Emergency Nursing Flashcards
Two types of triage systems
Basic system 3 categories
Emergency Severity Index (ESI)
3 categories of the basic system of triage
Emergent
Urgent
Nonurgent
Urgent category means
serious health problem but not life threatening
How many levels are in the ESI?
5 levels
1 - most urgent to 5 - least urgent
ESI stands for
Emergency Severity Index
The primary survey in the ER focuses on
stabilizing life-threatening conditions
AVPU mnemonic
Alert
Verbal
Pain
Unresponsive
A
B
C
D
E
Airway
Breathing
Circulation
Disability
Exposure (undress to assess)
The secondary survey in the ER consists of what components
health hx
head-to-toe assessment
Diagnostics/labs
Monitoring devices: ECG, ABGs
Splinting of fractures
Wound care
Types of airway and ventilation interventions
Oropharyngeal and nasopharyngeal airway insertion
Endotracheal intubation
King tube or laryngeal mask
Cricothyroidotomy
Once an airway is established, how is adequate ventilation assessed?
Listen to bilateral lung sounds
Check O2 sats
ABGs
Rise & fall of chest
Priorities of care for trauma patients
Determine extent of injury and est priorities of treatment
Stabilize C-spine
Injuries interfering with vital physiologic function
Assessment of intra-abdominal injuries
Obtain hx of injury
Assess for referred pain to indicate spleen or liver injury
Labs
US and CT scan
Abdominal assessment and other body systems
What assessment is specifically used for stab wounds?
sinography
Management of pt with intra-abdominal injury
Ensure ABCs
Immobilize C-spine
If viscera protruding, cover w sterile, moist saline dressing
Hold oral fluids
NG tube to aspirate stomach contents
Tetanus and abx prophylaxis
Rapid transport to sx if indicated
Complications of crush injuries
hypovolemic shock
spinal cord injury
erythema and blistering
fractures
AKI
Symptoms of shock
cool, moist skin
increase HR
decreased BP
decreased urine output
decreased cap refill
Management of hemorrhage
Assess for changes - SHOCK
Fluid replacement - isotonic, colloids, blood products
Control of bleeding
Patients in shock with low blood volume are at risk for what
MI
Goals of treating hemorrhage
control bleeding
maintain adequate circulation
prevent shock
Types of heat stroke
non-exertional
exertional
type of heat stroke with prolonged exposure to an environmental temperature of >39.2 C (102.5 F)
nonexertional
heat stroke caused by strenuous activity that occurs in hot environments
exertional
Who is at highest risk of heat stroke?
people not acclimated to heat
older or very young
ill or debilitated people
people taking certain meds
Manifestations of heat stroke
CNS dysfunction
elevated temp of 40.6 C (105 F) or higher
hot, dry skin
anhidrosis
tachypnea
hypotension
tachycardia
Management of heat stroke
ABCs
Reduce temperature as fast as possible using cool water and ice on back of neck, armpits, groin and chest
Monitor temp, VS, ECG, LOC, I&O
IVs to replace fluid
Meds: anticonvulsants, potassium, bicarb, benzos
Manifestations of frost bite
hard, cold and insensitive to touch
appears white or mottled
turns red and painful when rewarmed
Management of frostbite
Controlled but rapid rewarming; 37-40 C circulation water for 30-40 min intervals
Analgesics for pain
What should you NOT do with frostbite?
Rub or massage the area as it can cause more damage
Condition in which core body temperature is 35 C or less
hypothermia
Who is at highest risk for hypothermia
older adults
infants
persons with concurrent illness
homeless
trauma patients
Management of hypothermia
ABCs
Remove wet clothing
Rewarm
Cardiac monitoring
How can patients be internally rewarmed with hypothermia?
cardiopulmonary bypass, warm fluid admin, warm humified oxygen, warm peritoneal lavage
How can patients externally rewarmed with hypothermia?
Warm blankets
over-the-bed heaters
What happens when cold blood returns from the extremities in hypothermia?
it can cause cardiac dysrhythmias and electrolyte disturbances because of the high lactic acid content
Why is cardiac monitoring important in patients with hypothermia?
The return of cold blood from extremities has a high content of lactic acid which can cause dysrhythmias and electrolyte imbalances
condition in which any substance that when ingested, inhaled, absorbed, applied to the skin injures the body by its chemical action
poisoining
Treatment goals of poisoning
Remove or inactivate poison before absorbed
Provide supportive care in maintaining vital organ function
Assessment of the patient with poisoning
ABCs
Monitor VS, LOC, ECG, UO
Labs
Determine what, when, and how much substance was ingested
S/s of tissue damage
Health hx
Age and weight
Why is age and weight important to assess with poisoning?
Determines treatment such as amount of antagonist medication given
Management of poisoned patient
Use of emetics
Gastric lavage
Admin of specific antagonist as early as possible
Diuresis
Dialysis
Hemoperfusion
When do you not use emetics with a poisoning?
if it is a corrosive agent such as lye or drain cleaner
Patients with chemical burns are re-examined at what intervals?
24 hrs
72 hrs
7 days
Management of food poisoning
ABCs
Determine causative agent if possible
Treat fluid and electrolyte imbalances
Control N/V/D
Clear liquid diet, progress as tolerated
Management of overdose
ABCs
Support respiratory and CV function
Enhance clearance of causative agent using gastric lavage, activated charcoal, Narcan
Provide safety of patient and staff
Management of acute intoxication
ABCs
Monitor of CNS depression and hypotension
Watch for withdrawal symptoms
Management of psychiatric emergencies
Maintain safety of all
Determine if patient is at risk of injuring self or others
Maintain patient self-esteem
Determine psychiatric hx if any
Determine if has current care by psychiatrist or therapist
