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58 Cards in this Set
- Front
- Back
what are some SUBJECTIVE triage assessments
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chief complaint
traumatic event immunizations allergies last menses pregnancy |
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name some OBJECTIVE triage assessments
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VS
weight breath sounds skin color neuro pupil pain |
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members of a trauma team
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ED physician
surgeon nurses - 2 ED or 1 ED + 1 ICU lab tech chaplain recorder (RN) RT radiology |
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acuity classifications
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emergent
urgent non-urgent |
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describe EMERGENT acuity class
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life/limb threat
trauma, chest pain, cardiac arrest, severe resp dist, limb amput, acute neuro deficit, chemicals in eye |
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describe URGENT acuity class
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reqs prompt attention <2 hrs
fever > 104, DBP > 130, kidney stone, simple frax, abd pain, asthma w/o resp dist |
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describe NON-URGENT acuity class
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stable condition >2hrs
sprains, minor laceration, cold symptoms, rash, simple HA, chronic pain |
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describe primary survey trauma assessment
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ID & intervene life-threating sx
rapid approach consider multi-system damage |
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describe primary survey ABCDE approach
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A - airway
B - breathing C - circulaiton D - disability E - exposure |
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describe AIRWAY assessment in primary survey ABCDE approach
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airway w/ cervical spine immob
open airway suction as needed assess need for oral airway/ET intubation |
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describe BREATHING assessment in primary survey ABCDE approach
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look, listen, feel
breathing, effectiveness, assistance supplemental O2 |
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describe CIRCULATION assessment in primary survey ABCDE approach
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palpate pulses
bleeding - hypovol shock skin color, temp, cap refill 2 IVs |
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describe DISABILITY assessment in primary survey ABCDE approach
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neuro
AVPU for LOC |
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what does AVPU stand for
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A - alert
V - responds to verbal command P - responds to pain stim U - unresponsive |
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describe EXPOSURE assessment in primary survey ABCDE approach
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undress & visualize
prevent hypothermia determine need for transport prevent blood loss/hypovol shock |
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what is the most common cause of traumatic shock
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hypovolemia r/t blood loss
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how fast is blood initially lost
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250ml/min
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how is traumatic shock tx
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large bore cath followed by crystalloids (2-4L) then transfuse blood
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describe secondary survey for trauma assessment
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after primary survey complete
after life-threat injuries addressed |
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what does FGHI in secondary survey stand for
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F - Full set VS / Family present
G - give comfort - pain meds H - hx and head-toe assess I - identify injuries, inspect |
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if pt becomes unstable during secondary assessment what should nurse do
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revert back to PRIMARY survey
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what are most common causes of pediatric trauma
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falls, MVC, bicycle crash, drowning, burns, poison
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how much blood can a child lose and still maintain normal BP
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30%
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what are PaO2 critical values
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<60mmHg
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what is critical O2 sat
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<90%
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what is critical PCO2
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PCO2 > 50% w/ pH < 7.30
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s/s of resp failure
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dyspnea
ABGs HA, restlessness, confusion dysrhythmias, PVC, A-fib, tachy |
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interventions for resp failure
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treat cause - trauma or PNA
decrease CO2 levels support oxygenation sedatives |
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how do we decrease CO2 levels
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bronchodilators
TCDB hi fowlers postition |
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s/s of pneumothorax
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chest assymetry
restless resp distress absent breath sounds cyanosis tracheal deviation |
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s/s of ARDS
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profound hypoxemia
dyspnea decreased lung compliance diffuse bilat infiltrates |
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describe patho of ARDS
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alveoli & small lung BVs injured
blood/fluid leaks into spaces btw alveoli then INTO alveoli alveoli collapse |
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when does ARDS most commonly happen
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24-48 hrs post injury
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how does ARDS lead to multi-system failure
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decreased O2 caused by ARDS and leakage of cytokines leads to inflammation and complication of other organs
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how is ARDS tx
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mech vent
diuretics fluid management PEEP sedatives |
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when is mech vent used
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when pt has hypoxemia and progressive alveolar hypoventilation w/ resp acidosis
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what kind of sedatives are used to tx resp failure
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ativan, versed, morphine, fentanyl
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what causes flail chest
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blunt trauma leaves a loose segment
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what is the hallmark sign of flail chest
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paradoxic chest expansion - expands when it should be contracting and vice versa
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in the field what would the nurse do for flail chest
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apply pressure until intubation can be accomplished
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what % of lung collapse reqs chest tube
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>20% collaps
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is tracheal deviation early or late sign of pneumothorax?
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late
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what is considered aggresive nursing interventions for an ARDS pt
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extreme turning
monitor vent settings CLOSELY b/c chances of getting pneumothorax are big put on rotorest bed fluid management b/c leaky capillaries in lungs |
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what do we call lung trauma caused by a ventilator
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barotrauma
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what is the hallmark dx for ARDS
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white-out on CXR
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what are the bare minimum settings for ventilators
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tidal volume
rate FiO2 |
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if tidal volume, rate and FiO2 are NOT enuf for pt, what else can be done
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add PEEP
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what rhythm will be seen with hypoxia
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bradicardia then asystole
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what is the biggest problem for the nurse to consider with overdose
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cerebral depression
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when is gastric lavage recommended for an OD pt
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within 60 mins of ingestions of a known non-caustic, life-threatening drug
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how is OD on tricyclic antidepressants tx
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gastric lavage
admit to hospital tele - monitor for V-tach |
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after tx and OD w/ lavage, what is the next step
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tx w/ antidote
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what is the chief s/s of anemia
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fatigue
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what are important labs to dx anemia
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CBC
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what is the biggest problem with sickle cell anemia
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PAIN - cells clump together and obstruct flow causing ischemia and pain to distal parts
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thalassemia is common to what race of people
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mediteranean, african, middle eastern, southeast asian
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how does lead cause anemia problems
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lead binds to hemoglobin so O2 CANT bind
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why would kidney dz cause anemia
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erythropoetin
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