Emergency Nursing Flashcards
Emergent Triage
Patients with the highest priority (life threatening illness/injury)
- Chest pain
- Hypoxia
- Hemorrhage
- Unstable VS
Urgent Triage
Patients with serious conditions; not life threatening (but needs to be seen within 1 hour)
- Abdominal pain
- Lacerations (with no active bleeding)
- Respiratory illness not associated with hypoxia
Non-Urgent Triage
Patients who can wait several hours for treatment without deterioration of conditions
- Simple skin rashes
- Colds
- Strains/sprains
- Physicals
What is the triage nurse responsible for?
- Assessing patients initially
- Monitoring patients
- Reassessing patients at regular intervals
- Acting as a patient liaison and advocate of care
* * The foundation of all emergency nursing skills is assessment
* * Triage is an advanced skill not for the novice nurse
Priorities of Emergency Care
- Assign to triage category (resuscitation, emergent, or urgent)
- Stabilization
- Provide critical treatment
- Prompt transfer to appropriate unit (ICU, OR, Med-Surg)
Primary Survey of Client Needs
A - airway B - breathing C - circulation D - disability E - exposure
A- Airway/Cervical Spine
- The highest priority intervention is to establish a patent airway
- Clear airway of secretions
- Supplemental O2
- Stabilize cervical spine with c-collar/backboard
Who gets supplemental O2?
- Non-rebreather mask for spontaneous breathers (100% O2)
- Bag valve mask (BVM) O2 for patient needing ventilator support
- Definitive airway: ET tube, with mechanical ventilation
- GCS < 8
- Patient with airway compromise
Airway Symptoms
- Obstructions
- Blood
- Vomit
- Foreign body
- Facial/neck trauma
- Allergic Reaction
B - Breathing
- Expose, inspect, and palpate neck and chest
- Ausculatation of breath sounds in all lobes
- Evaluation of chest expansion or wall trauma
- Respiratory effort
- Physical abnormalities
Why are chest injuries assessed with breathing immediately after airway is established?
If MVA, gun shot, or stabbed in the chest can cause breathing and airway issues very quickly if not addressed
- Pneumothorax
- Flail chest
- Pulmonary contusions
Emergency Breathing Symptoms
- Increased respiratory effort
- Nasal flaring
- Tachypnea or bradypnea
- Wheezing or stridor
- Hypo/Hyperventilation
- Accessory muscles use
- Paradoxical chest movement
- Tracheal deviation
Two Types of Chest Trauma
- Blunt trauma
2. Penetrating trauma
Characteristics of Blunt Chest Trauma
- More common than penetrating trauma
- Organs usually affected
- Liver, kidneys, spleen, or blood vessels
- Liver most common injured solid organ - Timing is critical
- Often difficult to identify because patients may not seek treatment
What is the most common type of blunt chest trauma?
Rib Fractures
Rib Fractures
- Fracture of ribs 1 & 2 are associated with cranial, major vascular, and thoracic injuries; high mortality
- Ribs 4-10 are the most common site for rib fracture
- Fractures of the lower ribs (8-12) are associated with liver and spleen injuries
- Elderly patients with 3+ ribs fractured have a 5-fold increase in mortality and a 4-fold risk of pneumonia
Rib Fractures: Clinical Findings
- Pain on movement or inspiration
- Crepitus at injury site
- Abdominal involvement
- Muscle spasms
- Bruising around fracture site
Rib Fractures: Interventions
- Adequate ventilation
- Pain management
- TCDB, incentive spirometry
What causes most sternal fractures?
MVAs
Sternal Fractures: Clinical Findings
- Pain at fracture site
- Palpable defect at fracture site
- Crepitus
- Swelling
- Ecchymosis
Sternal Fractures: Interventions
- Maintain ventilation
- Pulse oximetry
- ECG
Assessment of Sternal and Rib Fractures
- Closely evaluate for cardiac injuries
- CXR
- ECG
- Continuous pulse oximeter
- ABGs
- Pain: usually subsides in 5-7 days (ribs)
- Most rib fractures heal in 3-6 weeks
Flail Chest: Physiology
- Frequently a complication of blunt trauma
- It involves 3 or more consecutive rib fractures in 2 or more places
- Produces a free floating rib segment and unstable chest wall.
- Chest wall loses stability causing respiratory impairment and distress
- The detached part of the rib segment (flail segment) moves in a paradoxical manner in that it is pulled in during inspiration, and on expiration the flail segment bulges out
Treatment of Flail Chest: General
- Ventilatory support
- Clearing secretions (Nursing Priority!!)
- Pain control
- If only a small segment of chest is involved we try to clear the airway through:
- Positioning
- Cough/deep breathing
- Suctioning
Flail Chest Symptoms
The mediastinum shifts back to the affected side
- Paradoxical action results in dead space
- Reduction in alveolar ventilation
- Decreased compliance
- Retained airway secretions and atelectasis
- Patient has hypoxemia and respiratory acidosis can develop because of CO2 retention
- Hypotension, inadequate tissue perfusion and metabolic acidosis follows
Treatment of Mild-Moderate Flail Chest
- Treat underlying pulmonary contusion
- Pulmonary physiotherapy
- Secretion management
- Monitor for respiratory compromise and deterioration
Treatment of Severe Flail Chest
- Intubation with vent support based on patient’s condition
- Provide stabilization of thoracic cage to allow fracture to heal, improves alveolar ventilation, and decreases the work of breathing
- Surgery
Pulmonary Contusion
Abnormal accumulation of fluid in the interstitial and intra-alveolar spaces
- Hemorrhage occurs in and between the alveoli
- The resulting edema decreases lung movement and reduces the area for gas exchange
- Increased muscular effort needed to ventilate contused lung
- Patient tires easily and becomes progressively hypoxic.
- Respiratory failure develops over time.
- At first, the patient may be asymptomatic; symptoms onset usually 24-48 hrs. based on the severity of the contusion.
Pulmonary Contusion Symptoms
Vary from decreased breath sounds, tachypnea, chest pain, hypoxemia, and blood tinged secretions to severe tachypnea, tachycardia, crackles, frank bleeding, cyanosis, and respiratory acidosis
Signs of Hypoxemia
- Agitation
- Combative behavior
- Changes in sensorium
Treatment of Pulmonary Contusions
- Maintain airways
- Supplemental O2 (mask/cannula for 24-36 hours)
- Pain control
- Hydration
- Antimicrobial therapy to decrease the potential of pneumonia
- Diuretics or fluid restriction (based on edema)
- PEEP with ventilator support
- NGT to relieve gastric distention
Most Common Penetrating Traumas
GSW and stab wounds
How are penetrating traumas classified?
By velocity: low, medium, high
Low velocity penetrating traumas
Knives, switchblades, ice picks
- Pneumothorax
- Hemothorax
- Cardiac tamponade
- Severe hemorrhage
Penetrating Traumas: GSW
Are low, medium, high velocity
- Based on distance, caliber of weapon, size of the bullet, quantity of GSWs
Most Common Organs Injured in GSW
- Liver (solid organ)
2. Small bowel (hollow organ)
Treatment for Penetrating Trauma
- Airway management
- Restore and maintain cardiopulmonary function
- Determine if any thoracic/abdominal injuries (organs)
- Chest tube insertion
- Large bore IV (prevent shock)
- Infuse 3L of isotonic fluid to replace 1L of blood loss - Colloid solutions, large molecule IV solutions, blood components (PRBCs, FFP, Plasma, Hespan, Dextran)
- Crystalloid solutions
- Monitor for ACS
Crystalloid Solutions
- 0.9% normal saline, LR, hypertonic solutions
- Requires more fluid to restore intravascular volume
- Complications: Fluid overload
* LR can cause metabolic acidosis and fluid overload
* NS and hypertonic solutions can cause hypernatremia
Abdominal Compartment Syndrome (ACS)
- Fluid leaks into the abdominal cavity increasing pressure that is displaced on surrounding vessels/organs
- Complications with infusion of large amounts of IVF
- Requires surgical decompression