Emergency nursing Flashcards
what are the priorities in the ED
- make life-saving decisions
- provide analgesia and symptom relief
- identify issues, invetsiagte, stabilize and start treatment
- decide resources, adission or discharge
what is the general approach in the ED
- rapid primary survey
- resuscitagtion done when needed
- detailed secondary survery
- definitive care
what is apart of the primary survey
- A: airway with spine control
- B: breathing and ventilation
- C : circulation
- D: disability such as neuro. status
- E: exposure and environment
how long should the primary survery be
less than one minute
what is apart of the airway assessment
- secure and protect the airway
- assess the ability to breathe and speak
- assume cervical injury in every trauma patient and immobilize with collar
what is apart of the breathing assessment
- positioning
- secretion management
- oxygen therapy
- rounds adjustment
what is the assessment of circulattion
- look, listen and feel
- identify signs of shock and correct inadequate perfusion
what does disability include
- identify neuro abnormalities like GCS, motor and pupils
what does the seconday survery include
- SAMPLE, PQRSTUI of the symptoms
- rapid physical assessment
- dianostic testing
- durther interventions
how long should it take for someone to be at-leats seen by one HCP upon arrival in the ED
10 minutes
what does pre-triage include
- less thaan 2 minutes
- ABCD, consult reason, PMHX. that is relevant
- quick infection cotrol
what are the three outcomes of pre-triage
- perform immediate nursing or medical prise-en-charge
- prioritizie a compleete evaluation (triage)
- re-direct to waiting room
how long should a triage assessment take
5 minutes or less
what should a triage be able to determine
- infectious risk and screening
- acuity and severity of the complaint
- establish the level of priority
- direct to approriate care
- activate any treatment protocols
what does SAMPLE stand for
S - signs and symptoms
A - allergy
M - medication and drugs
P - pmhx
L - lat meal, BM, MP
E - event prior to environment
what is the main purpose of CTAS
predicts how long a person can safely wait
CTAS level 1
immediate resuscitation where there is threat to life or limb
CTAS level 2
- 15 minutes
- very urgent, potential threat to life, limb, or function
CTAS level 3
- 30 minutes
- important discomfrot that impact a person abilitt to do ADLs with potential progression to more of a threat
CTAS level 4
- 60 minutes
- less urgent
CTAS 5
- 120 minutes
- may be acute but nn-urgent and can be apart of a chronic condition
what are first order modifier of priority
- respiraotyr distress
- hemodynamic instability
- LOC
- temperature, sepsis
- pain severity
- bleeding disorder
- frailty
what are second order modifiers of priority
- hypertension
- capillary blood glucose (<3 or >18)
- obstetrics
- mental health
what are geriatric factors affecting priority
- resp rate above 27
- systolic BP less than 110
- temp change
- change from baseline cognition
what are obstetric factors affecting priority
- first day of last menstrual period
- post-partum 6 weeks
- complaint must be related to pregnancy
what is don to prevent infection spreading in the ED
- heightened surveillance for emerging viruses, asking patient if they have traveled to certain places
- electronic screening tools
- isolating people who could be infectious or those who are immunocompromised
which patients should be isolated in the ED
- neutropenic
- cystic fibrosis
- bed bugs
- rashes with unknown etilogy
- insects such as scabies
who is at risk for contracting measles
- born after 1970
- have not had measles
- not vaccinated
- not received the appropriate vaccination doses
characteristsics of the measles rash
- begins 3-5 days after onset of syptoms
- maculopapular rash from the face to the trunk to the extremities
- rash lasting 5-7 days
what are complication frm measles
- can happen with young children and immunocompromised
- blindness, diarrhea, brain swelling, death
what is the main management for measles
- supportive management of releiving symptom, rest and hydration
what are the three types of head injury
- fractures
- scal-laceration
- neuronal injuries
Waddle’s Triad
- vehicle versus pedestrian accident
- tib-fib or femux fx.
- truncal injury
- cranio-facila injury
vault fractures
- linear, non-depressed are hte most common
basal fractures
- base of the skull
- retroauricular or battles sign (bruising behind the ears)
- raccon eyes
- serious risk for meningeal infection
Characteristics of face fractures
- they can be open fractures or sinus fractures
- severe ones can pose a risk to airway from bleeding
- neuronal injury possible
characteristics of scalp laceration
- big source of potential bleeding since vasoconstriction is poor in ths area
- subgalea laceration resolve without interventions
- portal of entry for infection
diffus neuronal injury
- mild TBIs = concussions
- diffuse axonal injury
focal neuronal injury
- contusions
- inracranial hemorrhage
what should the ED nursing assessmenet include for patients with head injury
- PMHx. and mechanism of injury (how did it happen)
- ABCDE
- Neurological examination - LOC, glasglow, history of amnesia or unconcousness, C-spine evela and protection of spine
- assess pupils
- altered or absent gag refex
- absent corneal reflex
- sudden onsent of neuro deficits
- changes in vital signs
- assess wound or area of impact
- vision or hearing impairements
- headache, vomiting, seizures
what could falsify the assessmet for head injuries
- medications
- very old or very young patients
what are the priorities for preveting secondary injury int he ED from head injuries
Avoid
- hypoxia
- ischemia
- decreaseed cerebral perfusion pressure
- seizures
nursing emergency preparedness for patient with head injury and inadequate airway protection
- patient position and establich suntioning
- ensure oxygen sunctioning and temporary measures ready
- Anticipate intubation
- ABG to assess oxygation
interventions to prevent secondary injury to the brain
- monitor baseline vital signs and maintain MAP above 60mmhg
- monitor for decreased cerebral perfusion pressure
- monitor signs of increaased ICP and recognize signs of cushings syndrome
- elevate the HOB at 20-30 degrees, keep head and neck neutral, normothermia and avoid noxious stimuli
interventions for potential injury to the C-spine
- place and ensure proper alignement of neck collar
- mobilize using the log roll method
interventions if the patient is at risk for impaired blood,fluid, electorlyte and gas exchange balance
- insert PIV
- collect CBC, CHEM 7, glucose, coag and VBG
- record In/out
- expect fluid or blood replacement
interventions for patients at risk for seizures
- ensure safe and calm environment
- suction equipment available
- pharmacological treatment
what is the goal in the ED for orthopedic fractures
- diagnose potentialy limb/limb threatening issues
- reduce and immobilize fractures as appropriate
- symptom relief
- ensure follow-up
what assessment should be done for a patient who comes in with an orthopedic fracture
- PMHX. and mechanism of injury
- ABCDE
- inspect for deformaties, swelling, shortening, rotation and assymetry
- gentle palpation to observe tenderness, pain or crepitus
- feel for peripheral pulses, ecchymosis
- skin integrity and laceration
- assess motor and sensory functions
intervention when someone comes in with abnormal circulation to a limb
- monitor neurovascular sign
- remove constricting items like jewlery, watches, rings ASAP
- expect bone reduction/realignement by a physician
- provide pain relief, assist with concious sedation
- sunction equipment and oxygen ready
- expect a STAT tranfer to OR and withhold oral intake if realignement unsucessful
what are the interventions if someone is at risk for pan, discomfort and anxiety
- non-pharmacological and pharmacological interventions (cold, elevation)
- splinting as indicated
- asses and treat other injuries
what should be done for patient who have ortho fractures who are at risk for infection
- look for signs of infection
- wound care with sterile technique
what is the clinical presentation of ETOH intoxication
- drowsiness, slurred speech, disinhibition, lack of coordination
- sudden mood changes
- nystagms, diplopia, dysarthria, ataxia
- respiratory and CNS depressiion
- hypotension
- in excess it can lead to coma and death
what is the nursing assessment for ETOH intoxication
- history of drinking habits
- social situation
- drugs and med intake
- complete physical exam
- search for signs of chronic alcoholic disease - LFT
- neurological deficits
- inspect signs of trauma and violence
interventions for ETOH patients who are at risk for occult or revert injuries related to ataxia or disinhibition
- establish the baseline and monitor evolution of the injury
- collect CBC and reasses bleeding
interventions for patents who are having ineffective breathing from CNS depression
- observe airway patency and trends of CNS depression signs
- emergency equipment ready
- anticipate possible respiratory infectious process
what is the interventions for patient with ETOH who are at risk for secondary deteriroration and lack of improvement
- collect labs - electrolytes, ammonia, CBG
- expect an IV dextrose admin, IV thiamine and lactulose
- observe for signs of alcohol withdrawal delirium syndrome
patient with ETOH who are at risk for agression
- promote calm and low stimulation environment
- close surveillance and use least restrictive restraints
- expect possible sedative therapy
- D/C patient once sober enough with no threat to themselves or others
what are the clinical manifestations of ETOH withdrawal
- tremor
- anxiety
- tachycardia
- N/V
- diaphoresis
- palpitation
- headache
- insomnia
nursing assessment for ETOH withdrawal
- ABCDE
- PQRSTUAI of the symptoms
- PMHx.
- substance use history
- situational context
- assess the sevrity of signs using CIWA protocl
what is the CIWA protocl for monitoing for alcohol withdrawal
- when pt. awake every 2 hours
- should be done for min. 24 hours max. of 72 until a score of less than 2 is obtained for 3 seperate intervals
what are interventions for patients as risk for neuro damage from ETOH
- constant/close sruveillance
- reorient patient to reality
- record CIWA score and adequate benzo. administration
- promote sleep and rest
- calm and non-stressful envrionment
- apply least restricive restraints
what are interventions for patients who are in withdrawal but at risk for significant cumulative fluid losses
- record strict IN/out
- admin of NS
- ## electrolyte replacement magnesium sulfate or KCl
interventions for ETOH withdrawal who are at risk of circulatory collapse
- install cardiac monitoring that includes:
- temp, pulse, BP
- sob and edema
- dysrhythmias
- resp and peripheral impairments
interventions for ketoacidosis risk
- blod sample and monitor metabolic acidosis, ketones, hypoglycemia
- evealute malnourishment, N/V ando. pain
- admin of thiamine and dextrose
when is a patient with ETOH withdrawal ready to be D/C
- stable vital
- can walk alone and fully oriented
- no danger to themselves or others
- social services
- follow-up and meds prescribed
what type of history should be obtained for an overdose patient
- age
- weight
- medical problems
- medications
- substance, route and quantity
- time and symptoms since exposure
- intetion and suicidality
assessment for overdose patients
- ABCs
- LOC/GCS
- vital
- pupils
steps to take for overdose patients
-
- identify patient
- provide antidote
- supportive care
- psych consult once medically clear
