits neurotransmission of acetycholine at the myoneural junction resulting
    • in disturbed muscle innervation.

    Diagnosis: Blood and CSF to r/o other causes – if botulism these will be normal

    • Treatment: IV botulinum antitoxin – must give intradermal sensitivity test to horse serum before giving
    • -Test dose followed by therapeutic dose of antitoxin, may be repeated in 2-4 hours if needed, and again 12-24 hours intervals if necessary.
    • -Antitoxin slows progression but does not reverse them.
    • -GI tract is purged with non-magnesium-containing laxatives, high colonic enemas, and gastric lavage
    • - Magnesium worsens toxin-induced neuromuscular blockade.

    Symptoms: N & V, diarrhea, abdominal cramping, within 12-36 hours following consumption.

    • Classic features: Intact mental status, Afebrile, Descending flaccid paralysis with cranial nerve deficits – develop rapidly or over several days
    • -Intact sensation, photophobia, ptosis, paralysis of extraocular muscles, blurred vision, diplopia, dry mouth,
    • sore throat, difficulty swallowing.
    • Other manifestations: paralytic ileus, seizures, respiratory muscle weakness can lead to arrest.
    • *Course depends on amount of toxin absorbed
    • *Death may occur from (5% of patients die)Circulatory failure, Respiratory paralysis, Development of pulmonary
    • complications
    • *Reportable disease – Local, state, and federal (CDC)
    • agencies must be notified.
  111. Botulism nursing management
    • Primary prevention = education
    • -Foods with low acid content which support germination and production of botulin
    • -Fish, vichyssoise, and peppers
    • -Boiling for 10 minutes can destroy toxin, however spores can be resistant to heat and survive in boiling water for 3-5 horus
    • -High pressure cooking is only safe method of canning – can according manufacturer’s instructions
    • -Do not use food from a swollen can
    • -Do not use food if forcefully expelled when opened
    • -If contents look or smell bad discard – flush down toilet or garbage disposal with a large amount of water
    • Supportive care – same for Guillain-Barre syndrome
    • Rest, maintain respiratory function, adequate nutrition, prevent muscle loss
  112. Tetanus
    • *Acute inflammation disorder of peripheral nervous system.
    • *Lockjaw – extremely severe polyradiculitis and polyneuritis affecting spinal and cranial nerves from a neurotoxin from bacillus Clostridium tetani – in spores of soil, garden mold, and manure Enters through traumatic or suppurative wound
    • Also dental infection, chronic otitis media, heroin injections, human and animal bites, burns, frostbite, open fractures, gunshot wounds.
    • Incubation period: usually 7 days – range 3-21 days –
    • longer incubation period less severe illness with better prognosis
    • *Symptoms usually appear after wound has healed.
    • Symptoms: stiffness in jaw (trismus) and neck,
    • fever, and symptoms of general infection.
    • As progresses neck muscles, back, abdomen, and extremeties become rigid

    • Severe forms – tonic convulsions with extreme
    • arching of back and retraction of head – can be set off by slightest noise, jarring motion, or bright light – very painful – mortality rate 100%
    • Laryngeal and respiratory spasms – apnea and anoxia
    • Profuse diaphoresis, labile hypertension, episodic tachycardia, hyperthermia, and dysrhythmia
  113. Tetnus nursing management
    • Tetanus prophylaxis – appropriate immunizations – adults booster every 10 years
    • Wound management
    • -Rinse wound immediately with soap and water
    • -If wounded and tetanus not within last 5 years – need booster
    • -Test for sensitivity if with equine tetanus – anaphylactic shock possible if allergic
    • -Discuss mild effects from immunization – sore arm, swelling at site, itching, lymphadenopathy
    • Mgmt of tetanus:
    • -Administration of tetanus, diphtheria toxoid (Td) booster AND tetanus immune globulin (TIG) in different sites before onset of symptoms
    • *Larger dose of TIG if clinical manifestations.
    • *Spasms controlled with deep sedation and muscle relaxation, may need to paralyzed – Valium, barbituates, Norcuron(neuromuscular blocking agent)
    • *Pain management with Opiods (morphine or fentanly)
    • *Antibiotic for 10-14 days – penicillin, metronidazole, tetracycling, doxycycline – to inhibit further growth or prevent secondary infection.
    • *Tracheostomy may be performed early if laryngospasms – mechanical ventilation
  114. Arthropod Bites and Stings
    • -May cause mild to moderate discomfort
    • -Managewith symptomatic measures and prevention of secondary infection
    • -Bees:stinger penetrates into skin
    • -Remove stinger ASAP
    • -Sensitization to bee stings may result in anaphylaxis

    • *Arthropods include insects, arachnids = mites, ticks, spiders, scorpions
    • *All spiders bite and have venom but most do not produce sufficient harmful toxin except – brown recluse and black widow – require IMMEDIATE attention
    • *Remove stinger from bee because muscle works it deeper and venom is pumped
    • *Need to get away from vicinity to prevent other stings.
    • *Epinephrine must be available for immediate administration – if hypersensitive it may only take one sting to produce generalized urticaria, respiratory difficulty, hypotension, and death.
    • *They should wear medical alert bracelet.
  115. Scabies
    • *Caused by scabies mite as female burrows into epidermis to deposit eggs and feces
    • *Inflammation occurs 30-60 days later
    • *Topical treatment: scabicides such as permethrin 5% or lindane
    • *Oral treatment: ivermectin if body weight is >15 kg
    • *Must follow specific instructionsfor each agent
    • Permethrin – applied to all skin from neckdown to toes – kept on for 8-14 hours and removed with bathing

    • Lindane – Not applied right after bath Removed after 8-12 hours with bathing.
    • -A second treatment with same lotion may be needed 7-10 days later.

    • *Pregnant women or younger children may be treated
    • with milder Crotamition applied once a day for 2 days, then bath 48 hours after last application
    • *Wash all clothes, bedding and towels in hot water and hot dryer
    • *Severe or crusted scabies – treat with ivermectin orally in a single dose – not licensed by FDA for treatment
    • of scabies
    • *Rash and itch may not be eliminated for 2-3 weeks may still need soothing ointments or antibiotics to prevent secondary infection.
  116. There is an outbreak of scabies in a long-term care facility. Which instruction should the infection control nurse provide to all client care staff concerning the transmission of this parasitic infection?

    a.Use only hand-washing foam when caring for clients with scabies.

    b.Wear gloves when providing hands-on care for a client with scabies.

    c.Wash all linen and clothes in cold water and dry them outside in the sun.

    d.Instruct clients to use plastic eating utensils for meals.
    • B. Because of the close living quarters, clients in long-term care facilities are at a high risk for developing scabies. Clients may have poor hygiene as a result of limited
    • physical ability and the nursing staff may transmit the parasite. Therefore,the nursing staff should wear gloves to provide a barrier to the mites.

    • a.Foam or soap and water can be used to clean hands.
    • C. Linens and clothing should be washed in hot water and
    • dried in dryer cycle because mites can survive up to 36 hours in linens.
    • D. Plastic eating utensils will not help prevent the spread
    • of scabies.
  117. Infections Transmitted by Arthropods
    Rickettsiae: Rocky Mountain spotted fever transmitted by infected fleas, ticks, and mites

    • Lyme disease: most common tick-borne disorder in United States.
    • Stage 1: 3-31 days following bite – red rings around bite area (erythema migrans)
    • Stage 2: most serious – several weeks after stage 1 completed – systemic involvement of neurologic, cardiac, and musculoskeletal
    • Stage 3: late stage – musculoskeletal pain, arthritis, deafness, chronic encephalopathy
    • Treatment:Doxycycline if older than 8 years
    • Amoxicillin if younger – if allergicuse cefuroxime or erythromycin
    • Monitor for:symptoms up to 30 days after bite – if develop skin lesion or viral infection seek help

    • *If treated in stage 1 will usually prevent further problems.
    • * There was a vaccine but was discontinued in 2002 due to lack of interest.

    • *Focus on prevention *
    • *Protect from bites by wearing appropriate clothing and repellent (DEET)
    • *Tetracycline or chloramphenicol
  118. Mammal Bites and Scratches
    • *Common pediatric problem, especially for those <4 years
    • Wound care
    • Prophylactic antibiotics for some types of bites
    • Rabies concern
    • Can cause mild to moderate pain
    • Managed by simple symptomatic measures:
    • Compresses, calamine lotion, prevention of secondary infection
  119. Human Bites
    • Lacerations from teeth of other humans
    • Risk of infection
    • Wound care
    • Dental plaque and saliva harbor pathogens need attention - if greater than 6 mm needs medical attention
    • Wash vigorously with soap and water
    • Pressure dressing to stop bleeding
    • Ice to minimize pain and swelling
    • Antibiotics toprevent infection
    • Tetanus if needed
  120. Cat Scratch Disease
    • Most common cause of regional lymphadenitis in children and adolescents
    • Usually benign and self-limiting, resolving spontaneously in 2-4 months
    • Treatment primarily supportive, but antibiotic therapy may speed resolution of adenopathy
Card Set
Med surg Test 3
Cognitive issues, alterations in protection/immunology,alterations in neuro function, alterations in mobility