Emergency Nursing Flashcards
ABCDE
D: disability - determine neuro status, AVPU
E: exposure - undress to assess wounds or areas of injury
AVPU
Alert
Verbal
Pain
Unresponsive
Secondary survey
- Health HX
- Head-to-toe assessment: reassess airway, breathing, VS
- DX and labs
- Monitoring devices: ECG, arterial lines, urinary catheters
- Splinting of FX’s
- Wound care
- Any other necessary interventions based on condition
Hemorrhage
Assessment changes
BP, HR, RR, SaO2, skin color, cap refill, pain (location, intensity, mechanism)
Hemorrhage
Fluid replacement
LR, NS, blood transfusion
Hemorrhage
Pressure points
Temporal Facial Carotid Subclavian Brachial Radial & ulnar Femoral
Multiple trauma
Priorities
Assume cervical spine injury
Injuries interfering w/vital physiologic function have highest priority
Intra-abdominal injuries
Assessment
- Obtain HX
- Abd assessment, referred pain may indicate spleen, liver, intraperitoneal injury
- Labs, CT, abdominal US, diagnostic peritoneal lavage
- Stab = sonography
Intra-abdominal injuries
Management
- Ensure airway, breathing, circulation
- Immobilize C-spine
- Continuous monitoring
- Document ALL wounds
- If viscera protruding, cover w/sterile, moist, saline dressing
- Hold PO fluids
- NG tube to aspirate stomach contents
- Tetanus & prophylactic ABX
- Rapid transport to SX if indicated
Crush injuries
Complications
- Hypovolemic shock
- Spinal cord injury
- Erythema, blistering
- FX
- AKI
Heat stroke
@ risk
People not acclimated to heat, older/very young, ill/debilitated, certain medications increase risk
Heat stroke
S/S
CNS dysfunction, elevated temp of 105 F (40.6 C), hot/dry skin, anhidrosis, tachypnea, hypotension, tachycardia
Heat stroke
Management
- Reduce temp to 102 F (39.2 C) as quick as possible
- Monitor temp, VS, ECG, LOC, I&O
- Cooling methods
- IVF
Heat stroke
Cooling methods
- Cool sheets, towels, sponging w/cool water
- Ice to neck, groin, chest, axillae
- Cooling blankets
- Immersion in cold water bath
Heat stroke
RX
Anticonvulsant, potassium, sodium bicarb, Benzos
Frostbite
S/S
Hard, cold, and insensitive to touch
May appear white or mottled
May turn red and painful as re-warmed
Frostbite
Management
- 37-40 C circulating bath for 30-40 min @ a time
- Analgesics for pain
- Do not massage or handle; if feet involved - no walking
Hypothermia
Internal core temp < 35 C
@ risk : older adults, infants, persons w/concurrent illness, homeless, trauma, alcohol increases susceptibility
Hypothermia
Management
- Remove wet clothing, rewarm, supportive care
- Rewarming methods
Hypothermia
Complications
Cold blood returning from extremities has high lactic acid level —> cardiac dysrhythmias & lyte disturbances
Hypothermia
Rewarming methods, active
Bypass, warm fluid admin, warm humidified O2, warm peritoneal lavage
Hypothermia
Rewarming methods, passive
Warm blankets, over the bed heaters
Poisoning
Assessment
- ABCs
- Monitor VS, LOC, ECG, UO
- Labs
- Determine what, when, & how much was ingested
- S/S of poisoning/tissue damage
- Age & weight
Poisoning
Measures to remove toxins
- Emetics
- Gastric lavage
- Activated charcoal
- Cathartic when appropriate
- Admin of specific antagonist ASAP
- Diuresis, dialysis, hemoperfusion
When is induced vomiting contraindicated?
Corrosive agents such as acids and alkalines —> destruction of tissues in esophagus
Carbon monoxide poisoning
S/S
CNS SYMPTOMS - headache, muscular weakness, palpitations, dizziness, confusion, coma
Skin color not reliable sign (can range from pink to cherry-red)
Carbon monoxide poisoning
Treatment
Get fresh air immediately
CPR as needed
Admin oxygen, 100% or under hyperbaric pressure
Chemical burns
Management
- Immediately flush skin w/running water from shower, hose, faucet
- *lye or white phosphorus should be brushed off skin (activated by water)
- Some substances may require prolonged flushes or irrigation
- Reexamination of areas in 24 hrs, 72 hrs, and 7 days
Victims of human trafficking
Presentation to ED
- Injury, accompanied by boyfriend or travel partner (generally older)
- Hx of chronic runaways, homelessness, self-mutilation
- Common behaviors: cowering, frightened, agitated, deferring to person accompanying them
- Common complaints: injuries, poor healing, abd pain, dizziness, HAs, rashes/sores
- Addiction, panic attacks, impulse control, hostility, SI
What is a positive finding on a diagnostic peritoneal lavage?
- Bile, feces, blood in specimen
- RBC greater than 100,000, WBC greater than 500
