unit 5 Flashcards
in a chest tube acts as a one way valve
air goes out - none in
water seal chamber
in a chest tube, the drainage system should be kept __
and the insertion site should be _____-
always be kept below the level of the chest
insertion site covered with air tight dressing
most common mechanism of injury. Injuries may not be easily noted; requires expert clinical judgment to diagnose.
Blunt trauma-
first 60 mins where a critically injured trauma patient must recieve life saving care
golden hour
when primary survey is done
3 interventions for problems with disability
Spinal stabilization
Monitor for neurogenic shock
Maintain perfusion
musculoskeletal injuries what 5 things
Bone Soft tissue Muscle Nerves Surrounding blood vessles
cardiac tamponade is diagnosed by _____
fast ultrasound
with a blood transfusion it is important to remember to remain with client for _______
Remain with patient 1t 15-30 miN
in the fluid remobilization phase:
H&H: Na: K: WBC: glucose: ABG's: protein & albumin:
H&H: decreased Na: decreased K: decreased WBC: decreased glucose: elevated ABG's: met.acidosis protein & albumin: decreased
5 P’s
pain - early sign pallor pulse -late sign paraesthesia - early sign paralysis
Fat globules from the long bones are released into the circulation and may lodge in the pulmonary system resulting in severe hypoxemia
May occur from fracture to the long bones and pelvis.
fat embolism
in a disaster situationclients that: have life threatening injuries that need immediate care
pneumothorax - tracheal deviation
chest bruising - flail chest
paradoxical breathing
Emergent
Crush injuries to the pelvis and/or both lower extremities or a prolonged entrapment often require
amputation
with a burn phase: begins with injury and continues for 24 to 48 hrs.
Resuscitative phase
Occurs when air escapes from injured lung into the pleural space, resulting in partial or complete collapse of the lung.
Pneumothorax
in the Resuscitative phase 6 things to remember with treatment
Stop the burning process Take off jewlery (nonadherant) Cool water - no ice or cold water Brush off chemical Prophalatic intubation FIO2 100%
Findings are usually mild and include itching, urticaria, and flushing.
The client can develop an anaphylactic transfusion reaction resulting in bronchospasm, laryngeal edema, and shock.
allergic blood transfusion reaction
5 interventions to remember with the acute phase of burns
Pain management - IV opioids Promote wound healing Prevent infection (protective isolation) Parental or TPN feedings Physical therapy
3 interventions for problems with circulation
2 large gauge IV with isotonic solution
Transfusion of blood - warm blood
Fast scan - small ultrasound machiene for no missed bleeding
3 nursing interventions for a bacterial blood transfusion reaction
Stop the transfusion.
Administer antibiotics and an IV infusion of 0.9% sodium chloride using new tubing.
Send a blood culture specimen to the lab for analysis.
burn where Destruction of all skin layers, extends to muscle, tendon, and bones
Black, eschar hard and inelastic
Insensate (no pain)
Deep Full thickness
mechanism of injury where the patient:
struck with an object
skin still intact but may be serious injury underneath
evaluated with ultrasound
blunt trauma
IV fluid resuscitation is instituted for patients with greater than __% TBSA
20
3 complications from organ donation
rejection
infection
post transplan malignancies