Perioperative Care Pathway
Nursing care of the surgical client, charted phase by phase — preoperative workup, intraoperative safeguards, and postoperative recovery — plus the transplant-nursing standards layered on top of it.
Overview & the Nurse's Role
Surgery scheduled → transfer to the OR table.
Transfer to the OR table → transfer to PACU.
Transferred to PACU → discharged home or to unit.
- Client advocate — primary role throughout all phases
- Works with team on an individualized plan of care
- Identifies nursing interventions based on diagnosis & surgery type
- Carries out interventions across all three perioperative phases
- Association of periOperative Registered Nurses
- Allows nurses to share surgical guidelines and principles
- Develops PNDS (Perioperative Nursing Data Set) — identifies nursing process steps specific to surgical clients
- Standards-based practice via AORN, ASA, and ASPAN
Perioperative Patient-Focused Model (4 Domains)
The client sits at the center of all four domains below.
Client safety throughout all phases. NPSG, wrong-site prevention, fall risk, pressure ulcer risk, cognitive decline in elderly.
Physical decline due to aging, dehydration, malnutrition. Addresses nursing problems and client outcomes.
Cognitive changes, ability to perform self-care, depression, coping, anxiety management, patient education outcomes.
Health care economics and outcomes. More emphasis on structural data elements and analytical reporting. Standardized reporting elements.
The client is at the center of all four domains. Safety & physiological responses address interventions and outcomes; health system & behavioral responses address reporting and data standardization.
Surgery Classifications
Risky; considerable work involved on the body.
Minimal work; minimal change to the body.
⚡ Appendectomy = Urgent (inflamed appendix, must be done within hours). Not emergent, not elective.
ASA Physical Status Classification System
Used by the American Society of Anesthesiologists as a risk assessment — based on physical status, not procedure type.
⚡ Social smoker + well-controlled DM = ASA II. Poorly controlled DM or BMI >40 = ASA III.
Perioperative Phases — Detailed
Phase 1 — Preoperative
- Medical & surgical history
- Baseline head-to-toe assessment + VS, height, weight
- Review provider orders
- Skin prep: clippers (not shaving) to remove hair; antiseptic cleanse
- Remove makeup, nail polish, jewelry, dentures, prosthetics, glasses, contacts, hearing aids
- Shower/bathe the evening before
- Ensure large-bore (18-gauge) IV access — for easier infusion of IV fluids or blood products ⚡
- Cover client with lightweight cotton blanket heated in a warmer to prevent hypothermia — hypothermia increases surgical wound infections, alters medication metabolism, and causes coagulation problems and cardiac dysrhythmias
- Withhold anticoagulants at least 48 hrs before surgery ⚡
- If client was on a beta-blocker, administer it prior to surgery to prevent a cardiac event and mortality ⚡
- Have client void before preoperative medications are administered
- Check medication orders — some (antihypertensives, anticoagulants, antidepressants) can be withheld until after procedure
- Determine if autologous blood or direct family donation is available if needed
- Assess fears, anxieties, coping mechanisms, support system
- Goal: decrease the body's stress response
- Establish trusting relationship with client & family
- Primary nursing intervention in preoperative phase: education
- Focus of preoperative phase: prepare client mentally & physically for surgery
- Minimize anxiety while waiting: distraction techniques (watching TV, reading, listening to music)
- Severe anxiety/panic: reassurance; sedation medications as prescribed; nonpharmacological interventions (distraction, imagery, music therapy)
NPO Guidelines (ASA Current Evidence-Based)
Historically "NPO after midnight" for all; current ASA guidelines are individualized based on procedure type and scheduled time. Some procedures still require bowel prep or additional restrictions per provider order.
Allergy Assessment ⚡
When a client reports food or environmental allergies, investigate further — certain food/environmental allergies indicate higher risk for latex allergy. All allergies must be documented in detail as they can indicate hypersensitivity to surgical medications.
| Allergy / Sensitivity | Surgical Implication |
|---|---|
| Banana or kiwi | ⚡ Indicates risk for latex allergy — latex-free precautions required |
| Eggs or soybean oil | ⚡ Contraindication to propofol (propofol is formulated in egg/soybean emulsion) |
| Shellfish | May not always contraindicate contrast media (iodine) — further data collection needed; not automatic contraindication |
Informed Consent ⚡
- Actual procedure being performed
- Potential risks of procedure
- Type of anesthesia and its risks
- Other procedures that could occur during surgery
- Postoperative plan of care & potential complications
- Description of professionals performing/participating
- Anticipated benefits of the treatment/procedure
- Options for other treatments; right to refuse treatment
- Surgeon/Provider — responsible for obtaining consent; reviews procedure, risks, benefits with client; documents verbal consent
- Nurse — verifies and witnesses consent; can clarify information already given, but cannot provide new information not previously given by provider
- If client unconscious or incompetent — legal guardian or health care surrogate may consent
- Surgery cannot proceed without consent (except emergent)
- 18 years of age or emancipated
- Mentally capable of understanding risks, reason, and options
- Free from influence of medications that affect decision-making (opioids, benzodiazepines, sedatives)
- Consent given voluntarily — no coercion involved ⚡
- Has received enough information to make a decision based on understanding
- Client can only sign with an "X"
- Client has vision or hearing impairments
- Language barrier present
- Provide a trained medical interpreter (not a family member or friend); document use of interpreter in medical record
Procedures requiring informed consent: Surgical procedures · Invasive procedures (biopsy, paracentesis, scopes) · Any procedure requiring sedation or anesthesia · Procedures involving radiation · Procedures placing the client at increased risk for complications.
⚡ If a client says "I'm not sure why I'm having this surgery" — notify the provider that informed consent is not complete. The nurse cannot explain the procedure; that is the surgeon's responsibility.
Surgical Safety Checklist (SSC)
Combined by TJC, WHO, and AORN. Primary goal: improve client safety and reduce surgical complications and deaths.
Includes risk for >500 mL blood loss ⚡ — units of blood on hand? Anticoagulant history assessed here.
Entire surgical team verifies: correct client, correct site (marked), correct procedure. Performed just before start.
Specimen labeling, instrument counts, key recovery concerns communicated.
⚡ Surgical site marking is done by the surgeon preoperatively. Priority nursing action: ensure surgeon marks the site (prevents wrong-site surgery, a National Patient Safety Goal).
Preoperative Diagnostic Screening
- CBC (Hgb, Hct, platelets)
- PT, INR, aPTT
- Electrolyte levels
- Serum creatinine & BUN
- Blood type & crossmatch — in case transfusion required; some clients may request autologous donation
- Pregnancy test (hCG) if applicable ⚡
- Urinalysis — renal function, rule out infection
- ABGs — oxygenation status
- Chest X-ray — heart and lung status
- 12-lead ECG — baseline rhythm, dysrhythmias; performed on all clients older than 40 years ⚡
- Positive hCG — possible pregnancy; elective surgery postponed until confirmed negative or after pregnancy
- Low platelet count (<150,000/mm³) — increased bleeding risk
- Abnormal results may cause surgeon/anesthesiologist to delay or postpone surgery
- Type & crossmatch ordered for procedures with high blood loss risk (e.g., total hip replacement)
Preoperative Surgical Risk Factors
| Risk Factor | Why It Increases Surgical Risk |
|---|---|
| Obstructive sleep apnea | Airway obstruction, oxygen desaturation |
| Pregnancy | Fetal risk with anesthesia |
| Respiratory disease (COPD, asthma, pneumonia) | Compromised oxygenation and ventilation |
| Cardiovascular disease (HF, MI, HTN, dysrhythmias) | Fluid overload, hemodynamic instability, dysrhythmias |
| Diabetes mellitus | Altered blood glucose, delayed healing, infection, impaired circulation |
| Liver disease | ⚡ Altered medication metabolism + increased risk for bleeding |
| Kidney disease | ⚡ Altered elimination and medication excretion |
| Endocrine disorders (hypo/hyperthyroidism, Addison's, Cushing's) | Metabolic instability; altered response to stress |
| Immune system disorders | Immunocompromised → infection, delayed healing |
| Coagulation defect | Increased risk of bleeding |
| Malnutrition | Delayed healing |
| BMI > 30 | Pulmonary complications (hypoventilation), altered anesthesia, poor wound healing |
| Medications (antihypertensives, anticoagulants, NSAIDs, TCAs, herbals) | Interaction with anesthesia, bleeding risk |
| Substance use (tobacco, alcohol) | Impaired healing, altered medication effects, respiratory risk |
| Genetic history (MH) | Life-threatening reaction to inhaled anesthetics/succinylcholine |
| Inability to cope / lack of support system | Psychosocial complications; poor recovery outcomes |
Age-Related Risks (65+)
| System | Change | Risk |
|---|---|---|
| Integumentary | Decreased subcutaneous fat; dry, fragile skin | Slower healing; pressure injury |
| Musculoskeletal | Arthritic, inflamed joints | Swelling, discomfort, fall risk |
| Renal/Urinary | Decreased kidney function; incontinence | Decreased waste excretion |
| Neurological | Impaired cognition; delayed reactions; sensory deficits | Delirium; fall risk |
| Cardiovascular | Hypo/hypertension; decreased circulation | Cardiac complications |
| Respiratory | Decreased oxygenation; decreased lung elasticity | Shortness of breath; atelectasis |
| Oral/Dental | Dentures, bridges, loose teeth | ⚡ Problems during intubation — must be identified preoperatively |
| Thermoregulation | Perspires less; decreased subcutaneous fat | Dry, fragile skin; susceptible to temperature changes; pressure injury |
| Fluid/Muscle | Reduced muscle mass; decreased body water | At risk for dehydration |
Older adults are at greater risk because normal aging decreases immune system function, delays wound healing, and provides less physiologic reserve — increasing risk of adverse reactions to anesthesia and preoperative medications. Chronic illnesses compound perioperative complications.
Phase 2 — Intraoperative
Begins when client is transferred to the OR table; ends when client is transferred to the PACU or critical care unit.
- Know type of surgery and anesthesia used
- Place client in correct position for surgery
- Assist surgeon or anesthesiologist as needed
- Maintain aseptic environment
- Monitor client for developing complications
- Complete documentation
- General anesthesia — loss of all sensation and consciousness
- Local/regional — loss of sensation in one area; client usually conscious
- Minimal sedation — responds to verbal commands; may have impaired cognition/coordination
- Moderate sedation — deeper state; cognitive/coordination impaired but airway maintained ⚡
- Deep sedation — cannot be awakened easily; IV or inhalation
⚡ Moderate sedation client in PACU → priority is monitoring level of consciousness (not airway — airway is patent with moderate sedation; cognitive function is what's impaired).
Phase 3 — Postoperative (PACU)
Begins when client is transferred to PACU; ends when client has recovered from the procedure. Transfer from OR to PACU is the responsibility of the anesthesia provider (anesthesiologist or CRNA). PACU nurses are certified in ACLS. Verbal hand-off given by circulating nurse and anesthesiologist/CRNA.
- Patent airway — #1 priority
- Immediate vital signs assessment; repeated for stability
- Monitor level of consciousness
- Pain assessment begins preoperatively (baseline)
- VS every 5–15 min for first hour; then per orders/protocol
- If temp <36°C (96.8°F) → rewarming measures (warming blanket, forced-air)
- Ensure respiratory & cardiovascular stability
- Manage postoperative pain
- Maintain adequate fluid balance (document I&O) ⚡
- Provide surgical site/wound care
- Monitor bowel function
- Assist with early ambulation
⚡ Outpatient discharge criteria: Client must demonstrate ability to swallow and safely ambulate to the bathroom with assistance. Must be accompanied by a significant other, relative, or caregiver who can receive discharge instructions and transport client home.
Postoperative Monitoring — Key Details
- Monitor O₂ sat; supplemental O₂ as prescribed
- Assist with coughing & deep breathing q1hr while awake; use pillow to splint
- Contraindications to coughing: cosmetic, eye, or intracranial surgeries ⚡
- Incentive spirometer q1–2hr while awake
- Reposition every 2 hr; early ambulation
- Output should equal intake within 3 days postoperatively
- Report urinary output <30 mL/hr
- After indwelling catheter removal: client should void within 8 hr
- Use bladder scan to monitor for suspected urinary retention
- Maintain NPO until return of gag reflex (aspiration risk) and peristalsis (paralytic ileus risk)
- Monitor bowel sounds in all four quadrants; ability to pass flatus
- Advance diet as prescribed (clear liquids → regular)
- Encourage gum chewing — stimulates gastric secretions and promotes return of intestinal peristalsis ⚡
- Irrigate NG suction tubes with saline as needed to maintain patency
- Do not move NG tubes in clients post gastric surgery (risk to incision)
- Check bowel sounds first, then administer prescribed antiemetic
- Position client on their side to reduce aspiration risk
- Do not quickly elevate HOB — change positions slowly (nausea from opioids)
- Administer prescribed IV solution based on client's hydration and electrolyte needs
- Encourage ice chips and fluids as prescribed/tolerated
- Provide frequent oral hygiene
Postoperative Pain Management
- If prescribed, use patient-controlled analgesia (PCA) pump; epidural and intrathecal infusions also used
- Around-the-clock scheduling is more effective than PRN delivery during the first 24–48 hr postoperatively ⚡
- Encourage client to ask for pain medication before pain gets severe
- Provide analgesia 30 min before ambulation or painful procedures ⚡
- Monitor for effectiveness after administration
- Monitor pain level frequently using a standardized pain scale
- Manifestations of pain: increased pulse, respirations, or BP; restlessness; wincing or moaning during movement ⚡
- Monitor for opioid adverse effects: respiratory depression, nausea (change positions slowly), urinary retention, constipation
- Nonpharmacological approaches: massage, relaxation techniques, meditation, diversion (listening to music), noise reduction
Incisions, Drains & Wound Healing
- Drainage progression: sanguineous → serosanguineous → serous ⚡
- Expected wound findings: pink wound edges, slight swelling under sutures/staples, slight crusting of drainage
- Report: redness, excessive tenderness, purulent drainage (infection signs)
- Monitor wound drains with each VS check; empty closed-suction devices as needed
- Report increases in drainage (possible hemorrhage)
- Surgeon performs the first dressing change ⚡; subsequent changes by nurse using surgical aseptic technique
- Use abdominal binder as prescribed for obese or debilitated clients with abdominal incision
- Remove sutures or staples in 5–10 days as prescribed ⚡
- Wound closure tape (Steri-strips) — instruct client to keep in place until strips fall off on their own
- Encourage diet high in calories, protein, and vitamin C ⚡
- If client has DM — maintain appropriate glycemic control
- Causes: dehydration, stress response (hypercoagulability), immobility, obesity, trauma, malignancy, history of thrombosis, hormones, indwelling venous catheter
- Avoid pressure behind the knee with pillow/blanket — constricts blood vessels, decreases venous return ⚡
- Do not elevate the knee gatch on the bed — decreases venous return ⚡
- Avoid dangling legs for long periods
- Prophylactic measures: low-molecular-weight heparin, low-dose heparin, or warfarin; anti-embolism stockings; pneumatic compression devices; ROM exercises; early ambulation
- Adequate hydration to reduce venous stasis
- Monitor extremities for calf pain, warmth, erythema, and edema ⚡
Aldrete Postanesthesia Score ⚡
Score of 8–10 required before PACU transfer or discharge. Five categories — each scored 0, 1, or 2.
| Category | Score 2 | Score 1 | Score 0 |
|---|---|---|---|
| Activity | 2 Move 4 extremities | 1 Move 2 extremities | 0 Cannot move |
| Consciousness | 2 Fully awake | 1 Arousable | 0 Unarousable |
| Respiration | 2 Breathe deeply & cough | 1 Dyspnea / hypoventilation | 0 Apneic |
| O₂ Saturation | 2 ≥92% on room air | 1 O₂ needed to keep >90% | 0 <90% even with O₂ |
| Circulation | 2 BP within 20% of pre-op | 1 BP 21–49% of pre-op | 0 BP ≥50% from pre-op |
ERAS® Protocol (Enhanced Recovery After Surgery)
Surgical protocol to drive client-centered postoperative processes. Requires all disciplines — nursing, surgeons, anesthesiologists. Discharge planning begins preoperatively.
Safety & Client Education
National Patient Safety Goals (NPSG) — Surgical
- Surgeon meets client preoperatively to mark the surgical site
- Nurse and surgeon verify marked site in surgical suite
- TIME-OUT performed by entire team just before start — verifies correct client, correct marked site
- ID band verified and cross-referenced with chart upon arrival
- Nurse reviews all documents: informed consent completed, history & physical reviewed, allergies double-checked
- Antibiotics given ~60 min before incision ⚡
- Stopped within 24 hr after surgery
- Do not shave — use clippers if hair removal needed
- Client may bathe/shower night before
- Antiseptic prep of surgical site
⚡ Surgery at 0900 → give antibiotic at 0800. Decreases risk of surgical site infection (SSI). Stop within 24 hr post-op.
SSI Risk Factors: Age ≥65 · Smokers · Immunocompromised · Obese · Existing infections · Chronic medical conditions · DM · Alcohol use disorder · Poor nutrition · Poor skin prep · Shaving (cuts) · Breaks in aseptic technique
TeamSTEPPS
Developed by AHRQ (Agency for Healthcare Research and Quality) to improve communication between health care team members. Four key principles: communication, leadership, situation monitoring, mutual support. Team structure surrounds the client at the center.
Hand-Off Communication Tools ⚡
⚡ Allergies are reported in the Safety (S) step of I PASS the BATON. Comorbidities are in Background (B) of SBAR.
Client Education — Preoperative & Postoperative
Preoperative education begins in the outpatient setting, days/weeks before the procedure. Best time for elective surgery teaching: several days before surgery. ⚡ Assess client's health literacy, learning needs, and knowledge level first.
- Dietary restrictions and NPO timing
- Medications to take or hold
- Skin/bowel preparation
- Breathing and relaxation exercises
- Coughing and incentive spirometer use
- Leg exercises and early ambulation
- Pain management strategies; use a pain scale to rate pain level
- Tips to reduce anxiety and fear
- Equipment they will see postoperatively (drains, catheters, IV lines — purpose of invasive lines)
- Wound care education ⚡
- Postoperative diet restrictions
- Stop aspirin 1 week before elective surgery to decrease bleeding risk ⚡
- Ask provider before taking any herbal or OTC medications — can increase bleeding risk or adverse effects from anesthesia
- These medications are usually allowed prior to surgery: cardiovascular disease meds, pulmonary meds, seizure meds, diabetes meds, some antihypertensives, glaucoma eye drops
- Avoid smoking, alcohol, and illicit drug use — interferes with surgical medications and increases risk for complications
- Reinforces preoperative teaching
- Maintaining adequate nutrition
- Medication regimen (continuing + new) — purpose, administration, adverse effects
- Activity restrictions (driving, stairs, limits on weight lifting, sexual activity)
- Lifestyle modifications
- Wound care and dressing changes; catheter care; use of assistive devices
- Emergency contact information; advise to inform surgeon if pain unrelieved
- Monitor and report signs of infection at surgical site to surgeon
- Follow-up care
- Discharge planning — begins at admission (ERAS protocol)
Diaphragmatic Breathing Exercise
Lie supine or sit in a supportive chair.
Place one or both hands over the stomach.
Inhale through the nose — lower belly rises, chest relaxed.
Exhale through pursed lips — stomach pulls toward the spine.
Repeat ×5.
Deep Breathing Exercise ⚡
Sit back in chair / sit up in bed, then follow the breath cycle below — repeat ×3.
Breathing and relaxation exercises help manage postoperative pain. ⚡ Begin pain management education preoperatively — pain is one of the first postoperative complications experienced.
Incentive Spirometer
- Sit upright; set goal marker on device
- Seal lips around mouthpiece; inhale slowly — piston rises to goal marker
- Hold breath for at least 5 seconds
- Exhale slowly; rest briefly; repeat 10 times
- Perform every hour while awake
Opioid Safety
Many clients' first exposure to opioids follows a surgical procedure. Over 80,000 opioid overdose deaths in the U.S. in 2022. Use least effective dose for shortest time; combine with non-pharmacological measures. Teach safe disposal resources.
Preoperative Medication Complications ⚡
Complications during the postoperative period can be related to medications given preoperatively. Monitor for the following:
| Medication | Complications | Nursing Actions |
|---|---|---|
| Sedatives (benzodiazepines, barbiturates) |
Respiratory depression, drowsiness, dizziness | Monitor RR & O₂ sat · Administer O₂ · Reversal agent: flumazenil ⚡ |
| Opioids | Respiratory depression, drowsiness, dizziness, constipation, urinary retention | Monitor RR & O₂ sat · Administer O₂ · Reversal agent: naloxone ⚡ · Perform intermittent catheterization as prescribed |
| IV Infusions (0.9% NaCl, lactated Ringer's) |
Fluid overload, hypernatremia | Monitor I&O closely · Decrease IV fluid rate · Administer prescribed diuretic |
| GI Medications (antiemetics, antacids, H2 receptor blockers) |
Alkalosis, cardiac abnormalities (some H2 blockers), drowsiness | Obtain preoperative cardiac history · Monitor for electrolyte abnormalities |
Applying the Nursing Process
Pre-op: Collect subjective & objective data — client history, VS, head-to-toe, oxygenation, medical record. Review allergies, medications (Rx, OTC, herbal), acute/chronic conditions, surgical history including anesthesia complications, pain level, diagnostic test results. Assess mental status, communication ability, pre-op anxiety. Screen for pressure injury risk (Braden scale). Verify adherence to NPO restrictions, skin prep, held/taken medications. Malignant hyperthermia (MH) — ask about personal AND family history of anesthesia complications (MH is genetic).
Post-op (PACU): Compare to pre-op assessment baseline. Assess oxygenation, VS, pain, consciousness, positioning, intake/output, IV site, drains/tubes (urinary catheter, wound drains), wound/dressing, skin temperature/color.
Pre-op: Identify findings that indicate potential for complications: aspiration, infection, DVT. SSI risk factors: DM, older age, obesity, smoking, poor skin prep, breaks in aseptic technique.
Post-op: Immediately determine adequate airway. Clients with obstructive sleep apnea have higher risk of difficult intubation, increased O₂ needs, cardiac and pulmonary complications (pneumonia, arrhythmia). ⚡ Sedatives and opioids may cause respiratory depression. Malnutrition increases risk of delayed wound healing, infection, longer hospital stay. Identify source of pain before treating it.
Pre-op: Immediately communicate latex, iodine, or other surgical allergies to the team. Resolve any confusion about consent before transfer to surgical suite.
Post-op: Priority in PACU = maintaining airway and respiratory status. Prevent complications next — inadequate pain management adversely affects early ambulation, increasing risks for atelectasis, HTN, constipation, delayed wound healing, DVT.
Complete the SSC; perform skin prep; initiate IV access; deliver IV fluids; administer pre-op medications (sedatives, antibiotics); perform pre-op labs. Apply sequential compression devices (SCDs) preoperatively for clients at VTE risk. ⚡
VTE Risk Factors: Orthopedic, thoracic, neurosurgical procedures · Central venous access · Prolonged operative time · Anesthesia · Immobility.
Pain management plan: Nonopioid for mild–moderate pain; opioid (±nonopioid) for moderate–severe; adjuvants (muscle relaxants, anxiolytics) for persistent severe pain.
Pre-op: Verify correct procedure/client/site. Administer preoperative medications 20–30 min before transfer to surgical suite. Keep client in bed with side rails up and call light within reach after preop meds. Initiate IV; administer antibiotics (60 min before incision).
Post-op: Monitor VS q5–15 min first hour. Rewarm if temp <36°C. Prevent atelectasis: incentive spirometry, deep breathing/coughing, turning, early mobility. Hemorrhage prevention: frequent VS, wound monitoring, I&O. For evisceration: cover wound with sterile saline-soaked dressing; notify provider immediately.
Pre-op: Document completion of informed consent, assessments, preparations, client teaching.
Post-op (PACU discharge): Aldrete score 8–10 required. Expected outcomes: stable VS, prevention/minimization of complications, effective pain management, demonstrated understanding of pre- and post-op teaching.
Postoperative Care by Anesthesia Type ⚡
| Anesthesia Type | Assessment Considerations | Nursing Interventions |
|---|---|---|
| General Endotracheal |
|
|
| Regional Peripheral nerve block Spinal / Epidural |
|
|
| Sedation (Minimal / Moderate / Deep) |
|
|
Premedication Facts
- Premedication (diazepam, lorazepam) works with anesthesia: promotes sedation, reduces anxiety, decreases N/V risk
- Given 20–30 min before transfer to surgical suite, as ordered by anesthesiologist
- After administration: bed with side rails up, call light within reach
- Antihypertensives (e.g., beta blockers) may be held — can interact with anesthesia causing hypotension or impaired circulation ⚡
- Enema not routine unless abdominal/pelvic surgery — provides better surgical view, prevents contamination from fecal material
Potential Postoperative Complications
Causes: Swelling or spasm of larynx/trachea, mucus in airway, or relaxation of tongue into nasopharynx — often manifests as stridor or snoring ⚡
Manifestations: Choking, noisy/irregular respirations, decreased O₂ sat, cyanosis
- Perform head-tilt/chin-lift to pull tongue forward and open airway ⚡
- Keep emergency equipment at PACU bedside: resuscitation bag, suction, airways
- Notify anesthesiologist; elevate HOB if not contraindicated
- Provide humidified oxygen
- Plan to assist with reintubation
Evidenced by: Decrease in oxygen saturation ⚡
Nursing Actions:- Monitor oxygenation status; administer O₂ as prescribed
- Encourage coughing and deep breathing to prevent atelectasis
- Position with HOB elevated; turn every 2 hr to facilitate chest expansion
- Monitor for pneumonia: fever, productive cough, purulent respiratory secretions
Trigger: Inhaled anesthetic medications and succinylcholine. Genetic — ask about personal AND family history of anesthesia complications. ⚡
Early manifestations:- Dantrolene — administer immediately
- Cooling blanket
- Infusion of cool IV normal saline solution
- Usually occurs intraoperatively; can occur postoperatively too
- Intervention must occur immediately — can be fatal
Dehiscence — separation of wound edges (spontaneous opening).
Evisceration — herniation/protrusion of abdominal organs through open wound.
Action for evisceration: ⚡ Call for help · Stay with client · Keep client NPO in case surgery is required · Cover wound with sterile dressing soaked in sterile saline · Place in low-Fowler's position with hips and knees bent · Monitor for shock · Notify provider immediately · Do NOT attempt to reinsert organs
- Obesity; coughing/moving without splinting
- Poor nutritional status
- Diabetes mellitus; infection
- Hematoma; steroid use
- Impaired circulation; malnutrition
- Smoking — impairs immune system, slows healing
Cause: Absence of GI peristaltic activity due to abdominal surgery or other physical trauma
Nursing Actions:- Monitor bowel sounds in all four quadrants
- Encourage ambulation
- Advance diet when bowel sounds or flatus present
- Administer prokinetic agents (metoclopramide) as prescribed ⚡
- May require NG tube insertion to empty stomach contents
Cause: Massive loss of circulating blood volume (hemorrhage)
Manifestations: Decreased BP & urinary output · Increased HR & RR · Narrowing pulse pressure · Slow capillary refill
Nursing Actions:- Monitor for above manifestations closely
- Administer oxygen
- Place client in supine position with legs elevated ⚡
- Assist with IV fluids and vasopressors as prescribed
Prevention: incentive spirometry, deep breathing/coughing exercises, frequent turning, early mobility.
For excessive secretions: suctioning, nebulizer, chest physiotherapy, respiratory therapy consultation.
Mechanical ventilation clients: IPPB, PEEP may reduce risk.
⚡ Sleep apnea → higher risk of difficult intubation, increased O₂ need, cardiac/pulmonary complications post-op. Monitor for respiratory depression.
Temp <36°C (96.8°F) → rewarming measures. Risk factor for: postoperative cardiac complications, SSI, and hemorrhage.
Postoperative Risk Factors & Their Complications
| Risk Factor | Potential Postoperative Complication |
|---|---|
| Immobility | Respiratory compromise, thrombophlebitis, pressure injury |
| Anemia | Blood loss, inadequate/decreased oxygenation, impaired healing |
| Hypovolemia | Decreased tissue perfusion, deep-vein thrombosis |
| Hypothermia (<36°C) | Surgical wound infection, altered medication absorption, coagulopathy, cardiac dysrhythmia |
| Cardiovascular disease | Fluid overload, DVT, dysrhythmia |
| Respiratory disease | Respiratory compromise |
| Immune disorder | Risk for infection, delayed healing |
| Diabetes mellitus | Gastroparesis (delayed gastric emptying), delayed wound healing, increased infection, impaired circulation, hyperglycemia |
| Coagulation defect | Increased risk of bleeding |
| Malnutrition | Delayed healing |
| BMI >30 | Respiratory compromise, postoperative N/V, wound healing issues, dehiscence, evisceration |
| Age-related (older adult) | Delayed orientation (meds/anesthesia) · Dry, fragile skin — use paper tape for dressings ⚡ · Susceptible to cold · Compromised nutrition → delayed healing |
Common Preoperatively-Identifiable Risk Factors ⚡
Insomnia and arthritis are NOT listed among the common preoperatively-identifiable risk factors for postoperative complications.
Transplant Nursing
ANA published 16 standards guiding transplant nursing practice: ethics, evidence-based practice, communication, collaboration, resource utilization, advocacy. Practice spans novice to expert.
- Federal law requires a certified organ procurement coordinator to lead discussions about donation
- Typically a nurse or social worker with specialized training & certification
- Provides info on: who legally can consent, which organs can be donated, associated fees, impact on burial/cremation
- NOT the critical care social worker, primary care provider, or transplant surgeon
- Monitor for acute graft rejection — unique element of post-transplant care
- First 24 hr: focus on preventing complications and recognizing acute graft rejection signs
- Immunosuppressive medications required → increased infection risk
- Monitor vital signs regularly; immediate intervention for complications
- Provide supportive care: fluids, blood products as ordered
Types of Graft Rejection ⚡
Caused by specific antibodies against the graft. Occurs within minutes to hours of transplantation.
Caused by lymphocytes in recipient detecting antigens in transplanted tissue. Typically begins days to weeks after transplant.
Manifests months or years after transplant. Can lead to total organ failure. Signs: nausea, jaundice, itching, recurrent infections, fatigue, weight gain, anemia.
Early Signs of Acute Rejection (Organ-Specific)
- Acute inflammation on laboratory studies
- Transplanted organ malfunction (e.g., elevated BUN → kidney transplant)
- Alteration in graft function (e.g., excessive bleeding → liver transplant)
Immunosuppressives ⚡
Immunosuppressives → client is immunocompromised → higher risk of secondary infections. ⚡ This is a unique complication for transplant clients during preoperative risk identification.
Collaboration Standard ⚡
Being part of a multidisciplinary care team to create a documented plan of care demonstrates the Collaboration standard of professional transplant nursing practice.
Postoperative Interdisciplinary Team
Exam High-Yield Summary
Transplant nurse — preoperative phase priority
Educating the client's caregivers about the transplant process
Cloze — client at highest risk for ___
Hypoxemia — as evidenced by hematology labs (low Hct/Hgb + excessive blood loss)
Teaching post-op pain — hysterectomy
Splinting the incision while performing deep breathing exercises
Informed consent — client unsure why surgery
Notify the provider — surgeon explains; nurse witnesses only
Appendectomy classification
Urgent — within hours (not emergent = minutes)
Transplant — higher infection risk from
Immunosuppression → secondary infection
I Pass the Baton — latex + penicillin allergy
Safety step (allergies, critical labs, safety alerts)
Preoperative phase — priority focus
Prepare the client mentally and physically for surgery
SBAR — describing comorbidities at hand-off
Background (history, allergies, comorbidities)
Deep breathing — correct instruction
Breathe in through your nose for 4 seconds → hold 8 sec → exhale pursed lips 8 sec
Best time for preoperative teaching
Several days before surgery (time to understand and prepare)
SCIP — antibiotic timing for SSI prevention
60 minutes before the surgical incision
When does perioperative care occur?
Before, during, and after surgery (all three phases)
Breathing/relaxation exercises help with
Postoperative pain management
Moderate sedation in PACU — intervention
Monitor LOC (airway self-maintained; not general anesthesia)
Surgical checklist — >500 mL blood loss assessed
SIGN-IN (before anesthesia induction)
Client nervous about surgery — best response
"Tell me what you have already been told about the surgery."
I&O documentation — which postop element
Maintaining adequate fluid balance
Transplant nurse — multidisciplinary care plan
Collaboration (standard of professional performance)
Collecting data — preoperative phase
Physical assessment
IV pain med + breathing exercises post-mastectomy
Managing postoperative pain (multimodal approach)
Organ donation discussion — who leads?
Organ procurement coordinator (federal law)
Periop Patient Education Model — analytical domain
Health System (economics, outcomes, structural data)
SBAR — "Dr. Jones performed a bowel resection"
Situation (why the client is here + procedure performed)
Client concerned about post-op infection
Educate about wound care preoperatively
Anesthesia history — most concerning finding
Malignant hyperthermia (genetic, triggered by anesthesia, life-threatening)
Post-transplant — unique element of care
Monitoring for graft rejection
Right knee arthroplasty — safety priority
Have the surgeon mark the surgical site (NPSG wrong-site prevention)
SATA — preop findings to report immediately
Platelet count 75,000/mm³ (bleeding risk) · Positive hCG (possible pregnancy)
Matrix — categorize assessment findings pre-op
Normal: Platelet count · Expected Abnormal: Temp, WBC, Pain level, Extremity assessment · Unexpected Abnormal: Positive hCG
SATA — preoperative risk factors for postop complications
Frequent falls · Sleep apnea · Smoking (not insomnia, not arthritis)
SATA — immunosuppressive objectives post-kidney transplant
Prevent rejection · Minimize side effects · Ensure adherence
ATI Practice Test
Integumentary Disorders
Skin structure and function, wound healing, pressure injuries, and burns — from the cell layer up to clinical management of psoriasis, dermatitis, and skin infections.
Skin Anatomy & Function
The skin is the largest organ in the body. It provides protection against infection, UV light, chemicals, and physical injury — and plays a role in temperature regulation, sensation, vitamin D production, and insensible fluid loss.
Outermost — waterproof; 4–5 layers (soles = 5); influences skin color via melanocytes; hosts normal flora (Staph epidermidis, S. aureus, Cutibacterium acnes); continually sheds & replaces itself.
2 layers beneath epidermis — contains sweat glands, hair follicles, muscle; sensory neurons; blood & lymphatic vessels. Hair follicles originate here.
Deepest = subcutaneous fascia. Adipose lobules + connective tissue, hair follicles, sensory neurons, blood vessels. Also called subcutaneous tissue.
Skin Thickness by Location
- Palms of hands
- Soles of feet
- Eyelids, axilla, genitals, mucous membranes
- Children have thin skin that thickens with age
- After age 50 — skin begins to thin again → increased injury risk
Thermoregulation
Vessel narrows — retains heat.
Vessel widens — releases heat; redness & warmth (also seen with inflammation).
Wound Healing
Four Stages of Wound Healing
Clotting cascade → fibrin mesh established. Vasoconstriction limits bleeding & pathogen invasion.
Vasodilation → hyperemia & edema. Neutrophils kill bacteria & debride; macrophages phagocytose. Cytokines released.
Day 3–10, weeks to complete. Granulation tissue forms; new vascular network; epithelialization begins; fibroblasts proliferate.
Day 21–1 yr. Collagen strengthens wound; edges contract; fibroblast apoptosis smooths scar; angiogenesis stops.
Nutrients Required for Healing
Tissue Repair Fuel
Fuel for repair cells. Often lost in wound exudate — increases needs. Losing 10% lean muscle mass = lowered immunity + infection risk.
Energy + Growth Signals
Fuel metabolic needs during healing. Increase hormone and growth factor secretion needed for repair.
Cell Function + Prostaglandins
Important for normal cell function. Precursors to prostaglandins — role in inflammation and cellular metabolism.
Arginine & Glutamate
Arginine: inflammatory process, collagen synthesis, stimulates growth hormones, activates T cells. Glutamate: inflammation + guards against wound infection.
A, B, C, D, E
A: fibroplasia & epithelialization · B: enzymatic function · C: collagen synthesis + angiogenesis · D: structural integrity · E: immune system + healthy tissue
Zinc & Curcumin
Zinc: immune response, decreases infection risk. Curcumin (turmeric): active in inflammatory, proliferation, and remodeling phases.
Conditions That Impair Wound Healing
- Vasoconstriction — cold, alpha-1 agonists, beta blockers, pain/fear, hypovolemia, nicotine
- Diabetes — poor perfusion, neuropathy, reduced collagen & angiogenesis, impaired neutrophil chemotaxis/phagocytosis
- Tobacco use — nicotine → vasoconstriction; CO → ↓ O₂; alters immune response
- Obesity — oxidative stress → impaired perfusion & epithelialization; ↑ infection risk
- Stress — elevated cortisol → impaired immune response
- Corticosteroids — immunosuppression
- Anti-inflammatories — if taken in first days post-injury
- Chemotherapy — impairs healing
- Radiation — limits O₂ delivery to wound
- Chronic venous insufficiency, peripheral artery disease
- Excessive wound exudate, biofilm, infection, slough, or eschar
Excessive Wound Healing / Scarring
- Excess collagen — organized and smooth
- Aligns with original wound margins
- May shrink over time
- Expands beyond original wound borders
- Hyperactive fibroblasts → irregular collagen
- Associated with: infection, tension, foreign bodies, trauma
- More common in Black, Hispanic, and Asian individuals
Chronic Wounds
A wound is considered chronic if it is open for more than 1 month or does not progress through normal healing stages. Most prevalent in clients older than 65.
Deep, punched-out, well-demarcated borders; may contain eschar; pale, hairless, cool skin. Cause: poor arterial perfusion (PAD).
Irregular edges, weeping, edema, pigmentation changes; typically lower leg. Cause: venous insufficiency / hypertension.
Common on ball of foot, callused border, may be painless due to neuropathy. Cause: neuropathy + poor perfusion.
Over bony prominence, staged 1–4 + unstageable + DTI. Cause: unrelieved pressure, friction, shear.
⚡ Diabetic foot ulcer interventions: antibiotic therapy · wound culture · antihyperglycemic medications · offloading pressure from foot. NOT indicated: positive pressure wound therapy as first-line, high-protein restriction. Manage blood glucose to promote healing.
Wound Assessment — COCA + STONEES
- Color
- Odor
- Consistency
- Amount
- Sanguineous = bloody · Serosanguinous = blood + serous · Purulent = pus
- Size becoming larger
- Temperature increasing
- Os (bone exposed)
- New breakdown
- Erythema
- Exudate
- Smell
Moisture-Related Skin Injuries
- Caused by prolonged exposure to urine and/or stool
- ICU incidence ~5%
- Skin becomes overhydrated → more susceptible to shearing & friction
- Skin flora can enter disrupted layer → worsens condition
- Inflammation of skin on folded surfaces — between fingers, axilla, under breasts
- Skin folds trap moisture
- Maceration can become infected with Candida or other organisms
- Broad category of moisture-related skin breakdown
- ICU incidence ~13%
- Skin is not too moist OR too dry — balance matters
- Includes IAD, wound edge maceration, perspiration-related damage
Skin Tears
- Traumatic wounds caused by mechanical forces — shearing, friction, trauma, falls
- Also caused by removal of adhesives (tape)
- Can be anywhere on the body
- Partial flap loss or total flap loss
- Age 65+ — highest risk; aging + fragile skin separates easily
- Chronic illness, aggressive behavior, prior skin tears
- Dependent on ADLs — requires assisted repositioning
- Chronic steroid use — thins skin significantly
Diagnostic Tools for Chronic Wounds
- Compares ankle BP to brachial BP
- ABI <0.9 = arterial perfusion problem
- Helpful in differentiating arterial vs. venous wounds
- Doppler ultrasound for venous problems
- BPA (Bacterial Protease Activity) — measures pathogenic bacteria in wound → guides treatment
- EPA (Excessive Inflammatory Protease Activity) — measures human protease in wound → identifies wounds unlikely to heal
- Elevated BPA or EPA → further debridement warranted
- Preferred method for wound culture without biopsy
- Culture >100,000 colony-forming units = infection
- Biopsy with culture is most definitive for chronic wounds
- Lab tests: CBC, BMP, serum protein, albumin, prealbumin, transferrin
Wound Treatments
Negative Pressure Wound Therapy
Occlusive dressing + vacuum → −50 to −125 mmHg. Removes exudate, promotes granulation tissue, reduces healing time and dressing changes.
150–250 volts
Electrodes near wound. Decreases infection, increases perfusion, accelerates healing.
Up to 3 ATM
Pressurized chamber + 100% O₂ → improves circulation and oxygenation → decreases edema. Can be whole-body or localized.
Light Therapy
Reduces bacteria, increases perfusion, increases ATP production. Improves inflammatory skin conditions and cancerous lesions.
⚡ Dressing logic: Wet wound = remove moisture. Dry wound = add moisture/hydration to wound bed.
Integumentary Diagnostic Procedures
- Room darkened → UV light used
- Best for light skin or hypopigmented areas
- Dark skin: use bright lighting to detect red/bluish-gray undertones
- Reveals infection, differentiates dermal vs. epidermal lesions
- Confirms fungal skin lesion
- Scales scraped and mixed with potassium hydroxide
- Positive = fungal hyphae (threadlike filaments) seen under microscope
Diascopy — Blanch Test
Painless glass slide pressed directly on the lesion:
Vascular / inflammatory lesion.
Hemorrhagic / nonvascular — petechiae, purpura, nevus.
Culture & Sensitivity
- Culture = isolate pathogen on culture media
- Sensitivity = effect of antimicrobials on microbe
- Do cultures BEFORE starting antimicrobial therapy
- Preliminary results: 24–48 hr; Final: 72 hr
- Bacterial: Culturette tube with cotton-tip applicator + fixative
- Viral: Cotton-tip applicator from intact vesicle fluid → immediately on ice
- Fungal: Wooden tongue depressor scrapes scales → clean container; punch biopsy if inconclusive
⚡ Herpes specimen: Use cotton-tipped applicator to obtain vesicle fluid from INTACT lesions. Place immediately on ICE. Viral — do NOT scrape with tongue depressor (bacterial/fungal method).
Biopsy Types
- Most common technique
- 2–6 mm plug removed with cutting instrument
- With or without sutures
- Removes only the raised portion of lesion
- Scalpel or razor blade
- No suturing required
- Larger and deeper specimen
- Suturing required
- Used when complete removal needed
⚡ Post-biopsy education: Dressings can be removed after 8 hr. Clean with tap water or 0.9% saline. Report redness, warmth, drainage, fever. Sutures removed in 3–10 days depending on site. Results may take several days.
Skin Disorders — Psoriasis & Dermatitis
Psoriasis
Autoimmune disorder — keratin overproduction at up to 7× normal rate. Periods of exacerbation and remission. No cure — treatment targets severity and epidermal turnover rate.
- Infections (strep throat, Candida, URI)
- Skin trauma (surgery, sunburn)
- Genetics · Stress · Obesity
- Hormones (puberty, menopause)
- Meds: lithium, beta blockers, indomethacin
- Warm weather = improves manifestations
- Mild — <5% BSA
- Moderate — 5–10% BSA
- Severe — >10% BSA
- Psoriasis Vulgaris — reddened, thickened, silvery white scales; bilateral distribution; elbows, knees, scalp, sacrum
- Exfoliative — erythema + scaling from severe inflammation; can cause dehydration & hypo/hyperthermia
- Palmoplantar Pustulosis — hyperkeratotic areas; palms & soles; cyclic course
Psoriasis Medications
| Medication | Action | Nursing Actions / Education |
|---|---|---|
| Corticosteroids (triamcinolone, betamethasone) — Topical | Reduce inflammation, suppress cellular division | Monitor for skin thinning, striae, hypopigmentation. Avoid face/skin folds. Plastic wrap occlusion OK up to 8 hr. Take medication vacations. |
| Coal Tar preparations | Suppress cellular division, reduce inflammation | Monitor for irritation. Causes staining + odor — apply at night, cover with old PJs/gloves/socks. |
| Vitamin D analogs (calcipotriene, calcitriol) | Prevent proliferation, regulate cell division | Monitor for hypercalcemia (muscle weakness, fatigue, anorexia). Limit sun exposure. Do not apply to face. |
| Vitamin A (tazarotene) | Slows cellular division, reduces inflammation | Contraindicated in pregnancy. Monitor burning, desquamation. Avoid UV light. |
| Methotrexate / Acitretin — Systemic | Reduce epidermal cell turnover; severe cases | Monitor liver & renal function. Bone marrow suppression risk. Contraindicated in pregnancy. Avoid alcohol. May reduce contraceptive effectiveness. |
| Biologics (adalimumab, etanercept, infliximab, ustekinumab, alefacept) | Suppress immune function, inhibit keratinocyte stimulation | Screen for latent TB and hepatitis B before starting. Inspect prefilled syringe for particles/discoloration. Rotate injection sites; do NOT rub after injection. Protect from light. No live vaccines. Lifelong treatment. Increased cancer risk. Do not take if pregnant/breastfeeding. |
| Cyclosporine / Azathioprine | Immunosuppressant — last resort | Short-term (<6 months). Nephrotoxicity. Monitor BP (can cause hypertension). |
Phototherapy (PUVA)
- Psoralen (methoxsalen) given orally 2 hr before UV treatment
- Treatments 2–3×/week — not consecutive days
- Narrow-band UVB: no medication needed, fewer treatments
- Laser light: mild–moderate, targets lesion only
- Wear eye protection during AND 24 hr after each treatment (indoors + outdoors)
- Avoid direct sunlight 8–12 hr post-treatment
- Apply sunscreen
- Long-term effects: premature aging, cataracts, skin cancer
- Regular eye exams required
Dermatitis
Health Promotion: Avoid exposure to harsh chemicals. Use appropriate skin hygiene — daily bathing/showering and thorough handwashing. Avoid known allergens and irritants.
- Thickened areas of skin
- Dry or moist/crusted
- Pruritus
- Symmetrical, anywhere on body
- Genetic predisposition, stress
- Direct exposure to allergen, chemical, or mechanical irritant
- Well-demarcated, localized rash
- Distribution varies by exposure site
- Patch test helpful for diagnosis
- Chronic — allergens or chronic disease
- Intense pruritus + thickened skin + scaling/desquamation
- Face, neck, upper torso, antecubital & popliteal folds
- More common in children; adults — often periorbital
- Unknown cause — immune, genetic, or environmental
Dermatitis Medications
| Medication | Use | Key Education |
|---|---|---|
| Steroids (topical/systemic) | Reduce inflammation | Taper when stopping long-term use. Do not use on infected lesions. Avoid occlusive dressings on topical steroids for dermatitis. |
| Antihistamines (diphenhydramine, cetirizine, fexofenadine) | Relieve redness, pruritus, edema | Photosensitivity. Drowsy — take systemic form at bedtime. Do not drive. Monitor for urinary retention. |
| Tacrolimus / Pimecrolimus (topical immunosuppressants) | Eczema resistant to glucocorticoids | No occlusive dressings. Avoid if infection present. Discontinue when rash clears. Avoid sunlight and tanning beds. |
⚡ Comfort measures for psoriasis: oatmeal baths, emollient creams, do not scratch or pick lesions. For contact dermatitis in children: colloidal oatmeal bath is recommended.
Skin Infections & Inflammation
Wound Infection Continuum
Microorganisms present — no infection yet. No signs.
Microbes multiplying — not yet causing infectious response. None / subtle.
Microbes overwhelm immune system. Warmth, redness, pain, drainage.
Beyond wound — cellulitis, lymph nodes. Extended erythema, lymphadenopathy, malaise, anorexia.
Bloodstream invasion — sepsis. Fever, organ involvement.
Biofilm: Sticky matrix of microbes forming a layer over the wound — makes wound resistant to antibiotics, not easily removed by cleansing. Requires debridement.
Common Skin Infections
Findings: pustules, papules, nodules; erythematous, edematous, warm, painful; fever, malaise, chills
Treatment: topical antibacterial superficial; systemic cephalosporin/penicillin extensive; vancomycin IV or oral linezolid/clindamycin for MRSA
Findings: itching, pain, stinging; vesicles → pustules → ulcerate → crust; face, oral mucosa, genitalia, trunk
Treatment: acyclovir, valacyclovir, or famciclovir; Burow's solution compress 20 min × 3/day
Findings: itching/burning; oral: white plaques; body folds: erythematous moist lesions
Treatment: nystatin, clotrimazole, miconazole (topical antifungals)
⚡ Clotrimazole is an ANTIFUNGAL — not for viral or bacterial. Apply to clean, DRY skin. Continue applying for up to 2 weeks after lesions are gone to prevent recurrence.
MRSA
MRSA = methicillin-resistant Staphylococcus aureus. Can begin as skin infection → progress to systemic infection → sepsis → death. Most common in older adults in long-term care. Treat with IV vancomycin or oral linezolid/clindamycin. More prevalent in recent years.
Chronic Wound Causes — Three Categories
- Diabetes mellitus
- Malnutrition
- Connective tissue diseases (e.g., rheumatoid arthritis)
- Neuropathy (e.g., diabetic peripheral neuropathy)
- Arterial or venous insufficiency
- Lymphatic problems
- Continued pressure (immobility)
- Infection
- Autoimmune conditions
Serious Skin Conditions
- Commonly called "flesh-eating bacteria"
- Often caused by Group A Streptococcus
- Rare but life-threatening
- Rapidly destroys skin, fascia, and underlying tissue
- Serious skin condition — often drug-induced
- Painful macules and papules → skin sloughing
- Involvement of mucous membranes (mouth, eyes)
- Distinguished from psoriasis (scaly patches, no sloughing) and atopic dermatitis (itchy, dry — no mucous membrane involvement)
Common Inflammatory Skin Conditions
- Redness and rash over nose and cheeks
- Chronic inflammatory condition
- Triggers: sun, heat, spicy food, alcohol
- Raised, itchy welts on skin surface
- Allergic reaction — IgE-mediated
- Can progress to anaphylaxis
- Treated with antihistamines
- Oil from skin blocks hair follicles → lesions (pimples)
- Common on face, back, chest
- Inflammatory + noninflammatory subtypes
Lifestyle & Nutritional Risk Factors for Inflammation
Omega-3 and omega-6 fatty acids have a protective effect against inflammatory skin diseases. Risk factors that worsen inflammation: decreased dietary fiber, decreased omega fatty acids, gluten ingestion (linked to eczema flares and celiac comorbidity), smoking, alcohol, obesity, and poor sleep. Avoid these to reduce inflammatory skin disease exacerbations.
Anaphylaxis
- Hives, GI upset, faint/dizzy
- Throat tightness, difficulty breathing, wheezing
- Low blood pressure, elevated heart rate
- Feeling of impending doom
- Cardiac arrest
- Seek treatment — call 911
- Allergen — identify it
- Follow up with allergy specialist
- Epinephrine kit — always carry
- ⚡ Priority action: administer epinephrine IM
⚡ Common allergen triggers: Food (peanuts, tree nuts, shellfish, milk, eggs) · Latex (gloves, IV tubes, catheters) — higher risk in healthcare workers · Medications (penicillin, ASA, NSAIDs, anesthesia) · Insect stings (bees, wasps, fire ants)
Contagious Skin Infections — Community Education
Scabies (mites) and lice (pediculosis): highly contagious; spread by direct skin-to-skin contact and sharing personal items (combs, clothing, bedding). Report to schools, daycares, and communal living facilities. All household/close contacts should be treated simultaneously. Wash all clothing/linens in hot water. Impetigo: contagious bacterial skin infection; keep child home from school until 24 hr after starting antibiotics. Contact precautions. Emphasize handwashing and not sharing towels/clothing.
Pressure Injuries
Pressure injuries (PIs) occur when unrelieved bidirectional pressure between a bony prominence and a surface compromises blood flow. Common sites: sacrum, hip, buttock, heel, back of head, shoulder, elbow. ICU incidence: 10–20%. Long-term care: 20–30%.
Risk Factors
- Fragile/thin skin · Low muscle mass
- Decreased blood flow · Poor nutrition
- Spinal cord injury · Obesity
- Excessive moisture (incontinence)
- Neurological injury · Immobility
- Sensory perception · Moisture
- Activity · Mobility
- Nutrition · Friction & Shear
- High volatility of friction/shear subscores predictive of hospital-acquired PI
PI Staging — Tissue Depth
Prevention Interventions
Offload
Elevate heels off bed. Reposition every 2 hr (unless hemodynamically unstable). Use air/pressure-relief beds. 30° lateral side-lying + wedge.
Gentle Repositioning
Reposition manually and gently. Protect sacrum with soft silicone multilayered foam dressing.
Minimize Sliding
Head of bed <30° when possible. Use glide sheets/hoists. Do NOT drag client.
Skin Protection
Clean promptly if incontinent. Gentle pH-balanced cleansers + moisturize. Apply barrier cream. Use breathable incontinence pad.
DIDN'T HEAL — Nonhealing PI Causes
⚡ Stage 4 PI with fever, COPD, diabetes, and yellow exudate → suspect infection. Order: WBC count, wound culture, total protein/albumin/prealbumin, HgbA1c, and consider MRI to evaluate extent of tissue involvement.
Burns
Health Promotion & Burn Prevention
- Ensure adequate number and placement of fire extinguishers, smoke alarms, and CO detectors — know how to use them
- Keep emergency numbers near the phone
- Have a family exit and meeting plan — never re-enter a burning building
- Follow stop, drop, and roll to extinguish fire on clothing/skin
- Store matches and lighters out of reach of children
- Set water heater to ≤48.9°C (120°F)
- Annual professional chimney/fireplace inspection
- Turn pot/pan handles to the side or use back burners
- Don't leave hot cups at counter edges
- Cover electrical outlets
- Keep flammable objects away from heat sources (candles, space heaters)
- Wear gloves when handling chemicals; keep chemicals away from children
- Wear sunscreen and protective clothing outdoors; avoid tanning beds
- No smoking in bed or under influence of alcohol/sedating medications
- Never add flammable substances (gasoline, lighter fluid) to an open flame
- Do not smoke or have open flames near oxygen equipment
Burns Pathophysiology — Three Zones
Coagulation of proteins; decreased blood flow → tissue loss.
Decreased blood flow but damage is reversible; salvageable with proper burn resuscitation.
Hyperemia from histamine & prostaglandins; least likely to sustain permanent damage.
Types of Burns
- Dry heat — open flames, explosions
- Moist heat / Scalds — hot liquid, steam (more common in older adults & young children)
- Contact — hot metal, tar, grease
- Chemical — caustic agents (drain cleaner, bleach, sulfuric acid)
- Electrical — current through body; can cause cardiac/respiratory arrest
- Radiation — sunburn, cancer therapy
- Flames — 41%
- Scalds — 31%
- Electrical — 3.6%
- Chemical — 3.5%
- Males 2× more likely than females in adults
- Children 1–15 and working-age adults 20–59 at highest risk
Burn Depth
⚡ Sunburn = Superficial (1°) — damage to epidermis only. Pink, painful, no blisters.
Rule of Nines & Burn Assessment Methods
Anterior view shown. Posterior trunk mirrors anterior: upper back 9% + lower back 9%.
- Head & neck — 9%
- Each arm — 9%
- Chest (anterior) — 9%
- Abdomen (anterior) — 9%
- Upper back — 9%
- Lower back — 9%
- Each thigh — 4.5%
- Each lower leg — 4.5%
- Perineum — 1%
- More exact method
- Accounts for age-specific differences in head/leg proportions
- Used in burn centers; can be in EHR
- Client's palm (including fingers) = 1% TBSA
- Used for scattered burns
- Quick estimate
Primary & Secondary Survey
- A — Airway: assess patency, inhalation injury
- B — Breathing: rate and quality of respirations
- C — Circulation: blood pressure, pulse, skin color
- D — Disability: neurological impairment or other trauma
- E — Exposure & environmental control: remove all clothing, jewelry, contact lenses; view entire body including back; assess temperature to prevent hypothermia
- History of events (type of burn, location, length of exposure, fuel source, blast/explosion)
- Full health history
- Head-to-toe assessment
- Determine depth, size, and severity of burn
- Severity reassessed at 48–72 hr (initial assessment may underestimate)
Stopping the Burning Process
⚡ Purpose of burn decontamination: remove potential toxins from the client (not for odor control, not for assessment, not to reduce medications). Wear PPE during decontamination: gloves, gown, eye protection, respiratory protection (BSI precautions).
- Extinguish flames or remove heat source
- Remove clothing and jewelry that may conduct heat
- Apply cool water soaks — do NOT use ice
- Chemical burns: brush dry chemicals off first, then flush with large amounts of water; liquid chemicals flush immediately
- Cover burn with clean cloth — prevents contamination and hypothermia
- Provide warmth
- Perform ABCDE primary survey
- Cool — cool water 3–5 min; no ice or ice water (causes hypothermia)
- Clean — mild soap & water or antibacterial wash; avoid excess friction
- Cover — antimicrobial ointment + absorbent nonadherent dressing (if clothing irritates burn)
- Comfort — OTC or Rx analgesics
- Teach family: NO butter or greasy lotions on burns
- Teach signs of infection; check tetanus immunization status
Burn Phases of Care
Secure airway, fluid replacement, pain management, infection prevention, wound care, maintain temperature, emotional support. Half of 24-hr IV fluid in first 8 hr from injury time, remainder over next 16 hr.
Fluid shift resolves. Monitor cardiovascular, respiratory, GI systems. Wound care, pain control, nutrition (may need 5,000 cal/day), psychosocial support.
Scar/contracture prevention, resumption of activities, psychosocial support. Compression dressings (23 hr/day, up to 24 months). Follow-up 2 years post-burn. Range of motion exercises.
System-by-System Nursing Management (Moderate/Major Burns)
- Monitor respiratory rate and depth; monitor chest expansion (eschar/dressings on chest/neck/back may restrict)
- Upper airway edema peaks 8–12 hr after fluid resuscitation begins; crowing/stridor/dyspnea = intubation needed
- Provide humidified supplemental O₂
- Mechanical ventilation + paralytics (atracurium/vecuronium) if PaO₂ <60 mmHg
- Tracheotomy if long-term intubation expected
- Chest physiotherapy, coughing, deep breathing, incentive spirometry
- Suction Q1hr or as needed; administer additional analgesics if needed
- Monitor chest tubes if present
- Monitor central and peripheral pulses
- Capillary refill, pulse oximetry
- Invasive and noninvasive blood pressure monitoring
- ECG changes (especially with electrical burns)
- Daily weights; monitor for edema and fluid shifts
- Third spacing (capillary leak syndrome): continuous plasma leak from vascular to interstitial → electrolyte imbalance + hypotension; expect in first 24–48 hr
- Skin loss → body loses heat; decreased temperature expected in first hours
- Interventions: warm inspired air, warm room, warming blankets, warm IV fluids; keep wounds covered; work quickly when wounds exposed
- Low-grade fever may develop later from ↑ metabolism and can persist for weeks
- Insert NG tube to reduce aspiration risk or for bowel decompression
- Some clients develop gastroparesis and vomiting
- Monitor stool, vomitus, and gastric secretions for blood
- Monitor for hypomotility and tolerance of feedings
- Insert indwelling urinary catheter
- Monitor I&O — urine output goal 0.5 mL/kg/hr (~30 mL/hr)
- Red-tinged urine = damage to red blood cells or muscles (myoglobin)
- Glycosuria = expected (glycogen breakdown via stress response)
- Mannitol: used after electrical burns when myoglobin obstructs renal tubules, hindering urine output
- Restrict plants and flowers — risk of Pseudomonas aeruginosa contact
- Check facility policy on fresh fruits/vegetables (may be restricted)
- Limit visitors — no sick individuals, small children, or other clients
- Use client-dedicated equipment (BP cuffs, thermometers)
- Administer tetanus toxoid
- Antibiotics to treat confirmed infection — monitor peak and trough levels
- Strict asepsis with all wound care
- Maintain correct body alignment; splint extremities
- Facilitate position changes to prevent contractures
- Active and passive range of motion exercises
- Assist with ambulation as soon as client is stable
- Apply pressure dressings to prevent contractures and scarring
- Monitor high-pressure areas (heels, sacrum, back of head)
- Provide emotional support; assist with coping
- Antianxiety medications may be needed
- Address body image concerns about altered appearance
- Assist client through stages of grieving
- Provide peer support with client's approval
- Involve client in decision-making (e.g., how long procedures will take) to reduce anxiety
Fluid Resuscitation Formulas
⚡ Fluid goals: Urine output 0.5 mL/kg/hr (~30 mL/hr average adult). Base deficit <2. SBP >90. No altered mental status. Use crystalloids (LR or 0.9% NaCl) — first choice. Colloids (albumin) after first 24 hr.
⚡ Signs of hypovolemia in burns: Urine output <30 mL/hr, confusion, hypotension, increased capillary refill time. If urine output low → request increased fluid; do NOT give diuretics.
Inhalation Injury — Danger Signs
⚡ Impending airway loss: Hoarseness · Brassy cough · Drooling or difficulty swallowing · Audible wheezes, crowing, stridor. Upper airway edema peaks 8–12 hr after fluid resuscitation begins. Signs of CO poisoning: headache, weakness, dizziness, confusion, cherry red skin. Carboxyhemoglobin >10% = smoke inhalation.
Burn Lab Values — Resuscitation Phase (0–24 hr)
- Hct/Hgb — hemoconcentration (fluid shift out)
- Glucose — stress response
- BUN — fluid loss
- Potassium — cell destruction (hyperkalemia)
- Chloride — renal reabsorption
- Sodium — third spacing (hyponatremia)
- Total protein / albumin
- Hct/Hgb ↓ (hemodilution — fluid shifts back)
- Potassium ↓ (hypokalemia — renal loss)
- Sodium remains ↓
- WBC — initial increase, then ↓ with left shift
- Plasma lactate ↑ = cyanide toxicity (from smoke inhalation)
- Liver enzymes — elevated (hepatic edema, apoptosis)
- Clotting studies — rare decrease in platelets or prolonged clotting in severe burns
- Carboxyhemoglobin >10% = smoke inhalation confirmed
- ABGs — possible metabolic acidosis
Burn Wound Care & Skin Coverings
- Silver nitrate 0.5% — bacteriostatic; stains clothing/linen black; depletes Na/K; doesn't penetrate eschar; apply with gauze dressing
- Silver sulfadiazine 1% — gram+ and gram−, yeast; usually pain-free; apply thin layer with clean glove; contraindicated in sulfa allergy, pregnancy, and infants; do not use around eyes; transient neutropenia risk; may cause gray/blue-green discoloration
- Nanosilver — slowly releases silver over 5 days; dressings changed less frequently
- Mafenide acetate — penetrates eschar; can cause metabolic acidosis; painful to apply and remove; use on small wounds only; apply twice daily
- Polymyxin B-bacitracin — gram+ bacteriostatic; painless; every 2–8 hr to keep burn moist
- Apiary honey — antimicrobial properties; promotes wound healing in burn wounds
- Autograft — client's own skin; permanent; best option; sheet or mesh graft
- Allograft (homograft) — cadaver skin; temporary (2–4 weeks)
- Xenograft (heterograft) — porcine (pig) skin; temporary; change every 2–3 days
- Amnion — human placenta; requires frequent changes
- Cultured epithelium — client's biopsied skin grown in lab; for clients with few graft sites
- Synthetic skin — plastic/silicone; usually clear (allows wound visualization); reduces pain
- Biosynthetic skin — combination of synthetic + biological materials; used for superficial partial-thickness burns or donor sites; exudate drains through the dressing
- Artificial skin — two layers derived from beef collagen and shark cartilage; promotes healing without grafting
- Escharotomy — incision through eschar to relieve circumferential constriction; prevents compartment syndrome
- Fasciotomy — incision through eschar AND fascia when escharotomy alone is insufficient to relieve tissue pressure
Wound Care Nursing Actions
- Premedicate client with analgesic before wound care
- Remove all previous dressings
- Note any odors, drainage, and discharge
- Monitor for sloughing, eschar, bleeding, and new skin-cell regeneration
- Cleanse wound thoroughly — remove all previous ointments
- Apply thin layer of topical antibiotic ointment; cover with dressing (sterile asepsis)
- Mechanical — scissors and forceps cut away dead tissue during hydrotherapy
- Hydrotherapy — warm tub or running water (shower-style); use mild soap or detergent, rinse with room-temp water; encourage client to exercise joints during treatment
- Chemical — topical enzyme (collagenase) applied to wound during daily dressing change to break down and remove dead tissue
- Surgical excision — remove thin layers of necrotic tissue until bleeding (viable tissue) ideally within first 48 hr
Skin Graft Nursing — Nonadherence Watch
Monitor for graft failure: Caused by poor wound bed preparation, shearing or traumatizing the graft, or infection. Signs of infection before/after grafting: discoloration of unburned skin surrounding wound · green subcutaneous fat · degeneration of granulation tissue · subeschar hemorrhage · hyperventilation (systemic infection) · unstable body temperature. Report graft nonadherence to provider immediately.
Post-graft nursing actions: Maintain immobilization of graft site · Elevate extremity · Provide wound care to donor site · Administer analgesics · Determine client's level of pain; additional measures for donor site pain.
Burn Complications
| Complication | Key Points | Nursing Actions |
|---|---|---|
| Sepsis — most common cause of death post-burn | Bacteria on skin not killed by burn can contaminate wound; hospital-acquired infections also occur | Monitor discoloration, edema, odor, drainage; monitor temperature/HR fluctuations; wound cultures; antibiotics; surgical asepsis; reinforce infection control education |
| Airway Injury | Effects may not appear for 24–48 hr; progressive hoarseness, brassy cough, drooling, copious secretions, wheezes, crowing, stridor | Support airway and ventilation; supplemental oxygen; intubation/mechanical ventilation if needed |
| Fluid Imbalances | Hypovolemic shock from inadequate replacement; fluid overload from excessive replacement → heart failure | Monitor perfusion (confusion, hypotension, low UO) and overhydration (bounding pulse, crackles, edema) |
| Contractures / Impaired Mobility | Scarring limits movement; scar tissue shortens and tightens skin, muscles, tendons | Active/passive ROM 3×/day; neutral positions with limited flexion; splints; ambulate ASAP; compression dressings up to 24 months |
| Compartment Syndrome | Edema increases as skin loses elasticity; circumferential burns especially at risk | Monitor peripheral circulation on affected extremities; escharotomy or fasciotomy if needed |
| Paralytic Ileus | Can be indicator of systemic infection | Monitor bowel sounds and abdominal distention; NG decompression until motility returns; report to provider |
| Post-Traumatic Stress Disorder | Burn = traumatizing event; psychosocial stress related to pain, appearance changes, and long recovery | Encourage client to discuss feelings about the event; refer to mental health professional |
Burn Center Transfer Criteria
Transfer to burn center if: Partial thickness burns >10% TBSA · Burns to face, hands, feet, genitalia, perineum, major joints · 3rd degree (full thickness) · Electrical (including lightning) · Chemical · Inhalation injury · Preexisting disorders that complicate recovery · Burns + other traumatic injuries
Burn Pain Management
⚡ During resuscitation phase — avoid routes other than IV (decreased absorption from other routes). IV opioids: morphine, hydromorphone, fentanyl, ketamine, nitrous oxide. PCA appropriate for some clients. Pre-medicate before dressing changes. Monitor for respiratory depression.
Burn Nutrition
Large burns create a hypermetabolic and hypercatabolic state requiring up to 5,000 calories/day. Caloric needs double or triple 4–12 days post-burn and can persist up to 3 years. High protein (55–60% carbohydrates to decrease protein catabolism). Enteral nutrition preferred over TPN. Daily calorie count + daily weights.
Burn Client Education — Recovery
Wear compression dressings/garments as prescribed (23 hr/day, up to 24 months) to minimize scarring. Massage scars with moisturizer daily. Avoid tight-fitting or dyed clothing over burned areas — use loose, dye-free fabric. Sexual activity is OK as desired. Use splints and assistive devices as instructed. Anticipate appearance changes — scarring/discoloration will occur. Follow-up appointments for 2 years post-burn.
Interprofessional Burn Team
Burn management involves a full interdisciplinary team:
Exam Hits
Burns — Fluid Route
IV Only During Resuscitation — Subcutaneous, oral, and transdermal routes have decreased absorption during the resuscitation phase. Administer analgesics IV only.
Rule of 10s Calculation
Round TBSA to Nearest 10 — 38% TBSA → round to 40 → 40 × 10 = 400 mL/hr. For weight over 80 kg add 100 mL/hr per extra 10 kg.
Fluid Resuscitation Timing
First 8 Hours — Half of 24-hr calculated volume → first 8 hr from time of burn (NOT admission time). Remaining half → next 16 hr.
Sunburn Classification
Superficial (1°) — Epidermis only. Pink, painful, no blisters. Heals in 3–6 days. No scarring.
Hoarseness + Brassy Cough
Inhalation Injury — Hoarseness + brassy cough + drooling = impending airway loss from inhalation injury. Not pulmonary edema, not pneumonia, not CO poisoning.
Burn Nutrition
Up to 5,000 Cal/Day — Large burns = hypermetabolic state. Caloric needs 2–3× normal, 4–12 days post-burn. High protein + high carbohydrate diet. Enteral preferred over TPN.
MRSA Treatment
Vancomycin IV — Or oral linezolid or clindamycin. Penicillin/cephalosporins won't work. Methicillin-resistant = resistant to standard beta-lactams.
Herpes Specimen
Cotton Tip + ICE — Cotton-tipped applicator from INTACT vesicle. Place immediately on ice. NOT a tongue depressor. NOT KOH solution (that's fungal).
KOH Test
Fungal Only — Confirms fungal lesion. Positive = fungal hyphae under microscope. Used after scraping scales with wooden tongue depressor.
Biopsy — Post-care
8 hr / 3–10 Days — Remove dressing after 8 hr. Clean with tap water or 0.9% saline. Suture removal: 3–10 days depending on site. Report redness, warmth, drainage, fever.
PUVA Eye Protection
During + 24 hr After — Wear eye protection during treatment AND for 24 hr after (indoors and outdoors). Avoid direct sunlight 8–12 hr post-treatment.
Colonization vs. Infection
Multiplying ≠ Infecting — Colonization = microbes are present and multiplying but NOT causing an infectious response. No local signs of infection yet.
Anaphylaxis Priority Action
Epinephrine IM — When respiratory or cardiovascular compromise is present → give epinephrine IM immediately. Not antihistamine first, not monitoring first.
NPWT Purpose
Remove Exudate + Promote Granulation — Negative pressure wound therapy removes moisture (exudate) and helps new skin cells fill in the wound. Not oxygen-based, not antibiotic-based.
Skin Tear Risk
Age 65+ + Steroids — Highest risk: elderly (>65) + chronic steroid use → thinned fragile skin → susceptible to shearing and friction skin tears.
Diabetic Foot Ulcers
Most Likely Chronic — Diabetes → poor perfusion + neuropathy → wounds heal slowly or fail to heal. Diabetic foot ulcers = most common chronic wound.
Epidermis Functions
Waterproof + Flora + Color — Epidermis: prevents fluid entry (waterproof), contains normal flora, influences skin color via melanocytes. Sweat glands and hair follicles are in the DERMIS.
Psoriasis PUVA Med
Methoxsalen — Oral 2 hr Before — Psoralen photosensitizing medication given 2 hr before UVA treatment. Treatments 2–3×/week, NOT consecutive days.
Chronic Wound Cause Categories
Systemic / Regional / Local — Systemic: diabetes, malnutrition, connective tissue disease. Regional: neuropathy, arterial/venous insufficiency. Local: pressure, infection, autoimmune. Neuropathy = regional, NOT systemic.
ABI Threshold
ABI < 0.9 = Arterial Problem — Ankle-brachial index less than 0.9 indicates arterial perfusion problem. Use Doppler ultrasound for venous insufficiency diagnosis.
EPA vs. BPA Test
BPA = Bacteria · EPA = Healing Unlikely — BPA measures pathogenic bacteria (treat infection). EPA measures human protease activity — elevated = wound unlikely to heal, guide further debridement.
Escharotomy vs. Fasciotomy
Escharotomy First, Fasciotomy If Insufficient — Escharotomy = incision through eschar only. Fasciotomy = incision through eschar AND fascia. Used when escharotomy alone cannot relieve compartment pressure.
Mannitol — Electrical Burns
Myoglobin Blocking Renal Tubules — Electrical burns → muscle destruction → myoglobin released → obstructs renal tubules → red-tinged urine. Mannitol clears obstruction and restores urine output.
Four C's — Minor Burns
Cool · Clean · Cover · Comfort — Cool with water 3–5 min (no ice). Clean with mild soap. Cover with antimicrobial ointment + absorbent dressing. Comfort with analgesics. Teach: NO butter or greasy lotions.
Burn Hypovolemia Actions
Two Large-Bore IVs + Catheter — Hypovolemia signs → insert two large-bore peripheral IVs for fluid replacement + urinary catheter for urine output monitoring + monitor extremity perfusion (compartment syndrome risk).
Paralytic Ileus in Burns
Sign of Systemic Infection — Paralytic ileus after burns can indicate systemic infection. Intervene: NG decompression, monitor bowel sounds + distention, report to provider.
Stevens-Johnson Syndrome
Skin Sloughing + Mucous Membranes — SJS: painful macules/papules → skin sloughing + mucous membrane involvement. Not psoriasis (scaly, no sloughing). Not atopic dermatitis (no mucous membranes). Often drug-induced.
Silver Sulfadiazine Contraindications
Sulfa Allergy · Pregnancy · Infants · Eyes — Contraindicated: sulfa allergy, pregnancy, infants, near eyes. Also causes transient neutropenia and gray/blue-green discoloration.
Burn Infection Prevention
Plants · Visitors · Tetanus — Restrict plants/flowers (Pseudomonas risk). Limit visitors — no sick, children, or other clients. Client-dedicated equipment. Administer tetanus toxoid. Strict asepsis for all wound care.
IAD vs. Intertrigo vs. MASD
Moisture Injury Distinctions — IAD = incontinence-related skin damage (urine/stool). Intertrigo = skin fold inflammation (axilla, under breasts) → Candida risk. MASD = broad category of moisture damage, ICU incidence ~13%.
Psoriasis Physical Findings
Scaly + Pitting Nails + Bleeding — Scaly patches + bleeding when scales removed + pitting/crumbling nails + pruritic lesions on elbows, knees, scalp, sacrum, lateral extremities. Exfoliative type can cause dehydration and temperature instability.
Biosynthetic Dressings
Synthetic + Biological — Drains Exudate — Biosynthetic dressings combine synthetic and biological materials. Used for superficial partial-thickness burns or donor sites. Exudate drains through the dressing. Distinct from synthetic (plastic/silicone, clear) and artificial skin (beef collagen + shark cartilage).
Diabetic Ulcer Interventions
Antibiotics · Wound Culture · Glucose Control — Diabetic ulcer interventions: antibiotic therapy, wound culture, antihyperglycemic medications, offload pressure. NOT positive pressure wound therapy as first-line. NOT protein restriction — protein is needed for wound healing.
Burn Decontamination
Purpose = Remove Toxins from Client — The purpose of burn decontamination is to remove potential toxins from the client. NOT for reducing smell, NOT for assessment ease, NOT to reduce medication needs. Wear full PPE (gloves, gown, eye protection, respiratory protection).
Burn Labs — Diuretic Phase
WBC Left Shift + Plasma Lactate — Diuretic phase (48–72 hr): WBC initially increases then ↓ with left shift. Plasma lactate ↑ = cyanide toxicity from smoke inhalation. Hct/Hgb ↓ (hemodilution). Potassium ↓ (hypokalemia). Sodium remains ↓.
Burn Respiratory — Paralytic Threshold
PaO₂ <60 → Vent + Paralytics — If PaO₂ <60 mmHg → mechanical ventilation + paralytics (atracurium or vecuronium). Tracheotomy if long-term intubation expected. Incentive spirometry, chest physio, cough/deep breathing. Suction Q1hr as needed.
ATI Practice Test
Immune System Malfunction, Infection & Anaphylaxis
When immunity misfires — attacking healthy tissue, losing the fight against pathogens, or overreacting to a harmless trigger. Lupus, rheumatoid arthritis, gout, fibromyalgia, infection & antimicrobial resistance, HIV/AIDS, and anaphylaxis.
Immune System Malfunction Map
Autoimmune disorders occur when small antigens bond with healthy tissue, and the body produces antibodies that attack that tissue — triggered by toxins, medications, bacteria, or viruses. There is no cure for autoimmune disease; treatment goals are to control manifestations and decrease the number and frequency of exacerbations. Occurrence of autoimmune disorders increases with age.
This unit also covers two related musculoskeletal/connective tissue conditions that don't sit neatly on the immune spectrum above: gout (a metabolic, crystal-deposition disease) and fibromyalgia (a chronic pain syndrome often seen alongside autoimmune disease).
Lupus Erythematosus (SLE & DLE)
Lupus is a chronic autoimmune disease — the immune system attacks the body's own tissue. It may involve a single organ or the entire body. There are two main types: Systemic Lupus Erythematosus (SLE) and Discoid Lupus Erythematosus (DLE). A temporary, medication-induced form also exists — findings resolve when the medication is discontinued.
- Most common type of lupus
- Affects tissues of multiple organ systems — can lead to major organ failure
- Inflammation can be acute or chronic
- Arthritis common, especially symmetric in hands, wrists, knees — usually no excess joint fluid
- Osteonecrosis can occur in later stages disability
- Common type of cutaneous lupus — immune system directly attacks the skin
- Red, scaly, coin-shaped lesions on face, ears, scalp, or other sun-exposed areas — can change to dark brown over time; sores may occur in the nose or mouth
- Can cause permanent scarring or hair loss if lesions develop on the scalp
- Not as severe as SLE, but can progress to SLE
Organ Systems Affected by SLE
The manifestation most indicative of lupus nephritis is hematuria — it reflects direct kidney involvement, unlike the more general SLE findings of facial rash, joint pain, or fatigue.
Raynaud's Phenomenon
(ischemia)
(cyanosis)
(rubor)
Epidemiology & Risk Factors
- Genetic predisposition — over 50 genes are associated with lupus
- Females (sex assigned at birth), 15–44 years old — estrogen may act as a trigger
- Ethnicity: Black, Hispanic, Asian, or Indigenous clients — younger onset, more severe manifestations, more complications
- Family history of lupus or another autoimmune disorder
- Environmental triggers: Epstein-Barr virus, UV light (including fluorescent light bulbs), silica dust, trauma, infection, certain medications, stress
- An estimated 160,000+ people in the U.S. have a definitive SLE diagnosis
A client newly diagnosed with SLE most classically reports fatigue — not weight gain (weight loss/anorexia is more typical), not petechiae (the butterfly rash is more classic), and not a systolic murmur (a pericardial friction rub is more typical).
Expected Findings
- Fatigue / malaise
- Alopecia
- Dry eyes
- Pleuritic pain
- Confusion, depression
- Joint pain, swelling, tenderness
- Headaches
- Anorexia / weight loss
- Fever — also a major indication of exacerbation
- Anemia, lymphadenopathy
- Pericarditis (cardiac or pleural friction rub)
- Raynaud's phenomenon
- Butterfly rash or discoid coin-shaped lesions
- Oral lesions
- Few to no manifestations if in remission
- Multi-system involvement with exacerbation
Butterfly-shaped facial rash + fatigue + recent hair loss anticipate an ANA (antinuclear antibody) assay to help confirm SLE. A strongly positive result indicates SLE.
Laboratory Testing
- Skin biopsy — diagnoses DLE by confirming lupus cells and cellular inflammation
- BUN & creatinine — increased with kidney involvement
- Urinalysis — positive for protein and RBCs with kidney involvement
- CBC — pancytopenia; also helps rule out other conditions that mimic lupus
- Diagnostic imaging — checks for infection/joint damage; doesn't confirm lupus but helps rule out other disorders
Knowledge check — an SLE client with fatigue, joint tenderness/swelling, and difficulty urinating: expect positive ANA titer, 2+ urine protein, and elevated BUN (not increased hemoglobin — anemia is typical; not increased C3/C4 — these decrease with active disease).
Complications
Psychosocial impact: chronic pain, severe fatigue, and cognitive issues make ADLs and work difficult. Facial rashes can cause self-consciousness. Unpredictable flare-ups take an emotional toll — anxiety and depression may occur.
Prognosis, Health Promotion & the Aging Adult
- Lupus is not considered a fatal disease, but about 10–15% of people who have lupus die prematurely due to health complications
- Takes an average of 6 years from first manifestations to diagnosis — subtle, flare/remit, mimic other disorders
- Cardiovascular disease (incl. stroke) plus kidney disease are risks from systemic inflammation
- Adequate rest, a balanced diet, and gentle exercise help ease manifestations
- Avoid environmental triggers (UV/fluorescent light, stress); treat any infection right away
- Both DLE and SLE can worsen with age — DLE may progress to SLE
- Older clients with SLE and kidney disease may require dialysis or transplant as they age
Coping strategies: finding a support system among family, friends, colleagues, or the community can reduce the psychosocial impact of lupus. Setting goals around what the client can control also promotes self-management.
Foamy urine suggests proteinuria and the ankle edema suggests fluid overload — together these are cues of lupus nephritis / nephrotic-range protein loss, not simply an arthritis flare. Prioritize monitoring fluid balance and renal status over the musculoskeletal complaint.
Nursing Process for Lupus Care
Medications
Treatment categories include antimalarials, steroids, NSAIDs, immunosuppressives, anticoagulants, monoclonal antibodies, and repository corticotropin injection.
- Pain, mobility, fatigue; vital signs (especially BP)
- Hypertension & edema (renal compromise); urine output
- Diminished breath sounds (pleural effusion)
- Tachycardia + sharp inspiratory chest pain (pericarditis)
- Rubor, pallor, cyanosis of hands/feet (Raynaud's)
- Mental status changes; BUN, creatinine, nutritional status
- Wide-brimmed hat, long sleeves/pants, sunscreen outdoors
- Avoid UV and prolonged sun exposure
- Use steroid creams for skin rash
- Report peri/periorbital edema promptly
- Avoid crowds/sick individuals — illness can trigger a flare
- No vaccinations without discussing with provider first
Sun exposure is a common environmental trigger for SLE flare-ups — client teaching should emphasize UV avoidance over exercise, weight gain, or caffeine concerns.
Rheumatoid Arthritis
RA is precipitated by WBCs attacking synovial tissue — the tissue becomes inflamed and thickened, and inflammation extends to cartilage, bone, tendons, and ligaments, causing joint deformity and bone erosion. RA affects joints bilaterally and symmetrically. It is also systemic — can affect blood vessels, the pleura, pericardium, and the eyes. Early diagnosis and treatment can prevent permanent joint damage.
Health promotion: continue using affected joints and ambulating to maintain function and ROM. Moderate physical activity for 150 min/week improves outcomes.
Risk Factors
- Female sex
- Age 30–60 years
- Genetic predisposition
- Bacterial or viral infection
- Stress and smoking
- Environmental factors; older age
Late-Stage Joint Deformities
Joint deformities are LATE manifestations of RA. Joint swelling, warmth, and erythema are common earlier findings.
Expected Findings
- Pain and stiffness in the morning, after long periods of sitting, or at rest
- Pleuritic pain (pain upon inspiration); xerostomia (dry mouth)
- Anorexia/weight loss; fatigue; recent illness/stressor
- Joint pain; limited range of motion; subcutaneous nodules
- Fever (generally low-grade); muscle weakness
Early manifestations of RA (fatigue, joint discomfort) are vague and can easily be attributed to other disorders in older adult clients — a key reason RA can be missed early.
Laboratory Tests
Knowledge check — tests used to diagnose RA: ESR, Anti-CCP antibodies, and ANA titer (not RBC count or potassium level).
Diagnostic Procedures
- Synovial fluid aspiration — increased WBCs & protein with RA
- Monitor for bleeding, pain, fever, swelling at the site; apply ice
- Take acetaminophen for pain; avoid strenuous exercise for a few days
- Determines degree of joint destruction and monitors progression
- Assist the client into position; minimize movement during the procedure
Home health priority for an RA client: assess the environment for fall risks. When collecting pain data, first ask "Where is your pain?" — location orients the rest of the assessment.
Nursing Care & Safety
- Assist with and encourage physical activity to maintain joint mobility
- Monitor for indications of fatigue
- Reinforce measures to maximize functional activity and minimize pain
- Monitor for medication effectiveness — reduced pain, increased mobility
- Assist with referrals for physical and occupational therapy
- Provide information for support organizations
- Facilitate assistive devices — power-lift chairs, raised toilet seats, grab bars
- Initiate fall precautions
Medications
- Infliximab Anticipated
- Naproxen Anticipated
- Dexamethasone Anticipated
- Opioid Not Anticipated
- Azathioprine Not Anticipated
- Hydroxychloroquine Not Anticipated
NSAIDs (naproxen) and corticosteroids (dexamethasone) treat active inflammation. A biologic anti-TNF DMARD (infliximab) is anticipated as second-line/combination therapy. Opioids are typically reserved for OA. DMARDs like hydroxychloroquine are usually started early — not newly added after 10 years.
Corticosteroid teaching SATA for an acute RA exacerbation — include: avoid crowds, your blood glucose may increase, and visual changes should be reported. (Not: long-term treatment — steroids are NOT long-term for RA.)
Therapeutic Procedures & Interprofessional Care
- Total Joint Arthroplasty — surgical repair/replacement for a severely deformed joint unresponsive to medication
- Synovectomy — surgical removal of the synovial membrane
- Plasmapheresis — removes circulating antibodies from plasma for a severe, life-threatening exacerbation
- Refer to occupational therapy for adaptive devices, ADL support, and deformity prevention; refer to support groups
Differentiating Joint Pain: RA vs. OA vs. Gout
RA is autoimmune, symmetric, worse with rest/morning stiffness. Osteoarthritis (OA) is largely wear-and-tear — a documented risk factor is a history of joint injury. Gout is a crystal-deposition disease, classically asymmetric and severe at the great toe.
For a client on long-term NSAIDs for osteoarthritis, the biggest red flag is a history of a stomach ulcer within the past 6 months.
Gout (Gouty Arthritis)
Gout is a systemic disorder caused by hyperuricemia (increased serum uric acid). Urate levels are affected by medications, diet, and overproduction in the body — leading to uric acid crystal deposits in the joints and a gout attack.
- Most common form
- Three stages: asymptomatic hyperuricemia, acute gouty arthritis, chronic gout
- Uric acid production > excretion by the kidneys
- Can have a genetic component
- Middle/older adult males and postmenopausal clients
- Caused by another disease/condition — chronic kidney failure, some carcinomas, excessive diuretic use
- Treatment targets the underlying condition
- Can affect people of any age
Primary Gout: 3-Stage Progression
Risk Factors
- BMI greater than 30
- Heredity; trauma
- Alcohol ingestion; diuretic use
- Some chemotherapy agents; chronic kidney disease
Knowledge check — risk factors for gout: diuretic use, BMI > 30, and excessive alcohol consumption. Deep sleep deprivation and depression are risk factors for fibromyalgia, not gout.
Uric Acid Threshold
Blood uric acid: repeated measurements are needed because dietary intake affects results. Consistent elevation above 6.8 mg/dL is associated with gout. Also elevated: urinary uric acid, BUN/creatinine, ESR.
Diagnostic procedure: aspiration of synovial fluid for analysis of uric acid crystals. Nursing care: monitor pain, redness/swelling of the affected joint, and blood uric acid levels.
Medications
- Colchicine — decreases pain/inflammation; use cautiously with impaired kidney function
- NSAIDs — contraindicated with impaired kidney function or stomach ulcers; do not take on an empty stomach
- Corticosteroids — treats inflammation; taper, don't stop abruptly
- Xanthine Oxidase Inhibitor (allopurinol, febuxostat) — uric acid production; take after meals with a full glass of water
- Uricosuric (probenecid) — promotes uric acid excretion
- Enzyme (pegloticase) — IV every other week for refractory gout; monitor closely for anaphylaxis
Client education: stay on a low-purine diet (no organ meats or shellfish); limit alcohol intake; avoid diuretics; increase fluid intake; practice medication adherence.
Fibromyalgia
Fibromyalgia manifests as widespread musculoskeletal pain, stiffness, tenderness, and generalized muscle weakness affecting both sides of the body. Pain is typically a constant dull ache lasting 3 months or more. Affects about 4 million people in the U.S. People who have fibromyalgia often have another rheumatologic disorder, such as RA or SLE.
Widespread Pain & Linked Symptoms
Risk Factors
- Females (sex assigned at birth) over 40 years of age
- History of stressors: trauma, infection, autoimmune disease, genetic history
- Deep sleep deprivation
- History of osteoarthritis, rheumatoid arthritis, lupus, or obesity
Nursing care: monitor pain, mobility, and fatigue. Provide emotional support to the client and family.
Medications
Knowledge check — for a new fibromyalgia diagnosis, anticipate a prescription for a tricyclic antidepressant (e.g., amitriptyline) — not a calcium channel blocker, loop diuretic, or beta blocker.
Other therapies: cognitive/behavioral therapy, sleep therapy and stress management, physical/occupational care. Client education: limit caffeine/alcohol; develop a sleep routine; regular low-impact exercise; complementary therapies (acupuncture, tai chi, hypnosis).
Infection, Sepsis & Antimicrobial Resistance
Virus vs. bacterium: viruses require a host to become active — they are dormant outside a host organism.
Infection Sites
Antimicrobial Resistance (AMR) — How Pathogens Fight Back
Not completing a full prescribed antibiotic course gives bacteria the opportunity to adapt and become resistant — a major contributor to AMR.
Client teaching about AMR: antibiotics used to treat an AMR infection may have more serious side effects, because first-line antibiotics may no longer be effective.
- Temperature Improved
- Breath sounds No Change
- Sodium level Declined
- Edema Declined
- Blood pressure Declined
- Follows commands Declined
- Peripheral circulation Declined
Even though temperature improved, this client is trending toward septic/hypovolemic shock — declining sodium, LOC, and peripheral circulation are the bigger red flags. Always look at the overall trend, not a single improved value.
5 findings requiring immediate follow-up: abdominal findings, vital signs, electrolytes, radiographic images, and pain characteristics — together indicating peritonitis causing hypovolemia.
HIV & AIDS
CD4-T-Cell Count & Disease Stage
Case in point: a client's CD4-T-cell count dropped from 650 cells/mm³ (2 months ago) to 150 cells/mm³ (today) — from the normal range into the AIDS range. Priority hypothesis: at risk for developing opportunistic infections.
Anaphylaxis & Hypersensitivity
Clients recovering from anaphylactic shock should be closely monitored for PTSD (posttraumatic stress disorder) as a psychosocial complication.
A client who wheezed after an insect bite should be taught to avoid walking outside barefoot to prevent future reactions.
Exam High-Yield Summary
Post-sepsis syndrome — manifestation to monitor
Reduced organ function
6-month NSAID use for OA — biggest concern
Treated for a stomach ulcer within the past 6 months
Pediatric meningitis — structure affected
Tissue surrounding the brain (meninges)
AMR — mechanism that removes antibiotics from the cell
Activation of drug efflux pumps
Butterfly rash + fatigue + hair loss — anticipated lab
Antinuclear antibody (ANA) assay
Hospitalized influenza — most concerning cue
Compromised alveolar function in the lungs
Acute sinusitis — expected finding
Facial pressure
Newly diagnosed HIV+ — barrier to care
Fear of social stigma
HIV education — preventing respiratory infection
Avoid smoking
Fever + stiff neck + photosensitivity — anticipated test
Lumbar puncture
College students — bacterial meningitis transmission
Prolonged contact (coughing, kissing)
Virus vs. bacteria — true statement
"Viruses require a host to become active."
Anaphylaxis anaphylactic shock — key indicator
Cardiac arrhythmia
Reducing flu spread — best recommendation
Disinfect surfaces frequently
Wheezing after insect bite — prevention teaching
Avoid walking outside barefoot
AMR — contributing client action
Not taking the entire prescribed antibiotic course
Acute-stage HIV — manifestation
Night sweats
Recovering from anaphylactic shock — psychosocial risk
PTSD
Acute sinusitis — risk factor
Recently having had a cold
Older adult with influenza — priority complication
Pneumonia
AMR client teaching
Antibiotics used to treat AMR may have more serious side effects
SLE — environmental flare trigger
Sun exposure
Osteoarthritis — risk factor
History of injury
Influenza — common manifestation
Fever
Influenza — increased risk for severe complications
History of diabetes
Case — HIV + active TB (SATA)
All 5 true: lifelong opportunistic infection testing, sputum cultures, AIDS/severe immunocompromise, active TB manifestations, CBC w/ diff
Case — cloze, CD4 650 150
At risk for opportunistic infections due to CD4-T-cell count
Case — RA meds, anticipated vs. not
Anticipated: infliximab, naproxen, dexamethasone. Not anticipated: opioid, azathioprine, hydroxychloroquine
Case — post-op sepsis trend
Improved: temperature only. Declined: sodium, edema, BP, LOC, peripheral circulation. No change: breath sounds
Case — diverticulitis peritonitis, 5 priority findings
Abdominal findings, vital signs, electrolytes, radiographic images, pain characteristics
ATI Practice Test
Anaphylaxis
A severe, systemic hypersensitivity reaction — from allergen exposure and mast cell degranulation to epinephrine-first emergency management and discharge teaching.
Anatomy, Physiology & Pathophysiology
Anaphylaxis is a severe allergic reaction that occurs after exposure to an allergen. Lymphocytes produce antibodies specific to the allergen; those antibodies then bind to receptors on mast cells and basophils. When the allergen binds those antibodies, the cells release histamine and other mediator chemicals that trigger inflammation — quickly, and across multiple body systems at once.
Sensitization Pathway — Why It Takes Two Exposures
Example: a person stung by a bee may have no reaction the first time. After becoming sensitized, a second sting can trigger a full anaphylactic reaction.
Mast Cell Degranulation
Histamine and other mediator chemicals stored in granules are released from mast cells. This causes blood vessels to become more permeable — fluid leaks out, causing swelling — and to dilate, which can result in a dangerous drop in blood pressure.
Body Systems Affected
Anaphylactic shock is the final manifestation of severe anaphylaxis and can cause organ damage or failure. The cardiovascular and respiratory systems are usually affected most seriously. If swelling is severe enough to block the airway, the client can suffocate.
Epidemiological & Etiological Risk Factors
Common Trigger Categories
A less common trigger is exercise-induced anaphylaxis (EIA) — caused by intense physical activity, usually in people who have other allergic triggers or in combination with a medication or food.
Who's at Higher Risk
Anyone with an allergy can develop anaphylaxis — even if a prior reaction was mild. The following groups face a higher risk of a serious or fatal reaction:
How Common Is It?
Rates of anaphylaxis have increased globally, mostly due to medication and food reactions. The stats above likely understate the true rate — most episodes are self-treated and never result in hospitalization.
Anaphylaxis usually needs exposure to a trigger at least twice — but a non-immunologic ("anaphylactoid") reaction can occur on the first exposure. Seen with substances like IV contrast dyes or opioids.
Histamine's Effects on the Body
Systemically, histamine causes vasodilation, increased capillary permeability (leading to edema), and bronchoconstriction — the combination responsible for anaphylaxis's breathing difficulty and blood pressure collapse.
Clinical Presentation, Diagnosis & Psychosocial Impact
Biphasic anaphylaxis — a reaction can resolve, then recur hours to days later without re-exposure to the allergen. Some reactions are also delayed and don't develop for several days.
Laboratory Testing & Diagnostic Studies
Anaphylaxis is mainly diagnosed clinically — testing helps identify allergens and severity after the fact, not in the moment.
Psychosocial Impact
There's an established link between anaphylaxis and PTSD (posttraumatic stress disorder) — clients recovering from anaphylactic shock should be closely monitored for it. Fear of triggers can also restrict social habits, and school-age children may face bullying.
Health Promotion & Prevention
The most effective prevention is trigger avoidance. Immunotherapy can also help: a provider exposes the client to small, gradually increasing amounts of an allergen until the body becomes desensitized. May be necessary if a client has cancer or an autoimmune disorder complicated by anaphylaxis to a medication.
Role of the Nurse: Environmental & Individual Factors
Latex-Food Cross-Reactivity
Latex allergy cross-reacts with foods sharing similar proteins to the rubber tree. If a client is allergic to latex, consider them likely allergic to these foods — and if they report an allergy to one of these foods, consider them likely allergic to latex.
- Food — clearly identify/report allergies to food service; ask about ingredients & prep; contact facility food service or a nutritionist ahead of an elective stay
- Medication — screen for drug allergies; verify true allergy vs. intolerance; check for a medical ID bracelet before giving high-risk drugs
- Latex — repeated exposure raises allergy risk, especially for health care workers; many facilities are latex-free
Food intolerance is an unpleasant food reaction that is not immunologically mediated — it doesn't require anaphylaxis treatment. Celiac disease, eosinophilic GI disorder, and food protein-induced enterocolitis syndrome also require different, specialized treatment.
Client Education to Avoid Anaphylaxis Triggers
- Read all food labels carefully
- Ask restaurants about ingredients & prep, including cross-contamination
- Let friends & family know how serious food triggers are
- Tell all health care providers about allergies and the reaction
- Check with the pharmacist when receiving medication
- Do not walk around outside without shoes
- Be aware of insects around beverages and food
- Avoid bright, flowery clothing, perfumes, or lotions
- Inform all health or personal care providers
- Ask about balloon decorations before attending events
- Inform partners not to use latex condoms before sexual activity
Clients at risk should always carry an ID identifying the allergy plus an emergency epinephrine (EpiPen) auto-injector — with two emergency doses on hand at all times. Check the expiration date frequently, and know how to store and use it.
Nursing Process
- Client breathes effectively with relaxed breathing at a normal rate
- Hemodynamic stability — peripheral pulse 60–100 bpm; SBP within 20 mm Hg of baseline
- Client is alert and responsive
- Severe or protracted reaction
- History of asthma, arrhythmia, or systemic mastocytosis
- Client lives alone or in a remote area far from emergency care
Treatments & Therapies
Exam High-Yield Summary
Most common food allergen causing anaphylactic shock
Peanut (not apple, beef, or potato)
First nursing intervention during active anaphylaxis
Administer epinephrine — before diphenhydramine, Trendelenburg positioning, or supplemental oxygen
Initial manifestations of anaphylaxis
Rash, itching, swelling, difficulty breathing, GI upset
Systemic effects of histamine
Vasodilation, capillary permeability (edema), bronchoconstriction
Who's at increased risk for anaphylaxis
Asthma/chronic lung disease, beta-/alpha-blocker use, mastocytosis
Why beta blockers are dangerous during anaphylaxis
They blunt the effect of epinephrine, the primary treatment
Anaphylactoid (non-immunologic) reaction
Can occur on the first exposure — no prior antibody sensitization needed (e.g., IV contrast dye, opioids)
Biphasic anaphylaxis
Initial reaction resolves, then a second, often more severe reaction recurs hours to days later without re-exposure
Epinephrine dosing
0.3–0.5 mg IM every 5 minutes until manifestations resolve
Tryptase blood test timing
Drawn 1–3 hours after the reaction to confirm mast cell activation
Latex-food cross-reactivity
Avocado, banana, chestnut, kiwi + 7 others — allergy to one suggests allergy to the other
Psychosocial risk after anaphylactic shock
PTSD (posttraumatic stress disorder)
Discharge education priorities
ID + epi auto-injector at all times, trigger-specific avoidance teaching, 2 emergency doses, check expiration regularly
Trendelenburg position purpose
Increases venous return / blood flow to the heart after epinephrine administration
Exercise-induced anaphylaxis (EIA)
Triggered by intense physical activity, often combined with another allergen (food/medication)