This girl is on fire
What are the three degrees (actual names)of burn?
Superficial- 1st degree
partial thickness (superficial and deep)- 2nd Degree
Full thickness- 3rd degree
What are some signs of an inhalation injury?
Burns on face or mouth
singed facial hair
sooty sputum
hoarse voice or stridor
cough or dyspnea
During evaluation for compatibility with the donor, a potential organ transplant recipient undergoes HLA matching. When explaining the importance of this test to the patient, what is the best rationale for the nurse to use?
A) This is simply a routine part of compatibility testing for all organs.
B) The higher the number of matching antigens, the lower the risk of rejection.
C) This test is used to ensure that the donor does not have an active infection.
D) HLA testing is part of the ongoing research into organ transplant success.
B) The higher the number of matching antigens, the lower the risk of rejection.
What causes postrenal AKI?
benign prostate hyperplasia, prostate cancer, calculi, trauma, tumors
A 35-year-old male client was admitted due to severe burns around his right hip. Which position is most important to use to maintain the maximum function of this joint?
B) hip at zero flexion with leg flat
The maximum function for ambulation occurs when the hip and leg are maintained at full extension with neutral rotation. Although the client does not have to spend 24 hours in this position, he or she should be in this position (in bed or standing) longer than with the hip in any degree of flexion.
What are some significant S/S that a victim from an electrical burn can experience?
arrythmias (Vfib, asys)
Cardiac arrest within first 24hrs without warning
metabolic acidosis
acute tubular necrosis
Rhabdomyolysis (due to catabolism)
What is the difference between an escharotomy and fasciotomy and why is it needed?
Escharotomy: incising through burnt skin to alleviate constriction
Fasciotomy: incising through to the muscle to alleviate constriction
Burnt skin is dead tissue that can not stretch making it susceptible to both compartment syndrome and infection
A patient has experienced brain death after a head injury and the family has consented to organ donation. In this situation, who does the nurse now recognize as managing the care of that donor?
A) Attending physician
B) Intensive care physician team
C) Registered nurse from organ procurement organization
D) Pathophysiologist from the medical examiners office
C) registered nurse from OPO
What will lab values should with AKI and CKD?
AKI- SUDDEN increase BUN and creatinine levels, increased urine specific gravity, sudden reduced GFR
CKD- slow increase in BUN and creatinine, decreased serum calcium, decreased H/H, increased phosphate, increased urine protein
Oliguria is a clinical sign of ARF that refers daily to a urine output of:
A. 1.5L
B. 1.0L
C. Less than 400ml
D. Less than 50ml
Calculate the BSA: full thickness burns on the front half of the left arm, the left half of the front of the torso, the entire front of the left leg.
Arm- 4.5% abdomen- 9% Leg- 9%
BSA=22.5%
What is something to watch out for with full thickness burns and eschar and what do you assess?
compartment syndrome
6 Ps- pain, pallor, pulselessness, poikilothermia, paresthesia, paralysis
What is the most definitive method of determining brain death?
cerebral angiogram
a procedure that uses a special dye (contrast material) and x-rays to see how blood flows through the brain
Why is chronic kidney disease hard to catch in the early stages?
Symptoms can take a while to present and it is known as a silent disease
A 40-year-old male client who was burned was admitted under your care. Assessment reveals he has crackles, respiratory rate of 40/min, and is coughing up blood-tinged sputum. What action will the nurse take first?
A) administer digoxin
B) perform chest physiotherapy
c) Monitor urine output
D)Place the client in an upright position
D) place the client in an upright position
Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out.
When does the acute phase begin, and what happens during it?
After fluid resuscitation is finished and ends with wound closure
This is when we focus on wound care, hemodynamic alterations, and early detection of complications
How long can it take for a inhalation injury to present and how long should you observe a patient for before discharge?
both are 24-48 hrs
A family member approaches the nurse caring for their gravely ill son and states, We want to donate our sons organs. What is the best action by the nurse?
a. Arrange a multidisciplinary meeting with physicians.
b. Consult the hospitals ethics committee for a ruling.
c. Notify the organ procurement organization (OPO).
d. Obtain family consent to withdraw life support.
C) notify the organ procurement organization
It is the ultimate responsibility of the organ procurement organization to approach the family and obtain consent for organ donation. The best action by the nurse is to notify the OPO.
What is the RAAS system?
works to maintain blood pressure through conserving sodium and water which decreases urinary output and increases BUN and Creatinine
A 22-year-old female client with a full-thickness burn is being discharged to home after a month in the hospital. Her wounds are minimally opened and she will be receiving home care. Which nursing diagnosis has the highest priority?
C) impaired adjustment
Recovery from a burn injury requires a lot of work on the part of the client and significant others. The client is seldom restored to her pre burn level of functioning. Adjustments to changes in appearance, family structure, employment opportunities, role, and functional limitations are only a few of the numerous life-changing alterations that must be made or overcome by the client.
If a patient presents with a burn that is blistering and extremely painful, what kind of burn do they have?
At what level do you want to keep ICP level under for full thickness burns?
below 30mmhg
The charge nurse is reviewing the status of patients in the critical care unit. Which patient should the nurse notify the organ procurement organization to evaluate for possible organ donation?
a. A 36-year-old patient with a Glasgow Coma Scale score of 3 with no activity on electroencephalogram
b. A 68-year-old male admitted with unstable atrial fibrillation who has suffered a stroke
c. A 40-year-old brain-injured female with a history of ovarian cancer and a Glasgow Coma Scale score of 7
d. A 53-year-old diabetic male with a history of unstable angina status post resuscitation
A) 36 yo with a GCS of 3
A patient with a GCS score of 3 and no activity on EEG is facing impending death. The OPO should be notified. There are no indications of impending death in any of the other patient scenarios.
What are the two types of tubular necrosis and what causes them?
Ischemic- decreased circulating blood volume (any kind of shock), damage to renal blood vessels (microscopic polyangiitis, HUS, TTP)
nephrotoxic- two causes endogenous (myoglobin and hemoglobin) and exogenous (drugs, dyes, organic solvents)
Acute renal failure caused by parenchymal damage to the glomeruli of kidney tubules results in all of the following except:
A. Decreased GFR.
B. Increased urine specific gravity.
C. Impaired electrolyte balance.
D.Progressive azotemia
B. increased urine specific gravity
What is the first burn phase, when does it start, and what are the nursing priorities?
Priorities: fluid resuscitation, pain management, nutritional status
If a patient presents to the ED with any burns to the face and neck, what order can the nurse expect to see? (what should happen within 1-2 hrs after injury?)
intubation
What are 3 clinical determinants to classify someone as being brain dead?
loss of cerebral hemisphere function
-demonstrates coma or unresponsiveness
loss of brain stem function
-absence of reflexes (cough or gag)
apnea
-absence of spontaneous breathing
initiating-This phase presents with normal urine output and usually lasts several hours and varies depending on the causative factor
Oliguric-The most common initial clinical mani- festation of AKI is oliguria, defined as a reduction in urine output less than 400 mL/day.
diuretic- In this phase, daily urine output is approximately 1 to 3 liters but can reach as high as 5 liters or more
recovery-This phase begins when the GFR increases, allowing plateau of the BUN and creatinine, then a gradual decline
On assessment, the nurse notes that the client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse’s next action?
D) prepare for intubation
Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose the effective movement of air. When this occurs, wheezing is no longer heard and neither are breath sounds. The client requires the establishment of an emergency airway. The swelling usually precludes intubation.
When would a burn patient be transferred to a burn center? (what is the criteria)
Partial thickness burns >10% BSA
Burns on face, hands, feet, genitalia, perineum, or major joints
any Full thickness, electrical, chemical
complex comorbidities
concomitant trauma with high risk of morbidity
special social, emotional, or rehab interventions requirements
What are the three types of inhalation injuries?
metabolic asphyxiation- CO or hydrogen cyanide
Upper airway injury- mouth, oropharynx, larynx
Lower airway injury- trachea, bronchioles, alveoli
The nurse is caring for an adolescent patient who is dying. The patient's parents are interested in organ donation and ask the nurse how the health care providers determine brain death. Which response by the nurse accurately describes brain death determination?
a. "If CPR does not restore a heartbeat, the brain cannot function any longer."
b. "Brain death has occurred if there is not any breathing or brainstem reflexes."
c. "Brain death has occurred if a person has flaccid muscles and does not awaken."
d. "If respiratory efforts cease and no apical pulse is audible, brain death is present."
b. "Brain death has occurred if there is not any breathing or brainstem reflexes."
How are the stages of CKD classified based off of GFR? (how many stages and what is the GFR expected)
Stage 1- 90%+
Stage 2- 89-60%
Stage 3- 59-30%
Stage 4- 29-15%
Stage 5- less than 15% (need treatment to live)
Significant nursing assessment data relevant to renal function should include information about:
A. Any voiding disorders.
B. The patient’s occupation.
C. The presence of hypertension or diabetes.
D. All of the above.
D. All of the above
What two ointments are used to treat burns and which one can penetrate eschar?
silver sulfadiazine
mafenide acetate- can penetrate eschar
What are two ways you can relieve respiratory distress in smoke inhalation injuries?
escharotomies if there is burnt tissue
early intubation
The nurse is managing a donor patient six hours prior to the scheduled harvesting of the patients organs. Which assessment finding requires immediate action by the nurse?
a. Morning serum blood glucose of 128 mg/dL
b. pH 7.30; PaCO2 38 mm Hg; HCO3 16 mEq/L
c. Pulmonary artery temperature of 97.8 F
d. Central venous pressure of 8 mm Hg
B) pH 7.30; PaCO2 38 mm Hg; HCO3 16 mEq/L
Donor management focuses on maintaining hemodynamic stability and normal laboratory parameters. Standardized order sets are usually used, and they focus on preserving organ function and viability. Immediate action is required for an arterial blood gas value of pH 7.30; PaCO2 38 mmHg; HCO3 16 mEq/L which indicates metabolic acidosis. All other values are within normal limits.
In an intrarenal AKI, what is happening with the filtering structure and why is the damage occurring?
impaired nephron functioning which compromises perfusion and filtration
Due to ischemia (acute tubular necrosis) and/or nephrotoxins (contrast dye)
The client has experienced an electrical injury of the lower extremities. Which are the priority assessment data to obtain from this client?
B) heart rate and rhythm
Electric current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate, rhythm, and ECG changes. It is also important to obtain the patient’s cardiac history, including any history of prior arrhythmias.
Using the Parkland Formula, What would be the amount of fluid needed in the first 8 hrs for a patient weighing 178lbs with 3rd degree on the front of both legs from ankle to upper thigh, and the bottom half of the torso?
BSA- 27%
Kg-80.9
Parkland formula- 4x27x80.9= 8737.2 ml
Half to be infused in first 8 hours= 4,368.6 mL
What kind of adventitious lung sounds might be auscultated in an inhalation injury patient and what kind of oxygenation should they receive?
wheezing, stridor, or crackles
HUMIDIFIED O2
The nurse is working for a hospital that holds an agreement with a local organ procurement organization (OPO). The patient has a Glasgow Coma Scale (GCS) score of 3 and discussions have been held with the family about withdrawing life support. Which statement by the nurse best describes requirements that must be met to sustain Centers for Medicare and Medicaid Services (CMS) Conditions of Participation?
a. I need to notify TransLife (OPO) of my patients impending death.
b. I will contact the physician to obtain informed consent for organ donation.
c. The charge nurse will notify TransLife (OPO) once the patient has been pronounced brain dead.
d. I need the physician to evaluate my patients suitability for organ donation.
A) I need to notify OPO of my patient's impending death
Hospitals that receive Medicare or Medicaid reimbursement must notify the local OPO in cases of impending death. It is the responsibility of the organ procurement organization, not the physician, to obtain family consent for organ donation and to evaluate the patient for potential suitability as a donor. Notification of the organ procurement organization must occur prior to death, not after the patient has been pronounced dead.
What are the causes of AKI and CKD?
AKI- dehydration, hypovolemia, surgery, infection, medications, and injury/trauma
CKD- uncontrolled diabetes or hypertension, malnutrition, polycystic kidney disease
3. Decreased levels of erythropoietin, a substance normally secreted by the kidneys, leads to which serious complication of chronic renal failure?
A. Anemia.
B. Acidosis.
C. Hyperkalemia.
D. Pericarditis.
A. anemia
due to decreased erythropoietin production could occur in patients with chronic renal failure.
What kind of dressing would you perform for a patient with partial thickness burns TBSA of greater than 30% and full thickness burns over TBSA 5% and why?
How do you assess a smoke inhalation injury?
looking for facial burns, such as loss of facial and intranasal hair as well as carbonaceous material or soot in the mouth or sputum. There may be accessory muscle usage, tachypnea, cyanosis, stridor, and rhonchi/rales/wheezing
What are the responsibilities of both nurses and NEDS during the organ donation process?
Nurses: document everything, maintain patient stability, schedule OR/OR team
NEDS: allocate/re-allocate organs, coordinate samples for pathology and transplant teams/recipients, NEDS surgical recovery staff, provide real time hospital education.
What are the S/S for AKI and CKD?
AKI- rapid onset, electrolyte imbalances, oliguria, azotemia, hypertension, decreased GFR, fluid retention
CKD- anemia, Ca and vitamin D deficiency, Oliguria, azotemia, hypertension, decreased GFR, fluid retention, Uremia
Three days after a burn injury, the client develops a temperature of 100° F, a white blood cell count of 15,000/mm3, and a white, foul-smelling discharge from the wound. The nurse recognizes that the client is most likely exhibiting symptoms of which condition?
D. Wound infection
Color change, purulent, foul-smelling drainage, increased white blood cell count, and fever could all indicate infection. Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention. Changes in sensorium, bowel habits, and respiratory rate usually precede fever and alteration of laboratory studies.