Triage+TBI Flashcards
Goal?
All pt to be assessed w/in 5-10 mins of arrival to the ED
will be performed by an RN an experienced
MUST be correct
-has major impact on pt outcomes&safety
Triage
1st step to ask, Is this pt dying?
then check A,B,C
a) checking “A” abnormal findings?
b) then check AVPU scale, what is it?
a) apneic(drunk,opioid)
Severe respiratory distress
SPO2 less than 90%
pulseless or irregular rate
hemodynamic unstable( map<65)
hypoglycemia
bleeding
b) Awake, voice,pain,unresponse
Triage level 1
how soon to seen?
example?
immediate
pt is being resuscitated
gsw absdomen BP 88
(serious wound with low BP)
chest pain, chest palpation
diaphoretic
recent LOC
chest palpaitations
“A” is abnormal and AVPU states either P or U
Next, determine either high risk situation or not.
Beucase unsafe for pt to wait to seen, treatment is time sesensitive
What cases are shouldn’t wait?
Severe pain (10/10)
New born with fever
neutropenia
potential major life or organ treat
acute change of LOC
suicidal/homicial
burns both arm
phyc pt who is screaming obscenities(強迫)
If determin this pt shouldn’t wait
Triage level 2
how soon to seen?
example?
vital is?
emergent
less than 15 min
will requier manny resources
vital is not stable(don’t have to check all vitals because vital is abnormal anyway)
will requre many resources but vitals are stable then what level?
Level 3=urgent
15-60 mins
fracture ankle
abdominal pain
most migraines
30-40% of pt seen in the ED
will require 1 ressource
pt is stabel then what level?
Level4=semi urgent
healthy 10Y sore throat&fever
healthy 29 Y with UTI& no bleeding
healthy 43Y w/stubbed toe-possibly broken
healthy 12Y w/ minor thumb laceration(deep cut)
will not require any resources
pt is not at risk for dying,level?
level 5=non-urgent
posion ivy(just rash)
prescription refill
involved in a car accident 2 days ago, wants to be checked. Nothing hurts
Cold
What are considered recourses?
Labs,ECG, X-ray,MRI, US
IV fluid
IV, IM meds
Specialty consultation
Simple procedure(foley)
complex procedure(sedation)
What are NOT consider resourcese?
provider
PO meds
Phone call to provider
Simple wound care(dressing)
The emergency department triage nurse is assessing 4 victims involved in a motor vehicle collision. Which patient has the highest priority for treatment?
A patient with no pedal pulses
A patient with an open femur fracture
A patient with bleeding facial lacerations
A patient with paradoxical chest movement
A patient with paradoxical chest movement
Rationale:
Most immediate deaths from trauma occur because of problems with ventilation, so the patient with paradoxical chest movements should be treated first. Face and head fractures can obstruct the airway, but the patient with facial injuries only has lacerations. The other two patients also need rapid intervention but do not have airway or breathing problems.
An unresponsive patient is admitted to the emergency department after falling through the ice while ice skating. Which assessment will the nurse obtain first?
Pulse
Heart rhythm
Breath sounds
Body temperature
Pulse
Rationale:
The priority assessment in an unresponsive patientrelates to CAB (circulation, airway, breathing) so a pulse check should be performed first. While assessing the pulse, the nurse should look for signs of breathing. The other data will also be collected rapidly but are not as essential as determining if there is a pulse.
A patient who is unconscious after a fall from a ladder is transported to the emergency department by emergency medical personnel. During the primary survey of the patient, the nurse should:
obtain laboratory tests.
auscultate bowel sounds.
obtain a Glasgow Coma Scale score.
ask about chronic medical conditions.
obtain a Glasgow Coma Scale score.
The Glasgow Coma Scale is included when assessing for disability during the primary survey. The other information is part of the secondary survey.
During the primary survey of a patient with severe leg trauma, the nurse observes that the patient’s left pedal and posterior tibial pulses are absent, and the entire leg is swollen. Which action will the nurse take next?
Send blood to the lab for a complete blood count.
Assess further for a cause of the decreased circulation.
Finish the airway, breathing, circulation, disability survey.
Start normal saline fluid infusion with a large-bore IV line.
Start normal saline fluid infusion with a large-bore IV line.
Rationale:
The assessment data indicate that the patient may have arterial trauma and hemorrhage. When a possibly life-threatening injury is found during the primary survey, the nurse should immediately start interventions before proceeding with the survey. Although a complete blood count is indicated, administration of IV fluids should be started first. Completion of the primary survey and further assessment should be completed after the IV fluids are initiated.
TBI
Basilar fracture
what s/s?
Raccoon eyes
Battle’s sign(purple under the ear)
Haol sign(red round on the skin)
a) Concussion
b) coup-contrecoup injury?
a) mild injury
occur w/in 72hrs, no identified brain damage
a) MVC, more severe
TBI
nursing care
“A” and “B”
“A”
making sure to adhere to C-spine precatutions(stabilize cervival spine)
“B”
Hypoxia cuases secondray brain injuries
Mantain PaCO2 @35
