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70 Cards in this Set
- Front
- Back
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Emergency
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Medical/surgical condition requiring immediate or timely intervention to prevent permanent disability or death
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Emergency Nursing
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the care of clients who require emergency intervention
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Definition - trauma
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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 |
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Brain cell - life without O2
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brain cells do not have an oxygenated blood supply, they begin to die within 4-6 minutes, there fore quick action is necessary
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Good Samaritan Act
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these laws provide protection against malpractice to persons who stop at the scene of an accident and render safe and appropriate care
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Disaster
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situation or event of greater magnitude than emergency, unforeseen, serious, or immediate threats to public health
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Natural disasters
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fires, earthquakes, floods, hurricanes, tornadoes
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Man made disasters
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war, terrorism, contamination of the environment
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Types of emergencies
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MVA
falls fires assaults (knives guns) swimming, boating poisoning machinery electrical |
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what to do in the event of an emergency
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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 |
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Identify problems
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anything unusual about situation?
clues: empty containers, suicide, poisoning, drug abuse, alcohol abuse check for medic alert tag |
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triage
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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 |
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Triage classification
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classification of clients to determine priority of need, proper place of tx
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hospital triage
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used to establish priorities and levels of care needed by clients
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disaster triage
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system utilized in event of a community disaster, different from hospital system
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emergency medial services (EMS)
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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 |
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Assessing in emergencies
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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 |
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9 diagnostics signs to observe initially
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1. respiratory effort
2. pupillary changes 3. skin color 4. refelxes 5. vital signs 6. LOC 7. posture 8. skin temp/turgor 9. deformities |
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ABCDE for assessment
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A - airway and cervical spine
B - breathing C - circulation and bleeding D - disability E - expose and examine |
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Airway and Cervical Spine
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check patency
immobilize c spine open air way using jaw thrust if no trauma may use head tilt chin lift method |
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Breathing
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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 |
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Circulation and bleeding
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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 |
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Pulse assessment
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weak rapid - loss of blood, shock
rapid, bounding - fear, anxiety slow, bounding - head trauma, heart block absent - death |
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skin assessment
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ashen - shock, fright
red - fever, sunburn cherry red - carbon monoxide purple - respiratory distress |
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Shock assessment
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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 |
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stop bleeding
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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) |
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Disability
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Neurologic: A, V, P, U
Assess eye signs |
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A, V, P, U
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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 |
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Eye signs
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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 |
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Expose and Examine
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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) |
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Head
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inspect for bleeding, depressions of skull, lacerations, avulsions, embedded foreign bodies, puncture wounds, swelling, ecchymosis
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Eyes
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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 |
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Ears
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inspect for drainage (note color, consistency of drainage)
inspect for bruising behind ears, lacertations |
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Nose
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inspect for drainage (note color and consistency)
palpate for tenderness, bony deformities |
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Neck
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inspect for penetrating objects, tracheal deviation, neck vein distension, swelling, bruising, palpate for tenderness, tracheal deviation, subcutaneous emphysema
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Chest
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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 |
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Abdomen
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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 |
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Pelvis/Genitalia
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inspect for deformity of pelvis and blood at the urinary meatus or rectum, check rectal sphincter tone
observe for priapism |
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Extremities
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inspect for deformities, lacerations, missing fingers or toes, swelling, bruising
assess circulation to area, sensation, ability to move - bilaterally palpate for tenderness, pain, pulses |
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Back
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inspect for deformities, lacerations, bruising
palpate for tenderness |
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shock - definition
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condition of profound hemodynamic and metabolic disturbance - inadequate tissue perfusion and body's inability to meet tissue demand for oxygen
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shock
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regardless of etiology, the primary pathophysiologic outcome in shock consists of hypoperfusion, which results in tissue hypoxia, acidosis, and end organ dysfunction
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shock can develop ____
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rapidly
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in shock, ______ _______ can keep a person responsive
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compensatory mechanisms
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Types of shock
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Hypovolemic
Cardiogenic Vasogenic Metabolic Obstructive Psychogenic |
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Hypovolemic shock
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caused by:
trauma hemorrhage severe burns dehydration |
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Cardiogenic shock
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caused by inefficiency of heart
Myocardial infarction Cardiac tamponade restrictive pericarditis pulmonary embolus arrhythmias |
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Vasogenic shock
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massive basodilation
neurogenic: interference with sympathetic nervous system anaphylactic: vasodilation secondary to massive histamine release, allergies septic: caused by severe infection |
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Metabolic shock
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often associated with diarrhea, vomiting, polyuria
alteration in pH, K, Na, electrolytes |
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Obstructive shock
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obstruction to central arteries or veins
pulmonary emboli tension pneumothorax |
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Psychogenic shock - fainting
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caused by nervous system reaction and is often results of fear
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Effects of shock on the five vital organs
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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 |
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Tx of shock
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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 |
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treating shock
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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 |
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cardiopulmonary emergencies
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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 |
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types of chest injuries
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blunt trauma
penetrating objects compression open - skin is broken closed - skin is not broken |
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S/S of chest injuries
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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 |
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subcutaneous emphysema
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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 |
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specif chest wounds
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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 |
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tx of chest wounds
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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 |
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complications of chest wounds
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tension pneumo - opening in the lung
hemothorax, hemopneumo cardiac tamponade traumatic asphyxia |
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cardiovascular emergencies - epistaxis
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if fractured skull, do not attempt to stop bleeding, could cause increase in ICP
if hypertension: may be body's safety valve against CVA |
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cardiovascular emergenices - fainiting, hemorrhage
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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 |
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MAST trousers
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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 |
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suspected heart attack
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S/S - chest pain, shortness of breath, diaphoresis, pressure
tx - MONA be prepared to perform CPR |
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neurological/neurosurgical emergencies
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head injuries, spinal cord trauma, strokes or brain attacks
manage to maintain ABCs other tx includes maintaining respirations, monitoring for increased ICP, medications, positioning |
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injuries to skull or spine
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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 |
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brain injuries
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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 |
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injuries to spine
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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 |
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tx for spine injuries
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stabilize neck and head
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