Week 8; Neuro and Trauma Flashcards
Critical Access Hospitals –
considered necessary providers of health care to community residents that are not close to other hospitals. Medicare and Medicaid has a process for this designation. Multi-specialty environment
Vulnerable populations include:
Homeless
Poor
Mental health issue
Substance abuse issues
Older adults
Older adults visiting the ED
Visit ED because of worsening of existing chronic condition. Remember with older adults, may need to get collateral information for history due to memory loss or acute delirium. Knowing the history is vital because this may complicate the cause for the ED visit.
Hand-off communication process from ED to next point of care needs to include
Situation
Pertinent medical history
Assessment and diagnostic findings (especially critical results)
Transmission-Based Precautions and safety concerns
Interventions in the ED
Hostile Patients or Visitors
Pose injury risks to staff and patients
Be alert for volatile situations
Be alert for people who demonstrate aggressive behavior
Identify escape route
Enact hospital security plan
Staff education a must
Managing violence, active shooter
Core competencies for a trauma nurse
Assessment – rapid, accurate interpretation
Clinical decision-making – prioritizing, triage
Multitasking- proficient in variety of technical skills
Documenting
Communication
Cognitive knowledge base
Flexibility and adaptability
Priority setting (triage process)
Collaborative
Triage
An organized system for sorting or classifying patients into priority levels depending on illness or injury severity
“Gatekeeper”
Sorts patients into priority levels based on ASSESSMENT of illness or injury severity
Highest acuity receives quickest intervention
Emergent
Patient has immediate threat to life or limb, and requires immediate treatment
Urgent
Patient should be treated quickly but immediate threat to life does not exist at the moment
Nonurgent
Patient can usually wait several hours for care without risk
ESI
Uses an algorithm that fosters rapid, reliable, and clinically pertinent categorization into 5 groups 1 emergent to level 5 non urgent. Organized process to maintain objectivity. Mistriage can be the root cause of delayed or inadequate treatment with potentially deadly consequences
Disposition
Admission to hospital
Transferred to specialty care center
Discharged to home with instructions and follow-up
Patient and family education:
Key role of the emergency nurse; health teaching
Topics are quite broad and range from safety issues such as fall prevention to medication education and home management of serious conditions, discharge instructions.
Death in ED
May occur sudden and unexpected, or be anticipated (e.g., terminal illness)
Family presence during resuscitation
For trauma deaths, suspected homicide, and abuse cases: leave IV lines, indwelling tubes in place
Communication with family members in crisis
Homelessness
Homelessness results from crisis or persistent poverty. Vulnerability to certain conditions. Challenges involved in evaluation, treatment, and disposition.
Trauma nursing principals
Injury management is a key component
Accredited trauma centers: additional opportunities for development of expertise
Mechanism of injury (MOI)
Manner in which traumatic event occurred:
Blunt trauma
Blast effect
Acceleration–deceleration forces
Penetrating trauma
Primary Survey and Resuscitation Interventions
Primary survey
(A) Airway/cervical spine
(B) Breathing
(C) Circulation
(D) Disability
(E) Exposure
Exception; in presence of excessive bleeding, use <C>ABC</C>
Secondary Survey and Resuscitation Interventions
Comprehensive head-to-toe assessment
Identifies other injuries/issues
The nurse anticipates
Insertion of gastric tube and urinary catheter
Preparation for diagnostic studies
Airway
Establishing a patent airway is highest priority unless massive, life-threatening external hemorrhage
Even minutes without adequate oxygen can lead to brain injury
Nonrebreather mask is best for the spontaneous breathing patient
Bag-valve mask ventilation with the appropriate airway adjunct and a 100% oxygen source is indicated for person who needs ventilatory assistance
Significantly impaired consciousness (8 or less on GCS) requires endotracheal tube and mechanical ventilation
Breathing
Assess whether ventilator efforts are effective
Listen to breath sounds, evaluate chest expansion and respiratory effort and any evidence of chest wall trauma
Circulation
Adequacy of heart rate, BP and overall perfusion. Common threats to circulation: cardiac arrest, myocardial dysfunction and hemorrhage leading to shock.
Disability
Rapid baseline of neurologic status
A Alert
V Responsive to Voice
P Responsive to Pain
U Unresponsive
OR USE GLASGOW COMA SCALE
Exposure
Remove clothing for complete exam
Prevent hypothermia, cover with blankets
If evidence preservation is issue, handle per policy
Secondary Survey and Resuscitation Interventions
More comprehensive head-to-toe assessment to identify other injuries or medical issues
Splints applied or temporary dressings until diagnostic testing.
Disposition
Transport to OR or interventional radiology suite
Admission to inpatient unit
Transfer to a higher level of care
Psychiatric referral or admission
HIGH Risk Alcohol abuse - Screening, Brief intervention, and referral to treatment (SBIRT)
Which patient will the emergency nurse triage for care first?
7-year-old with protruding ulnar fracture
19-year-old with nausea and back pain, stating “I have kidney stones”
43-year-old with weakness and 102 F fever
54-year-old with upper abdominal pain radiating to left shoulder and profuse sweating
D
Based on the information provided, the patient experiencing upper abdominal pain and profuse sweating should be triaged first. Upper abdominal with radiating left shoulder pain are possible signs of referred chest pain which may indicate a myocardial infarction—an emergent condition. The emergent triage category implies that a condition exists that poses an immediate threat to life or limb. The urgent triage category indicates that the patient should be treated quickly but that an immediate threat to life does not exist at the moment. Examples of patients who typically fall into the urgent category are those with renal colic, complex lacerations not associated with major hemorrhage, displaced fractures or dislocations, and temperature greater than 101 F (38.3 C).
A patient undergoing triage reports dizziness. As the nurse collects assessment information, the patient suddenly reports difficulty breathing and faints. The patient has a pulse of 80 and respirations are 22. BP 100/60. What are priority nursing actions? Select 2.
Repeat vital signs.
Contact Radiology for urgent chest x-ray
Evaluate the patient’s level of consciousness.
Assess airway, position and administer oxygen, as needed.
Summon help
E, D
Summon help from other ED staff!
The primary survey organizes the approach to the patient so that immediate threats to life are rapidly identified and effectively managed. The primary survey is based on a standard “ABC” mnemonic with a “D” and “E” added for trauma patients: airway/cervical spine (A), breathing (B), circulation (C), disability (D), and exposure (E). The highest priority intervention is to establish a patent airway. All other actions can be completed after the airway is established.
An 80 year old female patient is being evaluated for what her husband describes as a fall after tripping over their small dog. Upon assessment, multiple bruises in various stages of healing are noted around the patient’s face, neck, and upper arms. What is the appropriate nursing intervention?
Complete the physical examination.
Ask the ED’s forensic nurse examiner to see the patient.
Inquire, “Is everything okay between the two of you?”
Make an anonymous call to social services to report suspected domestic violence.
B
The nurse should ask the forensic nurse to see the patient. Many EDs have specialized teams that deal with high-risk populations of patients. Forensic nurse examiners (RN-FNEs) are educated to obtain patient histories, collect forensic evidence, and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence, also known as intimate partner violence (IPV). They are trained to recognize evidence of abuse and to intervene on the patient’s behalf.
Hypersensitivity
Altered immune response to an antigen that results in harm. Response may be bothersome or life-threatening
Type I hypersensitivity
(IgE-mediated)
Common hypersensitivity reactions
Examples: allergic asthma, hay fever, hives
Triggered when allergen interacts with free IgE
Allergens can be ingested in foods, injected, inhaled, absorbed
Systemic response
Anaphylaxis, urticaria, angiodema
Anaphylaxis:
acute systemic response, may result in shock, death in highly sensitive individuals. Localized response, such as asthma, more common with strong genetic predisposition.
Type II hypersensitivity
(cytotoxic)
Binding of IgG- or IgM-type with antigen activates complement cascade
Destruction of target cell
May be stimulated by:
Exogenous antigen (foreign tissue, cells)
Drug reaction
Withdrawal of drug stops hemolysis
Endogenous antigen
Results in autoimmune disorder
Type III hypersensitivity
(immune complex–mediated)
Results from formation of IgG or IgM antibody–antigen immune complexes in circulatory system
Systemic; immune complex deposited in small blood vessels, kidneys, joints
Serum sickness
Localized; immune complexes accumulate at specific site
Type IV hypersensitivity
(delayed)
Cell-mediated immune responses. Results from exaggerated interaction between antigen, normal cell-mediated mechanisms, contact dermatitis.
Latex allergy; common in certain patients
Spina bifida
Congenital, urologic, gastrointestinal (GI), tracheoesophageal defects
Multiple surgeries
Diabetes requiring insulin
History of atopy
Often coexists with allergy to certain foods
Immune mediated response risk factors
Incidence and intensity increase with previous exposure, age, sex, concurrent illnesses, previous reactions to related substances. Family member with allergy.
Development, severity factors: older age, lung disease, route of antigen entry, amount of antigen introduced, rate of absorption of antigen, degree of individual hypersensitivity
Four types of reactions
Type I: localized S/S
Hypotension, wheezing, GI or uterine spasm, stridor, urticaria
Four types of reactions
Type II: tissue specific S/S
Varying manifestations, dyspnea, fever
Four types of reactions
Type III: immune mediated S/S
Urticaria, fever, joint pain
Four types of reactions
Type IV: delayed, variable S/S
Fever, erythema, itching
Mild hypersensitivity responses s/s
Discomfort
Fatigue
Lasts hours to a few days
Resolve by themselves or with over-the-counter (OTC) treatment
Rhinitis or asthma lasting beyond a day or two may result in localized infection
Moderate hypersensitivity reactions s/s
Localized pain and inflammation
Difficulty breathing
Loss of smell, taste, appetite
Skin reactions: urticaria, atopic and contact dermatitis
Food allergies: urticaria, GI symptoms
Severe hypersensitivity reactions s/s
May lead to respiratory distress, death
Caring for pt with hypersensitivity rxn
Focus on minimizing exposure to allergen, preventing hypersensitivity reaction, providing prompt, effective interventions for allergic responses, identifying allergen is key, history of exposure, type of response, onset, manifestations, withdraw allergen immediately, maintain airway, cardiac output, manage bleeding, renal failure, supportive care to relieve discomfort
Laboratory testing
WBC count with differential
Radioallergosorbent test (RAST)
Blood type and crossmatch
Indirect Coombs test
Direct Coombs test
Immune complex assays
Complement assay
Skin testing
Determine causes of hypersensitivity reactions
Allergens selected according to patient’s history
Epicutaneous testing done first to avoid systemic reaction
Specific skin tests: prick (epicutaneous or puncture) test, intradermal test, patch test, food allergy test
Pharmacologic therapy for hypersensitivity rxn
Based on severity of hypersensitivity reaction: IV for severe reactions, oral for mild reactions
Antihistamines
Mast cell stabilizers
Leukotriene modifiers
Corticosteroids
Epinephrine
Immediate treatment for anaphylaxis
Patients with history of anaphylaxis should carry EpiPen
Nonpharmacologic therapies for hypersensitivity rxn
Dictated by severity of response, organ system affected
Airway management is highest priority for patient with acute anaphylactic reaction
Severe laryngospasm: emergency tracheostomy or endotracheal tube
IV line, fluid resuscitation
Anaphylaxis: risk for vasomotor collapse, hypotension
Nonpharmacologic therapies for hypersensitivity rxn: Plasmapheresis
Blood passed through blood cell separator
Plasma and glomerular-damaging antibody–antigen complexes removed
RBCs returned to patient with albumin, plasma
Done as a series of treatments
Potentially risky
Complementary therapies for hypersensitivity rxn
Patients with type I hypersensitivity should contact physician before using herbals, teas, aromatherapy
Concern about allergic reactions to chamomile
Individuals with __ __ and __ at increase risk for anaphylactic reaction
food allergies, asthma
Lifespan considerations with hypersensitivity rxn
Older adults at greater risk
Teens with food allergies at high risk
Tend to eat outside home
Less likely to carry their medication
Allergies tend to run in families
Results of studies on prevention confusing, controversial
May outgrow certain allergies as patient ages
Uncommon to outgrow allergy to peanuts, tree nuts, fish, shellfish
Individuals who develop allergies in adulthood typically have them for rest of their lives
Hypersensitivity in children, adolescents
Food allergies affect ~48.5% of children ages 0–18 years
Reduce risk of exposure
Educate families on what to do when child has allergic reaction
Peanut allergy increased significantly
EPIT could be first FDA-approved treatment for peanut allergy
Hypersensitivity in adults
Fish and shellfish allergy most prevalent, then allergies to peanuts and tree nuts
More likely to persist into adulthood than allergies to milk, eggs, wheat, soy
Drug allergies not uncommon, may be cause of up to 20% of anaphylaxis fatalities
Physical assessment for pt with hypersensitivity rxn
Mucous membranes of nose, mouth
Lesions, rashes on skin
Tearing, redness of eyes
Respiratory rate
Breath sounds
Planning for pt with hypersensitivity rxn
Goals may include that patient will:
Avoid known substances that provoke hypersensitivity response
Describe self-care to reduce symptoms of seasonal allergies
Describe proper self-administration of medications
Help determine substances that cause hypersensitivity by keeping an accurate food journal
