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Emergency nursing Flashcards

1
Q

what are the priorities in the ED

A
  • make life-saving decisions
  • provide analgesia and symptom relief
  • identify issues, invetsiagte, stabilize and start treatment
  • decide resources, adission or discharge
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2
Q

what is the general approach in the ED

A
  • rapid primary survey
  • resuscitagtion done when needed
  • detailed secondary survery
  • definitive care
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3
Q

what is apart of the primary survey

A
  • A: airway with spine control
  • B: breathing and ventilation
  • C : circulation
  • D: disability such as neuro. status
  • E: exposure and environment
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4
Q

how long should the primary survery be

A

less than one minute

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5
Q

what is apart of the airway assessment

A
  • secure and protect the airway
  • assess the ability to breathe and speak
  • assume cervical injury in every trauma patient and immobilize with collar
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6
Q

what is apart of the breathing assessment

A
  • positioning
  • secretion management
  • oxygen therapy
  • rounds adjustment
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7
Q

what is the assessment of circulattion

A
  • look, listen and feel
  • identify signs of shock and correct inadequate perfusion
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8
Q

what does disability include

A
  • identify neuro abnormalities like GCS, motor and pupils
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9
Q

what does the seconday survery include

A
  • SAMPLE, PQRSTUI of the symptoms
  • rapid physical assessment
  • dianostic testing
  • durther interventions
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10
Q

how long should it take for someone to be at-leats seen by one HCP upon arrival in the ED

A

10 minutes

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11
Q

what does pre-triage include

A
  • less thaan 2 minutes
  • ABCD, consult reason, PMHX. that is relevant
  • quick infection cotrol
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12
Q

what are the three outcomes of pre-triage

A
  1. perform immediate nursing or medical prise-en-charge
  2. prioritizie a compleete evaluation (triage)
  3. re-direct to waiting room
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13
Q

how long should a triage assessment take

A

5 minutes or less

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14
Q

what should a triage be able to determine

A
  • infectious risk and screening
  • acuity and severity of the complaint
  • establish the level of priority
  • direct to approriate care
  • activate any treatment protocols
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15
Q

what does SAMPLE stand for

A

S - signs and symptoms
A - allergy
M - medication and drugs
P - pmhx
L - lat meal, BM, MP
E - event prior to environment

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16
Q

what is the main purpose of CTAS

A

predicts how long a person can safely wait

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17
Q

CTAS level 1

A

immediate resuscitation where there is threat to life or limb

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18
Q

CTAS level 2

A
  • 15 minutes
  • very urgent, potential threat to life, limb, or function
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19
Q

CTAS level 3

A
  • 30 minutes
  • important discomfrot that impact a person abilitt to do ADLs with potential progression to more of a threat
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20
Q

CTAS level 4

A
  • 60 minutes
  • less urgent
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21
Q

CTAS 5

A
  • 120 minutes
  • may be acute but nn-urgent and can be apart of a chronic condition
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22
Q

what are first order modifier of priority

A
  • respiraotyr distress
  • hemodynamic instability
  • LOC
  • temperature, sepsis
  • pain severity
  • bleeding disorder
  • frailty
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23
Q

what are second order modifiers of priority

A
  • hypertension
  • capillary blood glucose (<3 or >18)
  • obstetrics
  • mental health
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24
Q

what are geriatric factors affecting priority

A
  • resp rate above 27
  • systolic BP less than 110
  • temp change
  • change from baseline cognition
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25
what are obstetric factors affecting priority
- first day of last menstrual period - post-partum 6 weeks - complaint must be related to pregnancy
26
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
27
which patients should be isolated in the ED
- neutropenic - cystic fibrosis - bed bugs - rashes with unknown etilogy - insects such as scabies
28
who is at risk for contracting measles
- born after 1970 - have not had measles - not vaccinated - not received the appropriate vaccination doses
29
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
30
what are complication frm measles
- can happen with young children and immunocompromised - blindness, diarrhea, brain swelling, death
31
what is the main management for measles
- supportive management of releiving symptom, rest and hydration
32
what are the three types of head injury
- fractures - scalp laceration - neuronal injuries
33
Waddle's Triad
- vehicle versus pedestrian accident - tib-fib or femux fx. - truncal injury - cranio-facila injury
34
vault fractures
- linear, non-depressed are hte most common
35
basal fractures
- base of the skull - retroauricular or battles sign (bruising behind the ears) - raccon eyes - serious risk for meningeal infection
36
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
37
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
38
diffus neuronal injury
- mild TBIs = concussions - diffuse axonal injury
39
focal neuronal injury
- contusions - inracranial hemorrhage
40
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
41
what could falsify the assessmet for head injuries
- medications - very old or very young patients
42
what are the priorities for preveting secondary injury int he ED from head injuries
Avoid - hypoxia - ischemia - decreaseed cerebral perfusion pressure - seizures
43
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
44
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
45
interventions for potential injury to the C-spine
- place and ensure proper alignement of neck collar - mobilize using the log roll method
46
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
47
interventions for patients at risk for seizures
- ensure safe and calm environment - suction equipment available - pharmacological treatment
48
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
49
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
50
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
51
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
52
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
53
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
54
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
55
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
56
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
57
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
58
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
59
what are the clinical manifestations of ETOH withdrawal
- tremor - anxiety - tachycardia - N/V - diaphoresis - palpitation - headache - insomnia
60
nursing assessment for ETOH withdrawal
- ABCDE - PQRSTUAI of the symptoms - PMHx. - substance use history - situational context - assess the sevrity of signs using CIWA protocl
61
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
62
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
63
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 -
64
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
65
interventions for ketoacidosis risk
- blod sample and monitor metabolic acidosis, ketones, hypoglycemia - evealute malnourishment, N/V ando. pain - admin of thiamine and dextrose
66
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
67
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
68
assessment for overdose patients
- ABCs - LOC/GCS - vital - pupils
69
steps to take for overdose patients ## Footnote -
- identify patient - provide antidote - supportive care - psych consult once medically clear
70
drowning
- death from suffocation after submerssion in water or another fluid medium
71
what does treatment of drowning focus on
- correcting hypoxia and fluid imbalances - rewarming when hypothermia is present - support basic physiological functions
72
what is the initial assessment for a drowning victim
- assessment of the airway - cervical spine protection - assessment of circulation
73
what type of mechanical ventilation is used for drowning
- mechanical ventilation with postivie PEEP or continuous positive airway pressure
74
what is the mandatory observation time for drowning victims
- 23 hours since copmplication can happen much later after dorwning
75
what is the ongoing monitoring for drowning vitims in the hospital
- monitor ABC, vitals and LOC - oxygen saturation and cardiac rhythm - temperature to maintian normothermia - monitor for signs of ARDS - monitor for signs of secondary drowning
76
risk factor for drowning
- inability to swim or exhaustion while swimming - entrapedment with object - secondary to loss of movement from other health problems - poor judgement - seizures while swimming
77
what is the recommendation for removing a bee stinger
- scraping motion with finegrnail, knife or credit card - tweeser should not be used since more venom can be released
78
how are mild bee stings treated
- cold compress - elevation - antipurititc lotiuons - oral antihistamines
79
what is the initial treatment for animal and human bites
- clraning with alot of irrigation - debridement - tetanus prophylaxis - analgesics PRN
80
when are prophylactic antibiotics used in bites
over wounds that are over joints, hands or foots
81
heat stress
brief exposure to intesne heat or prolonged exposure to less intense heat
82
risk factors for heat stress
- strenuous activities in hot or humid environments - clothign that interferes with sweating - high fevers - pre-existing illnesses
83
initial management of hyperthermia
- manage and maintain ABCs - provide high flow oxygen on non-rebreather mask or BVM device - establihs IV acess and begin replacement - cool environment - ECG - bloods for CHEM7 and CBC - insert catheter
84
initial management heatstroke
- rapid colling measures - remove clothign, place wet sheets over patient - place fan in front of pt. - immerse in ice-bath water - administer cooled IV fluids or lavage
85
risk factors for hypothermia
- age - duration of exposure - environmental temp - homelessness - pre-exhsiitng condtiions - meds that supress shivering - alcohol intoxication
86
hypothermia
- core temperature lower than 35 degress
87
clinical manifestations with mild hypothermia
- shivering - lethargy - confusion - minor heart rate changes - slurred speech - incoordination
88
89
manifestation of moderate hypothermia
- rigidity - bradycardia - slow RR - BP only by doppler - metbaolic and resp. acidosis - hypovolemia
90
manifestations of severe hypothermia
- coma - hypotension - arrhythmias - muscle rigidity
91
initial interventions for hypothermia
- remove patient from cold environement - manage and maintain ABC - high flow oxygen in non-rebreather or BVM - intubation if gaga reflex is diminished or absent - establihs IV acess with two large bore catheter for warm fluid - ECG - warm central trunk first to prevent rewarming shock - treat gently to avoid cardiac irritability
92
passive external rewarming
- remove wet clothing - apply dry clothing and warm blankets and radiant lights
93
active external warming
- heating devices
94
active core warming
- administer warmed IV fluids - heated and humidified oxygen - ECMO
95
what should continous monitoring entail for hypothermia
- monitor ABC, LOC, temp and vital signs - oxygen saturation and cardiad rate and rhythm - monitor electrolyte and glucose levels
96
clinical manifestations of heat exhaustion
- lightheadedness - nausea - vomiting - diarrhea
97
signs of heat exhaustion
- tachycardia - hypotension - tachypnea - increased body temperature - dialated pupils - ashen skin - diaphoresis
98
heat stroke
most serious form of heat related injury where thermoregulatory mechanisms of the body begin to fail
99
signs of heat stroke
- tachypnea - temperature above 41 degrees - increased sweating - skin is hot dry and ashen - hallucinations and confusion from cerebral edema or hemorrhage

illness management (12 decks)

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