Mod 3 Info To Know

Question 1

1. What are the principles of traditional vs. mass casualty triage?
   TRIAGE UNDER USUAL CONDITIONS?

Answer 1

1. Emergent (immediate threat to life)
2. Urgent (major injuries that require immediate treatment)
3. Nonurgent (minor injuries that do not require immediate treatment)
4. Does not apply

Question 2

TRIAGE UNDER MASS CASUALTY CONDITIONS:

Answer 2

1. Emergent or class I (red tag) (immediate threat to life)
2. / Urgent or class II (yellow tag) (major injuries that require treatment)
3. Nonurgent or class III (green tag) (minor injuries that do not require immediate treatment)
4. Expectant or class IV (black tag) (expected and allowed to die)

Question 3

Which triage- attention, please move to a designated area now!” (Green) Minimal or ambulatory. arm or leg.” Doing the most good for the most victims)

Answer 3

Mass triage

Question 4

(Which triage- sorting of patients by priority for treatment, evacuation or transport. Triage for transport will be carried out before patients leave the site in order to ensure the most appropriate distribution of casualties to receiving units.)
​​

Answer 4

traditional triage

Question 5

How do you decide who to assign the triage role?

Answer 5

• Emergent (class I) patients are identified with a red tag.
• Patients who can wait a short time for care (class II) are marked with a yellow tag.
• Nonurgent or “walking wounded” (class III) patients are given a green tag.
• Patients who are expected (and allowed) to die or are dead are issued a black tag (class IV).

Question 6

​What is the goal of mass casualty triage?

Answer 6

In mass casualty or disaster situations, implement a military form of triage with the overall desired outcome of doing the greatest good for the greatest number of people.

This means that patients who are critically ill or injured and might otherwise receive attempted resuscitation during usual operations may be triaged into an “expectant” or “black-tagged” category and allowed to die or not be treated until others received care.

Question 7

2. Name the categories of trauma
   Categories are based on their acuity and survival potential, type and seriousness of injury, likelihood of survival, and availability of resources.

Answer 7

Emergent- (life threatening): Respiratory distress Chest pain with diaphoresis Stroke Active hemorrhage Unstable vital signs.

Urgent- (needs quick treatment, but not immediately life threatening) Severe abdominal pain Renal colic Displaced or multiple fractures Complex or multiple soft tissue injuries New-onset respiratory infection, especially pneumonia in older adults.

Nonurgent- (could wait several hours if needed without fear of deterioration) Skin rash Strains and sprains “Colds” Simple fracture.

Question 8

What is the primary survey?

Answer 8

Priorities of care addressed in order of immediate threats to life as part of the initial assessment in the emergency department. Survey is based on an “ABC” mnemonic with “D” and “E” added for trauma patients: airway/cervical spine (A), breathing (B), circulation (C), disability (D), and exposure (E).

The initial assessment of the trauma patient is called the primary survey, which is an organized system to rapidly identify and effectively manage immediate threats to life.

The primary survey is typically based on a standard “ABC” mnemonic plus a “D” and “E” for trauma patients: airway/cervical spine (A); breathing (B); circulation (C); disability (D); and exposure (E). Resuscitation efforts occur simultaneously with each element of the primary survey. Even though the resuscitation team may encounter multiple clinical problems or injuries, issues identified in the primary survey are managed before the team engages in interventions of lower priority such as splinting fractures and dressing wounds.

After the airway is successfully secured, breathing becomes the next priority in the primary survey. This assessment determines whether or not ventilatory efforts are effective—not only whether or not the patient is breathing. Listen to breath sounds and evaluate chest expansion, respiratory effort, and any evidence of chest wall trauma or physical abnormalities.

Tourniquets that occlude arterial blood flow distal to the injury should be used to manage severe, compressible bleeding from extremity trauma when direct pressure fails to achieve hemorrhage control; hemostatic dressings (e.g., dressings impregnated with substances that speed the formation of a blood clot) are another essential tool to apply directly over the bleeding site in the management of life-threatening hemorrhage). Internal hemorrhage is a more hidden complication that must be suspected in injured patients or those who present in a shock state.

Question 9

Internal vs external disaster

Most important outcome?

Answer 9

A disaster can be either internal to a health care facility or external from situations that create casualties in the community.

Both internal and external disasters can occur simultaneously, such as when Superstorm Sandy incapacitated several hospitals on the Atlantic Coast of New York and New Jersey in late October 2012

An event occurring inside a health care facility or campus that could endanger the SAFETY of patients or staff is considered to be an internal disaster.

The event creates a need for evacuation or relocation. It often requires extra personnel and the activation of the facility’s emergency preparedness and response plan (also called an emergency management plan).

Examples of potential internal disasters include fire, explosion, loss of critical utilities (e.g., electricity, water, computer systems, and COMMUNICATION capabilities), and violence.

Each health care organization develops policies and procedures for preventing these events through organized facility and security management plans.

The most important outcome for any internal disaster is to maintain patient, staff, and visitor safety.

An event outside the health care facility or campus, somewhere in the community, which requires the activation of the facility’s emergency management plan is considered an external disaster. The number of facility staff and resources may not be adequate for the incoming emergency department (ED) patients.

External disasters can be either natural such as a hurricane, earthquake, or tornado, or technologic such as an act of terrorism with explosive devices or a malfunction of a nuclear reactor with radiation exposure.

Recent external disasters include the 2015 Ebola virus crisis in a Dallas hospital, the 2013 Boston Marathon bombing, and the West Texas fertilizer plant explosion. St. John’s Regional Medical Center in Joplin, Missouri, had an internal disaster compounding an external disaster in 2011 when it was directly hit by an EF-5 tornado that destroyed a large part of the town. Of the 142 dead, 6 people inside the hospital died.

Question 10

What are the color classifications of mass casualty triage?

immediate care: patient have obvious threat to life condition

delayed: need care soon but can be delayed about two hours

would not have any serious effects in the care were delayed for days

little to no chance of survival, the resources available for immediate care cannot be diverted to their care. Limited resources must be dedicated to saving the most lives rather than expending valuable resources to save one life at the possible expense of many others.

Answer 10

Red- immediate care: patient have obvious threat to life condition

Yellow-delayed: need care soon but can be delayed about two hours

Green- would not have any serious effects in the care were delayed for days

Black- little to no chance of survival, the resources available for immediate care cannot be diverted to their care. Limited resources must be dedicated to saving the most lives rather than expending valuable resources to save one life at the possible expense of many others.

Question 11

Give at least one patient example for each color

? -tagged patients- are those with massive head trauma, extensive full-thickness body burns, and high cervical spinal cord injury requiring mechanical ventilation.

? tagged patients have immediate threats to life such as airway obstruction or shock, and they require immediate attention.

? tagged patients have major injuries such as open fractures with a distal pulse and large wounds that need treatment within 30 minutes to 2 hours.

? tagged patients have minor injuries that can be managed in a delayed fashion, generally more than 2 hours. Examples of ?-tagged injuries include closed fractures, sprains, strains, abrasions, and contusions.

?-tagged patients are often referred to as the “walking wounded” because they may actually evacuate themselves from the mass casualty scene and go to the hospital in a private vehicle.

? tagged patients usually make up the greatest number in most large-scale multi-casualty situations.

Answer 11

Black-tagged patients- are those with massive head trauma, extensive full-thickness body burns, and high cervical spinal cord injury requiring mechanical ventilation.

Red-tagged patients have immediate threats to life such as airway obstruction or shock, and they require immediate attention.

Yellow-tagged patients have major injuries such as open fractures with a distal pulse and large wounds that need treatment within 30 minutes to 2 hours.

Green-tagged patients have minor injuries that can be managed in a delayed fashion, generally more than 2 hours. Examples of green-tagged injuries include closed fractures, sprains, strains, abrasions, and contusions.

Green-tagged patients are often referred to as the “walking wounded” because they may actually evacuate themselves from the mass casualty scene and go to the hospital in a private vehicle.

Green-tagged patients usually make up the greatest number in most large-scale multi-casualty situations.

Question 12

Name ways to prevent acute stress disorder in medical professionals

Answer 12

• Use available counseling.
• Encourage and support co-workers.
• Monitor each other’s stress level and performance.
• Take breaks when needed.
• Talk about feelings with staff and managers.
• Drink plenty of water and eat healthy snacks for energy.
• Keep in touch with family, friends, and significant others.
• Do not work more than 12 hours per day.

Question 13

What are the severity classifications of burns?

Degree

Severity

Answer 13

The severity of a burn is determined by how much of the body surface area is involved and the depth of the burn.

The degree of TISSUE INTEGRITY loss is related to the agent causing the burn, the temperature of the heat source, and how long the skin is exposed to it.

Burn wounds are classified as superficial-thickness wounds, partial-thickness wounds, full-thickness wounds, and deep full-thickness wounds. The partial-thickness wounds are further divided into superficial and deep subgroups Table-26-1

Burns are classified as minor, moderate, or major, depending on the depth, extent, and location of injury (Table 26-2)

Question 14

What priority actions should you perform for a patient with an electrical burn?

Answer 14

• At the scene, separate the patient from the electrical current.
• Smother any flames that are present.
• Initiate cardiopulmonary resuscitation.
• Obtain an electrocardiogram (ECG). Radiation Burns
• Remove the patient from the radiation source.
• If the patient has been exposed to radiation from an unsealed source, remove his or her clothing (using tongs or lead protective gloves).
• If the patient has radioactive particles on the skin, send him or her to the nearest designated radiation decontamination center.
• Help the patient bathe or shower.

Question 15

What is Curling’s ulcer?

And how is it prevented?

Answer 15

Curling’s ulcer Acute ulcerative gastroduodenal disease, which may develop within 24 hours of a severe burn injury because of reduced gastrointestinal blood flow and mucosal damage.

how is it prevented?
The use of H2 histamine blockers, proton pump inhibitors, drugs that protect GI tissues, and early enteral feeding.

Question 16

10. How does the patient’s metabolic needs change after a burn?

How does this effect your nursing care?

Answer 16

A serious burn injury greatly increases metabolism by increasing secretion of catecholamines, antidiuretic hormone, aldosterone, and cortisol.

With this hypermetabolism, the patient’s oxygen use and calorie needs are high. The catecholamines activate the stress response. The increased production (and loss) of heat break down protein and fat (catabolism), rapidly use glucose and calories, and increase urine nitrogen loss. The heat and water lost from the burn also increase metabolic rate and calorie needs. Depending on the extent of injury, the patient’s calorie needs double or triple normal energy needs. These increased rates peak 4 to 12 days after the burn and can remain elevated for months until all wounds are closed. The hypermetabolic condition also increases core body temperature. The patient loses heat through the burned areas. Core body temperature increases as a response to the adjustment in temperature regulation by the hypothalamus, resulting in a low-grade fever.

How does this effect your nursing care?

Dehydration along with calorie needs increase which means wounds may take longer to heal.

Question 17

11. List the phases of burn care and priority interventions for each phase

Answer 17

**The emergent/resuscitation phase is the first phase of a burn injury. It begins at the onset of injury and continues for about 24 to 48 hours. During this phase, the injury is evaluated and the immediate problems of fluid imbalance (loss), edema, and reduced blood flow are assessed.

The priorities for management during this period are to (1) secure the airway, (2) support circulation and organ PERFUSION by fluid replacement, (3) keep the patient comfortable with analgesics, (4) prevent infection through careful wound care, (5) maintain body temperature, and (6) provide emotional support.

**The acute phase of burn injury begins about 36 to 48 hours after injury, when the fluid shift resolves, and lasts until wound closure is complete. During this phase, the nurse coordinates interprofessional care that is directed toward continued assessment and maintenance of the cardiovascular and respiratory systems and toward GI and NUTRITION status, burn wound care, pain control, and psychosocial interventions

Patients in the acute phase of a more serious burn injury are most likely to be treated in an emergency department (ED)

Although rehabilitation efforts are started at the time of admission, the technical **rehabilitative phase begins with wound closure and ends when the patient achieves his or her highest level of functioning. The emphasis is on the psychosocial adjustment of the patient; the prevention of scars and contractures; and the resumption of preburn activity, including resuming work, family, and social roles. This phase may take years or even last a lifetime as patients adjust to life after a burn.

Although attention is placed first on the physical interventions for the burn injury, psychological care is equally important.

Continue to provide psychosocial support to the patient and family throughout hospitalization and in the rehabilitative phase.

Obtaining information from the patient and family aids in the assessment and diagnosis of psychological problems and directs management. Explore the patient’s feelings about the burn injury.

It is extremely difficult for patients to concentrate on the many tasks before them when obstacles such as guilt and grief are in the forefront. Ask whether there is a history of psychological problems.

To assist with a future plan of care, assess and document the type of coping mechanisms the patient has used successfully during times of stress. Also assess the patient’s family unit and the history of interaction.

Consider cultural, spiritual, and ethnic factors when planning psychosocial interventions. Throughout the hospitalization, the patient progresses through a variety of stages and exhibits many feelings, including denial, regression, and anger. Assess the patient’s feelings at each stage so appropriate plans of care can be implemented.

Care Coordination and Transition Management Discharge planning for the patient with a burn injury begins at admission to the hospital or burn center. The interdisciplinary team meets regularly to evaluate the progress of each discipline and help the patient reach mutually established discharge outcomes. Table 26-7 lists common discharge needs of the patient with burns.

Question 18

Needs to Address Before Discharge of the Patient With Burns:

Answer 18

• Early patient assessment • Financial assessment • Evaluation of family resources • Weekly discharge planning meeting • Psychological referral • Patient and family teaching (home care) • Designation of principal learners (specific family members or significant others who will help with care) • Development of teaching plan • Training for wound care • Rehabilitation referral • Home assessment (on-site visit) • Medical equipment • Public health nursing referral • Evaluation of community resources • Visit to referral agency • Re-entry programs for school or work environment • Long-term care placement • Environmental interventions • Auditory testing • Speech therapy • Prosthetic rehabilitation
• Assess for airway patency. • Administer oxygen as needed. • Cover the patient with a blanket. • Keep the patient on NPO status. • Elevate the extremities if no fractures are obvious. • Obtain vital signs. • Initiate an IV line and begin fluid replacement. • Administer tetanus toxoid for prophylaxis. • Perform a head-to-toe assessment.

Question 19

12. What are the signs and symptoms of inhalation injuries?

What is your priority action?

Answer 19

• Patients who were injured in a closed space

• Intra-oral charcoal, especially on teeth and gums
• Patients who were unconscious at the time of injury
• Patients with singed scalp hair, nasal hairs, eyelids, or eyelashes
• Patients who are coughing up carbonaceous sputum
• Changes in voice such as hoarseness or brassy cough
• Use of accessory muscles or stridor
• Poor oxygenation or ventilation
• Edema, erythema, and ulceration of airway mucosa
• Wheezing, bronchospasm
• Patients with extensive burns or burns of the face.

Priority action:
Monitor patient’s respiratory efforts closely to recognize possible airway involvement.

For a burn patient in the resuscitation phase who is hoarse, has a brassy cough, drools or has difficulty swallowing, or produces an audible breath sound on exhalation, respond by immediately applying oxygen and notifying the Rapid Response Team.

Question 20

What is the Rule of 9’s

Answer 20

The most rapid method for calculating the size of a burn injury in adult patients whose weights are in normal proportion to their heights is the rule of nines (Fig. 26-10).

With this method, the body is divided into areas that are multiples of 9%. It is useful at the site of injury, but more accurate evaluations using other methods are made in the burn unit.

Question 21

14. What is the Parkland formula?

Answer 21

Rapid infusion of IV fluids, known as fluid resuscitation, is needed to maintain sufficient blood volume for normal cardiac output, mean arterial pressure, and tissue oxygenation. Chart 26-4 lists best practices for fluid resuscitation. There are many formulas for calculating IV fluid needs, but the most commonly used one

for adult patients is the Parkland Formula (4 mL/kg/%TBSA burn of crystalloid solution). For example, the calculated fluid needs for a 154-lb man with a 50% TBSA burn would be 4 mL × 70 kg × 50% TBSA = 14,000 mL over the first 24 hours. Although the types and amounts of electrolytes, crystalloids, and colloids vary, the purpose of any formula is to prevent shock by maintaining blood fluid volume.
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Fluid replacement formulas are calculated from the time of injury and not from the time of arrival at the hospital. For example, if a burn injury occurred at 8 AM but the patient was not admitted to the hospital until 10 AM, the first 8-hour period would be completed at 4 PM (8 hours after the injury). Thus if resuscitation was delayed by 2 hours until admission to the hospital, calculated fluids would need to be given over the next 6-hour period rather than an 8-hour period. Burn resuscitation formulas are guides. The patient’s response to therapy determines exact fluid requirements.
Monitoring patient responses is critical to determine the adequacy of resuscitation for hydration and blood PERFUSION of the brain, heart, and kidneys. Urine output is the most common and most sensitive noninvasive assessment parameter for cardiac output and tissue PERFUSION. Regardless of the total amount of fluid calculated as needed for the patient, the amount of fluid given depends on how much IV fluid per hour is needed to maintain the hourly urine output at 0.5 mL/kg (about 30 mL/hr). Adjustment of the IV fluid rate on the basis of urine output plus serum electrolyte values is known as the titration of fluid. In burns larger than 35% TBSA, the use of invasive cardiac and pulmonary function monitoring may be needed in addition to urine output and vital signs to guide resuscitation.

Question 22

What is the goal of fluid resuscitation (how do you know if you are adequately resuscitating a patient?

Answer 22

The goals of fluid resuscitation include controlling bleeding, restoring lost blood volume which is essential for cardiac output, renal perfusion and tissue perfusion, and regaining tissue perfusion and organ function.
Adequate urine output is a key indicator that one is properly hydrated.

Question 23

List at least two possible serious complications from burns

Answer 23

Skin changes, functional changes, cardiac changes, pulmonary/respiratory changes, GI changes, metabolic changes, immunologic changes, electrolyte changes, and homeostasis changes in the body.

Question 24

After a mass casualty event, the nurse is triaging clients in the field. Which client is correctly classified?
A. 38-year-old with an open femur fracture: black tag
B. 42-year-old with multiple abrasions and contusions: yellow tag
C. 54-year-old with third-degree burns over 90% of the body: green tag
D. 61-year-old who is having difficulty breathing and wheezing: red tag

Answer 24

D

Question 25

Using the Parkland formula, calculate the total fluid replacement needed for the first twenty four hour period if the client weighs 180 pounds and has 55% total burn surface area.
​A. 18,000 mL
​B. 39,600 mL
​C. 87,120 mL
​D. 9,900 mL

4 mL × 81.82 kg × 55% TBSA = _____ mL

Answer 25

A

Question 26

A client has burns to the upper body and head after a structure fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. What is the best action for the nurse to take?
​A. Encourage the client to use the incentive spirometer
​B. Prepare for endotracheal intubation **
​C. Continue to monitor the client’s lung sounds
​D. Reposition the client to the Sims position

Answer 26

B

Question 27

An accident has occurred near the hospital, and a victim is brought to the emergency department with severe chest pain, a pulse of 120 beats/min, blood pressure of 100/60 mm Hg, and a respiratory rate of 28 breaths/min. The nurse assesses shortness of breath and diaphoresis. Which color tag does the nurse use when triaging this client?
​A. Red**
​B. Yellow
​C. Green
​D. Black

Answer 27

A

Question 28

A nurse is collecting data from a client who has severe burn injuries. The nurse shades in the diagram indicating the burned surface areas. What percentage of body surface area should the nurse estimate the client has burned? (round to nearest number)

​A. 45% **
​B. 32%
​C. 16%
​D. 56%

Answer 28

A.