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105 Cards in this Set
- Front
- Back
- 3rd side (hint)
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What is the purpose of triage? |
To sort and classify patients according to acuity & priority. |
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Who is the gatekeeper to the ER? |
The triage nurse |
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The triage nurse indicates _ based on assessment. |
protocols |
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What are the 3 main classifications and the three-tiered triage system? |
Emergent (life threatening). Urgent (quick treatment, but not immediately life threatening). Non-urgent (could wait several hours). |
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Give 3 examples of things that are emergent. |
Respiratory distress, chest pain, and unstable vital signs. |
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Give 2 examples of things that are urgent. |
Displaced or multiple fractures, or severe abdominal pain. |
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Give 3 examples of things that are non-urgent. |
Strain or sprain, "colds", or simple fracture. |
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What is the focus of the primary survey? Mnemonic? |
A, B, C, D, & E. Airway, breathing, circulation, disability, and exposure. |
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If life-threatening conditions related to ABCDE are identified during the primary survey, what will happen? |
Interventions are started immediately and before proceeding to the next step of the survey. |
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What happens during the secondary survey? |
Comprehensive head to toe assessment. |
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Primary survey - airway with cervical spine stabilization and / or immobilization. Name 4 signs / symptoms in a patient with a compromised airway. |
Dyspnea, inability to vocalize, presence of foreign body in airway, and trauma to face or neck. |
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Primary survey - in what order would we maintain the airway? |
Least to most invasive method. |
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Primary survey - name the four activities we would do to maintain airway and in the proper order. |
Open airway using the jaw-thrust maneuver. Suction and/or remove foreign body. Insert nasopharyngeal / oropharyngeal airway. Endotracheal intubation. |
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Primary survey - what are 6 things having to do with breathing that we would assess? |
Dyspnea, cyanosis, paradoxic / asymmetric chest wall movement, decreased / absent breath sounds, tachycardia, and hypotension. |
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Primary survey - what are two options for fixing a breathing problem? |
Administer high-flow oxygen via a non rebreather mask. Bag-valve-mask ventilation with 100% oxygen and intubation for life-threatening conditions. |
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Primary survey - after taking action to fix a breathing problem, what would we do next? |
Monitor patient response. |
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Primary survey - what would you check to assess circulation? |
Central pulse. |
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Primary survey - why would you check central pulse instead of checking peripheral pulses? |
Peripheral pulses may be absent because of injury or vasoconstriction. |
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Primary survey - what are for action / assessments for circulation? |
Assess skin for color, temperature, and moisture. Assess mental status and capillary refill. Insert 2 large bore IV catheters. Initiate aggressive fluid resuscitation using NS or LR solution. |
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Primary survey - what are 4 action / assessments for circulation? |
Assess skin for color, temperature, and moisture. Assess mental status and capillary refill. Insert 2 large bore IV catheters. Initiate aggressive fluid resuscitation using NS or LR solution. |
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Primary survey - what is a specific example of why we would check a central pulse instead of peripheral? |
Shock because if the patient is going into shock, he will have blood shunted to the core. |
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Primary survey - how do you measure disability? |
By the patient's level of consciousness. |
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Primary survey - what are three ways we would check the patient's level of consciousness for disability? |
AVPU, Glascow Coma Scale, and pupils. |
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Primary survey - What is AVPU? |
Alert, responsive to voice, responsive to pain, and unresponsive. |
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Primary survey - what 4 things do we assess in the pupils? |
Size, shape, response to light, and equality. PERRLA |
Pupils equal round reactive to light and accommodation. |
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Primary survey - what two things do we do about exposure / environmental control? |
Remove clothing. Provide temperature control - avoid hypothermia. |
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Secondary survey - what are the 3 F's? |
Full set of vital signs - / Five interventions / Facilitate Family presence. |
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Secondary survey - the complete set of vital signs include blood pressure, heart rate, respiratory rate and temperature. What are things to remember when getting the blood pressure and temperature? |
The blood pressure has to be bilateral and the temperature has to be rectal. |
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Secondary survey - what are the 5 interventions? |
Initiate ECG monitoring, initiate pulse oximetry, insert indwelling catheter, insert or a gastric / nasogastric tube, and collect blood for laboratory studies. |
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Secondary survey - what are the 5 interventions? |
Initiate ECG monitoring, initiate pulse oximetry, insert indwelling catheter, insert orogastric / nasogastric tube, and collect blood for laboratory studies. |
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Secondary survey - what is the proper way to inspect the posterior surfaces? |
Logroll the patient while maintaining the cervical spine immobilization. |
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Secondary survey - what are the last 3 things you do in the secondary survey? |
Evaluate the need for tetanus prophylaxis. Provide ongoing monitoring and evaluate patient's response to interventions. Prepare to transport for diagnostic tests; admit to general unit, telemetry, or intensive care unit; transfer to another facility. |
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What is crush syndrome? |
External crush injury that compresses one or more compartments in the leg, arm, or pelvis. |
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What happens to the muscle with crush syndrome? |
Muscle becomes ischemic and necrotic. |
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In crush syndrome myoglobin is released into circulation. What can this lead to? |
Acute renal failure. |
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What are 7 indications of crush injuries? |
Acute compartment syndrome, hypovolemia, hyperkalemia, rhabdomyolysis, acute tubular necrosis, dark brown urine, and muscle weakness and pain. |
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What are the 6 P's of acute compartment syndrome? |
Pain, paresthesias, paralysis, pallor, purpura, and pulselessness. |
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How would we treat hyperkalemia if it was very high? If not very high? |
Is high we may give a combo of insulin glucose and calcium or kayexalate. If not very high we may give diuretics. |
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What is rhabdomyolysis? |
When muscles begin to destroy themselves. |
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Why does Christian syndrome cause acute tubular necrosis? |
Toxins from the crushing of tissue are released into the blood. |
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Why does crush syndrome cause acute tubular necrosis? |
Toxins from the crushing of tissue are released into the blood. |
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How will we prevent acute tubular necrosis? |
By starting IV fluids to flush these molecules through the kidneys. |
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What is the purpose of diuretics in crush syndrome? |
Helps get rid of high potassium levels. |
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What is the purpose of low dose Deborah mean in crush syndrome? |
To keep the kidneys well perfused so they don't have to work as hard. |
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What is the purpose of low dose dopamine in crush syndrome? |
To keep the kidneys well perfused so they don't have to work as hard. |
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When will we have to resort to hemodialysis in crush syndrome? |
If levels of toxins are too high to be treated with the other methods. |
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What is Kehr's sign? |
Pain from diaphramic injury or splenic injury that is referred to the left shoulder. |
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How is diagnostic peritoneal lavage done? What are you checking for? Why? |
The abdomen is punctured and fluid is put in and allowed to come out to see the characteristics of it. If it is blood tinged the patient might need immediate surgery. |
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What is FAST? What does it help us to see? |
Focused abdominal sonography for trauma. Looking for bleeding or ruptured organs in the abdomen. |
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What will happens if there is a diaphragmatic injury? |
Guts will go through the diaphragm and into the lungs. |
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What will happen if there is a diaphragmatic injury? |
Guts will go through the diaphragm and into the lungs. |
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What are the purposes of the Foley in the NG tube for multiple trauma? |
The Foley is to monitor volume and NG tube to decrease the risk of aspiration. |
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Name 3 main causes for heat related emergencies. |
High environmental temperature > 95, high humidity > 80, & physical factors. |
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Heat related emergencies - what are 4 physical factors? |
Age, health status, medications, and hydration. |
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Heat related emergencies - name 2. |
Heat exhaustion and heat stroke. |
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Heat exhaustion - what is the primary cause? |
Dehydration |
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Heat exhaustion - to what other illness are the symptoms similar? |
Flu |
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Heat exhaustion - what is the normal characteristic of the person's temperature? |
Mild elevation |
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Heat exhaustion - what can happen if not treated? |
Can escalate to heat stroke. |
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Heat exhaustion - name 5 ways to treat this outside of the hospital. |
Move to a cool place, apply cold packs, soak in cool water, remove constrictive clothing, and provide sports drink. |
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Heat exhaustion - what are four ways to treat this in a clinical setting? |
Vital signs, rehydrate with normal saline, labs, and admission to the hospital if indicated. |
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Heat stroke - how do we regard this? |
It is a true medical emergency. |
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Heat stroke - describe the body temperature. |
It may exceed 104 degrees. |
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Heat stroke - if untreated what will occur? |
Organ dysfunction and death. |
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Heat stroke - what are the two types? |
Exertional and classic. |
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Heat stroke - for what 5 things do you assess? |
Elevated temperature, mental status changes, hypertension, tachycardia, and tachypnea. |
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Heat stroke - Name 2 complications. |
MODS and cerebral edema. |
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Heat stroke - pre hospital - name four ways to rapidly cool. |
Remove clothing, ice packs, immerse in cold water, and wetting patient and fanning. |
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Heat stroke - what are 7 things you would do to treat in the clinical setting? |
Airway breathing circulation, oxygen therapy, IV therapy with normal saline, iced gastric / bladder / peritoneal /thoracic lavage, aggressively cool until rectal temperature is 100.4, Thorazine for shivering, and benzodiazepines for seizure activity. |
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Heat stroke - why would you not use lactated ringers? |
Because they already have electrolyte imbalances. |
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Hypothermia - at what point would a person be considered hypothermic? |
Core body temperature <95 (this is a rectal temperature). |
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Hypothermia - what are 4 risk factors? |
Elderly, certain drugs, alcohol, and diabetes. |
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What are 4 symptoms of mild hypothermia? |
Shivering, mental slowness (confusion), cold diuresis, and minor heart rate changes. |
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Hypothermia - mild - what is the temperature range? Moderate? Severe? |
90-97 degrees 82 - 90 degrees Below 82 degrees |
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What are 5 symptoms of moderate to severe hypothermia? |
Motor impairment and weakness, cognitive deterioration, depressed vital signs, vfib threshold is decreased, and shivering disappears at < 92 degrees. |
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Hypothermia - why is it important to move a cold person around very carefully? |
If you jar them around you could send them into ventricular fibrillation. |
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Hypothermia - at what point would the patient go into a coma? |
When the core temperature is < 82.4 degrees. |
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Hypothermia - at what point would death usually occur? |
Core temperature <78°F |
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Profound hypothermia makes the person appear dead. What would be the core temperature at this point? |
<86°F |
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What three things happen with profound hypothermia? |
Bradycardia, asystole, and ventricular fibrillation. |
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Hypothermia - what is the actual cause of death? |
Refractory ventricular fibrillation. |
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Hypothermia - name 4 general actions to take in the treatment of hypothermia. |
Manage & maintain ABC's, rewarm patient, correct dehydration and acidosis, and treat cardiac dysrhythmias. |
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What are the 2 types of rewarming for mild hypothermia? |
Passive and active external rewarming. |
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Hypothermia - active external rewarming - what 3 things do you do? |
Body to body contact, fluid or air-filled warming blankets, and radiant heat lamps. |
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Hypothermia - what kind of rewarming for moderate to profound hypothermia? |
Active Core Rewarming |
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Hypothermia - what 3 things does active core rewarming involve? |
Use of heated, humidified oxygen; warmed IV fluids; peritoneal, gastric, or colonic lavage with warm fluids. |
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Hypothermia - what are three risks of rewarming? |
Afterdrop, hypotension, and dysrhythmias. |
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What is afterdrop? |
A further drop in core temperature. |
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Explain how hypotension and afterdrop happen during rewarming. |
Because (just like in shock) when we get cold, our body is going to shut down the peripheral circulation and shift everything to the core to preserve the heat in the core of the body. So when rewarming, the body will vasodilate and let blood back into the cold extremities. This causes hypotension. Also, when the blood goes from the extremities back to the core, it is going to bring cool blood. This causes afterdrop. |
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At what point should rewarming be discontinued? |
Once the core temperature reaches 95°F. |
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Frostbite - who is at higher risk? |
Client with impaired peripheral circulation. |
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Frostbite can be superficial or deep . Describe superficial frostbite. |
Frostnip - areas are pale, numb, and painful. |
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Frostbite - what are the four stages of deep frostbite? |
1st 2nd 3rd and 4th degree. |
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Frostbite - describe first degree. |
Reddened and edematous. |
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Frostbite - describe second degree. |
Large blisters and may have partial thickness necrosis. |
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Frostbite - describe 3rd degree. |
Small blisters with dark fluid. Cool to touch. Blue or red. Won't blanch because vasculature is reduced too much. Full thickness and sometimes subq becomes necrotic. Will require some debridement. |
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Frostbite - describe 4th degree. |
No blisters. Numb, cold, and bloodless. Necrosis goes all the way through the skin and subcutaneous tissue down to muscles and even bone. May require amputation. |
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How do you treat superficial frostbite? |
Use body heat to warm the affected area. |
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Name 5 ways to treat deep frostbite. |
Rapid rewarming in warm water bath, IV pain meds, elevate extremity, tetanus immunization, and surgery. |
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Why can you not rub a person with deep frostbite to warm them? |
Because they actually have ice crystals in them that can damage the tissue. |
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Submersion - what two things do we need to know about this occurrence? |
What kind of water was the patient in and how long was the patient submerged. |
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Submersion - what is the difference in being submersed in freshwater and saltwater? |
With fresh water, water rapidly leaks to the capillary bed & circulation causing water intoxication. Saltwater draws fluid into the alveoli. |
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Submersion - what three things happen to the lungs? |
Surfactant destruction, alveolitis, and destruction of alveolar-capillary membrane. |
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Submersion - what does submersion ultimately cause? |
respiratory failure |
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Submersion - following ABCD what 6 actions do we take? |
Mechanical ventilation PEEP or CPAP to improve gas exchange when pulmonary edema is present. Correct hypoxia. Correct acid-base & fluid imbalances. Support basic physiologic functions. Gastric decompression. Rewarm if hypothermia present. |
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