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
type of burn where
skin exposed to a caustic agent acids, bases, and organic compounds.
Contact
Inhalation of fumes
Ingestion or injection
(lye or oven cleaner)
Chemical burn
Findings include crackles, dyspnea, cough, anxiety, jugular vein distention, and tachycardia. Manifestations can progress to pulmonary edema.
circulatory overload blood transfusion reactions
2 treatments of Pneumothorax-
needle decompression
chest tube
Healthy individuals offer organs to a client with end-organ disease.
Examples of organs donated by living donors are kidneys, lung lobes, part of a pancreas
Living Donors
monitor chest tube drainage every ___ hours
unless fresh from surgery, then __ hours
4, 1
one who does not meet brain death criteria but has an illness from which no recovery is expected
Circulatory Death-
chest tubes can do what 3 things
restore inintrapleural pressure
allow reexpansion of the lungs
prevent air and fluid from returning into the chest
3 phases of a blast injury
positive pressure: organs that contain air can rupture
negative force: impailed with flying debris
Tossed about: how far from explosion determines injury
life threatening condition that is caused by rapid accumulation of fluid in pericardial sac
cardiac tamponade
is from fracture of 2 or more adjacent ribs creating a free-floating segment in the rib cage
A flail chest
in a chest tube, the drainage system should be kept __
and the insertion site should be _____-
coiled in a _______
always be kept below the level of the chest
insertion site covered with air tight dressing
coiled in a lazy loop
-Grafts for deep partial-thickness and full-thickness burns
Skin covering
for blood transfusions with older adults, administer the blood over ___-___ hours
2-4 hours
who is the most effected population for burns
children and elderly
less subcutaneous skin
includes obtaining the client’s medical history, getting lab specimens and radiology exams, possibly inserting foley catheters or NG tubes.
The secondary survey
4 treatments of A flail chest
Mechanical ventilation
Pain control
Pulmonary hygiene.
Cough and deep breathing
Results from a transfusion rate that is too rapid for the client. Older adult clients or those who have a preexisting increased circulatory volume are at an increased risk.
circulatory overload blood transfusion reactions
method used to calculate total body surface area rule of 9
head \_\_% each arm arm\_\_% torso\_\_% each leg\_\_% genitals \_\_%
head - 9 arm- 9 torso-18 leg-18 genital-1
posterior and anterior seprate
6 assesment findings that indicae a problem with breathing
Absent or unequal breath sounds Asymetrical chest expansion Accesory muscle use Anxiety Tracheal shift with tension pneumothorax Loc decreased
-Impalement of body from foreign objects-complications include organ damage, hemorrhage, and infection.
Penetrating trauma
secondary head injury may result from what 4 things
Seizures
Hypotension
Hypoxia
Cerebral edema
brain and spinal cord injuries are included in ____
disability
burn that goes deep into the dermis
swelling, red or white appearance
require dressing changes and possibly skin graft
Heals within 2 to 4 weeks
Deep Partial thickness
2 injuries that can lead to problems with circulation
bodly fluid loss
bleeding
hypothermia an lead to what 2 complications
cardiac dysrthmias
coagulation disorders
is one who is pronounced dead by neurologic criteria; cessation of brain function
Brain Death
Hypothermia is a major concern, occurs when body temperature is _____ or less.
35 C (95.0 F)
4 nursing interventions for ANAPHYLACTIC blood transfusion reaction
- Stop the transfusion.
- Administer epinephrine, oxygen, or CPR if indicated.
- Remove the blood tubing from the client’s IV access.
- Initiate an infusion of 0.9% sodium chloride using new tubing.
is it normal to have bubbling in suction chamber?
yes gentle bubbling when suction is applied
if you notice Continious bubbling in water seal chamber what should you do
check for leaks and notify HCP
4 clinical manifestations of A flail chest
Paradoxical chest movement
Increased work of breathing
Tachypnea
Hypoxemia.
type of burn whrere
Inhalation of hot smoke, chemical toxins, and products of incomplete combustion. Often occurs after fires or chemical leaks in enclosed space.
Superglottic injury & Subglottic injuries
Inhalation burn
with Fluid Resuscitation what type of IV fluids do burn victims recieve
0.9 or lactated ringers
warmed
with Fluid Resuscitation for burn patients
Administer half of total 24-hour IV fluids during first _ hours from time of injury
Administer the other half over the next __ hours from time of injury
8
16
primary head injury may result from what 2 things
blunt or penetrating trauma
Findings include chills, fever, low-back pain, tachycardia, flushing, hypotension, chest
tightening or pain, tachypnea, nausea, anxiety, hemoglobinuria, and an impending sense of doom.
are all signs of ______
acute hemolytic blood transfusion reaction
should you empty the contents of a drainage collection chamber?
no, can cause contamination of site
may mask neuro responses and misleading findings
Alcohol
Recreational drugs
burn that goes past the epidermis and into dermis layer
red or pinkish modeling , blisters and swelling
dressing changes with topical ointment
Heals in 7 to 10 days
Superficial Partial Thickness
for prevention of conflict of interest who asks the family for organ donation
OPO
3 complications from penetrating trauma
Organ damage
Hemmorage
Infection
dark leathery necrotic tissue that has to be debreided and needs skin graft
eschar
clinical manifestations of liver injuries include what 3 things
RUQ ecchymosis
Tenderness
Hypotension.
in a disaster situation: clients that are awake and alertwith minor injuries such as
fractures
scrapes and bruises
non-urgent
phase of burn that Begins 36 to 48 hours after injury when the fluid shift resolves
Ends with closure of the wound
Acute Phase
Early treatment of fractures includes hat 2 things
immobilization with splints and traction
surgical management may be required.
3 clinical manifestations that a patient is in the expectant category
Pupils fixed and dialated
Agonal respirations
Cervial spinal cord injuries
clinical manifestions of cardiac tamponade
Hypotension
Muffled heart sounds,
Jugular venous distension
burn patients Hypermetabolic-catabolic state (requiring _____ cal/day)
5000
mechanism of injury where the patient:
Blast injuries-
4 treatments for liver and spleen
bed rest
signs of hypovolemic shock
frequent CBC
surgical interventions
in a disaster situationclients that: have major injuries requiring care within the hour
stable vital signs
fractured pelvis
severe abdonminal injury
urgent
3 nursing interventions for circulatory overload blood transfusion reactions
Slow or stop the transfusion depending on the severity of manifestations.
Position the client upright with feet lower than the level of the heart.
Administer oxygen, diuretics, and morphine as prescribed.
ABCDE stands for
Airway Breathing Circulation Disability Exposure
with burns
GFR will be:
urine output wil be:
BUN & creatinine will be:
GFR will be: down
urine output wil be: down
BUN & creatinine will be: up
in a disaster situation:
Patients that are expected to die
comfort care measures
expectant
May occur from explosions and combines elements of blunt and penetrating trauma.
Blast injuries-
7 clinical manifestation of Pneumothorax-
Respiratory distress
Tachypnea
Tachycardia
Tracheal deviation
Chest pain
Blood tingled sputum
Diminished or absent breath sounds
with an Inhalation burn what 2 things can happen
edema and swelling in upper airway
stridor
increased pressure within a confined body space, especially of the leg or forearm.
Compartment syndrome
asess for 5 P’s
Results from a transfusion of blood products that are incompatible with the client’s blood type or Rh factor. Can occur following the transfusion of as few as 10 mL of a blood product.
acute hemolytic blood transfusion reaction
______ injuries occurs due to heat exposure below the glottis and often manifest breathing problem.
Subglottic
can lead to ARDS
4 interventions for problems with breathing
Chest tube -pneumothorax
Cspine stableization
Intubation
Needle decompression - tension pneumothorax
Destruction of entire epidermis and dermis as well as subcutaneous tissue
Thick, dry, red, black, brown, yellow, white, leathery appearance
Severe edema
Eschar hard and inelastic
Sensation minimal or no pain
skin graft needed
Full thickness
with a chest tube:
is drainage rising up and down in tubing normal?
yes,
tidaling
is a collection of blood in the pleural space.
Hemothorax
______ injury is heat exposure above the glottis that can lead to airway obstruction.
Superglottic
in chest tubes is bubbling in the water seal chamber okay
intermittin bubbling with coughin or forced expiration is okay
Continious bubbling is a sign of an air leak
mechanism of injury where the patient:
impailment of the body from a foreign object
gunshot, stabbing, accidnet, etc
penetrating trauma
Symptoms of splenic injury include what 3 things
LUQ tenderness,
Kehr’s sign (refered pain from left shoulder)
Hypotension.
3 nursing interventions for febrile blood transfusion reaction
Use WBC filter for administration to prevent the reaction from occurring.
Stop the transfusion and administer antipyretics.
Initiate an infusion of 0.9% sodium chloride using new tubing.
2 ways for prevention of DVT
low dose heparin
ambulation
Results from the development of anti-WBC antibodies. Can be seen when the client has received multiple transfusions.
febrile blood transfusion reaction
patients with abdoniminal injury and ____ injury will not be able to tell where their pain is coming from
head
for blood transfusions always prime with what type of IV solution
0.9 NS
open Pneumothorax treatment
3 sided dressing (allows the air to escape)
with burns
blod volume will be: blood pressure will be: cardiac output will be: heart rate will be: vasoconstriction will be:
blod volume will be: down blood pressure will be: down cardiac output will be: down heart rate will be:up vasoconstriction will be: up
What is the appropriate management of an opioid overdose?
narcan
5 interventions for ineffective airway with a trauma patient
Opening the airway
Gentle suctioning - bleeding or vomit in airway
Airway inserted (endotrachial tube)
Intubation
Neck injury - jaw thrust instead of head tilt
is the only permanent method of grafting
Autograft
treatment for Rhabdomyolysis
aggressive IV fluids
Skin damaged by contact with heat
exposed the flame, scalding liquids is what type of burn
thermal burn
cardiac tamponade treatment
Pericardiocentesis
initial appempts to cleanse wounds are done when the patient is
stabalized
4 interventions to prevent infection with burn patients
Restrict plants and flowers
No fresh fruits and vegetables
Limit visitors
Administer tetanus toxoid
5 problems that can cause a blocked airway
Vomiting
Obstruction from foreign object
Tongue occlusion
Edema
Bleeding
: more than 10% strongly indicates smoke inhalation
Carboxyhemoglobin
type of burn where
electrical current passes through the body and can cause sever damage including lethal dysrhythmias, central nervous system defects, and respiratory arrest.
(electrical current or struck by lightening)
entry point and exit point
Electrical burn
4 nursing interventions for allergic blood transfusion reaction
Stop the transfusion.
Initiate an infusion of 0.9% sodium chloride using new tubing.
Administer an antihistamine, such as diphenhydramine.
If the provider prescribes to restart the transfusion, do so slowly.
5 nursing inerventions for acute hemolytic blood transfusion reaction
Stop the transfusion.
Remove the blood tubing from the IV access.
Initiate an infusion of 0.9% sodium chloride using new tubing.
Monitor vital signs and fluid status.
Send the blood bag and administration set to the lab for testing.
5 injuries that can lead to problems with breathing
Spinal cord injury Chest or thoracic injury Rib fracture Altered LOC Pneumothorax
injury caused by external forces or violence.
Trauma
Results from a sensitivity reaction to a component of the transfused blood products.
allergic blood transfusion reaction
RhabdomyolysisMay result from crush injuries, compartment syndrome, burns.
Muscle damage leads to myoglobin (a muscle protein) released into the circulation
Rhabdomyolysis
6 nursing interventsion for poision
Obtain client history to identify the toxic agent. Contact poison control center. Prevent further absorption of the toxin Extract or remove the poison IV therapy Administer antidotes when necessary.
medication
drugs
household cleaners
snake and spider bites
are all types of
poisioning
during the secondary survey if patient shows signs of
asymetrical chest expansion restlessness confusion increase HR decrease in BP
this is a sign to ____
go back to primary survey
8 assesment findings that indicae a problem with circulation
Systolic BP less than 90 HR over 120 Anxiety Decreased LOC Obvious bleeding Weak and thready paulses
Pallor
MAP less than 70
burn that Epidermis only or small depth of dermis
Heals in 3 to 5 days without treatment
Erythema
Not calculated for fluid resuscitation
(sunburn)
not counted when calculating total body surface area
Superficial
is a treatment for poision
activated charcoal
syrup of ipecac no longer recommended
with a blood transfusion, you will need large bore IV acess between _____-____ gauge
18-20 G needle
older Adult - no larger than 19
4 clinical manifestions for Rhabdomyolysis
Dark tea colored urine
Hyperkalemia
Increase in creatinine
Decrease in GFR
Assess for neurological disabilities by evaluating what 3 things
Client’s LOC
Pupil response
Spontaneous movements.
in the Resuscitative Phase
H&H: Na: K: WBC: glucose: ABG's: protein & albumin: BUN:
H&H: increased NA: decreased K:increased WBC:increased glucose: increased ABG: resp alk/ met. acidosis protein & albumin: decreased BUN: increased
5 assesment findings that indicae a problem in the airway
Drooling Inability to speak or swallow LOC decreased Facial or head trauma Stridor
how to measure with Fluid Resuscitation
weight in kg plus TBSA%
is a surgical procedure used to treat full-thickness (third-degree) circumferential burns where incisions are made
Escharotomy
–% or more require burn center
20%
facial burns
genetalia burns
Results from a transfusion of contaminated blood products.
Findings include wheezing, dyspnea, chest tightness, cyanosis, hypotension, and shock.
bacterial blood transfusion reaction
Findings include chills, increase of 10 F (0.50 C) or greater from the pretransfusion temperature, hypotension, and tachycardia.
are all signs of _____
febrile blood transfusion reaction
if chest tube dislodges what 2 things need to be done
cover area with sterile dressing (vasoline etc)
notify HCP asap
candidates for organ donation are screened for what 3 things
alcohol or tobacco use
history of non compliance
active malignancy or infection
