Arterial vs venous symptoms
- Arterial: intermittent claudication, cramping, numbness, tingling
- Aggravating symptoms: walking, elevation
- Relieving factors: rest, or dangling.
- Associated symptoms: cool pale skin-poor healing injuries to extremities
- Venous: aching, tiredness, feeling of fullness
- aggravating symptoms: prolonged standing, sitting.
- relieving factors: elevation, lying, walking.
- associated symptoms: edema, varicosities, weeping ulcers at ankles.
Phases of burn patients nursing care
- Resuscitative phase: Life threatening, airway or breathing problems, cardiopulmonary instability, hypovolemia, hypothermia-shock phase. Every organ is involved in this response with a TBSA burn of 20% or greater.
- Acute Care phase: wound healing, wound closure prevention of infection.
- Rehabilitation phase: support for adequate wound healing, prevention of scarring, contractures, and psychological support
Critical care nursing management: Burns
- Oxygen alterations: assess airway, breathing, administer O2.
- monitor HBCO levels-carbon monoxide
- elevate HOB and implement HAP percautions
- assist with pulmonary secretion suctioning
- Observer for signs of airway obstructions
- Maintain accurate documentation
- Impaired gas exchange: High Flow Oxygen
- Ineffective airway clearance: laryngeal swelling can occur at anytime during first 24 hours and up to 72 hours increased risk of edema. monitor for intubation
- Fluid resuscitation: Parkland Burn Formula-(4ml X TBSA (%) X Weight (KG)) give 50% in first 8 hours. LR is the standard for the first 24-36 hours. Capillary Leak seals after 24 hours approx. which allows albumin to be given without leakage into the interstitium.
- Electrolytes: Potassium increased risk for hyper or hypo-due to cellular damage, kidney damage, metabolic acidosis. increased risk for hyponatremia as well
- Ineffective kidney tissue perfusion: myoglobinuria(proteins)-port wine color in urine-leading to damage to glomerular apparatus-tubules. Fluids, forced diuresis with mannitol, osmotic diuretics-hourly urine output that is double recommended. UO every hour for first 48-72 hours.
- Ineffective peripheral tissue perfusion: 6 P's (Pulselessness, pallor, pain, paraesthesia, paralysis, poikilothermia)
- Inflammatory phase: 3-5 days after injury.
- Proliferative phase: 4-20 days after injury.-epithelization-cells begin to cover the wound and bring collagen to heal.
- Maturation phase: 20-over a year-scar tissue begins to form.
- Imbalanced nutrition: metabolism increases 40-100% depending on TBSA burned.
- Topical antibiotic therapy is needed for burn injury. Silver sulfadiazine, mafenide acetate cream, bacitracin, pure silver.
- Wound closure: Autografts, allografts (homografts), xenografts, synthetic skins
- Type 1-absolute or relative insulin production:stress response, infection or missed insulin injection are some main causes of DKA in children or adolescence.
- S/S: BG elevated, ph low,urine ketonse, kussmaul respirations, WBC may be elevated.
- Focused assessment: respiratory status, LOC, hydration status, electrolyte acid balance.
- Treatment: hydration, insulin drip as ordered, continuous cardiac monitoring, monitor Potassium level, urine output >30ml/hr, neurological check every 1-2 hours-assess for signs of ICP due to increased risk of cerebral edema with re-hydration.
HOT SPOT Heart Auscultations
rating pitting edema
- +1: barely perceptible pit
- +2: deeper pit-rebounds in a few seconds
- +3: deep pit rebounds in 10-20 sec
- +4: deep pit rebounds in >30 sec
H2 receptor blockers ex
- cimentidine (Tagamat)
- ranitidine (Zantac)
- famotidine (pepcid)
Steps of IV and Tubing assessment
IV site to bag
mixing insulin RN (Regular to Nph)
Most commonly ordered insulin that are mixed: NPH (intermediate-acting) and Regular insulin (short-acting
- Never mix Insulin Glargine “Lantus” with any other type of insulin.
- Administer the dose within 5 to 15 minutes after drawing up because the regular insulin binds to the NPH and this decreases its action.
- insert air into both vials than draw from CLEAR TO CLOUDY