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Concepts Exam 3 > Rapid Response > Flashcards

Rapid Response Flashcards

1
Q

The nurse has several key roles in emergency management, what are they?

A

Assess and stabilize the patient condition

Obtains necessary equipment, and supplies

Organizes information to be communicated to the patient’s physician (SBAR)

Educates and supports the staff as they care for the patient

If circumstances warrant, assist with patient transferred to a higher level of care

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2
Q

What are the reasons to call for a rapid response?

A

Staff is worried

Acute change in heart rate (< 40 or >120)

Respirations (<8 or > 30)

Acute change in systolic blood pressure (<90 or >190)

Acute onset of chest pain

Acute and persistent change in saturation

Signs and symptoms of a new stroke

Significant bleeding

Urine output greater than 50 ml in 4 hours

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3
Q

Priority during CPR?

A

CAB

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4
Q

What is the primary survey?

A

ABCD
Airway, breathing, circulation, disability/differential diagnosis

Most crucial assessment tool in emergency care

1 to 2 minutes max

Designed to identify life-threatening injuries accurately

Establish priorities

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5
Q

What is the most common obstruction of your airway?

A

Tongue

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6
Q

How do you get the correct size for a nasopharyngeal airway nasal trumpet?

A

Measure from the tip of the ear to their nose

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7
Q

Signs and symptoms of an MI?

A

Chest pain

Shortness of breath

Nausea

Diaphoresis

Left arm pain

Jaw pain

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8
Q

If a patient presents with MI symptoms, what are the interventions that are initiated?

A

Pulse ox

Cardiac monitor

IV

Oxygen (if O2 sat is low or pt is SOB)

Cardiac work up

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9
Q

What is the immediate treatment of an MI

A

Mona

Morphine
Oxygen
Nitroglycerin
ASA or Plavix

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10
Q

What is a stroke?

A

Disruption of cerebral circulation, that result in motor and sensory deficits

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11
Q

What could cause a stroke?

A

A thrombus

An embolus

Hemorrhage, if a blood vessel in the brain ruptures

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12
Q

Signs and symptoms of a stroke

A

Syncope/dizziness

Change in LOC

Paresthesia

Headache

Aphasia/disoriented

Seizures

Slurred speech

Incontinence

Diminished reflexes

TIA

Weakness/paralysis

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13
Q

What is a TIA?

A

Transient neurological deficit

A TIA is signs and symptoms of a stroke that last less than 24 hours

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14
Q

What is a seizure?

A

Seizures or convulsions, are violent and sudden contractions or tremors of muscle groups

Movements are uncontrolled

The person may lose consciousness

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15
Q

What causes a seizure?

A

Seizures are caused by an abnormality in the brain

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16
Q

What are signs and symptoms of a seizure?

A

Aura

Loss of consciousness

Dyspnea

Fixed and dilated pupils

Incontinence

Abnormal movements and sensations

17
Q

What are procedures to anticipate during a seizure?

A

Protect airway/oxygen

Recovery position (on their side)

Protect from injury

Do not restrain

Loosen tight clothing

Continually monitor ABCs

18
Q

What are some interventions of a DVT?

A

Bedrest

Warm compress

Anticoagulation therapy

Elevate affected extremity

Analgesics

Early ambulation for prevention

Sequential compression devices for prevention

19
Q

What is a pulmonary embolism?

A

Pulmonary embolism is an often fatal complication of DVT

20
Q

What are the clinical manifestations of a pulmonary embolism?

A

Sudden death

Sudden onset dyspnea

Sudden onset chest pain

Rapid shallow respirations, SOB

Pale, dusky, or cyanotic skin

Signs of hypovolemic shock
-decreased BP
-Narrowing pulse pressure
-Tachycardia
-Low-grade fever
-Petechia

21
Q

What are the priority interventions of a PE?

A

Oxygen

Elevated head of bed

Bed rest

Thrombolytic therapy

Lovenox

Anticoagulants

Morphine

Diuretics

Cough and deep breath

22
Q

What is a fat embolism

A

Fat droplets in the circulation from a traumatic injury and fracture/surgery on a long bone or pelvis

23
Q

Definition of bleeding and shock

A

In adequate delivery or usage of oxygen by the body tissues, causing generalized abnormal cellular metabolism

24
Q

How can we see internal bleeding?

A

Bleeding from nose/ears

Bleeding from lungs with cough

From stomach with vomiting

Through urine (bladder, urinary tract, kidney)

Through rectum with stool (injury in intestines)

25
Q

When do signs and symptoms of shock begin?

A

Symptoms of shock do not begin until blood loss is more than 30%

26
Q

What are priority interventions for external bleeding?

A

Direct pressure
-Press near the wound
-Apply dressing
-Elevate if on extremity

Indirect pressure
-Press the pressure point

Pressure bandage
-use a roller bandage, sanitary pad or large dressing

27
Q

When does your body go into shock?

A

Shock results when organs and tissues do not get enough blood

28
Q

What causes shock?

A

Blood loss

Heart attack

Burns

Severe infection

29
Q

Signs and symptoms of shock

A

Pallor-mottled-cyanotic

Cold moist skin

Weak thready pulse

Nausea

Tachycardia

Decreased BP

Rapid shallow respirations

Anxiety, decreased LOC

30
Q

Signs and symptoms of hypoglycemia

A

Tired

Tachycardia
Irritability
Restless
Excessive hunger
Diaphoresis/depression

Also:
Anxious, sweaty, confused

Blurred or double vision

Cool, clammy skin

31
Q

How do you treat DKA?

A

Insulin

Hydration

Electrolyte replacement

32
Q

Signs and symptoms of DKA

A

Thirsty, dehydrated

Tachycardia, hypertension

High blood sugar over 240

Hyperkalemia

Polyuria

33
Q

What is dehiscence

A

Separation or splitting open of layers of a surgical wound

34
Q

What is evisceration?

A

Extrusion of viscera or intestines through a surgical wound

35
Q

What are the actions to take for dehiscence?

A

Steri strips

Apply sterile nonadherant or saline dressing and binder to the wound

Call MD, possibility for sutures

36
Q

Actions to take for evisceration

A

Patient supine

Cover with non-adherent dressing moistened with saline

Check vital signs

Notify surgeon

Do not reinsert organs

Monitor for shock

Concepts Exam 3 (6 decks)

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