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capstone > Care of the person who experiences trauma (BIG MOTHER FUCKING DECK) > Flashcards

Care of the person who experiences trauma (BIG MOTHER FUCKING DECK) Flashcards

1
Q

What is the purpose of the triage system?

A

To ensure that the level and quality of care that is delivered to the community is commensurate with objective clinical criteria

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2
Q

Explain the Australasian triage scale and the 5 categories

A
  • Immediately life-threatening (category1)
  • Imminently life-threatening (category2)
  • Potentially life-threatening or important time- critical treatment or severe pain (category 3)
  • Potentially life-serious or situational urgency or significant complexity (category 4)
  • Less urgent (category5)
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3
Q

Name factors that influence the triage role

A 
Physical environment
Time constraints
Language use
Nonverbal behaviours
Cultural diversity
Nature of the health concern
Expectations and assumptions
Emotions
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4
Q

What are impartant factors when checking airways?

A

Check patency

Check obstruction

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5
Q

What are important factors when checking Breathing?

A

Check for respiratory distress

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6
Q

What should you look out for when checking circulation?

A 
Heart rate
Pulse characteristics
Skin indicators
Oral intake
Output
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7
Q

What should you look out for when checking Disability?

A

GCS

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8
Q

what is AVPU and when is it used?

A 
when checking disability
A = alert
V = Responds to voice
P = Responds to pain - purposefully, non-purposefully, withdrawal/flexor response, extensor response
U = Unresponsive
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9
Q

What happens in a secondary survey?

A 
Full set or vital signs
Give comfort measures
History and head to toe
Individualised aspects
IDC
BGL
physical
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10
Q

What differs between rural and remote triage?

A

Lack of safety net
Time issues
Triage process may occur outside hospital setting
Personal safety
Lack of anonymity
Decisions may carry enormous financial or social ramifications to patients and family
Knowledge of the community

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11
Q

What are the different types of emergency presentations

A 
Burns
Submersion
Environmental emergencies
Spinal and head injuries
Anaphylaxis
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12
Q

what are the 3 Types of burns

not thickness

A
  • Thermal
  • Chemical
  • Electrical
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13
Q

Explain the characteristics and the thickness of different burns

A

– Superficial (epidermis): skin may pink to red and
dry, painful
– Partial thickness (epidermis and dermis): skin bright pink and blisters, painful
– Full thickness (epidermis, dermis, underlying tissues): skin appears waxy, dry, leathery, charred, no pain

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14
Q

What are the predisposing factors of burns

A

Age

  • under 3 yrs.- safety issues
  • 3-14 yrs. – flame burns most common - 15-60 yrs. – domestic or industrial
  • over 60 yrs. – medical problems
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15
Q

Describe a primary survey of a burn

A
  • Airway – possible smoke inhalation
  • Breathing – possible carbon monoxide poisoning
  • Circulation – haemodynamic stability
  • Disability – neurological and spinal status
  • Exposure – temperature, wound severity (size, depth, location, patients age
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16
Q

Explain a secondary survey of a burn

A
  • Nature of the incident
  • Mechanisms of injury
  • Pertinent medical history – pre-existing disease
  • Current medications
  • Allergies
  • Tetanus immunisation
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17
Q

How do we measure the extent of a burn?

A

Every body part is broken down into a percentage

The rule of 9’s

The Lund and browder method is the recommended method as there is a table for different ages

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18
Q

Why is the burn percentage important to us?

A

The Australian nz burns association relies on accurate burn measurement for referral

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19
Q

What are some burns referral criteria?

A 
Burns greater than 10%
Burns of special areas
Full thickness burs greater than 5%
Electrical burns
Chemical burns
Burns associated with inhalation injury
Burns at the extremes of age
Burns on people with pre existing medical disorders
Any burn patient with associated trauma
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20
Q

How is a partial thickness burn assessed for depth?

A

Sensation - Normal or increased sensitivity to pain and temperature
Colour - Red, will blanch with pressure indicating good capillary return
Blisters - Large, thick walled, will increase in size
Texture - Normal to firm

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21
Q

How is a full thickness burn assessed for depth?

A

Sensation - Anaesthetic to pain and temperature
Colour - White, brown, black, red. If red, does not blanch with pressure
Blisters - Usually none. If present, thin walled and do not increase with size
Texture - Firm to leathery. Eschar

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22
Q

What are some types of minor burns?

A

Sunburn

Scald burn - exposure to moist heat

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23
Q

What are some types of a major burns?

A
  • Includes all burns of the hands, face, eyes, ears, feet, and perineum, all electrical injuries, multiple traumas, and all clients that are considered high risk
  • Partial thickness burns of greater than 25% of the total body surface
  • Full thickness burns of 10% or greater of the total body surface area
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24
Q

Explain what happens in the Integumentary system in a major burn event

A

Integumentary

  • skin loss
  • sensory loss
  • decreased temp
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25
Q

How can you tell if a burn wound is infected or at risk of infection?

A

– Increased sloughing of burn tissue
– Increased edema around wound edges
– Partial-thickness wound converting to full- thickness wound
– Black or brown areas of discoloration

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26
Q

What is the recommended parameters for fluid resuscitation and for what burns is this necessary?

A
  • Necessary in all burns >15% TBSA
  • Hourly urine0.5mL-1mL/kg/hr
  • HR <120 beats/min
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27
Q

What needs to be considered for respiratory management for a burn?

A 
• TCDB every 2 hours
 - Prepare for intubation
• Maintain adequate tissue oxygenation with least amount of inspired oxygen necessary
• Continuous assessment of ABGS
• PEEP may be used
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28
Q

What do we do for pain management if a burn?

A
  • Do not administer IM analgesia
  • IV/CVC inserted
  • sliding scale order – e.g. Morphine infusion 5-25mg/hr with 2mg bolus prn – PCA
  • Change to oral medication when tolerating food and fluids
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29
Q

What types of surgery is done for burns?

A
  • Escharotomy
  • SurgicalDebridement
  • Grafting
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30
Q

Explain escharotomy

A

A scalpel or electrocautery incision through the full thickness eschar, usually performed at a burn centre, to restore circulation to compromised extremities

Removal of eschar

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31
Q

Explain burn contracture

A

Skin and scaring heals to tight

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32
Q

What nursing issues are associated with burns?

A

Distancing oneself from patients pain
Engaging with the patients pain
Seeking social support
Core role reconstruction

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33
Q

What is a submersion injury?

A

Results when a person becomes hypoxia due to submersion

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34
Q

What is the pathogenisis of submersion?

A

Immediate struggle sometimes surprise inhalation or breath holding

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35
Q

What is a wet drowning?

A

Vigorous breathing and water down into the lungs leads to aspiration

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36
Q

What is a dry drowning?

A

The laryngeal spasm closes the airway leads to aspiration

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37
Q

What happens when fresh water is aspirated?

A

Water leaks rapidly to the capillary bed

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38
Q

What happens when salt water is aspirated?

A

Fluid is dragged into the the alveoli

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39
Q

What does surfactant destruction lead to?

A

Pulmonary oedema

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40
Q

What is the treatment and assessment of a submersion?

A

• Manage and maintain ABC
• If ABC secure assess
– Tachycardia is common after near drowning
– CNS can range from coma to agitation to alert some may be lethargic, confused or irritable
– Resp assessment note rate rhythm cyanosis, frothy sputum
– Temp can be low grade in the first few hours
– Exclude other possible pathologies such as MI, Arrhythmia, Neurological epilepsy, head injury ,spinal injury, Alcohol and drug intox, Environmental hypothermia

41
Q

What is a thermoregulation issue?

A

Imbalance of temp

42
Q

What is internal heat input?

A

Eating or drinking

Muscle contraction

43
Q

What is external heat input?

A

Shower

engines

44
Q

What are the types of heat output?

A

Conduction
Convection
Radiation
Evaporation

45
Q

Where is the thermoregulation centre?

A

The hypothalamus

46
Q

How does the thermoregulation centre work?

A

Peripheral receptors send signals to the essential receptors in the hypothalamus which then sends the reponse

47
Q

In smooth muscles what happens in thermoregulation?

Describe the difference between cold and hot

A

Cold

  • muscles contract causing vasoconstriction
  • Less heat is carried from core to surface
  • extremities can turn blue and get frostbite

Hot

  • muscles relax causing vasodilatation
  • more heat is carried from core to surface
  • surface heat is lost by convection and radiation
  • skin turns red
48
Q

What happens in sweat glands in thermoregulation?

Describe the difference between cold and hot

A

Cold
- no sweat

Hot

  • Glands excrete sweat to suface
  • sweat cools body and evaporates
49
Q

In erector pili muscles what happens in thermoregulation?

Describe the difference between cold and hot

A

Cold
- Muscles contract raising the skin hairs which traps an insulating layer of still warm air next to the skin (goosebumps)

Hot
- muscles relax lowering skin hairs allowing air to flow over skin

50
Q

What do skeletal muscles do for thermoregulation?

Describe the difference between cold and hot

A

Cold
- shivering, muscles contract and relax repeatedly generating heat by friction

Hot
- no shivering

51
Q

Explain hypothermia

A

Hypothermia is a marked cooling of core body temperature

It produces depression of the
• CNS and respiratory systems,
• vasoconstriction
• alterations in micro circulation coagulation 
• and ischemia tissue damage
52
Q

What happens to metabolism the in hypothermia?

A
  • Initial ↑ in basal metabolic rate which results in tachycardia, vasoconstriction and shivering
  • As metabolism slows oxygen deprivation occurs
  • The metabolism movesto anaerobic producing lactate and resulting in metabolic acidosis
53
Q

What happens in the CVS in hypothermia?

A
  • ↑ HR, ↑ B/P, ↑ CO
  • Shunting of blood from peripheries to central organs
  • As temp falls to 32°C myocardial activity is suppressed resulting in bradycardia
  • As myocardial activity is further depressed CO falls with the result less perfusion to vital organs
54
Q

What happens in the respiratory system in hypothermia?

A

increased resp rate

as hypothermia worsens the medulla becomes depressed and respiratory function is depressed

Metabolically there is less CO2 being produced but there is less capacity to remove CO2 via the lungs and respiratory acidosis results

55
Q

What is the management of hypothermia?

A

Rewarming to raise temperature by 0.5 - 1 degree Celsius /hour

56
Q

What are the different types of rewarming?

A

Passive and active

57
Q

Explain Passive rewarming

A
  • Remove wet clothing
  • Replace with warm blankets
  • Increase room temperature
  • Eliminate drafts
  • Minimal handling
  • Warm oral fluids
58
Q

Explain Active rewarming

A
  • Immersion in heated water
  • Use of radiant heat
  • Devices such as Bair hugger
  • Use of space blankets
  • Cover the persons head (50 -60% of radiant heat loss occurs above the shoulders)
59
Q

What is hyperthermia?

A

Diagnosed when the core body temp is higher than 40

60
Q

What is the signs and symptoms of hyperthermia?

A

Heat cramps
• Severe muscle cramps
• Thirst

Heat exhaustion
• Pale or grey skin
• Fatigue weakness
• Sweating++
• Altered mental state
• Hypotension
• Tachycardia
• Thready pulse
• Temp >37.8 but <40C
61
Q

What is the management of hyperthermia?

A 
Remove from danger
Stabilise ABC, record temp
Remove excessive clothing
Cool – cold packs to axial / groin
spray with water and fan
Immerse part of body in cool/iced water
Continue to monitor ABC may need Oxygen and / or ventilation, cardiac monitor
Slow re hydration to prevent hyponatraemia
62
Q

How are head injuries described?

A

Open or closed

63
Q

What happens in raised ICP?

A

Blood or CSF or brain tissue swell and raise the pressure in the skull

64
Q

What is used to regulate and maintain ICP?

A

• Monro-Kellie doctrine
– If one component increases, another must decrease to maintain ICP.
• Normal ICP 5 to 15 mmHg
– Elevated if >20 mm Hg sustained

65
Q

What compensatory actions does the body do for increased ICP?

A

– Changes in CSF volume
– Changes in intracranial blood volume
– Changes in tissue brain volume

66
Q

Explain what happens in the cardiovascular system in a major burn event

A 
Third spacing
decreased BP
Increased HR
Decreased RBC's
Decreased cardiac output
Decreased tissue perfusion
67
Q

Explain what happens in the respiratory system in a major burn event

A 
Hypoxia
Increased respiration
Rhonchi
Decreased ciliary movement
Airway obstruction
68
Q

Explain what happens in the GI system in a major burn event

A 
Hyperacidity
Ileus
Melena
Hematemesis
Increased abdominal girth
69
Q

Explain what happens in the urinary system in a major burn event

A 
Decreased GFR
Increased creatinin
increased BUN
Increased Specific gravity
increased uric acid
increased myoglobinuria
70
Q

Explain what happens in the immune system in a major burn event

A 
Decreased T-Cells
Decreased B-cells
Increased WBC's
Decreased proteins
Phagacytosis
71
Q

Explain what happens in the metabolic system in a major burn event

A 
increased catabolism
decreased anabolism
weightloss
acidosis
hyperglycemia
72
Q

What do the adrenal and thyroid glands do for thermoregulation?

Describe the difference between cold and hot

A

Cold
- Glands excrete adrenaline and thyroxine which increased metabolic rate

Hot
- glands stop secreting adrenaline and thyroxine

73
Q

What behaviours do people do for thermoregulation?

A

Cold

  • huddling up
  • curling up
  • finding shelter
  • putting on more clothes

Hot

  • Stretching out
  • finding shade
  • swimming
  • removing clothes
74
Q

What happens to the neurological system in hypothermia

A

alteration in mentalstate, ↑anxiety, muscle incoordination, weakness and confusion

75
Q

What treatment can you do to actively internally rewarm a hypothermic patient?

A
  • Heated humidified air or oxygen
  • Heated/warmed IV fluids
  • CP bypass diverts blood flow via a pump oxygenator and heat exchanger
  • Continuous arteriovenous rewarming via a femoral catheter
76
Q

Explain the 4 stages of increased ICP

A

– Stage 1:total compensation
– Stage 2: ↓compensation; risk for ↑ICP
– Stage 3: failing compensation; clinical manifestations of ↑ICP (Cushing’s triad)
– Stage 4: imminent → death

77
Q

What are the clinical manifestations of raised ICP?

Give 3 examples

A

• Change in level of consciousness

• Change in vital signs
– Cushing’s triad (widened pulse pressure, bradycardia, irregular respirations)
– Change in body temperature

• Ocular signs
– Unilateral pupil dilation
– Sluggish or no response to light
– Inability to move eye upward
– Eyelid ptosis

Headache

Vomiting

78
Q

Regarding increased ICP what motor manifestations can occur?

A

↓ In motor function
– Hemiparesis/hemiplegia
– Decerebrate posturing (extensor) • Indicates more serious damage
– Decorticate posturing (flexor)

79
Q

What diagnostic studies are done for determining head and spinal injuries?

A
  • CTscan/MRI/PET
  • EEG
  • Cerebral angiography

GCS

80
Q

Where can you place an ICP monitoring device?

A 
Epidural
intraparenchymal
subarachnoid
ventricular
subdural
81
Q

What treatments are used for spinal or head injuries?

A 
• Treat under lying cause.
• Adequate oxygenation –PaO2 >100mmHg
– PaCO2 35-45 mm Hg
– Intubation
– Mechanical ventilation
• Surgery
82
Q

Give an example of 3 drug therapies that are used for head injuries?

A

– Mannitol (Osmitrol)
• Plasma expansion
• Osmotic effect
• Monitor fluid and electrolyte status.

– Hypertonic saline
• Moves water out of cells and into blood.
• Monitor BP and serum sodium levels.

– Corticosteroids
• Vasogenic edema
• Monitor fluid intake, serum sodium and glucose levels.
• Concurrent antacids, H2 receptor blockers, proton pump inhibitors

– Antiseizure medications 
– Antipyretics
– Sedatives
– Analgesics
– Barbiturates
83
Q

What nursing assessments can you do for a patient affected by a head injury?

A 
• Subjective data
• Level of consciousness (LOC)
• Glasgow Coma Scale 
– Eye opening
– Best verbal response 
– Best motor response
84
Q

What does one dilated and one normal pupil mean?

A

compressed cranial nerve 3

85
Q

What do bilateral dilation of pupils mean?

A

Ominous sign

86
Q

What do pinpoint pupils mean?

A

Damage to pons or drugs

87
Q

What cranial nerve assessments can you do?

A

– Eye movements
– Corneal reflex
– Oculocephalic reflex (doll’s eye reflex)
– Oculovestibular (caloric stimulation)

88
Q

What nursing interventions can you do for respiratory functioning of head injuries?

A 
– Maintain patent airway.
– Elevate head of bed 30 degrees. 
– Suctioning needs
– Minimize abdominal distention. 
– Monitor ABGs.
– Maintain ventilatory support.
89
Q

What nursing interventions can you do for pain management of head and spinal injuries?

A 
– Opioids
– Propofol (Diprivan)
– Dexmedetomidine (Precedex)
– Neuromuscular blocking agents
– Benzodiazepines
90
Q

What nursing interventions can you do for fluid and electrolyte imbalances patients with head and spinal injuries?

A

– Monitor IV fluids.
– Daily electrolytes
– Monitor for DI or SIADH

91
Q

How can you visually assess for a head injury?

A
  • Bruising
  • Swelling
  • Lacerations
  • Bleeding
92
Q

What are the different classifications of spinal cord injuries?

A

Traumatic and non traumatic

93
Q

What can cause a traumatic spinal injury?

A

vehicle accidents, sporting accidents, falls and assaults with weapons.

94
Q

What can cause a non-traumatic spinal injury?

A
  • cervical spondylosis
  • myelitis
  • osteoporosis
  • tumours
  • vascular disease
95
Q

What nursing management can you do for a spinal cord injury?

A
  • Immobilisation to prevent further injury.
  • Thermoregulation.
  • Bowel and bladder management.
  • Reduce spascity.
  • Prevent pressure areas.
  • Prevent resp complications
  • Assist with nutritional needs.
  • Control pain
  • Promote mobility and maintain suppleness of joints and muscle tone.
  • Psychological support
96
Q

What is a hypersensitive reaction?

A

Hypersensitivity describes an increased immune response to the presence of an allergen known as an antigen, which can potentially cause harm to the person

97
Q

What are the signs and symptoms of anaphylactic shock?

A
  • Rapid onset from seconds (can be up to one hour).
  • Rash, urticaria, pruritus.
  • Angioedema especially of the head, face, neck and upper airway.
  • Flushing
  • Chills
  • Diaphoresis
  • Laryngeal spasm (hoarseness, stridor)
  • Bronchospasm (wheeze or poor air entry)
  • Hypotension
  • Tachycardia
  • Arrhythmias
  • Cardio- pulmonary arrest
98
Q

What is the treatment and management of anaphylactic shock?

A
  • Secure patent airway, relieve obstruction
  • Remove allergen i.e. stinger, infusion etc
  • Adrenaline
  • Administer high flow oxygen via a non rebreather mask may require nebulised bronchodilator
  • Provide warmth
  • Corticosteroid
  • Administer histamine
  • Maintain BP with fluid, volume expanders, vasopressors
99
Q

Explain the triad of death

A

Sever blood loss leads to

  1. low body temp

which leads to decreased coagulation which leads to

  1. Blood clotting problems

which increase lactic acid in the blood which leads to

  1. Acidic blood

which decreases heart performance

And repeat steps 1-3 indefinitely until you save the patient

capstone (19 decks)

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