Pain
Pain that comes from bone, joint, skin, muscle or connective tissue is considered what type of pain?
Somatic
Name 3 signs/symptoms you may see in a patient who is nonverbal and cannot tell you they are experiencing pain.
Grimacing, groaning, wincing, guarding, wandering, pacing, crying, clenching teeth, fidgeting, rocking, rigid or tense posturing, aggressive behavior. Withdrawing, refusing care, refusing to eat, irritability, increased confusion, inability to sleep.
Which electrolyte imbalances place a patient at risk for cardiac arrythmias and what intervention/assessments are priority?
Potassium, Magnesium & Calcium
ECG & Cardiac Monitoring - high risk for arrythmias.
Which complication are patients diagnosed with skin conditions such as psoriasis or dermatitis most at risk for?
Infection due to break in the body's natural barrier (Think portal of entry)
Name a nursing intervention for a patient with dermatitis.
Educate - don't scratch - increases risk for infection and can open up skin. May wear mits at night.
Avoid hot baths/showers - tepid water only
Apply moisturizing creams
Infection prevention
A patient with chronic pain asks for pain medication for "severe" back pain, but they are smiling and laughing with a family member that is present and when you check their vitals they are normal. What should you do?
Provide ordered pain medication and document. The sympathetic nervous system often adapts in chronic pain so vitals may be unchanged. The patient's subjective report is the best indicator for pain.
What is the difference between acute & chronic pain?
Acute pain lasts for a shorter duration, is an indicator of tissue damage, generally resolves - the patient will experience physiological signs of pain such as changed vital signs.
Chronic pain lasts greater than 3-6 months and serves no purpose. Sympathetic nervous system often adapts so may not see signs/symptoms. Harder to manage.
How would you test for Trousseau's sign?
To test trousseau sign, inflate a blood pressure cuff around the patient's upper arm for 1 to 4 minutes. The hands and fingers will become spastic (tightens into spasm) and go into palmar flexion (hand bends down).
A skin condition that is characterized by red papules that join to form plaques with distinct borders - sometimes appearing with silvery scales.
Psoriasis
What is the cause?
Skin cells proliferating abnormally fast.
Goal of care during the emergent burn phase?
Stabilization - mainly airway maintenance and fluid resuscitation.
When using the PQRSTU assessment for a focused pain assessment, what does 'R' stand for?
Region/Radiation
When using a pain scale to evaluate pain - what are 2 important things to consider/remember?
Choose a pain scale that is specific to your patient - ensure they are able to use it.
Consistency - always assess pain using the same scale so that changes can be tracked.
Document!
Monitor electrolytes - depending on type may waste or spare electrolytes
Monitor fluid status - watch for hypovolemia
BP important prior to administration.
Educate Patient - signs and symptoms of hypovolemia, weigh themselves daily, get routine BW as ordered. (Low Bp, dizziness, low urine output, weight loss etc.)
A burn that involves all of the epidermis and only the papillae of the dermis.
Partial-thickness burn
How would we prevent contractures in a burn patient?
Encourage them to wear pressure garments as ordered and avoid positions of flexion.
You are caring for a patient who is taking regularly scheduled long-acting hydromorphone and is using a short-acting dose for breakthrough pain. You notice that over the last week the patient has been using 3-4 breakthrough doses daily and phone the physician to update him about this. What do you anticipate the physician will do?
Increase long-acting hydromorphone dose.
What is guided imagery and how is it performed.
The nurse helps the patient focus on a mental image in their mind - usually a place that brings them comfort. Have the patient focus on what they see, hear, smell, feel. This can effectively lessen the pain experienced.
What is hypervolemia? Name three potential causes and 3 potential signs/symptoms you may see in a patient experiencing hypervolemia.
Hypervolemia = fluid volume excess or fluid overload.
Causes: Kidney failure, CHF, increased intake of fluids (IV fluids), increased salt.
Signs/Symptoms: Hypertension, edema, crackles in lungs, shortness of breath, increased RR, increased work of breathing, cyanosis, weight gain, diluted urine, JVD, bounding pulses.
How would you correctly obtain a wound culture?
-Cleanse wound first with NS
-Swab entire wound diagonally back and forth 10 times applying light pressure - be sure to get edges.
What does care for a skin graft consist of?
Immobilization of the are for a short time initially to ensure graft adheres.
Frequent circulation checks (every 4 hours) of the grafted area
Monitor for bleeding underneath and signs of infection
You are caring for an elderly adult with kidney impairment who has just had abdominal surgery. You note that the patient has been prescribed a lower dose of an opioid for pain management than the 25-year-old down the hall who had the same surgery, but no comorbidities. Why would this be?
Older adults kidneys tend not to be as efficient as well as this patient's kidneys are already impaired. Therefore, the medication would not be excreted as effectively - allowing the medication to be more effective at lower doses as well as take longer to be fully excreted from the body.
You are administering an opioid medication for pain. Which assessments would be PRIORITY prior to administration of the medication to your patient.
LOC & Vitals - always before medications.
LOC - 2 reasons. You want to make sure your patient is safe to take oral medications and opioids can be sedating- you don't want to over sedate and risk aspiration if the patient vomits or inability to protect/maintain own airway.
Pay particular attention to SPO2 and respirations - remember that opioid depress the respiratory drive and often cause decreased respiration/hypoventilation.
When would you not give the med?
What is hypovolemia? Name three potential causes and 3 potential signs/symptoms you may see in a patient experiencing hypovolemia.
Hypovolemia = fluid volume deficit, or dehydration.
Causes: Poor fluid intake, vomiting, diarrhea, large wound drainage, large output (stool or urine) due to comorbidities, hemorrhage/bleeding, NG suction, excessive sweating.
Signs/Symptoms: Low blood pressure (associated dizziness & tachycardia), dry mucous membranes, thirst, tenting with skin turgor test, weight loss, weak pulses, low urine output with concentrated urine, change in LOC, may progress to impaired circulation and poor perfusion of organs leading to organ shut down (hypovolemic shock).
List at least 3 indicators of a possible inhalation injury after a burn.
Was in an enclosed space (such as a burning house)
Hoarse voice
Low SPO2, cyanosis, resp distress, coughing
Coughing up soot or blowing soot out of the nose
Facial burns or soot around the nose and mouth
Restlessness or change in LOC - early indicator for hypoxia
Which stage of burn recovery would focus on closure of wounds?
Acute stage