• 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

1/20

Click to flip

20 Cards in this Set

  • Front
  • Back
what components does the primary survey focus on
A airway
B breathing
C circulation
D disability
E exposure/environment
signs & symptoms of airway compromise
dyspnea
inability to vocalize
drooling
presence of foreign body in airway
trauma to face or neck
ways to maintain airway (least invasive to most invasive)
jaw thrust maneuver
suction and/or remove foreign body
insert NG/oropharyneal airway
endotracheal intubation
what should be assessed for breathing phase of primary survey
assess for SOB
tachycardia
cyanosis
paradoxical/asymmetric chest wall movement
decreased/absent breath sounds on one side not other
hypotension
interventions for breathing part of primary survey
administer high flow O2 (100% via nonrebreather mask
Bag-valve mask ventilation w/100% O2 and intubation for life-threatening conditions
monitor pt response
assessment for circulation part of primary survey
check central pulses (carotid, apical, femoral)
assess skin for color, temp, moisture
assess mental status & capillary refill
interventions for circulation part of primary survey
insert 2 large-bore IV catheters
initiate aggressive fluid resuscitation using NS or LR
assessment for disability part of primary survey
AVPU
Glasgow Coma Scale
Pupils (PERRLA)
what happens in exposure/ environment part of secondary survey
all clothing is removed
provide temperature control
explain the importance of knowing the mechanism of injury in the assessment and care of the patient
it's important to know the mechanism so you know how to treat the patient.
collaborative management of head injury to prevent/treat secondary injury
Preventing secondary injury – blood that’s caustic to brain tissue, pneumonia include:
• Timely diagnosis
• Surgery if necessary
Frequent neurological assessment and report any changes to PCP
Use calm, gentle approach
Maintain normothermia
Pain management
Infection control
CT scan
surgery
placement of ICP monitor
Prophylactic seizure meds, control glucose, antibiotics to prevent infection
identify the use of the Glasgow Coma Scale in predicting severity of injury
Evaluates opening of the eyes, verbal response and motor response.
Highest score possible is 15
The higher the score the higher the brain function
Lowest possible score 3
Score of 8 or less is poor prognosis
Nurses must document technique used to illicit response so that each new nurse can be able to tell if the response is changed (worse or better) by using the same technique.
identify the components & significance of Cushing's Triad.
Components: systolic hypertension, decreased pulse and altered respiration patter.
Significance: with increased ICP compensatory mechanisms begin to fail and there is a loss of autoregulation. the systolic BP rises in an attempt to maintain cerebral perfusion. This causes the triad.
explain the rationale for the measures used to prevent & treat increased ICP
monitor airway
hyperoxygenate prior to suctioning
head in midline neutral position & HOB greater than 30 degrees to promote venous drainage
avoid clustering nursing activities
avoid overstimulation of client
identify immobilization techniques used to prevent secondary injury in SCI patients
skeletal traction to stabilize or bring spine back into proper alignment
halo w/ or w/o vest
surgery to reduce fracture or decompress spinal cord
treatment priorities during acute phase of SCI
airway mgmt
hemodynamic monitoring
ECG
assess for signs of decr tissue perfusion (decr BP, confusion, diminished/absent peripheral pulses)
prevent DVTs
discuss effects of SCI r/t ongoing mgmt during subacute & transitional phase of injury
autonomic dysreflexia can occur just as pt is recovering from spinal shock
incr hypertension can cause MI or retinal & cerebral hemorrhage
orthostatic hypotension common
common causes of autonomic dysreflexia
prevent distention of bladder & bowel
keep clothes, appliances loose
good nail care
prevent/treat pressure ulcers
common symptoms of autonomic dysreflexia
sudden rise in BP
seeing spots/blurred vision
pounding headache
nasal stuffiness
facial flushing
red blotches on chest
excessive sweating above level of injury
goose bumps
cool, clammy skin
nausea
anxiety
bradycardia
emergency interventions for autonomic dysreflexia
raise HOB
remove any abdominal binder or other restrictive devices
rapid acting antihypertensives - Procardia (nifedipine), nitroglycerin