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Med Surg > Emergency Nursing Principles and Management > Flashcards

Emergency Nursing Principles and Management Flashcards

1
Q

Emergency Nursing Principles

A

guidelines that nurses follow to assess and manage emergency situations for a client or multiple clients.
Include: triage, primary survey, ABCDE, poisoning, rapid response team, cardiac emergency, and post resuscitation

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2
Q

5 levels of triage

A

used in the ED

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3
Q

Level 1

A

resuscitation; require immediate treatment to prevent death

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4
Q

Level 2

A

emergent

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5
Q

Level 3

A

urgent

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6
Q

Level 4

A

less urgent

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7
Q

Level 5

A

nonurgent; non life threatening, requiring simple evaluation and care management

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8
Q

Primary Survey

A
  • rapid assessment of life-threatening conditions
  • should be completed systematically so life-threatening conditions are not missed
  • standard precautions: gloves, gowns, eye protection, face mask, shoe covers- must me worn to prevent contamination of bodily fluids.
  • ABCDE principle guides survey
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9
Q

Standard Precautions

A

gloves, gowns, eye protection, face masks, and shoe covers.

prevent contamination with body fluilds

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10
Q

A

A

Airway and Cervical

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11
Q

Airway and Cervical

A
  • most important step in preforming the primary survey. IF a patent airway is not established, subsequent steps of the primary survey are futile. As a result of hypoxia, brain injury or death will occur within 3-5 minutes if the airways if not patent.
    -if the client is awake and responsive, the airway is open.
  • if the clients ability to maintain the airway is lost, it is important to inspect for blood, broken teeth, vomtius, or other foreign materials in the airway that can cause an obstruction
  • if the client is unresponsive without suspicion of trauma, the airway should be opened with the head-tilt/ chin-life maneuver.
    DO NOT preform this technique on clients who have potential cervical spine injury.
    To preform the head-tilt/chin lift maneuver, the RN should assume a position a the head of the client, place on hand on his forehead. His child should be tilted while his chin is lifted upward and forward. This maneuver lifts the tongue away from the laryngopharynx and provides for a patent airway.
  • if the client is unresponsive with suspicion of trauma, the airway should be opened with a modified jaw thrust maneuver.
    The nurse should assume a position at the head of the client, and place both hands on either side of the clients head. Locate the connection between the maxilla and the mandible. Life the jaw superiorly while maintaining alignment of the cervical spine.
  • once the airway is opened, it should be inspected for blood, broken teeth, commits, and secretions. If present, obstructions should be cleared with suction or a finger-sweep method if the object if clearly visible.
  • the open airway can be maintained with airway adjuncts, such as an OP or NP airway.
  • a BVM with 100% O2 source is indicated for clients who need additional support during resuscitation util an advanced airway is established.
  • A NRB mask with 100% O2 source indicated for clients who are spontaneously breathing.
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12
Q

B

A

Breathing

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13
Q

Breathing

A

once a patent airway is achieved, the RN should assess for the presence and effectiveness of breathing

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14
Q

Breathing Assessment

A
  • auscultation of breath sounds
  • observation of chest expansion and respiratory effort
  • notation of rate and depth of respirations
  • identification of chest trauma
  • assessment of tracheal position
  • assessment for JVD
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15
Q

If the client is no breathing or is breathing inadequately…

A

manual ventilation should be preformed with BVM with supplemental O2 or mouth-to-mask ventilation until a BVM is obtained.

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16
Q

C

A

circulation

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17
Q

Circulation

A
  • once adequate ventilation is accomplished, circulation is assessed.
  • nurses should assess HR, BP, peripheral pulses, and capillary refill for adequate perfusion.
  • RNs should consider cardiac arrest, MI, and hemorrhage as precursors to shock and leading to ineffective circulation.
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18
Q

Interventions geared toward restoring effective circulation:

A
  • CPR
  • Assess for external hemorrhage
  • hemorrhage control = apply direct pressure to visible, significant external bleeding.
  • Obtain IV access using large bore IV inserted into the AC fossa of both arms, unless there is obvious injury to the extremity.
  • Infuse isotonic IV fluids like LR or 0.9% NS, and/or blood products.
  • Shock can develop if circulation is compromised. Shock is the body’s response to inadequate tissue perfusion and oxygenation. It manifests with an increased HR and hypotension and can result in ischemia and necrosis of tissues.
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19
Q

interventions to alleviate shock

A
  • administer O2
  • apply pressure to obvious bleeding.
  • elevate lower extremities to shunt blood to the vital organs.
  • administer IV fluids and blood products
  • monitor vital signs.
  • remain with the client, and provide reassurance and support for anxiety
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20
Q

D

A

Disability

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21
Q

Disability

A
  • quick assessment to determine the clients level of consciousness.
  • the AVPU mnemonic is useful
  • GCS is another widely used method.
  • neurologic assessment must be repeated at frequent internals to ensure immediate response to any change.
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22
Q

AVPU

A

Alert
response to Voice
response to Pain
Unresponsive

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23
Q

Eye Opening Response

A

4: spontaneous
3: to voice
2: to pain
1: none

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24
Q

Verbal Response

A

5: oriented
4: confused
3: inappropriate words
2: incomprehensible words.
1: none

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25
Q

Motor Response

A

6: obeys commands
5: localizes pain
4: withdraws from pain.
3: flexion
2: extension
1: none

26
Q

E

A

Exposure

27
Q

Exposure

A
  • the RN removes the clients clothing for a complete physical assessment, the RN might need to cut off the clients clothing to accomplish this task.
  • clothing is always removed during resuscitation situation to assess for additional injuries for those related to chemical or thermal burns involving the clothing.
  • the RN should preserve items of evidence, such as clothing, bullets, drugs, or weapons.
  • hypothermia is a primary concern. Occurs when the clients core temp is 35 degrees C or less.
  • Victims of trauma are at risk for hypothermia due to exposure, unharmed O2, and cold IV fluids.
    Hypothermia can lead to eventual coma, hypoxemia, and acidosis.
28
Q

To prevent hypothermia

A
  • remove wet clothing
  • cover the client with warm blankets
  • increase the temperature of the room
  • use heat lamp to provide additional warmth
  • infuse warmed IV fluids
29
Q

Poisoning

A

is an exposure to a toxic agent.

  • medication, illicit drugs, ingestion of a toxic substance
  • environmental (eg, pollutants, snake and spider bites)
30
Q

Poisoning rapid management therapy

A
  • obtain a client history to identify the toxic agent
  • implement supportive care
  • determine type of poison
  • prevent further absorption of the toxin
  • extract or remove the poison
  • administer antidote if necessary
  • a snakebite from a venomous snake is a medical emergency,
    Children ages 1-9 are at highest risk for snakebites.
    The RN should be familiar with the indigenous snakes in the community./
    Generally, ice, tourniquets, heparin, and corticosteroids are contraindicated in the first 6-8 hours after the bite.
    Antivenom based on the type and severity of a snake bite is most effective if administered within 4-12 hours.
31
Q

Interventions to manage client exposed to who ingested a toxic agent

A
  • provide measures for respiratory support ( O2, airway management, mechanical ventilation)
  • monitor comprised circulation (resulting from excess perspiration, vomiting, diarrhea)
  • restore fluids with IV therapy
  • Monitor BP, cardiac monitoring. ECG
  • Assess for tissue edema every 15-30 minutes if bitten by a snake or a spider.
  • adminsister opioid medication for pain due to snake or spider bite.
  • monitor ABGs, blood glucose levels, coagulation profile
  • for ingested poison, three procedures are available: activated charcoal, gastric lavage (within 1 hour of ingestion), and aspiration. Syrup of Ipecac is no longer recommended.
  • administer diazepam if seizures occur.
  • reverse heroin and other opiate toxicity with naloxone
  • implement dialysis and an exchange blood transfusion as a nonpharm technique to remove toxic agents.
32
Q

Rapid Response Team

A
  • the team is a group of critical care experts (ICU RN, RT, and critical care provider, hospitalist)
  • responds to emergency call from RN or family members when a client exhibits indications of a rapid decline.
  • provides early recognition and response before a respiratory or cardiac arrest or stroke occurs.
  • policies and procedures are established in health care setting.
  • training for personnel is provided about criteria for calling and assistance when a clients condition changes toward a crisis situation.
  • SBAR communication techniques are used for contacting the team and documentation of event.
  • implement follow-up education, and sharing of information (debriefing) for participants after the call.
  • discuss information to identify system failures (no recognizing a crisis, lack of adequate communication, failure in the plan of care)
33
Q

SBAR

A

situation
background
assessment
recommendation

34
Q

Cardiac Arrest

A

the sudden cessation of cardiac function caused most commonly by V fib or ventricular asystole

35
Q

Ventricular Fibrillation (V fib)

A

a fluttering of the ventricles causing loss of consciousness, pulselessness, and no breathing. This requires collaborative care to defibrillate immediately using ACLS protocols.

36
Q

Pulseless Ventricular Tachycardia (VT)

A

an irritable firing of exotic ventricular beats at a rate of 140-180 beats per minute. the client over time will become unconscious and deteriorate to VF

37
Q

Ventricular Asystole

A

a complete absence of electrical activity and ventricular movement of the heart. the client is in complete cardiac arrest and requires implementation of BLS and ACLS protocol

38
Q

Pulseless electrical activity (PEA)

A

a rhythm that appears to have electrical activity but is not sufficient to stimulate effective cardiac contractions and requires implementation of BLS and ACLS protocols.

39
Q

Common Causes of PEA

A 
H:
hypovolemia
hypoxia
hydrogen ion accumulation --> acidosis 
Hyperkalemia or hypokalemia
Hypothermia
T:
Toxins
Tamponade (cardiac)
Tension pneumothorax
Thrombosis ( coronary)
Thrombosis (pulmonary)
40
Q

Alpha 1 Receptor Site

A

activation of receptors in arterioles of skin, viscera, and mucous membranes, and veins leads to vasoconstriction

41
Q

Beta 1 Receptor Sites

A

Heart stimulation leads to increase HR, increase myocardial contractility, and increased rate of conduction through the AV node.
Activation of receptors in the kidneys leads to release of renin.

42
Q

Beta 2 Receptor Sites

A

Bronchial stimulation leads to bronchodilation.
Activation of receptors in uterine smooth muscles causes relaxation
Activation of reports in the liver causes breakdown of glycogen into glucose
Skeletal muscle receptor activation leads to muscle contraction, which can lead to tremors.

43
Q

Dopamine Receptor Sites

A

Activation of receptors in the kidneys causes the renal blood vessels to dilate

44
Q

MAOI

A

promote the release of norepinephrine from sympathetic nerves and thereby prolong and intensify the effects of epinephrine and can cause hypertensive crisis.
Avoid use of MAOIs inc clients who are receiving epinephrine.

45
Q

Tricyclic Antidepressants

A

block the uptake of epinephrine which will prolong and intensify the effects of epinephrine
Clients taking these medications concurrently can need a lower dose of epinephrine.

46
Q

General Anesthetic

A

can cause the heart to become hypertensive to the effects of epinephrine, which leads to dysrhythmias
perform continuous ECG monitoring.
Notify the provider if the client experiences chest pain, dysrhythmias, or an elevated HR

47
Q

Beta-adrenergic blocking agents

A

such as propranolol, block the action at beta receptors.

propranolol may be used to treat chest pain, hypertension, MI, and dysrhythmias.

48
Q

Diuretics

A

promote beneficial effect of dopamine.

Monitor for therapeutic effects.

49
Q

VF or VT ACLS

A
  • initiate the CPR compressions of BLS
  • defibrillate according to BLS guidelines
  • establish IV access
  • administer IV antidysrhythmic medication such as epinephrine or vasopressin according to ACLS guidelines.
  • consider the following medications:
    Amiodarone
    Lidocaine
    Mag Sufate
50
Q

PEA ACLS

A
  • initiate CPR compressions of BLS
  • if shockable rhythm, defibrillate according to BLS guidelines
  • establish IV access
  • consider the most common causes
  • administer epinephrine 1mg IVP every 3-5 minutes
51
Q

Asystole

A
  • initiate CPR compressions of BLS
  • established IV access
  • give epinephrine 1mg IVP every 3-5 minutes
  • consider reversible causes
  • asystole is often the final rhythm as the electrical and mechanical activity of the heart has stopped. The provider should consider ceasing resuscitation if asystole persists.
52
Q

Pharm Management of Postresuscitation

A
  • medication therapy following a successful cardiac arrest includes IV medications that cause a catecholamine adrenergic agonist’s effect.
  • Catecholamine adrenergic agonists cannot be taken by the oral route, do no cross the BBB, and have a short duration of action
  • medications include epinephrine, dopamine, and dobutamine.
  • these mediations respond to an identifiable receptor and produce specific effects.
53
Q

Contraindications / Precautions with Postresuscitation Pharm Management

A
  • pregnancy Risk Category C : epinephrine, dopamine, and dobutamine.
  • theses mediations are contraindicated in clients who have tachydysrhythmias and VF
  • Use cautiously in clients who have hyperthyroidism, angina, history of MI, hypertension, and diabetes mellitus.
54
Q

Nursing Considerations and Client Education with Pharm Post arrest management

A
  • medications must be administered via continuous IV infusion.
  • use IV pump to control infusion
  • titrate dosage based on blood pressure response and/or heart rate response (these mediations affect HR and BP)
  • stop the infusion at the first sign of infiltration. Extravasion can be treated with local injection of alpha-adrenergic blocking agent, such as phentolamine.
  • assess/ monitor the client for chest pain. Notify the provider if the client experiences chest pain.
  • provide continuous ECG monitoring. Notify the provider if the client experiences tachycardia or dysrhythmias.
55
Q

Epinephrine (Alpha 1)

A 
Vasoconstriction
Slows absorption of local anesthetics. 
Manages superficial bleeding. 
Reduces congestion of nasal mucosa. 
Increased BP
Vasoconstriction from activation of alpha 1 receptors an lead to hypertensive crisis. 
Provide continuous cardiac monitoring. 
Report changes in vital signs to the provider.
56
Q

Epinephrine (Beta1)

A

Increases HR
Strengthens myocardial contractility.
Increase rate of conduction through the AV node.
Treatment of AV block and cardiac arrest.
Beta 1 receptor activation in the heart can cause dysrhythmias. Beta 1 receptor activation also increase the workload of the heart and oxygen demand, leading to the development of angina.
Provide continuous cardiac monitoring.
Monitor closely for dysrhythmias, changes in HR, and chest pain.
Monitor for hyperglycemia clients who have DM
Notify the provider if the client experiences dysrhythmias, and increased HR, or chest pain, and treat per protocol.

57
Q

Epinephrine (Beta2)

A

bronchodilation
asthma
the activation of beta 1 receptors in the liver and skeletal muscles cause hyperglycemia from the breakdown of glycogen.

58
Q

Dopamine ( Low dose)

A

2-5mcg/kg/min
Renal blood vessel dilation.
Treat: shock, HF, acute kidney injury

59
Q

Dopamine (Moderate)

A

Beta 1
5-10mcg/kg/min
Renal blood vessel dilation
Increase: HR, myocardial contractility, rate of conduction through AV node, BP.
Treat: Shock, HF, acute kidney injury
Provide continuous cardiac monitoring.
Monitor for urinary output less than 30mL/hr

60
Q

Dopamine (High)

A

Beta1, alpha 1
>10mcg/kg/min

renal blood vessel vasoconstriction

Increase: HR, myocardial contractility, rate of conduction though AV node, BP, vasoconstriction.
Treat: Shock, HF, acute renal injury
Discontinue the infusion at the first sign of irritation.
Infuse dopamine into central line, monitor IV site carefully.
Necrosis can occur from extravasation due to high doses of dopamine.

61
Q

Dobutamine (Beta 1)

A

Increases: HR, myocardial contractility, rate of conduction through AV node.
Treat: HF
AE: Increased HR
Rn: provide continuous monitoring. Report changes in vitals to provider. Monitor urine output less than 30mL/hr.

Med Surg (14 decks)

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