[Type here]
NURS MISC / med surg 2 final
Chapters 14
The irreversible stage=use of mechanical ventilation, altered consciousness, and profound acidosis.
The compensation stage = decreased urinary output, confusion, and respiratory alkalosis.
BP normal
respirations are above 20
heart rate is above 100 but below 150
serum sodium and blood glucose levels are elevated
The progressive stage =metabolic acidosis, lethargy, and rapid, shallow respirations.
BP can no longer compensate
the MAP falls below normal limits.
Patients are clinically hypotensive;
SBP of less than 90 mm Hg
four main categories of shock are
hypovolemic
CVP reading is typically low in hypovolemic shock.
circulatory (distributive),
obstructive,
cardiogenic, depending on the cause
Vasoactive medications
should be administered through a central venous line, because infiltration and extravasation of some
vasoactive medications can cause tissue necrosis and sloughing. An IV pump must be used to ensure that
the medications are delivered safely and accurately. These medications are not given by IM or by rapid IV
push.
neurogenic shock.
parasympathetic stimulation.
the client flat and elevates his or her feet.
s/sx dry, warm skin, bradycardia, hypotension
,[Type here]
NURS MISC / med surg 2 final
cardiogenic shock.
Treatment : Sodium nitroprusside
Chapters 62- Burn
Lactated Ringer's solution= replaces lost sodium and corrects metabolic acidosis, both of which
commonly occur following a burn.
Albumin is used as adjunct therapy, not as primary fluid replacement.
D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client
is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving
potassium would be detrimental.
Acticoat
moistened with sterile water only; never use normal saline.
Do not use topical antimicrobials with Acticoat burn dressing.
Keep Acticoat moist, not saturated.
deep partial-thickness burn injuries,
recovery is expected in 2 to 4 weeks.
pulmonary damage from an inhalation injury?
singed nasal hair,
hoarseness,
voice change,
stridor,
burns of the face or neck,
sooty or bloody sputum,
tachypnea.
,[Type here]
NURS MISC / med surg 2 final
dressing change at the site of an autograf t is performed how soon after the surgery?
2 to 5 days after surgery.
foul odor or purulence may indicate infection and should be reported to the surgeon immediately.
Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation
postoperatively.
Homografts are skin obtained from recently deceased or living humans other than the client. biologic
dressings and are intended to be temporary wound coverage.
Xenografts = skin taken from animals (usually pigs). biologic dressings and are intended to be temporary
wound coverage.
Expected outcomes of fluid resuscitation
urine output between 0.5 and 1.0 mL/kg/hr (30–50 mL/hr;
75 to 100 mL/hr if electrical burn injury),
mean arterial pressure (MAP) pressure > 60 mm Hg,
voids clear yellow urine with specific gravity within normal limits,
serum electrolytes are within normal limits
The greatest volume of fluid loss occurs
first 24 to 36 hours after the burn
, peaking by 6 to 8 hours.
The key sign of the onset of acute respiratory distress syndrome (ARDS)
hypoxemia
zone of coagulation ( inner ) = at the center of the injury and is the area of injury that is most severe and
the deepest. Where cellular death occur.
zone of stasis ( middle)= the area of intermediate burn injury. compromised blood supply, inflammation,
and tissue injury
zone of hyperemia (outer zone) =the area of least injury, where the epidermis and dermis are only
minimally damaged.
,[Type here]
NURS MISC / med surg 2 final
Biobrane is a nylon-silicone membrane coated with a protein.
Mederma ia a topical gel that can reduce scarring.
Integra consists of a two-layer membrane: one is a synthetic epidermal layer , and the other contains
cross-linked collagen fibers that mimic the dermal layer of skin.
Transcyte is created by culturing human fibroblasts from the dermis with a biosynthetic semipermeable
membrane attached to nylon mesh.
Natural debridement =nonliving tissue sloughs away from uninjured tissue.
Mechanical debridement = use of surgical tools to separate and remove the eschar.
Enzymatic debridement= encompasses the use of topical enzymes to the burn wound.
Surgical debridement = use of forceps and scissors during dressing changes or wound cleaning.
The ABA consensus formula
WT;80kg
Burn 30%
Given 50% first 8 hours? What is the amount first 8 hrs?
first 24 hours in a range of 2 to 4 mL/kg/percentage TBSA
Half of the calculated total should be given over the first 8 postburn hours
, and the other half should be given over the next 16 hours.
:2 mL × 80 kg × 30 = 4,800 mL of solution to be administered in the first 24 hours,
4800/2=2,400 mL, to be administered in the first 8 hours.
clothing is on fire,
placed in a horizontal position
rolled in a blanket to smother the fire.
NURS MISC / med surg 2 final
Chapters 14
The irreversible stage=use of mechanical ventilation, altered consciousness, and profound acidosis.
The compensation stage = decreased urinary output, confusion, and respiratory alkalosis.
BP normal
respirations are above 20
heart rate is above 100 but below 150
serum sodium and blood glucose levels are elevated
The progressive stage =metabolic acidosis, lethargy, and rapid, shallow respirations.
BP can no longer compensate
the MAP falls below normal limits.
Patients are clinically hypotensive;
SBP of less than 90 mm Hg
four main categories of shock are
hypovolemic
CVP reading is typically low in hypovolemic shock.
circulatory (distributive),
obstructive,
cardiogenic, depending on the cause
Vasoactive medications
should be administered through a central venous line, because infiltration and extravasation of some
vasoactive medications can cause tissue necrosis and sloughing. An IV pump must be used to ensure that
the medications are delivered safely and accurately. These medications are not given by IM or by rapid IV
push.
neurogenic shock.
parasympathetic stimulation.
the client flat and elevates his or her feet.
s/sx dry, warm skin, bradycardia, hypotension
,[Type here]
NURS MISC / med surg 2 final
cardiogenic shock.
Treatment : Sodium nitroprusside
Chapters 62- Burn
Lactated Ringer's solution= replaces lost sodium and corrects metabolic acidosis, both of which
commonly occur following a burn.
Albumin is used as adjunct therapy, not as primary fluid replacement.
D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client
is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving
potassium would be detrimental.
Acticoat
moistened with sterile water only; never use normal saline.
Do not use topical antimicrobials with Acticoat burn dressing.
Keep Acticoat moist, not saturated.
deep partial-thickness burn injuries,
recovery is expected in 2 to 4 weeks.
pulmonary damage from an inhalation injury?
singed nasal hair,
hoarseness,
voice change,
stridor,
burns of the face or neck,
sooty or bloody sputum,
tachypnea.
,[Type here]
NURS MISC / med surg 2 final
dressing change at the site of an autograf t is performed how soon after the surgery?
2 to 5 days after surgery.
foul odor or purulence may indicate infection and should be reported to the surgeon immediately.
Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation
postoperatively.
Homografts are skin obtained from recently deceased or living humans other than the client. biologic
dressings and are intended to be temporary wound coverage.
Xenografts = skin taken from animals (usually pigs). biologic dressings and are intended to be temporary
wound coverage.
Expected outcomes of fluid resuscitation
urine output between 0.5 and 1.0 mL/kg/hr (30–50 mL/hr;
75 to 100 mL/hr if electrical burn injury),
mean arterial pressure (MAP) pressure > 60 mm Hg,
voids clear yellow urine with specific gravity within normal limits,
serum electrolytes are within normal limits
The greatest volume of fluid loss occurs
first 24 to 36 hours after the burn
, peaking by 6 to 8 hours.
The key sign of the onset of acute respiratory distress syndrome (ARDS)
hypoxemia
zone of coagulation ( inner ) = at the center of the injury and is the area of injury that is most severe and
the deepest. Where cellular death occur.
zone of stasis ( middle)= the area of intermediate burn injury. compromised blood supply, inflammation,
and tissue injury
zone of hyperemia (outer zone) =the area of least injury, where the epidermis and dermis are only
minimally damaged.
,[Type here]
NURS MISC / med surg 2 final
Biobrane is a nylon-silicone membrane coated with a protein.
Mederma ia a topical gel that can reduce scarring.
Integra consists of a two-layer membrane: one is a synthetic epidermal layer , and the other contains
cross-linked collagen fibers that mimic the dermal layer of skin.
Transcyte is created by culturing human fibroblasts from the dermis with a biosynthetic semipermeable
membrane attached to nylon mesh.
Natural debridement =nonliving tissue sloughs away from uninjured tissue.
Mechanical debridement = use of surgical tools to separate and remove the eschar.
Enzymatic debridement= encompasses the use of topical enzymes to the burn wound.
Surgical debridement = use of forceps and scissors during dressing changes or wound cleaning.
The ABA consensus formula
WT;80kg
Burn 30%
Given 50% first 8 hours? What is the amount first 8 hrs?
first 24 hours in a range of 2 to 4 mL/kg/percentage TBSA
Half of the calculated total should be given over the first 8 postburn hours
, and the other half should be given over the next 16 hours.
:2 mL × 80 kg × 30 = 4,800 mL of solution to be administered in the first 24 hours,
4800/2=2,400 mL, to be administered in the first 8 hours.
clothing is on fire,
placed in a horizontal position
rolled in a blanket to smother the fire.
