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97 Cards in this Set
- Front
- Back
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What is triage?
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way of sorting or choosing; a process or system used to determine the severity of need for ED care
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What is the subjective material in a triage assessment?
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chief complaints, Hx surrounding illness, allergies, medications, past medical Hx
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What is the objective information in a triage assessment?
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vital signs, weight, breath sounds, skin color, pain assessment
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How is acuity classified?
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emergent: life or limb threatening
Urgent: do not need immediate attention Non-urgent: stable condition |
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What is the A,B.C.D.E approach?
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A: airway with cervical spine immobilization
B: breathing, look, listen, feel C: circulation D:Disability E: exposure and evaluation |
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There is a high risk for ____ ____ related to blood loss.
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hypovolemic shock
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To promote circulation, what type of IV lines should be placed?
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2 large bore, warmed LR
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What is the AVPU method for monitoring LOC?
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A:alert
V: verbal response P: pain U: unresponsive |
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What is the most common cause of hypovolemic shock?
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blood loss
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When does the secondary assessment occur?
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begins after primary assessment is complete and all life threatening injuries are addressed
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What are the components of a secondary assessment?
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full set of vitals, pain meds, history and toe assessment, identify all injuries, if client becomes unstable, revert back to primary assessment
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How are children different from adults r/t trauma?
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a child's BP may be maintained with up to 30% of acute blood loss
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What is the leading cause of injury-related death in children 4 yrs and younger?
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maltreatment
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What are the different types of trauma?
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minor trauma, multiple , blunt, penetrating
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This is not a disease, but is a consequence of blood gas abnormalities.
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respiratory failure
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What are the types of resp. failure?
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mechanical abnormality of the lung or chest wall, defect in the respiratory control center in the brain, impaired ventilatory muscle function
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What are the dysrhythmias associated with resp. failure?
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PVC, A-fib, tachycardia
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What are the interventions for respiratory failure?
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treat the cause, decrease CO2 levels, support oxygenation, sedatives
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How can CO2 levels be decreased in a patient with resp. failure?
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bronchodilators, deep breathing and coughing, High Fowlers
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What are the causes of resp. failure?
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blunt or penetrating chest wall trauma, COPD, ARDS
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What can cause rib fractures?
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blunt trauma
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What can rib fractures lead to?
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lead the patient to hypoventilate, which leads to pneumonia
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What is the treatment for rib fractures?
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splint fracture and pain medications
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___ ___ usually involves one side of the chest and results from multiple fractures.
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Flail chest
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What is the treatment for flail chest?
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oxygen, pain management, promotion of deep breaths, positioning, mechanical ventilation
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Which type of pneumothorax is life threatening?
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tension
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What causes a spontaneous pneumothorax?
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bleb rupture, pot smoking
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What are the s/s of pneumothorax?
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asymmetry of the chest, respiratory distress, absence of breath sounds on affected side, tracheal deviation,
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What is the treatment for pneumothorax?
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chest tube
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What causes ARDS?
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sepsis, trauma, and severe pulmonary infections. No exact cause
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When does ARDS develop?
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24-48 hours after injury
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What can ARDS lead to?
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MSOF multiple system organ failure
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What is the treatment for ARDS?
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mechanical ventilation, diuretics, fluids, use of PEEP, use of sedatives
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____ _____ is most often used in patients with hypoxemia and progressive alveolar hypoventilation with resp. acidosis.
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Mechanical ventilation
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What are the types of temporary modes for mechanical ventilation?
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continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP)
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What type of patient is CPAP used for?
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spontaneously breathing patient
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Which type of pneumothorax is life threatening?
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tension: air cannot escape
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What are the s/s of pneumothorax?
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asymmetrical chest, absence of breath sounds on affected side, tracheal deviation
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What is the treatment for pneumothorax?
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chest tube
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What causes ARDS?
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acute injury commonly resulting from sepsis, trauma, and severe pulmonary infections
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When does ARDS usually develop?
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24-48 hours after initial injury
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What is the treatment of ARDS?
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mechanical ventilation, diuretics, fluid management, use of PEEP, use of sedatives
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Mechanical ventilation is most often used in the patient that has ______ and progressive alveolar hypoventilation with ____ ____.
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hypoxemia, respiratory acidosis
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CPAP is for what type of patient?
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spontaneously breathing; applies positive pressure throughout the whole respiratory cycle
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What is the most commonly used ventilator?
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positive-pressure; during inspiratory air is pushed into the lungs and expands the chest
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This is the volume of air the patient receives with each breath.
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tidal volume
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How much oxygen can a ventilator deliver?
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21-100%
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What is peak pressure?
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highest pressure reached during inspiratory phase
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What happens to peak inspiratory pressure if lungs become stiff?
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PIP increases
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What does PEEP improve?
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oxygenation by enhancing gas exchange and preventing atelectasis
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What is one reason why people die after a drug overdose?
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cerebral depression
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WHo is gastric lavage recommended for?
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patients that present within 60 minutes of ingestion of a known non-caustic substance that may be potentially life threatening
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What is essential to have in order for the bone marrow to produce hemoglobin?
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Iron
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____ is toxic to the bone marrow.
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Lead
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This can occur whenever the bone marrow is damaged by radiation, medications, or chemotherapy.
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Aplastic anemia
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What kind of things might be diagnosed within 2 hours after trauma?
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subdural hematoma, hemothorax, ruptured spleen
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What kind of things might be diagnosed within days to weeks after trauma?
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sepsis, MSOF
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What is the process used to assess the severity of a condition?
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triage
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What is triage not meant to do?
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diagnose
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______ is not a priority, but a psychosocial need.
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Pain
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What takes priority over pain?
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A,B,C
Give fluids fast to promote circulation and prevent hypovolemic shock |
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What is the number one thing to deal with in pediatric trauma?
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parent's guilt
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What do children have a greater capacity for than adults?
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compensation
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What are nurses mandated to report?
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suspected cases of maltreatment; failure to report could result in civil or criminal charges
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How do we assess penetrating trauma?
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keep foreign object in to prevent bleeding; try and figure out what is being penetrated; get pt safely into OR
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What does the spleen hold?
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a great deal of blood; if it ruptures you can have an incredible amount of blood loss
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What is respiratory failure?
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major blood gas abnormality; PCO2 greater than 50, pH less than 7.3
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What is a huge sign of respiratory problems?
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restlessness
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What do PVCs indicate?
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look at potassium--> electrolyte problems, hypoxia
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What might BZDs do to the respiratory center?
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decrease RR
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What is a major problem that can cause respiratory failure?
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rib fractures
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If decreased lung sounds are heard on affected side what should be done next?
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get a CXR to diagnose pneumothorax
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What is the hallmark with flail chest?
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paradoxical chest expansion; suck down and then go out; opposite of what is normal--> leads to resp. failure
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You see a patient with trauma to lung and paradoxical chest expansion what should you do?
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apply pressure to side of chest to give structure to ribs until they can get intubated
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What is flail chest?
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loose skeletal structure of rib cage allowing for extreme expansion of lungs
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What is the most common complication of flail chest?
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pneumothorax
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Who typically has blebs?
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COPD patients; hyperinflation in lungs leads to spontaneous bleb rupture
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What percentage do you need a chest tube for pneumothorax?
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over 20%; chest tube will not be placed for small pneumothorax
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What can causes PEA?
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tension pneumothorax
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What is the nurse's role for chest tube set up?
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make sure equipment is ready to go, medicate patient with Versed beforehand; make sure chest tube is set up (water, waterless), apply sterile dressing, and make sure CXR is ordered
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What is the waterless chest tube set up?
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water is in the waterseal
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What is a late sign of pneumothorax?
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tracheal deviation
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What are the clinical manifestations of ARDS?
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hypoxemia, increased RR, decreased lung compliance
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What is surfactant?
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phospholipid--> decreases surface tension
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What is the role of cytokines in ARDS?
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inflammatory response--> extreme inflammation leading to MSOF
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What is the most aggressive thing you can do for patient with ARDS?
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move and reposition q1'; monitor vent settings carefully--> chances of getting a pneumothorax is huge
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What type of bed might be good for a patient with ARDS?
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rotorest bed- continual movement
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What is the hallmark diagnostic for ARDS?
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white-out on CXR
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What do BiPAP and CPAP do?
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create PEEP in lungs
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What is considered a high volume of oxygen on a ventilator?
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above 50%
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What are the three settings for ventilators?
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tidal volume, RR, FiO2
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What does cerebral depression lead to?
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drowsiness and coma
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What is one of the drugs that a patient might OD on and need lavage?
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tricyclic antidepressants--> patients are typically lavaged; can be very toxic to heart, need to be on telemetry (VT within 48'
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When would we do lavage?
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for a tricyclic antidepressant overdose
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What are the main s/s of anemia?
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Fatigue
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What is the most common cause of anemia?
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hemorrhage
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Why do we have SOB with anemia?
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decreased O2 carrying capacity; if HCT is low, oxygen is low
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