MS 1
Fluid Compartments
Fluid and electrolytes
•
•
•
Body fluids
-
Male: LALAKI (6 letters) 60%
(made out of muscle)
Female: BABAE 50% (made out of
fats)
Intravascular / Extracellular
o IV (Plasma)
o Outside the cell
o The only one that is
measurable
Intracellular
o
Inside the cell
o
Has the same
manifestations as
intracellular and interstitial
Interstitial
o In between the cell
o Has the same
manifestations as
intracellular and interstitial
o If no fluid is present in the
interstitial, then there is
no intracellular fluid
Who is prone to dehydration? Male
-
Infant: BATA-BATA 80% fluid
Priority of hydration: infant (then
geriatric) male female
“IV FLUIDS”
Hypertonic
-
Geria- thirst regulating center
(hypothalamus) is delayed
More than 0.9%
o D50 water (because 50%)
o D10 water (because 10%)
o
o
D5LRS (because 5%)
D5NM (because 5%)
❖ What is the first sign of
o
dehydration? Constipation
❖ Where are you supposed to check
for skin turgor in the elderly?
D5 0.9% NaCl / D5NSS
(because 50% dextrose)
o
D5 0.45% NaCl / D5 half
saline solution
Board Question:
Clavicle
-
D50W – given for hypoglycemics ;;
very high sugar content – note
that sugar loves water, so more
fluid in the extracellular
compartment == too little fluid in
cell / cellular dehydration, which is
more dangerous
-
Too much hypertonic solution:
o Hypervolemia
o Hypertension
o Polyuria
o Cell will shrink / Cellular
dehydration
o
-
Too much isotonic / fast drip
o Fluid concentration is
increased = Signs of fluid
excess
o Hypervolemia = high fluid in
blood vessels
Dry mouth (mouth is made
o
up of cells)
Hypertension = high fluid
high pressure
o
Polydipsia
o
Rales or crackles
o
Dry skin
o
Dyspnea – sign of fluid
o
Altered mental status (due
to dehydrated brain cells)
Disorientation (confusion)
o
overload
Pulmonary edema – signs
include rales and dyspnea
o
-
Too little isotonic
o Weak concentration = signs
of fluid deficit
o Hypovolemia
o
o
o
o
Hypotension → become
prone to shock
Shock (hypovolemic)
Dehydration
Oliguria
Isotonic
-
Concentration is 0.9%
o ALL PLAINS
o
-
plain NSS is 0.9% sodium
chloride
o Plain LRS
o D5W 200 ml
There is EQUAL shifting between
the Intra and extracellular spaces.
Hypotonic
-
less than 0.9%
o 0.25% NaCl (because
0.25%)
0.33% NaCl (because
0.33%)
o 0.45% NaCl
o D5W higher than 200 ml
0/33% NaCl – very low sodium
concentration in the blood vessel,
o
-
so fluid moves towards the cell
(cellular hydration) → hypovolemia
BON:
What is a complication of shock? Renal
failure
Can you use lotion as a diabetic patient?
Yes, due to dry skin, except in between
the toes and areas of skin breakdown.
o
BP is low
o
Hypotension → hypovolemic
During the emergent phase of burns,
what do you transfuse? Isotonic PLRS
o
shock
Decreased blood flow to
the kidney → oliguria
-
Cellular hydration – swelling cell
o Edema
o Ascites
o Cerebral edema
-
Mannitol
o It helps you make more
urine and to lose salt and
excess water from your
body. It treats swelling
from heart, kidney, or liver
disease. It also treats
swelling around the brain or
in the eyes.
Newly inserted D5W is isotonic
pH
-
(normal) 7.35-7.45
PCo2
-
35 – 45
Placement of electrolytes
PISO
-
ELECTROLYTES
-
-
Most abundant in the cell –
Potassium (INTRACELLULAR)
Most abundant electrolyte in the
blood vessel – Sodium (OUTSIDE
THE CELL)
Interstitial – calcium
Sodium (Na+)
-
135 – 145 MEQ
Potassium (K+)
-
3.5 – 4.5 (5.5) MEQ
Calcium (Ca+)
-
4.5 – 5.5 MEQ
-
(when ka mu-inom ug gatas –
morning + evening) 8-10 mg/dl
Magnesium (Mg+)
-
1.5 -2.5 MEQ
Meeting of sodium and potassium pumping -- (action potential) – cause
muscle contraction – of course, if they
stop, there is muscle relaxation
-
This is also what carries stimulus
to the brain.
muscles in the hand and wrist (i.e.,
carpopedal spasm) that occurs
after the compression of the
upper arm with a blood pressure
cuff.
Hypercalcemia prevents pumping, thus
there is decreased muscle contraction.
-
Bradycardia
Hypoventilation
Decreased alertness
Drowsiness (that’s why you drink
-
milk)
Muscle weakness
Hypocalcemia – there is a lot of
contraction
-
Tachycardia
Hyperventilation
Increased alertness
Insomnia
-
Muscle spasms
-
The Chvostek sign is a clinical
finding associated with
hypocalcemia, or low levels of
calcium in the blood. This clinical
sign refers to a twitch of the
facial muscles that occurs when
gently tapping an individual's
cheek, in front of the ear.
-
Tetany
Trousseau's sign refers to the
involuntary contraction of the
Normal Sodium 135-145 MEQ
Hypernatremia
-
Sodium attracts water
Thus, there is an increase in fluids
in the extracellular area
Signs of hypertonic are signs of
hypernatremia
o Hypervolemia
o Hypertension
o
o
Cellular dehydration
Polyuria – leads to
dehydrated cell and blood
-
vessel
Nursing diagnosis: fluid volume
-
deficit due to polyuria
Plan of care:
o
o
Low in sodium
Increase fluid intake to
o
dilute sodium
Give hypotonic IVF
o
Give hypertonic IVF + fast
drip isotonic (NSS)
Hyponatremia
-
Too little sodium, too little
attraction
-
thus, fluid goes into the cell
signs of hypotonic are signs of
hyponatremia
o hypovolemia
o hypotension
o oliguria
o edema
o ascites
nursing diagnosis: fluid volume
excess because there is retention
-
-
of fluid in the cells, which are not
removed by the kidneys/urinated
Plan of Care:
o
High in sodium diet
▪
▪
o
Normal Potassium 3.5 – 4.5(5.5) MEQ,
if international can be up to 6
-
NaCl (table salt)
MSG (monosodium
glutamate)
▪
NaHCo3
▪
Na Nitrate
(processed foods)
Restrict fluids
Potassium maintains cardiac
contraction
o Contraction of smooth
muscle (internal organs ex.
Heart, GIT)
o
-
The most life threatening
electrolyte is potassium.
Calcium initiates cardiac
contraction
Hyperkalemia
-
-
-
-
▪
Drug of choice: kayexalate
Can be caused by renal failure or
burns
Fast heart contractility
o
o
Tachycardia
Arrhythmia
o
Cardiac arrest
▪
•
▪
effect of calcium
(stops sodium-
o
(given if the patient is
diabetic)
▪ D5W + D50W +
insulin
▪
▪
▪
FIRST
Decreases heart
rate and thus
preventing
o
arrythmias
Kayexelate (Sodium
Polysterene / Na
Polysterene)
Increases the blood
sugar to decrease
potassium, because
potassium follows
glucose into the cell
Effect in 30 mins
Hypokalemia
-
potassium pump) …
thus you should
administer this
Effect is within 6-8
hours
Glucose insulin infusion
▪
administration: Calcium
gluconate – glucose insulin
o
o
Hypernatremi
a
hypokalemia (complication)
o Abdominal cramping
Affects upper extremities
o Increased hyperactivity of
the heart and the brain
Plan of care:
o Order of med
o
Hypokalemia
Side effect:
•
Increased peristalsis
o Diarrhea → could lead to
infusion – kayexalate
Furosemide – potassium
wasting diuretic
Diet: low in potassium
Antidote: Calcium Gluconate
▪ It antagonizes the
Exchanges its
sodium into
potassium and
excretes it into the
stool
Expected effect:
-
Decreased cardiac contraction
o
Bradycardia
o
Arrhythmia (sinus
bradycardia)
o
Cardiac arrest
Decreased peristalsis
o Constipation
o Abdominal distension
o
Paralytic ileus (adynamic
ileus)
▪ + 20MEQ KCl (post
abdominal surgery)
to promote
peristalsis
-
-
Affects lower extremities
o Muscle weakness
o Fatigue
o Apathy
Plan of care:
o Diet high in potassium
Monitor VS, especially HR, because only
the doctor can obtain an ECG.
(ABC)
o
▪
Apple, Avocado
▪
Banana
▪
Citrus fruits
▪
Ka remember sad ko
before na all above
ground are high in
potassium, all below
ground high in
sodium
Drug of choice
▪
▪
ORAL: Kalium durule
(potassium tablets)
IV: KCL
• never give IV
push
• incorporate in
IV or via
solu-set
-
Widening of QRS – hyperkalemia
Narrowing of QRS - hypokalemia
ST elevation – hyperkalemia
ST depression - hypokalemia
Flattened T wave – hypokalemia
Tall or Peaked T wave hyperkalemia
The presence of u-wave indicates
hypokalemia. This also indicates digitalis
toxicity.
NORMAL CALCIUM:
4.5 – 5.5 MEQ OR 8-10 MG/DL
-
initiates cardiac contraction
-
responsible for the contraction of
-
the large and skeletal muscles
largest amount in the bone
the effect of calcium is the
opposite to potassium
o high potassium in the blood
= increase muscle
contraction
o
high calcium in the blood =
decrease in muscle
contraction
Hypercalcemia
-
-
decreased muscle contraction /
there is muscle relaxation
o bradycardia
o hypoventilation
o
o
decreased alertness
drowsiness
o
lethargy
o
o
muscle weakness
apathy
Trousseau's sign –
carpopedal spasms
Plan of care:
o Diet high in calcium (milk
and dairy products)
o Vitamin D helps absorb
o
-
calcium
o
Calcium supplement
o
Drug of Choice: Calcium
Gluconate
o renal calculi (stone)
plan of care:
o diet low in calcium
o increased fluid intake (due
to renal calculi)
o vitamins C to increase
acidity or neutralize the
alkaline (because
hypocalcemia is alkaline //
o
note milk)
drug of choice: magnesium
sulfate
Hypocalcemia
-
muscle contraction is increased
o
o
o
tachycardia
hyperventilation
increased alertness
o
o
insomnia
muscle spasms
o
o
leg cramps
fatigue
o
o
osteoporosis
Chvostek – facial twitching
o
Tetany – extreme facial
twitching (more extreme
hypocalcemia)
What controls the BP? Sodium
Cardiovascular Disorders
“ARRHYTHMIAS”
-
-
50-200 joules, maximum of 3 – 4
attempts (50, 100, 150, 200)
Synchronized (synch mode) to
the R wave == meaning you deliver
a shock on the R wave
What indicates effective
cardioversion? When the P wave
returns to normal
-
Defibrillators
-
-
flutter
o
Has 2 paddles
o 1 paddle on the sternum
(labeled)
o 1 paddle on the apex
(labeled)
Considerations/ Nursing Safety;
o Shave the area (chest) –
o
o
Atrial fibrillation and atrial
o
▪
▪
▪
Procainamide
(Pronestyl)
Quinidine
Anti-coagulant
(heparin /coumadin)
optional
Apply gel on the paddles to
prevent burning of the skin
Clear the area – be sure no
one is touching the patient,
anyone touching might die
from the 360 joules
introduced; thus, this is the
most significant
Complication is thrombus /
clot formation
Drug of Choice:
Defibrillation
-
Indicated in ventricular
arrhythmias
Problem in the QRS complex
200 – 360 joules (200, 250, 300,
360) maximum of 4 attempts =
larger because the ventricles are
larger
Cardioversion
-
Indicated in atrial arrhythmias
Problem in the P wave
No need to synchronize
Drug of Choice:
▪ Magnesium Sulfate
▪ Lidocaine
Followed by Ventricular fibrillation
o (-) breathing & (-) pulse
o Cardiac arrest
o
-
o
P wave is atrial depolarization
QRS wave is ventricular depolarization
Defibrillation first before
CPR
-
Lastly, asystole (PEA – pulseless
electrical activity)
o
o
o
No breathing no pulse
Cardiac arrest
CPR first then
defibrillation
Cardiac arrest
-
This arrhythmia is seen before
-
cardiac arrest.
-
Starts with Ventricular
tachycardia
o Wide and bizarre QRS
o (-) Breathing & (+) Pulse
o Respiratory Arrest
o Needs rescue breathing
▪ Conscious – can no
longer talk but can
feel the treatment
being given – can
only give low energy
▪
(cardioversion)
Unconscious – can no
longer feel
-
▪
▪
(defibrillation)
(+) pulse (ideal) –
cardioversion
(-) pulse –
defibrillation
because this will increase cardiac
contractility
Acid base imbalance: metabolic
acidosis (due to cell deprivation of
O2// blood is no longer moving,
therefore no exchange of O2)
o Drug of choice: sodium
bicarbonate – this will
reverse the acidosis
Never electrocute the heart without
electrical activity.
Myocardial Infarction
-
Common cause: thrombus
-
formation (clot formation),
coronary artery thrombosis
Most commonly affected part of
treatment – can give
high energy
Drug of Choice: epinephrine –
the heart: left ventricle because
-
it has the thickest myocardium
Major manifestation: chest pain
Characteristic: chest
tightness
o Universal sign: levine sign =
chest-hand clutching
Complications of MI:
o Most life-threatening
a. Manifested by ST elevation
b. STEMI (ST elevation MI)
i. Presence of
extensive damage
c. Non-STEMI (Non-ST
elevation MI)
o
-
complication: ventricular
i. Negative for
arrhythmia / dysrhythmia
▪
The most unstable is
extensive damage
3. Infarction (Occlusion)
within the first 6-8
▪
-
o PVC
Most specific and most sensitive
diagnostic test: TROPONIN I
o Sensitive – result within 1-3
o
-
hours
Safest time is after
24-48 hours
hours and remains elevated
up to 7 days
Specific – only becomes
positive once presence of
tissue necrosis
▪ Angina still has no
a. Pathologic Q-wave
PVC = premature ventricular
contraction
-
tissue necrosis
Most commonly used to diagnosed
MI: ECG
o
Findings: look for the
zones of MI
-
Contains no P waves
Bizarre QRS
Widening of the QRS
Need to count = 6-8 PVCS per
minute should be reported
Trigeminal PVC – should also be
reported
1st line drug:
o Lidocaine
o Xylocaine
▪ Both of these
decreases the heart
rate (bradycardia)
PVC with Bradycardia
o
-
Atropine sulfate – an
anticholinergic
2nd line drug: when the first line
drugs are not available
o Amiodarone
o Cordarone
Three Zones of MI
1. Ischemia (low O2)
a. Inverted T wave
2. Injury (Cardiac Damage)
MS 2
o
o
o
MYOCARDIAL INFARCTION
Oxygen
Nitroglycerin
Aspirin = this is antiplatelet
Occlusion:
-
-
-
Thrombus formation
o Most common cause of MI
Atherosclerosis – plaque formation
-
Arteriosclerosis – hardening of
plaques
Priority:
o
Morphine Sulfate – narcotic
analgesic
▪ Analgesic is to
relieve pain
▪ Narcotic is a CNS
depressant (makes
▪
▪
▪
brain sleep) –
reduces anxiety,
muscle relaxant,
main use in MI is
decreasing O2
demand thereby
decreasing oxygen
consumption
Leads to respiratory
depression
Decreased RR =
check RR, hold if
less than 12 BPM
Antidote: Narcan
Myocardial Ischemia/ Myocardial
Insufficiency
-
relieve ischemia in the myocardium
o 1-5 LPM nasal cannula
o 5-10 LPM (high flow) face
mask
o
Can also be
used for
-
Caused by Myocardial Ischemia
-
Relieved by oxygen
BON:
-
which is also
a narcotic
What oxygen is initially given for
MI? High Oxygen 6-8 Liters to
saturate the ischemic myocardium
-
Demerol
(Meperidine)
Respiratory alkalosis – use
rebreather
Chest Pain
(Naloxone)
•
Seen as an inverted T wave
Insufficient oxygen
High flow O2 (6-8L) is given to
What is priority first for MI?
Morphine
-
What is most commonly used
first? Oxygen
-
Drug of choice for angina –
nitroglycerin
If the cause is due to thrombus
o MONAT
▪ Thrombolytics – to
dissolve thrombus
▪
Streptokinase
▪
t-PA (tissue-
-
3 tablets at 5 minutes
interval
o Give for anginal pain
o Pain unrelieved by
Nitroglycerin, it may be MI
MorPhine Sulfate – anticipate MI
-
Aspirin Thrombolytics Heparin
o
o
plasminogen
Complication: causes
bleeding
activator)
-
if due to hypertension
o MONA + Beta Blockers
▪ To treat
▪
▪
hypertension
All -olol
Propanolol
Three types of Angina
-
-
-
Stable (typical)
o Predictable pain
o Occurs on activity
Unstable (atypical)
o Unpredictable pain
o Often occurs at rest
Prinzmetal (variant)
o Exposure to cold
o Vasospasm
Nitroglycerine – cardiac nitrates
ANGINA or UNKNOWN CHEST PAIN
-
Effect: vasodilatation
-
Side effect: hypotension
Check:
o Blood pressure = hold if
systolic BP is less than
Priority RONPATH
-
-
Rest (sit) – same as morphine, to
decrease O2 demand and O2
consumption
-
100mmHg
Headache – most common
Oxygen administration (high) – to
saturate the ischemic myocardium
-
complaint upon the 1st take
Route: tablets sublingual (under
o
-
Give for chest pain
Nitroglycerine – drug of choice
for angina
the tongue)
o The largest blood vessel is
sublingual
-
-
Burning / tingling sensation under
the tongue is normal, this
indicates vasodilatation
Give three tablets at five-minute
interval
Nitroglycerin spray is used the
Partial
Thromboplastin time
(ptt [looks like an H
ang duha ka t])
Coumadin (warfarin) [in war there
is killing]
▪
-
same as the tablets
o
If you accidentally do 2
sprays at the same time,
o
Antidote: Vitamin K
o
INR (international
Normalize Ratio)
consider that as second
-
dose, give the last/ 3rd
spray after 5 minutes.
Stored in dark and air tight
container due to photosensitivity
Storage is only up to 6 months.
Should be taken before any
strenuous activity (since these
increase O2 consumption)
Prothrombin Time (pt) normal value: 1012 seconds
Partial Thromboplastin time (ptt) normal
value: 30-45 seconds
International Normalize Ratio (INR): 12 seconds
MI sex:
-
Anticoagulants
-
Only prevent blood from
furthering clotting / clot
formation
-
Heparin (in heaven there is peace)
o Antidote: protamine sulfate
o
Check lab:
Can resume sex after 6-wks post
MI
when they are able to climb at
least 2 flights of stairs without
SOB
-
sex before eating
-
non-weight bearing
Left Sided Congestive Heart Failure
1. Complication of MI
2. These is tissue necrosis in the left
CONGESTIVE HEART FAILURE
Signs and Symptoms
ventricle, making it unable to pump
blood out, thus there is backflow
back into the lungs.
3. Manifestations are related to the
lungs
1. presence of S3 – ventricular gallop
2. “Murmur”
3. FAILURE – L first before R, you
can see left sided failure
manifestations before right sided
failure
Right Sided Congestive Heart Failure
o
o
Breathing manifestations
▪ Dyspnea
▪ Orthopnea
▪ Rales / crackles
▪ Pulmonary edema
Decreased cardiac output
▪ Fainting
▪
1. Complication of COPD
2. There is mitral stenosis, leading to
backflow of blood towards the
system
3. There should be systemic
manifestations
o These can all be seen by
the naked eye
o
Jugular vein distension
o
o
Distended neck veins
Cardiac cirrhosis – ischemic
liver
▪
o
o
Edema
▪
▪
Ascites
Jaundice
▪
Hepatomegaly
Oliguria
Weight gain
Laennec’s cirrhosis if due to alcohol ang
liver cirrhosis.
▪
▪
▪
▪
▪
Syncope due to
decreased brain
blood
Dizziness
Light-headedness
Weakness
Fatigue
Apathy
Plan of Care for CHF
•
Goal: To decrease cardiac
workload → to decrease O2
consumption
o Bedrest
o
Diazepam (Valium)
▪ Sedatives
▪
•
•
higher the better due to dyspnea
(sitting, upright, high backrest)
Muscle relaxant
Increase cardiac output
o Digoxin / Lanoxin →
Right CHF = position of choice:
LOW FOWLERS/ 30 degrees
angle – to measure the jugular vein
distension
Digitalis:
▪ Decrease HR
• Check apical
pulse, hold if
less than 60
bpm
▪ Increase cardiac
▪
▪
will increase:
expect
polyguria
(diuresis) //
normal
•
Report for
oliguria –
indicates
toxicity
▪
o
/overdose
Potassium wasting
• Complication:
hypokalemia
More than 4 cm JVD is
indicative of Right-sded
CHF
POC if general: high fowlers
because left sided CHF is always
seen first
contractility
Increase force of
ventricular
contraction
Increase Cardiac
output
• Blood flow to
the kidney
(note
presence of
u-wave)
▪ Do not give together
with Furosemide
Left CHF= position of choice, the
•
•
Give oxygen to left sided CHF
Restrict fluids due to fluid excess
•
Restrict sodium because sodium
causes water retention
Diuretics = to eliminate excess
•
fluid
o
Effective if there is clear
lung sounds or absence of
crackles upon auscultation
Signs of Digitalis Toxicity / Overdose
[BANDAV] where ANDA is all GI
•
•
•
Bradycardia
Anorexia (loss of appetite)
Nausea = 1st sign
•
•
Diarrhea
Abdominal cramping
•
Visual disturbance
o
-
-
vision
Antidote of Digoxin:
DIGIBIND
•
IMMUNO FAB
o
productive cough
o
airway problem (problem
oxygen entering)
Wil complain of seeing the
color green or yellow halo
•
Cough is common in the morning /
early morning cough (smoker’s
cough)
s/s:
o inflammation of the
bronchus
-
o
dyspnea with cyanosis
o
o
o
“Blue Bloaters”
Fat
Dyspnea at rest
Breathing technique:
diaphragmatic breathing
Emphysema
-
RESPIRATORY DISORDERS: COPD /
CAL (Chronic Airflow / Airway
Limitation)
-
-
Common cause: smoking
Common cause: chronic bronchitis,
asthma, congenital (rare – smoker
mother)
Over-distension of the alveoli that
eventually leads to rupture →
collapse of the alveoli → hypoxia
Non-productive cough
s/s
o overdistension of the
alveoli
o
o
Asthma no longer counted because it is
reversible.
expansion (problem with
Chronic Bronchitis
-
Common cause: smoking
-
Inflammation of the bronchus with
accumulation of secretions
-
Productive cough that lasts for 3
months in 2 consecutive years
non-productive cough
breathing problem – lung
o
o
o
-
CO2 not going out)
dyspnea without cyanosis
(because here you can’t
take CO2 out)
“Pink Puffers”
Thin but with barrel chest
o Dyspnea on activity
Breathing technique: pursed lip
breathing
-
o Upright
o High back rest
Drug of choice
o Bronchodilators
▪ Salbutamol
(Ventolin)
o
Steroids (antiinflammatories)
o
Cough medications
▪
suppresses cough
(ex.
Dextromethorphan,
BON:
-
-
-
-
What breath sounds will the nurse
auscultate in COPD? Diminished
breathe sounds due to collapsed
alveoli.
Acid base imbalance in COPD?
▪
Respiratory Acidosis due to CO2
retention
o Hypoventilation
If CO2 is high → patient breaths
only at low level of oxygen
(hypoxic drive)
if CO2 is high and O2 is also high
then breathing will be suppressed
→ apnea (complication)
Antitussive –
▪
-
codeine)
Mucolytics – liquifies
secretions (ex.
Mucomyst
/mucosolvan,
Carbocysteine, nacetylcysteine)
Expectorants –
expels secretions
(ex. Guiafenesine,
rubitussin)
Encourage coughing and deep
breathing
-
Increase fluid intake to liquify
secretions
-
Decreased O2 admin = safest is
2LPM via venturi mask (most
accurate)
o
Plan of Care for COPD
-
Position of choice:
o orthopneic (sitting + leaning
forward) BEST!
o
Sitting
-
Nasal cannula (most
comfortable)
Promote rest
Diet
o
Should be small frequent
meals
o
Composed of:
▪
▪
▪
calorie (HIGH to
provide energy),
carbohydrates
(LOW, because the
more carbohydrates,
the more CO2 – cns
-
-
Care: Check the patient’s heart
rate
Initial Action: Stop the source
Priority: safety of victim and
rescuer
You will die from arrhythmia
depressant)
-
Check heart rate
protein (HIGH to
-
Lightning – when thunder roars, go
-
help in the
inside, hands and feet must touch
absorption of
the ground
bronchodilators)
o
THIS IS WHERE WE STOPPED OUR
ANKI
After struck by lightning,
not electrically charge, can
touch
(NAG-brownout – check
nalang ang screenshot)
BURNS
Types:
Thermal Burn
-
Chemical Burn
Due to exposure to hot surfaces
NLE: What to do when a small
-
portion of the body area is
exposed to burn? Put on running
water
-
Due to strong acid
NLE: evidence
o
o
Management:
o
Powder Chemical Burn
▪ Scrape
▪ Remove with a brush
o
Liquid Chemical Burn (ex.
Electrical Burn
-
Due to exposure of electrical
-
source
Life-threatening complication:
arrhythmia
Liquefaction necrosis
Presence of stain
Liquid sosa?)
▪ Flood with water for
at least 20 mins
-
Radiation Burn
-
UV exposure (ex. Sun burn,
o Presence of blisters
Examples
o Ulceration
o Scalding – boiling water
radiation therapy)
-
Management
o Apply cold packs
o Avoid alcohol, lotion,
powder
FULL THICKNESS
-
Here nerves are already damaged
→ painless
3rd degree
-
Epidermis + dermis + subcutaneous
tissue
White eschar
4th degree
Degrees of Burn
-
This can also be used for bedsores
PARTIAL THICKNESS
1st degree (superficial partial)
-
Epidermis
S/S:
o Signs of inflammation [PRS]
▪
▪
▪
-
Painful
Redness
Swelling
Best example: sun burn
o Exfoliation
o
Dermatitis
2nd degree (deep partial)
-
Epidermis + Dermis
-
S/S
o
The most painful
-
Epidermis + Dermis +
-
Subcutaneous tissue + Muscle
(Bone)
Black Eschar
Charred Eschar
Constrictures – stiffening of the
muscles
o Management: range of
motion exercises
Eschar is fresh - EJ
Basically eschar is still healing, scab if
dry nya naa nay like coagulation, then scar
na after
-
PHASE OF BURNS
Fluid will shift back from
interstitial into blood vessel
o Hypervolemia
o Increase bp from
previously low BP, not
necessarily hypertension
o
Polyuria (diuresis)
o
Hemodilution
o
Decreased viscosity of
blood
st
A: Emergent Phase (occurs 1 48 hours)
-
Stage of shock
-
Stage of fluid shift
Priority here is fluid replacement
Fluids shift from IV (plasma) → to
interstitial
o Blood vessel fluid is low
(hypovolemia)
o
o
o
o
BP is low (prone to shock:
hypovolemic shock)
Oliguria (due to decreased
fluid going to the kidney)
Hemoconcentration
Blood viscosity is high –
prone to thrombus –
management is IV fluid
o
o
replacement
Increased hematocrit
Hyperkalemia (metabolic
acidosis)
o
Hyponatremia (because
sodium rushed into the
cells, basically mura daw
siyag fireman)
o
o
Low HCT
Hypokalemia (Metabolic
Alkalosis)
o
Hyponatremia because
sodium is excreted through
diuresis
C: Recovery Phase (5-6 days after)
-
Hypokalemia (all potassium are in
-
the cell; potassium is used in
cellular repair)
Hypocalcemia (calcium is used in
-
scar formation)
Priority:
o Pain management: DOC:
Narcotic analgesic OR
Morphine Sulfate
o
B: Diuretic Phase (occurs after 48 hours)
-
Stage of fluid remobilization
Prevent infection: reverse
isolation + private room +
hand washing + DOC:
antibiotic as cream
[causative agent is
pseudomonas → sulfamylon
penetrates in the skin +
painful, so need to
administer analgesic 30
mins to 1 hour before
application]
▪
Best Way to apply
antibiotic Cream?
With gloved hands
to control the
pressure
Alarm
-
Press the fire alarm
Scream/ Yell “Help!”
Confine or contain the fire
-
Close the door
Extinguish the fire
-
H2O
Fire extinguisher
If immunosuppressed: private room
If you are infectious: isolation room
Collaborative Management in Burn Cases:
1. On the scene
o Priority:
o
Use only on onset of fire
o
o
o
o
o
Use the abbreviation PASS
Pull the pin
Aim low
Squeeze the lever
Sweeping manner
IF OUTSIDE [ARCE]
Alarm
Rescue
Confine
Extinguish
Small Fire:
-
IF INSIDE [RACE}
Rescue
Waste basket
Fire is not taller than you
Priority is Extinguish
2. After the burn process:
o Priority → establish airway
o
-
Remove the victim
(if the patient is on fire) tell them
-
to drop and roll on the floor
Throw a blanket
Check for stridor,
hoarseness,
wheezing == all
o
o
these indicate
laryngospasms
Restlessness –
indicates hypoxia
Cherry red mucus –
indicates smoke
inhalation
3. On emergent phase (stage of
4ml PLRS x % of Burns (TBSA) x wt (kg)
= 24 hours
Example:
4ml PLRS x 31.5% x 50kgs = 6300 ml (24
hours
1st 8H (transfuse 50%) -- 3150 ml
shock)
o
3rd: Parklands Rule/ Hartmann’s Rule
Priority: fluid resuscitation
/ replacement
o IVF PLRS
(Crystalloid –
o
hyper hypo iso)
Effective if there
is normal
hematocrit –
indicates adequate
fluid
STEPS IN FLUID REPLACEMENT
1st: get the weight in kilograms
2nd: apply the rule of 9
The remaining 1% is the genital.
Entire chest is 9. Half of chest is 4.5.
2nd 8H (transfuse 25%) – 1575 ml
3rd 8H (transfuse 25%) – 1575 ml
6300 ml = transfused at 7AM
How much was transfused at 11 PM? 4725
ml