High Acuity Exam Iv

Front 1

Primary Survey - Airway

Causes of life threatening conds

Back 1

inhalation injury
obstruction from foreign object or tongue
penetrating wounds to upper resp system

Front 2

Primary Survey - Breathing

Causes of life threatening conds

Back 2

anaphylaxis
flail chest w/pulm contusion
hemothorax (blood in chest)
pneumothorax (air in chest)

Front 3

Primary Survey - Circulation

Causes of life threatening conds

Back 3

cardiac injury (MI, trauma)
pericardial tamponade
shock (hypovolemia, r/t massive burns)
uncontrolled hemorrhage
hypothermia

Front 4

Primary Survey - Disability

Causes of life threatening conds

Back 4

head injury
stroke

Front 5

Secondary Survey - FGHI

What does each letter represent?

Back 5

F - full set of vitals, focused tx (EEG - HR and rhythm, O2 sat, add dx tests, etc), facilitate family prescence

G - Give comfort measures

H - hx, head-to-toes assessment

I - inspect posterior surfaces

Front 6

What is FAST?? When is it done?

Back 6

Focused assessment with sonography for trauma

Typically done in Secondary Survey - H - BUT can be done in primary (****remember this test should NOT delay emergency tx**)

It's done if intraabdominal hemorrhage is suspected and determine if **hemoperitoneum (blood in peritoneal space) is present
- if a retroperitoneal bleed is possible, need CT,
can't use this test
Benefits - non-invasive
- can be performed quickly and at bedside
- less radiation than CT - safe for peds - can be repeated mult times

Front 7

CARDINAL RULES of Multiple Trauma Pts
- List 3 of the 7 cardinal rules

Back 7

ALWAYS ASSUME a c-spine injury, if head/face trauma is present

ALWAYS ASSUME head injury, if alt LOC - Neuro assess

ALL young pts with unpalpable pulse are in SHOCK

ALWAYS ASSUME internal injuries or hemorrhaging, If CLINICAL S&S ARE PRESENT (hypOtension, tachycardia, pallor) - even if there are NO external injuries

ALWAYS ASSUME anyone w/ chest trauma is CRITICAL

ALWAYS ASSUME pericardial tamponade, if pt has distended neck veins

ALWAYS ASSUME penetrating wounds below or at nipple involve chest and abdomen

Front 8

Systemic BP is estimated to be ________ w/ a palpable radial pulse

Back 8

80 - 100mmHg

Front 9

Systemic BP is estimated to be ________ w/ a palpable femoral pulse

Back 9

70 mmHg

Front 10

Systemic BP is estimated to be ________ w/ a palpable carotid pulse

Back 10

60 mmHg

Front 11

Management of pt w/ multiple injuries - 1st and 2nd priority

Back 11

1 - ALWAYS establish and MAINTAIN a patent airway/ventilation

2 - control hemorrhage w/ direct pressure - WEAR gloves
NO tourniquet - need to assess pulses

Front 12

Management of pt w/ multiple injuries - 3rd and 4th priority

Back 12

3 - prevent and tx hypovolemic shock (commonly r/t loss of BF - tx is blood expanders/IV fluid)

4 - assess for head and neck injuries - ALWAYS immobilize anyone SUSPECTED of head injury until it's ruled out. Cont neuro assessment

Front 13

Management of pt w/multiple injuries - 5th and 6th priority

Back 13

5 - eval for add injuries and immobilize or open/cmpd fractures - cover w/ clean cloth and do NOT fix deformity

6 - carry out a more detailed head-to-toe exam

Front 14

Management of pt w/multiple injuries -

What are we monitoring when trying to prevent/tx hypovolemic shock??

Back 14

Typically r/t loss of blood flow - tx is IV fluids and blood volume expanders

**Monitor -
**rate of admin of fluid/expanders (may need pump)
**fluid overload, hypothermia
**urinary output - inds if pt is getting adequate fluid replacement and keeping BP high enough for kidney perfusion (kidney perfusion = urine output)

Front 15

RN Interventions - ongoing assessments after surveys

Back 15

After 2nd survey - record all findings, monitor and evaluation of interventions

*******#1 PRIORITY - ALWAYS airway patency and effectiveness of breathing

Then....
monitor RR and rhythm, O2 sats, ABGs (if ordered)
monitor LOC, vitals, peripheral pulses, urine output, skin temp color and moisture

Front 16

Shock r/t Trauma - Define

Back 16

*****MEDICAL EMERGENCY******* - definite threat to loss of life, emergent triage, need full team of MDs

D - a severe cond causing hypOtension, oliguria/anuria, and cell/tissue hypoxemia

Front 17

4 Types of Shock

Back 17

1. Cardiogenic shock

2. Hypovolemic shock

3. Distributive shock
Neurogenic shock
Septic shock
Anaphylactic shock

4. Obstructive shock

Front 18

Initial S&S of shock

Back 18

- weak, thready pulse
- tachypnea (increase RR to get more O2 in and compensate)
- hypOtension (may have slight increase initially as body is trying to compensate, pt is NOT improving)
- cold, clammy hands and feet

Front 19

Cardiogenic shock - causes

Back 19

issue with the pump and results in reduced cardiac output

Front 20

Cardiogenic shock - S&S

Back 20

tachycardia
hypotension
NARROWED pulse pressure
crackles r/t pulmonary congestion
INCREASE in pulmonary arterial wedge pressure and
pulmonary vascular resistence
peripheral hypoperfusion AEB decrease urine output r/t
Na/H20 retention
decreased cerebral perfusion AEB anx, confusion,
agitation

Front 21

Hypovolemic shock - causes

Back 21

loss of intravascular fluid volume and remaining volume is inadequate to fill vascular space

pipes don't work

Front 22

Hypovolemic shock - diff b/t absolute and relative

Back 22

absolute - external loss of fluid via hemorrhage, vomiting, DI, DM

relative - no actual fluid loss - fluid volume shifts, moving out of vascular space b/c of "leaky" walls and create 3rd spacing. Caused by burns, massive vasodilation r/t sepsis

Front 23

List stages of Shock

Back 23

Stage 1 - compensated or nonprogressive

Stage 2 - decompensated or progressive, symptomatic evident

Stage 3 - irreversible

Front 24

Cardiogenic shock - Dx tests

Back 24

labs (troponin, cardiac enzymes, etc), ECG, EKG, and CXR

Front 25

Hypovolemic shock - patho

Back 25

reduced intravascular volume = decreased venous return to heart -> decreased preload -> decreased stroke volume ->decreased CO

Front 26

Hypovolemic shock - S&S

Back 26

Increased HR, CO, RR and resp depth
Stroke volume, central venous pressure (CVP) & PAWP decrease r/t decreased circ vol

Front 27

Hypovolemic shock - Dx tests

Back 27

Hgb
Hct
electrolytes
lactate
blood gasses
central venous oxygenation
hourly urine output

Front 28

Neurogenic shock - causes

Back 28

pipes don't work b/c of loss of nerve innervation

spinal cord injury causing a loss of SNS vasoconstrictor tone and allowing for massive vasodilation

Front 29

Neurogenic shock - S&S

Back 29

hypotension (r/t massive vasodilation) & bradycardia, may not be able to regulate temp - risk for hypothermia

Front 30

Septic shock - causes

Back 30

systemic inflamm response to a documented or suspected infection

Front 31

Septic shock - S&S

Back 31

..

Front 32

Stage 1 of Shock - name and what S&S are occurring

Back 32

compensated or nonprogressive

Few initially - body is trying to compensate, low blood perfusion is first S&S
Tachycardia
May *initially have low BP, but it increases b/c of vasoconstriction caused by CNS
Decreased urine output - holding onto fluid
***IMP to have a baseline of vitals to notice these slight changes

Front 33

Stage 1 of Shock - Tx

Back 33

Tx is CRUCIAL - if corrected, pt will recover w/ little to no residual effects

If left uncorrected, will worsen to progressive stage

Front 34

Stage 2 of Shock - name and what S&S are occurring

Back 34

decompensated or progressive - symptoms evident

Body's comp mechs failing - chgs in mental status are imp - may have confusion, disoriented, agitated
Sustained hypoperfusion - increased systemic interstitial edema (or diffuse profound edema), weak peripheral pulses, dysrhythmias/MI.AMI, increased PA (pulm artery) pressure from arterioles constricting, vent-perf mismatch, etc etc etc

Front 35

Stage 2 of Shock - Tx

Back 35

AGGRESSIVE, rapid interventions can reverse this and pt won't have any lasting effects - prevent further progression to final stage or developing MODS

Front 36

Stage 3 of Shock - name and what S&S are occurring

Back 36

irreversible

Profound hypotension and hypoxemia.
Failure of liver, lungs, kidneys -> accumm of waste products (lactate, urea, ammonia, CO2)

continued loss of intravascular volume continues to worsen hypotension, tachycardia and decreasing coronary BF -> worsening myocardial depression -> further decline in CO -> cerebral ischemia

Front 37

Anaphylactic shock - S&S

Back 37

wheezing, diff breathing, itching/puiritis, rash progression causes chg in vitals

Front 38

Anaphylatic shock - causes

Back 38

histamine release causes S&S r/t constriction of bronchioles and blood vessels

Front 39

Initial Tx of Shock

Back 39

Early ID of S&S and chgs in clincial manis!!!

Modified trenelenburg positon - returning venous BF to R side of heart but preventing compression of diaphragm

Fluid resuscitation - get fluid BACK INTO cellular compartment - typically use lactated ringers, but can also use dextran (plasma expander) or albumin (fluid shift)

Front 40

Concerns with Tx of shock? Dx testing done?

Back 40

Fluid vol overload from giving albumin or fluids.
Will see pulm edema/heart failure
Use CVP (det pressure at RA) to determine if they are in fluid overload. If CVP is 10+, it indicated CHF

Front 41

Blood Admin - always check clients -

Back 41

allergies
previous blood transfusions or blood transfusion reactions

Front 42

Blood Admin - Window for admin

Back 42

MUST be admin w/in 30 min of getting it from blood bank, infusing over 2-4 hours.

Front 43

Blood Admin - Checks?

Back 43

ALWAYS check off b/t 2 RNs

Checking -
ABO - group
Rh factor
Pts name
expiration date
hospital MRN

Front 44

Blood Admin - tubing?

Back 44

MUST have special filter to prevent clots going to pt
Can ONLY admin NS with it
NEVER add any meds to blood

Front 45

Blood Admin - Concerns? Intervention?

Back 45

Constantly check and assess pt, esp first 15 min - most likely when rxns will occur. STOP infusion and open NS fully, call MD

Front 46

Blood Transfusions - What is a febrile rxn? Tx?

Back 46

a mild rxn w/ S&S similar to the flu or a cold - chills, fever, HA, flushing, tachycardia, increase anx

Tx - tx S&S that pt is experiencing and continue to infuse blood

Front 47

Blood Transfusions - What is an allergic rxn? Tx?

Back 47

a anaphylactic rxn to an antibody in the blood, can be mild to severe

Mild - hives, pruritus, facial flushing - Tx w/ antihistamines
Severe - severe SOB, bronchospasm, anx - Tx w/epinephrine and follow anaphylactic protocol

Front 48

Blood Transfusions - What is a hemolytic rxn? Tx?

Back 48

a rxn caused by the pt getting the wrong type blood - not as common b/c of today's blood typing and screening

S&S - *low back pain,* hypotension, tachycardia, chest pain, tachypnea, hemoglobinuria - may be sudden onset of S&S

Tx - STOP infusion; notify MD; chg IV tubing; Tx S&S with O2, fluids, epinephrine - PRN; recheck crossmatch record w/blood; hemolytic - 2 samples distal to infusion site/UA test for hemoglobinuria/monitor fluid & electrolyte balance/eval serum Ca2+ levels

Front 49

SIRS - Systemic inflamm response syndrome - define

Back 49

a systemic inflamm response to a wide variety of insults - ie infection/sepsis, ischemia, infarction, injury/trauma

Front 50

SIRS - Systemic inflamm response syndrome - S&S

Back 50

Resp system - typically first place - alveolar edema, alveoli collapse and gas exchange cannot occur, worsening vent-perf and eventually leading to ARDS

Front 51

SIRS - Systemic inflamm response syndrome - Dx Criteria:

Back 51

temp >38/100.4 or <36/97
HR>90
RR>20
PaCO2<32 = alkalosis (normal 35-40)
WBC count >12000 or <4000 and >10% bands - MUST look at WBC AND differential (looking for immature neutrophils)

Front 52

MOSF - Multiple organ system failure - cause

Back 52

Caused by the progression of SIRS, it occurs when 2 or more organs stop working normally and commonly occurs b/c of serious infections (sepsis), low BP r/t shock, or serious injuries caused by trauma
The more organs not fctning, less chance for recovery

Front 53

DIC - Disseminated Intravascular Coagulation - define

Back 53

it is a serious bleeding and thrombotic disorder caused by initiated and accelerated clotting, decreasing future clotting factors and platelets, causing increased risk for uncontrollable hemorrhage

Front 54

DIC - Disseminated Intravascular Coagulation - causes

Back 54

systemic activation of blood coagulation -> deposit of fibrin -> microvascular thrombi in various organs -> leading to multiple organ failure

seen in pts w/ long standing disorders or autoimmune diseases

ALWAYS a secondary cond that involved the activation of systemic inflamm - trauma, sepsis, severe transfusion rxn, heat stroke