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MED/SURG: TRAUMA > MED/SURG: TRAUMA: NURSING CARE > Flashcards

MED/SURG: TRAUMA: NURSING CARE Flashcards

1
Q

Trauma Nursing Care

Trauma Nursing Care

REMEMBER USE TRAUMA PROTOCOL

LIST (7)

A
  1. AIRWAY IS EVERYTHING
  2. B
  3. C
  4. D
  5. **ICP **treat when ICP > 20
  6. HOB
  7. SBP > 90
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2
Q

Trauma Nursing Care

ICP assessing for early to late s/s of increased ICP

  1. Early Signs of ICP: (3)
  2. Progressing: (3)
  3. Late: (3)
  4. Very Late: (2)
A
  • Early Signs:
  1. Restless,
  2. fidgeting
  3. RR increase
  • Progressing Signs:
  1. Pupil changes,
  2. HA increase with movement,
  3. motor deficits L vs R
  • Late Signs:
  1. Posturing,
  2. LOC decreasing
  3. RR decrease,
  • Very Late Signs:
  1. ​Pupils F&D
  2. No gag reflex
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3
Q

Trauma Nursing Care

Ventriculostomy

A

A ventriculostomy, also called an external ventricular drain (EVD) or ventricular catheter, is a catheter placed into the ventricles, fluid-filled spaces within the brain, and drains cerebrospinal fluid (CSF) externally. It is typically connected by tubing to a cerebrospinal fluid collection device which can be elevated or lowered at the bedside to vary the amount of CSF that is drained.

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4
Q

Trauma Nursing Care

Decreasing ICP (4)

A
  1. Mannitol
  2. Hypertonic Solution
  3. HOB
  4. Hypothermia Protocol
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5
Q

Trauma Nursing Care

Decreasing ICP

Mannitol what kinda fluid?

A

Osmotic diuretic

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6
Q

Trauma Nursing Care

Hypertonic solutions

A

Maintain vigilance when administering hypertonic saline solutions because of their potential for causing intravascular fluid volume overload and pulmonary edema -

Hypertonic solutions shouldn’t be given to patients with cardiac or renal conditions who are dehydrated. These solutions affect renal filtration mechanisms and can cause hypervolemia. Patients with conditions causing cellular dehydration, such as diabetic ketoacidosis shouldn’t be given hypertonic solutions, because it will exacerbate the condition. - See more at: http://www.nursingcenter.com/lnc/cearticle?tid=1157503#sthash.Nsm5R55a.dpuf

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7
Q

Trauma Nursing Care

Water and Electrolyte Balance

  1. Assess Na levels
  2. What happens when hypertonic?
  3. Low sodium causes?
A
  1. ok
  2. Pulmonary Edema and Fluid overload
  3. SEIZURES
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8
Q

Trauma Nursing Care

Controlling Fever (4)

A
  1. Identify and treat cause of fever
  2. Sheets
  3. Cooling Blankets
  4. Tylenol IV STAT
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9
Q

Trauma Nursing Care

Protection…pt can’t (5)

A

Patient can’t…

  1. BLINK
  2. SWALLOW
  3. BREATH
  4. COUGH
  5. CLEAR THE AIRWAY
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10
Q

Trauma Nursing Care

NURSING CARE GOALS

  1. BP
  2. SAT
  3. HYPERVENTILATION
  4. SEDATE TO DECREASE DEMAND:
  5. NAME PARALYZING AGENTS
  6. ASSESS
A
  1. BP > 90
  2. Sat > 90
  3. Hyperventilation = NO
  4. Sedate to decrease demand:

Barbituates, vec, roc, pan PARALLYZING AGENTS

ASSESS BUCKING THE VENT

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11
Q

Trauma Nursing Care

RHABDOMYOLYSIS

  1. What is it?
  2. What kind of injury leads to this?
  3. What kind of drugs lead to this?

Can be caused by:

  • Genetic muscle disease
  • Extremes of body temp
  • MI
  • Low phophate
  • Severe exercise
A
  1. breakdown of muscle tissue leads to fiber in the blood which is harmful to kidneys causing coke urine
  2. Crush Injuries
  3. Cocaine, Heroin
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12
Q

Trauma Nursing Care

Rhabdomyolysis S/S (6)

A
  1. Cola- colored urine
  2. Decreased Urine output
  3. General weakness
  4. Muscle stiffness or aching (myalgia)
  5. Muscle tenderness
  6. Weakness of the affected muscles
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13
Q

Trauma Nursing Care

Rhabdomyolysis

FOCUS OF NURSING CARE

THE SOLUTION FOR POLLUTION IS DILUTION

​GOAL What is the Nursing Intervention?

  1. Prevention and early detection
  2. Limit further muscle damage
  3. Enhancement of toxin clearance
  4. Ongoing nursing care
A

check ppt it is bookmarked

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14
Q

Spinal Cord Injury

SPINAL CORD INJURY (SCI)

  • PRIMARY ASSESSMENT: List nursing goals/interventions in the emergency room
  • SECONDARY ASSESSMENT:
A
  • PRIMARY ASSESSMENT: ABCDE⇒Stabilize
  • SECONDARY ASSESSMENT:
  • Tests
  • Medications
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15
Q

Spinal Cord Injury

SPINAL CORD INJURY

  1. When assessing SCI consider three specific factors related to the injury
A
  1. Anatomy
  2. Mechanism of Injury
  3. SCI
  • Complete or Incomplete
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16
Q

Spinal Cord Injury Critical Care

Spinal Cord Injury Critical Care

  1. Name 8 systems/equipment to
  • Assess
  • Monitor
  • Evaluate
A
  1. Airway
  2. Breathing/Ventiliation
  3. Circulation/Monitoring
  4. Disability/SCI
  5. Nutrition
  6. Bladder/Bowel
  7. Skin
  8. AD?
17
Q

Spinal Cord & Spinal Nerves

You need

C ___,___,___

TO STAY ALIVE…

A

C3

C4

C5

TO STAY ALIVE…

18
Q

SPINAL CORD PATHOPHYSIOLOGY

  1. Anterior part of cord?
  2. Dorsal part of cord?
  3. Motor tracts Ascending/Descending?
  4. Sensory tracts Ascending/Descending?
  5. Axons extend from the ___?___ to the ___?___
  6. Axons crossover in the ___?___ before traveling down the spinal column
A
  1. Motor
  2. Sensory
  3. Motor tract descending “motor down”
  4. Sensory tract ascending
  5. Cerebral cortex to the corresponding segment
  6. Axons crossover in the medulla
19
Q

Suspected Head or Neck Injury

Suspected Head or Neck Injury

3 Immediate Concerns:

If patient has S/S of head or neck injury how to immobilize

A
  1. Maintain abilty to breathe
  2. Keep client from going into SHOCK
  3. Rigid neck collar and rigid carrying board
20
Q
A

MED/SURG: TRAUMA (13 decks)

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