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BURNS-The risk of death increases in the very and the very .-Where do most burns occur?-After a burn many different pathophysiological changes occur. WHY?a.Why does plasma seep out into the tissue?Increased permeabilityb.When does the majority of this occur?c.Why does the pulse increase?Anytime you're in a FVD, Pulsed.Why does the cardiac output decrease?e.Why does the urine output decrease?Kidneys are either trying to hold on or they aren't beingf.Why is epinephrine secreted?Makes you , shunts blood to vital organsg.Why are ADH and aldosterone secreted?Retain & with aldosterone andRetain with ADHLess to pump out.Therefore your blood volume will go-What is the most common airway injury? poisoning-Normally oxygen should bind with hemoglobin. Carbon monoxide can run much fasterthan oxygen . . . . Therefore, it gets to the hemoglobin first and binds . . . . . Can oxygen bindnow . . . . yes/no-Carbon monoxide poisoning cannot be determined with O2 saturations; the sat monitorpicks up anything that is bound to hemoglobin so if carbon monoxide is bound to the Hbthen the sat may appear normal-Carboxyhemoglobin: blood test to determine carbon monoxide poisoningNow the patient is .Tx:Hurst Review Services16

From this information do you think it would be important to determine if the burn occurred in anopen or closed space?-When you see a patient with burns to the neck/face/chest you had better think what?-A patient is burned over 40% of their body. How do you think this is determined?*Estimate of Total Body Surface AreaHead Each arm Each leg Anterior trunk Posterior trunk Genitalia -One of the most important aspects of burn management is .-It is not uncommon for albumin to be given after a major burn. (Not given during the first24 hours). You know that albumin holds onto in the vascular space.-This will increase/decrease the vascular volume.-What will it do to kidney perfusion?-What will it do to BP?-What will it do to cardiac output?-Will this help correct a fluid volume deficit?-When you start giving a patient albumin you know that the vascular volume will increase.What will happen to the work load of the heart?-If you stress the heart too much you know that the patient could be thrown into fluid volume.-If this occurs what will happen to CO?-What will the lung sounds be like?-On any patient who is receiving fluids rapidly, what is a measurement (hint: heart) youcan take hourly to make sure you’re not overloading them?-Is it important to know that the burn occurred at 11:00 p.m.?Why? Because you know that fluid therapy (for the first 24 hours) is based on the time theinjury occurred, not when treatment was started.Hurst Review Services17

Common rule: Calculate what is needed for the first 24 hours and give half of it during the first 8hours. This is the Parkland Formula.1st 8 hours ½ of total volume2nd 8 hours ¼ of total volume3rd 8 hours ¼ of total volumeTo calculate fluid replacement properly you also need to know the patient’s weight and TBSAaffected.If the patient is restless it may mean fluid replacement is inadequate, pain, or hypoxia.*Priority:If you had to pick, which of the following would you choose to determine if a patient’s fluid volumeis adequate? Their weight or their urine output?-A patient’s respirations are shallow. You know they are retaining what?Therefore, which acid-base imbalance will they have?-A patient was given only 5 mg of Morphine when the order was for a maximum of 10mg. Whydid the nurse do this?-Why are IV pain meds preferred over IM with burns?-Why is the patient given a tetanus toxoid plus the immune globulin?(1)Tetanus Toxoid:*takes 2-4 weeks to get the AB’s(active immunity)(2)Immune globulin: think immediate protection(passive immunity)-Do you think there is more death with upper or lower body burns?-A patient has a circumferential burn on their arm. What does this mean and what should yoube checking?-If a patient’s vascular checks in this arm are bad the doctor may do what procedure to relievepressure?-A patient was wrapped in a blanket to stop the burning process. Since the flames aregone does that mean the burning process had stopped?-What else could have been done to stop the burning process?-How else did the blanket help? Held in and kept out .-Why is it important that jewelry be removed?Hurst Review Services18

-What kinds of things do you look for to determine if any airway injury has occurred?-A foley catheter was inserted so you could measure urine output.-How often will this need to be monitored?-Is it possible that when you insert the catheter that no urine will return?Why? Kidneys are either attempting to the fluid or they might not be beingperfused adequately.-What would you do if the urine was brown/ red?-If there is no urine output or if it is less than 20cc/hour, what would you start worrying about?-What drugs might be ordered to increase kidney perfusion?-After 48 hours, the patient will begin to diurese. Why? Because fluid is going back into thespace. Now we have to worry about fluid volume .What will naturally happen to urine output during this time?-The patient’s serum potassium level is 5.8. You know that potassium likes to live inside oroutside of the cell?With a burn, what happens to cells?So, what happens to the number of potassiums in the serum (vascular space)?Therefore, you better monitor your patient for which electrolyte imbalance? hypokalemia orhyperkalemia-Why do you think Mylanta , Protonix , Pepcid , and Reglan are ordered?Antacids: aluminum hydroxide, Amphogel , or magnesium hydroxide, Milk of Magnesia H2 Antagonist: Zantac , Pepcid ,Axid Proton Pump Inhibitors: Protonix , Nexium -Why do you think the doctor wants the patient to be NPO and have an NGT hooked to suction?-If a patient doesn’t have bowel sounds, what will happen to the abdominal girth?-Do you think the patient will need more or less calories than before?-The NGT will be removed when you hear what?Hurst Review Services19

-When you start GI feedings, what could you measure to ensure that the supplement was movingthrough the GI tract ok?-What is some lab work you could check to ensure proper nutrition and a positive nitrogen balance?-Since the patient has 2nd and 3rd degree burns, is it possible that they could have problems withcontractures?-Since they have burns on their hands, what are some specific measures that may be taken?-Neck?-If a patient has a perineal burn, what do you think the number one complication will be?-What is eschar?-Does it have to be removed?-If it’s not removed can new tissue regenerate?-What likes to grow in eschar?-What type of isolation will you use with the patient?-Travase or Collagenase : enzymatic drug eats dead tissue-Don’t use on face-Don’t use over large nerves-Don’t use if pregnant-Don’t use if area opened to a body cavity-Hydrotherapy is also used to debride.Hurst Review Services20

Common drugs used with burns:a. Silvadene -soothing, apply directly, if rubs off apply more,can lower the WBC, can cause a rashb. Sulfamylon-can cause acid base problems, stings, if it rubsoff apply morec. Silver nitrate-keep these dressings wet; can causeelectrolyte problemsd. Betadine -stings, stains, allergies, acid-base problems-Why should these drugs be alternated?-Broad spectrum antibiotics are avoided to prevent super-infections. However, they will be useduntil the wound cultures have returned.-If grafting is done, a pressure dressing will be applied in surgery .Then when the bleeding hasstopped the wound will be left open to air.-If the skin graft should become blue or cool what would this mean?-Sometimes the doctor will order for you to roll sterile Q-tips over the graft with steady, gentlepressure from the center of the graft out to the edges. Why?-If a patient has a chemical burn what do you do?-If the patient has an electrical burn there will usually be 2 wounds. What are they?-If a patient comes in with an electrical injury what is the first thing you should do?-What arrhythmia is this patient at high risk for?-With electrical burns toxins can build up and cause damage.-It is not uncommon for this patient to be placed on a spine board with a c-collar.Why? Electrical injuries tend to occur in places.-Are amputations common?Why?-Other complications of electrical wounds: cataracts, gait problems, and just about anytype of neurological deficit.Hurst Review Services21

ONCOLOGYGeneral Information:- Alcohol tobacco co-carcinogenic-Tobacco is the #1 cause of preventable cancer.-Suspected dietary causes of cancer:- Low fiber diet-Nitrites (processed sandwich meat)- Increased red meat- Alcohol- Increased animal fat-Preservative and additives-Increased incidents of cancer in the immunosuppressed*that is why there is a higher incident of cancer age 60-The most important risk factor for cancer aging-Cruciferous veggies (broccoli, cauliflower, and cabbage), Vitamin A foods (Colored veggies), andVitamin C could decrease risk-African Americans have a greater incident than Caucasians.-Primary Prevention: Ways to prevent actual occurrence (sunscreen and no smoking)-Secondary Prevention: Using screenings to pick up on cancer early when there is a greater chancefor cure or control-Chronic brings about uncontrolled growth of abnormal cells.-Female:a. Monthly self- breast examb. Yearly clinical breast exam for women 40 years old- Between ages 20-39 needed every 3 yearsc. Annual pelvic examd. Pap smear every 3 years if there's been no probleme. Mammogram-baseline at 35-40, yearly after 40 (2 views of each breast)f. Colonoscopy at age 50 then every 10 years.Hurst Review Services22

-Male:a. Monthly self-breast examb. Monthly testicular exam - testicular tumors grow fastc. Yearly digital rectal exam and yearly PSA (prostate specific antigen) for men over age 50d. Colonoscopy at age 50 then every 10 yearsCAUTION: (Change in bowel/bladder habits; A sore that does not heal;Unusual bleeding/discharge; Thickening or lump in breast or elsewhere;Indigestion or difficulty swallowing; Obvious change in wart or mole;Nagging cough or hoarseness)-Cancer can invade bone marrow anemia and thrombocytopenia- Cachexia- extreme wasting and malnutrition-Radiation therapy:a. Internal Radiation (brachytherapy)- With all brachytherapy, the radioactive source is inside the patient; radiation is being emitted1. Unsealed: patient and body fluid emit radiation-isotope is given IV or PO-usually out of system in 48 hours2. Sealed or solid: patient emits radiation; body fluids not radioactive-implanted close or in the tumor-In general terms, do radiation implants emit radiation to the general environment?- Nursing assignments should be rotated daily, so that the nurse is not continuously exposed- The nurse should only care for one patient with a radioactive implant in a given shift-Precautions:-private room-restrict visitors*no visitors less than 16 years of age-no pregnant visitors/nurses-mark the room-wear a film badge at all times- limit each visitor to 30 min per day-visitors must stay at least 6 feet from sourceHurst Review Services23

-How can you help prevent dislodgment of the implant?-Keep the patient on .-Decrease in the diet.-Prevent bladder .-What do you do if the implants become dislodged and you see it?*Don’t forget this patient is immunosuppressed.b. External Radiation (teletherapy, beam radiation)-Usual side effects: usually limited to the exposed tissues*erythema, *shedding of skin, *altered taste, *fatique*pancytopenia (all blood components are decreased)**many signs and symptoms are location and dose related.- Is it okay to wash off the markings?- Is it okay to use lotion on the markings?- Protect site from sun for 1 year after completion of therapy-Chemotherapy: works on the cell cycle- Usually scheduled every 3-4 weeks- Most Chemo drugs are given IV via port- Many absorb through the skin and mucous membranes; be careful handling them-Usual side effects: alopecia, N/V, mucositis, immunosuppression, anemia,thrombocytopenia-A patient's WBC count must be at least before they will receive theirtreatment.-A vesicant is a type of chemo drug that if it infiltrates (extravasates) will cause tissue.-What are s/sx of extravasation?Hurst Review Services24

- The number one thing to remember with extravasation is PREVENTION!-What do you do if this happens?General ways to prevent infection:-Private room-Wash hands-Have own supplies in room-Limit people (visitors and nurses) in room-Change dressings daily and IV tubing-Cough and deep breath-No fresh flowers or potted plants-Avoid crowds-Do not share toiletries-Bath warm moist areas daily-Wash hands after touching pet-Avoid raw fruits and veggies-Drink only fresh water-Slight increase in temp may mean sepsis-Absolute neutrophil count most importantHurst Review Services25

Specific Types of Cancer:Cervical Cancer-Risk Factors: sex/pregnancy at young age, repeated STD's- Often asymptomatic in pre-invasive cancer- Invasive cancer classic symptom: painless vaginal bleeding- Other general S/Sx: watery, blood-tinged vaginal discharge, leg pain along sciatic nerve,and back/flank pain-l00% cure if detected early-What is the test that helps diagnose this?Abnormal ? Repeat testTx:- electrosurgical excision, laser, cryosurgery- radiation and chemo for late stages-conization- remove part of cervix-hysterectomyHurst Review Services26

Uterine Cancer-Risk Factors: greater than 50 years of age, family hx, late menopause, no pregnancyMajor Symptom: post menopausal bleedingOther s/sx: watery/ bloody vaginal discharge, low back/abd pain, pelvic painDx: CA-125 (blood test) to R/O ovarian involvementTest to evaluate for metastasis:-CXR-CT-IVP-liver and bone scan-BEThe most definitive diagnostic test is D&C (dilatation & curettage) and endometrial biopsyTreatment:1. Surgery:Hysterectomy*TAH (total abd hysterectomy) uterus and cervix only!Tubes & ovaries removed?-bilateral oophorectomy (ovaries)-bilateral salpingectomy (tubes)Radical Hysterectomy-may remove all of the pelvic organs-pt may have colostomy, ileal conduit*The greatest time for hemorrhage following this surgery is during the first 24 hours.Why? Pelvic congestion of .*Major complication with abd hysterectomy?*Major complication with vaginal hysterectomy?*Will probably have a foley; if she doesn't you better make sure she does what in thenext 8 hours?*Why is it so important to prevent abdominal distension after this surgery?*We do not want tension on the .*Dehiscence and Evisceration*Why do we avoid high-fowler's position in this patient?*May have an abdominal and perineal dressing to check.Hurst Review Services27

*As this patient is at risk for pneumonia, thrombophlebitis, and constipation what isone thing you can do to prevent these complications?*Avoid sex and driving. Also avoid girdles and douches.*Any exercise, including lifting heavy objects that increases pelvic congestion shouldbe avoided.*Is it possible that the patient could hemorrhage l0-l4 days after this surgery?*Is a whitish vaginal d/c okay?*Showers or baths?2. Radiation: intra-cavitary radiation to prevent vaginal recurrence3. Chemotherapy: Doxorubicin , Cisplatin 4. Estrogen inhibitors: Depro-Provera , Tomoxifen , Novadex Hurst Review Services28

Breast Cancer- One has a 3 fold risk increase of developing breast cancer if a first degree relative(mother, sister, daughter) had pre-menopausal breast cancer- Known risk factors:-High dose radiation to thorax prior to age 20-Period onset prior to age 12-Menopause after age 50-No pregnancies (null parity)-First birth greater than 30-S/Sx: Change in the appearance of the breast (orange peal appearance, dimpling, retraction,discharge from breast), or lump-Tail of Spence:-Tx:1. Surgery-Post-op care-Bleeding? dressings, back, hemovac, Jackson- Pratt drain-Elevate arm on side-Associated nursing care: Stay away from arm on affected side for lifetime of patient:No constriction, no BP's or injections, wear gloves when gardening, watch smallcuts, no nail biting, and no sunburn, no IV-Brush hair, squeeze tennis balls, wall climbing, flex and extend elbow.Why? Promotes circulation-Look at incision-Reach to Recovery (Support Group)-Lymphedema* Two functions of the lymphatic system: fights infection and promotes drainage2. Chemotherapy drugs: Taxol , Adriamycin 3. Estrogen receptor blocking agents: Tomxifen (Nolvadex , Tamofen )4. Estrogen synthesis inhibitors: Lupron , Zoladex 5. RadiationHurst Review Services29

Lung Cancer-Leading cause of cancer death worldwide-5 Year survival rate is 14%Major risk factor: Smoking*when you have stopped smoking for 15 years, the incidence of lung cancer is almost likethat of a non-smokerS/Sx: hemoptysis, dyspnea (may be confused with Tb, but Tb has night sweats), hoarseness,cough, change in endurance, chest pain, pleuritic pain on inspiration, displaced trach*may metastasize to boneDx: a. Bronchoscopy-NPO pre and NPO until returns-Watch for respiratory depression, hoarseness, dysphagia, SQ emphysemab. Sputum specimen-Best time to obtain?-Is this sterile?-What should the pt do first?*Trying to decrease bacterial count in the mouth.c. CTd. MRITx:Surgery: The main tx for stage I and IIa. Lobectomy:-chest tubes and surgical side upb. Pneumonect

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