MDC4 Final Exam - Lecture notes 1-11 PDF

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MDC4 Final Exam Chest Injury 1. Pneumothorax: air that suddenly enters the pleural space; sudden addition of air

causes a loss of negative pressure and a reduction in vital capacity which can cause the lung to collapse o Types 

Spontaneous/iatrogenic: not associated with trauma; blebs; Valsalva; may resolve on its own; if 20%

o Electrical 

Don’t touch victim if still in contact with source of electricity; remove electrical source

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Remove patient from contact with source

o Chemical Injuries 

Remove clothing, brush solid particles off the skin, flush with large amounts of water

o Small thermal burns

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Cover with clean, cool, tap water- dampened towel burns 2000ml: death is near, >140 HR, hypotension, no urine, mental status (coma) o reportable events

urinary output decreased, mental status changes, increased HR, hypotensive o fluid resuscitation  crystalloids (normal saline/lactated ringer): add more fluids to intravascular system, increases preload, stroke volume and cardiac output; monitor for fluid overload (hemodynamic, elevated CVP, fluid in the lungs, jugular vein distention); through capillary wall; 3 ml of fluids per 1 ml of body fluid lost  colloids (albumin, hetastarch): large molecules can’t diffuse through capillary wall, stays in intravascular space; more expensive; may have anaphylactic shock; monitor for fluid overload  keep the fluids warm!!  Blood/products (packed RBC, platelets, fresh frozen plasma): PRBC help replace fluid/provides patient with hemoglobin (carry O2), used when crystalloid fluid is not working, experience severe bleeding/hypovolemic shock; platelets for uncontrolled bleeding to help with thrombocytopenia; FFP if patient needs clotting factors, monitor for transfusion reaction 7. Reportable events Vasopressin o Anaphylaxis, rash, itch, trouble swallowing, trouble breathing, swelling, low sodium, numb/tingling, pounding in head/ears, dizzy, spinning sensation, pale skin, stomach pain, gas, nausea/vomiting, sweating 8. Indications of developing Multi-Organ Failure o Shock conditions continue for long periods of time without treatment, resulting metabolites that are released in body cause cell damage o Injuries at risk for MODS: shock and burns, severe hypotension, reperfusion of ischemic cells, inadequate tissue perfusion (lungs, kidneys, heart, GI), environmental, chronic illness, immune function, autoimmune o Appear to do well and then…  Low grade fever  Tachycardia  Dyspnea  Increased neutrophils/WBC  Seizures  Decreased UOP  Chest pain  Edema  Elevated glucose  Pulmonary infiltrates  Renal (creatinine >2, UOP 8)  Platelets increased with stress but will fall with persistent sepsis (N 150000-450000)  WBC/Neutrophil will increase (N 4500-11000 WBC & 2500-7000 neutro) 

Magnesium Calcium Phosphate Glucose Serum creatinine BUN Bilirubin Alkaline phosphate (ALP): Alanine aminotransferase (ALT): Serum lactate will be elevated o Nursing actions  Assess organ function  Provide support measures (vent, inotropic meds)  Implement measures to compensate for dysfunction (clotting factors, dialysis) 9. Situational Questions that require selection of interventions          

o 10. Septic Shock: persistently low mean arterial blood pressure as a result of

overwhelming infection despite adequate fluid resuscitation o clinical manifestations  hypotension (systolic 4mmol/L, apply vasopressors if hypotensive during/after fluid resuscitation to maintain a mean arterial pressure >65 11. Mean Arterial Pressure calculation o Blood volume (fluid intake vs. fluid loss) o Effectiveness of heart as a pump (cardiac output – HR/stroke volume)

Resistance of the system of blood flow (size/diameter of arterioles) Relative distribution of blood between arterial/venous blood vessels (diameter of the veins) o Systolic: 140, diastolic: 80, results: 100 o Equation: ((diastolic * 2) + systolic)/3  Usually ranges 70-110 DIC: characterized by systemic activation of blood coagulation, overstimulation of clotting cascade; results in deposition of fibrin; leads to microvascular thrombi in various organs; contribute to multiple organ dysfunction syndrome 1. S/S o Excessive clotting and bleeding, microvascular clots, hypoxia, acidosis, shock, stroke 2. clinical manifestation 3. microvascular clots impairing circulation (kidneys, lungs leading to ARDS), hypoxia, acidosis, shock, systems affected skin, lungs, kidneys, CNS and GI, stroke, severe bleeding, lack of blood flow to arms, legs and organs o ARDS: acute respiratory distress syndrome  Life threatening disorder that may cause permanent damage to the lungs; high mortality rate; associate with acute lung injury in people without pulmonary disease; pay close attention to oxygenation (hallmark sign is hypoxemia) persists even when 100% O2 is given, which is known as refractory hypoxemia  Other key features  Decreased pulmonary compliance (elasticity)  Lowered production of surfactant  Dyspnea  Noncardiac-associated bilateral pulmonary edema  Dense pulmonary infiltrates on x-ray known as ground glass appearance  Assessment  Respiration effort/work of breathing  Signs of hyperpnea (rapid/deep breaths) (NOT HYPERVENTILATION)  Noisy respirations  Cyanosis  Pallor  Retractions (intercostal and substernal)  Lung sounds are normal  Assess vital signs at least hourly  Depends on client acuity  Monitor for hypotension and tachycardia  Telemetry o

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 Monitor for cardiac dysrhythmias  Temperature  Core body temperature Will often need mechanical ventilation with positive end expiratory pressure (PEEP) or continuous positive airway pressure (CPAP) Keep tidal volumes low at 6 ml/kg of body weight, PEEP is started at 5 cm H2O and increased to keep oxygen saturations adequate Treatment: do not reverse or treat lung damage; centered on preventing further lung damage and treating underlying cause (Sepsis)

4. Assessment o Observe all drainage for blood (GI, mucous, eyes, nose, mouth) o Check for petechiae/purpura of skin (early symptoms of hemorrhage) o Hypotension, tachycardia, decreased loss of consciousness o Avoid sharp objects o No IM injections o In prone position 5. Treatment: address underlying disorder (broad spectrum antibiotic, evacuation of uterus in abruptio placentae), fluid replacement with crystalloid/colloid solutions, replacement therapy (fresh frozen plasma, cryoprecipitate, platelets), heparin (not for OB cases; used in early DIC) Emergency Severity Index 1. Prioritize patient care o

Level 1: Resuscitation- immediate, lifesaving intervention required without delay; cardiac arrest, massive bleeding

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Level 2: Emergent- high risk of deterioration, signs of a time critical problem, altered mental status, severe pain; cardiac related chest pain, asthma attack

Level 3: urgent- stable, with multiple types of resources needed to investigate or treat (labs, 2. Prioritize actions with patient presentation o Systemic before local/life before limb o Acute before chronic o Actual problems before potential future problems o According to Maslow’s hierarchy of needs o Recognize and respond to trends vs. transient findings (level of consciousness) o Recognize signs of emergency/complications vs expected client findings o

Apply critical knowledge to procedural standards to determine the priority action 3. Mass Casualty Process o CAB: circulation, airway, breathing Trauma o

1. Frostbite o

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clinical manifestation 

stage 1: least severe, only superficial layer of exposed skin are affected with hyperemia and edema

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stage 2: blisters cover the exposed skin areas causing necrotic tissue death and swelling

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stage 3: extensive edema and blisters to the affected skin which does not blanch. Affected areas will be treated by debridement of damaged tissue

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stage 4: affected area completely lacks blood supply and is considered full thickness necrosis of skin with potential progression to gangrene. Extent of gangrene may require amputation of affected areas

treatment 

stop exposure

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don’t rub if client has frostnip

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submerge in a warm water tub (104-108) to improve blood circulation and promote healing of damaged tissue

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rewarming process is painful

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administer analgesics

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watch for development of compartment syndrome from the swelling

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severe frostbite is managed like thermal burn

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administer tetanus vaccine to prevent complications related to growth of tetanus in wounds

assessment 

circulation, wound (odor, exudate), pain, effective debridement, control of infection, acceptability for the patient, numb areas

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S/S  

Cold skin Prickling feeling

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Numbness

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Red, white, bluish white or grayish yellow skin

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Hard or waxy looking skin

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Clumsiness due to joint and muscle stiffness

Blistering after rewarming in severe cases 2. Hypothermia: can cause vasoconstriction, metabolic acidosis, hypertension; below 95 o clinical manifestations  shivering  mild: 90-95  moderate: 82.4-90  Severe: below 82.4 o Treatments  Warming blankets, heat lamps, warmed fluids  Mild:  Shelter, remove wet clothes, provide sources of warmth, drink warm high card liquids, no alcohol or caffeine  Moderate/Severe:  Supine position  Maintain ABC  Administer meds with caution: cold slows the metabolism; drugs can become potentially toxic when rewarming takes place; withhold medication except for vasopressors until core body temp is 86F  Closely monitor cardiac response: CPR if no spontaneous circulation is present; monitor for v tach and v fib  Rewarm core first and then extremities: use warm IV fluids, hated O2, heated peritoneal, pleural, gastric, and bladder lavage  Severe hypothermia: use extracorporeal rewarming methods such as cardiopulmonary bypass or hemodialysis  Watch for signs of potential complications: fluid/electrolyte imbalance, ARDS, acute renal failure, pneumonia o rationale for monitoring  monitor BP, temp= cardiac dysrhythmias, alters metabolism/medications, causes coagulation issues 3. Heat Stroke 

clinical manifestation treatment  NPO  Initiate ALS measures (airway, remove from hot environment, follow protocols of heat exhaustion to cool patient)  Transport to hospital  In Hospital  Protect airway  IV with large bore cath  Administer 0.9 NS- use cool solutions if available  Use cooling blankets  Use rectal probe to measure core bodytemp  Obtain baseline VS and monitor VS  Administer muscle relaxants if shivering  Stop cooling once core temp reaches 102 o Meds  Muscle relaxers (benzodiazepines) 4. Priority emergency assessment o Rapidly identify life threatening injuries o Comp head to toe o Interventions: foley, dressings, splints 5. Initial Nursing Survey of pt in emergent situations o CAB: circulation, airway, breathing o Airway, alertness, cervical spine protection, manual stabilization with 2 hands , GCS o Breathing: spontaneous, symmetrical, resp rate, signs of distress, chest contusion, tracheal deviation, inhalation injury, auscultate, palpate o Circulation: assess pulse quality, skin color, obvious external hemorrhage o Disability: neurologic status, GCS, assess potential for altered mental status o Exposure: remove clothing, assess for further injuries, preserve clothing in paper bags for evidence, cover patient with warm blankets, give warm fluids, warm lights o Full set of vitals o Get monitoring devices, give comfort 6. Concepts of o Pre hospital triage  Completed quickly; EMS personal take only 60 seconds to perform a quick assessment and tag appropriately  during assessment evaluation focusses on the following  respirations (ventilation)- is the patient breathing  pulse/perfusion- does the patient have a pulse and are they bleeding (if they are bleeding take measures to stop the bleeding)  neurological status- is the patient able to follow commands, is the patient conscious o o

Triage Tags  Emergent Class I: immediate threat to life  Chiefs  Manage logistics  Planning  Budget  Finance  Delegates duties to department officers and unit managers  Non-emergent Class II: injured and require treatment  Triage officer  Works closely with medical command physician  medical command role can be taken over by an experienced triage nurse or nurses  Walking wounded Class III: minor injuries  Medical command (physicians)  Decides number acuity and medical resources needs of victims arrive from the incident scene to the hospital  Calls in specialties (trauma surgeons, general surgeons, infectious disease specialists)  Class IV: expected to die or already dead 7. UAP roles in tx and interventions to reduce the temperature o Treatment: o Interventions to reduce temperature: 8. Nsg assessment for a peripheral response to pain in an unconscious pt o

o 9. Informed Consent, the sequence of responsible parties o Obtained after client receives complete disclosure of all pertinent

information provided by the provider regarding the surgery or procedure to be performed. Obtained only if the client understands the potential benefits and risk associated with the surgery or procedure. o Elements of informed consent  Individual giving consent must fully understand the procedure that will be performed, the risks, expected/desired outcomes, expected complications/side effects, alternate treatments/therapies available  Consent is given by a competent adult, legal guardian or DPOA, emancipated/married minor, parent of a minor, court order  Trained medical interpreter must be provided when the person giving consent is unable to communicate due to language barrier o Nurses’ role: witness the client’s signature/ensure the provider gave the necessary information/that the client understood/is competent to sign; notify provider if clarification is needed o Documentation: thorough documentation includes reinforcement of information given by provider, any irregular occurrences, and use of an interpreter

10. MAP indicates what o Enough blood flow, resistance, and pressure to supply blood to all major

organs DP + 1/3 (SP-DP) Dosage Calc o

1. Few questions 2. Heparin know the desired therapeutic levels for PE o 1.5x baseline control value or upper limit of normal range of aPTT o Protamine titration: 0.2-0.4 o Anti factor Xa chromogenic assay: 0.3-0.7

Neuro 1. Nsg interventions to decrease ICP while repositioning pt o

Elevated HoB

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Avoid extreme flexion, extension, rotation of head, maintain body in a midline neutral position

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Maintain patent airway, provide mechanical ventilation

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Administer oxygen, PaO2 greater than 60

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Stool softeners/avoid Valsalva maneuver

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Calm, restful environment

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Brief periods of hyperventilation for intubation after first 24 hours

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Manifestations 

Headache, nausea, vomiting

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Decreased level of consciousness, restless, irritable

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Dilated/pinpoint nonreactive pupils

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Cranial nerve dysfunction

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Alteration in breathing pattern

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Decreased motor function, abnormal posturing (decerebrate, decorticate, flaccidity)

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Cushing’s triad: late finding characterized by severe hypertension with a widening pulse pressure and bradycardia

 seizures 2. CSF Characteristics o Meningitis: bacterial=cloudy, clear=viral, elevated WBC/protein, decreased

glucose=bacterial, elevated CSF pressure Leakage from nose/ears can indicate basilar skull fracture; halo sign: clear/yellow ring surrounding a drop of blood when bloody drainage is placed on gauze 3. Autonomic Dysreflexia o occurs secondary to the stimulation of the SNS and inadequate compensatory response by the PNS. Lesions below T6 do not experience dysreflexia because the parasympathetic nervous system is able to neutralize the sympathetic response. Sympathetic stimulation is usually caused by triggering stimulus in the lower part of the body. Stimulation of the SNS causes extreme hypertension, sudden severe headache, pallor below level of spinal cord lesion, blurred vision, diaphoresis, restlessness, nausea, goosebumps/piloerection. Stimulation of parasympathetic nervous system causes bradycardia, flushing above corresponding dermatome to the spinal cord lesion (flushed face/neck), nasal stuffiness. o nsg interventions  sit the client up to decrease blood pressure  notify provider  determine/treat cause  distended bladder is most common: insert cath, check existing cath for kinks, irrigate if needed  remove fecal impaction  adjust room temp/block drafts  remove tight clothing  assess for injury (lower extremity fracture, kidney/bladder infection)  monitor vitals for severe hypertension/bradycardia  administer antihypertensives (nitrates/hydralazine) 4. Hemianopsia nursing interventions o Provide assistance with ADL o Dress affected side first o Scan environment o Frequent rest periods 5. Myasthenia Gravis patient education o Autoimmune condition: body attacks muscle receptors that control voluntary muscles, leading to muscle weakness; voluntary muscles- eyes (1st sign: double vision, eyelid droop), throat (common, voice changes, swallowing is changed, chewing is an effort), face, arms/legs, respiratory (severe) o Weakness gets worse with repetitive activities o At risk for aspiration o Plan for rest, get more activities done first thing after waking o

Myasthenic crisis: disease can go to remission but can experience acute exacerbation/severe muscle weakness and respiratory failure; cause- not enough anticholinesterase med, stress, respiratory infection, surgery o Cholinergic crisis: too much anticholinesterase med, severe muscle weakness and respiratory failure o Order tensilon test: give edrophonium (anticholinesterase, prevents the breakdown of acetylcholine, more available at neuromuscular junction); myasthenia gravis, strength will improve; cholinergic crisis strength will worsen, then give atropine as antidote o Sit up to eat; eat larger meals in the morning, small meals in the day o Schedule meals 30 min to 1 hour after taking anticholinesterase o Thicken liquids o Small bites, soft food o Use assistive devices o Declutter environment o Well lighting 6. Parkinson’s Disease patient education o

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Progressive neurodegenerative disease; debilitating disease affecting mobility Cardinal symptoms: tremor, muscle rigidity, posture instability, bradykinesia/slow movement, akinesia/no movement Due to lack of dopamine in brain, too much acetylcholine not enough dopamine, interferes with movement, decreasing influence of sympathetic nervous system, resulting in orthostatic hypotension, drooling, nocturia. Primary: idiopathic/unsure of cause, may be genetic or environmental; risk factors: male, 40y+, family history (first degree relatives and siblings) Secondary: from condition (brain tumor/certain antipsychotic drug); risk factors: brain tumor Onset usually between 40-70 years old 5 stages: initial (hand tremble, minimal weakness), mild (bilateral affect, tremble, mask like, slow gait shuffle), moderate (postural instability, increased gait), severe (akinesia-loss of function, rigidity), ADL dependent Symptoms: fatigue, handwriting changes, decrease manua...