NUR 278 PN3 EXAM 2 STUDY GUIDE
PN3 Exam 2 Study Guide
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
PN3 Exam 2 Study Guide
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
