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NUR 202 Week 13 > Emergency Triage/Trauma > Flashcards

Emergency Triage/Trauma Flashcards

1
Q

Nursing Concepts

✓ Comfort
✓ Collaboration
✓ Oxygenation
✓ Perfusion
✓ Safety
✓ Stress
✓ Teamwork
✓ Trauma
✓ Violence

A

EDs

☞ Provide services to all seeking care
☞ Responsible for safety via public surveillance & emergency disaster preparedness
☞ Interprofessional speciality teams
☞ Critical Access Hospitals
☞ Multi-specialty environment

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2
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Common Reasons People Seek ED Care

✂ Abd pain
✂ Breathing difficulty
✂ CP
✂ Fever
✂ HA
✂ Injuries (esp falls in older adults)
✂ Pain (the most common sx)

A

Demographic Data and Vulnerable Populations

Care provided across the lifespan

Vulnerable populations
- Homeless
- Poor
- Mental health issue
- Substance abuse issue
- Older adults

  • Pt acuity varies from life-threatening to minor issues
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3
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6
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Emergency Nursing Principles

✭ Triage
* Process of rapidly determining pt acuity
* Represents a critical assessment skill
* Categorizes pts so most critical are treated first

Common system is Emergent / Urgent / Non-urgent

Different types of triage SYSTEMS, but the PRIORITIES ARE UNIVERSAL

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7
Q

?

Pt can usually wait several hrs for care w/o risk

e.g., skin rash, strains/sprains, cold, simple fx’s

A

Non-urgent

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8
Q

?

Pt has immediate threat to life or limb, & req immediate treatment

e.g., resp distress, CP w/diaphoresis, stroke, active hemorrhage, unstable VS

A

Emergent

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9
Q

?

Pt should be treated quickly but immediate threat to life does not exist @ the moment

e.g., severe abd pain, renal colic, displaced or mult fx’s, complex or mult soft tissue inj, new onset resp infectons, esp in older adults

A

Urgent

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10
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11
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A

Trauma Nursing Principles

  • Trauma - bodily injury
  • Unintentional injury - leading cause of death in US for individuals under 35 y.o.

🌟 Trauma-informed care (TIC) - is a model of care that ensures pt safety through 4 key practices:
✨ realizing the widespread effect of trauma
✨ recognizing the s/s of trauma
✨ responding by fully integrating trauma knowledge into practices & procedures
✨ seeking to actively resist re-traumatization

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12
Q

Trauma Centers

A

Mechanism of Injury (MOI)

Manner in which traumatic event occurred:
- Blunt trauma
- Blast effect
- Acceleration-deceleration forces
- Penetrating trauma

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13
Q

Trauma Assessment

  • Primary survey
    (A) Airway
    (B) Breathing
    (C) Circulation
    (D) Disability
    (E) Exposure

! Exception
- In presence of excessive bleeding, use CAB (circulation, airway, breathing

A
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14
Q

Primary Survey - Airway/CSpine

  • Airway w/cervical spine stabilization and/or immobilization
  • s/s in pt w/compromised airway
    > Dyspnea
    > Inability to vocalize
    > Presence of foreign body in airway
    > Trauma to face or neck
A
  • Maintain airway: least to most invasive method
  • Open airway using the jaw-thrust maneuver
  • Suction and/or remove foreign body
  • Insert nasopharyngeal/oropharyngeal airway
  • Endotracheal intubation
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15
Q

Rapid-sequence intubation
- Preferred procedure for unprotected airway
- Involves sedation or anesthesia & paralysis

A

Stabilize/immobilize c-spine
- Face, head, or neck trauma and/or significant upper torso injuries

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16
Q

Primary Survey - Breathing

✓ Assess for dyspnea, cyanosis, paradoxic/asymmetric chest wall movement, decreased/absent breath sounds, tachycardia, hypotension

! Fractured ribs, pneumothorax, penetrating injuries, allergic reactions, pulmonary emboli, asthma attacks, flail chest

A
17
Q

Primary Survey - Circulation

✓ Check central pulse (peripheral pulses may be absent b/c inj or vasoconstriction)

✓ Insert two large-bore IV catheters (16g) AC

✓ Initiate aggressive fluid resuscitation using NS (0.9%) or LR’s; crystalloid solutions

A
  • Hypertonic saline may be used for head trauma (higher than physiologic 0.9% w/2%, 3%, 5%, 7%, & 23% NaCl preparations)
  • Fluids warmed
  • Blood products can also be given BUT priority is to stop the bleeding
18
Q

! AMS & delayed cap refill (>3 sec) are the most significant signs of shock (consider factor of a cold environment)

Presence of a radial pulse = BP @ least ___ mmHG systolic

Presence of a femoral pulse = BP @ least ___ mmHG systolic

Presence of a carotid pulse = BP @ least ___ mmHG systolic

A

80

70

60

19
Q

Primary Survey: Disability

Measured by pt’s LOC

AVPU -
A = alert
V = responsive to voice
P = responsive to pain
U = unresponsive

A

GCS lowest score 3, highest 15

Pupils

20
Q

Primary Survey: Exposure/environmental survey

☞ Remove clothing to perform physical assessment

☞ Prevent heat loss

☞ Preserve evidence whenever possible

A

☆ Preservation of evidence is often needed for rape, elder abuse, domestic violence, homicide, suicide, drug overdose, & assault

21
Q

Secondary Survey - Brief Systematic Process to id all injuries

Full set of VS/5 interventions/facilitate family presence

  1. BP (bilat)
  2. HR
  3. RR
  4. O2 sat
  5. Temp
A

Full set of VS

  • Initiate ECG monitoring
  • Initiate pulse oximetry
  • Insert indwelling catheter
  • Insert orogastric/nasogastric tube
  • Collect blood for lab studies
22
Q

Secondary Survey - full set of VS/5 interventions/facilitate family presence

☆ Family presence: family members who wish to be present during invasive procedures/resuscitation view themselves as participants in care

☆ Their presence should be supported

A

☆ Give comfort measures
- Pain management strategies

  • Combination of:
    > Pharmacologic measures
    > Nonpharmacologic measures
23
Q

☞ History & head-to-toe assessment (ONLY IF VS ARE STABLE)

  • Obtain history of event, illness, inj from pt, family, & emergency personnel
  • Perform head-to-toe assessment to obtain info about all other body systems
A

AMPLE

A = Allergies to drugs, food, environment
M = Medication hx
P = Past health hx
L = Last meal
E = Events/environment leading to the illness or inj

24
Q

☞ Inspect the posterior surfaces
- Logroll pt (while maintaining c/s immobilization) to inspect the posterior surfaces

A

☞ Evaluate need for tetanus prophylaxis

☞ Provide ongoing monitoring & evaluate pt’s response to interventions

25
Q

Secondary Survey & Resuscitation Interventions

  • Comprehensive head-to-toe assessment
  • Identifies other inj/issues (after immediate life threats have been addressed)
A
  • The nurse anticipates:
    > Insertion of gastric tube & urinary catheter
    > Preparation for diagnostic studies
    > Application of splints, temporary dressings
26
Q

Disposition

  • Transport to OR or interventional radiology suite
  • Admission to inpatient unit
  • Transfer to a higher lvl of care
A
  • Before disposition is determined
    > Assess psychosocial needs
    > Consult w/social services & rehab team
    > Coordinate w/other support services as needed
    > Be alert for signs of human trafficking
    > Implement SBIRT
    ⤷ Assessing for problem drinking = screening, brief intervention, & referral to treatment
27
Q

Gerontologic Considerations Emergency Care

➙ Older adults are @ high risk for inj - primarily from falls

A

Causes
- Generalized weakness
- Environmental hazards
- Orthostatic hypotension (e.g., s/e of rx’s, dehydration)
- Important to determine whether physical findings may have caused fall or may be d/t fall

NUR 202 Week 13 (4 decks)

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