You are on page 1of 16

BON Res 112: Care Competencies  Patient Care - Safe and quality nursing care - Communication - Collaboration and

teamwork - Health Education  Empowering - Legal responsibility - Ethico-moral responsibility - Personal and professional development  Enabling - Record management - Management of resources and environment  Enhancing - Quality Improvement - Research Critical Update:  Phil Nursing Practice Reform Act of 2011  Due for implementation on February 2012  Senate Bill 2988 filed last October 10, 2011 by Sen Ralph Recto Burns:  Prolonged exposure to physical, chemical and electrical agents  Impaired Skin Integrity: Fluid Loss  Keratinized: Protect body, preserves moisture to keep fluid loss Straight Positioning/alignment Immobilized Neck neutral Extension Avoided TRIAGE Primary Survey: Airway (head and neck) Breathing (chest)

Circulation (Extremities) Disability (level of consciousness) Secondary Survey comprehensive (assessment) History Diagnostics and Lab test

Things done in the ER Stabilize Treat Transfer- transitional

Inflammation: contain the injury Stress Response 1) Local 2) General Stress Release of Histamine Vasodilation Capillary permeability Intravascular Fluid Interstitial Spaces Leak into Surface Open to Air Evaporation Capillary permeability Fluid shifting Thickening of mucous Obstruction of Airway hypoxia ALOC Intracellular: 2/3 of total body water -70% More stable

Extracellular: 1/3 of total body water Shock happens in extracellular Intravascular 5% Interstitial 25%: First to be affected by burns

Stridor: Airway Obstruction Wheezing: Narrow Airway

Nurse Care 1) 2) 3) 4) Head of bed elevated Deep Breathing Exercises Humidified O2, 100% (Venturi, Face Mask) Intubation (ET Tube) - ET tube fit pinky of patient - Ambu bag: Symmetrical Chest Expansion, Breath Sounds: Bruit (Turbulent sound) - Test the Functionality of Laryngoscope - ET Tube, and Guide Wire/Stylet

CVP: 5-10 cm H2O, dehydration status  Use the same position for measuring CVP all through out Pulmonary Wedge Pressure: best for congestion Elements of Negligence (Res IpsaLoquitor)     Duty on part of the nurse to do something Forseeability of what can happen if duty was not observed What a Prudent nurse should do Harm

Fluid Replacement: Central access, peripheral access might already be collapsed 1) 2) 3) y y 4) Ineffective Airway Clearance rt inhalation burn injury Impaired breathing pattern rt airway obstruction Fluid Volume deficit rt insensible fluid losses Weight is best indication for fluid balance 1kg=1 Liter of water 1g=1mL Decreased Cardiac Output rt fluid deficit

Parameters monitored:      Pulse rate Blood Pressure RR LOC Urine Output - BUN - Creatinine .6-1.4 (Initially dehydration is suspected: Fluid Challenge is done but if not corrected then renal pathology is suspected) - HCT 42-52%- index of fluid status, measurement of solutes. (high-low fluid) - Specific gravity 1.001-1.025 (up- concentration, down-diluted)

Aldosterone: controls renal tubules to retain water and sodium Oliguria: less than 30ml/Hr Major: more than 25%, Moderate: less than 25% but not less than 15 % Minor: less than 15 % Superficial partial: First degree Deep partial: 2nd degree Full thickness: 3rd degree T wave in ECG in Hyperkalemia is Peak T wave in ECG inverted: angina Hydrogen: goes with Potassium, brings about acidosis. Metabolic in nature. Both HCO3 and CO2 down then compensated Stress: Proton Pump Inhibitor: Omeprazole H2 blocker: Ranitidine Burns -wound brought about by prolonged exposure to thermal, electrical and chemical agents. - skin (Fluid Balance, Thermo Balance, Protection,) - Fluid Volume Deficit (Actual Problem) - Risk for Infection (Potential Problem) Emergency Nursing Triage: ABC 1) 2) 3) 4) Age- very young and old Burn Location Head and Neck (Airway) Chest (Breathing) Extremities (Circulation) Coverage- TBSA, Rule of 9s, Palm Method (1%) Classification- 2 Layers of Skin, Epidermis and Dermis

Epidermis - Erythema - Edema Partial Thickness- painful, blisters, - Superficial - Deep Full Thickness- eschar, painless, needs graft, ETAT (Emergency Triage Assessment and Treatment) STAT (Simple Triage, Assessment and Treatment) Red: Emergent Yellow: Urgent Green: Non Urgent y y IV Fluid given so that oxygen can be redistributed again in the body Respiratory

Carbon Monoxide: Less than 5 % in the body Carboxyhemoglobin: interferes with O2 transport and affinity Pulse Oximeter: used to assess O2 available in body, O2 level: Critical level once it reached 85% SPO2 (Saturation of Peripheral) SAO2 (Saturation of Arterial) y Person who is ill always secondary (Early detection and prompt treatment ) and tertiary (rehabilitative) treatment

Arrythmia 1) Sinus 2) Atrial 3) Ventricular: Life Threatening Oliguria - Urine output of less than 30mL per hour Cardiac Output is directly proportional to the GFR which is directly proportional to urine output

y y y y y y y y y y y

Lanoxin or Digoxin is recommended to CHF because it increases cardiac output by causing inotropic effects which increases pumping ability of heart, then which it increases glomerular filtration rate which increases urine output K is expelled by the body when sodium is retained by the renal tubules. You lose the P (potassium) when you pee. K 3.5-5, intracellular Elevated K: Kidney Injury and Cellular Injury Acid Base Imbalance: pH: 7.35-7.45 CO2: 35-45 HCO3: 22-32 PO2: 80-100 Retention of Metabolic Waste BUN: 10-20mg/dl Creatinine: 0.7-1.5

Sympathetic/Adrenergic Inhibitory to GI and GU Parasympathetic/Cholinergic Excitatory to Systemic Paralytic Ileus: Causes obstruction because it will not pass the food being taken in which leads to feeling of bloatedness, leading to nausea and lead to forceful vomiting which may lead to aspiration.

Hypovolemic Shock  Low BP  High HR  High RR Stridor:  Inspiratory  Airway obstruction  Threatening and Alarming Wheezing:  Expiratory  Airway Narrowing CVP  5-10mmHg

 Positioning must be constant  Uses for indication of hypovolemia Pulmonary Wedge Pressure   y y Good indication of congestion Uses Swanganz catheter ABG is preferred to be obtained from radial pulse instead of brachial artery. Allen s Test used to test patency of the alternate artery to assure that circulation to the area will still be maintained.  Placed on NPO because of no bowel sounds which may lead to paralytic ileus then lead to vomiting and risked for aspiration. Also to forsee a possible surgery

Craniotomy: Coronal Mastectomy: Halstead CABG: Sternal Splint Appendectomy: McBurneys Thyroidectomy: Collar line Cholecystectomy: Right Subcostal Incision/Kochers Cessarean Section: Phafnesteal Explore Lap: Medial Abdominal Lobectomy/Pneumonectomy: Thoracotomy Incision/Anterio Lateral Hypertonic Solution: makes blood concentrated, so water from cells go to blood making cells shrink Hypotonic Solution: solutes not enough so water from blood goes into the cells which makes cells swell Isotonic Solution (NSS, LRS): components are closer to blood composition HCT: 42-52% (refers to the solid components of blood, if it goes down then it refers to bleeding, if it goes up dehydration) Olguric Phase: Kidney Injury: High Potassium; Low Na, High Phosphate; Low Ca Angina/Ischemia  Zone of Injury: ST segment elevated  Zone of Necrosis: widened Q wave

Different Phases of Burns: 1) y y 2) y y y y y y y y 3) y Emergent From time of exposure until the completion of fluid resuscitation Fluid Balance must be obtained Acute Fluid balance and close monitoring Diuresis phase Promote healing Prevent infection Promote comfort: towel that is cool and clean, pain medications (opiods) Promote joint mobility Promote positive self-concept Prevent complications Convalescent/Rehabilitation Wound healing a) Primary Intention: wounds created by surgeries b) Secondary: Granulation, products of traumas, can develop scars and keloid c) Tertiary: wounds that are deep based and wide gap needing secondary sutures such as grafting and debridement: keloids are definitely expected

Oncology, End of Life Issues, GI, Burns, Fluid and Electrolytes APR: Anterio Perineal Resection Cancer (Oncology) Condition where the cells is affected Maturation process(G1-presynthesis, S-DNA,G2-RNA, M) There is a defect in maturation process which will lead to mutation Cells divide they multiply Mother cell transmit everything to daughter cell Abnormal cells (cancer cell) Plus i. Rapid cell division ii. Angiogenesis Minus i. Apoptosis (automatic cell death) ii. Contact inhibition (all the reason to spread, does not stop dividing) 1) Invasion-Stage 3, comes first, local spread within the marginal space of the tissue of origin 2) Metastasis- Stage 4 (Bone and the Lungs, Brain and the Liver) Mechanisms of spread

Lymphatic (most common spread mechanism) Hematogenous

Stage in Carcinogenisis     Initiation (First exposure) Promotion (Repeat Exposure) Progression (Increasing size of tumor-Group of abnormal cells) Proliferation

Carcinogenic  Allergen  Stressor Tumor  Benign i. Encapsulated ii. Movable mass iii. Adenoma  Malignant i. Spreads rapidly ii. Recurring iii. Highly metastasis iv. Harmful to host v. Cachexia- rapid weight loss vi. sarcoma / carcinoma  Levels of Prevention: Health education is part of all levels 1) Primary: health promotion and disease prevention; wellness <--RISK REDUCTION 2) Secondary: Early detection and treatment 3) Tertiary: rehabilitation; symptomatic treatment and supportive care  Signs of Cancer i. Change in bowel habits ii. A sore that does not heal iii. Unusual bleeding iv. Thickening or Lump v. Indigestion vi. Obvious change in wart or mole vii. Nagging cough/Hoarseness of voice viii. Unexplained Weightloss ix. Severe Anemia  Height: Chronic malnutrition  Weight: Acute malnutrition Diagnosis

 History i. Risk factors 1) Genes 2) Lifestyle 3) Environment ii. Signs and Symptoms iii. Physical Examination 1) Changes in structure  Diagnostic Testing i. Imaging: used at the start to identify right away 1) Indirect: Non invasive A. Xray not reliable especially for lung cancer B. CAT: Computerized Axial Tomography - Plain - Contrast: better imaging, allergy to iodine, renal function (creatinine level 1.31.5: upper limit) C. MRI 2) Direct: Invasive a. Endoscopic: consent (obtained by the doctor) - GUIAC test, Fecal Occult blood Test: No meat for atleat 3 days ii. Lab test: done to support the imaging, confirmation. 1) CA 2) PSA  Biopsy (Diagnostic Surgery) i. Needle ii. Incisional  Process Specimen i. Frozen Section ii. Paraffin: Better, 24 hrs  Staging of Cancer (clinical aspect) i. Tumor ii. Nodes iii. Metastasis  Grading of cancer (cellular differentiation) - Maintain the characteristic of the tissue of origin i. well Differentiated ii. poorly undifferentiated (Anaplasia, Dysplasia)  Treatment i. Cure: total eradication surgery ii. Control: Limit spread a) Chemotherapy: Systemic cancer (spread) unless Leukemia or Lymphoma iii. Palliation: Terminal illness, relieve sign and symptoms

 DNR: terminal illness ONLY - Ordinary or extraordinary measures  Treatment modality i. Surgery: primary management a. Local incision: just a part b. Wide resection: tumor together with marginal tissue y Salvage Surgery: secondary surgery to save the body ii. Radiation a. Internal: After therapy patient is no longer radioactive right away y Local: Sealed Source: beads or needles = bowel movement should be reduced = modify activities of daily living = bladder should never be full = PREVENT DISLODGEMENT = KEEP FORCEPS AT BEDSIDE AND LEAD CONTAINER y Systemic: Unsealed source = all fluids are radioactive = universal precaution =Time (no more than 30mins per shift) =Distance (6 feet) =Shielding (PPE) Lead uniform b. External y Teletherapy 1) EBRT 2) Sterotactic: Deep seeded tumors, rays directed specifically to the organ iii. Chemotherapy y Anti neoplastic agents y Little bit of everything, y To mitigate the effect, give the little bit of everything y Not given continuously y Narrow therapeutic Index y Destroy all cells of the body 1) CCS: Cell cyle specific (Anti metabolites, Fluouracil, Methotrexate) 2) NCCS: Non cycle specific. More potent: not given at full dose (Alkylating Agents: Cisplatin) = protect nurse by preparing drugs: may irritate mucous membranes = check patency of line, since drug is a vesicant which irritates the veins (Backflow by lowering IV bag, ) = maximum of 3 days per IV peripheral line

= Infiltration: Stop the IV Chemo. Aspirate the remaining drug. Cold compress except for Oncovir and vincristy =Risk for infection and bleeding =Neutropenic Diet =Tumor Lysis Syndrome: K is released so increase potassium which means risked for arrhythmias. =Nausea and Vomiting, crackers, candy, small frequent feeding  Category 1: Sputum positive, newly diagnosed, extrapulmonary  Category 2: secondary exposure, relapse  Category 3: Minimal PTB, Regimen 3 (Rifampicin,Isoniazid,Streptomycin)  Category 4:  FDCA: no ethambutol  FDCB: with ethambutol  RHZE (Rifampicin, Isoniazid, Streptomycin, Ethambutol) Liver Cirrhosis Esophageal Varices Portal Hypertension Digestive Disorders Colorectal Cancer - Genetics - Diet: low fiber and high in meat (fatty foods) - Obese - Sigmoid area - Men i. Signs and symptoms a. Change in bowel movement (Melena and hematochezia) b. Weight loss c. Nausea and Vomiting d. Indigestion (obstruction in large bowel) ii. Diagnostic a. Lower GI series: Barium Enema Bowel prep: Low residue: low fiber, laxative 8-12hrs before it will take effect, NPO, cleansing enema b. Lower GI endoscopy c. Biopsy d. Surgery APR: Abdomino-Perineal Resection  Colostomy 1) Double Barrel Proximal: drain feces, Distal: drain mucous: Temporary only 2) Single Barrel: Permanent

 Diet: Low fiber, avoid large meals, avoid odor forming food (meat, poultry)  Skin Care: Charcoal inside the colostomy bag, soap and water, keep it dry, karaya powder, skin barrier, 1/3-1/2 full must change (risk of spillage, and force on the skin)  Colostomy irrigation: Bowel Training, distend walls of colon to stimulate peristalsis, reestablish bowel habits. Starts 3-5 days after colostomy creation to provide ample time to achieve peristalsis. After 5 days then there is no peristalsis then it is time to irrigate, hang irrigate bag around 12-18 inches. Normal color: Pinkish, not dusky or cyanotic. Prime with finger.

 Liver Cirrhosis Failure secondary to Fibrosis (scarrius) wound injury  Hepatitis A, Fatty Food, Obese, Alcohol  Liver Functions 1) metabolism of CHO, CHON, Fats 2) Synthesis of albumin Colloid osmotic pressure Oncotic Pressure , pulling effect of blood 3) Synthesis of clotting factors 4) Storage and synthesis of Vitamins ADEK (Vit K needed for synthesis of prothrombin: 1015secs normal value) Anti-coagulant Warfarin/Coumadin (Extrinsic pathway, orally given; PTT) Heparin (Intrinsic Pathway;PT) 5) Detoxification a) Endogenous: Hormones (Aldosterone), Bilirubin Breakdown of RBC (Bilirubin + Water+ Cholesterol=BILE) Conjugation(recycling ) y If conjugated is high in blood then gall bladder has a problem but if unconjugated is high then the problem is in liver. b) Exogenous: Food Fats (Liver and Pancreas: only organ needed for fat metabolism since it is metabolize only be lipase coming from the pancreas)and CHONs (more harmful, because of NH3 (commonly known as ammonia) which is then converted to NH4 then converted to NH2(CO)2, commonly known as urea), Alcohol, Drugs. y High ammonia: problem in liver, High Urea: problem in kidney y Sedatives never given to people with liver or kidney problems because of possible encephalopathy, due to presence of Nitrogen in blood brought to the brain thru blood which damages brain cells and results to brain damage. y Imaging: Abdominal UTZ, Liver Biopsy (needle aspiration, turn on affected side) y Any thing post surgery should be turned on the unaffected side EXCEPT for lobectomy (promote lung expansion of the unaffected site, danger of mediastinal shift where trahea may deviate which is a medical emergency because airway is obstructed) and liver biopsy (liver malignancy or liver cirrhosis, so bleeding is possible then increase pressure is needed on the site of biopsy). y Mediastinal Shift Tension Pneumothorax, Pneumonectomy. (Pneumothorax is most dangerous because it can lead to tension pneumothorax)

 Signs and symptoms 1) Impaired metabolism: easy fatigability and body weakness (bed rest, high in calories and high in CHO but low in CHON and fat butterball diet, CHO are CHON sparers since ammonia is prevented) 2) Cannot synthesize albumin: Edema, ascities Portal hypertension, hypoalbuminemia 3) Impaired clotting factor synthesis: bleeding: TPAG (Total Protein Albumin and Globulin Ratio) 4) Malnutrition: cannot synthesize ADEK 5) Toxemia: cannot detox aldosterone, pulling more water and sodium. y Edema: due to high hydrostatic pressure because of accumulation of water and sodium, then low oncotic pressure due to hypoalbuminemia. y Fetor Hepaticus: Ammonia breath y Encephalopathy, altered level of conscious y Asterixes y Liver Cirrhosis: SGPT/SGOT y Faitgue (earliest sign) y Nursing Care: Bed rest

 Complications: 1) Portal Hypertension (Gateway to the heart is the portal circulation) 2) Esophageal Varices: Rupture and bleeding = prevent intra abdominal pressure = Given lactulose to prevent straining and will also acidify the stool = sengstaken Blakemore tube: Airway, Breathing, Circulation (suction, head of bed elevated to promote lung expansion, monitor level of consciousness), scissors at bedside, deflate balloon every 8 hours for 5-10mins a) Vasopressin b) Sclerotherapy: Inject a drug that will harden the vessel wall leading to support of the vein thus preventing further distention. c) Balloon Tamponade d) Surgical Ligation 3) Hepatic Encephalopathy

     

Proportionate (ordinary) and Disproportionate (extraordinary) DNR applicable only if terminal stage already Euthanasia: hastening death Orthonasia: following usual process of death Dysthanasia: prolonging death Nobody is bound to do the extraordinary

 Terminal illness: fatal pathology where death is imminent 3 Questions to ask and know if ordinary or extraordinary means:  Going to reverse the problem  Reasonable hope for recovery  Burden DNR  Renewed every 24 hours Case II           Stable angina has a predictable pain associated with increase in activity Maximum effect of NTG tablets should have with effected in 20mins Anterior wall of the left ventricle near the apex s the most common site of MI Left side heart failure is most common, which is coronary in origin Relief of pain: priority for patients immediate post MI S2 license: for sedatives Yellow form: for narcotics or dangerous drugs board Altered Level of Consciousness: sign of MI in geriatric patients Troponin T: enzyme indicating myocardial damage, found 3-6 hours after MI ECG: best indicator of MI at point of contact because it allows immediate diagnostic ability to know if there is presence of MI  Secondary HPN most likely kidney in cause

AHA Guidelines on Blood Pressure Prediction     Step 1) Weight reduction measures: for immediate and positive impact on his blood pressure Step 2) Monotherapy Step 3) Adjust the drug of Monotherapy Step 4) Combination therapy

 Coumadin: monitor PT (10-20 secs) for effectiveness of the therapy, illustrates extrinsic pathway by presence of vitamin K  Heparin: anti thrombin, if on this property then PTT should have a range of (50-70 secs). Should have PROTAMINE SULFATE as antidote for heparin treatment  PTT: 25-55 secs, intrinsic factor

 Patients taking anti-HPN should avoid exposure to sunlight and warm bath  patients immediate post MI should be bed bound  Lactulose: brain attack, heart attack, liver cirrhosis  Monitoring CHF: early manifestations best detected by obtaining daily weight  Congestive Heart Failure: Acute in nature  Heart Failure: Chronic in nature  Cardiac Arrest: will have both metabolic and respiratory acidosis  Fully compensated when pH has reached the normal level  Na deficit: CNS depression: low blood concentration: directly proportional: osmosis  Na excess: CNS irritability  Mannitol increase urine high blood concentration in ECF fluid shifting fluid from ICF goes to ECF via osmosis cells shrinking in brain  Hyperventilation: there will be a decrease in CO2 in the blood and increase in blood pHt  SOP: COPD  SOAP: Bronchial Asthma (Smoking, Occupation, Asthma, Pollution)  Carbon dioxide narcosis: found in COPD