Rapid Response Flashcards
(36 cards)
The nurse has several key roles in emergency management, what are they?
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
What are the reasons to call for a rapid response?
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
Priority during CPR?
CAB
What is the primary survey?
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
What is the most common obstruction of your airway?
Tongue
How do you get the correct size for a nasopharyngeal airway nasal trumpet?
Measure from the tip of the ear to their nose
Signs and symptoms of an MI?
Chest pain
Shortness of breath
Nausea
Diaphoresis
Left arm pain
Jaw pain
If a patient presents with MI symptoms, what are the interventions that are initiated?
Pulse ox
Cardiac monitor
IV
Oxygen (if O2 sat is low or pt is SOB)
Cardiac work up
What is the immediate treatment of an MI
Mona
Morphine
Oxygen
Nitroglycerin
ASA or Plavix
What is a stroke?
Disruption of cerebral circulation, that result in motor and sensory deficits
What could cause a stroke?
A thrombus
An embolus
Hemorrhage, if a blood vessel in the brain ruptures
Signs and symptoms of a stroke
Syncope/dizziness
Change in LOC
Paresthesia
Headache
Aphasia/disoriented
Seizures
Slurred speech
Incontinence
Diminished reflexes
TIA
Weakness/paralysis
What is a TIA?
Transient neurological deficit
A TIA is signs and symptoms of a stroke that last less than 24 hours
What is a seizure?
Seizures or convulsions, are violent and sudden contractions or tremors of muscle groups
Movements are uncontrolled
The person may lose consciousness
What causes a seizure?
Seizures are caused by an abnormality in the brain
What are signs and symptoms of a seizure?
Aura
Loss of consciousness
Dyspnea
Fixed and dilated pupils
Incontinence
Abnormal movements and sensations
What are procedures to anticipate during a seizure?
Protect airway/oxygen
Recovery position (on their side)
Protect from injury
Do not restrain
Loosen tight clothing
Continually monitor ABCs
What are some interventions of a DVT?
Bedrest
Warm compress
Anticoagulation therapy
Elevate affected extremity
Analgesics
Early ambulation for prevention
Sequential compression devices for prevention
What is a pulmonary embolism?
Pulmonary embolism is an often fatal complication of DVT
What are the clinical manifestations of a pulmonary embolism?
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
What are the priority interventions of a PE?
Oxygen
Elevated head of bed
Bed rest
Thrombolytic therapy
Lovenox
Anticoagulants
Morphine
Diuretics
Cough and deep breath
What is a fat embolism
Fat droplets in the circulation from a traumatic injury and fracture/surgery on a long bone or pelvis
Definition of bleeding and shock
In adequate delivery or usage of oxygen by the body tissues, causing generalized abnormal cellular metabolism
How can we see internal bleeding?
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)
