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Exam Notes
MDC4 Final
Parkland Formula a) 4ml x % BSA x weight (kg)= volume of fluid that needs to be infused b) ½ of the total volume of fluid in first 8 hours c) Last half in 16 hours MAP Calculation a) MAP= 1/3 * SBP + 2/3 * DBP Treatment for frostbite a) Rewarming the skin a. Rewarm the area using a warm-water bath for 15 to 30 minutes b. Skin may turn soft and look red or purple c. You may be encouraged to gently move the affected area as it rewarms. b) Oral pain medicine a. The rewarming process can be painful c) Protecting the injury a. Once the skin thaws, loosely wrap the area with sterile sheets, towels, or dressing to protect the skin. b. May have to protect fingers and toes as they thaw by gently separating them from each other c. You may need to elevate the affected area to reduce swelling d) Debridement (removal of damaged tissue) a. To heal properly, frostbitten skin needs to be free of damaged, dead or infected tissue. e) Whirlpool therapy or physical therapy a. Hydrotherapy can aid healing by keeping skin clean and naturally removing dead tissue b. Pt may be encouraged to move the affected area f) Antibiotics a. If the skin or blisters appear to be infected, the doctor may prescribe oral antibiotics g) TPA a. IV injection of a drug that helps restore blood flow (thrombolytic) such as TPA. b. TPA lowers the risk of amputation c. These drugs can cause serious bleeding and are typically used only in the most serious situations and within 24 hours of exposure. h) Wound care i) Surgery a. Severe frostbite patients may need surgery or amputation to remove dead or decaying tissue. j) Hyperbaric oxygen therapy a. Some patients show improved symptoms after this therapy, but more study is needed.
Treatment and differences of heat stroke and heat exhaustion a) Heat exhaustion a. Symptoms i. General weakness, increased heavy sweating, a weak but faster HR, N/V, possible fainting, pale/cold/clammy skin b. Treatment i. Stop physical activity, transfer to cool space ii. Cooling measures (ice water bath, mist skin with water, ice packs, special cooling blanket) iii. Rehydration therapy b) Heat stroke a. Symptoms i. Elevated body temperature above 103 F (39.4 C), rapid and strong HR, loss or change of consciousness, hot, red, dry, or moist skin b. Treatment i. Oxygen therapy, IV lines, urinary catheter, continuous cooling (Ice bath, mist skin with water, ice packs, special cooling blanket), benzodiazepine if shivering occurs, monitor for multi system organ dysfunction syndrome and electrolyte imbalances. Priority assessment in triage a) ABC’s Temperature reduction strategies a) Ice bath, mist skin with water, ice packs, special cooling blanket Skin injury related to frostbite a) Frostbite occurs in several stages: a. Frostnip i. Mild form of frostbite- does not permanently damage the skin ii. Continued exposure leads to numbness in the affected area iii. As the skin warms, the patient may feel pain and tingling. b. Superficial Frostbite i. Appears as reddened skin that turns white or pale ii. The skin may begin to feel warm- a sign of serious skin involvement iii. If you treat frostbite with rewarming at this stage, the surface of skin may appear mottled and you may notice stinging, burning, and swelling iv. Fluid-filled blisters may appear 12 to 36 hours after rewarming the skin c. Deep (Severe) Frostbite i. Skin turns white or bluish grey, and the patient may experience numbness, losing all sensation of cold, pain, or discomfort in the affected area. ii. Joints/muscles may no longer work
to a trauma center as soon as feasible. With the exception of the needle decompression, other advanced level procedures are best done while en route.
Addressing ventilator alarms a) Should never be turned off or ignored during mechanical ventilation b) The major alarms on the ventilator indicate either a high pressure or low exhaled volume c) If the alarm cannot be determined, ventilate the patient manually with a resuscitation bag until the problem is corrected by another health care professional Fractured ribs and flail chest a) Rib fracture a. Important info i. The most common cause is blunt trauma from a fall or car accident. Trauma can increase your risk for organ damage when your rib is fractured. ii. Older age, osteoporosis, or a tumor can increase your risk for rib fractures. iii. A stress fracture can happen in your upper or middle ribs. Stress fractures can happen when you have a forceful long- term cough. They can also be caused by forceful athletic movements, such as in golf, throwing, or rowing. iv. A condition called flail chest occurs if 3 or more of your ribs are broken in 2 or more places. This condition may make it hard for you to breathe. b. Signs and symptoms i. Chest wall pain that worsens when you breathe, move, or cough ii. Bruising or swelling near your injury iii. Shortness of breath or difficulty taking a deep breath c. Treatment i. Medications
- NSAIDs , such as ibuprofen, help decrease swelling, pain, and fever.
- Prescription pain medicine may be given.
- Intercostal nerve block may be given to numb the injured area for about 6 hours. It is given as a shot between 2 of your ribs in the fractured area. You may need this if your pain continues or is getting worse even after you take oral pain medicines. ii. Surgery may be needed if your rib fracture is severe or several ribs are badly broken. Surgery is often needed for a flail chest. d. Management of symptoms i. Take deep breaths and cough 10 times each hour. This will decrease your risk for a lung infection. Hug a pillow on your injured side to decrease pain while you take deep breaths. Take a deep breath and hold it for as long as you can. Let the air out and then cough. Deep breaths help open your airway. You may be given an incentive spirometer to help you take deep breaths. Put the plastic piece in your mouth and take a slow, deep breath, then let the air out and cough. Repeat
b) Flail chest Cover it with a towel. Ice helps prevent tissue damage and decreases swelling and pain. a. an injury that occurs typically following a blunt trauma to the chest. When three or more ribs in a row have multiple fractures within each rib, it can cause a part of your chest wall to become separated and out of sync from the rest of your chest wall. b. The chest moving unevenly between the separated part and rest of the chest is often the most definitive sign that you have a flail chest. The area of your chest that’s been traumatized will draw in when you breathe in, while the rest of your chest expands outward. When you breathe out, the affected area will expand out while the rest of your chest draws in. c. Treatment i. Your doctors will need to protect your lungs while ensuring that you can breathe adequately. They will give you an oxygen mask to assist your breathing and give you medication to help with your pain. ii. In more serious cases where there is associated underlying lung injury, you may need to be put on a mechanical ventilator in order to keep your chest cavity stable. It’s possible that surgery will be required, depending on the extent of injury and risks versus benefits of surgery. Chest injury a) Patients may be asymptomatic at first and can later develop various degrees of respiratory failure and possibly pneumonia b) These patients often have decreased breath sounds or crackles and wheezes over the affected area c) Other symptoms include bruising over the injury, dry cough, tachycardia, tachypnea, and dullness to percussion. d) At first the chest x ray may show no abnormalities but a hazy opacity in the lobes or parenchyma may develop over several days e) Management includes maintenance of ventilation and gas exchange Pneumothorax a) Collapsed lung b) Signs and symptoms a. sudden chest pain and shortness of breath. c) Causes a. Chest injury. i. Any blunt or penetrating injury to your chest can cause lung collapse. Some injuries may happen during physical assaults or car crashes, while others may inadvertently occur during medical procedures that involve the insertion of a needle into the chest. b. Lung disease. c. Ruptured air blisters.
i. Small air blisters (blebs) can develop on the top of the lungs. These blebs sometimes burst — allowing air to leak into the space that surrounds the lungs. d. Mechanical ventilation. i. A severe type of pneumothorax can occur in people who need mechanical assistance to breathe. The ventilator can create an imbalance of air pressure within the chest. The lung may collapse completely. d) Diagnosis a. chest X-ray. In some cases, a computerized tomography (CT) scan may be needed to provide more-detailed images. Ultrasound imaging also may be used to identify a pneumothorax. e) Treatment a. Observation i. If only a small portion of your lung is collapsed, your doctor may simply monitor your condition with a series of chest X- rays until the excess air is completely absorbed and your lung has re-expanded. This may take several weeks. b. Needle aspiration or chest tube insertion c. Nonsurgical repair: i. Using a substance to irritate the tissues around the lung so that they'll stick together and seal any leaks. This can be done through the chest tube, but may be done during surgery. ii. Drawing blood from your arm and placing it into the chest tube. The blood creates a fibrinous patch on the lung (autologous blood patch), sealing the air leak. iii. Passing a thin tube (bronchoscope) down your throat and into your lungs to look at your lungs and air passages and place a one-way valve. The valve allows the lung to re- expand and the air leak to heal. d. Surgery: i. Sometimes surgery may be necessary to close the air leak. In most cases, the surgery can be performed through small incisions, using a tiny fiber-optic camera and narrow, long- handled surgical tools. The surgeon will look for the leaking area or ruptured bleb and close it off. ii. Rarely, the surgeon will have to make a larger incision between the ribs to get better access to multiple or larger air leaks. ARDs a) Overview a. Acute respiratory distress syndrome (ARDS) occurs when fluid builds up in the tiny, elastic air sacs (alveoli) in your lungs. The fluid keeps your lungs from filling with enough air, which means less oxygen reaches your bloodstream. This deprives your organs of the oxygen they need to function. b) Symptoms a. Severe shortness of breath
i. These medications are often given to people at risk of clots before and after an operation — as well as to people admitted to the hospital with medical conditions, such as heart attack, stroke or complications of cancer. b. Compression stockings. i. Compression stockings steadily squeeze your legs, helping your veins and leg muscles move blood more efficiently. c. Leg elevation. i. Elevating your legs when possible and during the night also can be very effective. d. Physical activity. i. Moving as soon as possible after surgery can help prevent pulmonary embolism and hasten recovery overall. This is one of the main reasons your nurse may push you to get up, even on your day of surgery, and walk despite pain at the site of your surgical incision. e. Pneumatic compression. i. This treatment uses thigh-high or calf-high cuffs that automatically inflate with air and deflate every few minutes to massage and squeeze the veins in your legs and improve blood flow. d) Treatment a. Medications: i. Blood thinners (anticoagulants). These drugs prevent existing clots from enlarging and new clots from forming while your body works to break up the clots. Heparin is a frequently used anticoagulant that can be given through the vein or injected under the skin. It acts quickly and is often overlapped for several days with an oral anticoagulant, such as warfarin, until it becomes effective, which can take days. ii. Clot dissolvers (thrombolytics). While clots usually dissolve on their own, sometimes thrombolytics given through the vein can dissolve clots quickly. Because these clot-busting drugs can cause sudden and severe bleeding, they usually are reserved for life-threatening situations. b. Surgical and other procedures: i. Clot removal. If you have a very large, life-threatening clot in your lung, your doctor may suggest removing it via a thin, flexible tube (catheter) threaded through your blood vessels. ii. Vein filter. A catheter can also be used to position a filter in the body's main vein (inferior vena cava) that leads from your legs to the right side of your heart. This filter can help keep clots from going to your lungs. This procedure is typically reserved for people who can't take anticoagulant drugs or when they have had recurrent clots despite use of anticoagulants. Assessment of LOC
Ways to minimize the risk of autonomic dysreflexia a) a syndrome that leads to a sudden onset of high blood pressure and can be accompanied by low heartbeats, is not uncommon. a. In fact, about fifty percent of individuals with a spinal cord injury get it. It is most common in individuals with spinal cord injuries, at, or above the thoracic (T6) nerves of the spine or above. b) When the skin or bladder is irritated, signals are sent to the spinal cord, which triggers a reflex action. This reflex tightens blood vessels below the injury, causing blood pressure to rise. c) Prevention a. Sit up when possible i. Sitting up helps blood move to lower parts of the body and helps ease blood pressure. b. Take off tight clothes i. At times, autonomic dysreflexia can be caused by skin conditions. c. Medications i. The most commonly used drugs are nifedipine (immediate release form) as well as nitrates. Other commonly used agents are prazosin, captopril, terazosin, mecamylamine, diazoxide, and phenoxybenzamine. d. Use the bathroom regularly i. While an individual's bladder will still store urine from their kidneys, their brain may not be able to control their bladder because of the injury. This can make patients more susceptible to urinary tract infections. e. Watch for bladder infection signs i. An autonomic dysreflexia episode that remains unexplained by most of the other causes can also be due to a urinary tract infection. Spinal shock injuries and how to assess
iii. Place your hand at the edge of a page to make it easy to determine the margin of a page. iv. Hold the text at a 45- to 90-degree angle so that reading is done vertically rather than horizontally. People with a right hemianopsia should read down, while those with a left hemianopsia should read up. In each case, this will keep the next line of text within the available field of vision. b. Strategies to improve navigating the environment: i. When moving through the environment, learn to direct the eyes toward the good visual field. ii. When walking into a new environment, pause and move your head from one side to another. Observe where objects and people are located. Think about painting a picture of what you see in your brain. Practicing this, particularly in the 6 months after vision loss, can help train your brain to do this automatically. iii. When looking for objects in the blind field consciously make large eye movements to that side and then let the eyes come back to the object. iv. When walking, let a partner walk on the blind side and provide his or her arm for guidance. v. When in group situations, situate people in the good field of vision as much as possible. vi. When in a theater, sit far over to the blind side so that the action takes place in the normal visual field. vii. Play real-life (not computer-based) card games and do crossword puzzles to regain coordination between vision and touch. viii. Do word search or picture search puzzles to improve eye scanning at near distances. c. Other treatment i. Prisms on glasses may help to expand the area for central vision. A prism can displace images of objects into the field of vision. ii. Some makers of computer-assisted programs claim to promote recovery of the entire field of vision. However, there are no proven studies showing such programs are effective. In addition, they are very expensive. iii. Driving a motor vehicle is hazardous for many people with homonymous hemianopsia, particularly if other neurological problems are present. Practice on a driving simulator offers a chance to regain driving skills and allows an instructor to determine if the patient is able to drive again. Prevention of myasthenic and cholinergic crises a) Myasthenic crisis a. It is a complication of a condition known as myasthenia gravis, a chronic autoimmune disorder that is characterized by rapid fatigue and weakness of voluntarily controlled muscles.
b. Symptoms
d. Increase fluid intake to 2000 mL/day.
e. Monitor for constipation. f. Promote independence along with safety measures. g. Avoid rushing the client with activities. h. Assist with ambulation and provide assistive devices. i. Instruct client to rock back and forth to initiate movement. j. Instruct the client to wear low-heeled shoes. k. Encourage the client to lift feet when walking and avoid prolonged sitting. l. Provide a firm mattress, and position the client prone, without a pillow, to facilitate proper posture. m. Instruct in proper posture by teaching the client to hold the hands behind the back to keep the spine and neck erect. n. Promote physical therapy and rehabilitation. o. Administer anticholinergic medications as prescribed to treat tremors and rigidity and to inhibit the action of acetylcholine. p. Administer antiparkinsonian medications to increase the level of dopamine in the CNS. q. Instruct the client to avoid foods high in vitamin B6 because they block the effects of antiparkinsonian medications. r. Instruct the client to avoid monoamine oxidase inhibitors because they will precipitate hypertensive crisis. Management of Guillain-Barre syndrome a) an autoimmune disease in which there is an acute inflammation of the spinal and cranial nerves manifested by motor dysfunction that predominates over sensory dysfunction. b) Symptoms a. often begins with tingling and weakness starting in your feet and legs and spreading to your upper body and arms b. Prickling, pins and needles sensations in your fingers, toes, ankles, or wrists c. Weakness in your legs that spreads to your upper body d. Unsteady walking or inability to walk or climb stairs e. Difficulty with facial movements, including speaking, chewing, or swallowing f. Double vision or inability to move eyes g. Severe pain that may feel achy, shooting or cramp like and may be worse at night h. Difficulty with bladder control or bowel function i. Rapid heart rate j. Low or high blood pressure k. Difficulty breathing c) Treatment a. Plasma exchange (plasmapheresis) i. The liquid portion of part of your blood (plasma) is removed and separated from your blood cells. The blood cells are then put back into your body, which manufactures more plasma to make up for what was removed. Plasmapheresis may work by ridding plasma of certain antibodies that contribute to the immune system's attack on the peripheral nerves.
spirometer.
c) Encourage your child to be as active as allowed. a. Your child will be asked to move around in bed and to sit up as much as he/she can. The head of the bed can be raised to help your child breathe better. Turning your child from side to side helps to prevent secretions from staying in one place in the lungs. Sometimes chest physiotherapy (CPT) may be ordered for your child. d) Encourage your child to get out of bed and walk as soon as allowed by the doctor. Different types of wound drainage and wound assessment a) Types a. Serous Drainage i. A pale yellow or transparent fluid found most frequently inside the body’s cavities
- Examples blisters, Seromucous inflammation, and Serous pulmonary alveolitis b. Sanguineous drainage i. involves solely blood that comes from a fresh wound. It usually is of a bright red color seen in partial -thickness and full-thickness wounds c. Serosanguineous drainage i. pink exudate d. Seropulent drainage i. It is also commonly named ‘’seropus’’ that is similar to serum when it comes to consistency but a bit more cloudier, yellowish in color. e. Purulent drainage i. It is often yellow, green or even brown in color, has unpleasing smell and is a sure sign that there is an infection b) Assessment a. Size, width, length and depth i. important to be measured and documented so that the progress of the wound can be measured over time. b. Undermining and tunnelling c. Wound bed tissue type i. A wound can consist of different tissue types, which can be categorized by name and/or colour. Record the percentages of the differing tissue types. d. Wound edge (margin) i. can indicate the stage of healing and provide information as to the wound aetiology. The margin type that is good to see is skin that is smooth and adheres firmly to the wound bed. Lab values of note: Sodium, Hgb, Platlet, Creatinine a) Sodium 1 35- 145 a. Low: use of diuretics, diarrhea, adrenal insufficiency b. High: kidney disease, dehydration, Cushing’s syndrome b) Hgb F: 1 2. 1 -15. 1 M: 13 .8-
