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
if the patient has ingested corrosive agents
give MILK or WATER
do not have them throw up
gastric lavage time limit
one hour after ingestion
Co2 poisoning symptoms
mostly CNS symptoms, appear intoxicated, confusion, headache, palpitations, dizziness, confusion can rapidly progress to a coma
pulse ox is not valid, can have pink or red skin or cyanotic
CO2 treatment
fresh air asap, CPR as needed, 100% oxygen, oxygen under hyperbaric pressure, continuous monitoring
chemical burn treatment
flush the skin with water, decon shower might be used over a sink
white phosphorus or lye: brush off the skin before washing
wear appropriate PPE
danger of food poisoning due to botulism or fish
can lead to respiratory paralysis
treatment goals for drug overdose
Support respiratory and cardiovascular function
Enhance clearance of the agent
Provide safety of patient and staff
naloxone works for
reverse an overdose from opioids—including heroin, fentanyl, and prescription opioid medications
acute alcohol intoxication
a multisystem toxin
Alcohol poisoning may result in death
Maintain airway and observe for CNS depression and hypotension
may need sedation for belligerent patients
high risk for seizure
withdrawals begin 24-72 hours after last drink so if they come in drunk by day 2 they might be goofy
restraints
frequent monitoring (respiratory, circulation) and documentation
SANE or SART certification
certifications for sexual assault nurse examiner
nurse priority in a disaster
Greatest good for greatest number of people
nurse priorities for victims of human trafficking
provide support
victims of human trafficking
will likely not be traveling alone
Hx of chronic runaway, homelessness, self-mutilation
Common behaviors: cowering, frightened, agitated, deferring to the person accompanying them
Common complaints: injuries, poor healing, abd pain, dizziness, headaches, rashes or sores
May demonstrate behaviors: addiction, panic attacks, impulse control, hostility, suicide ideations
ethical complications of disasters
Assisted suicide, confidentiality, consent, duty, futile therapy, rationing care, resuscitation
questions for possible victims of human trafficking
are you safe? are you in control of your own money? are you able to come and go as you please? who is that person with you?
often they will decline assistance
psychiatric emergencies
Maintain the safety of all persons and gain control of the situation
Determine if the patient is at risk for injuring him- or herself or others
Maintain the person’s self-esteem while providing care
Determine if the person has a psychiatric history or is currently under care to contact that therapist
behavioral issues in disasters
Anxiety, compassion fatigue, depression, impaired performance, interpersonal conflicts, posttraumatic stress disorder, somatization (fatigue, general malaise, headaches, gastrointestinal disturbances, skin rashes), substance use disorder
level A ppe
self-contained breathing apparatus (SCBA) and vapor-tight chemical resistant suit, gloves, and boots
level b ppe
high level of respiratory protection (SCBA) but lesser skin and eye protection; chemical-resistant suit
level c ppe
air-purified respirator, coverall with splash hood, chemical-resistant gloves and boots
level d ppe
normal work clothes
red/immediate triage level
sucking chest wound, airway obstruction secondary to mechanical cause, shock, hemothorax, tension pneumothorax, asphyxia, unstable chest and abd wounds, incomplete amputations, fractures of long bones, 15-40% of body burned
yellow/delayed triage level
stable abd wounds without evidence of significant hemorrhage, soft tissue injuries, maxillofacial wounds without airway compromise, injuries with okay circulation, gi tract disruption, fx requiring open reduction, debridement, and external fixation, most eye and CNS injuries
green/minimal triage level
walking wounded, behavioral or psych issues
black/oh he dead
dead, unresponsive, brain tissue peaking out, high spinal cord injuries, wounds involving multiple anatomical sites or organs, 2nd/3rd degree burns covering more than 60% of the body, seizures and vomiting 24 hours after radiation exposure, profound shock with multiple injuries, agonal respirations
Primary to blast injury
tympanic membrane rupture, air embolism (prone, left lateral position)
secondary to blast injury
penetrating injuries from debris
tertiary to blast injury
injuries from being thrown by the blast so this includes head injury
quaternary to blast injury
preexisting injuries are being exacerbated
alcohol withdrawal management
CIWA score, seizure pad, HTN, elevated heart rate, hallucinations (private, quiet room with no TV, well lit), near the nurse’s station
