• Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/70

Click to flip

70 Cards in this Set

  • Front
  • Back
Emergency
Medical/surgical condition requiring immediate or timely intervention to prevent permanent disability or death
Emergency Nursing
the care of clients who require emergency intervention
Definition - trauma
a wound or injury and usually is caused by a force outside the person
we must decide quickly what needs to be done
if you appear to be confident others will follow your instructions and assist you
Brain cell - life without O2
brain cells do not have an oxygenated blood supply, they begin to die within 4-6 minutes, there fore quick action is necessary
Good Samaritan Act
these laws provide protection against malpractice to persons who stop at the scene of an accident and render safe and appropriate care
Disaster
situation or event of greater magnitude than emergency, unforeseen, serious, or immediate threats to public health
Natural disasters
fires, earthquakes, floods, hurricanes, tornadoes
Man made disasters
war, terrorism, contamination of the environment
Types of emergencies
MVA
falls
fires
assaults (knives guns)
swimming, boating
poisoning
machinery
electrical
what to do in the event of an emergency
assess safety - make sure scene safe before rushing to assist in an emergency
check environment
if unsafe, call for help before assisting
the person should not be moved if the area is safe
Key concept - universal precautions should be followed whenever possible
carry disposable gloves and a face mask
Identify problems
anything unusual about situation?
clues: empty containers, suicide, poisoning, drug abuse, alcohol abuse
check for medic alert tag
triage
process of sorting and classifying a person to determine priority of needs
involves determining life-threatening situations and those pts first. May be done in ER or clinic
Triage classification
classification of clients to determine priority of need, proper place of tx
hospital triage
used to establish priorities and levels of care needed by clients
disaster triage
system utilized in event of a community disaster, different from hospital system
emergency medial services (EMS)
EMT - trained to provide basic lifesaving measures prior to arrival at the hospital
Paramedic - more specialized, trained to provide advanced life support to client requiring emergency interventions
Assessing in emergencies
make primary assessment ASAP (60 sec max)
Secondary assment - taking VS (write them down) and a dead to toe assessment (1-2 min)
unless immediate intervention needed
if life-threatening problem secondary assessment may be delayed
9 diagnostics signs to observe initially
1. respiratory effort
2. pupillary changes
3. skin color
4. refelxes
5. vital signs
6. LOC
7. posture
8. skin temp/turgor
9. deformities
ABCDE for assessment
A - airway and cervical spine
B - breathing
C - circulation and bleeding
D - disability
E - expose and examine
Airway and Cervical Spine
check patency
immobilize c spine
open air way using jaw thrust
if no trauma may use head tilt chin lift method
Breathing
listen for breath sounds
feel for breathing
if not present - pinch nose and give 2 rescue breaths
if unable to ventilate, reposition head and reattempt
maintain airway, remove vomit
tongue can occlude
observe respirations - normal rate and depth
color and moisture
cyanosis
Circulation and bleeding
palpate the pulse for 5-10 seconds
observe the pulse - note rate and regularity
is it normal?
do not count it now - just observe
Pulse assessment
reassess for breathing
assess skin
assess for shock
stop bleeding
Pulse assessment
weak rapid - loss of blood, shock
rapid, bounding - fear, anxiety
slow, bounding - head trauma, heart block
absent - death
skin assessment
ashen - shock, fright
red - fever, sunburn
cherry red - carbon monoxide
purple - respiratory distress
Shock assessment
use capillary refill to evaluate for shock
pupils will dilate
press finger into middle of forehead until white
remove finger, count seconds for color to return
if takes >3 seconds shock is progressing
assess for hemorrhage
stop bleeding
must be done immediately
place sterile compress over wounds and apply pressure
do not remove old dressings - place additional compress
implement measure to stop bleeding
apply a direct pressure
elevate a bleeding limb above heart level
apply ice or cold pack
apply indirect pressure
if severe, reach into the wound and try to grasp the bleeder with your fingers
apply tourniquet (final option)
Disability
Neurologic: A, V, P, U
Assess eye signs
A, V, P, U
A - alert - speaks and moves spontaneously, answers questions about name place, date correctly
V - responsive to verbal stimulus only, answers when directly addressed
P - responsive to painful stimulus only (rubbing sternum or pressure on nail beds)
U - unresponsive
Eye signs
assess pupillary responses
pupils should be the same size, round, and constrict when a bright light is quickly shined on them
abbr: PERRLA +c (coordinated)
failure to react: r/t blindness, nerve damage, cataract, death, head injury
Expose and Examine
check any site for possible injury, even if already examined and pt still complains of it
after you have life-threatening under control, obtain info from pt
try to find out what happened
VS q 5min - count pulse and resp for 30 sec (this records a baseline for future treatment)
Head
inspect for bleeding, depressions of skull, lacerations, avulsions, embedded foreign bodies, puncture wounds, swelling, ecchymosis
Eyes
palpate for tenderness, bony deformities, bruising around the eyes
redness in eyes, contact lenses, assess gross vision - can they see from both eyes
assess pupillary response, size of pupils and symmetry, assess movement of eyes
Ears
inspect for drainage (note color, consistency of drainage)
inspect for bruising behind ears, lacertations
Nose
inspect for drainage (note color and consistency)
palpate for tenderness, bony deformities
Neck
inspect for penetrating objects, tracheal deviation, neck vein distension, swelling, bruising, palpate for tenderness, tracheal deviation, subcutaneous emphysema
Chest
inspect for penetrating objects, lacerations, avulsions, embedded foreign bodies
look at symmetry and expansion of chest wall
observe rate of respirations, depth, use of accessory muscles (flail chest)
auscultate for heart and lung sounds
Abdomen
inspect for penetrating objects, lacerations, avulsions, embedded foreign bodies, puncture wounds, swelling, ecchymosis
inspect for protruding abdominal contents and distension
palpate for tenderness, rigidity
auscultate for bowel sounds
Pelvis/Genitalia
inspect for deformity of pelvis and blood at the urinary meatus or rectum, check rectal sphincter tone
observe for priapism
Extremities
inspect for deformities, lacerations, missing fingers or toes, swelling, bruising
assess circulation to area, sensation, ability to move - bilaterally
palpate for tenderness, pain, pulses
Back
inspect for deformities, lacerations, bruising
palpate for tenderness
shock - definition
condition of profound hemodynamic and metabolic disturbance - inadequate tissue perfusion and body's inability to meet tissue demand for oxygen
shock
regardless of etiology, the primary pathophysiologic outcome in shock consists of hypoperfusion, which results in tissue hypoxia, acidosis, and end organ dysfunction
shock can develop ____
rapidly
in shock, ______ _______ can keep a person responsive
compensatory mechanisms
Types of shock
Hypovolemic
Cardiogenic
Vasogenic
Metabolic
Obstructive
Psychogenic
Hypovolemic shock
caused by:
trauma
hemorrhage
severe burns
dehydration
Cardiogenic shock
caused by inefficiency of heart
Myocardial infarction
Cardiac tamponade
restrictive pericarditis
pulmonary embolus
arrhythmias
Vasogenic shock
massive basodilation
neurogenic: interference with sympathetic nervous system
anaphylactic: vasodilation secondary to massive histamine release, allergies
septic: caused by severe infection
Metabolic shock
often associated with diarrhea, vomiting, polyuria
alteration in pH, K, Na, electrolytes
Obstructive shock
obstruction to central arteries or veins
pulmonary emboli
tension pneumothorax
Psychogenic shock - fainting
caused by nervous system reaction and is often results of fear
Effects of shock on the five vital organs
heart - decreased coronary artery perfusion causes decreased function of the heart muscle as a pump, stroke volume and blood pressure decrease
brain: if oxygen and nutrient supplies are inadequate, brain function diminishes and unconsciousness follows
lungs: as the partial pressure of oxygen decreases because of decreased blood volume or blood pressure, gas exchange does not take place at the capillary membrane level
liver: glycogen stores are depleted by an excess of circulating epinephrine, metabolic acids that are normally detoxified in the liver cause acidosis
kidneys: a drop in cardiac output causes a decrease in blood flow through the kidneys, decreased urinary output and renal failure result
Tx of shock
hypovolemic - restore volume
cardiogenic - improve myocardial function
septic - IV antibiotics and fluids
neurogenic - meds for hypotension
anaphylactic - identify cause - epi/benandryl
obstructive - identify and treat the cause
treating shock
keep pt lying and calm
call for assistance
establish and maintain and monitor airway
administer high concentrations of O2
control bleeding
maintain body temp
NPO
elevate lower extremities
use position that is most comfortable for pt
immobilize fx
monitor LOC, VS q 5 min
cardiopulmonary emergencies
emergencies that jeopardize the function of the heart and lungs
may result from trauma or illness
manage to maintain the ABCs
other tx modalities include testing, meds, and prevention of complications
types of chest injuries
blunt trauma
penetrating objects
compression
open - skin is broken
closed - skin is not broken
S/S of chest injuries
pain
shock
distended neck veins
painful/difficult breathing
trachea deviation - pushed to uninjured side
coughing up blood
failure of chest to expand equally
pain on compression of side of chest wall
subcutaneous emphysema
air from puncture in airway or lung that has invaded tissues of thorax and neck
pt reports crackling sensation under skin or you may feel this placing fingers over the injury site
unequal air entry
specif chest wounds
pneumothorax
spontaneous pneumothorax - usually when a weakened section of lung ruptures and releases air into the thoracic cavity - can become life threatening if tension pneumo develops
tx of chest wounds
maintain airway
O2
care for shock
monitor pt making certain airway is open
seal chest wound asap - can used gloved hand - do not delay sealing the wound to find an occlusion dressing (saran wrap must be folded several times to suffice)
2 methods of dressing - tape occlusive dressing in place with one corner unsealed to relieve pressure as pt inhales it will seal
tape all 4 edges - seal last edge when pt forcefully exhales, if effective respirations will stabilize
complications of chest wounds
tension pneumo - opening in the lung
hemothorax, hemopneumo
cardiac tamponade
traumatic asphyxia
cardiovascular emergencies - epistaxis
if fractured skull, do not attempt to stop bleeding, could cause increase in ICP
if hypertension: may be body's safety valve against CVA
cardiovascular emergenices - fainiting, hemorrhage
hemorrhage -
first assess the type of bleeding
if capillary: slow, oozes from wound
if arterial: spurts bright red or pink
if venous: steady flow, darker red. Usually minor and stops by self
if internal: major emergency
MAST trousers
military antishock trousers
used in cases of massive internal hemorrhage or hypovolemia
pressure is evenly applied to body and supports circulation and lessens shock
applied only by emergency personnel
nurse never applies or removes them
suspected heart attack
S/S - chest pain, shortness of breath, diaphoresis, pressure
tx - MONA
be prepared to perform CPR
neurological/neurosurgical emergencies
head injuries, spinal cord trauma, strokes or brain attacks
manage to maintain ABCs
other tx includes maintaining respirations, monitoring for increased ICP, medications, positioning
injuries to skull or spine
fx to cranium or face which can cause direct or indirect injury to brain
Open - if bones of cranium are fx and dura is broken
closed - if bones of cranium are intact
brain injuries
concussion - may feel groggy after receiving blow to head, headache common
amnesia common r/t events surrounding incident
contusion - bruised brain - when force fo blow is great enough to rupture cerebral blood vessels
subdural hematoma - brain is bruised, lacerated, punctured. Blood from ruptured vessels flow between meninges. blood clot between dura mater and brain
epidural hematoma - when blood flows between the meninges and skull
intracerebral hematoma - blood pools in the brain
lacerations - penetrating or perforating wounds of cranium
injuries to spine
S/S r/t extent of injury and location
tenderness at injury site
deformity of spinal column is rare
impaired breathing
priapism
posturing
involuntary loss of bowel and bladder control
nerve impairment of extremities
paralysis of extremities is probably the most reliable sign of spinal injury in conscious patients
severe shock
tx for spine injuries
stabilize neck and head