Week 6 Flashcards
Emergency nursing: what does the emergency RN do?
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
What are the diverse conditions and situation that present unique challenges in the ED?
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
What are the triage categories?
Emergent
Urgent
Nonurgent
What are the triage in a disaster?
Expectant (0 - black)
Immediate (I - red)
Delayed (II - yellow)
Minimal (III - green)
Disaster triage: expectant
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
Disaster triage: immediate
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
Disaster triage: Delayed
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.
Disaster Triage: minimal
Patients have minimal injuries, are ambulatory, and can self-treat or seek alternative medical attention independently.
Examples include minor lacerations, contusions, and abrasions
On exam, you do not need to know the difference between yellow and green
They will be grouped together. you need to decifer because black, red, and yello-green
ABCDE
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
What does a partial airway obstruction lead to?
Can lead to progressive hypoxia, hypercarbia, and respiratory arrest
Who is most at risk for airwar obstruction?
children
how long does it taken for brain death to occur with an airway obstruction
3-5 minutes
Clinical manifestations of airway obstruction
Clutching the neck Apprehensive appearance Inspiratory/expiratory stridor Anxiety Restlessness Confusion Cyanosis and LOC (late sign)
Medical and nursing management of a partial airway obstruction
Cough forcefully
Persist with spontaneous coughing and breathing
Monitor oxygenation
Medical and nursing management of a complete airway obstruction
Rescue breathing - absent or inadequate
No pulse = compressions
what is the hiemlick called now
abdominal pulse
How to establish an airway
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
When is a situation that you would not do the head-tilt-chin-lift maneuver
When you suspect that someone has a spinal cord injury
What is an oropharyngeal airway?
Prevents tongue from falling back - forces tongue down. Helps get more air into lungs
How to do decide what size of oropharyngeal airway someone gets?
Angle of mandible to midpoint of incisors
Cricothyroidotomy
Used for spinal injuries, laryngeal spasms, maintains airway
aka tracheostomy
How to maintain the airway
Adequate ventilation (prevent hypoxia and hypercapnia)
Assess lung sounds - diminshed breath sounds
Pulse ox
Capnography
ABGs
Maintain cervical spine immobilization until verified
Capnography
Capnography is the monitoring of the concentration or partial pressure of carbon dioxide in the respiratory gases
- measures CO2
tension pneumothorax mimics what?
hypovolemia
– however remember ABC
What should capnography values be
35-45 – same as ABG
What do you want to do with a sucking, open chest wound
You want to tape down 2 sides and leave one side, — you want o occlude it to increase the intrathoracic pressure
How do we manage a hemorrhage
Assess for s/s shock Fluid resuscitation Stop bleed Apply pressure proximal to the wound Tourniquet as last result
What are the nursing goals for managing hemorrage
Control bleeding
Maintain adequate circulation blood volume
Prevent shock
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?
Pale, cool, diaphoretic Anxious HR up BP down Delayed cap refill RR up
What kinds of fluids are you going to give someone with a hemorrhage?
Isotonic - LR, NS
Colloids - albumin
Blood products
What would you do if an recent amputee started bleeding out their amputated limb?
Tournequete
What are things to keep in mind with wounds?
Caution with clipping hair - can get into wound
Never remove eyebrow hairs
Cleanse site with NS
No antibacterial until thorough cleansing
Closure
Delayed closer
delayed closure may be due to what
tissue loss
high potential or infection
Intra-abdominal injuries: Penetrating - Gunshot and stab
Typically go straight to surgery
Assess small bowel and liver
Extensive tissue damage
Looking for enter and exit for gunshot
Intra-abdominal injuries: Blunt (MVA, explosions, falls)
Challenging
Delayed care
Blood loss into peritonial cavities
check H&H
Intra-abdominal injuries: assessment
H/H ABG Abdominal assessment Vitals INR WBC Pain
Intra-abdominal injuries: internal bleeding
CT scan to see where its at
liver and spleen (because they impact clotting)
Intra-abdominal injuries: intraperitoneal injury
Tenderness Rebound tenderness Guarding Rigidity Spasms Increased distention Pain
Intra-abdominal injuries: Geritourinary injury
Rectal or vaginal inspection
Crush injuries
Assess for hypovolemic shock
spinal cord injury
check they dont go into rhabdomyelosis
Heat induced illness
Heat stroke - make sure we hydrate and keep them cool
Frostbite
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)
Hypothermia
When core temp is less than 95 degrees
You want them to be really warmed
nonfatel drowning concern
hypoxia and acidosis
ingested poison
control airway - ventilation, oxygenation - then stabilize cardiovascular
nonfatal drowning
Someone was found in water, but they did not die in first 24 hours after drowning
Carbon monoxide poisoning medical treatment
Hyperoxygenate (hyperbaric chambers)
- get to fresh air
- blanket to keep warm
How might someone with carbon monoxide poisoning look like
Headache Weakness Palpitations dizzy confusion coma
Snakebites - what causes the damage?
Proteins that broad range of physiologic effects - neuro, respiratory, cardiac
Snakebites s/s
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
What is the initial first aid at the site of a snakebite
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
snakebites: Initial evaluation in the ED is performed quickly and includes information about the following:
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).
Disaster nursing
Man made or natural event that overwhelms community resources
- disaster plans
- natural disasters
- biologic agents
–> must do greatest good for greatest number of people
What are the zones of burns (aka, pathophysiology)
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)
What variables impact the prognosis of burns
severity of the burn Presence of the inhalation injury association injuries age comorbid conditions
Gerontological considerations with burn injuries
Morbidity and mortality rates are greater
Loss of SQ tissue increases risk for deep injury
Decreased sensation
Changes in vision
How can we help elderly prevent burns
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
how are burns classified?
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
What are the types of burns
Superficial
Superficial partial thickness
Deep partial-thickness
Full-thickness injury
there will be pix on the midterm you will need to know the type of burn it is
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Superficial burn
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
Superficial Partial-Thickness brun
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
Deep partial thickness burn
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
Deep partial thickness burn example
scalding
What is a risk for a deep partial thickness burn?
Compartment syndrome d/t swelling - take of restrictive clothing
Full thickness burn: ex
flames, prolonged exposure to hot liquids, chemicals
Full thickness Burn
Total destruction of the dermis and extends into the subutaneous fat - can involve muscle and bone
Full thickness burn s/s
pain free
shock
hematuria with possible hemolysis
possible entrance
Full thickness - wound color
mottled white to red, brown, or black
Full thickness burn - skin
dry, pale white, charred and leathary, edema, eschar, slough
Hair follicles and sweat glands destroyed
Full thickness: healing
Does not happen spontaneously, requires surgery or grafting
How to estimate total body surface area (TBSA)
Rule of nines
What percentage of the body for Rule of Nines for the following: head, each arm, torso, genitals, each leg
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
Management of fluid loss and shock with burns
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)
When is fluid resusitation the most important for burn victims?
first 8 hours
go practice parkland formula
go
Classification of burn injury extent
minor burn injury
Moderate uncomplicated burn injury
Major burn injury
Minor burn injury
less than 15% TBSA
What are considered the major burn areas?
Eyes ears face genitalia hands feet
What do burns of 60% TBSA cause?
Depressed myocardial contractility - plus a loss of circulating plasma volume, hemoconcentration and massive edema formation - distributive and hypovolemic shock
When is fluid loss the greatest for a burn victim
First 4-8 hours - this is why we bolus them half the amount we calculate from the parkland formula
When does capillary integrity return after a burn
toward normally 36-48 hours after the burn
Burn shock
Think hypovolemia - “leaky, third spacing” of fluid, severe hypovolemia and CO
Burn shock: initial systemic event - hemodynamic instability
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
Burn shock alterations:
Fluid electrolyte Pulmonary Renal Immunologic Thermoregulatory GI
Fluid and electrolyte alterations (burns)
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
Fluid and electrolyte alterations: treatment
Elevation of extremity
Remove eschar
Escharotomy
Fasciotomy
Burns > 30% TBSA, inflammatory mediators stimulate local and systemic reactions resulting in what
extensive shift of intravascular fluid, electrolytes, and proteins into he surrounding interstitium.
Pulmonary alterations (BURNS)
Occurs even when lung tissues have not been damaged directly
- upper airway injury
- inhalation therapy
- patient at risk for ARF and ARDS
inhalation injury usually related to what
carbon monoxide
ABC - what is most concerning with burns
Circulation - unless there is an inhalation injury
Cardiovascular changes - burns
Hypovolemic shock - monitor vitals and cardiac rhythm, especially in cases of electrical burn injuries
What are the nutritional needs of a burn patient
Patient may require > 5,000 calories/day in large burns
High calorie/protein
May require supplemental feedings to meet nutritional requirements
Vascular alterations for burn victims
Fluid shift
- fluid imbalance, electrolyte, acid-base (hyperkalemia, and hyponatremia, and hemoconcentration)
Renal impacts of burns
May be altered as a result of decreased blood volume
Immune system impact of burns
immune system diminishes resistance to infection (sepsis)
thermoregulation - burns
loss of skin also results in an inability to regulate body temp
GI complications of burns
paralytic ileus and Curling’s ulcer
ABC - burns
Circulation, airway, breathing, disability
What kind of analgesia are we going to give burn patients
IV meds typical morphone
Phases of burn injuries
Emergent/resusitative
Acute/intermediate
Rehabilitation
Emergent/resuscitative phase: duration
From onset of injury to completion of fluid resuscitation
Emergent/resuscitative phase: priorities
First aid Prevention of shock Prevention of respiratory distress Detection and treatment of concomitant injuries Wound assessment and initial care
Acute/intermediate phase of burn: duration
From beginning of diuresis to near completion of wound closure
Acute/intermediate phase of burn: priorities
Wound care and closure
Prevention or treatment of complications, including infection
Nutritional support
Rehabilition phase of a burn: duration
From major wound closure to return to patient’s optimal level of physical and psychosocial adjustment
Rehabilitation phase of a burn: priorities
Prevention of scars and contractures
Physical, occupational, and vocational rehabilitation
Functional and cosmetic reconstruction
Psychosocial counseling
Burns: nursing management
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
what phase of burns does infection occur
acute phase
skin grafting: autograft
own skin, decrease of rejection
Skin grafting: homograft/allograft
Cadavar
- temorary wound coverve
- protect wound coverage
- effective barrier
Skin grafting: Heterograft/Xenograft
different species
