Exam #1 Study Guide: Nursing Care Of The Emergency Patient

Question 1

Triage

Answer 1

• “To sort”
• Process of rapidly determine patient acuity.
• Represents a critical assessment skill.

Question 2

Triage System

Answer 2

Categorizes patients so most critical are treated first

Question 3

Emergency Severity Index

Answer 3

…

Question 4

Five-Levels ESI are based on

Answer 4

1. Stability of vital functions (ABCs)
2. Life threat or organ threat
3. How soon patient should be seen by HCP
4. Expected resource intensity (do they need people with them until they’re stable)

Examples are on Slide 9

Question 5

ESI-1

Answer 5

• Most critical patient*
  1. Stability of Vital Functions = Unstable
  2. Life threat or organ threat = Obvious
  3. How soon patient should be seen by HCP = Within 10 minutes
  4. Expected resource intensity = High resource intensity; multiple, often complex diagnostic studies; frequent consultation; continuous monitoring

Question 6

ESI-2

Answer 6

• High risk patient*
  1. Stability of vital functions = Threatened (abnormal)
  2. Life threat or organ threat = Likely by not always obvious
  3. How soon patient should be seen by HCP = Up to 1 hour
  4. Expected resource intensity - Medium to high resource intensity; multiple diagnostics studies; complex procedure

Question 7

ESI-3

Answer 7

1. Stability of Vital Functions = Stable (normal)
2. Life threat or organ threat = Unlikely but possible
3. How soon should be seen by HCP = Could be delayed
4. Expected resource intensity = Low resource intensity; one simple diagnostic study

Question 8

ESI-4

Answer 8

1. Stability of vital functions = Stable
2. Life threat or organ threat = No
3. How soon should be seen by HCP = Could be delayed
4. Expected resource intensity = Low resource intensity; examination only

Question 9

ESI-5

Answer 9

1. Stability of vital functions = Stable
2. Life threat or organ threat = No
3. How soon patient should be seen by HCP = Could be delayed
4. Expected resource intensity = Low resource intensity; examination only

Question 10

Emergency Nursing: After initial focused assessment to determine actual or potential threats to life, proceed with more detailed assessment including

Answer 10

• Systematic approach decreases the time needed to identify potential threats to life.
• Trauma patients: primary survey and secondary survey
• Nontrauma patients: primary survey and focused assessment

Question 11

Emergency Nursing: ABCDEFGH

Answer 11

1. Alertness and airway
2. Breathing
3. Circulation
4. Disability
5. Exposure and environmental control
6. Facilitate adjuncts and family
7. Get resuscitation adjuncts
8. History and head-to-to assessment

Question 12

Emergency Nursing: Primary Survey focuses on

Answer 12

• ABC’s

- Diability, exposure, facilitation of adjuncts and family, and other resuscitation aids

Question 13

Emergency Nursing: If uncontrolled external hemorrhage is noted during a primary survey, what should be done?

Answer 13

• The usual ABC assessment format may be reprioritized to ABC for hemorrhage control. ( stands for catastrophic hemorrhage which needs to be controlled first)
• Apply direct pressure with sterile dressing followed by a pressure dressing to any obvious bleeding sites.

Question 14

Emergency Nursing: If life-threatening conditions related to ABC’s are identified during primary survey, what should be done?

Answer 14

Interventions are started immediately and before proceeding to the next step of survey

Question 15

Emergency Nursing: Alertness and airway

Answer 15

-Determine LOC
-Assess patient response to verbal and/or painful stimuli
(AVPU: A = alert, V = responsive to voice, P = responsive to pain, U = unresponsive)

Question 16

Primary Survey: Airway Obstruction

Answer 16

• Cause of nearly all immediate trauma deaths
• Saliva, blood secretions, vomitus, laryngeal trauma, dentures, facial trauma, fractures and the tongue can obstruct the airway.

Question 17

Patients at risk for airway compromise include

Answer 17

• Seizures
• Drowned
• Anaphylaxis
• Foreign body obstruction
• Cardiopulmonary arrest

Question 18

Primary Survey: Signs and symptoms of a compromise airway

Answer 18

• Dyspnea
• Inability to speak
• Gasping (agonal) breaths
• Foreign body in airway
• Trauma to fake or neck

Question 19

Treatment for a Compromised Airway

Answer 19

1. Open airway using jaw-thrust maneuver (avoid hyperextending the neck)
2. Suction and/or remove foreign body
3. Insert nasopharyngeal or oropharyngeal airway (in unconscious patients only)
4. Endotracheal intubation (ventilate patients with 100% O2 using a bag-valve mask before intubation)

Question 20

If intubation is impossible because of airway obstruction, what can be done?

Answer 20

An emergency cricothyroidotomy or tracheotomy is performed (patient needs to be ventilated with 100% O2 using a bag-valve-mask device prior to cricothyroidotomy)

Question 21

Rapid-sequence intubation

Answer 21

• Preferred procedure for securing an unprotected airway
• Involves sedation or anesthesia paralysis (these drugs aid intubation and reduce the risk of aspiration and airway trauma)

Question 22

Primary Survey: You should suspect cervical spine trauma in any patient with

Answer 22

• Face, head or neck trauma

- Significant upper chest injuries

Question 23

For patients with suspected cervical spine trauma, you must

Answer 23

• Stabilize cervical spine using a cervical collar and cervical immobilization device.
• Secure the patients forehead to the backboard.

Question 24

Treatment for patients with trouble breathing include

Answer 24

• Administering high-flow O2 via a nonrebreather mask
• For life threatening conditions (i.e flail chest, tension pneumothorax):
  
  • Bag-valve mask ventilation with 100% O2
  • Needle decompression
  • Intubation
  • Treatment of underlying cause

Question 25

Primary Survey: Circulation

Answer 25

- Check central pulse (because peripheral pulse may be absent d/t injury or vasoconstriction): assess quality and rate - Assess skin: color, temperature, moisture - Assess for signs of shock: mental status, delay capillary refill (longer than 3 seconds is a common sign of shock however cold temperature can delay refill)

Question 26

Primary Survey: What to do if circulation is compromised?

Answer 26

- Insert 2 large-bore IV catheters - Initiate aggressive fluid resuscitation using normal saline or lactated ringer’s solution. -Give packed RBC’s if needed (in emergency situation, give uncrossmatched blood if immediate transfusion is warranted)

Question 27

Primary Survey: Disability (Neurologic Examination)

Answer 27

- Measured by patient’s level of consciousness - Glasgow Coma Scale - Pupils: size, shape, equality, reactivity

Question 28

Primary Survey: Exposure and environmental control. What should the nurse do for these patients?

Answer 28

- Remove clothing to perform physical assessment - Do not remove impale objects - Prevent heat loss - Maintain privacy

Question 29

Secondary Survey includes

Answer 29

- Facilitates adjuncts and family | - Complete set of vital signs

Question 30

Primary Survey: Family Presence

Answer 30

- Beneficial for patients, caregivers and staff - Provides comfort, advocate, remind staff of the person behinds the trauma - Serve as staff helpers - Remember to explain care and answer questions

Question 31

Primary Survey: Getting Resuscitation adjuncts - LMNOP

Answer 31

1. Laboratory studies 2. Monitor ECG 3. Nasogastric tube or orogastric tube (to decompress and empty the stomach, reduce the risk of aspiration and test contents for blood) 4. Oxygenation and ventilation assessment 5. Pain management

Question 32

Primary Survey: Pain Management

Answer 32

- Primary complaint of most patients - Combination of strategies: Pharmacologic or Nonpharmacologic - General comfort measures: verbal reassurance, listening, reducing stimuli, developing trust

Question 33

Secondary Survey is a

Answer 33

Brief systematic process to identify all injuries.

Question 34

Secondary Survey: History and Head-to-Toe Assessment

Answer 34

- Obtain history and mechanism of injury, or illness from patient, caregivers, friends, bystanders, and emergency personnel - Provides suggestions for specific assessment and intervention

Question 35

Secondary Survey: SAMPLE

Answer 35

1. Symptoms 2. Allergies 3. Medication History 4. Past health history 5. Last meal/oral intake 6. Events or environmental factors leading to illness or injury

Question 36

Secondary Survey: Head, neck and face

Answer 36

- General appearance, skin color and temperature - Disconjugate gaze (indicates neurologic damage) - Battle’s signs - Raccoon eyes - Assess ears for blood and CSF - Airway - Neck: assess for bruising, edema, bleeding, distended neck veins. Midline trachea?

Question 37

Battle’s Sign

Answer 37

Bruising directly behind the ears that may indicate a fracture of the base of the posterior portion of the skull.

Question 38

Raccoon eyes or periorobital ecchymosis

Answer 38

Usually an indication of a fracture of the base of the frontal portion of the skull

Question 39

Secondary Survey: Assessment of the Chest

Answer 39

- Assess for paradoxic chest movements - Assess for large sucking chest wounds - Palpation of the sternum, clavicles and ribs for deformity, tenderness and crepitus. - Ausculation: breath and heart sounds - Assess for pneumothorax, open pneumothorax, rib fractures, pulmonary contusion, blunt cardiac injury, hemothorax (Chest x-ray, ECG)

Question 40

Secondary Survey: Assessment of the abdomen and flanks

Answer 40

1. Frequent evaluation for subtle changes is essential (blunt trauma, penetrating trauma, inspections/auscultation (bowel sounds)/percussion/palpation) 2. FAST for intraabdominal hemorrhage

Question 41

Secondary Survey: Assessment of the Pelvis and Perineum

Answer 41

- Gently palpate pelvis (do not rock the pelvis) to determine stability: pain may indicate pelvic fracture/x-ray - Inspect genitalia: quality of or inability to void - Rectal exam may be performed by HCP

Question 42

Secondary Survey: Assessment of the extremities

Answer 42

- Assess for point tenderness, crepitus and deformities (Treat with RICE) - A pulseless extremity is a time-critical emergency (should be realigned by the HCP and splinted) - Compartment Syndrome

Question 43

Secondary Survey: How to inspect the posterior surfaces

Answer 43

- Log roll patient (while maintaining cervical spine immobilization) to inspect the posterior surfaces - Requires 3-4+ people - Support head and assess for echymosis, abrasions, puncture wounds, cuts and obvious deformities. - Palpate entire spine for misalignment, deformity and pain.

Question 44

Acute Care and Evaluation

Answer 44

- Evaluate need for tetanus prophylaxis - Provide ongoing monitoring - Evaluate patient’s response to interventions - Insert an indwelling catheter as indicated.

Question 45

Depending on the patient’s injuries or illness, the patient may

Answer 45

1. Be transported for diagnostic tests or to OR for surgery 2. Admit to general unit, telemetry or ICU 3. Transfer to another facility

Question 46

Death in the Emergency Department: Prepare for the times when sudden death occurs

Answer 46

- Anticipate your own reactions/feelings - Help caregivers grieve (collecting personal belongings, viewing the body, making mortuary arrangements, ensure privacy, offer chaplain visit)

Question 47

Death in the Emergency Department: Autopsies may be arranged based

Answer 47

- Upon family request - In case of death within 24 hours of ED admission - When suspected trauma or violence has occurred

Question 48

Considering Organ Donation

Answer 48

``` 1. Organ procurement organizations (OPOs) assist in Screening potential donors Counseling donor families Obtaining informed consent Harvesting organs 2. Can be distressing 3. May be 1st positive step in grieving ```

Question 49

Poisonings

Answer 49

- Chemicals that harm body accidentally, occupationally, recreationally or intentionally. - Severity depends on type, concentrations and route of exposure. - Toxins can affect every tissue of the body: symptoms can be seen anywhere

Question 50

Poison Management

Answer 50

- Decrease absorption - Enhance elimination - Implement toxin-specific interventions per poison control center

Question 51

Poisoning Management: Decreasing Absorption

Answer 51

Gastric Lavage which is performed within one hour of ingestion of moist poisons

Question 52

What happens during a gastric lavage?

Answer 52

- Intubated before lavage if altered LOC or diminished gag reflex - Involves oral insertion of a large-diabetes (36F-42F) gastric tube for irrigation of copious amounts of saline.

Question 53

Gastric Lavage is contraindicated with

Answer 53

- Caustic agents - Coingested sharp objects - Ingested nontoxic substances

Question 54

Problems associated with gastric lavage include

Answer 54

- Esophageal perforation | - Aspiration

Question 55

Activated Charcoal

Answer 55

- Most effective intervention for management of poisonings. - Toxins adhere to charcoal and pass through the GI tract rather than being absorbed into circulation. - Administered orally or via gastric tube within 1 hour of poison ingestion.

Question 56

What are contraindications of activated charcoal?

Answer 56

- Diminished bowel sounds - Paralytic ileus - Ingestion of substance poorly absorbed by charcoal

Question 57

Activated charcoal can absorb and neutralize antidotes, therefore

Answer 57

Do not give immediately before, with, or shortly after charcoal.

Question 58

Poisonings: Dermal cleansing/eye irrigation

Answer 58

- Removal of toxins from skin and eyes using copious amounts of water or saline. - Most toxins, with the exception of mustard gas, can be safely removed with water and saline (this is because water mixes with mustard gas and releases chlorine gas) - Brush dry substances front he skin and clothing before using water. (Do not remove powdered lime with water, should be brushed off)

Question 59

During dermal cleansing/eye irrigation,

Answer 59

- Wear PPE | - Decontamination takes priority over all interventions except BLS measures

Question 60

Poisoning Management: Enhance Elimination

Answer 60

- Cathartics (sorbitol) | - Whole bowel irrigation *high risk of electrolyte imbalance

Question 61

Cathartics

Answer 61

Give with first dose of charcoal to stimulate intestinal motility/increase elimination

Question 62

Poisoning Management: Hemodialysis/hemoperfusion

Answer 62

- Reserved for severe acidosis -Urine alkalinization (Phenobarbital and salicylate poisoning) - Chelating agents (↑ Amphetamine and quinidine excretion) - Antidotes (Very few available) *check notes

Question 63

Slide 53??

Answer 63

..

Question 64

Terrorism

Answer 64

- Involves overt actions for expressed purpose of cause harm. - Includes Biologic agents, Chemical agents, Radiologic/nuclear, explosive devices

Question 65

Bioterrorism

Answer 65

- Includes Anthrax, plague, and tularemia (Treated with antibiotics assuming sufficient supplies and nonresistant organisms) - Smallpox can be prevented or ameliorated by vaccination even when given after exposure - Botulism *read notes

Question 66

How is botulism treated?

Answer 66

Antitoxin

Question 67

Chemical Agents of Terrorism

Answer 67

- Categorized by target organ or effect. | - Examples: sarin, phosgene, mustard gas

Question 68

Chemical Agents of Terrorism: Sarin

Answer 68

- Toxic nerve gas that can cause death within minutes of exposure - Enters body through eyes and skin - Acts by paralyzing respiratory muscles

Question 69

Antidotes for nerve agents include

Answer 69

- Atropine | - Pralidoxime chloride

Question 70

Chemical Agents of Terrorism: Phosgene

Answer 70

- Colorless gas normally used in chemical manufacturing - If inhaled at high concentrations for long enough period, causes severe respiratory distress, pulmonary edema, and death

Question 71

Chemical Agents of Terrorism: Mustard Gas

Answer 71

- Yellow to brown in color with garlic-like odor | - Irritates eyes and causes skin burns/blisters

Question 72

Radiologic/Nuclear Agents of Terrorism “Dirty Bombs”

Answer 72

- Mix of explosives and radioactive material - When detonated, blast scatters radioactive dust, smoke, and other material into environment, resulting in radioactive contamination - Main danger from RRDs: explosion

Question 73

Radiologic/Nuclear Agents of Terrorism: Ionizing radiation

Answer 73

- (e.g., nuclear bomb, damage to a nuclear reactor) - Serious threat to safety of victims and environment - Exposure may or may not include skin contamination with radioactive material

Question 74

Acute Radiation Syndrome develops after

Answer 74

a substantial exposure to ionizing radiation and follows a predictable pattern.

Question 75

Explosive Devices as Agents of Terrorism: Results in one or more of the following types of injuries

Answer 75

- Blast, crush, or penetrating - Blast injuries from supersonic overpressurization shock wave that results from explosion (Damage to lungs, middle ear, gastrointestinal tract)

Question 76

Emergency

Answer 76

Any extraordinary event that requires a rapid and skilled response and can be managed by a community’s existing resources

Question 77

Mass Casualty Incident

Answer 77

Manmade or natural event or disaster that overwhelms community’s ability to respond with existing resources

Question 78

Emergency And Mass Casualty Incident Preparedness

Answer 78

- When an emergency or MCI occurs, first responders (e.g., police, emergency medical personnel) are dispatched - Triage of casualties differs from usual ED triage and is conducted in <15 seconds

Question 79

Emergency and Mass Casualty Incident Preparedness: System

Answer 79

-Colored tags designates both seriousness of injury and likelihood of survival

Question 80

MCI colored tags: Green

Answer 80

Minor injury

Question 81

MCI colored tags: Yellow

Answer 81

Non-life-threatening injury

Question 82

MCI colored tags: Red

Answer 82

Life-threatening injury

Question 83

MCI colored tags: Blue

Answer 83

Those who are expected to die

Question 84

MCI colored tags: Black

Answer 84

Identifies the dead

Question 85

Total number of casualties a hospital can expect is estimated by doing what

Answer 85

Doubling the number of casualties that arrive in the first hour.

Question 86

CERT’s

Answer 86

are partners in emergency preparedness, and training helps citizens to understand their personal responsibility in preparing for natural/manmade disaster

Question 87

Role of all HCP’s in emergency and MCI preparedness

Answer 87

- Knowledge of the hospital’s emergency response plan | - Participation in emergency/MCI preparedness drills is required

Question 88

National Incident Managemetn System

Answer 88

Section within the U.S. Department of Homeland Security that is responsible for the coordination of the federal medical response to MCIs

Question 89

DMATs: disaster medical assistance teams

Answer 89

- Categorized according to ability to respond to an MCI | - Have a critical incident stress management unit.

Question 90

Critical Incident Stress Management Unit

Answer 90

- Unit arranges group discussions to allow participants to share and validate their feelings and emotions about the experience. - This is important for emotional recovery.