Nsg241 Study Guide Exam 5

8/15/2019 Nsg241 Study Guide Exam 5

1/76

STUDY GUIDE EXAM 5

Understand the concept of triage in Emergency nursing

Triage system: categorizes patients so most critical are treated first

Emergency Seerity Inde!:

"ie#leel triage system t$at incorporates illness seerity and reso%rce

%tilization

T$e ESI incl%des a triage algorit$m t$at directs yo% to assign an ESI leel

to patients presenting to t$e ED&

Be familiar with the ESI triage system.

Color coding system, and priority/emergent, etc. classifications. Know clinical examples of

each of these.


2/76

'olor( )ords or n%m*ers sorting system

'olors: +ed,emergent( yello),%rgent( Green,non#%rgent

-%m*ers: .riority I,emergent( priority II,%rgent( .riority III,non#%rgent

Emergent

/ife,lim*( or eye t$reatening0 needs immediate attention

Tra%ma( c$est pain( cardiac arrest( seere respiratory distress( c$emicals in t$e eyes( lim*

amp%tation( ac%te ne%rological deficits

Urgent

-eeds treatment in 12 min%tes to 1 $o%rs

"eer 3 42 "( diastolic 6. 3 472 mm 8g( 9idney stone( simple fract%re( a*dominal pain( andast$ma,no respiratory distress

-on#%rgent

'an )ait $o%rs or days

Sprain( minor laceration( cold symptoms( ras$( simple 8A

hat is primary and secondary sur!ey"


3/76

Emergency -%rsing

Primary survey focuses on airway, breathing, circulation, and disability,

exposure (ABCDE

Identifies life#t$reatening conditions

If life#t$reatening conditions related to A6'D are identified d%ring primary s%rey( interentions

are started immediately and *efore proceeding to t$e ne!t step of t$e s%rey

.rimary S%rey

Air)ay )it$ cerical spine sta*ilization and,or immo*ilization #

-early all immediate tra%ma deat$s occ%r *eca%se of air)ay o*str%ction&


4/76

Salia( *loody secretions( omit%s( laryngeal tra%ma( dent%res( facial tra%ma( fract%res(

and t$e tong%e can o*str%ct t$e air)ay&

.atients at ris9 for air)ay compromise incl%de t$ose )$o $ae seiz%res( near#dro)ning(

anap$yla!is( foreign *ody o*str%ction( or cardiop%lmonary arrest&

Signs,symptoms in patient )it$ compromised air)ay

Dyspnea

Ina*ility to ocalize

.resence of foreign *ody in air)ay

Tra%ma to face or nec9

Maintain airway: least to most invasive method

;pen air)ay %sing t$e


5/76

Insert intraeno%s =I>? lines into eins in t$e %pper e!tremities %nless

contraindicated( s%c$ as in a massie fract%re or an in.U

A C alert

> C responsie to oice

. C responsie to pain

U C %nresponsie

Glasgo) 'oma Scale

.%pils

E!pos%re,enironmental control # ;nce t$e patient is e!posed( it is important to limit $eat loss(

preent $ypot$ermia( and maintain priacy *y %sing )arming *lan9ets( oer$ead )armers( and

)armed I> fl%ids&+emoe clot$ing to perform p$ysical assessment&

.reent $eat loss&

At this point, determine whether to proceed with the secondary survey or perform additional

interventions.

Secondary Sur!ey $ull set of !ital signs/$i!e inter!entions/$acilitate family

presence

'omplete set of ital signs

6lood press%re =*ilateral?

8eart rate

+espiratory rate

;!ygen sat%ration

Temperat%re

!econdary !urvey

"ive interventions -T$ese foc%sed ad


6/76

"acilitate family presence .atients report t$at $aing caregiers present comforts t$em0

caregiers sere as adocates for t$em and $elp to remind t$e $ealt$ care team of t$eir

person$ood&

"amily presence: family mem*ers )$o )is$ to *e present d%ring inasie

proced%res,res%scitation ie) t$emseles as participants in care

T$eir presence s$o%ld *e s%pported&

#ive comfort measures$ General comfort meas%res s%c$ as er*al reass%rance( listening(

red%cing stim%li =e&g&( dimming lig$ts?( and deeloping a tr%sting relations$ip )it$ t$e patient

and caregier s$o%ld *e proided to all patients in t$e ED&

.ain management strategiesF com*ination of

.$armacologic meas%res

-onp$armacologic meas%res

%istory and head&to&toe assessment'

;*tain $istory of eent( illness( in


7/76

#Eal%ate need for tetan%s prop$yla!is&

rovide ongoing monitoring, and evaluate patient!s response to interventions.

Prepare to '

Transport for diagnostic tests =e&g&( !#ray?

Admit to general %nit( telemetry( or intensie care %nit

Transfer to anot$er facility

#T$e n%rse may accompany critically ill patients on transports&

#T$e n%rse is responsi*le for monitoring t$e patient d%ring transport( notifying t$e $ealt$

care team s$o%ld t$e patientBs condition *ecome %nsta*le( and initiating *asic and

adanced life#s%pport meas%res as needed&

H$at are t$e differences *et)een t$e t)o s%reys H$at assessments occ%r )it$in eac$ s%reyH$at interentions occ%r )it$in eac$ s%rey Jno) clinical e!amples for eac$ s%rey&

hat happens when there has )een a death in the E*"

M%st recognize importance of $ospital rit%als in preparing t$e *ereaed to griee&

T$ese can incl%de collecting t$e *elongings( arranging for an a%topsy( ie)ing t$e *ody(

and ma9ing mort%ary arrangements&

H$eneer possi*le( proide an area for priacy( and( if appropriate( arrange for a isit

from a c$aplain&

Determine if patient co%ld *e candidate for nonK$eart *eating donation&Tiss%es and organs =e&g&( corneas( $eart ales( s9in( *one( and 9idneys? can *e $arested from

patient after deat$&

Approac$ing caregiers a*o%t donation after an %ne!pected deat$ is distressing to *ot$

t$e staff and t$e caregiers& "or many( $o)eer( t$e act of donation may *e t$e first

positie step in t$e grieing process&

"rgan procurement organi#ations =;.;s? are aaila*le to assist in t$e process of

screening potential donors( co%nseling donor families( o*taining informed consent( and

$aresting organs from patients )$o are on life s%pport or )$o die in t$e ED&

hat are the gerontologic considerations in the Emergency +epartment"

Elderly are at $ig$ ris9 for in


8/76

T$e t$ree most common ca%ses of falls in t$e elderly are generalized )ea9ness(

enironmental $azards =e&g&( loose mats( f%rnit%re?( and ort$ostatic $ypotension

=e&g&( side effect of medications( de$ydration?&

'a%ses

Generalized )ea9ness

Enironmental $azards

;rt$ostatic $ypotension

hat is heat exhaustion"

• .rolonged e!pos%re to $eat oer $o%rs or days

• T$is occ%rs )$en t$ermoreg%latory mec$anisms s%c$ as s)eating( asodilation( and

increased respirations cannot compensate for e!pos%re to increased am*ient

temperat%res&

• Stren%o%s actiities in $ot or $%mid enironments( clot$ing t$at interferes )it$

perspiration( $ig$ feers( and pree!isting illnesses predispose indiid%als to $eat stress&

• /eads to $eat e!$a%stion

•

hat are the clinical manifestations of heat exhaustion"

"atig%e

/ig$t#$eadedness

-a%sea,omiting

Diarr$ea "eelings of impending doom

Tac$ypnea

Tac$ycardia

Dilated p%pils

Mild conf%sion

As$en color

.rof%se diap$oresis

8ypotension and mild to seere temperat%re eleation =NN&O to 42O " P7Q&5O to

2O 'R? d%e to de$ydration $eat e%haustion usually occurs in individuals engaged in strenuous activity in hot, humid

weather, but it also occurs in sedentary individuals.

hat are the treatments for heat exhaustion"

.lace patient in cool area and remoe constrictie clot$ing&


9/76

.lace moist s$eet oer patient to decrease core temperat%re&

.roide oral fl%id&

+eplace electrolytes&

Initiate normal saline I> sol%tion if oral sol%tions are not tolerated&

• Monitor the patient for A&'s, including cardiac dysrhythmias (due to electrolyte

imbalances).

• *alt tablets are not used because of potential gastric irritation and hypernatremia.

• 'onsider hospital admission for the elderly, the chronically ill, and those who do not

improve within + to hours.

hat are the differences )etween heat stroe and heat exhaustion"

hat are the special considerations concerning the elderly and heat related issues"

Elderly $ae decreased a*ility to perspire( less s%* tiss%e( as )ell as decreased a*ility

to asodilate( decreased t$irst mec$anism( diminis$ed a*ility to concentrate %rine( maynot drin9 eno%g$ )ater

Tend to 9eep )indo)s closed

hat is heat stroe"

$eatstroe is the most serious form of heat stress.


10/76

/he patient has core temperature greater than 012 3 (12 '), altered mentation,

absence of perspiration, and circulatory collapse. /he sin is hot, dry, and ashen.

'erebral edema and hemorrhage may occur as a result of direct thermal in4ury to the

brain and decreased cerebral blood flow.

"ail%re of t$e $ypot$alamic t$ermoreg%latory processes

>asodilation( increased s)eating( and respiratory rate deplete fl%ids and electrolytes(

specifically sodi%m&

S)eat glands stop f%nctioning( and core temperat%re increases =342O " P2O 'R?&

hat are the clinical manifestations of heat stroe"

A/I56/ I* 7ARM A68 8R9 7I/$ A /5M 01.1 "R 1.1

hat are the treatments for heat stroe"

Treatment: sta*ilize patientBs A6's and rapidly red%ce temperat%re

'ooling met$ods

+emoe clot$ing&

'oer )it$ )et s$eets&

.lace patient in front of large fan&

Immerse in ice )ater *at$&

Administer cool fl%ids or laage )it$ cool fl%ids&

Administration of 011; "< compensates for the patient!s hypermetabolic state. =entilation with

a &=M or intubation and mechanical ventilation may be required.

S$iering: increases core temperat%re( complicates cooling efforts

Aggressie temperat%re red%ction %ntil core temperat%re reac$es 421O " =7&NO '?

Monitor for signs of r$a*domyolysis( myoglo*in%ria( and disseminated intraasc%lar

coag%lation& /he muscle breadown leads to myoglobinuria, which places the idneys at

ris for acute failure.

hat is hypothermia" hat are the clinical manifestations"

8ypot$ermia

'ore temperat%re N5O " =75O '?

+is9 factors

Elderly

'ertain dr%gs

Alco$ol

Dia*etes

'ore temperat%re O " =72O '? is potentially life#t$reatening&


11/76

7et clothing increases evaporative heat loss to > times greater than normal? immersion

in cold water (e.g., near drowning) increases evaporative heat loss to times greater

than normal. $ypothermia mimics cerebral or metabolic disturbances causing ata%ia, confusion, and

withdrawal, so the patient may be misdiagnosed.

Know the difference )etween mild, moderate and se!er hypothermia.

Mild $ypot$ermia =N7&1O to N&O "

P7O to 7O 'R?

S$iering

/et$argy

'onf%sion

+ational to irrational *e$aior

Minor $eart rate c$anges

Moderate $ypot$ermia =O to N7&1O " P72O to 7O 'R?

+igidity

6radycardia( *radypnea

6lood press%re *y Doppler

Meta*olic and respiratory acidosis

8ypoolemia

S$iering disappears at temperat%re

O " =72O '?&

Seere $ypot$ermia =O " P72O 'R? ma9es t$e person appear dead&

6radycardia

Asystole

>entric%lar fi*rillation

Metabolic rate, heart rate, and respirations are so slow that they may be difficult to detect.

Refle%es are absent and pupils fi%ed and dilated

Know treatment differences for each.

Harm patient to at least N2O " =71&1O '? *efore prono%ncing dead&

'a%se of deat$Frefractory entric%lar fi*rillation

Treatment of $ypot$ermia

Manage and maintain A6's&


12/76

+e)arm patient&

'orrect de$ydration and acidosis&

Treat cardiac dysr$yt$mias&

Mild $ypot$ermia: passie or actie e!ternal re)arming .assie e!ternal re)arming: Moe patient to )arm( dry place0 remoe damp

clot$ing0 place )arm *lan9ets on patient&

Actie e!ternal re)arming:

*ody#to#*ody contact( fl%id# or

air#filled )arming *lan9ets( radiant $eat lamps

@entle handling is essential to prevent stimulation of the cold myocardium.

'losely monitor the patient for mared vasodilation and hypotension during rewarming.

Moderate to seere $ypot$ermia: actie core re)arming

Use of $eated( $%midified o!ygen

Harmed I> fl%ids

.eritoneal( gastric( or colonic laage )it$ )armed fl%ids

'onsider cardiopulmonary bypass or continuous arteriovenous rewarming in severe

hypothermia.

Know implications in!ol!ed in rewarming.

+is9s of re)arming

Afterdrop( a f%rt$er drop in core temperat%re

8ypotension

Dysr$yt$mias

+e)arming s$o%ld *e discontin%ed

once t$e core temperat%re reac$es N5O " =75O '?&

hat is su)mersion in-ury"

Dro)ning: deat$ from s%ffocation after s%*mersion in fl%id

Immersion syndrome occ%rs )it$ immersion in cold )ater( )$ic$ leads to

stim%lation of t$e ag%s nere and potentially fatal dysr$yt$mias&

-ear#dro)ning: s%rial from potential dro)ning


13/76

hat are the differences )etween actual drowning, immersion syndrome and near

drowning" ow does treatment differ for these"

-ear dro)ning

Delayed p%lmonary edema All ictims of near dro)ning s$o%ld *e o*sered for # $o%rs

S%*mersion In


14/76

'omplications can develop in patients who are essentially free of symptoms immediately after

the near-drowning episode. /his secondary drowning refers to delayed death from drowning due

to pulmonary complications.

Know and understand tic )ites, tic paralysis, and treatment. Know and understand )ee

stings, medical emergency associated with )ee stings and treatment.

hat is the difference )etween human and animal )ites" hat complications are seen with

each" hich age group is most suscepti)le to each type of )ite" hat treatments would )e

gi!en for )ites"

Animal 6ites

'$ildren at greatest ris9

Animal *ites from dogs and cats are most common( follo)ed *y *ites from )ild or

domestic rodents&

'omplications Infection

Mec$anical destr%ction of s9in( m%scle( tendons( *lood essels( *one

5very year, more than > million animal bites are reported in the Bnited *tates.

/he bite may cause a simple laceration or may be associated with crush in4ury, puncture wound,

or tearing of multiple layers of tissue.

Initial treatment: clean )it$ copio%s irrigation( de*ridement( tetan%s prop$yla!is( and

analgesics

.rop$ylactic anti*iotics for *ites at ris9 for infection

Ho%nds oer


15/76

+a*ies prop$yla!is essential in management of animal *ites

Initial in


16/76

Administration of cathartics, whole-bowel irrigation, hemodialysis, urine alalini#ation,

chelating agents, and antidotes promote the elimination of poisons.

.oisonings

Decreasing a*sorption

Gastric laage

Int%*ate *efore laage if altered leel of conscio%sness or diminis$ed gag

refle!

.erform laage )it$in 1 $o%rs of ingestion of most poisons&

'ontraindicated

'a%stic agents

'o#ingested s$arp o*


17/76

.oisonings

En$ance elimination&

'at$artics =e&g&( sor*itol?

Gie )it$ first dose of c$arcoal to stim%late intestinal motility,increase

elimination& H$ole#*o)el irrigation

7hole-bowel irrigation can be effective for swallowed ob4ects such as cocaine-filled balloons or

condoms, and heavy metals such as lead and mercury.

ow do the E* personnel address the patient who has attempted suicide"

M%st *e eal%ated *y mental $ealt$ proider

Screening tool e!ists to identify t$ose at ris9 for s%icide and,or repeat attempts

ow do the E* personnel address !iolence that occurs within families and domestic

situations"

>iolence

Acting o%t of emotions =e&g&( fear or anger? to ca%se $arm to someone or somet$ing

;rganic disease

.syc$osis

Antisocial *e$aior

/he patient cared for in the 58 may be the victim of violence or the perpetrator of violence.=iolence can tae place in a variety of settings, including the home, community, and worplace.

58s have been identified as high-ris areas for worplace violence.

"amily and Intimate .artner >iolence

.attern of coercie *e$aior in a relations$ip0 inoles fear( $%miliation( intimidation(

neglect( and,or intentional p$ysical( emotional( financial( or se!%al in


18/76

Ma9e referrals&

.roide emotional s%pport&

Inform ictims a*o%t options&

Domestic >iolenceIntimate partner iolence incl%ding se!%al assa%lt

V-%rse stays )it$ client

VHritten consent to collect eidence incl%ding p$otos

V.olice report patient decision

V'$ildren and %lnera*le ad%ltBs e!ception =mandatory reporting?

ow is the sexual assault !ictim helped in the E*"

'risis interention *egins immediately

.atient is seen immediately 'ollection of forensic eidence

Specially trained n%rses0 se!%al assa%lt n%rse e!aminer =SA-E?

atients reaction to rape? rape trauma syndrome

hat is terrorism" ow do the E* personnel address persons affected )y terrorism" hat

are the most commonly expected agents that would )e used in a terrorist attac and how

will the E* personnel prepare and treat persons in these situations"

Terrorism # Ta*le N#41

Inoles oert actions for t$e e!pressed p%rpose of ca%sing $arm

Disease pat$ogens =e&g&( *ioterrorism?

'$emical agents

+adiologic,n%clear( e!plosie deices

6ioterrorism

Ant$ra!( plag%e( and t%laremia: treated )it$ anti*iotics( ass%ming s%fficient s%pplies and

nonresistant organisms

Smallpo! can *e preented or ameliorated *y accination een )$en first gien after

e!pos%re&

Agents most liely to be used in a terrorist attac are anthra%, smallpo%, botulism, plague,

tularemia, and hemorrhagic fever.

&otulism is treated with antito%in.

6o treatment has been established for most viruses that cause hemorrhagic fever.


19/76


20/76

hat is a mass casualty incident"

Manmade or nat%ral eent or disaster t$at oer)$elms comm%nityBs a*ility to respond

)it$ e!isting reso%rces

M'Is usually involve large numbers of victims, physical and emotional suffering, and permanent

changes within a community.

In addition, M'Is always require assistance from people and resources outside the affected

community (e.g., American Red 'ross, 3ederal 5mergency Management Agency F35MAG).

hat is the difference )etween the military and the ci!ilian model and how does this

impact treatment during a mass casualty"

Military model

T$ose )it$ t$e least serio%s )o%nds may *e t$e first treatment priority'iilian model =Mass cas%alty( disaster?

T$ose )it$ t$e most serio%s *%t realistically salagea*le in


21/76

/riage of victims of an emergency or M'I must be rapid and conducted in less than 0> seconds.

In general, two thirds of victims will be tagged green or yellow, and the remaining will be tagged

red, blue, or blac.

Green

Minor in


22/76

Emergency and Mass 'as%alty Incident .reparedness

Total n%m*er of cas%alties a $ospital can e!pect is estimated *y do%*ling n%m*er of

cas%alties t$at arrie in first $o%r&

Generally( 72@ )ill re%ire admission to $ospital( and $alf of t$ese )ill need

s%rgery )it$in $o%rs&

'ritical incident stress de*riefing


23/76

.romote effectie coping strategies to aoid .TSD or professional *%rn o%t

Gro%p leader enco%rages gro%p disc%ssion *y as9ing a series of %estions designed to

ma9e eeryone inoled tell $is or $er o)n story and e!plain t$e personal impact&

8elps place incident in perspectie and dispel any feelings of *lame or g%ilt

WWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWW

WWWWW

hat is a )urn"

A burn occurs when there is in4ury to the tissues of the body caused by heat, chemicals,

electric current, or radiation. /he resulting effects are influenced by temperature of the

burning agent, duration of contact time, and type of tissue that is in4ured.

An estimated >11,111 Americans see medical care each year for burns.

Appro%imately 1,111 people are hospitali#ed, one half of whom require care in

speciali#ed burn centers.

About 111 Americans die annually as a direct result of their burns.

/he highest fatality rates occur in children years of age and younger, and in adults over

the age of C>.

Although burn incidence has decreased over the past few years, burn in4uries still occur

too frequently, and most should be viewed as preventable. /he focus of burn prevention

programs has shifted from concentrating on individual blame and changing individual

behaviors to include more legislative changes.

/he aim of these changes is to mae improvements in the environment. 'oordinated

national programs include child-resistant lighters, nonflammable children!s clothing, tap

water anti-scald devices, fire-safe cigarettes, stricter building codes, hard-wired smoe

detectorsHalarms, and fire sprinlers.

9ou can advocate for burn ris reduction strategies in the home. 9ou also can educate

worers to reduce burn in4uries in the wor setting.

ho are most at ris"

• 8ig$ +is9 .op%lations


24/76

Yo%ng c$ildren( older ad%lts( dr%g or alco$ol a*%sers( c$ronically ill or de*ilitated( or

t$ose )or9ing $ig$ ris9


25/76

• 'ar*on mono!ide =';? poisoning

• '; is prod%ced *y t$e incomplete com*%stion of *%rning

materials&

• In$aled '; displaces o!ygen&

• 8ypo!ia

• 'ar*o!y$emoglo*inemia

• Deat$

• *moe and inhalation in4uries result from the inhalation of hot air or

no%ious chemicals and can cause damage to the tissues of the respiratory

tract. 3ortunately, gases are cooled to body temperature before they reach

the lung tissue.

• Although damage to the respiratory mucosa can occur, it seldom happens

because the vocal cords and glottis close as a protective mechanism.

Redness and airway swelling (edema) may result when damage occurs.

•

&ecause smoe inhalation in4uries are a ma4or predictor of mortality inburn patients, rapid assessment is critical.

• Electrical *%rns

• In$alation in


26/76

• T$ermally prod%ced

• 8ot air( steam( or smo9e

• M%cosal *%rns of orop$aryn! and laryn!

• Mec$anical o*str%ction can occ%r %ic9ly

• Tr%e medical emergency

Mucosal burns of the oropharyn% and laryn% are manifested by redness, blistering, and edema.

• In$alation in


27/76

5lectrical &urns'ontinued

• 'urrent that passes through vital organs will produce more life-threatening sequelae

than current that passes through other tissue.

• Types of 6%rn In


28/76

ow are )urns classified"

• 'lassification of 6%rn In


29/76

barrier to the sin, hold in fluids and electrolytes, help to regulate body temperature, and eep

harmful agents in the e%ternal environment from in4uring or invading the body.

/he dermis, which lies below the epidermis, is appro%imately +1 to > times thicer than the

epidermis. /he dermis contains connective tissues with blood vessels and highly speciali#ed

structures consisting of hair follicles, nerve endings, sweat glands, and sebaceous glands. Bnder the dermis lies the subcutaneous tissue, which contains ma4or vascular networs, fat, nerves,

and lymphatics.

/he subcutaneous tissue acts as a heat insulator for underlying structures, which include the

muscles, tendons, bones, and internal organs.

8epth of &urn'ontinued

• 6%rns $ae *een defined *y degrees =4st( 1nd( 7rd( and t$?&

• A6A adocates categorizing t$e *%rn according to dept$ of s9in destr%ction&

.artial#t$ic9ness *%rn

"%ll#t$ic9ness *%rn

• *in-reproducing (re-epitheliali#ing) cells are located throughout the dermis and along

the shafts of the hair follicles and sebaceous glands. If significant damage to the dermis

occurs (e.g., a full-thicness burn), remaining sin cells are insufficient to regenerate

new sin. A permanent, alternative source of sin then needs to be found.

8epth of &urn'ontinued

• S%perficial partial#t$ic9ness *%rn

Inoles t$e epidermis

• Deep partial#t$ic9ness *%rn

Inoles t$e dermis

• "%ll#t$ic9ness *%rn

Inoles fat( m%scle( *one

H$at calc%lations are %sed to ascertain t$e amo%nt of *%rned area of t$e *ody H$at is t$e

significance of t$e classifications 8o) does t$e classification affect treatment

• 'lassification of 6%rn In


30/76

considered more accurate because the patient!s age, in proportion to

relative body-area si#e, is taen into account

+%le of nines

'onsidered ade%ate for initial assessment of ad%lt patients and easy to

remem*er&

• /he *age &urn 8iagram is a free Internet-based tool that is available for estimating

/&*A burned (www.sagediagram.com).

• /he e%tent of a burn is often revised after edema has subsided and a demarcation of the

#ones of in4ury has occurred.

'undBrowder Chart

*ule of 0ines Chart


31/76

&urn 'lassification continued

Ma4or burn

.artial t$ic9ness *%rns greater t$an 15@ T6SA

"%ll t$ic9ness *%rns greater t$an 42@

Any *%rns inoling t$e eyes( ears( face $ands( feet( perine%m Electrical in


32/76

• &urns of the hands, feet, 4oints, and eyes are of concern because they mae self-care very

difficult and may 4eopardi#e future function. &urns of the hands and feet are challenging

to manage because of superficial vascular and nerve supply systems and the need to

maintain their function during healing.

• &urns to the ears and the nose are susceptible to infection because of poor blood supply

to the cartilage.

• &urns to the buttocs or perineum are highly susceptible to infection.

ocation of &urn

• 'irc%mferential *%rns of t$e e!tremities can ca%se circ%latory compromise&

• .atients may also deelop compartment syndrome

atients may also develop compartment syndrome from direct heat damage to the muscles and

subsequent edema andHor preburn vascular problems. *ee 'hapter C+ for more information.

atient Ris 3actors

• ;lder ad%lts $eal more slo)ly t$an yo%nger ad%lts&

and usually e%periences more difficulty with rehabilitation

• .ree!isting cardioasc%lar( respiratory( and renal diseases contri*%te to poorer prognosis&

&ecause of the tremendous demands placed on the body by a burn in4ury.

• Dia*etes mellit%s contri*%tes to poor $ealing and gangrene&

/he patient with diabetes mellitus or peripheral vascular disease is at high ris

for poor healing and gangrene, especially with foot and leg burns.

• .$ysical de*ilitation renders patient less a*le to recoer&

Alco$olism

Dr%g a*%se

Maln%trition

• 'onc%rrent fract%res( $ead in


33/76

as functional assessments can be performed. 7ound care is the primary focus of the acute phase,

but it also taes place in both the emergent and rehabilitative phases.

+escri)e prehospital care for each type of )urn.

• .re$ospital 'are

+emoe t$e person from t$e so%rce of t$e *%rn and stop t$e *%rning process&

+esc%er m%st *e protected from *ecoming part of t$e incident&

/he burn patient may have sustained other in4uries that tae priority over the burn wound. It is

important for individuals involved in the prehospital phase of burn care to adequately

communicate the circumstances of the in4ury to the hospital-based health care providers. /his is

especially important when the in4ury involves entrapment in a closed space, ha#ardous

chemicals, electricity, or possible trauma (e.g., fall).

• 5lectrical in4uries +emoe patient from contact )it$ so%rce&

• '$emical in


34/76

Do not immerse in cool )ater or pac9 )it$ ice&

• /o prevent hypothermia, large burns should be cooled for no longer than

01 minutes.

+emoe *%rned clot$ing&

Hrap in clean( dry s$eet or *lan9et&

• Inhalation in4ury

;*sere for signs of respiratory distress or compromise&

Treat %ic9ly&

• /hey need to be treated quicly and efficiently at the scene if they are to

survive. If '" into%ication is suspected, the patient should be treated with

011; humidified "


35/76

T$rom*osis

Eleated $ematocrit

• /he circulatory status is also impaired because of hemolysis of R&'s.

• /he R&'s are hemoly#ed by circulating factors (e.g., o%ygen free radicals) released at

the time of the burn, as well as by the direct insult of the burn in4ury.

• /hrombosis in the capillaries of burned tissue causes an additional loss of circulating

R&'s.

• An elevated hematocrit is commonly caused by hemoconcentration resulting from fluid

loss. After fluid balance has been restored, lowered hematocrit levels are found

secondary to dilution.

-a\ s$ifts to t$e interstitial spaces and remains %ntil edema formation ceases&

J \ s$ift deelops *eca%se in


36/76

Conditions that lead to )urn shoc

• Emergent .$ase

'omplications

• 'ardiovascular system Dysr$yt$mias and $ypoolemic s$oc9

Impaired circ%lation to e!tremities

Tiss%e isc$emia

-ecrosis

'irculation to the e%tremities can be severely impaired by deep

circumferential burns and subsequent edema formation. /hese processes

occlude the blood supply by acting lie a tourniquet.

If untreated, ischemia, paresthesias, necrosis, and eventually gangrene

can occur. An escharotomy (a scalpel or electrocautery incision throughthe full-thicness eschar) is frequently performed following transfer to a

burn center to restore circulation to compromised e%tremities.

Impaired microcirc%lation and

[ iscosity sl%dging

Initially, blood viscosity is increased with burn in4uries because of the

fluid loss that occurs in the emergent period. Microcirculation is impaired


37/76

by damage to sin structures that contain small capillary systems. /hese

two events result in a phenomenon termed sludging. *ludging can be

corrected by adequate fluid replacement.

• Respiratory system

Upper respiratory tract in


38/76

factor of time e%posure plus the type and density of the material

inhaled.

• /he initial chest %-ray may appear normal on admission, with

changes noted over the ne%t


39/76

5%tubation may be indicated when the edema resolves, usually + to C days

after burn in4ury, unless severe inhalation in4ury is involved.

5scharotomies of the chest wall may be needed to relieve respiratory

distress secondary to circumferential, full-thicness burns of the nec and

trun.

7ithin C to 0< hours after in4ury in which smoe inhalation is suspected, a

fiber optic bronchoscopy should be performed to assess the lower airway.

*ignificant findings include the appearance of carbonaceous material,

mucosal edema, vesicles, erythema, hemorrhage, and ulceration.

7hen intubation is not performed, treatment of inhalation in4ury includes

administration of 011; humidified " lines for 345@ T6SA

Type of fl%id replacement *ased on size,dept$ of *%rn( age( and indiid%al

considerations

.ar9land =6a!ter? form%la for fl%id replacement

'olloidal sol%tions

5stablishing intravenous (I=) access is critical for fluid resuscitation and

drug administration. At least two large-bore I= access routes must beobtained for burns 0>; /&*A. It is critical to establish I= access that

can accommodate large volumes of fluid. 3or burns +1; /&*A, a

central line for fluid and drug administration and blood sampling should

be considered. An arterial line also should be considered if frequent A&@s

or invasive & monitoring is needed.

5ach burn center has a preference for a replacement regimen. 3luid

replacement is accomplished with crystalloid solutions (usually lactated

Ringer!s), colloids (albumin), or a combination of the two. aramedics

generally give I= saline until the patient!s arrival at the hospital.

/he arland (&a%ter) formula for fluid replacement is the most common

formula used, followed by the modified &rooe formula. It is important to

remember that all formulas are estimates and must be titrated based on

the patient!s physiologic response. 3or e%ample, patients with an

electrical in4ury may have greater than normal fluid requirements.

'olloidal solutions (e.g., albumin) may be given. $owever, administration

is recommended after the first 0< to


40/76

permeability returns to normal or near normal. After this time, the plasma

remains in the vascular space and e%pands the circulating volume. /he

replacement volume is calculated based on the patient!s body weight and

/&*A burned.

Assessment of the adequacy of fluid resuscitation is best made using

clinical parameters. Brine output is the most commonly used parameter.

Understand the principles of wound care in the )urn patient.

artial-thicness wounds are pin to cherry red and wet and shiny with serous e%udate. /hese

wounds may or may not have intact blisters and are painful when touched or e%posed to air.

3ull-thicness wounds will be dry and wa%y white to dar brownHblac and will have only minor,

locali#ed sensation because nerve endings have been destroyed.

Emergent .$ase

6ursing and 'ollaborative Management • Ho%nd care

S$o%ld *e delayed %ntil a patent air)ay( ade%ate circ%lation( and ade%ate fl%id

replacement $ae *een esta*lis$ed

'leansing

'leansing and gentle de*ridement( %sing scissors and forceps( can *e

proided in a cart s$o)er( a reg%lar s$o)er( or a patient *ed,stretc$er *y

yo% and *y p$ysicians&

De*ridement

May need to *e done in t$e ;+

/oose necrotic s9in is remoed&

• 5%tensive surgical debridement is performed in the operating room ("R). 8uring

debridement, necrotic sin is removed. Releasing escharotomies and fasciotomies can be

carried out in the emergent phase, usually in burn centers by burn physicians. 'are

should be taen to accomplish these procedures as quicly and effectively as possible.

• atients find the initial wound care to be both physically and psychologically demanding.

9our emotional support is invaluable and assists in building an important sense of trust.

Infection is t$e most serio%s t$reat to f%rt$er tiss%e in


41/76

Multiple dressing changes or closed method

Sterilized ga%ze dressings are laid oer a topical anti*iotic&

T$ese dressings are c$anged any)$ere from eery 41 to 1 $o%rs to once

eery 4 days( depending %pon t$e prod%ct& Most *%rn centers s%pport t$e

concept of moist )o%nd $ealing and %se dressings to coer *%rned areas()it$ t$e e!ception of t$e *%rned face&

H$en open *%rns )o%nds are e!posed( staff s$o%ld )ear

Disposa*le $ats

Mas9s

Go)ns

Gloes

• 7hen removing contaminated dressings and washing the dirty wound, you may use

nonsterile, disposable gloves.

• *terile gloves are used when applying ointments and sterile dressings.

• In addition, the room must be ept warm (appro%imately >2 3 F


42/76

shoc or paralytic ileus, and (+) intramuscular (IM) in4ections will not be absorbed

adequately in burned or edematous areas, causing pooling of medications in the tissues.

7hen fluid mobili#ation begins, the patient could be inadvertently overdosed from the

interstitial accumulation of previous IM medications.

• /he need for analgesia must be reevaluated frequently as patients! needs may change and

tolerance to medications may develop over time. Initially, opioids are the drug of choice

for pain control. 7hen given appropriately, these drugs should provide adequate pain

management.

• *edativeHhypnotics and antidepressant agents can also be given with analgesics to

control the an%iety, insomnia, andHor depression that patients may e%perience.

• Analgesic requirements can vary tremendously from one patient to another. /he e%tent

and depth of burn may not correlate with pain intensity.

Tetan%s imm%nization

/etanus to%oid is given routinely to all burn patients because of thelielihood of anaerobic burn wound contamination. If the patient has not

received an active immuni#ation within 01 years before the burn in4ury,

tetanus immune globulin should be considered.

Antimicro*ial agents

Topical agents

Siler s%lfadiazine =Siladene?

Mafenide acetate =S%lfamylon?

Systemic agents are not %s%ally %sed in controlling *%rn flora&

Initiated )$en diagnosis of inasie *%rn )o%nd sepsis is made

• After the wound has been cleansed, topical antimicrobial agents are applied and covered

with a light dressing.

• *ystemic antibiotics are not routinely used to control burn wound flora because little or

no blood supply to the burn eschar is available, and consequently, delivery of the

antibiotic to the wound is limited.

• In addition, the routine use of systemic antibiotics increases the chance of development of

multiresistant organisms.

• *ome topical burn agents penetrate the eschar, thereby inhibiting bacterial invasion of

the wound.

• *ilver-impregnated dressings (Acticoat, *ilverlon, Aquacel Ag) can be left in placeanywhere from + to 0 days and are used in many burn centers. *ilver sulfadia#ine

(*ilvadene, 3lama#ine) and mafenide acetate (*ulfamylon) creams are also used.

• *epsis remains a leading cause of death in the patient with ma4or burns, which may lead

to multiple organ dysfunction syndrome. *ystemic antibiotic therapy is initiated when the

clinical diagnosis of invasive burn wound sepsis is made, or when some other source of

infection (e.g., pneumonia) is identified.


43/76

>TE prop$yla!is

/o)#molec%lar#)eig$t $eparin or lo)#dose %nfractionated $eparin is

started&

T$ose at $ig$ *leeding ris9( )it$ mec$anical >TE prop$yla!is )it$

se%ential compression deices

• 3or burn patients at ris for =/5 (e.g., lower e%tremity burns, obesity), and if no

contraindications are nown, it is recommended that low-molecular-weight heparin

(eno%aparin Foveno%G) or low-dose unfractionated heparin (heparin F$ep-ocG)

should be started as soon as it is considered safe to do so.

• 3or burn patients who have a high bleeding ris, it is recommended that mechanical =/5

prophyla%is with sequential compression devices andHor graduated compression

stocings be used until the bleeding ris is decreased and heparin can be started.

hat is the importance of nutritional therapy and how is it addressed"

• -%tritional t$erapy

"l%id replacement ta9es priority oer n%tritional needs&

Early and aggressie n%tritional s%pport )it$in $o%rs of *%rn in


44/76

8ypermeta*olic state

+esting meta*olic e!pendit%re may *e increased *y 52@ to 422@ a*oe

normal&

'ore temperat%re is eleated&

'aloric needs are a*o%t 5222 9cal,day&

8ypermeta*olic state

Early( contin%o%s enteral feeding promotes optimal conditions for )o%nd

$ealing&

S%pplemental itamins and iron may *e gien&

• A hypermetabolic state proportional to the si#e of the wound occurs after a ma4or burn

in4ury.

• Resting metabolic e%penditure may be increased by >1; to 011; above normal in

patients with ma4or burns.

• 'ore temperature is elevated. 'atecholamines, which stimulate catabolism and heat

production, are increased. Massive catabolism can occur and is characteri#ed by protein

breadown and increased gluconeogenesis.

• 3ailure to supply adequate calories and protein leads to malnutrition and delayed

healing. 'alorie-containing nutritional supplements and milshaes are often given

because of the great need for calories. rotein powder can also be added to food and

liquids. *upplemental vitamins may be given as early as the emergent phase, with iron

supplements often started in the acute phase.

hat are the pathophysiological changes in the acute phase"

• T$e ac%te p$ase *egins )it$ t$e mo*ilization of e!tracell%lar fl%id and s%*se%ent

di%resis&

• T$e ac%te p$ase is concl%ded )$en t$e *%rned area is completely coered *y s9in grafts(

or )$en t$e )o%nds are $ealed&

athophysiology

• Di%resis from fl%id mo*ilization occ%rs( and t$e patient is less edemato%s&

• 6o)el so%nds ret%rn&

• 8ealing *egins )$en H6's s%rro%nd t$e *%rn )o%nd and p$agocytosis occ%rs&

• Areas that are full- or partial-thicness burns are more evident than in the

emergent phase.


45/76

• /he patient may now become aware of the enormity of the situation and may

benefit from additional psychosocial support.

• -ecrotic tiss%e *egins to slo%g$&

• Gran%lation tiss%e forms&

• A partial#t$ic9ness *%rn )o%nd $eals from t$e edges&

• "%ll#t$ic9ness *%rns m%st *e coered *y s9in grafts&

"ften, healing time and length of hospitali#ation are decreased by early e%cision and grafting.

hat changes occur in the )urn wound during this phase" hat treatment is employed

during the acute phase"

• Ac%te .$ase'linical Manifestations

• .artial#t$ic9ness )o%nds form esc$ar&

;nce esc$ar is remoed(

re#epit$elialization *egins&

• "%ll#t$ic9ness )o%nds re%ire de*ridement&

• artial-thicness wounds form eschar, which begins separating fairly soon after in4ury.

"nce the eschar is removed, re-epitheliali#ation begins at the wound margins and

appears as red or pin scar tissue.

• 5pithelial buds from the dermal bed eventually close in the wound, which then heals

spontaneously without surgical intervention, usually within 01 to


46/76

• Manifestations of $yponatremia incl%de )ea9ness( dizziness( m%scle cramps( fatig%e(

$eadac$e( tac$ycardia( and conf%sion&

Hater into!ication

• T$e *%rn patient may also deelop a dil%tional $yponatremia called water into%ication.

To aoid t$is condition( t$e patient s$o%ld drin9 fl%ids ot$er t$an )ater( s%c$ as omiting( diarr$ea

.rolonged gastrointestinal s%ction

• 'ardioasc%lar and respiratory systems

Same complications can *e present in t$e emergent p$ase and may contin%e into

t$e ac%te p$ase& A6'&

• -e%rologic system

Us%ally no pro*lems %nless seere $ypo!ia or complications from electrical

in


47/76

• 6eurologically, the patient usually has no physical symptoms, unless severe hypo%ia from

respiratory in4uries or complications from electrical in4uries occur.

• $owever, some patients may demonstrate certain behaviors that are not completely

understood. /he patient can become e%tremely disoriented, may withdraw, or may

become combative.

• 8elirium is more acute at night and occurs more often in the older patient.

• 'onsultation with psychiatric or geriatric services is helpful in quicly diagnosing and

treating delirium or similar behaviors. 9ou can then focus on strategies to orient and

reassure the confused or agitated patient.

• /his is a transient state, lasting from a day or two to several wees.

• =arious causes have been considered, including electrolyte imbalance, stress, cerebral

edema, sepsis, sleep disturbances, and the use of analgesics and antian%iety drugs.

• M%sc%los9eletal system

Decreased +;M

'ontract%res )usculos*eletal system

/he musculoseletal system is particularly prone to complications during the acute

phase. As the burns begin to heal and scar tissue forms, the sin is less supple and pliant.

R"M may be limited, and contractures can occur.

&ecause of pain, the patient will prefer to assume a fle%ed position for comfort. 9ou

should encourage the patient to stretch and move the burned body parts as much as

possible. *plinting can be beneficial to preventHreduce contracture formation.

Gastrointestinal system

.aralytic ile%s

Diarr$ea

'onstipation

'%rlingBs %lcer

#astrointestinal system

aralytic ileus results from sepsis.

8iarrhea may be caused by the use of enteral feedings or antibiotics.

'onstipation can occur as a side effect of opioid analgesics, decreased mobility, and a

low-fiber diet. 'urling!s ulcer is a type of gastroduodenal ulcer characteri#ed by diffuse superficial

lesions (including mucosal erosion). It is caused by a generali#ed stress response,

resulting in decreased production of mucus and increased gastric acid secretion. /his

condition is due to decreased blood flow to the @I tract during the emergent phase.

/he best measure for preventing 'urling!s ulcer is feeding the patient as soon as

possible. Antacids, $


48/76

inhibitors (e.g., esomepra#ole F6e%iumG) are used prophylactically to neutrali#e stomach

acids and inhibit histamine and the stimulation of hydrochloric acid ($'l acid) secretion.

atients with ma4or burns may also have occult blood in their stools during the acute

phase.

• Endocrine system

[ 6lood gl%cose leels

[ Ins%lin prod%ction

• An increase in blood glucose levels may be seen transiently because of stress-mediated

cortisol and catecholamine release, resulting in increased mobili#ation of glycogen

stores, gluconeogenesis, and subsequent production of glucose.

• An increase in insulin production and release is noted. $owever, the effectiveness of

insulin is decreased because of relative insulin insensitivity, leading to an elevated blood

glucose level.

• ater, hyperglycemia can be caused by the increased caloric intae necessary to meet some patients! metabolic requirements. 7hen this occurs, the treatment is supplemental

I= insulin, not decreased feeding. *erum glucose levels are checed frequently, and an

appropriate amount of insulin is given if hyperglycemia is present. @lucometers may be

used to assess blood glucose at the bedside? serum glucose samples are more accurate

than capillary blood analysis by glucometer.

• As the patient!s metabolic demands are met and less stress is placed on the entire system,

this stress-induced condition is reversed.

ow is wound care addressed" hat a)out infection"

• Infection

/ocalized inflammation( ind%ration( and s%pp%ration

.artial#t$ic9ness *%rns can *ecome f%ll#t$ic9ness )o%nds in t$e presence of

infection&

Ho%nd infection may progress to transient *acteremia&

.atient may deelop sepsis&

'ondition *ecomes critical&

• /he body!s first line of defense, the sin, has been destroyed by burn in4ury. athogens

often proliferate before phagocytosis has adequately begun. /he burn wound is now

coloni#ed with organisms. If the bacterial density at the 4unction of the eschar with

underlying viable tissue rises to greater than 01> Hg of tissue, the patient has a burn

wound infection.


49/76

• Invasive wound infections may be treated with systemic antibiotics based on culture

results.

• &urn wound infection may progress to transient bacteremia and sepsis as a result of burn

wound manipulation (e.g., after showering and debridement) (see 'hapter CE).

• Manifestations of sepsis include hypothermia or hyperthermia, increased heart and

respiratory rate, decreased &, and decreased urine output. Mild confusion, chills,

malaise, and loss of appetite may be observed. /he 7&' count will usually be between

01,111HQl (01 01D H) and


50/76

• Ho%nd care =contBd?

Appropriate coerage of t$e graft:

Ga%ze ne!t to t$e graft follo)ed *y middle and o%ter dressings

Unmes$ed s$eet grafts %sed for facial grafts

Grafts are left open& 'omplication: 6le*s

• If grafting is necessary, the meshed, split-thicness sin graft may be protected with the

same greasy gau#e dressings ne%t to the graft, followed by middle and outer dressings.

• 7ith facial grafts, the unmeshed sheet graft is left open, so it is possible for blebs

(serosanguineous e%udates) to form between the graft and the recipient bed.

• &lebs prevent the graft from permanently attaching to the wound bed. /he evacuation of

blebs is best performed by aspiration with a tuberculin syringe and only by those who

have received instruction in this speciali#ed sill.

• Ac%te .$ase 6ursing and 'ollaborative Management

• E!cision and grafting

Esc$ar is remoed do)n to t$e s%*c%taneo%s tiss%e or fascia&

Graft is placed on clean( ia*le tiss%e&

Ho%nd is coered )it$ a%tograft&

Donor s9in is ta9en )it$ a dermatome&

'$oice of dressings aries&

• 'urrent therapeutic management of full-thicness burn wounds involves early removal of

the necrotic tissue followed by application of split-thicness autograft sin.• /his therapy has changed the management and mortality rate of burn patients. In the

past, patients with ma4or burns had low rates of survival because healing and wound

coverage too so long that the patient usually died of sepsis or malnutrition. &ecause of

current earlier intervention, mortality and morbidity rates have been greatly reduced.

• Many patients, especially those with ma4or burns, are taen to the "R for wound e%cision

on day 0 or < (resuscitation phase). /he wounds are covered with a biological dressing

or allograft for temporary coverage until permanent grafting can occur.

• 8evitali#ed tissue (eschar) is e%cised down to the subcutaneous tissue or fascia,

depending on the degree of in4ury. *urgical e%cision can result in massive blood loss, and

blood conservation techniques are used to limit this complication. /opical application of

epinephrine or thrombin, application of e%tremity tourniquets, and application of a new

fibrin sealant (Artiss) all wor to decrease surgical blood loss.

• "nce hemostasis has been achieved, a graft is then placed on clean, viable tissue to

achieve good adherence.

• 7henever possible, the freshly e%cised wound is covered with autograft (person!s own)

sin.


51/76

• E!cision and grafting =contBd?

'%lt%red epit$elial a%tograp$s ='EAs?

Gro)n from *iopsies o*tained from t$e patientBs o)n s9in

Used in patients )it$ a large *ody s%rface *%rn area or t$ose )it$ limited

s9in for $aresting• In the patient with large body surface area burns, only a limited amount of unburned sin

may be available as donor sites for grafting, and some of that sin may be unsuitable for

harvesting.

• 'ultured epithelial autograft ('5A) is a method of obtaining permanent sin from a

person with limited available sin for harvesting. '5A is grown from biopsy specimens

obtained from the patient!s own unburned sin.

• /his procedure is performed in some burn centers as soon as possible after admission on

suitable patients.

• /he specimens are sent to a commercial laboratory, where the biopsied eratinocytes are

grown in a culture medium containing epidermal growth factor. After appro%imately 0to days, the eratinocytes have e%panded up to 01,111 times and form confluent sheets

that can be used as sin grafts.

• /he cultured sin is returned to the burn center, where it is placed on the patient!s e%cised

burn wounds.

• &ecause '5A grafts are made only of epidermal cells, meticulous care is required to

prevent shearing in4ury or infection. '5A grafts generally form a seamless, smooth

replacement sin tissue. roblems related to '5A include a poor graft tae due to thin

epidermal sin graft loss during healing, infection, and contracture development.

• Ac%te .$ase

6ursing and 'ollaborative Management

• .ain management

.atients e!perience t)o 9inds of pain&

'ontin%o%s *ac9gro%nd pain

Treatment#ind%ced pain

Seeral dr%gs in com*ination

Morp$ine )it$ $aloperidol

Treatment#ind%ced pain managed )it$ potent( s$ort#acting analgesic

• "ne of the most critical functions you perform is individuali#ed and ongoing pain

assessment and management. Many aspects of burn care cause pain. $owever, patients

e%perience moments of relative comfort if they receive adequate analgesia. A coordinated

understanding of both the physiologic and psychologic aspects of pain is essential if you

are to intervene with actions that are beneficial.

• /he first line of treatment is pharmacologic (see /able -0).

• 7ith bacground pain, a continuous I= infusion of an opioid will allow for a steady,

therapeutic level of medication. If an I= infusion is not present, slow-release twice-a-day


52/76

opioid medications (e.g., M* 'ontin) are indicated. Around-the-cloc oral analgesics can

also be used. &reathrough doses of pain medication need to be available, regardless of

the regimen selected. An%iolytics, which frequently potentiate analgesics, are also

indicated and include lora#epam (Ativan) or mida#olam (=ersed).

• 3or treatment-induced pain, premedication with an analgesic and an an%iolytic is

required via the I= or oral route. 3or patients with an I= infusion, a potent, short-acting

analgesic, such as fentanyl (*ublima#e) is useful. 8uring treatmentHactivity, small doses

should be given to eep the patient as comfortable as possible.

• 5limination of all the pain is difficult to achieve, and most patients indicate satisfaction

with JtolerableK levels of discomfort. ain management is comple% and ever-changing

throughout the patient!s hospital stay and after discharge.

• Ac%te .$ase

6ursing and 'ollaborative Management

•

.ain management =contBd? -onp$armacologic strategies

+ela!ation strategies

>is%alization( g%ided imagery

8ypnosis

6iofeed*ac9

M%sic t$erapy

• /hey are not meant to be used e%clusively to control pain but may help some patients

cope with the painful aspects of care, both in the hospital and after discharge.

• Ac%te .$ase

-%rsing and 'olla*oratie Management

• -%tritional t$erapy

Meeting daily caloric re%irements is cr%cial&

'aloric needs s$o%ld *e calc%lated *y dietitian&

8ig$#protein( $ig$#car*o$ydrate foods

"aorite foods from $ome

.atients s$o%ld *e )eig$ed reg%larly&

• /he burn patient is in a hypermetabolic and highly catabolic state as a result of the burn

in4ury. 8ecreasing catecholamine release by minimi#ing pain, fear, an%iety, and cold can

ma%imi#e patient comfort and conserve energy. Infection also increases metabolic rate.

• If the patient is on a mechanical ventilator or is unable to consume adequate calories by

mouth, a small-bore feeding tube is placed and enteral feedings are initiated. 7hen the

patient is e%tubated, a swallowing assessment should be performed by a speech

pathologist before the oral feeding is commenced.


53/76

• /he alert patient should be encouraged to eat high-protein, high-carbohydrate foods to

meet increased caloric needs.

• If caregivers wish to bring in favorite foods from home, this should be encouraged.

Appetite is usually diminished, and constant encouragement may be necessary to achieve

adequate intae.

• Ideally, weight loss should not be more than 01; of preburn weight. 9ou need to record

the patient!s daily caloric intae using calorie count sheets, which are monitored by the

dietitian. atients are weighed routinely to evaluate progress.

• .$ysical and occ%pational t$erapy

Good time for e!ercise is d%ring )o%nd cleaning&

.assie and actie +;M

Splints s$o%ld *e c%stom#fitted&

Rigorous physical therapy throughout burn recovery is imperative to maintain muscle strength and optimal 4oint function.

A good time for e%ercise is during and after wound cleansing, when the sin is softer and

buly dressings are removed.

assive and active R"M should be performed on all 4oints. /he patient with nec burns

must sleep without pillows or with the head hanging slightly over the top of the mattress

to encourage hypere%tension.

'ustom-fitted splints are designed to eep 4oints in functional position. /hese must be

ree%amined frequently to ensure an optimal fit, with no undue pressure that might lead to

sin breadown or nerve damage.

hen does the reha) phase occur"

• T$e re$a*ilitation p$ase *egins )$en

6%rn )o%nds are $ealed

.atient is a*le to res%me a leel of self#care actiity

• /his can occur as early as < wees or as long as E to months after the burn in4ury.

• @oals for this period are to (0) assist the patient in resuming a functional role in society,

and (


54/76

• +e$a*ilitation .$ase

athophysiologic 'hanges

• 6%rn )o%nd $eals eit$er *y primary intention or *y grafting&

• /ayers of epit$elialization *egin to re*%ild t$e tiss%e str%ct%re&

• 'ollagen fi*ers add strengt$ to )ea9ened areas&

• /he new sin appears flat and pin.

• In appro!imately to )ee9s( t$e area *ecomes raised and $yperemic&

• Mat%re $ealing is reac$ed in

mont$s to 1 years&

• S9in neer completely regains its original color&

• In appro%imately to C wees, the area becomes raised and hyperemic. If adequate R"M

is not instituted, the new tissue will shorten, causing a contracture.

• Mature healing is reached in about 0< months, when suppleness has returned and the

pin or red color has faded to a slightly lighter hue than the surrounding unburnedtissue. It taes longer for more heavily pigmented sin to regain its dar color because

many of the melanocytes have been destroyed.

• 3requently, the sin does not regain its original color. aramedical cosmetic camouflage,

the implantation of pigment within the sin, can help even out unequal sin tones and

improve the patient!s overall appearance and self-image.

• Discoloration of scar fades )it$ time&

• .ress%re can $elp 9eep scar flat&

• -e)ly $ealed areas can *e $ypersensitie or $yposensitie to cold( $eat( and

to%c$&• 8ealed areas m%st *e protected from direct s%nlig$t for 4 year&

• *carring has two components: discoloration and contour. /he discoloration of scars will

fade somewhat with time. $owever, scar tissue tends to develop altered contours, that is,

it is no longer flat or slightly raised but becomes elevated and enlarged above the

original burned area.

• It is believed that pressure can help eep a scar flat. @entle pressure can be maintained

on the healed burn with custom-fitted pressure garments (e.g., Sobst garments). /hey

should never be worn over unhealed wounds and are removed only for short periods

while bathing.

• /hese garments are worn up to


55/76

• As JoldK epithelium is replaced by new cells, flaing will occur. /he newly formed sin is

e%tremely sensitive to trauma. &listers and sin tears are liely to develop from slight

pressure or friction.

• Additionally, these newly healed areas can be hypersensitive or hyposensitive to cold,

heat, and touch. @rafted areas are more liely to be hyposensitive until peripheral nerve

regeneration occurs. $ealed burn areas must be protected from direct sunlight for about

+ months to prevent hyperpigmentation and sunburn in4ury.

• +e$a*ilitation .$ase

'omplications

• S9in and


56/76

• An emollient )ater#*ased cream s$o%ld *e %sed&

• 'osmetic s%rgery is often needed follo)ing ma


57/76

patient has been previously treated for a psychiatric illness, or if the in4ury was a suicide

attempt. /he diagnosis of posttraumatic stress disorder is made in a number of burn

patients.

WWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWW

Know the )asic statistics of cancer in the US.

Incidences of l%ng( colorectal( and oral cancer $ae Z

H$ereas incidences of -on#8odg9inBs /ymp$oma and s9in cancer $ae [

8ig$er in men t$an )omen

Incidence and deat$ rates are $ig$er in African Americans t$an in )$ites and ot$er

minorities&

Second most common ca%se of deat$ in t$e United States after )$at

Understand the pathophysiological changes occurring in the de!elopment of cancer.

"ig%re 4#7


58/76

'ancer

Disease process t$at *egins )$en a cell is transformed *y m%tation of cell%lar D-A

Impacts0

.roliferation =cell gro)t$?

'ancer cells tend to diide $ap$azardly and indiscriminately&

-o contact in$i*ition

Differentiation =%ni%e f%nction of t$e cell?

'ancer cells are capa*le of infiltrating far )ay tiss%es0 Metastasis

Defect in 'ell%lar .roliferation ;nce m%tated

'ells can die from damage or *y initiating programmed cell%lar s%icide

=apoptosis?&

'an recognize damage and repair itself

'an s%rie and pass on damage to t)o or more da%g$ter cells

S%riing m%tated cells $ae potential to *ecome malignant&


59/76

T)o types of genes t$at can *e affected *y m%tation are

.rotooncogenes

+eg%late normal cell%lar processes s%c$ as promoting gro)t$

T%mor s%ppressor genes

S%ppress gro)t$

T%mors can *e classified as *enign or malignant neoplasms

6enign neoplasm

Hell differentiated

Us%ally encaps%lated

E!pansie mode of gro)t$

'$aracteristics similar to parent cell

Metastasis is a*sent&

+arely rec%r

/he ability of malignant tumor cells to invade and metastasi#e is the ma4or difference between

benign and malignant neoplasms.

Malignant neoplasm

May range from )ell differentiated to %ndifferentiated

%)le to metastasi1e

Infiltratie and e!pansie gro)t$

"re%ent rec%rrence

Moderate to mar9ed asc%larity

+arely encaps%lated

6ecomes less li9e parent cell

Deelopment of 'ancer

/i9ely to *e m%ltifactorial

;rigin of cancer may *e

Genetic

'$emical

Enironmental

>iral or imm%nologic

May arise from ca%ses not yet identified

Deelopment of 'ancer

Initiation

M%tation of cellBs genetic str%ct%re

M%tated cell $as t$e potential to deelop into clone of neoplastic cells&

.romotion

'$aracterized *y reersi*le proliferation of altered cells

Actiities of promotion are reersi*le&


60/76

▪ ;*esity

▪ Smo9ing( alco$ol

▪ Dietary fat

/atent period

May range from 4 to 2 years

/engt$ of latent period associated )it$ mitotic rate of tiss%e of origin and

enironmental factors

"or disease to *e clinically eident( t%mor m%st reac$ a critical mass t$at can *e

detected&

.rogression

'$aracterized *y

▪ Increased gro)t$ rate of t%mor

▪ Inasieness

▪ Metastasis

Most fre%ent sites of metastasis are l%ngs( *rain( *one( lier( and adrenal glands& .rogression

Metastasis process *egins )it$ rapid gro)t$ of primary t%mor&

▪ Deelops its o)n *lood s%pply =angiogenesis?

▪ 'ertain segments of primary t%mor can detac$ and inade s%rro%nding

tiss%es&

Deelopment of metastasis


61/76

Fig. 16-5. The pathogenesis of cancer metastasis. To produce metastases,

tumor cells must detach from the primary tumor and enter the circulation,

survive in the circulation to arrest in the capillary bed, adhere to capillary

basement membrane, gain entrance into the organ parenchyma, respond

to growth factors, proliferate and induce angiogenesis, and evade host

defenses.

Understand the role of the immune system in the de!elopment of cancer.

'ytoto!ic T cells

Jill t%mor cells directly

.rod%ce cyto9ines

-at%ral 9iller cells and actiated macrop$ages can lyse t%mor cells&

6 cells prod%ce anti*odies directed to t%mor s%rface antigens&

Imm%nologic escape


62/76

Mec$anism *y )$ic$ cancer cells eade imm%ne system

▪ S%ppression of factors t$at stim%late T cells

▪ Hea9 s%rface antigens allo) cancer cells to snea9 t$ro%g$ s%reillance&

Know the different ways to classify cancer. 3a)le 456 7p. 859:

'linical staging classifications

2: 'ancer in sit%

4: T%mor limited to tiss%e of origin0 localized t%mor gro)t$

1: /imited local spread

7: E!tensie local and regional spread

: Metastasis

T-M classification system

Anatomic e!tent of disease is *ased on t$ree parameters:

▪ T%mor size and inasieness =T?▪ Spread to lymp$ nodes =-?

▪ Metastasis =M?

'ist and explain the primary and secondary pre!ention and how it pertains to cancer&

.rimary preention foc%s is )it$ red%cing cancer ris9 in $ealt$y people&

Secondary preention foc%s is detection and screening to ac$iee early diagnosis and

interention&

.rimary .reention

Aoid 9no)n carcinogens&

/ifestyle and dietary c$anges to red%ce cancer ris9 =o*esity( alco$ol( decrease dietary fat(

stop smo9ing?

.%*lic and patient ed%cation

"actors t$at can infl%ence deelopment of cancer

;ncogenic ir%ses and *acteria

S%nlig$t( radiation( c$ronic irritation

'$emical agents: to*acco( as*estos

'ertain Medications =incl%ding '$emot$erapy?

Genetic and familial factors

Diet

8ormones

Age

Secondary .reention


63/76

Identification of patients at $ig$ cancer ris9

'ancer screening

Self#*reast e!am

Self#testic%lar e!am

Screening colonoscopy

.ap test

.%*lic and patient ed%cation

ow is cancer diagnosed" #t Complaints %cronym ;C%U3I


64/76

.alliation0 foc%s is on %ality of life at t$e $ig$est leel for t$e longest possi*le period of

time& E!amples incl%de0

De*%l9ing of t%mor to reliee press%re

'olostomy for t$e relief of *o)el o*str%ction

ow does radiation control or eradicate cancer" hat are the effects of radiation on the

)ody systems" hat nursing care is needed for the patient who recei!es this treatment"

+adiot$erapy: interr%pt cell%lar gro)t$

E!ternal radiation =telet$erapy?

Total dose =rads? *ased on t%mor size,type is diided into daily fractions&

Treatment is typically deliered 4 ! day for 1# )ee9s

Internal radioisotope

6rac$yt$erapy0 implanted( I> or s)allo)ed

Unsealed0 not completely confined to one area& E!creted in *ody fl%ids(

%s%ally )it$in $o%rs

Sealed0 solid implant& Emits radiation =E!creta does not?& /eft in place

%ntil prescri*ed amo%nt of radiation deliered&

+adiation Ta*le 4#41 =p& 14?

Hill in

Effect on t$e GI system

Stomatitis( dysp$agia( dry mo%t$( loss of taste( -,> ( diarr$ea

Effect on *one marro) Myelos%ppression# pancytopenia

Systemic effects

"atig%e( anore!ia

/ong#term effects and tiss%e c$anges

"i*rotic c$anges res%lt of decreased asc%lar s%pply

-%rsing 'are of t$e +adiation .t&

E!plain proced%re( )$at to e!pect =area is mar9ed?

Do not remoe radiation mar9ings

Assess s9in and oral m%cosa

S%ggest strategies to offset side effects s%c$ as fatig%e and anore!ia

Goals0 promote $ealing of )o%nd( proide comfort meas%res( preent infection

S9in s$o%ld *e protected against temperat%re e!tremes& Aoid tig$t clot$ing( irritating

c$emicals&

Has$ area )it$ )arm )ater

Do not %se ointments or po)ders %nless prescri*ed


65/76

Hear soft clot$ing

Do not s%ntan or $eat,cold e!pose

'lient )it$ a sealed so%rce

.riate room

'a%tion sign on door ;rganize n%rsing tas9s

/imit time to 72 min%tes per s$ift

Hear a lead s$ield

Dosimeter *adge

Time,distance,s$ielding =lead?

A dislodged radiation so%rce

Do not to%c$ )it$ *are $ands

Use long $andled forceps to pic9 %p and place in lead container

ow does chemotherapy control or eradicate cancer" hat are the ma-or classifications of

chemotherapeutic agents" hat nursing precautions are needed when deli!ering

chemotherapy" hat effects are seen in each )ody system in a chemotherapy patient"

hat nursing care is needed to assist the chemotherapy patient"

'$emot$erapy

Agents %sed to destroy t%mor cells *y interfering )it$ cell%lar f%nction and replication

'%re

'ontrol

.alliatie

Seeral factors determine response:

Mitotic rate of tiss%e of origin

▪ +apid mitotic rate( *etter response

Size of t%mor

▪ Smaller t%mor( greater response

Age of t%mor

▪ Yo%nger t%mor( greater response

/ocation of t%mor

▪ "e) agents cross *lood#*rain *arrier&

.resence of resistant t%mor cells

▪ +esistant malignant cells pass resistance to da%g$ter cells( )$ic$ contin%e

to proliferate and remain resistant&

'lassification of 8rugs


66/76

'lassified *y

Molec%lar str%ct%re

Mec$anism of action

T)o ma


67/76

Metic%lo%s oral care( Anest$etic gels( Magic mo%t$)as$

T$rom*ocytopenia

.latelet inf%sion

-,>

.rop$ylactic antiemetics( Monitor ",E

"atig%e

-e%tropenia0 ne%tropenic preca%tions

"atig%e

-early %niersal symptom

Manage ot$er symptoms

Hal9ing program or ot$er actiity $elps mood

De*ilitating cycle of fatig%e#depression#fatig%e

Alopecia

+adiation and c$emot$erapy

Us%ally reersi*le

'an gro) *ac9 as a different color and te!t%re

-%rsing 'are

>esicants,e!traasation

If it $appens0

Stop dr%g

Apply ice =%s%ally?

In


68/76

Syngeneic =t)in?

.roced%re

'ells $arested: donor or self

6ody conditioned0 c$emo and radiation to eradicate *one marro) prod%cing cells

6one Marro) resc%e0 Donated( $ealt$y cells transplanted ia I> 1# $o%rs after

c$emot$erapy eliminated from *ody

Ta9es 1# )ee9s for t$e transplanted marro) to start prod%cing engraftment& .rotectie

isolation necessary

'omplications

Infections

Graft ers%s 8ost disease =p& 1N1?

Donor T cells attac9 and destroy %lnera*le tiss%es =s9in( GI tract( lier?

Q#72 days after transplant

8ard to treat( corticosteroids( imm%nos%ppression dr%gs *etter for preention

+adiation of *lood prod%cts *efore administration may *e $elpf%l

.erip$eral stem cell transplant %se more mat%re cells t$%s recoery s$orter and

fe)er,less seere complications

hat surgical treatments are employed for the cancer patients" Descri*e t$eir *enefits&

Diagnostic s%rgery

6iopsy: e!cisional( needle( incisional

T%mor remoal: )ide e!cision( local e!cision

.rop$ylactic s%rgery +econstr%ctie s%rgery

De*%l9ing

palliatie

H$at is an oncological emergency /ist t$e most prealent ones seen in practice& H$at are t$e

clinical manifestations H$at treatments are %sed to com*at t$ese pro*lems

S%perior ena caa syndrome0 ;*str%ction of ena caa *y t%mor or clot&

s,s0 facial edema( distended nec9 eins Most common ca%ses0 cancers of t$e l%ng( *reast

Treatment0 radiate site&

Spinal cord compression0 t%mor presses on cord

s,s *ac9 pain( n%m*ness in e!tremities( *o)el,*ladder pro*lems

T%mor /ysis syndrome

'a%sed *y rapid release of c$emicals,cell%lar components as a response to c$emo


69/76

+ise in p$osp$ate dries calci%m leels do)n

Uric acid leels increases0 ca%ses A+"

"o%r $allmar9 signs are0 $yper%ricemia( $yperp$osp$atemia( $yper9alemia( and

$ypocalcemia

.rimary goal0 preent A+"( treat electrolyte dist%r*ances

Allop%rinol for %ric acid leels

8ydration for A+"

Syndrome of inappropriate AD8 =SIAD8?

A*normal or s%stained prod%ction

'ancer cells are a*le to man%fact%re( store( and release AD8&

Some c$emot$erape%tic agents stim%late release&

Treatment of fl%id restriction or I> of 7@ -a'l in seere cases

Monitor sodi%m leel *eca%se correcting SIAD8 rapidly may res%lt in seiz%res or

deat$

;cc%rs most fre%ently in carcinoma of t$e l%ng =especially small cell l%ngcancer?

8ypercalcemia

.arat$yroid $ormoneKli9e s%*stance secreted from cancer cells in a*sence of

*ony metastasis

Signs incl%de

▪ Apat$y( depression( fatig%e( )ea9 m%scles

▪ Electrocardiogram c$anges( poly%ria( noct%ria( anore!ia( na%sea( omiting

'an *e life#t$reatening

Treatment is aimed at primary disease& Ac%te $ypercalcemia is treated *y

▪ 8ydration

▪ Di%retic administration

▪ 6isp$osp$onate

;t$er oncologic emergencies

Septic s$oc9

Disseminated intraasc%lar coag%lation =DI'?

'ardiac Tamponade

'arotid artery r%pt%re

+escri)e the proper management of pain in the cancer patient.

.atient report s$o%ld al)ays *e *elieed and accepted as primary so%rce for pain

assessment data&

Dr%g t$erapy s$o%ld *e %sed to control pain&


70/76

Moderate to seere pain occ%rs in appro!imately 52@ of patients )$o are receiing

actie treatment for t$eir cancer and in 2@ to N2@ of patients )it$ adanced cancer&

"ear of addiction is %n)arranted&

-%mero%s dr%g options for pain management

-onp$armacologic interentions( incl%ding rela!ation t$erapy and imagery( can *e %sedeffectiely&

sychologic *upport

Emp$asis is placed on maintaining optimal %ality of life&

.ositie attit%de of patient( family( and $ealt$ care proiders can $ae a positie impact

on t$e patientBs %ality of life&

May also infl%ence prognosis

/ist and descri*e t$e different forms of *reast cancer& H$at t$erapies and s%rgical treatments are%sed for *reast cancer H$at is lymp$edema and )$y is it a pro*lem for t$e *reast cancer

patient

6reast 'ancer =p& 4744#474N?

Types

-on#inasie D%ctal 'arcinoma In Sit%

If left %ntreated can proceed to inasie0 most often infiltrating d%ctal cell

carcinoma

.agetBs Disease

+are( inoles nipple,areola lesion =disc$arge( %lceration? Inflammatory *reast cancer0 most malignant of all types

Aggressie and fast gro)ing

'an *e mista9en for an infection =mastitis?

S%rgical interentions


71/76

Ad


72/76

Aoid %ncoo9ed foods

8ormonal t$erapy

Tamo!ifen0 antiestrogen agent

Gien as a c$emo preention agent in some patients

.rop$yla!is in )omen at $ig$ ris9 for 6reast 'A Jno) dr%g alerts for

Adriamycin =p& 474?

Tamo!ifen =p& 474N?

/ymp$edema

'an $appen after lymp$ node dissection

To preent lymp$edema d%ring .ost op period:

e!ercises designed to maintain m%scle tone and improe lymp$ flo)&

Affected arm s$o%ld neer *e dependent een )$ile sleeping

-o 6. readings( enip%nct%re, or I>Bs on affected arm

Elastic *andages s$o%ld not *e %sed in early po period

.rotect t$e arm from any tra%ma t$at co%ld lead to infection

'ist and descri)e the different types of hematologic cancers. 'ist the clinical

manifestations. +escri)e their pathophysiology. hat age groups and demographics do

they affect"

ematologic cancers 7p. 59>?@>:


73/76

/e%9emia

8ematopoietic malignancy )it$ %nreg%lated proliferation of le%9ocytes:

Ac%te myeloid le%9emia

'$ronic myeloid le%9emia Ac%te lymp$ocytic le%9emia

'$ronic lymp$ocytic le%9emia

Ac%te Myeloid /e%9emia =AM/?

Defect in t$e stem cells t$at differentiate into all myeloid cells: monocytes( gran%locytes(

eryt$rocytes( and platelets

Most common nonlymp$ocytic le%9emia acco%nts for 5 @ of ad%lt ac%te cases

Affects all ages )it$ pea9 incidence at age 2

.rognosis is aria*le

Manifestations: feer and infection( )ea9ness and fatig%e( *leeding tendencies( pain from

enlarged lier or spleen( $yperplasia of g%ms( and *one pain

Treatment is aggressie c$emot$erapy: 6MT

Ac%te /ymp$ocytic /e%9emia

Uncontrolled proliferation of immat%re cells from lymp$oid stem cell

Most common in yo%ng c$ildren( *oys more often t$an girls


74/76

.rognosis is good for c$ildren0 2@ eent#free after 5 years( *%t s%rial drops )it$

increased age

Manifestations: lier( spleen( and *one marro) pain( feer( *leeding( )ea9ness( fatig%e

Treatment: c$emot$erapy( 6MT

'$ronic /ymp$ocytic /e%9emia Malignant 6 lymp$ocytes( most of )$ic$ are mat%re *%t nonf%nctional( may escape

apoptosis( res%lting in e!cessie acc%m%lation of cells

Most common form of le%9emia in ad%lts

More common in older ad%lts and affects men more often

S%rial aries from 1 to 4 years depending %pon stage

Manifestations: lymp$adenopat$y( $epatomegaly( splenomegaly0 in later stages( anemias

and t$rom*ocytopenia0 a%toimm%ne complications feer( s)eats( and )eig$t loss

Treatment: early stage may re%ire no treatment( c$emot$erapy

'linical manifestations

+es%lt from *one marro) fail%re

;ercro)ding *y a*normal cells

Inade%ate prod%ction of normal elements

.redisposed to anemia( t$rom*ocytopenia

/e%9emia cells *egin to infiltrate organs

Splenomegaly( lymp$adenopat$y( *one pain( meningenal irritation

Ind%ction t$erapy

Goal to ind%ce remission

8ig$ doses of c$emo

+is9 of seere *one marro) red%ction

If ind%ction s%ccessf%l t$an maintenance t$erapy of same dr%g eery 7# )ee9s for

prolonged period of time

-%rsing Diagnoses

+is9 for *leeding

+is9 for impaired s9in integrity

Impaired gas e!c$ange

Impaired m%co%s mem*rane

Im*alanced n%trition

Ac%te pain

"atig%e and actiity intolerance

Impaired p$ysical mo*ility

+is9 for e!cess fl%id ol%me

Diarr$ea

+is9 for deficient fl%id ol%me


75/76

Self#care deficit

An!iety

Dist%r*ed *ody image

.otential for spirit%al distress

Grieing

Deficient 9no)ledge

Goals

a*sence of complications(

maintenance of ade%ate n%trition( actiity tolerance(

a*ility for self#care

cope )it$ t$e diagnosis and prognosis(

positie *ody image

%nderstanding of t$e disease process and its treatment

/ymp$oma -eoplasm of lymp$

8odg9inBs lymp$oma

-on#8odg9inBs lymp$oma

8odg9inBs /ymp$oma

S%spected iral etiology =E6>?0 familial pattern0 incidence occ%rs in early 12s and again

after age 52

E!cellent c%re rate )it$ treatment

;nset of symptoms %s%ally insidio%s

Manifestations: painless( moea*le lymp$ node enlargement0 pr%rit%s0 feer( s)eats( and)eig$t loss

Treatment is determined *y stage of t$e disease and may incl%de c$emot$erapy and,or

radiation t$erapy

-on#8odg9ins /ymp$oma =-8/?

/ymp$oid tiss%es *ecome infiltrated )it$ malignant cells t$at spread %npredicta*ly0

Incidence increases )it$ age0 t$e aerage age of onset is 52 to 2

.rognosis aries )it$ t$e type of -8/

Treatment is determined *y type and stage of disease and may incl%de interferon(

c$emot$erapy( and,or radiation t$erapy

M%ltiple Myeloma

Malignant disease of plasma cells in t$e *one marro) )it$ destr%ction of *one

Median s%rial is 7 to 5 years0 t$ere is no c%re

Manifestations: *one pain( osteoporosis( fract%res( eleated ser%m protein( $ypocalcemia(

renal damage( renal fail%re( anemia( fatig%e( )ea9ness(

Treatment may incl%de c$emot$erapy( corticosteroids( radiation t$erapy


76/76

Nsg241 Study Guide Exam 5

Documents

Transcript of Nsg241 Study Guide Exam 5