Unit 4 exam Flashcards
S.A.L.T.
What does it stand for?
Sort
Assess
Lifesaving interventions
Treatment and/or transport
What tag is this for mass casualty color coding?
Potentially serious but stable enough to wait a short while for medical treatment
Includes:
* Fractures
* Burns < 20%
* Soft tissue injuries minimal bleeding
* Torso wounds w/o shock
* Facial injury w/o airway involvement
Yellow or delayed
What mass casualty tag would this be?
Life-threatening, treatable with immediate attention
Includes:
* Airway obstruction
* MI
* Hemorrhage
* Severe abdominal injury
* Tension pneumothorax
* Shock, head injury
* Threatened loss of limb
Red or Immediate
What mass casualty tag would this recieve?
Minor injuries can wait for longer periods of time
Includes:
* Ambulatory
* Minor burns
* Sprains
* Lacerations
Green or minimal
What mass casualty tag would this recieve?
- Dead, no VS, injuries incompatible with survival
Includes: - Full thickness burns > 50% TBSA
- No pulse or breathing after airway opened
- High SCI
- Transcranial GSW
Black or expectant
A-B-C-D-E
What does it stand for?
A - Airway w/ C-spine
B - Breathing/ventilation
C - Circulation
D - Disability/deficits
E - Exposure/environmental
To prevent hypothermia:
o Remove wet clothing
o Cover with blankets
o Increase room temp
o Infuse warmed fluids
o Heat lamp
F.G.H.
What does it stand for?
F - Fast Five
G - Give comfort measures
H - History
Fast five interventions
- Full set of vital signs
- Further labs and x-rays
- Foley Catheter
- Facial trauma presence
- Facilitate family presence
The following are S/S of what?
- Tachycardia
- Hypotension
- Tachypnea
- Increased CO
- Decreased CVP
- Decreased SVR
- Hyperthermia
- N/V/D
- Increased WBC , CrP
- Warm , flushed skin later progresses to cool pale and molted
Septic Shock or Disruptive Shock
The following are s/s of what?
- Tachycardic
- Cool, pale skin
- Weak thready pulses
- Hypothermia
- Hypotension
- Lethargy
- Coma
- Anuria
Late stage sepsis
S/S of Late stage sepsis
- Tachycardic
- Cool, pale skin
- Weak thready pulses
- Hypothermia
- Hypotension
- Lethargy
- Coma
- Anuria
List s/s of septic shock or disruptive shock
- Tachycardia
- Hypotension
- Tachypnea
- Increased CO
- Decreased CVP
- Decreased SVR
- Hyperthermia
- N/V/D
- Increased WBC , CrP
- Warm , flushed skin later progresses to cool pale and molted
The following are S/S of what?
o Weak peripheral pulses
o Decreased co
o Tachycardia
o Hypotension
o Cool, clammy , skin , capillary refil less than 3 sec
o Increased cvp
o Increased SVR
o Bradypnea
o JVD
o Chest pain
o Oliguria
o Confused , agitation
Cardiogenic shock
List the S/S of cardiogenic shock
o Weak peripheral pulses
o Decreased co
o Tachycardia
o Hypotension
o Cool, clammy , skin , capillary refil less than 3 sec
o Increased cvp
o Increased SVR
o Bradypnea
o JVD
o Chest pain
o Oliguria
o Confused , agitation
The following are S/S of what?
o Weak, thready pulse
o Cyanosis
o Cool,pale skin
o Decreased capillary refill
o Deceased co
o Decreased CVP
o Tachycardia
o Hypotension
o Bradypnea
o Increased SVR
o Increased or decreased HCT
o Oliguria
o Confused /agitated /restlessness
o Dry mucous membrane , loss of skin turgor
o Flattened neck veins
Hypovolemic shock
The following are s/s of what?
o Warm dry skin , flushed
o Decreased CO
o Decreased right and left filling volumes
o Decreased SVR
o Bradycardic
o Hypothermia
o Decreased o2 (bradypnea)
Neurogenic shock
List examples of obstructive shock
o Tension pneumothorax
o Cardiac tompanade
o Severe valvular disease
List S/S of neurogenic shock
o Warm dry skin , flushed
o Decreased CO
o Decreased right and left filling volumes
o Decreased SVR
o Bradycardic
o Hypothermia
o Decreased o2 (bradypnea)
All of the following are S/S of what?
***** Hypotension
* Tachycardia
* Dysrhythmias noted early (pvc’s, sinus tach)
* Vfib /vtach /cardiac arrest
* Muffled heart sounds
* Distended neck veins /JVD
* Hyperventilation/tachypnea= respiratory alkalosis
* Agitation/anxiety
* Decreased LOC
* SHOB /dyspnea
* Tracheal deviation toward the unaffected side hallmark sign
* Subcutaneous emphysema
* Cyanosis
* Absent breath sounds
Tension Pneumothorax
List S/S of a tension pneumothorax
- Hypotension
- Tachycardia
- Dysrhythmias noted early (pvc’s, sinus tach)
- Vfib /vtach /cardiac arrest
- Muffled heart sounds
- Distended neck veins /JVD
- Hyperventilation/tachypnea= respiratory alkalosis
- Agitation/anxiety
- Decreased LOC
- SHOB /dyspnea
- Tracheal deviation toward the unaffected side hallmark sign
- Subcutaneous emphysema
- Cyanosis
- Absent breath sounds
What needs to be done in a case of emergent pneumothorax?
- A needle decompression performed to remove the air from the pleural space may be required.Large bore needle (14-16G)
- Followed by chest tube insertion.
Priority interventions for a chest tube
Apply 100% non rebreather oxygen mask
Prepare for intubation and mechanical ventilation
Elevate head of the bed
Encourage deep breathing and coughing q1-2 hrs
Encourage ambulation as soon as possible
Chest tube management - Never clamp the chest tube!
Administer pain medications
Assess LOC
Collect ABG
Assess for subcutaneous emphysema
If chest tube becomes disconnected from drainage system…
immediately submerge the end of the chest tube in sterile was to preserve the water seal,
If chest tube becomes dislodged from chest
Apply Vaseline gauze dressing and notify HCP immediately.
Steps of decontamination
- Remove patients clothing and bagging clothing. Eliminating 60%-90% of continents ASAP
- Wet the patients skin and wash with soap and water for 5-10 minute. Gently cleaning
- Pay special attention to hair, face, hands, and other areas that were exposed but were not covered by clothing
- Follow washing by copious rinsing of the patient with tepid water
- Determine the level of PPE required for staff to wear
- Controlling access to the decontamination site as well as the hospital
- Having a container ready to receive contaminated clothes , valuables , and contaminated supplies
- Ensuring screens are available for patient privacy
- Ensuring collection system for water run off is available if needed
S.T.A.R.T
What does it stand for?
Simple Triage and Rapid Treatment
Spinal injury with total loss of motor and sensory function below the level of injury
Complete injury
Spinal injury with incomplete structural damage with some function preserved below the primary injury level.
Incomplete injury
- Type of incomplete SCI
- Etiology: hyperextension injury with central cord swelling
- Clinical manifestations: functional motor loss greater in arms than legs, bladder dysfunction, variable loss of sensation
Central cord syndrome
- Type if incomplete SCI
- Etiology: acute anterior compression from bony fragments or acute disk herniation
- Clinical manifestations: loss of motor function (paresis or paralysis), Pain, Temperature, Crude touch and pressure below the level of injury, preserved sense of proprioception (position sense), fine touch and pressure and vibration
Anterior cord syndrome
- Type of incomplete SCI
- Etiology: acute compression
- Clinical manifestations: loss of proprioception, fine touch and pressure and vibration, intact pain, temperature, and crude touch and pressure
Posterior Cord Syndrome
- Type of incomplete SCI
- Etiology: Hemisection of the spinal cord resulting from penetrating injury (gunshot, knife injury), may result also from primary ischemia, infection, or hemorrhagic event
- Clinical manifestation:
- Ipisilateral loss of motor function, proprioception, and vibration, contralateral loss of pain and temperature
Brown-Sequard syndrome
on same side as the injury
Ipisilateral
on opposite side of injury
contralateral
What level of SCI is this?
Quadriplegia with loss of spontaneous respiratory function
C1-C4
What level of SCI is this?
Quadriplegia with possible phrenic nerve involvement
C4, C5
What level of SCI is this?
Quadriplegia with gross arm movements, phrenic nerve intact
C5, C6
What level of SCI is this?
Quadriplegia with biceps intact, diaphragmatic breathing
C6, C7
What level of SCI is this?
Quadriplegia with triceps, biceps, and wrist extension intact and some function of intrinsic hand muscles
C7, C8
What level of SCI is this?
Paraplegia with trunk and leg involvement, normal arm and hand movement
T1-T5
What level of SCI is this?
Paraplegia with fair ability to control balance and trunk, little or no voluntary bowel or bladder control
T6-T12
What level of SCI is this?
Cauda equina injury, variable motor and sensory loss in lower extremities; a reflexice bowel and bladder
Below L1
What type of immobilization device is this?
- Used to maintain cervical immobilization for specific types of cervical fractures.
- Made up of a ring around the patients head attached to a special vest by 4 rods.
- Titanium screws are screwed into the skull bone and attached to the halo device
- Weights connect to the halo at the head of the bed over a pulley system
Halo traction device
What type of immonilization/stabilization is this?
- Used for spinal traction
- U shaped tongs
- Pressure controlled pins are inserted into the skull at opposite ends to permit longitudinal force to be applied to the axis of the spinal column.
- Tongs are attached to weights using a pulley system at the head of bed
Gardner-wells tongs
- Occurs immediately after injury and applies to all phenomena surrounding spinal cord transection. This results in a complete but temporary loss or depression of spinal reflexes , sensory, motor and autonomic activity below the injury level.
- Can last from 24 hrs to 1-6 weeks , return of reflex activity below level of injury indicate the end
Spinal Shock
All of the following are clinical manifestations of what?
Flaccid paralysis of skeletal muscles
Absence of deep tendon reflexes
Impaired proprioception
Decreased visceral /somatic sensations
Penile reflex
Urinary/ fecal retention
Anhidrosis (absence of sweating)
Paralytic ileus
Spinal Shock
- Disruptive type of shock
- Cardiac output decreased d/t the vessels lose tone, allowing blood to pool in the periphery and blood pressure to fall.
- Only shock with Bradycardia
Neurogenic Shock
All of these fall under what mass casuality color code?
- Airway obstruction
- MI
- hemorrhage
- Severe abdominal injury
- Tension pneumothorax
- Shock
- Head injury
- Threatened loss of limb
Red or immediate
All of these fall under what mass casuality color code?
- Fractures, burns < 20%
- Soft tissue injuries minimal bleeding
- Torso wounds w/o shock
- Facial injury w/o airway involvement
Yellow or delayed
All of these fall under what mass casuality color code?
- Ambulatory
- Minor burns
- Sprains
- Lacerations
Green or minimal
All of these fall under what mass casuality color code?
- Full thickness burns > 50% TBSA
- No pulse
- No breathing after airway open
- High SCI
- Transcranial GSW
Black or expectant
What should be done to open airway of c-spine is not cleared?
Jaw thrust
Hoarsness can indicate what?
Laryngeal injury or inhalation injury
How often does Joint Comission say emergency response plan should be practiced?
2 times a year
All of the following are clinical manifestations of what?
- Motor weakness
- Numbness, Tingling, pain
- Muscle atrophy
- Decreased/absent DTR or Areflexia
- Ascending flaccid paralysis from lower extremities over several days
- Autonomic manifestations: sweating and tachycardia
Guillain-Barre Syndrome (GBS)
Cranial nerves to assess with GBS
VII, IX, X, XI, XII
Involvement of cranial nerve X can cause what?
autonomic dysfunction
Cardiac Dysrythmias
Paroxysmal hypotension
Orthostatic Hypotension
Paralytic Ileus
Urinary Retention
Potential antidiuretic hormone
Maslow’s Hierarchy of needs
- Self Actualization
- Self esteem
- Love and belonging
- Safety and security
- Physiological needs
Priority Levels of care
- Level 1- ABC’s
- Level 2- Sudden change in VS and LOC
- Level 3- Unstable metabolic disorders
- Level 4- C/O pain, except chest pain
- Level 5- Complex treatments and skills
- Level 6- Discharge teaching and referral
Prioritization principals
- Systemic before local
- Acute before chronic
- Actual problems before potential problems
- Recognize condition changes/emergencies (unstable) vs. expected findings (stable)
Elements of assertive communication between HCP’s
- Establish trust
- Use ‘I’ statements, you statements can indicate blame
- State concerns –open, honest, direct
- Focus on issue of conflict
- Use ‘CUS’ method to get attention to problem (Concerned, Uncomfortable, Safety)
Conflict resolution steps and actions
- Strive for “win-win”
- Identify the problem or issue
- Generate a possible solution
- Evaluate suggested solutions
- Choose the best solution
- Implement the solution chosen
- Evaluate: Is the problem resolved?
Communication with families in a crisis
- Keep them updated
- Allow to stay close
- Appoint an advocate
- Don’t use medical jargon
- Give factual information
5 rights of delegation
- Right Task
- Right Circumstance
- Right Person
- Right Direction/communication
- Right Supervision/evaluation
5 key words for delegation
- P- Planning
- A-Assessment
- C-Collaboration
- E- Evaluate
- T- Teaching
Unprofessional behaviors
- blaming or criticizing other healthcare providers in the presence of patients i.e.“Sorry you didn’t get your pain medication, the night-shift was short staffed”
- acting outside the scope of practice
- accepting duties/responsibilities you are not prepared & competent for
- diverting drugs/supplies
- failing to safeguard a patient from incompetent practice of another nurse
- falsifying documentation
Factors associated with professional commitment
- Strong belief in and acceptance of the profession’s code, role, goals, values, and morals
- Willingness to exert considerable personal effort on behalf of the profession
- Strong desire to maintain membership in the profession
- Pattern of behaviors congruent with the nurses’ professional code of ethics
a pattern of coercive control founded on and supported by physical and/or sexual violence or threat of violence of an intimate partner.
Battering
Why do victims stay with abusers
- Period after leaving abuser at 75% greater risk of being killed by the partner.
- Fear for their lives or lives of their children
- Fear of retaliation by the partner
- Fear of losing custody of their children
- Lack of financial resources
- Lack of a support network
- Religious reasons
- Having hope that the partner will change, and they can have good times again
- Lack of attention to the danger
Nursing priorities for suspected child abuse
- Reporting to authorities when there is reason to suspect child abuse or neglect
- Provide shelter and promote reassurance of safety
- Stay with pt
- Promote trust
All of the following are S/S of what?
- Re-expiernce the traumatic event
- Flashbacks
- Sustained high level of anxiety or arousal
- General numbing of responsiveness
- Intrusive recollections or nightmares
- Amnesia to certain aspects of trauma
- Depression
- Survivors guilt
- Anger
- Substance abuse
- Relationship problems
- Suicidal thoughts
PTSD
List S/S of PTSD
- Re-expiernce the traumatic event
- Flashbacks
- Sustained high level of anxiety or arousal
- General numbing of responsiveness
- Intrusive recollections or nightmares
- Amnesia to certain aspects of trauma
- Depression
- Survivors guilt
- Anger
- Substance abuse
- Relationship problems
- Suicidal thoughts
Treatment for PTSD
- Cognitive therapy
- Prolonged exposure therapy
- Group family therapy
- Eye movement desensitization and reprocessing
- Psychopharmacology
Medications used to treat PTSD
o SSRI (first line): paroxetine , sertraline
o Tricyclic antidepressants: Amitriptyline (evlavil)
o MOA inhibitors
o Benzos, busprione , propranolol
Nursing priorities for PTSD
- Establish therapeutic relationship encourage patient to share feelings
- Provide safe , non threatening , routine environment
- Assess client for suicidal ideation , take precautions as needed
- Use multiple strategies to decrease anxiety (music, imagery, relaxation, breathing techniques )
- If pt is a child involve caregivers in treatment
Root cause analysis process
- Identify problem
- Define problem
- Understand problem
- Identify root cause
- Corrective action
- Monitor
Repeat
What medication is this?
- Purpose: control seizure disorders , neuropathic pain, restless legs syndrome
- Action: Slowing the entrance of sodium and calcium back into the neuron, thus extending the time it takes for the nerve to return to its active state and slows the frequency of neuron firing
- CNS effect: Somnolence, dizziness, ataxia, fatigue, nystagmus, peripheral edema diminish in time
- Special considerations: Monitor plasma levels, do not admin within 2 hrs of antacids, renal dosing w/ renal impairment pt’s, monitor for suicidal thoughts
Gabapentin
What medication is this?
- Purpose: decreased muscle spasticity
- Action: inhibits reflexes
- S/e : dizziness, weakness, confusion, headache, nausea, constipation, difficulty falling asleep, tiredness, frequent urination
- A/E: visual / audio hallucinations, seizures
- Special considerations: Monitor for s/s of overdose, do not give with MAO Inhibitors, alcohol, antihistamines, or opioid analgesics, can increase glucose, alkaline phosphate, AST, and ALT, needs to be d/c’d over 2 wks or more
Baclofen
What medication is this?
- Use: First drug of choice for BP – unresponsive to adequate fluid resuscitation
- Effects: Increase BP, MAP, CVP, SVR,
o Cardiac stimulation
o peripheral vasoconstriction
o renal and splanchnic vasoconstriction
o Can increase or decrease cardiac output - Special considerations:
o Administer via central line d/t risk of ischemia
o Requires CVP monitoring
o Monitor pt for dysrhythmias
o Notify HCP if urine OP is <30
o Needs to be discontinued gradually
Vasopressors or Norepinephrine
What medication is this?
- Purpose: vasodilation of renal, mesenteric and coronary arteries
- Typical dose 2-10 MCG/KG/MIN
- S/e: Arrhythmias, hypotension, angina, palpitations
- Toxicity: If excessive HTN occurs rate of infusion should be decreased or temporarily d/c’s until BP is decreased
- Do not admin with beta blockers, general anesthetics, and phenytoin
Dopamine
- Action: peripheral vasoconstriction, increased cardiac contractility, smooth muscle relaxation
- Used to treat: Hypotension associated with septic shock, severe allergic rxn, cardiac arrest, inhalation injury
- S/E: angina, arrhythmias, HTN, Tachycardia, nervousness, restlessness, tremor
- A/E: Paradoxical bronchospasms w/ excessive use of inhalers-If wheezing is heard hold med and notify HCP immediately
- Can cause increased glucose
- Dose 2-10mcg/min
Epinephrine
What medication is this?
- Action: arterial vasoconstriction- increases BP
- Dose: 40-200 mcg/min
Phenylephrine
What medication is this?
- Action: increased cardiac contractility, mild vasodilation
- Dose: 5-15 mcg/kg/min
Dobutamine
Inotropic
What medication is this?
- Action : black the action of the vagus nerve in the parasympathetic nervous system increasing HR
- used in neurogenic shock to treat bradycardia
Atropine
What medication is this?
- Use: work by blocking epinephrine.
- Effects: Lowers HR and decreases cardiac workload
- Special considerations:
- Do not give if HR is less than 60, remember to use apical pulse
- Monitor for hypotension after 1st dose
- Teach pt to rise slowly from seated or lying positions to avoid orthostatic hypotension
- Use cautiously in pt’s w/ HF and asthma
Beta blockers
What medication is this?
- Use: lowers HR and BP , angina , dysrhythmias
- Action:
- S/e :
o Ortho hypotension, dizziness, flushing,HA, Peripheral edema , constipation
o Considerations:
o avoid grape juice , elevate legs to & compression to reduce edema, to help with constipation give ( all F’s Fluids, fiber, fruits)
Calcium Channel blockers
What medication is this?
- Use: First line medication use to treat HTN, HF, MI. Used to treat cardiomyopathy
- Effects: Reduces after-load, relaxes blood vessels, decreases BP
- Special considerations:
- Can cause K retention so be careful when administering K sparing diuretics, potassium supplements, and check labs
- Do not give to pregnant pt
- S/e : remember acronym ACE
ACE Inhibitors
What medication is this?
- Action: binds to cell receptors enhancing the effects of GABA., slows/ calms activity of the nerves in the brain
- Uses: acute anxiety, sedation/muscle relaxant ,siezures, etoh
- A/e: Drowsiness, lightheadedness, ataxia, visual disturbances, anger, restlessness, nausea , constipation, lethargy, apathy , dry mouth.
- Considerations:
- Monitor for s/s of withdrawals, not meant for long term use, must be tapered off,
Benzos
-zepam, -zolam
What medication is this?
- Action: inhibits uptake of serotonin – increased serotonin
- Uses: depression, anxiety, ocd, eating disorders
- S/e: Headache , tremors, difficulty sleeping, nausea, dry mouth/thirst, constipation, urinary retention, sexual dysfunction
- A/e: serotonin syndrome
- Considerations:
- May take 4-6 weeks to take effect, take in the morning, first line for depression and anxiety
SSRI’s
(-atlopram, -oxetine, -zodone)
