Exam 4 Flashcards
What is ESI?
emergency severity index
assigns 5 levels based on life-threatening to least urgent
How are emergency assessments triaged by color? Which are stable and unstable?
Red: life-threatening, unstable
orange: potentially life-threatening, unstable
yellow: stable but needs emergency care
green: stable but needs medical treatment within a reasonable time
blue: may be taken care of with another care level
stable: yellow, green, blue
unstable: orange, red
What is the ABCDE of asessment?
airway
breathing
circulation
disability
exposure
How is breathing thoroughly assessed?
- Auscultate breath sounds bilaterally
- Observation of chest expansion and respiratory effort (work of breathing)
- Rate and depth of respirations
Identification of chest trauma - Assess tracheal position (midline or deviated?)
- Assess for JVD
- Manual ventilation with bag valve mask if not breathing
- Set up for endotracheal intubation if not ventilating or oxygenating
What is a thorough primary survey of circulation?
- HR, BP, peripheral pulses, skin color
- CPR
- external or internal bleeding
- control hemorrhage
- reverse anitcoag therapies if possible
- IV access
*stabilize with fluids and blood
what constitutes a primary survey of disability?
determine LOC
AVPU: alert, verbal stimuli, painful stimuli, unresponsive
Glasgow coma scale
frequent neurological assessments
What can cause hypothermia in an emergency situation? What is the threshold for a hypthermic temp? What can result?
exposure
cold IV fluids
unwarmed O2
wet clothing
35 degrees
com, hypoxemia, acidosis
What is included in the secondary survey?
health history
head to toe
diagnostic and lab testing
monitoring devices, ECG, arterial lines, catheters
splinting fractures
wound care
interventions based on the condition
if instability occurs go back to ABCDEs
What are potential chest injuries (10)? What are interventions (6)?
Rib fractures
flail chest (2 fracture sites of at least 2 ribs)
Sternal fractures
Pulmonary contusion
Pneumothorax
Hemothorax
Cardiac contusion
cardiac tamponade
cardiac dysrhythmias
Aortic rupture
- Needle chest decompression if a tension pneumothorax
- Chest tube insertion for pneumothorax or hemothorax
- Cardiac monitor for dysrhythmias
- Pericardiocentesis if cardiac tamponade is occurring
- IV analgesia for pain control
- Frequent monitoring of breathing, including RR,O2 sats,and work of breathing
What is a wound cleaned with? What should not be used?
NS
betadine
What is assessed with crush injuries?
Hypovolemic shock
Spinal cord injury
Erythema and blistering
Fractures; usually extremity
Acute kidney injury
What are cooling methods?
Cool sheets, towels, or sponging with cool water
Ice to neck, groin, chest, and axillae
Cooling blankets
Immersion in cold water bath
What are the degrees measuring the severity of frostbite?
1st degree superficial
Only layers of exposed skin are affected with hyperemia and edema. Numb central white area without blistering.
2nd degree partial thickness
Blisters cover the exposed skin areas causing necrotic tissue death and swelling.
3rd degree full thickness
Extensive edema and hemorrhagic vesicles andblisters. No blanching. Need debridement.
4th degree full thickness
Full thickness freezing with necrosis. Complete lack of blood flow. Potential for gangrene.
What are clinical manifestations of frostbite? Immediate treatment? What can treatment cause? What is administered? What should not be done? What are nursing actions after rewarming?
progress from distal to proximal
Hard, cold, and insensitive to touch
Skin may appear white or mottled
Skin may turn red and become painful when re-warmed
Immediate treatment: cover affected areas and rewarming
Controlled but rapid rewarming with warm bath (104 to 108 °F)
Can cause severe pain
Administer tetanus toxoid if > 5 years
Administer analgesics forpain during rewarming
Do not massage, rub or handle; if feet are involved, do not allow client towalk
Once re-warmed, elevate affected extremity
Assess for compartment syndrome
Swelling
Increase in pain
Needs immediate treatment!
What are rewarming methods for hypothermia? What is the risk of cold blood returning from the extremities?
Active core re-warming: Cardiopulmonary bypass, warm fluid administration, warm humidified oxygen, and warm peritoneal lavage, warm bladder irrigation
Passive external re-warming:
Warm blankets and over-the-bed heaters (Bear-Huggers)
cardiac dysrhythmias and electrolyte imbalances because of the high levels of lactic acid in the cold blood
What are intervention methods with ingested poisons? What should not be induced with corrosive (acids/alkaline) agents?
N/G tube suction
gastric lavage
activated charcoal
specific antidote
diuresis, dialysis, hemoperfusion
most poisons just need supportive care
induce vomiting, corrosive agents cause destruction to tissue
what is the patho of carbon monoxide inhalation? Manifestations? What are unreliable signs?
Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin, which prevents the transport oxygen
Hemoglobin binds carbon monoxide 200 times more readily than oxygen
Manifestations
CNS symptoms predominate, HA, Dizziness
Skin color is not a reliable sign and pulse oximetry is not valid
Color ranges from pink to cherry-red to cyanotic and pale
What are common bacteria that cause food borne illness?
salmonella
shigella
E coli
campylobacter
Why should antidiarrheals be avoided with food borne illness?
prevents flushing out of the bacteria through the diarrhea
What food poisoning sources can result in respiratory paralysis and death?
botulism (honey)
certain fish poisonings
What are IV drug users at high risk for?
HIV infection
Hep B and C
tetanus
What can acute alcohol poisoning result in? Primary actions? What other causes can present like alcohol intoxication? What is indicted for withdrawal syndrome? What is CIWA?
death (respiratory depression)
Maintain airway and observe for CNS depression and hypotension
head injury,stroke,illness
Withdrawal syndrome will require high doses of benzodiazepines to control symptoms (lorazepam or diazepam)
CIWA (Clinical Institute Withdrawal Assessment for Alcohol)score is used to assess and manage the withdrawal stage of alcohol
What is the treatment for snakebites? What is contraindicated and for how long? What is the timeframe for antivenom administration? How often should the nurse assess for edema?
Lie down
Remove constrictive items (rings)
Provide warmth
Cleanse the wound
Cover with dressing
Immobilize injured body part below the level of the heart
No ice, tourniquets, heparin, and corticosteroids in the first 6 to 8 hours after the bite
4 to 12 hours
Assess for edema every 15-30 minutes
What antipsychotics are used for hallucinations? Agitation?
haloperidol,olanzapine, quetiapine, or risperidone are used for hallucinations, delusions
benzodiazapines such as diazapam or lorazapam
What are the 4 levels of PPE?
Level A: self-contained breathing apparatus (SCBA) and vapor-tight chemical resistant suit, gloves, and boots
Level B: high level of respiratory protection (SCBA) but lesser skin and eye protection; chemical-resistant suit
Level C: air-purified respirator, coverall with splash hood, chemical-resistant gloves and boots
Level D: typical work uniform
What are the 4 color codes for disaster triage?
red: priority 1, immediate
yellow: priority 2, urgent
greed: priority 3, delayed
black: dead or dying
What is the patho of anthrax? Transmission? Symptoms? Treatment?
Bacteria that results in hemorrhage, edema, and necrosis
Incubation: 1-6 days
Transmission: skin contact, GI ingestion, inhalation
Symptoms: skin lesions, fever, N&V, abdominal pain, diarrhea (some manifestations depend on route of transmission)
Respiratory symptoms that mimic influenza
Treatment: ciprofloxacin
What type of illness is small pox? Transmission? Symptoms? Treatment?
Virus
Extremely contagious; spread by direct contact, by contact with clothing or linens, or by droplets person-to-person
Manifestations: High fever, malaise, headache, backache, and prostration; after 1 to 2 days a maculopapular rash appears on the face, mouth, pharynx, and forearms
Treatment is supportive care
Vaccine can be given after known exposure. Not routinely prophylactically administered except in active military
What are examples of vesicant chemical agents? What do they cause? Nursing action? Treatment for lewisite?
Lewisite, sulfur mustard, nitrogen mustard, phosgene
Cause blistering and burning
Respiratory effects can be serious and cause death
Decontamination with soap and water; do not scrub or use hypochlorite solutions
Eye exposure requires copious irrigation
Treatment for lewisite exposure: dimercaprol IV or topically
What are examples of chemical nerve agents? Patho? Treatment? Decontamination? Why is plastic contraindicated?
Sarin, soman, tabun, organophosphates, and VX
Inhibit cholinesterase, causing cholinergic symptoms progressing to loss of consciousness, seizures, copious secretions, apnea, and death
Treatment: supportive care, atropine, benzodiazepine, and pralidoxime
Decontaminate with copious amounts of soap and water or saline for at least 20 minutes
Blot; do not wipe off
Plastic equipment will absorb sarin gas- do not use oral airway
What is hemodynamic shock? What occurs in all forms of shock? What has already occured before the BP drops? What is the physiologic response?
A condition in which tissue perfusion is inadequate to deliver oxygen and nutrients to support vital organs and cellular function and can lead to organ failure
Low blood pressure occurs in all forms of shock!
cellular and tissue damage has begun
Rapidly progressing and life-threatening process
hypoperfusion of tissues, hypermetabolism, and activation of the inflammatory response
What are the 4 types of shock?
Hypovolemic: A decrease in intravascular volume of at least 15% to 30%
Cardiogenic: failure of the heart to pump effectively due to a cardiac factor
Obstructive: Impairment of the heart to pump effectively as a result of a noncardiac factor
Distributive: Widespread vasodilation and increased capillary permeability, including neurogenic, septic, and anaphylactic shock
What are the 4 stages of shock?
Initial: no visible changes in client parameters; only changes on cellular level
MAP decreases 5 to 10 mm Hg from baseline; mild vasoconstriction; HR increases
Compensatory (non-progressive): Measures that increase CO to restore tissue perfusion and oxygenation
Vasoconstriction increases; HR increases; MAP decreases 10 to 15 mm Hg from baseline; mild acidosis and hyperkalemia
Progressive: Compensatory mechanisms start to fail to maintain CO and BP
MAP decreases >20 mm Hg from baseline; vital organs experience hypoxia; moderate acidosis and hyperkalemia
Refractory (irreversible): Irreversible shock and total body failure
Severe tissue hypoxia; MODS; possibly death
What are the physiologic responses during the compensatory stage of shock?
Sympathetic NS causes vasoconstriction, increased HR, and increased contractility
This attempts to maintain blood pressure and CO
Body shunts blood away from skin, kidneys, and GI tract
Results in cool, clammy skin, hypoactive BS, and decreased UO
Perfusion of tissues has become inadequate
Acidosis occurs because of anaerobic metabolism (lactic acid formation)
Respiratory rate increases due to acids circulating in the bloodstream
Confusion may occur from evolving acidosis
What mechanisms are activated during compensatory shock? What is the main purpose?
Activation of Sympathetic NS Activation of RAAS
Release of cortisol*
- It’s all about mechanisms trying tomaintain blood pressure to vital organs**
What are physiologic responses during the progressive stage of shock?
Mechanisms that regulate BP can no longer compensate, and BP and MAP decrease
All organs suffer from hypoperfusion (including heart, lung, and brain)
Vasoconstriction of arterioles continues, further compromising cellular perfusion to organs
Mental status further deteriorates because of decreased cerebral perfusion and hypoxia