Chapter 13: nursing care of patients w/ emergent conditions and disaster/bioterrorism response Flashcards
Primary survey: abcde
a = airway
b = breathing
c = circulation
d = disability
e = exposure: remove clothing, look for injuries and medical alert jewelry
secondary survey
- for patient w/ severe trauma
- identifies non life threatening injuries
- rapid head to toe assessment
- keep covered and warm
shock
- circulatory failure
- decreased cellular perfusion
- treatment: control bleeding, vital signs, keep warm, IV fluids
types of shock
hypovolemic
cardiogenic
obstructive
distributive
shock nursing care
- control bleeding
- monitor vital signs
- give oxygen as ordered
- give iv fluids as ordered
- keep warm
- give medications as ordered
anaphylaxis
- severe allergies reaction to protein/drug
- sudden
- distributive shock
- signs and symptoms: respiratory distress (wheezing), hypotension, decreased consciousness
anaphylaxis treatment
- airway
- oxygen
- epinephrine
- antihistamines
- steroids
shock nursing diagnoses
- risk for shock
- risk for ineffective peripheral tissue perfusion
- risk for allergic reaction
- ineffective airway clearance
major trauma
- mechanism of injury
- penetrating (open) injuries
- blunt (closed) injuries
mechanism of injury
transfers environmental energy to person
penetrating (open) injuries
sharp object, projectiles
blunt (closed) injuries
trauma extends to surrounding structures
surface trauma
closed wound
open wound
closed wound
contusion, hematoma
open wound
- abrasion, puncture, laceration
- avulsion, amputation
tetanus
- cause: bacillus clostridium tetani
- spores enter open wound and active
signs and symptoms of tetanus
- jaw spasm (lockjaw)
- abdominal rigidity
- dysphagia, dyspnea
- muscle stiffness
- seizures
- death
tetanus vaccinations
boosters every 10 years
treatment for tetanus
- hospitalization
- airway maintenance
- human tetanus immune globulin (intramuscular)
- muscle spasm control
- wound care
- tetanus toxoid booster
head trauma
first phase
second phase
first phase of head trauma
initial injury
second phase of head trauma
- involve intracerebral bleeding and edema
- increased intracranial pressure (ICP)
signs and symptoms of ICP
- headache
- nausea/vomiting
- change in LOC
late signs and symptoms of ICP
- dilated, nonreactive pupils
- unresponsive
- abnormal posturing
- decreased pulse rate, widening pulse pressure
- changes in respiratory pattern
head trauma treatment: decrease ICP
- oxygen
- head elevated 30-45 degrees
- head midline
spine trauma
- suspect w/ all trauma pts
- stabilize spine (neck/back) until injury ruled out
- maintain airway
chest trauma: heart and lung damage
- pericardial tamponade
- hemothorax
- tension pneumothorax
- flail chest
treatment for chest trauma
- oxygen
- chest tube as needed (PRN)
- surgery
abdominal trauma
- spleen, liver, bladder, intestinal damage
- monitor for shock
- abdominal distention
- IV fluids
- surgery
orthopedic trauma
- emergency care: “splint it as it lies”
- fractures
- joint dislocations
- treatment
treatment for orthopedic trauma
- immobilize
- elevate
- ice
- open/closed reduction
- pain control
majo trauma assessment
- identify mechanism of injury
- vital signs
- pain level
- glascow coma scale
major trauma nursing diagnoses
- acute pain
- risk for ineffective cerebral tissue perfusion
- ineffective breathing pattern
- ineffective airway clearance
- impaired physical mobility
- decreased cardiac output
- deficient fluid volume
- risk for infection -
major trauma nursing care
closed wound
open wound
monitor vital signs
closed wound
elevation, ice, rest
open wound
control bleeding
cover w/ sterile (dry/saline soaked) dressing
clean w/ sterile saline
tetanus immunization within 5 years
burns
- primary survey: ABCDE
-airway/respiratory monitoring - treatment
treatment for burns
- oxygen
- IV fluid resuscitation
- temperature regulation
- pain control
- wound care/infection control: silver sulfadiazine
hypothermia
- core temp below 95 degrees Fahrenheit
- rewarming (active/passing)
- stabilizing vital functions
- prevent further heat loss
frostnip vs frostbite
- frostnip: extremities cold, not frozen
- frostbite: extremities frozen. protect, never rub. dry, sterile dressing. no weight bearing. elevate.
hyperthermia
- heat cramps
- heat exhaustion
- heatstroke
- treatment
heat cramps
muscle spasms
heat exhaustion
- excessive sweating
- hypovolemia
heatstroke
- inability to sweat
- temp 106 degrees Fahrenheit
treatment for hyperthermia
- cool environment
- loosen clothing
- oral or IV fluids/electrolytes
poisoning and drug overdose
- ingested
- inhaled
- injected drugs, stings
- venom bites
- treatment
poisoning and drug overdose: ingested
drugs
plants
chemicals
poisoning and drug overdose: inhaled
natural gas
carbon monoxide
chlorine
treatment for poisoning and drug overdose
- identify substance
- contact poison control center
- treat as indicated
near drowning
- water submersion w/ survival
- respiratory failure
- neurological injury
treatment for near drowning
primary survey: abcde
airway, oxygen
rewarm
nursing diagnosis for near drowning
ineffective tissue perfusion related to severe anoxia
disaster response
- overwhelming event
- institutional disaster plan activated
- casualties are triaged
- disaster drills
bioterrorism agents
bacteria
viruses
toxins
anthrax
- bacterial disease
- three forms
- no isolation; use standard precautions
- fatal if not treated
- antibiotic therapy
three forms of anthrax
inhalation
cutaneous
gastrointestinal
botulism
- caused by clostridium botulinum
- most potent lethal toxin known
- potent neurotoxin
- paralytic illness: blocks neurotransmission
- not contagious
botulism signs and sympms
- classic triad of botulism:
1. afebrile
2. symmetrical descending flaccid paralysis w/ prominent bulbar palsies - clear mentation
botulism treatment: trivalent ABE quine antitoxin
prevents progression of disease
supportive care for botulism treatment
monitor airway, gag reflex, cough, swallowing, oxygenation
botulism infection control
- standard precautions: wash exposed clothes, shower if aerosol exposure, use 0.1% hypochlorite bleach solution for surfaces
plague
- coccobacillus yersinia pestis
- biological attack: primary pneumonic plague
- incubation per8iod 2-4 days
plague signs and symptoms
- high fever, chills
- headache
- chest discomfort
- dyspnea
- cough, hemoptysis
- GI symptoms
- rapidly progressive respiratory failure and sepsis 2-4 days after onset
treatment for plague
antibiotics
