medsurg / reading 1
Reading 1 · Med-Surg

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.

Preoperative Intraoperative Postoperative Transplant Nursing Safety / NPSG
01

Overview & the Nurse's Role

Perioperative nursing · 3 phases · AORN · patient-focused model
1
Phase 1
Preoperative

Surgery scheduled → transfer to the OR table.

2
Phase 2
Intraoperative

Transfer to the OR table → transfer to PACU.

3
Phase 3
Postoperative

Transferred to PACU → discharged home or to unit.

Primary Role of the Nurse
  • 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
AORN Role
  • 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.

Domain 1
Safety

Client safety throughout all phases. NPSG, wrong-site prevention, fall risk, pressure ulcer risk, cognitive decline in elderly.

Domain 2
Physiological Responses

Physical decline due to aging, dehydration, malnutrition. Addresses nursing problems and client outcomes.

Domain 3
Behavioral Responses

Cognitive changes, ability to perform self-care, depression, coping, anxiety management, patient education outcomes.

Domain 4
Health System

Health care economics and outcomes. More emphasis on structural data elements and analytical reporting. Standardized reporting elements.

BIG PICTURE

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.

02

Surgery Classifications

Purpose · seriousness · urgency · ASA physical status
Diagnostic
Diagnose/confirm disease
Colonoscopy, laparoscopy, gastroscopy
Curative
Eliminate disease/condition
Tumor resection, appendectomy
Preventative
Prevent future complications
Prophylactic mastectomy, colostomy before cancer spreads
Ablative
Remove/destroy tissue
Colectomy, endometriosis procedure
Palliative
Relieve pain
Remove pain-causing tumor
Constructive
Restore lost function present since birth
Cleft lip/palate repair
Restorative
Repair/restore damaged body part
Scar revision, breast reconstruction
Transplant
Transfer organ/tissue
Kidney, lung transplant
Cosmetic
Change physical appearance
Facelift, rhinoplasty
Seriousness — Major
Major Surgery

Risky; considerable work involved on the body.

Cardiac surgery, colon resection
Seriousness — Minor
Minor Surgery

Minimal work; minimal change to the body.

Dental, cataract, cosmetic facial
Emergent within minutes
Save life — severe trauma, cardiac procedure
Urgent within hours
Save life — appendectomy ⚡, cholecystectomy
Expedited within days
Not an emergency — carpal tunnel
Elective client's schedule
No urgency — joint replacements
EXAM TRAP

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.

I
II
III
IV
V
VI
Normal, healthy adult — no smoking, little alcohol use
Mild medical conditions — social smoker, drinker, well-controlled DM
Moderate–severe conditions — poorly controlled DM, BMI >40, HTN, pulmonary disorders
Severe condition in last 3 months — recent MI or stroke
Critical; likely to die without procedure — ruptured aneurysm, major organ dysfunction
Brain dead; organs preserved for donation — legally pronounced dead
QUICK CHECK

⚡ Social smoker + well-controlled DM = ASA II. Poorly controlled DM or BMI >40 = ASA III.

03

Perioperative Phases — Detailed

Preoperative prep · intraoperative care · postoperative recovery

Phase 1 — Preoperative

Physical Preparations
  • 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
Psychological Support
  • 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)

2hMinimum fast — clear liquids
6hMinimum fast — light meal (e.g. toast)
8hMinimum fast — fatty meal
GOOD TO KNOW

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 ⚡

SAFETY FLAG

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 / SensitivitySurgical Implication
Banana or kiwi⚡ Indicates risk for latex allergy — latex-free precautions required
Eggs or soybean oilContraindication to propofol (propofol is formulated in egg/soybean emulsion)
ShellfishMay not always contraindicate contrast media (iodine) — further data collection needed; not automatic contraindication

Informed Consent ⚡

What It Must Include (Provider Obtains)
  • 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
Roles
  • 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)
Client Must Be Legally Capable ⚡
  • 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
Two Witnesses Required When ⚡
  • 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
CHECKLIST

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.

NCLEX SCENARIO

⚡ 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)

ORIGIN

Combined by TJC, WHO, and AORN. Primary goal: improve client safety and reduce surgical complications and deaths.

1
Pre-anesthesia
Sign-In

Includes risk for >500 mL blood loss ⚡ — units of blood on hand? Anticoagulant history assessed here.

2
Before incision
Time-Out

Entire surgical team verifies: correct client, correct site (marked), correct procedure. Performed just before start.

3
Before leaving OR
Sign-Out

Specimen labeling, instrument counts, key recovery concerns communicated.

PRIORITY ACTION

⚡ 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

Common Tests
  • 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
Key Abnormals to Report Immediately ⚡
  • 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 FactorWhy It Increases Surgical Risk
Obstructive sleep apneaAirway obstruction, oxygen desaturation
PregnancyFetal risk with anesthesia
Respiratory disease (COPD, asthma, pneumonia)Compromised oxygenation and ventilation
Cardiovascular disease (HF, MI, HTN, dysrhythmias)Fluid overload, hemodynamic instability, dysrhythmias
Diabetes mellitusAltered blood glucose, delayed healing, infection, impaired circulation
Liver diseaseAltered medication metabolism + increased risk for bleeding
Kidney diseaseAltered elimination and medication excretion
Endocrine disorders (hypo/hyperthyroidism, Addison's, Cushing's)Metabolic instability; altered response to stress
Immune system disordersImmunocompromised → infection, delayed healing
Coagulation defectIncreased risk of bleeding
MalnutritionDelayed healing
BMI > 30Pulmonary 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 systemPsychosocial complications; poor recovery outcomes

Age-Related Risks (65+)

SystemChangeRisk
IntegumentaryDecreased subcutaneous fat; dry, fragile skinSlower healing; pressure injury
MusculoskeletalArthritic, inflamed jointsSwelling, discomfort, fall risk
Renal/UrinaryDecreased kidney function; incontinenceDecreased waste excretion
NeurologicalImpaired cognition; delayed reactions; sensory deficitsDelirium; fall risk
CardiovascularHypo/hypertension; decreased circulationCardiac complications
RespiratoryDecreased oxygenation; decreased lung elasticityShortness of breath; atelectasis
Oral/DentalDentures, bridges, loose teethProblems during intubation — must be identified preoperatively
ThermoregulationPerspires less; decreased subcutaneous fatDry, fragile skin; susceptible to temperature changes; pressure injury
Fluid/MuscleReduced muscle mass; decreased body waterAt risk for dehydration
WHY IT MATTERS

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

TIMEFRAME

Begins when client is transferred to the OR table; ends when client is transferred to the PACU or critical care unit.

Key Nursing Interventions
  • 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
Types of Anesthesia / Sedation
  • 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
TEST QUESTION

⚡ 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)

TIMEFRAME

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.

Immediate Priorities
  • 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)
Postoperative Care Elements
  • 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
DISCHARGE RULE

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

Airway & Breathing
  • 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
Kidney Function ⚡
  • 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
Bowel Function
  • 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)
Nausea & Vomiting ⚡
  • 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)
Fluid Status & Oral Comfort
  • 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

Effective Strategies
  • 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
Assessment & Nonpharmacological
  • 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

Monitoring Drainage & Wound
  • 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
Wound Healing & Nutrition
  • Encourage diet high in calories, protein, and vitamin C
  • If client has DM — maintain appropriate glycemic control
DVT Prevention — Key Details ⚡
  • 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.

CategoryScore 2Score 1Score 0
Activity2 Move 4 extremities1 Move 2 extremities0 Cannot move
Consciousness2 Fully awake1 Arousable0 Unarousable
Respiration2 Breathe deeply & cough1 Dyspnea / hypoventilation0 Apneic
O₂ Saturation2 ≥92% on room air1 O₂ needed to keep >90%0 <90% even with O₂
Circulation2 BP within 20% of pre-op1 BP 21–49% of pre-op0 BP ≥50% from pre-op

ERAS® Protocol (Enhanced Recovery After Surgery)

PROTOCOL

Surgical protocol to drive client-centered postoperative processes. Requires all disciplines — nursing, surgeons, anesthesiologists. Discharge planning begins preoperatively.

Early mobility Early nutrition & fluids Mild analgesics Manage N/V early Discontinue IV early Continue client/family education
04

Safety & Client Education

NPSG · SCIP · TeamSTEPPS · SBAR · I PASS the BATON · breathing exercises

National Patient Safety Goals (NPSG) — Surgical

Prevent Mistakes in Surgery (Universal Protocol)
  • 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
Prevent Infections (SCIP)
  • 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
60mAntibiotic given before incision
DO THE MATH

⚡ Surgery at 0900 → give antibiotic at 0800. Decreases risk of surgical site infection (SSI). Stop within 24 hr post-op.

RISK LIST

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

ORIGIN

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 ⚡

SBAR — Postoperative Hand-off
S
SituationWhy is client here? Introductions, confirm correct client, surgeon, procedure, site ⚡
B
BackgroundMedical/surgical history, allergies, age, lab & x-ray results, comorbidities ⚡
A
AssessmentAbnormal results, allergies, relevant history, prosthetics, family waiting, significant info
R
RecommendationNotify providers of abnormals, prevent allergic reactions, previous surgical complications communicated
I PASS the BATON — Pre-Intraoperative Transfer
I
IntroductionIntroduce yourself, role, job (include the client)
P
PatientIdentifiers, age, pronouns, gender, sex assigned at birth, location
A
AssessmentChief complaint, VS, manifestations, diagnosis
S
SituationCurrent status, code status, recent changes, response to treatment
S
Safety ⚡Critical lab values, socioeconomic factors, allergies, alerts (falls, isolation)
B
BackgroundComorbidities, previous episodes, current medications, family history
A
ActionsWhat actions were taken or required? Brief rationale.
T
TimingLevel of urgency, explicit timing and prioritization of actions
O
OwnershipWho is responsible? Include client & caregiver responsibilities.
N
NextWhat will happen next? Anticipated changes? Plan? Contingency plans?
MEMORY HOOK

Allergies are reported in the Safety (S) step of I PASS the BATON. Comorbidities are in Background (B) of SBAR.

Client Education — Preoperative & Postoperative

TIMING

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.

Preoperative Education Includes
  • 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
Postoperative Education Includes
  • 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

1

Lie supine or sit in a supportive chair.

2

Place one or both hands over the stomach.

3

Inhale through the nose — lower belly rises, chest relaxed.

4

Exhale through pursed lips — stomach pulls toward the spine.

5

Repeat ×5.

Deep Breathing Exercise ⚡

Sit back in chair / sit up in bed, then follow the breath cycle below — repeat ×3.

4sInhale, through nose
8sHold
8sExhale, pursed lips
WHY IT WORKS

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

SAFETY ALERT

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:

MedicationComplicationsNursing 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
05

Applying the Nursing Process

Recognize → Analyze → Prioritize → Generate → Act → Evaluate
1
Recognize Cues (Assessment)

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.

2
Analyze Cues (Analysis)

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.

3
Prioritize Hypotheses

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.

4
Generate Solutions (Planning)

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.

5
Take Actions (Implementation)

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.

6
Evaluate Outcomes

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 TypeAssessment ConsiderationsNursing Interventions
General Endotracheal
  • Respiratory: airway, lung sounds
  • Cardiovascular: arrhythmias
  • GI: N/V, return of peristalsis
  • Urinary: urinary retention (palpate, bladder scan)
  • Hypothermia · Malignant hyperthermia (MH)
  • Early ambulation (prevents atelectasis, constipation, urinary retention)
  • Incentive spirometry / deep breathing & coughing
  • Position to prevent aspiration during vomiting
  • NGT to suction if prescribed
  • Straight catheterization for urinary retention
  • Rewarming blanket for hypothermia
  • Dantrolene + cooling blanket / cool IV NS for MH ⚡
Regional
Peripheral nerve block
Spinal / Epidural
  • Nerve block: include tourniquet time in hand-off; neurovascular assessment (sensation, movement); monitor site for hematoma, infection, pain
  • Spinal/epidural: assess for spinal headache; monitor site for hematoma, infection, pain
  • Nerve block: proper positioning of numbed extremity to prevent injury
  • Spinal/epidural: proper positioning to prevent spinal headache
Sedation
(Minimal / Moderate / Deep)
  • Respirations & O₂ sat — respiratory depression
  • Blood pressure — hypotension
  • Level of consciousness & mental status
  • Ensure resuscitation equipment is available
  • IV fluids for hypotension
  • Reversal medications (e.g., naloxone) if needed

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
06

Potential Postoperative Complications

Malignant hyperthermia · airway obstruction · hypoxia · wound complications · paralytic ileus · DVT · hypothermia · hypovolemic shock
Airway · Priority Airway Obstruction

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

Nursing Actions:
  • 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
Respiratory Hypoxia

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
Genetic · Life-Threatening Malignant Hyperthermia (MH)

Trigger: Inhaled anesthetic medications and succinylcholine. Genetic — ask about personal AND family history of anesthesia complications. ⚡

Early manifestations:
TachycardiaTachypneaCardiac arrhythmiasHyperkalemiaHypercarbiaMuscular rigidity
Treatment:
  • 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
Wound Wound Dehiscence & Evisceration

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

Risk Factors:
  • Obesity; coughing/moving without splinting
  • Poor nutritional status
  • Diabetes mellitus; infection
  • Hematoma; steroid use
  • Impaired circulation; malnutrition
  • Smoking — impairs immune system, slows healing
GI Paralytic Ileus

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
Circulatory Hypovolemic Shock

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
Respiratory Atelectasis & Respiratory Complications

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.

WATCH FOR

⚡ Sleep apnea → higher risk of difficult intubation, increased O₂ need, cardiac/pulmonary complications post-op. Monitor for respiratory depression.

Temp Inadvertent Perioperative Hypothermia

Temp <36°C (96.8°F) → rewarming measures. Risk factor for: postoperative cardiac complications, SSI, and hemorrhage.

Postoperative Risk Factors & Their Complications

Risk FactorPotential Postoperative Complication
ImmobilityRespiratory compromise, thrombophlebitis, pressure injury
AnemiaBlood loss, inadequate/decreased oxygenation, impaired healing
HypovolemiaDecreased tissue perfusion, deep-vein thrombosis
Hypothermia (<36°C)Surgical wound infection, altered medication absorption, coagulopathy, cardiac dysrhythmia
Cardiovascular diseaseFluid overload, DVT, dysrhythmia
Respiratory diseaseRespiratory compromise
Immune disorderRisk for infection, delayed healing
Diabetes mellitusGastroparesis (delayed gastric emptying), delayed wound healing, increased infection, impaired circulation, hyperglycemia
Coagulation defectIncreased risk of bleeding
MalnutritionDelayed healing
BMI >30Respiratory 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 ⚡

Malnutrition Frequent falls Sleep apnea History of postoperative delirium VTE Inadvertent hypothermia Smoking Obesity Diabetes Inability to cope / lack of support system Disease processes involving multiple body systems
NOT ON THE LIST

Insomnia and arthritis are NOT listed among the common preoperatively-identifiable risk factors for postoperative complications.

07

Transplant Nursing

Organ procurement · donor care · rejection types · immunosuppressives
STANDARD

ANA published 16 standards guiding transplant nursing practice: ethics, evidence-based practice, communication, collaboration, resource utilization, advocacy. Practice spans novice to expert.

Organ Procurement Coordinator ⚡
  • 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
Unique to Transplant Post-op ⚡
  • 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 ⚡

1
Minutes–Hours
Hyperacute Rejection

Caused by specific antibodies against the graft. Occurs within minutes to hours of transplantation.

2
Days–Weeks
Acute Rejection

Caused by lymphocytes in recipient detecting antigens in transplanted tissue. Typically begins days to weeks after transplant.

3
Months–Years
Chronic Rejection

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 ⚡

1
Objective 1
Prevent rejection of the new organ
2
Objective 2
Minimize medication side effects
3
Objective 3
Ensure medication adherence (improve quality of life)
TRADE-OFF

Immunosuppressives → client is immunocompromised → higher risk of secondary infections. ⚡ This is a unique complication for transplant clients during preoperative risk identification.

Collaboration Standard ⚡

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

Providers Pharmacists Dietitians Physical Therapists Case Managers Nurses
08

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

09

ATI Practice Test

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Reading 2 · Med-Surg

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 Wound Healing Burns Pressure Injuries Skin Disorders Diagnostics
01

Skin Anatomy & Function

Three layers, temperature regulation, normal flora
BIG PICTURE

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.

1
Outermost
Epidermis

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
Middle
Dermis

2 layers beneath epidermis — contains sweat glands, hair follicles, muscle; sensory neurons; blood & lymphatic vessels. Hair follicles originate here.

3
Deepest
Hypodermis

Deepest = subcutaneous fascia. Adipose lobules + connective tissue, hair follicles, sensory neurons, blood vessels. Also called subcutaneous tissue.

Skin Thickness by Location

Thicker Areas
  • Palms of hands
  • Soles of feet
Thinner Areas
  • 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

Vasoconstriction

Vessel narrows — retains heat.

Vasodilation

Vessel widens — releases heat; redness & warmth (also seen with inflammation).

02

Wound Healing

Stages, conditions needed, factors that impair healing, chronic wounds, scarring

Four Stages of Wound Healing

1
Hemostasis

Clotting cascade → fibrin mesh established. Vasoconstriction limits bleeding & pathogen invasion.

2
Inflammation

Vasodilation → hyperemia & edema. Neutrophils kill bacteria & debride; macrophages phagocytose. Cytokines released.

3
Proliferation

Day 3–10, weeks to complete. Granulation tissue forms; new vascular network; epithelialization begins; fibroblasts proliferate.

4
Tissue Remodeling

Day 21–1 yr. Collagen strengthens wound; edges contract; fibroblast apoptosis smooths scar; angiogenesis stops.

Nutrients Required for Healing

Proteins

Tissue Repair Fuel

Fuel for repair cells. Often lost in wound exudate — increases needs. Losing 10% lean muscle mass = lowered immunity + infection risk.

Carbohydrates

Energy + Growth Signals

Fuel metabolic needs during healing. Increase hormone and growth factor secretion needed for repair.

Fats

Cell Function + Prostaglandins

Important for normal cell function. Precursors to prostaglandins — role in inflammation and cellular metabolism.

Amino Acids

Arginine & Glutamate

Arginine: inflammatory process, collagen synthesis, stimulates growth hormones, activates T cells. Glutamate: inflammation + guards against wound infection.

Vitamins

A, B, C, D, E

A: fibroplasia & epithelialization · B: enzymatic function · C: collagen synthesis + angiogenesis · D: structural integrity · E: immune system + healthy tissue

Minerals

Zinc & Curcumin

Zinc: immune response, decreases infection risk. Curcumin (turmeric): active in inflammatory, proliferation, and remodeling phases.

Conditions That Impair Wound Healing

Systemic / Physiological
  • 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
Medication / Treatment
  • 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

Hypertrophic Scars
  • Excess collagen — organized and smooth
  • Aligns with original wound margins
  • May shrink over time
Keloid Scars
  • 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

DEFINITION

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.

Arterial
Arterial Ulcer

Deep, punched-out, well-demarcated borders; may contain eschar; pale, hairless, cool skin. Cause: poor arterial perfusion (PAD).

Venous
Venous Ulcer

Irregular edges, weeping, edema, pigmentation changes; typically lower leg. Cause: venous insufficiency / hypertension.

Diabetic
Diabetic Ulcer

Common on ball of foot, callused border, may be painless due to neuropathy. Cause: neuropathy + poor perfusion.

Pressure
Pressure Injury

Over bony prominence, staged 1–4 + unstageable + DTI. Cause: unrelieved pressure, friction, shear.

DO / DON'T

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

COCA — Describe Drainage
  • Color
  • Odor
  • Consistency
  • Amount
  • Sanguineous = bloody · Serosanguinous = blood + serous · Purulent = pus
STONEES — Signs of Infection
  • Size becoming larger
  • Temperature increasing
  • Os (bone exposed)
  • New breakdown
  • Erythema
  • Exudate
  • Smell

Moisture-Related Skin Injuries

IAD — Incontinence-Associated Dermatitis
  • 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
Intertrigo
  • Inflammation of skin on folded surfaces — between fingers, axilla, under breasts
  • Skin folds trap moisture
  • Maceration can become infected with Candida or other organisms
MASD — Moisture-Associated Skin Damage
  • 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

Definition & Causes
  • 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
Risk Factors
  • 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

ABI — Ankle-Brachial Index
  • 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 vs. EPA Tests
  • 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
Levine Technique
  • 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

NPWT

Negative Pressure Wound Therapy

Occlusive dressing + vacuum → −50 to −125 mmHg. Removes exudate, promotes granulation tissue, reduces healing time and dressing changes.

Electrical Stimulation

150–250 volts

Electrodes near wound. Decreases infection, increases perfusion, accelerates healing.

Hyperbaric Oxygen

Up to 3 ATM

Pressurized chamber + 100% O₂ → improves circulation and oxygenation → decreases edema. Can be whole-body or localized.

Photodynamic Therapy (PDT)

Light Therapy

Reduces bacteria, increases perfusion, increases ATP production. Improves inflammatory skin conditions and cancerous lesions.

RULE OF THUMB

Dressing logic: Wet wound = remove moisture. Dry wound = add moisture/hydration to wound bed.

03

Integumentary Diagnostic Procedures

Wood's light, diascopy, culture & sensitivity, KOH test, biopsy
Wood's Light Exam
  • 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
KOH Test
  • 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:

Blanches (Fades)

Vascular / inflammatory lesion.

Does NOT Blanch

Hemorrhagic / nonvascular — petechiae, purpura, nevus.

Culture & Sensitivity

Key Points
  • 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
Specimen Collection
  • 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
COMMON MIX-UP

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

Punch Biopsy
  • Most common technique
  • 2–6 mm plug removed with cutting instrument
  • With or without sutures
Shave Biopsy
  • Removes only the raised portion of lesion
  • Scalpel or razor blade
  • No suturing required
Excisional Biopsy
  • Larger and deeper specimen
  • Suturing required
  • Used when complete removal needed
AFTERCARE

⚡ 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.

04

Skin Disorders — Psoriasis & Dermatitis

Pathophysiology, classifications, medications, phototherapy

Psoriasis

~28dNormal epidermis turnover
~4dPsoriasis turnover
MECHANISM

Autoimmune disorder — keratin overproduction at up to 7× normal rate. Periods of exacerbation and remission. No cure — treatment targets severity and epidermal turnover rate.

Risk Factors
  • Infections (strep throat, Candida, URI)
  • Skin trauma (surgery, sunburn)
  • Genetics · Stress · Obesity
  • Hormones (puberty, menopause)
  • Meds: lithium, beta blockers, indomethacin
  • Warm weather = improves manifestations
Classification by BSA
  • Mild — <5% BSA
  • Moderate — 5–10% BSA
  • Severe — >10% BSA
Types
  • 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

MedicationActionNursing Actions / Education
Corticosteroids (triamcinolone, betamethasone) — TopicalReduce inflammation, suppress cellular divisionMonitor for skin thinning, striae, hypopigmentation. Avoid face/skin folds. Plastic wrap occlusion OK up to 8 hr. Take medication vacations.
Coal Tar preparationsSuppress cellular division, reduce inflammationMonitor for irritation. Causes staining + odor — apply at night, cover with old PJs/gloves/socks.
Vitamin D analogs (calcipotriene, calcitriol)Prevent proliferation, regulate cell divisionMonitor for hypercalcemia (muscle weakness, fatigue, anorexia). Limit sun exposure. Do not apply to face.
Vitamin A (tazarotene)Slows cellular division, reduces inflammationContraindicated in pregnancy. Monitor burning, desquamation. Avoid UV light.
Methotrexate / Acitretin — SystemicReduce epidermal cell turnover; severe casesMonitor 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 stimulationScreen 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 / AzathioprineImmunosuppressant — last resortShort-term (<6 months). Nephrotoxicity. Monitor BP (can cause hypertension).

Phototherapy (PUVA)

Protocol
  • 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
Education
  • 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

PREVENTION

Health Promotion: Avoid exposure to harsh chemicals. Use appropriate skin hygiene — daily bathing/showering and thorough handwashing. Avoid known allergens and irritants.

Nonspecific Eczematous
  • Thickened areas of skin
  • Dry or moist/crusted
  • Pruritus
  • Symmetrical, anywhere on body
  • Genetic predisposition, stress
Contact Dermatitis
  • Direct exposure to allergen, chemical, or mechanical irritant
  • Well-demarcated, localized rash
  • Distribution varies by exposure site
  • Patch test helpful for diagnosis
Atopic Dermatitis
  • 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

MedicationUseKey Education
Steroids (topical/systemic)Reduce inflammationTaper 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, edemaPhotosensitivity. Drowsy — take systemic form at bedtime. Do not drive. Monitor for urinary retention.
Tacrolimus / Pimecrolimus (topical immunosuppressants)Eczema resistant to glucocorticoidsNo occlusive dressings. Avoid if infection present. Discontinue when rash clears. Avoid sunlight and tanning beds.
COMFORT TIP

⚡ Comfort measures for psoriasis: oatmeal baths, emollient creams, do not scratch or pick lesions. For contact dermatitis in children: colloidal oatmeal bath is recommended.

05

Skin Infections & Inflammation

Bacterial, viral, fungal · Wound infection continuum · Anaphylaxis

Wound Infection Continuum

1
Contamination

Microorganisms present — no infection yet. No signs.

2
Colonization

Microbes multiplying — not yet causing infectious response. None / subtle.

3
Local Infection

Microbes overwhelm immune system. Warmth, redness, pain, drainage.

4
Spreading Infection

Beyond wound — cellulitis, lymph nodes. Extended erythema, lymphadenopathy, malaise, anorexia.

5
Systemic Infection

Bloodstream invasion — sepsis. Fever, organ involvement.

DEFINITION

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

Bacterial
Furuncles, Carbuncles, Cellulitis, MRSA

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

Daily antibacterial soap, warm compresses, do NOT squeeze, good hand hygiene
Viral
Herpes Simplex/Zoster

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

Avoid triggers, no tight clothing, air dry lesion, good hand hygiene
Fungal
Tinea/Candidiasis

Findings: itching/burning; oral: white plaques; body folds: erythematous moist lesions

Treatment: nystatin, clotrimazole, miconazole (topical antifungals)

Keep skin clean & dry, no sharing footwear, increase airflow
COMMON MIX-UP

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

DEFINITION

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

Systemic Causes
  • Diabetes mellitus
  • Malnutrition
  • Connective tissue diseases (e.g., rheumatoid arthritis)
Regional Causes
  • Neuropathy (e.g., diabetic peripheral neuropathy)
  • Arterial or venous insufficiency
  • Lymphatic problems
Local Causes
  • Continued pressure (immobility)
  • Infection
  • Autoimmune conditions

Serious Skin Conditions

Necrotizing Fasciitis
  • Commonly called "flesh-eating bacteria"
  • Often caused by Group A Streptococcus
  • Rare but life-threatening
  • Rapidly destroys skin, fascia, and underlying tissue
Stevens-Johnson Syndrome (SJS)
  • 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

Rosacea
  • Redness and rash over nose and cheeks
  • Chronic inflammatory condition
  • Triggers: sun, heat, spicy food, alcohol
Urticaria (Hives)
  • Raised, itchy welts on skin surface
  • Allergic reaction — IgE-mediated
  • Can progress to anaphylaxis
  • Treated with antihistamines
Acne
  • Oil from skin blocks hair follicles → lesions (pimples)
  • Common on face, back, chest
  • Inflammatory + noninflammatory subtypes

Lifestyle & Nutritional Risk Factors for Inflammation

NUTRITION LINK

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

Signs
  • Hives, GI upset, faint/dizzy
  • Throat tightness, difficulty breathing, wheezing
  • Low blood pressure, elevated heart rate
  • Feeling of impending doom
  • Cardiac arrest
Be SAFE
  • Seek treatment — call 911
  • Allergen — identify it
  • Follow up with allergy specialist
  • Epinephrine kit — always carry
  • ⚡ Priority action: administer epinephrine IM
KNOW YOUR TRIGGERS

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

COMMUNITY HEALTH

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.

06

Pressure Injuries

Stages, Braden scale, risk factors, prevention, DIDN'T HEAL
DEFINITION

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

Client Factors
  • Fragile/thin skin · Low muscle mass
  • Decreased blood flow · Poor nutrition
  • Spinal cord injury · Obesity
  • Excessive moisture (incontinence)
  • Neurological injury · Immobility
Braden Scale Subscores
  • Sensory perception · Moisture
  • Activity · Mobility
  • Nutrition · Friction & Shear
  • High volatility of friction/shear subscores predictive of hospital-acquired PI

PI Staging — Tissue Depth

1
2
3
4
UN
DTI
Intact skin. Nonblanchable erythema.
Partial thickness — into dermis. Shallow ulcer or blister; red-pink bed.
Full thickness — into subQ. Deep crater; slough; undermining/tunneling.
Full thickness — to bone, tendon, or muscle exposed.
Unstageable — obscured by slough/eschar. Depth unknown until debrided.
DTI — deep tissue damage under intact skin. Persistent deep red/maroon/purple.

Prevention Interventions

Pressure

Offload

Elevate heels off bed. Reposition every 2 hr (unless hemodynamically unstable). Use air/pressure-relief beds. 30° lateral side-lying + wedge.

Friction

Gentle Repositioning

Reposition manually and gently. Protect sacrum with soft silicone multilayered foam dressing.

Shear

Minimize Sliding

Head of bed <30° when possible. Use glide sheets/hoists. Do NOT drag client.

Moisture

Skin Protection

Clean promptly if incontinent. Gentle pH-balanced cleansers + moisturize. Apply barrier cream. Use breathable incontinence pad.

DIDN'T HEAL — Nonhealing PI Causes

D
Diabetes
I
Infection
D
Drugs
N
Nutrition
T
Tissue necrosis
H
Hypoxia
E
Excessive wound tension
A
Another wound
L
Low temperature in wound area
RED FLAG

⚡ 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.

07

Burns

Classification, depth, rule of nines, fluid resuscitation, wound care, phases

Health Promotion & Burn Prevention

Home Safety
  • 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
Kitchen & Burn Source Safety
  • 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

1
Closest to source
Zone of Coagulation

Coagulation of proteins; decreased blood flow → tissue loss.

2
Next zone outward
Zone of Stasis

Decreased blood flow but damage is reversible; salvageable with proper burn resuscitation.

3
Outermost
Zone of Hyperemia

Hyperemia from histamine & prostaglandins; least likely to sustain permanent damage.

Types of Burns

By Source
  • 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
Leading Causes (Adults, US)
  • 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

Superficial
Area: epidermis only · Appearance: pink/red, no blisters, mild edema, no eschar · Sensation/Healing: painful/tender; heals 3–6 days; no scar · Example: sunburn, flash burn
Superficial Partial
Area: entire epidermis + some dermis · Appearance: pink/red, blisters, mild–moderate edema · Sensation/Healing: painful; heals 2–3 wks; minor pigment changes · Example: flash flame, scalds
Deep Partial
Area: entire epidermis + deep dermis · Appearance: red to white, rare blisters, moderate edema; soft dry eschar · Sensation/Healing: painful, sensitive; heals 2–6 wks; scarring likely; possible graft · Example: flame, scalds, grease, tar, chemical
Full Thickness
Area: entire epidermis + dermis ± subcutaneous · Appearance: red/black/brown/yellow/white; no blisters; severe edema; hard inelastic eschar · Sensation/Healing: minimal/absent sensation; weeks–months; scarring; grafting · Example: scalds, grease, chemical, electrical
4°+Deep Full Thickness
Area: all layers to muscle, tendons, bone · Appearance: black; no blisters; no edema; hard inelastic eschar · Sensation/Healing: no pain; weeks–months; severe scarring; grafting · Example: high-voltage or prolonged electrical burns
QUICK ID

Sunburn = Superficial (1°) — damage to epidermis only. Pink, painful, no blisters.

Rule of Nines & Burn Assessment Methods

Head & Neck
9%
Each Arm
9%
Chest (Anterior)
9%
Abdomen (Anterior)
9%
Each Thigh
4.5%
Perineum
1%
Each Lower Leg
4.5%

Anterior view shown. Posterior trunk mirrors anterior: upper back 9% + lower back 9%.

Rule of Nines — Full Breakdown
  • 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%
Lund & Browder
  • More exact method
  • Accounts for age-specific differences in head/leg proportions
  • Used in burn centers; can be in EHR
Palmar Method
  • Client's palm (including fingers) = 1% TBSA
  • Used for scattered burns
  • Quick estimate

Primary & Secondary Survey

Primary Survey — ABCDE
  • 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
Secondary Survey
  • 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

COMMON MIX-UP

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).

At the Scene
  • 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
Minor Burns — Four C's
  • 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

1
Injury → 24–48 hr
Emergent / Resuscitative

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.

2
48–72 hr → wound closure
Acute

Fluid shift resolves. Monitor cardiovascular, respiratory, GI systems. Wound care, pain control, nutrition (may need 5,000 cal/day), psychosocial support.

3
Wound healed → years
Rehabilitative

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)

Respiratory System
  • 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
Cardiovascular System
  • 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
Thermoregulation
  • 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
Gastrointestinal System
  • 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
Urinary System
  • 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
Infection Prevention
  • 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
Restoration of Mobility
  • 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)
Psychological Support
  • 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

Most TestedParkland Formula
2–4 mL × kg × % TBSA = total volume (mL). Half in first 8 hr, remainder over 16 hr.
Example: 4 mL × 70 kg × 40% = 11,200 mL → 700 mL/hr for 8 hr, then 350 mL/hr.
Adults ≥40 kgRule of 10s
TBSA (rounded to nearest 10) × 10 = rate (mL/hr). Add 100 mL/hr per 10 kg over 80 kg.
38% burn → round to 40 → 40 × 10 = 400 mL/hr. ⚡ Common test format.
Adults 40–80 kgABA Consensus
(TBSA × weight in kg) ÷ 8 = rate (mL/hr)
Example: 40% × 70 kg ÷ 8 = 350 mL/hr
TARGETS

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.

RED FLAG

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

RED FLAG

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)

Elevated
  • Hct/Hgb — hemoconcentration (fluid shift out)
  • Glucose — stress response
  • BUN — fluid loss
  • Potassium — cell destruction (hyperkalemia)
  • Chloride — renal reabsorption
Decreased
  • Sodium — third spacing (hyponatremia)
  • Total protein / albumin
Diuretic Stage (48–72 hr)
  • Hct/Hgb ↓ (hemodilution — fluid shifts back)
  • Potassium ↓ (hypokalemia — renal loss)
  • Sodium remains ↓
  • WBC — initial increase, then ↓ with left shift
Additional Labs to Monitor
  • 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

Topical Agents
  • 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
Skin Grafts & Coverings
  • 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

Procedure Steps
  • 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)
Debridement Methods
  • 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

WATCH FOR

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.

CARE PLAN

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

ComplicationKey PointsNursing Actions
Sepsis — most common cause of death post-burnBacteria on skin not killed by burn can contaminate wound; hospital-acquired infections also occurMonitor discoloration, edema, odor, drainage; monitor temperature/HR fluctuations; wound cultures; antibiotics; surgical asepsis; reinforce infection control education
Airway InjuryEffects may not appear for 24–48 hr; progressive hoarseness, brassy cough, drooling, copious secretions, wheezes, crowing, stridorSupport airway and ventilation; supplemental oxygen; intubation/mechanical ventilation if needed
Fluid ImbalancesHypovolemic shock from inadequate replacement; fluid overload from excessive replacement → heart failureMonitor perfusion (confusion, hypotension, low UO) and overhydration (bounding pulse, crackles, edema)
Contractures / Impaired MobilityScarring limits movement; scar tissue shortens and tightens skin, muscles, tendonsActive/passive ROM 3×/day; neutral positions with limited flexion; splints; ambulate ASAP; compression dressings up to 24 months
Compartment SyndromeEdema increases as skin loses elasticity; circumferential burns especially at riskMonitor peripheral circulation on affected extremities; escharotomy or fasciotomy if needed
Paralytic IleusCan be indicator of systemic infectionMonitor bowel sounds and abdominal distention; NG decompression until motility returns; report to provider
Post-Traumatic Stress DisorderBurn = traumatizing event; psychosocial stress related to pain, appearance changes, and long recoveryEncourage client to discuss feelings about the event; refer to mental health professional

Burn Center Transfer Criteria

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

ROUTE MATTERS

⚡ 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

METABOLIC DEMAND

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

RECOVERY TIMELINE

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:

Dietitian (caloric needs) Social worker (psychosocial/financial) Psych counselor (PTSD, body image) Physical therapist (ROM, contracture prevention) Occupational therapist (ADLs, splinting) Respiratory therapist (airway management) Case manager (discharge planning) Home health nursing Speech therapy (if airway/swallowing involved) Prosthetics specialist (if amputation required) Vision/hearing specialists (if eyes/ears affected)
08

Exam Hits

High-yield facts from practice test + source review

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 / LocalSystemic: 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.

09

ATI Practice Test

Reading 2 test bank — Integumentary Disorders, Wound Healing & Burns
Reading 2  ·  Integumentary Disorders, Wound Healing & Burns
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Reading 3 · Med-Surg

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.

Lupus Rheumatoid Arthritis Gout Fibromyalgia Infection & AMR HIV/AIDS Anaphylaxis
01

Immune System Malfunction Map

Four ways immunity goes wrong — and where each disorder in this reading fits

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.

Attacks Self
Autoimmune
Immune system mistakenly targets the body's own tissue, causing chronic inflammation and tissue destruction.
Lupus (SLE/DLE)Rheumatoid Arthritis
Pathogen Invasion
Infection
Bacteria or viruses invade faster than the immune system — or antibiotics — can clear them.
SepsisMeningitisInfluenzaSinusitisAMR
Can't Defend
Immunodeficiency
Immune cells are destroyed or suppressed, leaving the body vulnerable to infections it would normally fight off.
HIVAIDSOpportunistic infection
Overreacts
Hypersensitivity
Immune system responds explosively to a trigger that is normally harmless.
AnaphylaxisAllergy

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).

02

Lupus Erythematosus (SLE & DLE)

"The great mimicker" — chronic autoimmune inflammation across multiple organ systems

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.

Systemic
Systemic Lupus Erythematosus (SLE)
  • 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
Cutaneous
Discoid Lupus Erythematosus (DLE)
  • 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

Head & Nervous System
Hair loss (alopecia), high fever, headaches. Inflammation of the nervous system can cause memory loss, seizures, behavior changes, confusion, psychoses, or paresis.
Mouth & Nose
Oral lesions and ulcers.
Skin
Erythematous butterfly-shaped rash across the nose and cheeks (raised, dry, scaly) and red patches. Photosensitivity is common.
Heart
Endocarditis, atherosclerosis, pericarditis. Cardiovascular inflammation can lead to coronary artery disease and raise risk of heart attack and stroke.
Lungs & Digestive System
Pleuritis, pneumonitis, pulmonary emboli/hemorrhage. Serositis can affect the lungs and digestive system.
Abdomen
Severe abdominal pain.
Blood
Anemia, hypertension, lymphadenopathy.
Muscles & Joints
Pain, arthritis, aches, swollen/tender joints — symmetric in hands, wrists, knees. Raynaud's phenomenon can affect the hands and feet.
Kidneys
Blood in urine (hematuria) — reflects inflammation of the renal blood vessels and renal capsule lupus nephritis.

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

Pale
(ischemia)
Blue
(cyanosis)
Red
(rubor)
Arteriolar vasospasm in response to cold or stress — fingers/toes pale, then turn blue, then flush red as circulation returns.

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

Client-Reported
  • Fatigue / malaise
  • Alopecia
  • Dry eyes
  • Pleuritic pain
  • Confusion, depression
  • Joint pain, swelling, tenderness
  • Headaches
  • Anorexia / weight loss
Physical Assessment
  • 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

ANA
Positive in ~90% of clients with lupus. Homogenous, peripheral, or speckled pattern suggests SLE. ~10% of people without lupus also test positive.
Complement C3/C4
The exaggerated immune response of SLE depletes these complement proteins. C4 is diagnostic for SLE.
ESR
Elevated from systemic inflammation — but not specific to lupus (infections also raise ESR).
  • 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

Lupus Nephritis
Leading cause of death related to SLE. Can require dialysis or transplant. Monitor periorbital/lower-extremity swelling, hypertension, renal status.
Pericarditis & Myocarditis
Monitor chest pain, fatigue, arrhythmias, fever. Report chest pain; avoid stress and illness.
Pregnancy Risk
Higher risk of miscarriage, premature birth, or fetal death. Some medications can harm a fetus — counsel on birth control.
Osteonecrosis
Can occur in later stages of SLE — causes disability and loss of function.

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

Prognosis
  • 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
Health Promotion & Aging Adult
  • 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.

CaseRecognizing Renal Risk
SLE client reports increased fatigue, a persistent butterfly rash, hair loss, and pain/stiffness (7/10) in both wrists and knees — no joint swelling observed. Bilateral 2+ pitting edema is noted in the ankles, and the urine appears cloudy, yellow, with foam noted.

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

1
Recognize Cues
Assessment
Lupus can be difficult to diagnose — manifestations can be subtle early on or mimic other disorders. A facial rash is common but not universal.
2
Analyze Cues
Analysis
Review the complete medical history, including all manifestations and how they change over time. Family history matters — testing should rule out other disorders.
3
Prioritize
Hypotheses
Prioritize by which manifestations affect the client most — skin integrity, pain level, fatigue level, coping ability.
4
Generate Solutions
Planning
Lupus is chronic with no cure — planning focuses on managing manifestations and preventing complications such as organ damage.
5
Take Actions
Implementation
Explain the treatment plan, lifestyle adjustments, and medication effects. Communicate with all other providers; consult a rheumatologist.
6
Evaluate
Outcomes
Treatment needs change over time. Monitor for changes; DLE can progress systemically. Monitor kidney, heart, and lung function to catch progression early.

Medications

Treatment categories include antimalarials, steroids, NSAIDs, immunosuppressives, anticoagulants, monoclonal antibodies, and repository corticotropin injection.

Antimalarials
Hydroxychloroquine, Chloroquine
Reduce autoantibodies, prevent blood clots. Takes 1–3 months to work. Encourage frequent eye exams (retinal risk).
NSAIDs
Reduce Inflammation & Pain
Contraindicated with ulcers. Monitor for NSAID-induced hepatitis.
Corticosteroids
Prednisone
Immunosuppression + anti-inflammatory. Monitor fluid retention, HTN, bruising. Do not stop abruptly — taper.
Immunosuppressants
Methotrexate, Azathioprine
Monitor for toxic effects and infection (bone marrow suppression, liver enzymes).
Monoclonal Antibody
Belimumab
Inhibits B-cell stimulation, reducing the autoimmune response.
Nursing Care & Monitoring
  • 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
Client Education
  • 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.

03

Rheumatoid Arthritis

Chronic, symmetric, progressive autoimmune synovitis

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

Ulnar Deviation
Fingers drift toward the ulnar (pinky) side of the hand at the knuckles.
Swan Neck
Hyperextension of the PIP joint with flexion of the DIP joint — an "S"-shaped curve.
Boutonnière
Flexion of the PIP joint with hyperextension of the DIP joint — a "buttonhole" deformity.

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

Anti-CCP Antibodies
Detects antibodies to cyclic citrullinated peptide. Positive in most people with RA — more sensitive than RF.
Rheumatoid Factor (RF)
Reference range <20 units/mL. Not specific to RA.
ESR
Elevated with inflammation, acute/chronic infection, or advanced neoplasm.
CRP
Alternative to ESR. Useful for diagnosing disease and monitoring activity. Reference range <1.0 mg/dL.
ANA Titer
Positive titer is associated with RA, but not specific.

Knowledge check — tests used to diagnose RA: ESR, Anti-CCP antibodies, and ANA titer (not RBC count or potassium level).

Diagnostic Procedures

Arthrocentesis
  • 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
X-Ray
  • 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

Nursing Care
  • 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
Provide a Safe Environment
  • 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

NSAIDs — First-Line
Analgesic, antipyretic, anti-inflammatory. Can cause GI distress. Take with food/milk/antacids; observe for GI bleeding.
Corticosteroids
Prednisone for acute exacerbations — NOT for long-term therapy. Observe for Cushingoid changes; follow taper.
DMARDs
Hydroxychloroquine, methotrexate, etanercept, infliximab, adalimumab, and more. Slow RA progression + suppress the immune reaction. Avoid crowds; avoid alcohol.
Case10-Year RA History, Worsening Deformities — Anticipated Prescriptions
  • 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.

04

Gout (Gouty Arthritis)

Hyperuricemia uric acid crystal deposits in joints and tissue

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.

Primary Gout
  • 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
Secondary Gout
  • 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

Asymptomatic Hyperuricemia Stage 1
Elevated serum uric acid with no symptoms yet — crystals may already be silently depositing.
Acute Gouty Arthritis Stage 2
Sudden, severe joint pain — classically the metatarsophalangeal joint of the great toe. Attacks last 1–2 weeks.
Chronic Gout Stage 3
Appearance of tophi — deposits of sodium urate crystals under the skin — with long-standing disease.

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

0–4
4–6
6–6.8
6.8–8
8–10 mg/dL

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

Acute Gout
  • 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
Chronic Gout
  • 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.

05

Fibromyalgia

Chronic, widespread musculoskeletal pain syndrome

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

Sleep
Sleep disturbances, deep sleep deprivation.
Head
Migraines, headaches, jaw pain — sensitive to smells, loud noise, bright light.
Mood & Cognition
Depression/anxiety, concentration & memory difficulties ("fibro fog").
GI
Irritable bowel syndrome — abdominal pain, constipation, diarrhea.
GU
Interstitial cystitis — frequency, urgency, dysuria, pelvic pain.
Fatigue
Moderate to severe fatigue.

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

SNRIs & Anticonvulsants
Pregabalin, Duloxetine
Increase serotonin/norepinephrine release decreased nerve pain. No alcohol; can cause drowsiness.
NSAIDs
Decrease Pain & Inflammation
Contraindicated with impaired kidney function or ulcers. Take with food.
Tricyclic Antidepressants
Amitriptyline, Nortriptyline, Trazodone
Help induce sleep and decrease pain. Monitor sleep patterns and pain.

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).

06

Infection, Sepsis & Antimicrobial Resistance

Pathogen invasion, systemic response, and resistant organisms — exam priority throughout

Virus vs. bacterium: viruses require a host to become active — they are dormant outside a host organism.

Infection Sites

Head — Meningitis
Inflammation of the meninges. Fever, stiff neck, photosensitivity anticipate a lumbar puncture. Among college students, N. meningitidis usually spreads via prolonged contact (coughing, kissing).
Face — Acute Sinusitis
Facial pressure is the hallmark finding. Commonly follows a cold.
Lungs — Influenza
In severe cases, compromised alveolar function is the most concerning cue. Pneumonia is the priority complication in older adults; a history of diabetes increases risk.
Bloodstream — Sepsis & Post-Sepsis Syndrome
Post-sepsis syndrome can present with reduced organ function during recovery.

Antimicrobial Resistance (AMR) — How Pathogens Fight Back

⤴ Efflux Pumps
Removes the Drug
Pathogen pumps antibiotics back out of the cell after they enter — removes antibiotics entering the cell wall.
Target Alteration
Blocks Binding
Pathogen modifies the molecular target the antibiotic normally binds to, so the drug can no longer act.
Uptake Inhibition
Blocks Entry
Pathogen blocks the antibiotic from entering the cell in the first place.
Enzymatic Inactivation
Breaks Down Drug
Pathogen produces enzymes that break down or chemically modify the antibiotic.

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.

CasePost-Op Sepsis Trend
Critical care unit, post-op day 2 from a bowel resection (admitted 2 days ago for a ruptured appendix). Vital signs 2 days ago: T 39.1°C, pulse 122/min weak & thready, RR 24/min, BP 86/64, SpO₂ 92%. Today: T 38.4°C, pulse 120/min bounding, RR 24/min, BP 80/60, SpO₂ 92%.
  • 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.

CaseDiverticulitis Peritonitis (ED)
History of appendectomy, cholecystectomy, diverticulitis (2015). VS at 1000: T 37.9°C, pulse 100/min, RR 24/min, BP 102/68, SpO₂ 93%. By 1200: T 39.1°C, pulse 120/min weak & thready, RR 24/min, BP 82/68, SpO₂ 89%. Abdominal X-ray: free air, fluid, distended bowel loops. Abdomen tight, skin shiny/hot, girth increasing, bowel sounds absent, breathing labored.

5 findings requiring immediate follow-up: abdominal findings, vital signs, electrolytes, radiographic images, and pain characteristics — together indicating peritonitis causing hypovolemia.

07

HIV & AIDS

Progressive immunodeficiency — from acute infection to opportunistic disease

CD4-T-Cell Count & Disease Stage

Normal Range 600–1,500
Reference range for CD4-T-cell count in a healthy adult (cells/mm³).
Acute HIV Infection High viral load
Manifestations to monitor: night sweats (classic finding), plus fever, headache, muscle aches, sore throat, swollen lymph nodes.
Clinical Latency Declining
CD4 count slowly declines. Often few or no symptoms while the virus remains active at low levels.
AIDS < 200
Severely immunocompromised — high risk for opportunistic infections. Lifelong routine testing needed.

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.

Barriers to Care
Newly diagnosed HIV-positive clients often face fear of social stigma as a major barrier to care — stigma and discrimination can cause depression and isolation.
Preventing Opportunistic Infection
To help prevent respiratory opportunistic infections, teach clients with HIV to avoid smoking.
CaseHIV + Suspected Active TB
HIV diagnosed 2 months ago, previous IV drug user, smokes 2 packs/day; TB skin test positive last week. Onset 2 days ago: extreme fatigue, night sweats, anorexia, hemoptysis, fever. Today: productive cough, 20 lb weight loss/month, malnourished; red/purple lesions on mouth, face, neck; swollen tender tonsillar lymph nodes; breathing labored. CD4 dropped 650 150 cells/mm³. Chest X-ray: pleural effusion, right lower lobe.
HIV-Positive Clients
Require routine testing for opportunistic infections throughout their lives.
TB Suspicion
Sputum cultures should be obtained to verify tuberculosis.
CD4 = 150 cells/mm³
Labs indicate this client has likely progressed to AIDS.
Clinical Picture
Extreme fatigue, night sweats, hemoptysis, productive cough, weight loss indicate active TB.
CBC with Differential
Helps determine whether an infection is viral, bacterial, or fungal.
08

Anaphylaxis & Hypersensitivity

Allergen exposure escalating to systemic, life-threatening shock — see Reading 4 for the full picture
1
Exposure
Allergen Contact
Client exposed to a known allergen (food, latex, medication, insect sting).
2
Local Reaction
Skin & GI
Skin flushing, urticaria, mild GI upset.
3
Systemic
Anaphylaxis
Vascular dilation & increased permeability fluid leaks into surrounding tissue; headache, wheezing.
4
Shock
Anaphylactic Shock
Cardiac arrhythmia is the key indicator that anaphylaxis has progressed to shock.

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.

09

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

10

ATI Practice Test

Reading 3 test bank — Immune System Malfunction, Infection & Anaphylaxis
Reading 3  ·  Immune System Malfunction, Infection & Anaphylaxis
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Reading 4 · Med-Surg

Anaphylaxis

A severe, systemic hypersensitivity reaction — from allergen exposure and mast cell degranulation to epinephrine-first emergency management and discharge teaching.

Mast Cell Degranulation Multi-System Reaction Epinephrine First-Line Biphasic Risk Discharge Education
01

Anatomy, Physiology & Pathophysiology

Mast cell degranulation, histamine release, and why the first exposure never causes a reaction

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

1st Exposure — Sensitization Only
1
Allergen enters the body for the first time
2
Lymphocytes produce antibodies specific to that allergen
3
Antibodies attach to receptors on mast cells & basophils
SENSITIZED — no reaction occurs yet
2nd Exposure — Reaction Occurs
1
Same allergen re-enters the body
2
Allergen binds the pre-formed antibodies already on mast cells
3
Mast cells degranulate — histamine & mediators released
ANAPHYLAXIS — systemic reaction occurs

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.

02

Body Systems Affected

A systemic reaction — histamine circulates and disrupts five body systems at once
Nervous
Headaches, anxiety, dizziness, confusion, fainting — from hypotension & fluid shifts.
Integumentary
Flushing, rash, edema (incl. angioedema), urticaria/hives, itching.
Respiratory
Dyspnea, wheezing, stridor — fluid into tissue interferes with breathing, talking, swallowing.
Cardiovascular
Tachycardia, hypotension; arrhythmia or MI possible in severe cases.
Digestive
Nausea, vomiting, diarrhea, abdominal discomfort — smooth muscle & fluid/electrolyte changes.

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.

03

Epidemiological & Etiological Risk Factors

Common triggers, who's at higher risk, and how common anaphylaxis really is

Common Trigger Categories

Insect Stings
Bees, wasps, ants, ticks
Food
Milk, eggs, peanuts, tree nuts, fish, shellfish, soy, wheat, sesame
Medication
Antibiotics, NSAIDs, chemotherapy, neuromuscular blockers, radiocontrast dye, opioids
Latex
Medical gloves, balloons, condoms

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:

Lung Disease
Asthma or chronic lung disease higher risk of serious allergic reactions that result in anaphylaxis.
Beta/Alpha Blockers
Clients taking a beta blocker or alpha-adrenergic blocker for cardiovascular disease are at higher risk of death — these medications blunt the effects of epinephrine.
Mastocytosis
A rare mast cell mutation condition causing a higher-than-normal number of mast cells — also increases anaphylaxis risk.

How Common Is It?

1.6–5.1%of the U.S. population has experienced anaphylaxis
1–6%of the U.S. population has a latex allergy
1 in 12U.S. children have a food allergy
29%of food-allergic children also have asthma
0.26%of all U.S. hospital admissions
0.5–1%mortality rate among hospitalized clients

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.

04

Histamine's Effects on the Body

One biochemical mediator, eight simultaneous effects
Blood Clots
Clotting cascade activation
Heart Rate
Tachycardia
Edema & Inflammation
Tissue swelling
Adrenaline Released
Compensatory response
Capillary Permeability
Fluid leaks into tissue
Bronchoconstriction
Airways narrow, wheezing
Dilated Vessels
Blood pressure drops
Gastric Acid
GI upset

Systemically, histamine causes vasodilation, increased capillary permeability (leading to edema), and bronchoconstriction — the combination responsible for anaphylaxis's breathing difficulty and blood pressure collapse.

05

Clinical Presentation, Diagnosis & Psychosocial Impact

Onset window, biphasic relapse, and how anaphylaxis is confirmed
1
0 min
Exposure
Client contacts the trigger substance.
2
20 min – 2 hr
Acute Reaction
Rash/urticaria, dyspnea/wheezing, stomach pain/nausea, facial swelling, lightheadedness or fainting.

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

Skin Testing
A small amount of allergen is placed under the skin; the reaction is noted.
Tryptase Blood Test
Measures mast cell activation; drawn 1–3 hours after the reaction.

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.

06

Role of the Nurse: Environmental & Individual Factors

Latex cross-reactive foods, and conditions that can look like anaphylaxis

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.

Avocado
Banana
Chestnut
Kiwi
Apple
Carrot
Celery
Papaya
Potato
Tomato
Melon
Environmental Screening
  • 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
Conditions That Mimic Anaphylaxis
Acute Anxiety
Difficulty swallowing, hyperventilation, feeling faint
Hypoglycemia
Can also cause fainting
Reactive Airway Disease
Can cause respiratory distress

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.

07

Client Education to Avoid Anaphylaxis Triggers

Organized by trigger category, straight from discharge teaching
Food
  • Read all food labels carefully
  • Ask restaurants about ingredients & prep, including cross-contamination
  • Let friends & family know how serious food triggers are
Medication
  • Tell all health care providers about allergies and the reaction
  • Check with the pharmacist when receiving medication
Insect Stings
  • Do not walk around outside without shoes
  • Be aware of insects around beverages and food
  • Avoid bright, flowery clothing, perfumes, or lotions
Latex
  • 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.

08

Nursing Process

Applying the Clinical Judgment Model to an anaphylactic client
1
Recognize Cues
Assess & Interview
Assess facial swelling & other visual cues; interview re: history/habits. Many cases are self-treated and go undiagnosed — early intervention improves outcomes & reduces shock risk.
2
Analyze Cues
Differentiate
Thorough trigger history (food, meds, insects, other); differentiate true anaphylaxis from mimicking conditions.
3
Prioritize Hypotheses
Judge Severity
Judge severity & need for emergency intervention — gas exchange, tissue perfusion, breathing pattern, pain, skin integrity.
4
Generate Solutions
Act Immediately
Early intervention reduces severity & can prevent hospitalization or death. Remove the allergen if still in contact; place client lying down or in recovery position.
5
Take Actions
Monitor & Support
Monitor even without hospitalization; keep client lying down (sudden sitting/standing risks a BP crash & organ hypoxia); watch for biphasic relapse; provide epi auto-injector Rx & education.
6
Evaluate Outcomes
Follow Up
Refer to an immunologist/allergy specialist, especially if trigger unknown. Have client document episodes/triggers & share with providers.
Sample Care Goals
  • 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
Consider Hospital Observation If...
  • Severe or protracted reaction
  • History of asthma, arrhythmia, or systemic mastocytosis
  • Client lives alone or in a remote area far from emergency care
09

Treatments & Therapies

Epinephrine first, always — the escalating emergency algorithm
1
First-Line — Do Not Delay
Epinephrine IM
0.3–0.5 mg IM every 5 minutes until manifestations resolve (IV if already hospitalized). Causes vasoconstriction — reverses the BP drop and tissue fluid loss.
2
Supportive Care
Position, Oxygen & IV Fluids
Place supine, recovery, or Trendelenburg position to boost blood flow to the heart. Give supplemental O₂ + pulse oximetry. IV saline for BP support (caution with heart failure). Note: beta blockers can blunt epinephrine's effect.
3
If Not Responding
Glucagon
Given if the client is not responding to epinephrine and is experiencing anaphylactic shock.
4
If Improving
Continue Monitoring
Keep supine; continuously monitor VS and O₂; watch for a biphasic relapse. Never let the client sit or stand suddenly.
5
If Unresponsive or Not Breathing Normally
CPR + Emergency Transport
Initiate CPR. If not already in a hospital setting, transfer via emergency services for immediate care and observation after stabilization.
10

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)

11

ATI Practice Test

Reading 4 test bank — same cumulative ATI test as Reading 3 (Immune System Malfunction, Infection & Anaphylaxis)
Reading 4  ·  Immune System Malfunction, Infection & Anaphylaxis
ATI — Multiple Choice & SATA. Select your answer(s), then click CHECK.
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