Week 11 THURS Flashcards
Adult trauma
determining the severity of clients’ problems and how fast they need to be seen
triage
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
- clearly document LOC and pts health staus on chart
Order to treat client with multiple injuries in
establish airway, control hemorrhage, prevent hypovolemic shock, assess for head injury
What solid abdominal organ is most frequently injured in an MVA
Liver
used to sort patients into groups based on the severity of their health problems & immediacy with which these problems must be treated
triage
This category is reassessed every 15 minutes
emergent
This category is reassessed every 30 minutes
urgent
this category is reassessed every 120 minutes
non-urgent
What information do you need to get/ what does the nurse do during triage
- 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
What is a primary survey
- focuses on stabilizing life-threatening conditions
- ABCDE’s
Primary Survey: Airway
- 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?
Primary Survey: Breathing
- achieve maximum cellular oxygenation, prevent hypoxia and hypercapnia
- observe and auscultate lungs
- O2 sats and ABGs
Primary Survey: Circulation
- palpate pulses - auscultate heart sounds
- HR & BP
- skin temp and cap refill
- check for bleeding
- manage fluid status
- assess pt for shock
Primary Survey: Disability
- determine neurological disability, assess GCS, and motor/sensory eval of spine
- quick neuro assessment
- AVPU> alert, verbal, pain, unresponsive
Primary Survey: Exposure
- expose the pt to ensure there are no open wounds
- maintain body temp
- keep pt dignity
Secondary Survey components
- complete health hx
- HTT assignment
- diagnostic and lab testing
- splinting fractures
- cleansing, closure, dressing of wounds
- pain management
- insert/ apply ECG, IV/PICC, catheters
Risk factors for traumatic injuries
- Age> 15-24yo more at risk
- Gender> males
- alcohol use
- geography> rural(high intentional), urban (high intentional)
T or F GOLDEN HOUR FOR RESUSCITATION OF SEVERELY INJURED PT IS SECOND HOUR FLOOWOING THE TRAUMA
False!!
- it is the first hour after!
Trauma resuscitation: first peak
- occurs within minutes of injuries
- death results from devasting injuries to brain, upper spinal cord, heart, aorta, or other major blood vessels
Trauma resuscitation: Second peak
- occurs mins- hours after arrival in emergency department
- death related to subdural/epidural hematoma, ruptured spleen, lacerated organs> BLOOD LOSS
Trauma resuscitation: third peak
- occurs days to weeks after injuries
- complications of systemic inflammatory response syndrome & MODS
What is the most common cause of hypovolemic shock
- acute blood loss
what is the goal of resuscitation
treat shock so it does not progress to irreversible state
Caused by single catastrophic event that causes life threatening injuries to at least 2 distinct organs or organ systems
Multiple trauma
Assessment & diagnostic findings for multiple trauma
- 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
Management of multiple traumas
- 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
Complications of traumatic injuries
- 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
Nursing assessment & diagnosis; s/s of complications of traumatic injury
- 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
Traumatic injury where there is tissue deformation w/out interruption of skin integrity
- may be life-threatening
blunt trauma
Injury sustained by transmission of energy in body tissues from moving objects that interrupts skin and tissue integrity
penetrating trauma
Penetrating abdominal trauma has a high incident injury to ___________, and gunshot wounds cause _________ which can cause extensive tissue damage
1.) hollow organs
2.) High velocity> entrance and exit wounds
Intra-abdominal injury assessment
- 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
Intra-abdominal injury diagnostics
- Serial HgB and Hct, lactate, ABG, INR & coags, WBC
- CT scan, abdominal ultrasound (FAST), diagnostic peritoneal lavage
- Stab wound: sinography
Intra-abdominal injury Management
- Ensure airway, breathing, and citrculation
- immobilize c spine
- tetanus & prophylactic antibiotics
- hold oral fluids
- NG tube to aspirate stomach
- urinary catheter
- document all wounds
injury occurs when a person is caught between opposing forces
crush injury
Assessment/ diagnosis (what to look for) for crush injuries
- 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
Management for crush injuries
- 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
Management of a fracture
- 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
Injury that causes failure of heat-regulating mechanisms> can cause death
Heat stroke
management for heat stroke
- ABC’s!
- cooling methods> ice, cold water, cool sheets
- monitor VS esp temp
- IVto replace fluid losses
- meds; anticonvulsants, electrolytes, bicarb, benzos
Trauma from exposure to freezing temperature and freezing of fluid in the intracellular and intercellular spaces
frostbite
What not to do with frostbite
- Do not massage or handle, if feet are involved do not walk!
- no super hot baths right away
Internal cor temp is 35C or less may cause injuries
hypothermia
Management for hypothermia
- 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
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
Poison
Treatment goal for poisoning
- 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
Management for pt who ingested poison
- 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
Why is carbon monoxide posioning threatening
Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin. It does not transport oxygen
treatment for carbon monoxide poisoning
- get fresh air immediately
- Administer 100% oxygen
- cpr as necessary
What treatment works best for chemical burn management
- immediatly flush the skin with running water from a shower, hose, or fauce- some chemicals may need prolonged flushes
A sudden illness caused by ingestion of contaminated food or drink
food poisoning
Nursing role and interventions for victims of human trafficing
- offer opportunity to speak alone w/out companion
- use targeted questions
- report> national human trafficking hotline
