PN3 Exam 2 Study Guide
ALL SOLUTION 100%
CORRECT SPRING
FALL-2022
GUARANTEED GRADE
A+
Priority intervention for a client with burn injuries in resuscitation phase
o Administer analgesics
o Prevent infection
o Fluid replacement
Prevention of ventilator associated pneumonia:
o Adherence to proper hand hygiene
o Administer anti-ulcer meds
o HOB elevated at least 30 degrees
o Oral care
o Handwashing
Ventilator Bundle: greatly reduced the overall incidence of VAP
• Oral care is the key component of VAP prevention
Possible PE signs and symptoms
o Chest pain when breathing in
o Dizziness
o Tachycardia
Care of a patient on mechanical ventilation: assess the patient’s respiratory status and gas
exchange at least every 4 hours for the first 24 hours
DVT Risk Factors
• Dehydration
• Prolonged immobility
• Prolonged travel
• Central venous catheters
• Surgery
• Obesity
• Advancing age
• Increased blood clotting
• Hx of thromboembolism
Why would a patient on mechanical ventilation get Ranitidine?
o Prevents ulcers from the stress of the ventilation, specifically Curling’s ulcers
, Flail chest S/S: chest wall does not appear to be moving normally with respiration, oxygen
saturation is low (82%) and cyanotic; must prepare for intubation
• Occurs when 2 or more ribs are fractured in 2 or more places and are no longer attached
to the thoracic cage
• Interventions focus on ensuring adequate oxygenation, administration of fluids, and
analgesia to improve ventilation, 100% oxygen by non-rebreather
Escharotomy: treatment of circumferential burns; slicing parts of the body through the eschar to
release pressure and pain
Signs and Symptoms of Compartment Syndrome
• Color of tissue is pale and cyanotic
• Edema
• Pain
• Parathesia
• Weak pulse
• Numbness/tingling
• Necrosis
• Pain that is unrelieved with analgesics
Parkland Formula: 4mL x kg x %TBSA for adults
Rule of 9’s:
• Head: 9%
• Right arm 9%
• Left arm 9%
• Right leg 9%
• Left leg 9%
• Anterior trunk 18%
• Posterior trunk 18%
• Genitalia 1%
Secondary Survey: begins when the primary survey is completed, potentially life-threatening
injuries identified, and resuscitation has been initiated
• During this time procedures such as ECGs, radiographic studies, ultrasounds, and
insertion of gastric and urinary catheters are done
• AMPLE
o Allergies
o Medications currently being taken
o Past medical illness/pregnancy
o Last meal
o Events/environment r/t injury
Burns in children: parkland formula is used; 2-4mL/kg for body surface area burn; 2 is for
children, 4 is for adults
• Death rate higher in children younger than 4
Superficial Thickness
• Involves injury to the epidermis; the blood supply to the dermis is still intact
• Mild to severe erythema (pink to red) is present, NO blisters
ALL SOLUTION 100%
CORRECT SPRING
FALL-2022
GUARANTEED GRADE
A+
Priority intervention for a client with burn injuries in resuscitation phase
o Administer analgesics
o Prevent infection
o Fluid replacement
Prevention of ventilator associated pneumonia:
o Adherence to proper hand hygiene
o Administer anti-ulcer meds
o HOB elevated at least 30 degrees
o Oral care
o Handwashing
Ventilator Bundle: greatly reduced the overall incidence of VAP
• Oral care is the key component of VAP prevention
Possible PE signs and symptoms
o Chest pain when breathing in
o Dizziness
o Tachycardia
Care of a patient on mechanical ventilation: assess the patient’s respiratory status and gas
exchange at least every 4 hours for the first 24 hours
DVT Risk Factors
• Dehydration
• Prolonged immobility
• Prolonged travel
• Central venous catheters
• Surgery
• Obesity
• Advancing age
• Increased blood clotting
• Hx of thromboembolism
Why would a patient on mechanical ventilation get Ranitidine?
o Prevents ulcers from the stress of the ventilation, specifically Curling’s ulcers
, Flail chest S/S: chest wall does not appear to be moving normally with respiration, oxygen
saturation is low (82%) and cyanotic; must prepare for intubation
• Occurs when 2 or more ribs are fractured in 2 or more places and are no longer attached
to the thoracic cage
• Interventions focus on ensuring adequate oxygenation, administration of fluids, and
analgesia to improve ventilation, 100% oxygen by non-rebreather
Escharotomy: treatment of circumferential burns; slicing parts of the body through the eschar to
release pressure and pain
Signs and Symptoms of Compartment Syndrome
• Color of tissue is pale and cyanotic
• Edema
• Pain
• Parathesia
• Weak pulse
• Numbness/tingling
• Necrosis
• Pain that is unrelieved with analgesics
Parkland Formula: 4mL x kg x %TBSA for adults
Rule of 9’s:
• Head: 9%
• Right arm 9%
• Left arm 9%
• Right leg 9%
• Left leg 9%
• Anterior trunk 18%
• Posterior trunk 18%
• Genitalia 1%
Secondary Survey: begins when the primary survey is completed, potentially life-threatening
injuries identified, and resuscitation has been initiated
• During this time procedures such as ECGs, radiographic studies, ultrasounds, and
insertion of gastric and urinary catheters are done
• AMPLE
o Allergies
o Medications currently being taken
o Past medical illness/pregnancy
o Last meal
o Events/environment r/t injury
Burns in children: parkland formula is used; 2-4mL/kg for body surface area burn; 2 is for
children, 4 is for adults
• Death rate higher in children younger than 4
Superficial Thickness
• Involves injury to the epidermis; the blood supply to the dermis is still intact
• Mild to severe erythema (pink to red) is present, NO blisters
