Running head: REFLECTION ARTIFACT 1

Reflection Artifact

Mallory White

Aspen University

N-556 Advanced Pathophysiology B

December 2017
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Reflection Artifact

Pathophysiology is the study of the functional changes in organs, tissues, and cells altered

by disease and injury. To better understand pathophysiology, an Advanced Practice [AP] nurse,

must have knowledge and understanding of standard cellular biology, anatomy, and physiology

of various body systems. Pathophysiology helps bridge clinical experiences and real-world

nursing experiences to classroom learning. McCance, Huether, Brashers, and Rote (2010)

explained that the models of pathophysiology that nurses carry in their minds influences what

they do with their observations and what rationales are provided for nursing actions. AP nurses

must have an understanding of pathophysiology as a science, but also understand that disease

designates suffering in people.

This pathophysiology course has allowed this nurse to recognize and categorize diseases.

It has also allowed triggered higher thinking and the formulation of differential diagnosis based

on clinical manifestations, signs, and symptoms of certain diseases. From there, this nurse was

able to perform further patient assessments and investigations, treatment plans, and patient

evaluations. With the knowledge gained in this course, clinical outcomes and treatment

successes were able to be determined.

Many times, patients present with vague complaints or symptoms that can match many

different disease processes. Others present with highly specific causative agents and processes.

This course has further enhanced knowledge about not only essential cellular function as well as

the idea of patients are whole bodies, made up of complex and intertwined organ systems. If not

adequately treated, diseases in one body system, can cause dysfunction of other body systems or

can lead to a body-wide infection. This course has brought to light concepts of interacting

factors and how they relate to one another to cause other diseases and increase morbidity.
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Module one in this course centered around reproductive function. Diseases of the

reproductive system are at times difficult to diagnose and treat due to the stigma and symbolism

associated with reproductive organs. Patients may also experience embarrassment, guilt, fear, or

denial when facing reproductive system disease or dysfunction. As with the distinct physical

differences between men and women, there are differences in reproductive diseases. Men may

experience disorders that affect their prostate or their testicles and the flow of sperm. Women

may experience uterine or breast diseases. Both men and women can experience sexually

transmitted infections.

AP nurses must be aware of the clinical manifestations and pathologic changes that occur

in reproductive disorders as many times patients will not be entirely forthcoming about their

symptoms. Due to feelings of embarrassment or loss of pride, many patients do not openly

discuss problems associated with reproductive organs. AP nurses play a vital role in not only

treating patients, but in educating them on the importance of regular self-examinations, yearly

screenings, and sexual safety.

Module two focused the digestive system. The digestive system involves all of the organs

of the gastrointestinal [GI] tract as well as other organs like the pancreas and those of the biliary

system. McCance, Huether, Brashers, & Rote (2010) explained that the biliary system includes

the liver, gallbladder, and bile ducts. AP nurses must gain a knowledge and skills to assess a

patient for common clinical manifestations of gastrointestinal disorders. They must also be able

to compare and contrast the pathophysiology, clinical manifestations, and risk factors for gastric

and intestinal diseases to be able to diagnose and treat patients correctly. The body as a whole is

made up of interwoven function, and the AP nurse must be aware of that. Understanding the

liver’s role in metabolism can help the AP nurse understand the liver’s significance systemically.
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Hepatitis and peptic ulcer disease are two common digestive disorders that nurses may see.

Being able to correctly identify, treat, and educate patients about these diseases is essential for

AP nurses practice.

The digestive system plays a vital role in normal bodily function. The GI tract is the

location of food and nutrient consumption and absorption. Other digestive organs, like the liver,

play essential roles in blood filtration and the production and destruction of blood cells. AP

nurses must be knowledgeable about various digestive diseases and the pathophysiology and

clinical manifestations associated with them. Finally, AP nurses play a crucial role in the

detection, treatment, and education of patients with common digestive system diseases like

peptic ulcer disease and various forms of hepatitis.

Module three in this course focused on the endocrine system. The endocrine system

involves complex interrelationships and interactions of hormones to maintain dynamic steady

states and provide growth and reproductive capabilities. Altered functions of the endocrine

system can include either hyposecretion or hypersecretion of the various hormones, which

therefore leads to abnormal concentrations of those hormones in the blood. AP nurses must know

the underlying pathophysiology of endocrine disorders, like hypothyroidism, Cushing disease,

Addison disease, and various types of diabetes. AP nurses must also understand hormonal effects

on metabolism when treating patients with endocrine abnormalities. Case studies and personal

experiences allow AP nurses to apply classroom knowledge with clinical scenarios to improve

assessment and treatment of patients with endocrine disorders.

The human body is made up of multiple body systems that are intricately intertwined.

The endocrine system, and the hormones it produces play an essential role in many bodily

processes. Hormones have effects on metabolism, energy levels, weight control, and many more
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processes. It is critical for AP nurses to understand the how abnormalities in endocrine function

can affect other bodily systems and processes. Personal experiences and case studies allow the

practical application of classroom knowledge to improve assessments and treatment regimens of

patients with endocrine disorders.

Module four focused on the neurological system. The neurological system is made up of

a complex network of neurons and supportive cells that enable rapid communication between

central processing neurons, sensory receptors, and functional responses. Alterations in

neurologic function may be a short or long term, and they may result from genetics, infection,

trauma, or may be due to normal aging. Disorders of the neurological system can include

neurologic and neuropsychological disorders. A prudent AP nurse must be aware of clinical

symptoms, causes, and neurobiological mechanisms of diseases like schizophrenia and major

depression. AP nurses must also have a strong understanding of the differences in signs,

symptoms, assessments, and treatment of acute and chronic pain. Finally, an AP nurse must be

aware of the population for which she is caring. Being able to understand seasonal disorders like

seasonal affective disorder can allow an AP nurse to better care for his or her patient base.

The neurologic system is highly complex and involves a wide variety of diseases and

illnesses. Neurologic and neuropsychological disorders can occur as a result of infection,

trauma, disease, genetics, or be a part of normal aging. Neurological disorders can have

detrimental effects on patients. These illnesses can potentially be debilitating and rob the

affected person of meaningful work, academic goals, self-actualization, close relationships, and

in worst-cases, survival. AP nurses must not only know the clinical manifestations and

treatments of neurological diseases, but they must also be aware of how many neurological
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disorders can trigger depression. AP nurses must also understand that depression itself is a

neuropsychological disorder that has neurobiological mechanisms.

Module five was centered around the central nervous system. Alterations in central

nervous system function can be altered by traumatic injury, infectious or inflammatory

processes, metabolic disorders, or degenerative processes. Brain injuries can have different

mechanisms and clinical manifestations depending on what area of the brain is affected. Central

nervous system disorders that can affect adults include degenerative disk disorders or stroke, to

name a couple. Disorders of the central nervous system do not only affect adults; children can

suffer from seizure disorders or central nervous system tumors. A prudent AP nurse must be

aware of the various types of central nervous system disorders as well as the clinical

manifestations and treatment regimens for them.

AP nurses must have an understanding of various central nervous system disorders, the

clinical manifestations, and treatment regimens for both adults and children. Many of the

disorders that affect adults happen as a result of injury, a part of a disease process or a part of

natural aging. Neurological alterations in children can be congenital or acquired. Case studies

allow AP nurses to apply classroom knowledge about the central nervous system to clinical

situations to better their assessment and treatment skills to better real patient outcomes.

Module six focused on the musculoskeletal system. The musculoskeletal system provides

support for our physical body as well as allowing movement. Alterations in the musculoskeletal

system can occur in bones, joints, or muscles that can be caused by injuries or trauma, tumors,

inflammatory or noninflammatory diseases, infections, or metabolic disorders. Both children

and adults can be affected by alterations in musculoskeletal function.

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AP nurses must have an understanding of the musculoskeletal system in order to assess,

treat, and educate patients properly. Being able to identify and treat musculoskeletal

abnormalities like bone fractures, bone masses, or bone infections is important for practitioners

that care for patients of all ages. Understanding the pathophysiology and clinical manifestations

of different classifications of arthritis will help when caring for elderly patients whereas

understanding common muscular dystrophies can be beneficial when caring for children. The

case studies that Brashers (2006) presented allows AP nurses to apply the academic classroom

knowledge to patient scenarios to improve diagnosing and treating live patients.

Module seven was an integumentary module. The integumentary system is the largest

system of the body. The skin, the largest organ of the body, acts as a protective barrier. The skin

also acts as a mirror for the interior condition of the body. Other components of the

integumentary system include hair and nails. Alterations in hair and nail growth can symbolize a

multitude of systemic diseases. Integumentary disorders can affect a person of any age, but often

times affect adults differently than children and adolescents. Prudent AP nurses must be aware of

integumentary disorders like pressure ulcers, melanomas, and alopecia to provide safe and

effective care to all patients.

Finally, module eight was focused on multiple interacting systems. The human

body is made up of various organ systems that interact with one another in sickness and in

health. It is crucial for advanced practice nurses to not only understand how each body system

works, but how they all work together to complete the picture of patient presentation. Because of

the body’s interconnectedness, when one body system fails, the others may soon follow.

Advanced Practice [AP] nurses must have an understanding of not only individual body systems

and the signs of one system’s dysfunction but also the signs of multiorgan dysfunction
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syndromes. Finally, burns are one type of trauma that can have dramatic and drastic effects on all

body systems, regardless of where the burn occurs. AP nurses must be knowledgeable about

how to accurately assess burns and the associated complications that may ensue in patients of all

ages.

It is important for AP nurses to understand how the human body is made up of

interconnected body systems. Trauma, burns, and sepsis can have drastic effects on overall

health and patient outcomes. Shock can be life-threatening and has high mortality rates. Each

type of shock has different characteristics, but all are associated with deficiencies of cellular

oxygen consumption and can lead to systemic inflammatory responses. If untreated, shock can

lead to multiple organ dysfunction syndromes. Burns are another injury that can cause systemic

injuries.

Throughout this course, one fundamental concept has shown over and over again. The

human body is comprised of many organ systems that rely on the normal function of other

systems so that it can function properly. When performing a patient assessment, making

differential diagnoses, analyzing test results, working up a treatment plan, or implementing

patient education, it is vital for AP nurses to realize that ideal. When thinking about the

pathophysiology of the human body when going through the nursing process, one must consider

cause and effect or how the recommended actions will affect other body systems and overall

patient health and well being. Brashers (2006) gave great examples of case studies that allowed

this nurse to take knowledge learned from this course and combine it with previous knowledge

and experience to diagnose, treat, and educate patients with a variety of diseases.

Representation of Learning
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The human body is made up of various organ systems that interact with one another in

sickness and in health. It is crucial for advanced practice nurses to not only understand how each

body system works, but how they all work together to complete the picture of patient

presentation. Because of the body’s interconnectedness, when one body system fails, the others

may soon follow. Advanced Practice [AP] nurses must have an understanding of not only

individual body systems and the signs of one system’s dysfunction but also the signs of

multiorgan dysfunction syndromes. Finally, burns are one type of trauma that can have dramatic

and drastic effects on all body systems, regardless of where the burn occurs. AP nurses must be

knowledgeable about how to accurately assess burns and the associated complications that may

ensue in patients of all ages.

Types of Shock

Cardiogenic Shock

Cardiogenic shock occurs as a result of cardiac dysfunction that in turn results in

inadequate cardiac output. Copstead and Banasik (2014) explained that cardiogenic shock is

most often a result of ventricular dysfunction, with the most common cause being a myocardial

infarction [MI] that causes greater than 40% loss of the left ventricular

myocardium. Cardiogenic shock may also be caused by end-stage cardiomyopathy, congenital

heart defects, papillary muscle dysfunction, or right ventricular MI.

As the left ventricle [LV] loses its pumping power, preload increases. Increased LV

preload forces fluid to move from the pulmonary vasculature into pulmonary interstitial spaces,

which results in interstitial pulmonary edema and alveolar pulmonary edema (Copstead &

Banasik, 2014). As a compensatory mechanism to increase cardiac output, the sympathetic

nervous system [SNS] is stimulated to increase the heart rate and systemic vascular resistance.
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Patients in cardiogenic shock present with a normal blood pressure, tachycardia, and

increased vascular resistance despite the decreased cardiac output. Many times, patients will

present with signs and symptoms that are typical of an MI. These include complaints of chest

pain, faintness, feelings of impending doom, and dyspnea. McCance et al. (2014) explained that

classic signs of cardiogenic shock include tachypnea, jugular vein distension, tachycardia with

faint or irregular pulses, cyanosis, and peripheral edema. As compensation begins to fail, the

patient will experience a drop in systolic blood pressure while experiencing an increase in

diastolic blood pressure (Copstead & Banasik, 2014). Because the patient is experiencing

vasoconstriction, they will present with clammy and cool skin. As fluid builds up in their lungs,

healthcare providers will be able to auscultate crackles in lung fields. Copstead and Banasik

(2014) explained that patients would also present with increased pulmonary artery pressures,

measurements that can be achieved with the placement of a pulmonary artery catheter.

Cardiogenic shock can be difficult to treat as many times the underlying damage to the

myocardium is not reversible. Goals of treatment and management include increased cardiac

output, decreasing myocardial oxygen demands, and increasing myocardial oxygen

delivery. Patients are often treated with inotropic drugs, like dopamine or dobutamine to help

increase contractility. They may also be treated with vasodilators like nitroglycerin or

nitroprusside to help decrease the workload of the heart (Copstead & Banasik, 2014).

Hypovolemic Shock

Hypovolemic shock occurs when the body undergoes a significant amount of blood or

fluid loss, and there is an adequate supply for the heart to pump to organs throughout the

body. McCance et al. (2014) explained that fluid loss could include whole blood, plasma, or
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interstitial fluid. Patients typically develop hypovolemic shock when about 15% of total

intravascular volume is gone.

As hypovolemia develops, the body began to offset the decreased intravascular volume

and decreased cardiac output through compensatory mechanisms. Catecholamines are released

by the adrenal glands that cause tachycardia and increased systemic vascular resistance. This, in

turn, increases cardiac output and ensures adequate tissue perfusion pressures. Other body

systems are also involved in compensation during hypovolemic shock. McCance et al. (2014)

explained that in the kidneys, renin stimulates the retention of sodium and water as well as the

release of aldosterone. The pituitary gland secretes an antidiuretic hormone to increase water

retention, and the liver and spleen disgorge stored red blood cells and plasma to add to the

circulating blood volume. These compensatory mechanisms can only maintain an adequate

blood pressure for a short period. If blood or fluid loss continues or worsens, compensation fails

and decreased tissue perfusion issues.

The American College of Surgeons (2017) has classified hypovolemic shock into four

classes that are based on the degree of blood volume lost. Stage I is the initial stage where the

patient experiences about 15% blood loss and presents with minimal tachycardia and normal

pulse pressure. Hypovolemic shock can progress to stage IV, or the refractory stage, where the

patient has lost greater than 40% of their blood volume and presents with marked tachycardia,

decreased systolic blood pressure and decreased urinary output. Patients in stage IV

hypovolemic shock may also experience cold and pale skin or loss of consciousness.

Treatment of hypovolemic shock revolves around treating the underlying cause of blood

or volume loss. Many times, treatment for hypovolemic shock involves surgical intervention

(Copstead & Banasik, 2014). The secondary treatment plan for hypovolemic shock includes
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replacing the lost fluid volume. McCance et al. (2014) explained that many times crystalloid

solutions, like lactated Ringer solution or normal saline are used. If the patient lost a significant

amount of blood, the patient may require a transfusion of whole blood or packed red blood

cells.

Neurogenic Shock

Neurogenic shock is caused by severe damage to the central nervous system. Damage to

the brain or spinal cord can cause a sudden loss of SNS stimulation, which causes blood vessels

to relax therefore decreasing blood pressure and peripheral vascular resistance. Neurogenic

shock can be caused by trauma, spinal cord injuries, drug overdose, or high spinal anesthesia

(Copstead & Banasik, 2014).

Patients with neurogenic shock experience hypotension and decreased cardiac

output. Copstead and Banasik (2014) explained that dependant upon the patient’s body position,

he or she may experience differences in cardiac output. They explained that when a patient is

lying down cardiac output and blood pressure may be sufficient. However, when standing

upright, the patient experiences pooling effects from gravity which causes a severe drop in blood

pressure and cardiac output. Patients must change positions slowly to avoid drastic changes in

the distribution of blood to prevent syncopal episodes. Neurogenic shock is the only type of

shock in which patients experience tachypnea and bradycardia at the same time.

Patients with neurogenic shock can present with symptoms of all different body

systems. Neurologically, they may present as confused, restless, or comatose. Cardiovascularly,

the patient will present with profound hypotension and bradycardia, they may also experience

chest pain. Respiratory wise patients may present with tachypnea with respirations as high as 60

breaths per minute (Anthony, 2017). The patient with gastrointestinal upset and nausea as well as
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decreased urine output from the genitourinary system. The patient’s skin may be dry and warm

secondary to vasodilation. The skin may also appear pale or discolored.

Treatment for neurogenic shock is centered around restoring blood flow to the central

nervous system. Treatment options may include fluid volume resuscitation to restore normal

hemodynamics. The patient may also require vasopressors, like norepinephrine, to maintain

adequate blood pressure and cerebral perfusion (Anthony, 2017). Finally, if the patient’s become

too bradycardic, they may require atropine to increase the heart rate and therefore increase

cardiac output.

Anaphylactic Shock

Anaphylactic shock occurs as a response to an antigen that causes excessive mast cell

degranulation that is mediated by IgE antibodies(Copstead & Banasik, 2014). Once activated,

the IgE antibodies trigger vasoactive chemicals to be released that result in increased capillary

permeability, peripheral vasodilation, and bronchoconstriction. Anaphylactic reactions are

typically triggered by foods, medications, venoms, or animal proteins (Copstead & Banasik,

2014). Common food allergies include peanuts, tree nuts, and crustaceans like crab or

shrimp. The most common class of medications that trigger anaphylaxis are antibiotics. Bee

stings and snake bites can initiate venom-induced anaphylaxis whereas animals like cats, dogs,

and horses, can initiate animal protein anaphylaxis reactions.

Signs and symptoms of an anaphylactic reaction can occur anywhere from two to 30

minutes following exposure to an antigen. Copstead and Banasik (2014) shared that rarely,

symptoms can develop several hours after exposure. Clinical manifestations vary depending on

the stimulus and the degree of patient sensitivity. Patients may present with increased respiratory

and heart rates, anxiousness, hypotension, hives, itching, and angioedema. Patients may also
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present with bronchoconstriction that causes wheezing and cyanosis as well as laryngeal edema

that results in stridor and hoarseness.

Prevention is key in managing anaphylactic reactions. Patients should avoid all known

allergens. If the patient does develop anaphylactic shock, initial therapy is aimed at removing the

inciting antigen if possible. In order to maintain an adequate airway, patients may require

bronchodilators to manage bronchospasms, or they may require tracheal intubation and assisted

ventilation (Copstead & Banasik, 2014). Epinephrine is often given to prevent mast cells from

further releasing inflammatory mediators. Antihistamines may also be administered to block

histamine receptors. Steroids may be given as anti-inflammatory support, but it is important to

note that the onset may be slow. When therapies are initiated promptly, nearly all patients have

good outcomes. However, Copstead and Banasik (2014) explained that approximately 1% of

patients with anaphylactic episodes die.

Septic Shock

Sepsis occurs when microorganisms are present in the bloodstream. Copstead and

Banasik (2014) explained that normally, the body’s immune system effectively destroys the

bacteria to prevent widespread dissemination of the infection, but this does not occur with

sepsis. Systemic inflammatory response syndrome [SIRS] occurs when the body’s response to

the infection causes widespread inflammation and systemic infections. SIRS can lead to septic

shock if the infection and other associated symptoms are not controlled and eliminated in a

timely manner.

Patients with septic shock present with hypotension despite fluid resuscitation. Schmidt

and Mandel (2014) explained that bacteriotoxins cause the plasma to leak into the tissues, which

results in hypovolemia. Without an adequate blood supply, the patient may develop multiple
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organ dysfunction syndromes. McCance et al. (2014) explained that septic shock is a common

cause of death in intensive care units throughout the United States.

Patients with septic shock present with signs and symptoms of infection that may include

fever and increased white blood cell counts. As SIRS and septic shock develops, the patient may

also present with hypotension, tachycardia, lactic acidosis, decreased urine output, or altered

mental status. McCance et al. (2014) described that because septic shock is complicated by

dysfunction of one or more organ system, it may be difficult to differentiate between sepsis-

related organ dysfunction and an underlying organ dysfunction without infection.

Neurologically, patients may present with confusion. Cardiovascular wise, patients with septic

shock present with a decreased blood pressure, increased heart rate, and increased cardiac output

(Schmidt & Mandel, 2017). The patient with septic shock may also present with tachypnea as an

early sign that they are developing respiratory alkalosis. The patient’s skin will appear to be

warm and flushed, and they may experience peripheral edema despite intravascular

hypovolemia.

Treatment of septic shock includes antibacterial or antifungal medications to rid the

bloodstream of the underlying microorganism. Fluid resuscitation is also important for patients

with septic shock. Schmidt and Mandel (2017) shared that patients symptoms should be

managed with pain medications and antipyretics as needed. Patients may also require

supplemental oxygen therapy to help correct any respiratory alkalosis that may be present.

Multiple Organ Dysfunction Syndrome

When two or more organ systems develop some sort of dysfunction, it is known as

multiple organ dysfunction syndromes, or MODS (Copstead & Banasik, 2014). MODS can be

the result of primary insults, like trauma, or occur as secondary reactions to SIRS and develop
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days or weeks after the primary insult. Copstead and Banasik (2014) shared that the most

common causes of secondary MODS are sepsis and septic shock.

MODS is thought to be initiated by overactive and over-destructive immune mechanisms

that affect endothelium throughout the body. MODS is a leading cause of mortality in the United

States with approximately 54% mortality rates for patients with two failing organ systems to

100% mortality rate in patients with five failing organ systems (McCance, Huether, Brashers, &

Rote, 2014).

Patients with MODS in the pulmonary system present with failure to perform normal gas

exchange. Arterial blood gases will show arterial hypoxemia. Marshall (2016) shared that

atelectasis and intravascular thrombosis may contribute to ventilation and perfusion

mismatch. Infection and trauma can also compromise lung function. If ventilatory support is not

properly managed, increased ventilator volume or pressure can lead to further atelectasis and

further damage to the lung tissue.

Marshall (2016) shared that renal dysfunction in MODS is characterized by changes in

excretory function, rising creatinine levels, and fluid and electrolyte abnormalities. Renal

dysfunction can occur from reduced renal blood flow, altered regional perfusion, or increased

intra-abdominal pressure. Kidney dysfunction may also occur as a result of nephrotoxic drugs or

obstruction within the kidney. Patients with renal dysfunction initially present with oliguria

despite having an adequate intravascular volume. Later signs of kidney dysfunction include

rising creatinine levels. Marshall (2016) explained that MODS could be scored from 0 -4 based

on organ system dysfunction. When serum creatinine levels are less than 100 μmol/liter, the

MODS score is 0. When serum creatinine levels are greater than 500, the MODS score is a 4.
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Patients with renal dysfunction in MODS will also present with a wide degree of fluid and

electrolyte imbalances and may require dialysis.

Cardiovascular dysfunction in MODS consists of five main etiologic features (Marshall,

2016 ). Patients may present with a reduction in a peripheral vascular tone that occurs from the

activity of nitric oxide. Patients will also present with diffuse capillary leaking and edema as a

result of increased capillary permeability. Capillary leaking and edema can lead to dysfunction of

other organ systems (Marshall, 2016). Patients with cardiovascular dysfunction in MODS may

also present with alterations in blood flow to specific organs. Arteriovenous shunting occurs as

occlusions in microvasculature become blocked with abnormally rigid erythrocytes and

leukocytes. Finally, patients with cardiovascular dysfunction in MODS may present with right-

sided heart failure that is caused by myocardial depression. All of these abnormalities can

present with hypotension that is unresponsive to an increase in preload. It is important for AP

nurses to measure mean arterial pressure in patients with known or suspected cardiovascular

dysfunction as increasing values represent worsening of cardiac function.

Gastrointestinal and hepatic dysfunction and MODS likely results from reduced blood

flow and changes in normal microbial flora (Marshall, 2016). Patients with gastrointestinal

[GI] dysfunction in MODS may present with GI bleeding, intolerance of feedings, bloating, and

diarrhea. Cholestasis and hyperbilirubinemia reflect hepatic dysfunction in MODS. Patients with

hepatic dysfunction may present with non-specific systemic inflammation, and increased levels

of CRP and alpha-1 antitrypsin levels in the acute phases and decreased albumin levels in later

stages of hepatic failure.

Neurologic dysfunction is measured by a patient’s level of consciousness. The Glasgow

Coma Scale [GCS] is the most commonly used assessment tool for neurologic function
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(Marshall, 2016). Patients with minimal neurologic dysfunction may present with a GCS of 15

whereas severe dysfunction presents with GSC less than six. The GCS measures a patient’s eye

opening response, verbal responses, and motor responses. Patients that can open their eyes

spontaneously, are oriented to person, place, and time, and can obey commands will score

higher. Patients that have no or minimal eye, verbal, or motor responses will have lower GCS

scores. Marshall (2016) shared that patients with a GCS score of 8 or less are usually comatose

whereas a patient with a score of 3 is totally unresponsive.

Classification of Burn Injuries

The term burn is a generic word that is used to describe cutaneous injuries that result

from chemical, thermal, or electrical environmental causes. McCance et al. (2014) explained

that burns are most often associated with smoke inhalation or other traumatic injuries. Burns are

classified based on wound depth and the associated symptoms of the affected skin. Healthcare

providers also use a system to estimate the total surface area of the injured tissue (Alspach,

2016).

Classification of wounds by depth begins with superficial partial-thickness burns. These

burns only involve the epidermal layer and are pink and red in appearance without blistering but

with blanching when pressure is applied. Patients with superficial partial-thickness burns may

experience discomfort with a touch of the affected area and itchiness that decreases in severity as

the area heals (Alspach, 2016). Superficial partial-thickness burns typically heal within three-to-

five days and rarely leave scars.

Moderate partial-thickness burns affect the superficial dermal layer of the skin. These

burns appear red, pink, or mottled with blisters present. Skin is usually moist and weeping and
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also blanches when pressure is applied (Alspach, 2016). Moderate partial-thickness burns are

very painful and can take up to three weeks to heal.

Deep partial-thickness burns affect the deep dermal layer of the skin. These burns are a

pale ivory to pink in appearance and wound beds may be dry with bullae or blisters. Deep

partial-thickness burns do not blanch under pressure. Pain responses with deep partial-thickness

burns vary from minimal discomfort to severe pain (Alspach, 2016). Healing of deep partial-

thickness burns typically takes three-to-six weeks.

Finally, full-thickness burns extend beneath the dermal layers of the skin to muscle, fat,

and bone. These burns may appear white, red, brown, or black and usually do not have blisters

(Alspach, 2016). Full-thickness burns may also appear leathery, dry, and hard as well as

depressed if the underlying muscle is affected. Patients with full-thickness wounds experience

deep aching pains, but a superficial pain to pinprick is usually absent (Alspach, 2016). Healing

for full-thickness burns typically requires skin grafting and can take longer than one month.

McCance et al. (2014) described the ‘rule of nines’ that is used to measure the estimated

total body surface area [TBSA] that is affected by burns. This method is only used for burns that

are of moderate thickness or more. Using the ‘rule of nines’ many appendages or body areas are

divided up so that the surface area is a factor of nine. For example, the head is a total of 9%, so if

the patient only experienced burns to half of their head, they would have approximately 4.5% of

TBSA affected. The trunk accounts for 18% per side and each leg accounts for 9% each

side. The arms account for 9% each arm. Smaller areas, like the hands or genitals, account for

approximately 1% each.

Burn Shock
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Initial management of patients with burns includes airway support and fluid resuscitation

for burn shock (Faldmo & Kravitz, 2013). The amount of fluid resuscitation a patient requires is

based on the depth and extent of the burn injuries. Faldmo and Kravitz (2013) shared that the

initial 24 hours after a burn injury occurs is key to increasing the chances of patient survival

while minimizing complications. Copstead and Banasik (2014) explained that burn shock is a

systemic process in which the capillary system throughout the body becomes leaky causing

intravascular hypovolemia. Fluid loss can be lost in the area of the burn as seepage or be

evaporated through the environment. Fluids can also leak throughout the body causing extensive

interstitial edema.

An essential part of managing a patient with burns is fluid resuscitation. Copstead and

Banasik (2014) shared that the volume and rate of fluids lost are directly related to the severity of

the burn. They also shared the Parkland formula that uses lactated Ringer solution {LRS] as

resuscitation fluid using the time from the initial burn injury, TBSA affected, and the patient’s

body weight. The Parkland formula administers one-fourth of the total required fluid within the

first eight hours after the burn and the remaining one-fourth in the third eight hours. Copstead

and Banasik (2014) shared an example of a 70-kg patient with 50% TBSA burn. Using the

Parkland formula of 4 mL LRS/ % TBSA/kg body weight, the patient would require 14,000 mL

of LRS within the first 24 hours of initial burn injury.

To monitor the effectiveness of fluid resuscitation, AP nurses should monitor the global

response of the patient. Patients with adequate resuscitation should maintain an adequate blood

pressure, heart rate and capillary refill time. These patients should also have normalization of

their mental status and arterial pH and be able to maintain urine output of at least 0.5-1 ml/kg per
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hour for adults. Copstead and Banasik (2014) explained that patients should receive

maintenance fluids as long as clinically necessary to improve patient outcomes.

Children with Burns

Burns in children are a common cause of disfigurement and accidental death in

children. Common causes of burns in children are related to hot foods or water, grills or stoves,

flames, appliances, and curling irons (Hay, Levin, Deterding, & Anzug, 2016). Atiyeh and

Janom (2014) explained that children are at a higher risk for burns compared to adults because of

their thin skin and decreased ability or agility to move away from the source of the burn. Burns

in children can be accidental, or more concerning, an act of child abuse. Hay et al. (2016) shared

that up to 25% of burns in children can result from child abuse or neglect.

Burns in children are classified in ways that are similar to adults with thickness and

TBSA assessments. The ‘rule of nines’ does not apply to children because of the varying stages

of growth and development. Superficial- and partial-thickness burns in children are generally

treated in outpatient settings (Hay, Levin, Deterding & Anzug, 2016). If wounds affect the

hands, face, digits, geet, or perineum, patients should be referred to a burn surgeon as soon as

possible for treatment. Pain control for children with burns is paramount as our youngest

patients are not able to fully express their level of discomfort. Medications like hydrocodone and

oxycodone are frequently used for pain control (Hay, Levin, Deterding, & Anzug, 2016).

Wounds may be managed with antibiotic ointments and non-adherent dressings. Larger blisters

and bullae may require drainage and protection with a bulky dressing. Finally, superficial- and

partial-thickness burns in children can be treated with the use of cool compresses.

Deeper burn wounds require healthcare professionals to pay attention to the ABCs of

trauma management (Hay, Levin, Deterding, and Anzug, 2016). Artificial airway management
REFLECTION ARTIFACT 22

may be necessary, especially if the patient is suffering from facial or nasal buns. The patient’s

breathing and circulation should be monitored and maintained through pediatric advanced life

support measures when needed. These patients may experience a great deal of fluid loss and

require aggressive fluid resuscitation. Hay, Levin, Deterding, and Anzug (2016) explained that

the Parkland formula that is used in adults is also used to determine the fluid resuscitation

volume needed in children with burns. The effectiveness of fluid resuscitation in children is

typically measured by monitoring urine output with a goal of at least 1-2 mL/kg/hr. Treatment

for deep burn wounds in children requires a burn specialist. These patients require frequent

dressing changes to ensure wound beds stay clean and moist to promote healing. Many patients

with deep burn wounds require skin grafting and surgery.

Burn injuries in children can affect them physically and mentally. Growing up with scars

from old burn wounds can be challenging for children and their self-esteem. If patients suffer

deep burn wounds, they may require physical rehabilitation to regain the muscle strength needed

to walk again. Atiyeh and Janom (2014) shared the importance of physical rehabilitation in

pediatric patients with burns. They shared that rehabilitation for patients with burns has been

shown to improve their cognitive, social, and physiological functioning. Using physical and

occupational therapies in conjunction with a team of physicians, nurses, psychologists, and social

workers, pediatric patients were able to return to normal life after extensive burns with maximal

function and independence in the activities of daily living. Rehabilitation after burns has also

been beneficial in helping to reintegrate the patient back into the community and their home after

such a traumatic experience.

REFLECTION ARTIFACT 23

Burns

Copstead and Banasik (2014) shared that electrical burns account for fewer than 2% of

admissions to burn facilities, but the number of admissions in the United States has been on the

rise. Electrical burns can occur with low-voltage or high-voltage injuries. Household burns are

usually low-voltage injuries whereas occupational associated burns are frequently high-voltage

sources. Lightning strikes are also classified as high-voltage burn injuries and are reported to kill

between 150-300 American’s per year (Copstead & Banasik, 2014). Electrical burns are

classified based upon the degree of thickness and TBSA, just like other types of

burns. Typically the extent of the damage is related to the voltage. Patients with electrical

burns should receive fluid resuscitation as well as extensive monitoring of cardiac electrical

activity. Copstead and Banasik (2014) shared that electrocardiogram changes in patients with

electrical burns can include ventricular or atrial fibrillation, prolonged QT intervals. Patients

may also experience sudden cardiac death. Electrical burn patients may also experience CNS

changes following major electrical injuries. Symptoms can vary from memory deficits to ataxia

and gait alterations, and usually resolve within four-to-six weeks after the initial injury (Copstead

& Banasik, 2014).

Chemical burns occur in approximately 3% of all burn cases in the United States

(Copstead & Banasik, 2014). Chemical burns can happen from many different products, many

of which are kept in all households. Chemical burns may also occur from occupational hazards in

jobs that use substances like anhydrous ammonia, wet cement, asphalt or hydrofluoric acid.

Finally, chemical burns may be associated with chemicals used in airbag deployments after a car

crash. Clinical management of chemical burns involves first removing the substance from the

skin. Subsequent management involves frequent dressing changes to keep the wound beds clean
REFLECTION ARTIFACT 24

and moist as well as incorporating antibiotics if infection is suspected and analgesics if burns are

painful for the patient.

As previously mentioned, burns are measured and classified based upon the depth of

tissue involvement, and the TBSA affected. Treatment for all types of burns includes removal of

the causative agent and prevention and management of systemic complications. Patients with

deep burns require fluid resuscitation to ensure adequate cardiac output and perfusion to all

tissues so that healing can take place. Wounds need to be treated with proper ointments or

creams as needed to prevent infection and to promote skin healing. If wounds are severe,

patients may require surgical intervention like skin grafting (McCance, Huether, Brashers, &

Rote, 2014). Prevention of multiple organ dysfunction is important for patients with burns. It is

the job of the AP nurse and the healthcare team to prevent complications and intervene early to

improve patient outcomes.

Sepsis

Case studies allow nursing students and practicing nurses to apply clinical knowledge to

professional practice. The following case study was presented to a group of medical-surgical

nurses at a staff meeting. The nurses were asked to predict the patient’s diagnosis and expected

physician orders.

Mrs. H is a 79-year-old female who was admitted to a post-surgical unit with weakness in

bilateral legs after a lumbar laminectomy two months ago. Per family, she has been spending

more time in bed, has had a decreased appetite, a and slight increase from baseline confusion.

The patient also complains nausea. She has an extensive medical history, including myocardial

infarction, atrial fibrillation, bradycardia, hypertension, bilateral knee replacements, pancreas

resection and splenectomy, lumbar surgery over ten years ago with repeat recently done.
REFLECTION ARTIFACT 25

Upon initial presentation, the patient is awake and alert and oriented to person, place, and

time. Her vital signs are as follows; temperature 95.6°F temporal, heart rate 68, blood pressure

122/65, respiratory rate of 18 breaths per minute, pulse ox of 92% on 2L of supplemental oxygen

via nasal cannula. Her abdomen is soft, nontender and nondistended with bowel sounds present

in all four quadrants. Lung sounds are clear throughout all lung fields. Oral mucous membranes

are dry. Her bilateral lower extremities have slight weakness with plantar- and dorsiflexion. She

is able to move all extremities freely.

Laboratory testing was ordered, and the results were: white blood cells count of 5.3,

hemoglobin 12, hematocrit 37.1, platelets 82, sodium 140, potassium 6.2, BUN 71, creatinine

2.1, and glucose 82. Urinalysis and culture were positive for bacteria, nitrites, leukocytes, and

white blood cells. Chest radiograph results were negative for any acute processes.

Nurses were asked to consider differential diagnoses and what further orders were

expected from the physician. Initial orders were for Rocephin 1 gm IV daily, normal saline IV at

100 mL/hr and lasix 40 mg IV daily. Differential diagnoses include hyperkalemia of unknown

origin, acute kidney injury, and urinary tract infection.

The patient was assessed by a registered nurse [RN] with minimal variations in

assessment. Mrs. H continued to have bilateral lower extremity weakness. She became forgetful

but was easily reoriented. A foley catheter was inserted to monitor urine output following IV

fluid and lasix administration. Her vital signs were also assessed every four hours and were as

follows:
REFLECTION ARTIFACT 26

Nurses were asked to analyze vital signs and identify any areas of concerns. Nurses

O2
Temp Pulse Resps BP Pulse Ox
delivery

95.6
68 18 122/65 92% 2L NC
Temporal

57 16 110/68 95% 2.5L NC

98 12 108/72 90% 2.5L NC

107 20 106/64 91% 3L NC

pointed out that her pulse ox dropped requiring an increase in supplemental oxygen. Her blood

pressure decreased throughout the day. Nurses also pointed out that the patient’s temperature

had not been checked since her initial vital signs.

When the next shift came on and assessed Mrs. H, she was found with cool and clammy

skin. She was also more confused than she had been previously. Her vital signs were

temperature 89.9°F temporal, heart rate 107, blood pressure 98/61, respiratory rate of 14 breaths

per minute, and a pulse ox of 90% on 4L supplemental oxygen via nasal cannula. Her blood

sugar was 91 and she had 275mL of urine output over the last four hours. The nurse notified the

physician of the patient’s low temperature and initiated a warming blanket.

After four hours, the patient’s temperature had increased to 98.4°F. Her respiratory rate

increased to 28 breaths per minute and her pulse ox dropped to 79% on 4L of supplemental

oxygen via nasal cannula. Her blood pressure had dropped to 85/48 and her blood sugar was 60.

The nurses began to feel uncomfortable with the patient’s condition and called a medical
REFLECTION ARTIFACT 27

emergency team [MET]. Nurses were asked to predict physician orders and plan of care for the

patient during the MET. They were also asked to consider the potential diagnosis.

Nurses predicted physician orders of dextrose IV and a 1L normal saline fluid bolus.

Arterial blood gasses [ABGs] were also ordered. ABG results showed a pH of 7.53, pCO2 of 37,

and pO2 of 70. The patient was intubated and subsequently transferred to the intensive care unit

[ICU]. Nurses predicted a diagnosis of sepsis and septic shock.

While in the ICU, the patient continued to receive IV fluids and antibiotics. The patient

presented with typical signs of sepsis that include increased white blood cells, tachycardia, and

an infection in her urine. The Society of Critical Care Medicine (2016) shared that elderly

patients may not always present with typical signs of sepsis and septic shock. They explained

that elderly patients experiencing sepsis might experience shortness of breath, confusion, and

hypothermia.

Conclusion

It is important for AP nurses to understand how the human body is made up of

interconnected body systems. Trauma, burns, and sepsis can have drastic effects on overall

health and patient outcomes. Shock can be life-threatening and has high mortality rates. Each

type of shock has different characteristics, but all are associated with deficiencies of cellular

oxygen consumption and can lead to systemic inflammatory responses. If untreated, shock can

lead to multiple organ dysfunction syndromes. Burns are another injury that can cause systemic

injuries.
REFLECTION ARTIFACT 28

References

American College of Surgeons. (2017). Advanced trauma life support course for physicians.

Advanced Trauma Life Support. Retrieved from https://www.facs.org/quality-

programs/trauma/atls

Anthony, K. (2017). Neurogenic shock: Causes, symptoms, and treatment. Healthline. Retrieved

from https://www.healthline.com/health/neurogenic-shock

Brashers, V. L. (2006). Clinical applications of pathophysiology: An evidence-based approach

(3rd ed.). St. Louis, MO: Mosby Elsevier.

Copstead, L. E., & Banasik, J. L. (2014). Pathophysiology (5th ed.). St. Louis, MO: Elsevier.

McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2014). Pathophysiology: The

biologic basis for disease in adults and children (7th ed.). Maryland Heights, MO:

Mosby Elsevier.

Schmidt, G. A., & Mandel, J. (2017). Evaluation and management of suspected sepsis and septic

shock in adults. UpToDate. Retrieved from

https://www.uptodate.com/contents/evaluation-and-management-of-suspected-sepsis-

and-septic-shock-in-adults?search=septic%2Bshock

Society of Critical Care Medicine. (2016). Bundles. Surviving Sepsis Campaign. Retrieved from

http://www.sccm.org/SiteCollectionDocuments/SSCBundleCard_Web.pdf