Exam 1 Flashcards
Mitigation phase of emergency nursing
planning phase
proactive rather than reactive
Preparedness phase of emergency nursing
practicing the plan
training a disaster team
Emergency response phase of emergency nursing
Implementation of the plans
assessing if the plan is working
Recovery phase of emergency nursing
returning everything to a new normal
PTSD may occur and should be assessed
What is the #1 priority of emergency nursing?
SAFETY
know where your exits are, put on PPE and know who is around you
What is trauma?
injury to any body part/wound or shock from sudden physical injury
How long should a rapid assessment take?
60 seconds or less
What should be gathered with your rapid assessment?
vitals signs
GCS
extent of injuries
Reverse/disaster triage is used in what situation?
mass casualty
>100 people
In what order do you assess with reverse/disaster triage?
treat less injured 1st and leave severely injured to die possibly
the greatest good for the greatest amount of people
What elements are involved with a primary survey?
Airway
Breathing
Circulation
Disability
Exposure
What is your priority when assessing airway?
are there any obstructions?
clear obstructions with suction, turn to side to expel vomit/blood and anticipate intubation
ONLY insert an oropharyngeal airway if the patient doesn’t have what?
Gag reflex
because otherwise, you will not be able to get the tube down and secure the airway
What does a C-collar do?
controls airway and CNS
What should not be done if they have a potential cervical spine injury?
Head tilt/chin lift
What should you do if the patient is unresponsive without trauma to the airway?
head tilt/chin lift
What should you do if the patient is unresponsive with trauma to the airway?
Jaw thrust
If you suspect they have blunt force trauma, what should you do?
Stabilize their spine and log roll
What should you look/listen for when assessing breathing?
symmetrical chest rise & fall
use of accessory muscles
listen to all 5 lung sounds
broken ribs
If 3 plus ribs have broken what has most likely happened?
Lung has collapsed
What may sub-q edema indicate?
flail chest
This is a medical emergency, and you should intervene immediately
What should you do if the patient has a flail chest?
raise HOB
apply O2 or Ambu bag for inadequate breathing
if the flail chest progresses into a collapsed lung then prepare of intubation
What should be assessed when looking at circulation?
HR
BP
Peripheral pulses (radial)
central pulses (carotid/femoral) (check this 1st)
cap refill
skin color
LOC
urine output
What is the priority action when assessing circulation?
Get 2 IV access points using large-bore IV caths in the antecubital fossa of both arms
Infuse isotonic IV fluids and or blood products
What should be assessed with disability?
LOC with GCS (less than 8, intibate)
AVPU
pupillary response
How should you assess exposure/environment?
expose & look at the patient (front/back/naked)
preserve evidence found
Priority is to maintain body heat and privacy/dignity
What is the trauma triad of death
Hypothermia (keep warm)
acidosis (replace volume loss)
coagulopathy (monitor for s/sx of shock)
Secondary survey includes…?
Full set of VS, 5 adjuncts, family presence
Give comfort measures
Head to toe
Inspect posterior
What are the 5 adjuncts?
Foley catheter
Full set of labs
cardiac monitor
NG or OG tube
some sort of radiology (x-ray or CT)
What does AMPLE stand for?
Allergies
meds
past medical hx/menstrual period
last intake & output
exposures
When inspecting posteriorly, what should you check for?
check rectal tone to assess for spinal cord injury
if there is no tone, assume spinal cord injury
What is pre-load?
amount of blood going into the right atrium
Involves central venous pressure (CVP)
& pulmonary artery wedge pressure (PAWP)
Central venous pressure
measures the right atrial pressure/the volume of blood going into the right atrium
How is CVP measured?
Central line
PA catheter
CVP range
2-6
if CVP is >6
There is too much fluid
pump problem
give diuretics
if CVP is <2
not enough fluid, need volume
give fluids
Pulmonary Artery wedge pressure
pressure generated by the left ventricle
What is after-load?
Pressure the ventricles have to pump against to move blood out of the heart & to the lungs or body
involves pulmonary vascular resistance (PVR) & systemic vascular resistance (SVR)
Pulmonary vascular resistance
pressure the RV must overcome to pump blood to the lungs
Systemic vascular resistance
Pressure the LV must overcome to pump blood to the body
Mean arterial pressure
> 65mmHG
PAWP
6-15
Cardiac output
3-6 L/min
amount of blood pumped in one minute
CO= SV x HR
PA pressure systole
15-28
PA pressure diastole
5-16
SVR
800-1200
stroke volume
50-100mL/sec
Ejection fraction
normal: 55-70%
acute heart failure: <40%
% of blood ejected with each beat
Elevated preload (CVP&PAWP) s/sx
crackles
JVD
hepatomegaly
peripheral edema
taut skin turgor
too much fluid
Decreased preload s/sx
poor skin turgor
dry mucous membranes
not enough fluid
Elevated afterload (PVR&SVR) s/sx
cool extremities
weak peripheral pulses
not enough fluid
Decreased afterload s/sx
warm extremities
bounding peripheral pulses
too much fluid
Pulmonary artery catheter (swan-ganz)
a catheter that is threaded into the RA, then RV, then into a branch of the PA
measures right atrial pressure, pulmonary artery pressure and left ventricle pressure
measures fluid INSIDE the heart
What happens if there is high PA pressure? why?
pulmonary HTN
pulmonary edema
RA is having to work hard bc the afterload is high
give sildenafil, even females
How do you measure PAWP/LV pressure?
Inflate the balloon!
You MUST deflate the balloon after bc it’s in the PA & is cutting off blood flow which could lead to massive PE or necrosis
high risks for clots with this procedure
Arterial lines are most commonly placed in what artery?
Radial
What are the indications for an arterial line?
pt needs a continuous BP reading
frequent ABGs
the patient is on vasopressors
What does an ART line measure?
continuous BP readings in the arteries leaving the heart
measures ABGs ( can draw blood from these lines for ABGs)
What should you not use the ART line for?
giving meds or IV fluids through the ART line
What is the biggest risk with this procedure?
cutting off the blood flow to the hand
before inserting, complete an Allen’s test
if the pt says their hand hurts, call dr!
the art line is accurate when the _____ is level with the atrium of the heart
Transducer
if the pt heart is higher than the transducer then
pressure is too high
if the pt heart is lower than the transducer then
pressure it too low
if the transducer is higher than the heart then
the pressure is low
if the transducer is lower then the heart then
the pressure is high
What is the first major sign of shock?
hypotension
What is the priority for shock?
early detection
Initial phase of shock
no visible changes
only at the cellular level
Non-progressive (compensatory) of shock
the body compensates to perfuse organs
at 1st, BP increases but this can’t last long
CO & BP start to drop, so HR increases
no big changes bc the body can compensate
RR increase
cold and clammy
urine decreases
Progressive phase of shock
Compensatory mechanisms fail
S/sx of progressive shock
pale
poor skin turgor
cool skin
decreased cap refill
decreased peri pulses
restless/anxious
decreased LOC
pulmonary edema
lactic acid builds up
Refractory stage of shock
irreversible & total system failure
the patient is going to die
S/sx of refractory shock
rapid, shallow breaths
cyanotic skin
no urine output
High CVP leads to
JVD
Causes of hypovolemic shock
trauma
dehydration
hemorrhage
What will be increased in hypovolemic shock?
HR
SVR
RR
What will hypovolemic shock patients complain of feeling?
not being able to breathe
What is the priority nursing intervention for hypovolemic shock?
replace fluids with normal saline or blood
What is the first-line drug for hypovolemic shock?
Norepinephrine
Whole blood is given when
the patient has lost a large amount of blood
In what time frame must whole blood be transfused before the coagulation factors deteriorate?
within 24 hours of collection
Fresh frozen plasma is used to treat
active bleeding
coagulation disorders
extensive burns
shock
replacement therapy for coagulation factors
Albumin does what
expands blood volume and increases BP
packed red blood cells are used when?
to restore or maintain adequate organ oxygenation and circulating blood volume
Platelets are used for?
Thrombocytopenia
aplastic anemia
chemotherapy induced bone marrow suppression
Cryoprecipitate
thawed frozen plasma that contains coagulation factors
What should you do pre-procedure before admin blood products
obtain blood samples to determine compatibility
assess for hx of transfusion reactions
start large-bore IV access
2 RNs must verify product & pt within 30 min of transfusion
How often should you monitor VS and reactions intra-procedure?
stay with the pt for the first 15-30 min
monitor VS at 15 min, 30 min, 1 hr, immediately after and 1 hour after transfusion
What should you do post transfusion?
take VS
dispose of tubing
complete paperwork and document
What should you consider when transfusion older adults?
assess VS q 15 min (at risk for fluid volume overload)
withhold IVF during transfusion
give furosemide/diuretics post transfusion
If adverse reactions occur, what should you immediately do?
STOP transfusion
remove the tubing
remove blood products
start NS with new tubing
monitor VS
send blood & tubing to the blood bank for testing
Acute hemolytic reaction onset
Immediately
S/sx of acute hemolytic reaction
chills
fever
low back pain
flushing
Hemoglobinuria
impending sense of doom
Nurse action for acute hemolytic reaction
monitor VS & fluid status
Febrile reaction onset
within 2 hrs of starting infusion
Febrile reaction S/sx
1-degree temp difference from pretransfusion temp
febrile reaction nurse action
admin antipyretics
Allergic reaction onset
up to 24 hours after transfusion
allergic reaction s/sx
itching
flushing
Anaphylaxis
Nurse actions for allergic reaction
admin antihistamine and may restart if ordered at a slower rate
Anaphylactic reaction onset
up to 24 hours after transfusion
Anaphylactic reaction s/sx
bronchospasm
laryngeal edema
shock
Nurse action for anaphylactic reaction
admin epi, O2 and possible CPR
Bacterial reaction onset
during or several hours after transfusion
S/sx of bacterial reaction
wheezing
dyspnea
cyanosis
shock
Nurse action for bacterial reaction
admin antibiotics
Circulatory overload onset
any time during the transfusion
S/sx of circulatory overload
crackles
dyspnea
cough
JVD
anxiety
Nursing actions for circulatory overload
slow the transfusion
position the pt upright w/ feet lower than heart level
admin O2
Diuretics and morphine
What is an infarction?
tissue has NO blood flow
irreversible
what is ischemia?
tissue damage w/ little blood flow
reversible
what is unstable angina?
increased chest pain that is not relieved by rest or the admin of nitroglycerine
What labs should be monitored for AMI, UA & CAD?
Myoglobin
CK-MB
Troponin I or T
What is the earliest marker of an MI?
Myoglobin
gone after 24 hours of potential MI
What is the CK-MB level?
0.1-4.9
peaks around 24 hours after the onset of chest pain
specific for AMI, when elevated this indicates damage to the cardiac muscle
What is the Troponin I or T range?
0.01-0.03
elevation indicates cardiac tissue damage
after 4-6 hrs w/ T
after 2-4 hrs w/ I
What is involved with the PCI and Cardiac catheterization
the wire goes into the femoral or brachial artery, guided up through the aorta to the coronary arteries
an angiogram can be done to visualize blockages
What are some precautions to take before and after an angiogram?
before: assess for shellfish & iodine allergy
after: load pt with fluids to flush out all of the dye and monitor BUN & creatinine closely, pt must also lay flat for 4 hours after
Emergent interventions for AMI/ unstable angina
monitor for dysrhythmias, hypoTN, increased chest pain
ONAM
Single chamber pacemaker (VVI)
sense & paces the right ventricle only
Will only see one pacemaker spike
Dual chamber pacemaker (DDD)
senses & paces both right atria and right ventricle
will see 2 pacemaker spikes
Who will need a pacemaker no matter what?
3rd degree heart block pts
What should you teach your patient about their pacemaker?
minimize shoulder movement
carry a pacemaker ID card because it will set off airport security
take their pulses daily at the same time
microwaves are okay to be around but stay away from objects generating magnetic field
no heavy lifting or contact sports
What are the most important things you should teach your patient about an angioplasty?
conscious sedation
the leg that is cannulated must remain straight for at least 4-6 hours following the procedure
What are the complications associated with an angioplasty?
cardiac tamponade
hemorrhage at the insertion site
Acute kidney injury from IV contrast dye
What is the backup procedure if the PCI does not work?
Coronary artery bypass graft (CABG)
Who is indicated to receive CABG treatment?
unable to open the CA w PCI
3 vessel blockage
50% occlusion of the left main CA
What are some complications of CABG?
hypovolemic shock
decreased cardiac output
Hypothermia
Electrolyte imbalance
S/SX of cardiac tamponade?
JVD
muffled heart sounds
paradoxical pulses (10mmHg difference)
narrowing pulse pressure
tachypnea
Bradycardia
cardiac arrest (late sign)
Nursing actions for cardiac tamponade?
notify dr immediately
treatment is pericardiocentesis
S/sx of cardiomyopathy
decreased ejection fraction
decreased cardiac output
s/sx of right and left HF
S3 & S4
murmur
syncope after activity
cardiomegaly
fatigue, weakness, dysrhythmias
Risk factors/ causes of cardiomyopathy
family hx
sudden cardiac arrest
endocrine/metabolic diseases
Alcoholism
HTN
Nursing care for acute heart failure
daily weights & I&Os
oxygen
bed rest
restrict fluid & Na
if hemodynamically unstable, then give dobutamine
if BNP is increased, give diuretics and O2
put on a cardiac monitor
start large bore IV 16 or 18 gauge (centrally located)
What is increased in cardiogenic shock?
HR
CVP
SVR
S/sx of cardiogenic shock
resp distress-crackles
JVD
tachycardia w/ hypotension
altered LOC
decreased peripheral pulses
thermodynamically unstable
nursing interventions for cardiogenic shock
apply oxygen and vent PRN
put pt on cardiac monitor
start a central line
ONAM
Complications of cardiogenic shock
DIC
multiple organ dysfunction syndrome (MODS)
What is the systolic BP for a hypertensive crisis?
180-240
What is the diastolic BP for a hypertensive crisis?
> 100
What are some s/sx of a hypertensive crisis?
severe HA
blurred vision
epistaxis
dizzy/disoriented
What is the first-line medication for a hypertensive crisis?
Nitroprusside (vasodilator)
How should you admin nitroprusside?
IV admin low dose initially so the BP doesn’t drop too fast and become hypotensive
What are the nursing actions during a hypertensive crisis?
continuous BP monitoring (every 5-15min) but it is ideal to have an arterial line
assess neuro status
Aortic aneurysm is weakness in what?
dilated section of the aorta
LIFE THREATENING
Aortic dissection is what?
an accumulation of blood within the arterial wall
what are some risk factors for an aortic aneurysm/ dissection?
male
uncontrolled HTN
atherosclerosis
old age
S/sx of an abdominal aortic aneurysm (AAA)
constant gnawing pain in the abdomen radiating to flank or back
there will be a bruit over the aneurysm
AUSCULTATE 1ST!!! DO NOT PALPATE!!! YOU WILL KILL YOUR PT!!!
S/sx of a thoracic aortic aneurysm
severe back pain
cough/SOB
Difficulty swallowing
S/sx of a dissecting aneurysm
can occur with AAA or thoracic
if the pulse is lost, then the aneurysm has been dissected
sudden change in symptoms from AAA/thoracic to tearing, ripping, stabbing abdominal or back pain
see s/sx of hypovolemic shock (MEDICAL EMERGENCY, GO STRAIGHT TO THE OR)
Nursing care for aortic aneurysms
control BP (goal is systolic 100-120)
give antihypertensive
assess pain, pulses, urine output
have one central line and 2 peripheral lines w/ large boreholes
keep warm
no smoking
for AAA, keep pt supine
