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NURSING 3 > Week 6 > Flashcards

Week 6 Flashcards

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1
Q

Emergency nursing: what does the emergency RN do?

A

establishes priorities, monitors, and continuously assesses patients who are acutely ill and injured, supports and attends to families, supervises allied health personnel and educates patients and families within a time-limited, high-pressured care environment

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2
Q

What are the diverse conditions and situation that present unique challenges in the ED?

A

Legal issues
Occupational health and safety risks for staff
It can be hard to provide hollistic care in the fast paced, technology driven environment in which serious illensses are death encountered on a daily basis

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3
Q

What are the triage categories?

A

Emergent
Urgent
Nonurgent

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4
Q

What are the triage in a disaster?

A

Expectant (0 - black)
Immediate (I - red)
Delayed (II - yellow)
Minimal (III - green)

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5
Q

Disaster triage: expectant

A

Patients have lethal injuries and usually will die despite treatment.

Examples include devastating head injuries, major third-degree burns over most of the body, and destruction of vital organs. Retriage of this group may be done as resources become available

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6
Q

Disaster triage: immediate

A

Patients have life-threatening injuries that probably are survivable with immediate treatment.

Examples are tension pneumothorax, respiratory distress, major external hemorrhage, and airway injuries.

Ideally, with limited resources, the only patients categorized as red will be those who would benefit from immediate short-duration treatment and then could be retriaged as yellow

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7
Q

Disaster triage: Delayed

A

Patients require definitive treatment, but no immediate threat to life exists.

Patients can wait for treatment without jeopardy.

Examples include minor extremity fractures, laceration with hemorrhage controlled, and burns over less than 25% of body surface area.

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8
Q

Disaster Triage: minimal

A

Patients have minimal injuries, are ambulatory, and can self-treat or seek alternative medical attention independently.

Examples include minor lacerations, contusions, and abrasions

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9
Q

On exam, you do not need to know the difference between yellow and green

A

They will be grouped together. you need to decifer because black, red, and yello-green

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10
Q

ABCDE

A

A: Establish patient AIRWAY

B: Provider adequate ventilation, employing resuscitation measures when needed. Protection of cervical spine in trauma patients is mandatory when ventilating and resuscitation measures are needed

C. Evaluate and restore cardiac output by controlling hemorrhage, preventing and treating shock, and maintaining or restoring effective circulation, including the prevention and management o hypothermia

D. determine NEUROLOGIC DISABILITY by assessing neuro function using GCS

E. EVALUATE for spinal injury if indicated

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11
Q

What does a partial airway obstruction lead to?

A

Can lead to progressive hypoxia, hypercarbia, and respiratory arrest

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12
Q

Who is most at risk for airwar obstruction?

A

children

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13
Q

how long does it taken for brain death to occur with an airway obstruction

A

3-5 minutes

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14
Q

Clinical manifestations of airway obstruction

A 
Clutching the neck 
Apprehensive appearance
Inspiratory/expiratory stridor
Anxiety
Restlessness
Confusion
Cyanosis and LOC (late sign)
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15
Q

Medical and nursing management of a partial airway obstruction

A

Cough forcefully
Persist with spontaneous coughing and breathing
Monitor oxygenation

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16
Q

Medical and nursing management of a complete airway obstruction

A

Rescue breathing - absent or inadequate

No pulse = compressions

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17
Q

what is the hiemlick called now

A

abdominal pulse

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18
Q

How to establish an airway

A

Head tilt, chin lift
– reposition head to prevent tongue from obstruction

Abdominal thrusts
Head-tilt-chin-life maneuver
Insert specialized equipment - open airway, remove foreign body, maintain airway

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19
Q

When is a situation that you would not do the head-tilt-chin-lift maneuver

A

When you suspect that someone has a spinal cord injury

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20
Q

What is an oropharyngeal airway?

A

Prevents tongue from falling back - forces tongue down. Helps get more air into lungs

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21
Q

How to do decide what size of oropharyngeal airway someone gets?

A

Angle of mandible to midpoint of incisors

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22
Q

Cricothyroidotomy

A

Used for spinal injuries, laryngeal spasms, maintains airway

aka tracheostomy

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23
Q

How to maintain the airway

A

Adequate ventilation (prevent hypoxia and hypercapnia)
Assess lung sounds - diminshed breath sounds
Pulse ox
Capnography
ABGs
Maintain cervical spine immobilization until verified

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24
Q

Capnography

A

Capnography is the monitoring of the concentration or partial pressure of carbon dioxide in the respiratory gases

  • measures CO2
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25
Q

tension pneumothorax mimics what?

A

hypovolemia

– however remember ABC

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26
Q

What should capnography values be

A

35-45 – same as ABG

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27
Q

What do you want to do with a sucking, open chest wound

A

You want to tape down 2 sides and leave one side, — you want o occlude it to increase the intrathoracic pressure

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28
Q

How do we manage a hemorrhage

A 
Assess for s/s shock
Fluid resuscitation
Stop bleed
Apply pressure proximal to the wound
Tourniquet as last result
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29
Q

What are the nursing goals for managing hemorrage

A

Control bleeding
Maintain adequate circulation blood volume
Prevent shock

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30
Q

You walk into a room, and you see blood on the bed. What else, besides the blood would tell you that the patient is in shock?

A 
Pale, cool, diaphoretic 
Anxious 
HR up
BP down 
Delayed cap refill 
RR up
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31
Q

What kinds of fluids are you going to give someone with a hemorrhage?

A

Isotonic - LR, NS
Colloids - albumin
Blood products

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32
Q

What would you do if an recent amputee started bleeding out their amputated limb?

A

Tournequete

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33
Q

What are things to keep in mind with wounds?

A

Caution with clipping hair - can get into wound
Never remove eyebrow hairs
Cleanse site with NS
No antibacterial until thorough cleansing
Closure
Delayed closer

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34
Q

delayed closure may be due to what

A

tissue loss

high potential or infection

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35
Q

Intra-abdominal injuries: Penetrating - Gunshot and stab

A

Typically go straight to surgery
Assess small bowel and liver
Extensive tissue damage
Looking for enter and exit for gunshot

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36
Q

Intra-abdominal injuries: Blunt (MVA, explosions, falls)

A

Challenging
Delayed care
Blood loss into peritonial cavities
check H&H

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37
Q

Intra-abdominal injuries: assessment

A 
H/H
ABG
Abdominal assessment
Vitals 
INR 
WBC
Pain
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38
Q

Intra-abdominal injuries: internal bleeding

A

CT scan to see where its at

liver and spleen (because they impact clotting)

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39
Q

Intra-abdominal injuries: intraperitoneal injury

A 
Tenderness
Rebound tenderness
Guarding
Rigidity
Spasms
Increased distention
Pain
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40
Q

Intra-abdominal injuries: Geritourinary injury

A

Rectal or vaginal inspection

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41
Q

Crush injuries

A

Assess for hypovolemic shock
spinal cord injury
check they dont go into rhabdomyelosis

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42
Q

Heat induced illness

A

Heat stroke - make sure we hydrate and keep them cool

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43
Q

Frostbite

A

want to check for this, especially in homeless population

  • remove restrictive clothing (compartment syndrome)
  • pain meds
  • elevate extremitity to decrease swelling
  • stick sterile gauze on it because skin might stick to frostbite (toes)
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44
Q

Hypothermia

A

When core temp is less than 95 degrees

You want them to be really warmed

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45
Q

nonfatel drowning concern

A

hypoxia and acidosis

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46
Q

ingested poison

A

control airway - ventilation, oxygenation - then stabilize cardiovascular

47
Q

nonfatal drowning

A

Someone was found in water, but they did not die in first 24 hours after drowning

48
Q

Carbon monoxide poisoning medical treatment

A

Hyperoxygenate (hyperbaric chambers)

  • get to fresh air
  • blanket to keep warm
49
Q

How might someone with carbon monoxide poisoning look like

A 
Headache
Weakness
Palpitations 
dizzy
confusion
coma
50
Q

Snakebites - what causes the damage?

A

Proteins that broad range of physiologic effects - neuro, respiratory, cardiac

51
Q

Snakebites s/s

A

edema, ecchmyosis, hemorrhagic bullae - leading to necrosis of site
- lymphnode tenderness, n/v, numbness, metallic taste in mouth. Without treatment, these s/s can progress to fasciculations, hypotension, paresthesias, sz., coma

52
Q

What is the initial first aid at the site of a snakebite

A 
Have person lie down
Removing constrictive items (rings)
Provide warmth
cleanse wound 
Cover wound with lite, sterile dressing
Immobilize the injured body part BELOW heart
ABC = priorities 
NO - ice, incision, suction, or tournequette
Tetanous and analgesia should be given
53
Q

snakebites: Initial evaluation in the ED is performed quickly and includes information about the following:

A

Whetdiscourage bringing the snake for identification—even a dead snake’s venom is poisonous.

Sequence of events, signs, and symptoms (fang punctures, pain, edema, and erythema of the bite and nearby tissues).

Severity of poisonous effects. Call the local poison control

Vital signs.

Circumference of the bitten extremity or area at several points.

Laboratory data (complete blood count, urinalysis, and coagulation studies).

54
Q

Disaster nursing

A

Man made or natural event that overwhelms community resources

  • disaster plans
  • natural disasters
  • biologic agents

–> must do greatest good for greatest number of people

55
Q

What are the zones of burns (aka, pathophysiology)

A

A. Zone of coagulation (tissue is completely destroyed)
B. Zone of stasis (nonviable tissue and potentially viable tissue)
C. Zone of hyperemia (increased blood flow secondary to the natural inflammatory response)

56
Q

What variables impact the prognosis of burns

A 
severity of the burn
Presence of the inhalation injury
association injuries
age
comorbid conditions
57
Q

Gerontological considerations with burn injuries

A

Morbidity and mortality rates are greater
Loss of SQ tissue increases risk for deep injury
Decreased sensation
Changes in vision

58
Q

How can we help elderly prevent burns

A 
Backburners on stove
lower water heater 
smoke detector checks 
loud smoke detector 
carbon monoxide detectors 
fire extinguisher 
escape plan
sprinkler systems 
no smoking on oxygen
59
Q

how are burns classified?

A

classified according to the depth of the burn

  • how it occurred
  • causative agent
  • temp of burning agent
  • duration of contact with burning agent
  • thickness of the skin in the burned area
60
Q

What are the types of burns

A

Superficial
Superficial partial thickness
Deep partial-thickness
Full-thickness injury

61
Q

there will be pix on the midterm you will need to know the type of burn it is

A

k

62
Q

Superficial burn

A 
Formally known as 1st degree
Only epidermis injured 
Redness and edema 
No blisters 
Heals in about 3 days or less with no scarring

ex. sunburn, curling iron, stove

63
Q

Superficial Partial-Thickness brun

A

Examples: sunburn, low intensity electrocurrent

Epidermis injured, may extent to the dermis
The exposed dermis is red, blanches with pressure, dry
Tingling, hyperparesthesia, pain (soothed by cooling)
Hair still intact

Heals within 5-10 days
Peeling possible
No scarring

64
Q

Deep partial thickness burn

A

Extends to the reticular layer of the dermis
s/s: pain, hyperparesthesia, sensitive to cold air

Wound appearance:
- blistered, broken epidermis, weeping surface, edema, mottled red base

Increased risk for infection
Heals in 3-8 weeks, some scarring and depigmentation

65
Q

Deep partial thickness burn example

A

scalding

66
Q

What is a risk for a deep partial thickness burn?

A

Compartment syndrome d/t swelling - take of restrictive clothing

67
Q

Full thickness burn: ex

A

flames, prolonged exposure to hot liquids, chemicals

68
Q

Full thickness Burn

A

Total destruction of the dermis and extends into the subutaneous fat - can involve muscle and bone

69
Q

Full thickness burn s/s

A

pain free
shock
hematuria with possible hemolysis
possible entrance

70
Q

Full thickness - wound color

A

mottled white to red, brown, or black

71
Q

Full thickness burn - skin

A

dry, pale white, charred and leathary, edema, eschar, slough

Hair follicles and sweat glands destroyed

72
Q

Full thickness: healing

A

Does not happen spontaneously, requires surgery or grafting

73
Q

How to estimate total body surface area (TBSA)

A

Rule of nines

74
Q

What percentage of the body for Rule of Nines for the following: head, each arm, torso, genitals, each leg

A 
Head: 9% (4.5% front, 4.5% back)
Each arm: 9% (4.5% front, 4.5% back) x2 
Torso: 36% (18% front, 18% back)
Genitals: 1% 
Each leg: 18% (9% front, 9% back) x2

neck is considered part of the head

75
Q

Management of fluid loss and shock with burns

A

IV resuscitation formulas used as a guide
Patient’s response to fluid resuscitation determine fluid therapy

Parkland Formula:
2mL of LR x Kg x % TBSA (normal)
4mL of LR x Kg x % TBSA (children and electrical burns)

76
Q

When is fluid resusitation the most important for burn victims?

A

first 8 hours

77
Q

go practice parkland formula

A

go

78
Q

Classification of burn injury extent

A

minor burn injury
Moderate uncomplicated burn injury
Major burn injury

79
Q

Minor burn injury

A

less than 15% TBSA

80
Q

What are considered the major burn areas?

A 
Eyes 
ears 
face
genitalia 
hands
feet
81
Q

What do burns of 60% TBSA cause?

A

Depressed myocardial contractility - plus a loss of circulating plasma volume, hemoconcentration and massive edema formation - distributive and hypovolemic shock

82
Q

When is fluid loss the greatest for a burn victim

A

First 4-8 hours - this is why we bolus them half the amount we calculate from the parkland formula

83
Q

When does capillary integrity return after a burn

A

toward normally 36-48 hours after the burn

84
Q

Burn shock

A

Think hypovolemia - “leaky, third spacing” of fluid, severe hypovolemia and CO

85
Q

Burn shock: initial systemic event - hemodynamic instability

A

Shift of fluid, sodium and protein from the intravascular space into the interstitial spaces

In major burns – this process exceeds the useful effect of the inflammatory response

Progressive edema develops in unburned tissue and organs causing hypoperfusion and hypovolemic shock

Cardiac Output and BP drop

Increase in peripheral vascular resistance secondary to edema formation, decrease in blood volume and decrease in CO

86
Q

Burn shock alterations:

A 
Fluid electrolyte
Pulmonary
Renal
Immunologic
Thermoregulatory
GI
87
Q

Fluid and electrolyte alterations (burns)

A

Edema begins quickly after burn.

  • Potassium increase – massive cell destruction
  • Sodium depletion – plasma loss or as water shifts from the interstitial space and returns to the vascular space
  • RBC decrease – destroyed or damaged
  • Hct elevated – plasma loss
  • Thrombocytopenia, coagulation abnormalities, prolonged clotting time
88
Q

Fluid and electrolyte alterations: treatment

A

Elevation of extremity
Remove eschar
Escharotomy
Fasciotomy

89
Q

Burns > 30% TBSA, inflammatory mediators stimulate local and systemic reactions resulting in what

A

extensive shift of intravascular fluid, electrolytes, and proteins into he surrounding interstitium.

90
Q

Pulmonary alterations (BURNS)

A

Occurs even when lung tissues have not been damaged directly

  • upper airway injury
  • inhalation therapy
  • patient at risk for ARF and ARDS
91
Q

inhalation injury usually related to what

A

carbon monoxide

92
Q

ABC - what is most concerning with burns

A

Circulation - unless there is an inhalation injury

93
Q

Cardiovascular changes - burns

A

Hypovolemic shock - monitor vitals and cardiac rhythm, especially in cases of electrical burn injuries

94
Q

What are the nutritional needs of a burn patient

A

Patient may require > 5,000 calories/day in large burns

High calorie/protein

May require supplemental feedings to meet nutritional requirements

95
Q

Vascular alterations for burn victims

A

Fluid shift

- fluid imbalance, electrolyte, acid-base (hyperkalemia, and hyponatremia, and hemoconcentration)

96
Q

Renal impacts of burns

A

May be altered as a result of decreased blood volume

97
Q

Immune system impact of burns

A

immune system diminishes resistance to infection (sepsis)

98
Q

thermoregulation - burns

A

loss of skin also results in an inability to regulate body temp

99
Q

GI complications of burns

A

paralytic ileus and Curling’s ulcer

100
Q

ABC - burns

A

Circulation, airway, breathing, disability

101
Q

What kind of analgesia are we going to give burn patients

A

IV meds typical morphone

102
Q

Phases of burn injuries

A

Emergent/resusitative
Acute/intermediate
Rehabilitation

103
Q

Emergent/resuscitative phase: duration

A

From onset of injury to completion of fluid resuscitation

104
Q

Emergent/resuscitative phase: priorities

A 
First aid
Prevention of shock
Prevention of respiratory distress
Detection and treatment of concomitant injuries
Wound assessment and initial care
105
Q

Acute/intermediate phase of burn: duration

A

From beginning of diuresis to near completion of wound closure

106
Q

Acute/intermediate phase of burn: priorities

A

Wound care and closure
Prevention or treatment of complications, including infection
Nutritional support

107
Q

Rehabilition phase of a burn: duration

A

From major wound closure to return to patient’s optimal level of physical and psychosocial adjustment

108
Q

Rehabilitation phase of a burn: priorities

A

Prevention of scars and contractures
Physical, occupational, and vocational rehabilitation
Functional and cosmetic reconstruction
Psychosocial counseling

109
Q

Burns: nursing management

A

Vital signs and respiratory status – closely monitored

Circulation, sensation and mobility (CSM) assessed hourly – of burn site

Neurovascular checks of extremities affected

I&Os – hourly

Continuous checking of cardiovascular, renal and pulmonary system

PNA (pulmonary mainentance)

Infection prevention (PPE, abx, wound care)

blood products if needed
pain management
mobility
psychological and emotional support

110
Q

what phase of burns does infection occur

A

acute phase

111
Q

skin grafting: autograft

A

own skin, decrease of rejection

112
Q

Skin grafting: homograft/allograft

A

Cadavar

  • temorary wound coverve
  • protect wound coverage
  • effective barrier
113
Q

Skin grafting: Heterograft/Xenograft

A

different species

NURSING 3 (16 decks)

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