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Acute Care Exam 1 > CH 56: Emergencies and disasters > Flashcards

CH 56: Emergencies and disasters Flashcards

1
Q

roles of an ER nurse

A

Establish priorities
Continuous assessment
Supervises allied health personnel
Teaching with time-limits
Deliver care in a high-pressured environment

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2
Q

foundational concepts of emergency nursing

A

Triage
Primary and Secondary Surveys

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3
Q

what is triage

A

Categorization of clients based on severity and urgency of health problems
Process of rapidly determining patient acuity; Represents a critical assessment skill

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4
Q

types of assessments performed for triage

A

The highest acuity needs receive the quickest evaluation
Gatekeeper of ER
Emergency Severity Index (ESI)
Four-level system (Disaster triage)

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5
Q

Four-level system (Disaster triage)

A

Immediate (I – red)
Delayed (II – yellow)
Minimal (III – green)
Expectant (0 – black)

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6
Q

5 level triage algorithm

A

Emergency severity index (ESI)

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7
Q

ESI is a five level triage algorithm that considers:

A

Clinical presentation
VS
Amount/type of resources needed to treat client

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8
Q

1 score of ESI

A

Have to resuciatate
needs immediate intervention

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9
Q

5 score on the ESI

A

patient does not need resources for treatment
best possible outcomes

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10
Q

unintentional or intentional wound/injury inflicted on the body from a mechanism and the body can’t protect itself

A

trauma

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11
Q

patient comes in with frontal trauma from a car accident, what injuries am i Exspecting?

A

rib cage
pelvic fracture
heart, lungs, arteries
abdominal injuries/bleeding

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12
Q

what is a multiple trauma

A

one injuries causes harm to multiple body systems; higher mortality
Should assume all have spinal cord injury until cleared!

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13
Q

goal for treatment of trauma

A

Determine extent of injuries and establish priorities of treatment

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14
Q

level 1 trauma center #1 cause of death

A

fall from standing height
older adult population with delayed signs

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15
Q

A-E assessment

A

Alertness
Airway
Breathing
Ventilation
Circulation
Hemorrhage Control
Disability
Exposure
Environment

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16
Q

preparation for triage

A

Activate
Prepare
PPE and safety
General impression
–Uncontrolled external hemorrhage
–Unresponsiveness/apnea

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17
Q

temperature of the trauma bay

A

above 90 degrees to keep body temperature up

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18
Q

what pain medication do we give to trauma patients to not drop blood pressure

A

fentanyl

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19
Q

A-E assessment

A

Alertness, Airway, spine
Breathing, ventilation
Circulation, hemorrhage control (pulse and skin)
Disability (pupillary response)
Exposure, Environment (strip pt to see any injuries)

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20
Q

***GCS scale components
lowest score:

A

eyes
motor response
verbal response

lowest score is 3

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21
Q

A-E: Alertness

A

AVPU (alert, verbal, pain, unresponsive)

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22
Q

If the patient is unable to open their mouth or responds only to pain, perform the jaw–thrust maneuver. Do the following:

A
  1. Stand at the head of the bed.
  2. Place your index fingers under the angle of the lower jaw on each side of the patient’s face, your palms close to or on each cheekbone for stabilization.
  3. Gently move the mandible upwards (vertically) and towards the patient’s feet (horizontally).
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23
Q

A-E: Airway

A

Bony deformity
Burns
Edema
Fluids (blood, vomit, or secretions)
Foreign objects
Inhalation injury (burns,singed facial hair,soot)
Loose or missing teeth
Sounds (snoring, gurgling, stridor)
Tongue obstruction
Vocalization

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24
Q

indications for oropharyngeal airway (OPA)

A

Unresponsive and without a gag reflex
Correctly sized = tongue in correct anatomical position
Temporary measure: opens airway
–Facilitate spontaneous respirations or manual ventilation

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25
Q

audible breathing sound when there is a breathing obstruction

A

snoring (caused by tongue)

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26
Q

how to perform OPA

A

Measure: Proximal end of OPA at corner of the mouth, tip should reach the angle of mandible
Depress tongue with tongue blade or rigid suction device and advance straight over the tongue OR insert OPA at 90-degree angle and turn.
Avoid trauma to palate
Care must be taken to avoid pushing tongue backward
Reassess!

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27
Q

indications for Nasopharyngeal Airway (NPA)

A

Open the airway
Enables air to pass behind the tongue
Can be used in responsive patients with a gag reflex
An NPA is an absolute contraindication with facial trauma or a known or suspected basilar skull fracture
For the right nares

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28
Q

how to perform Nasopharyngeal Airway (NPA)

A

Measure: Tip of nose to tip of ear lobe
–Too long may enter esophagus
–Sustained blanching to naris = too large
–Improper size may cause epistaxis
Apply water soluble lubricant
Insert with bevel facing septum
Advance until flange rests against naris
Resistance – rotate slightly
Reassess!

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29
Q

***steps for verification of placement for an endotracheal tube placement

A
  1. Attach CO2 detector device
  2. Observe for rise and fall of chest
  3. Auscultate:
    –First over epigastrium
    –Breath sounds
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30
Q

What should you do in the airway assessment if your patient arrives with an endotracheal tube (ETT) in place?

A

If the patient has a definitive airway in place, first assess for correct placement of the airway device, then move to the next step of the primary survey.

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31
Q

assessment for proper placement of a definitive airway consists of the following three steps:

A

Attachment of a CO2 detector device. After 5 to 6 breaths, assess for the presence of exhaled CO2
Observation of adequate rise and fall of the chest with assisted ventilation
Auscultation, first for absence of gurgling over the epigastrium, and then for presence of bilateral breath sounds

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32
Q

***What is the normal range for ETCO2?

A

The normal range is 35–45 mm Hg (4.7–6.0 kPa)

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33
Q

A-E: Breathing and Ventilation

A

Breath sounds
Depth, pattern, rate
Increased work of breathing
Open wounds or deformities
Skin color
Spontaneous breathing
Subcutaneous emphysema
Symmetrical chest rise and fall
Tracheal deviation or JVD

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34
Q

What is the next step if the breathing assessment reveals adequate ventilation?

A

Continue oxygen via an appropriate device for the ordered flow rate

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35
Q

What is the next step if your breathing assessment reveals absent or inadequate ventilation?

A

-Open the airway using a jaw-thrust maneuver while maintaining SMR and insert an airway adjunct
-If the patient remains apneic or without adequate ventilation, assist ventilations with a bag-mask device

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36
Q

A-E: Circulation and Control of Hemorrhage

A

Inspect and palpate
–Color
–Temperature
–Moisture
Palpate a pulse
Control of hemorrhage

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37
Q

wanted gauge of IV for trauma patient

A

14
bigger the better for fluids and blood products

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38
Q

What interventions should be anticipated for hypovolemic shock due to hemorrhage?

A

Examples could include the following as indicated: control of hemorrhage with direct pressure, application of a tourniquet, balanced resuscitation, damage control resuscitation, FAST exam, and pelvic binder.

39
Q

A-E: Disability (neurologic status)

A

Glasgow Coma Scale
–Best eye opening
–Best verbal response
–Best motor response
Pupils
Glucose if indicated

40
Q

Focus is on assessing neurological function and evaluate spinal cord injury.

A

disability

41
Q

Assess neuro status including LOC

A

Glasgow Coma Scale (with VS, every 5 min)
AVPU
Repeat at frequent intervals

42
Q

what is AVPU

A

alert
verbal stimuli
painful stimuli
unresponsiveness

43
Q

potential intervention for disability

A

Stabilize the cervical spine with backboard and collar

44
Q

A-E: Exposure and Environmental Control

A

Remove all clothing
–Inspect for injuries
*Warming measures
–Blankets
–Increase room temperature
–Warmed IV fluids
–Warming lights

45
Q

F: Assessment

A

Full Set of Vital Signs and Family Presence
Obtain a full set of vital signs
Facilitate family presence

46
Q

Get Adjuncts and Give Comfort (L-P)

A

L: Laboratory analysis
M: Cardiac monitor; consider 12-lead ECG
N: Consider naso- or orogastric tube
O: Oxygenation and capnography; consider weaning oxygen
*P: Assess pain using appropriate scale
–Consider analgesia
–Nonpharmacologic comfort

47
Q

history:assessment

A

Pre-hospital personnel
Patient or family generated

48
Q

head to toe assessment

A

Inspect, auscultate, and palpate
–Head
–Face
–Neck
–Chest
–Abdomen/flanks
–Pelvis/perineum
–Extremities

49
Q

inspect posterior: assessment

A

Unless contraindicated by known or suspected spine or pelvic injury
–Turn, inspect and palpate
–Remove backboard

50
Q

When might it be unsafe to turn the patient? Why?

A

If the patient has signs or symptoms suggestive of a spine or pelvic injury, logrolling can cause more trauma or worsen bleeding from pelvic fractures

51
Q

What should be done if a spinal injury and/or unstable pelvic fracture is suspected?

A

Whenever possible movement should be delayed until imaging of the pelvis or spine is completed. If imaging is deferred or confirms the presence of an unstable spine, extreme caution, with consideration of risks and benefits, is used with any patient movement. The healthcare team uses the safest technique possible based on the available staff and handling devices. Alternate methods to move the patient include air-assisted mattresses and the 6-plus lift-and-slide

52
Q

Anticipate Interventions or Diagnostics

A

A patient has a deformity of the upper arm
Anticipate a radiograph of the area
Splint

53
Q

Just keep reevaluating: VIPP

A

V: Vital signs
I: Injuries and interventions
P: Primary survey
P: Pain

54
Q

rapid response team

A

Team of critical care experts
Who??? depends on the sight and hospital
Responds to emergency calls when indications of rapid decline
Provides early recognition BEFORE code blue
Debriefing occurs after
Rapid response roles
Training for rapid response
Why would a nurse call a rapid response?
—deteriorating patient
What is the nurse’s responsibility while the rapid response team shows up?

55
Q

What questions would you ask a patient with penetrating trauma?

A

-Type of weapon and location of external injuries for stab and gunshot wounds
-Estimated blood loss at the scene; often poorly estimated

56
Q

What specific implications are you considering for penetrating trauma?

A

Stab wounds traverse adjacent structures
Trajectory, cavitation, and bullet fragmentation affect wounds sustained
–Indicates the severity of the injury

57
Q

What questions would you ask a patient after blunt trauma when considering the abdominal and pelvic region?

A

Where on the body was the patient struck?
Is there a history of previous abdominal/pelvic surgery or bariatric surgery?

58
Q

What specific implications are you considering for blunt trauma?

A

Point of impact will be the assessment focus.
Previous surgery may have weakened the abdominal wall and jeopardized the protection it provides.

59
Q

solid organs

A

-Liver, spleen, kidneys, and pancreas
-Tear, lacerate, fracture
-More commonly injured
-Hemorrhage is the major concern; potential for rapid deterioration and death - leakage into abdominal cavity

60
Q

hollow organs

A

Gallbladder, stomach, small bowel, and large bowel
Less frequently injured in blunt trauma due to their flexible nature
Contents leak into peritoneal cavity  peritoneal irritation
Involuntary guarding
Abdominal distention
Abdominal pain
With or without palpation
Rebound tenderness
These signs are slower to evolve

61
Q

What can the abdominal exam tell you for solid vs hollow organs?

A

Potential organs involved, continued hemorrhage

62
Q

What diagnostics can you anticipate for solid and hollow organs?

A

Imaging: FAST, radiographs, CT
Diagnostic peritoneal aspiration or lavage (DPA/DPL)
Labs: Serial hemoglobin and hematocrit, liver function tests, lipase, amylase

63
Q

When would you anticipate operative intervention?

A

If the patient becomes hemodynamically unstable, with decreasing hemoglobin and hematocrit

64
Q

**s/s of intra-abdominal injuries

A

Look for obvious signs of injury
Dependent on damaged organs
Abd distention, guarding, tenderness, pain, muscular rigidity, rebound tenderness = peritoneal irritation
Loss of bowel sounds
S/s of shock
Ecchymosis around umbilicus (Cullen’s sign)**
Ecchymosis in flank (Grey-Turner’ sign)**
Referred left shoulder pain due to diaphragmatic irritation from splenic injury (Kehr sign)**
Referred right shoulder pain due to liver injury

65
Q

diagnostics of intra-abdominal injuries

A

U/A
CT
Labs
Focused Assessment for Sonographic Examination in Trauma (FAST) - free floating fluid
Diagnostic peritoneal lavage

66
Q

Intra-Abdominal Injuries Medical and Nursing Management

A

IVF or blood
Monitor VS, 02, U/O, and LOC
Assess for entry and exit wounds for penetrating trauma
02
Establish patent airway
Apply direct pressure to wounds
NGT for decompression
Establish IV access
Tetanus and IV ABX for prophylaxis
Exploratory lap
DO NOT REMOVE AN IMPALED OBJECT!!!!!

67
Q

Care of the client with evisceration

A

Stay calm and stay with the client
Call for help (RRT)
Immediately cover the area with sterile, moist saline dressings
–DO NOT ATTEMPT TO REINSERT THE ORGANS
Place the client in a low-Fowler’s position with hips and knees bent
Prepare the client for surgery
Document

68
Q

What might you see with a pelvic fracture?

A

Vascular injuries common
Assessment of pelvic stability
Assessment findings
Patterns of injury
Palpable motion, pain, or bony crepitus on palpation of the pelvis
Hypovolemic shock (may or may not be present)
Shortening or abnormal rotation of the leg on the affected side
Perineal edema and ecchymosis
Blood at the urinary meatus, hematuria, or intraabdominal injury
Rectal bleeding

69
Q

signs that resuscitative thoracotomy may be necessary

A

patient with penetrating chest trauma arrives with unstable vital signs, impending arrest, or sudden loss of vital signs.

70
Q

Indications for performing resuscitative thoracotomy in the resuscitation room include:

A

Relief of cardiac tamponade
Support cardiac output with internal massage
Cross clamp the descending aorta to preserve thoracic and cerebral blood flow
Defibrillate the heart internally (more effective than external defibrillation)
Control massive air embolism
Limit hemorrhage from the heart or great vessels

71
Q

Resuscitative thoracotomy is rarely successful in patients with:

A

blunt chest trauma and cardiac arrest

72
Q

Medical and Nursing Management for poisoning

A

ABC support
Continuous assessment
Placement of indwelling catheter
Determine type of poison, time of ingestion, the amount, s/s, pertinent history
Consult with Poison Control Center***
Evaluate mental health/psychosocial status
Monitor for complications
If ingestion of corrosive agent, milk or water is used to dilute
Not given for airway issue or evidence of GI burn or perforation
Syrup of ipecac
But not for corrosive! Increases risk of vomiting  aspiration
Gastric lavage
Activated charcoal
If it is absorbed by charcoal
Cathartic
Administration of antidote
Dialysis
Diuresis
Hemoperfusion

73
Q

A sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material and economic losses that exceed the community’s or society’s ability to cope using its own resources

A

disaster

74
Q

typically occur on a more frequent basis and may have substantial effect at the local level.

A

multi-casualty incident

75
Q

Casualties numerous enough to overwhelm and disrupt the healthcare services in the affected community or geographic area.

A

mass casualty event (MCE)

76
Q

disaster life cycle

A

mitigation
preparedness
response
recovery

77
Q

Which phase of the disaster life cycle occurs when you receive the notification of a 20-car crash?

A

Notification occurs in the response phase, which is typically the shortest phase.

78
Q

Mitigation plans include the following:

A

Lessons learned, deficiencies identified, and areas of improvement. These items provide insight into prevention and minimizing the impact on the facility.
Incorporating information from previous and likely events into future planning for subsequent events

79
Q

START Adult Disaster MCI Triage algorithm.

A

Respirations: > 30 breaths/minute = Immediate, < 30 breaths/minute move to perfusion
Perfusion: Capillary refill > 2 seconds or pulse absent = Immediate, < 2 seconds or radial pulse present move to mental status
Mental status: Can do (can follow commands) or can’t do (cannot follow commands)

80
Q

green/minor

A

Anyone able to walk are often called the “walking wounded” and have all RPM elements intact.

81
Q

yellow/delayed

A

These patients have RPM intact but are nonambulatory. The nurse should maintain a high index of suspicion for underlying serious or life-threatening injury.

82
Q

red/immediate

A

At least one of the RPM assessments is compromised. An immediate, life-threatening injury is involved, and the patient needs immediate attention.

83
Q

Black/EXPECTANT

A

These patients are unlikely to survive. Physiologically, the patient does not have an intact airway after repositioning the airway (or 5 rescue breaths for pediatrics). These patients receive respite care

84
Q

differences between pediatric and adult disaster triage parameters. Highlight the differences:

A

Pediatric patients who are not breathing after positioning of the upper airway receive 5 rescue breaths
Target respiratory rate 15-45 breaths/minute
AVPU instead of can or cannot follow commands

85
Q

There are three considerations that can help determine who receives treatment first

A

task, time, and treaters.

86
Q

chemical agents

A

Nerve agents produce symptoms noted in the SLUDGE mnemonic: Salivation, Lacrimation, Urination, Defecation, GI upset, Emesis

87
Q

biologic agents

A

Bio agents can spread via person to person by contact, inhalation, and ingestion, thus making the spread a public health emergency

88
Q

radiologic/nuclear

A

Radiological dispersal device (dirty bomb) or nuclear irradiation (bomb or reactor leak)

89
Q

five levels of explosive blast injury

A

Primary blast injury: direct blast pressurization
Secondary blast injury: projectiles propelled by explosion
Tertiary blast injury: victim thrown by blast wind
Quaternary blast injury: explosion related such as from heat or fumes
Quinary blast injury: associated with CBRN (example, dirty bomb)

90
Q

primary survey

A

focus on stabilizing life -threatening conditions
circulation, airway, cervical spine, breathing, disability, exposure to see injuries
primary ends at E

91
Q

secondary survey

A

health history
head to toe
diagnostics

92
Q

pneumothorax

A

simple - outside of pleural space - pain with resp
open = air escaping from hole out of the body - occlusive dressing on only 3 side
tension = emergency - pressure building in plueral space - pressure on organs with hemodynamic changes - HR increase, bp decrease, decreased cardiac output

93
Q

what is PEA caused from tension pneumo

A

pulseless electrical activity – presenting rhythm for tension pneumo – blood is running out

94
Q

what to when having a human made disaster injury

A

have to decontaminate before bringing them into hospital so it does not spread

Acute Care Exam 1 (3 decks)

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