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