medsurg test 4 Flashcards
ESI (emergency severity index)
system emergency nurses use to evaluate the anticipated needs and severity of symptoms
legal issues in emergency nursing
when the patient is unable to consent for surgery/emergency procedures and no family is around, consent must be assumed by the physician
the nurses role is to document LOC and accurate assessment of the patient’s condition
occupational risk in emergency nursing
we don’t know what germs the patients have, there is always the risk of exposure
priorities for emergency nursing
safety. physical safety, delay in care, medication errors
patient oriented emergency nursing interventions
keep family with the patient as much as possible, provide education and explanations, alleviate anxiety and provide a sense of security
Primary survey: ABCDE
Airway: establish airway
Breathing: establish proper ventilation
Circulation: evaluate and restore cardiac output, control hemorrhage and prevent/treat shock
Disability: determine neurologic status. AVPU eval (alert, verbal, pain, unresponsive)
Exposure: undress to evaluate wounds
Multiple trauma
single catastrophic event that causes life-threatening injuries to at least two distinct organs or organ systems
assume cervical spine injury
traid of death
hypothermia, coagulopathy and acidosis
why are abdominal injuries serious?
Abdominal trauma can cause massive life-threatening blood loss into abdominal cavity
non obvious assessment points for abdomen
thorough history, referred pain (shoulder pain could indicate liver or spleen injury), look for changes in vital signs (low blood pressure, elevated HR, decreased urine, cool and moist skin could indicate internal bleeding)
management of abdominal injuries
ABC, C-spine precaution, NPO, monitor VS and assess for wounds
If viscera are protruding, cover with sterile, moist saline dressing and prepare the patient for OR
NG tube for aspirating stomach contents (as long as there is no facial trauma)
complications for crush injuries
rhabdomyolysis, hypovolemic shock, erythema and blistering, fractures, c-spine precautions, AKI
rhabdomyolysis
toxic syndrome caused by release of myoglobin from the ischemic skeletal muscles - results in tubular necrosis
s/s of hyperthermia
CNS dysfunction, elevated temperature, hot and dry skin, anhidrosis, tachypnea, HTN, tachycardia
heat stroke types
exertional: from strenuous activity
non exertional: from the environment
cooling methods for patients with hyperthermia
Cool sheets, towels, or sponging with cool water
Ice to neck, groin, chest, and axillae
Cooling blankets
Immersion in cold water bath
medications for hyperthermia
anticonvulsant, potassium, sodium bicarbonate, benzodiazepines
does frostbite or hypothermia take priority?
hypothermia takes precidence
rewarming a patient with hypothermia
Active core rewarming
Cardiopulmonary bypass, warm fluid administration, warm humidified oxygen, warm peritoneal lavage
Passive external rewarming
Warm blankets/bair huggers and over-the-bed heaters
dangers of cold blood
Cold blood returning from the extremities has high levels of lactic acid and can cause potential cardiac dysrhythmias and electrolyte disturbances
measures to remove toxins and poisons
Use of emetics
Gastric lavage
Activated charcoal - if the substance can be absorbed by charcoal
Cathartic when appropriate
Administration of a specific antagonist as early as possible
Other measures may include diuresis, dialysis or hemoperfusion
