Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Complex Care > Week 11 THURS > Flashcards

Week 11 THURS Flashcards

Adult trauma

1
Q

determining the severity of clients’ problems and how fast they need to be seen

A

triage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Pt comes in with no ID and has low LOC and needs emergency treatment. What action by the nurse is priority regarding consent for treatment

A
  • clearly document LOC and pts health staus on chart
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Order to treat client with multiple injuries in

A

establish airway, control hemorrhage, prevent hypovolemic shock, assess for head injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What solid abdominal organ is most frequently injured in an MVA

A

Liver

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

used to sort patients into groups based on the severity of their health problems & immediacy with which these problems must be treated

A

triage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

This category is reassessed every 15 minutes

A

emergent

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

This category is reassessed every 30 minutes

A

urgent

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

this category is reassessed every 120 minutes

A

non-urgent

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What information do you need to get/ what does the nurse do during triage

A
  • inital VS
  • medical Hx
  • provide basic first aid & inital protocal based prescriptions
  • ensure safe environment
  • relieve anxiety and provide sense of security
  • adequate teaching and explanation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is a primary survey

A
  • focuses on stabilizing life-threatening conditions
  • ABCDE’s
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Primary Survey: Airway

A
  • assess airway obstruction
  • check for obstruction
  • stabilize C spine
  • reposition head or jaw thrust to access airway
  • neuro check> for LOC
  • establish an airway if pt doesn’t have one
  • observe the pt> how do they look?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Primary Survey: Breathing

A
  • achieve maximum cellular oxygenation, prevent hypoxia and hypercapnia
  • observe and auscultate lungs
  • O2 sats and ABGs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Primary Survey: Circulation

A
  • palpate pulses - auscultate heart sounds
  • HR & BP
  • skin temp and cap refill
  • check for bleeding
  • manage fluid status
  • assess pt for shock
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Primary Survey: Disability

A
  • determine neurological disability, assess GCS, and motor/sensory eval of spine
  • quick neuro assessment
  • AVPU> alert, verbal, pain, unresponsive
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Primary Survey: Exposure

A
  • expose the pt to ensure there are no open wounds
  • maintain body temp
  • keep pt dignity
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Secondary Survey components

A
  • complete health hx
  • HTT assignment
  • diagnostic and lab testing
  • splinting fractures
  • cleansing, closure, dressing of wounds
  • pain management
  • insert/ apply ECG, IV/PICC, catheters
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

Risk factors for traumatic injuries

A
  • Age> 15-24yo more at risk
  • Gender> males
  • alcohol use
  • geography> rural(high intentional), urban (high intentional)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

T or F GOLDEN HOUR FOR RESUSCITATION OF SEVERELY INJURED PT IS SECOND HOUR FLOOWOING THE TRAUMA

A

False!!
- it is the first hour after!

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

Trauma resuscitation: first peak

A
  • occurs within minutes of injuries
  • death results from devasting injuries to brain, upper spinal cord, heart, aorta, or other major blood vessels
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Trauma resuscitation: Second peak

A
  • occurs mins- hours after arrival in emergency department
  • death related to subdural/epidural hematoma, ruptured spleen, lacerated organs> BLOOD LOSS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Trauma resuscitation: third peak

A
  • occurs days to weeks after injuries
  • complications of systemic inflammatory response syndrome & MODS
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is the most common cause of hypovolemic shock

A
  • acute blood loss
23
Q

what is the goal of resuscitation

A

treat shock so it does not progress to irreversible state

24
Q

Caused by single catastrophic event that causes life threatening injuries to at least 2 distinct organs or organ systems

A

Multiple trauma

25
Q

Assessment & diagnostic findings for multiple trauma

A
  • External evidence may be sparse or absent
  • Always assume spinal cord injury until proven otherwise
  • Sometimes the least suspecting injury might be the most lethal
    Pelvis fracture can cause severe internal bleeding
26
Q

Management of multiple traumas

A
  • determine extent of injuries to establish priorities of treatment
    Injury interfering with vital physiologic function is first priority> airway, breathing, circulation
  • Lifesaving measures performed simultaneously by emergency team
  • Trauma team alerted for big traumas
  • Trauma team nurse role (depends on institution)
    -Assess & monitor patient, ensure/maintain airway, IV access, administer medications, collect labs, document activities
  • Establish airway and ventilation, control hemorrhage, prevent/treat hypovolemic shock, assess head/neck for injuries & stabilize with backboard or neck brace, evaluate for other injuries, splint fractures and assess pulses
27
Q

Complications of traumatic injuries

A
  • Thoracic> DIC & ARDS
  • Abdominal trauma> Hemorrage/ fluids/ infections
  • Orthopedic trauma> prolonged immobility
  • VTE> DVT, PE
  • Sepsis> SIRS, septic shock
  • Acute resp distress syndrome> resp failure, direct/indirect lung injury
  • Disseminated Intravascular Coag> excessive clotting or lack of clotting
  • AKI> necrosis from hypoperfusion
  • SIRS and MODS
28
Q

Nursing assessment & diagnosis; s/s of complications of traumatic injury

A
  • Elevation of white blood cell count
  • Fever
  • Change in characteristics of wound drainage
  • Decreasing oxygenation
  • Decreasing level of responsiveness
  • Decreased urine output
  • Diaphoresis
  • Cool, mottled skin
  • Presence of bleeding
  • Changing trends in vital signs or hemodynamic readings
29
Q

Traumatic injury where there is tissue deformation w/out interruption of skin integrity
- may be life-threatening

A

blunt trauma

30
Q

Injury sustained by transmission of energy in body tissues from moving objects that interrupts skin and tissue integrity

A

penetrating trauma

31
Q

Penetrating abdominal trauma has a high incident injury to ___________, and gunshot wounds cause _________ which can cause extensive tissue damage

A

1.) hollow organs
2.) High velocity> entrance and exit wounds

32
Q

Intra-abdominal injury assessment

A
  • Obtain history
  • Abdominal assessment and assess other body systems for injuries that frequently accompany abdominal injuries
  • Assess for referred pain which may indicate spleen, liver, or intraperitoneal injury
    Inspection: obvious injury, bruises, penetration, abrasions
  • Auscultation: baseline data, absence of bowel sounds=intraperitoneal involvement
  • Assess for abdominal distension, involuntary guarding, tenderness, pain, muscular rigidity, rebound tenderness
  • Hypotension and signs of shock
  • Assess for signs of internal hemorrhage, intraperitoneal injury, genitourinary injury
33
Q

Intra-abdominal injury diagnostics

A
  • Serial HgB and Hct, lactate, ABG, INR & coags, WBC
  • CT scan, abdominal ultrasound (FAST), diagnostic peritoneal lavage
  • Stab wound: sinography
34
Q

Intra-abdominal injury Management

A
  • Ensure airway, breathing, and citrculation
  • immobilize c spine
  • tetanus & prophylactic antibiotics
  • hold oral fluids
  • NG tube to aspirate stomach
  • urinary catheter
  • document all wounds
35
Q

injury occurs when a person is caught between opposing forces

A

crush injury

36
Q

Assessment/ diagnosis (what to look for) for crush injuries

A
  • Observe for hypovolemic shock resulting from extravasation of blood & plasma into injured tissues after compression has been released
  • Spinal cord injury
  • Erythema and blistering of skin
  • Fractures
  • AKI
37
Q

Management for crush injuries

A
  • maintain, breathing, circulation
  • observe for AKI
  • manage pain and anxiety
  • wound debridement and fracture repair
  • control bleeding
  • watch for rhabdomyolysis> severe muscle damage causes ischemia
38
Q

Management of a fracture

A
  • immediate managment can determine pts eventual outcome
  • assess pain over or near bone, swelling, circulatory disturbances
  • always splint before moving pts
  • if pulseless extremity> reposition alignment
  • clothing removed to visualize fractures
39
Q

Injury that causes failure of heat-regulating mechanisms> can cause death

A

Heat stroke

40
Q

management for heat stroke

A
  • ABC’s!
  • cooling methods> ice, cold water, cool sheets
  • monitor VS esp temp
  • IVto replace fluid losses
  • meds; anticonvulsants, electrolytes, bicarb, benzos
41
Q

Trauma from exposure to freezing temperature and freezing of fluid in the intracellular and intercellular spaces

A

frostbite

42
Q

What not to do with frostbite

A
  • Do not massage or handle, if feet are involved do not walk!
  • no super hot baths right away
43
Q

Internal cor temp is 35C or less may cause injuries

A

hypothermia

44
Q

Management for hypothermia

A
  • ABC’s!
  • remove wet clothing
  • supportive care
  • watch for cold blood return as it has high lactate levels and cause cardiac dysrhymias and electrolyte disturbances
45
Q

what is any substance that when ingested, inhaled, absorbed, applied to the skin, or produced within the body in relatively small amounts injures the body by its chemical action

A

Poison

46
Q

Treatment goal for poisoning

A
  • Remove or inactivate the poison before it is absorbed
  • Provide supportive care in maintaining vital organ function
  • Administer specific antidotes
  • Implement treatment to hasten the elimination of the poison
47
Q

Management for pt who ingested poison

A
  • Measures to remove the toxin or decrease its absorption
  • Corrosive agents such as acids and alkaline cause destruction of tissues by contact. Do not induce vomiting with corrosive agents
48
Q

Why is carbon monoxide posioning threatening

A

Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin. It does not transport oxygen

49
Q

treatment for carbon monoxide poisoning

A
  • get fresh air immediately
  • Administer 100% oxygen
  • cpr as necessary
50
Q

What treatment works best for chemical burn management

A
  • immediatly flush the skin with running water from a shower, hose, or fauce- some chemicals may need prolonged flushes
51
Q

A sudden illness caused by ingestion of contaminated food or drink

A

food poisoning

52
Q

Nursing role and interventions for victims of human trafficing

A
  • offer opportunity to speak alone w/out companion
  • use targeted questions
  • report> national human trafficking hotline
53
Q
A

Complex Care (26 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions