Unit 4 exam Flashcards by Krissa Thrift

S.A.L.T.

What does it stand for?

Sort
Assess
Lifesaving interventions
Treatment and/or transport

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What tag is this for mass casualty color coding?

Potentially serious but stable enough to wait a short while for medical treatment
Includes:
* Fractures
* Burns < 20%
* Soft tissue injuries minimal bleeding
* Torso wounds w/o shock
* Facial injury w/o airway involvement

Yellow or delayed

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What mass casualty tag would this be?

Life-threatening, treatable with immediate attention
Includes:
* Airway obstruction
* MI
* Hemorrhage
* Severe abdominal injury
* Tension pneumothorax
* Shock, head injury
* Threatened loss of limb

Red or Immediate

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What mass casualty tag would this recieve?

Minor injuries can wait for longer periods of time
Includes:
* Ambulatory
* Minor burns
* Sprains
* Lacerations

Green or minimal

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What mass casualty tag would this recieve?

Dead, no VS, injuries incompatible with survival
Includes:
Full thickness burns > 50% TBSA
No pulse or breathing after airway opened
High SCI
Transcranial GSW

Black or expectant

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A-B-C-D-E

What does it stand for?

A - Airway w/ C-spine
B - Breathing/ventilation
C - Circulation
D - Disability/deficits
E - Exposure/environmental

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To prevent hypothermia:

o Remove wet clothing
o Cover with blankets
o Increase room temp
o Infuse warmed fluids
o Heat lamp

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F.G.H.

What does it stand for?

F - Fast Five
G - Give comfort measures
H - History

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Fast five interventions

Full set of vital signs
Further labs and x-rays
Foley Catheter
Facial trauma presence
Facilitate family presence

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The following are S/S of what?

Tachycardia
Hypotension
Tachypnea
Increased CO
Decreased CVP
Decreased SVR
Hyperthermia
N/V/D
Increased WBC , CrP
Warm , flushed skin later progresses to cool pale and molted

Septic Shock or Disruptive Shock

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The following are s/s of what?

Tachycardic
Cool, pale skin
Weak thready pulses
Hypothermia
Hypotension
Lethargy
Coma
Anuria

Late stage sepsis

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S/S of Late stage sepsis

Tachycardic
Cool, pale skin
Weak thready pulses
Hypothermia
Hypotension
Lethargy
Coma
Anuria

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List s/s of septic shock or disruptive shock

Tachycardia
Hypotension
Tachypnea
Increased CO
Decreased CVP
Decreased SVR
Hyperthermia
N/V/D
Increased WBC , CrP
Warm , flushed skin later progresses to cool pale and molted

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The following are S/S of what?

o Weak peripheral pulses
o Decreased co
o Tachycardia
o Hypotension
o Cool, clammy , skin , capillary refil less than 3 sec
o Increased cvp
o Increased SVR
o Bradypnea
o JVD
o Chest pain
o Oliguria
o Confused , agitation

Cardiogenic shock

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List the S/S of cardiogenic shock

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The following are S/S of what?

o Weak, thready pulse
o Cyanosis
o Cool,pale skin
o Decreased capillary refill
o Deceased co
o Decreased CVP
o Tachycardia
o Hypotension
o Bradypnea
o Increased SVR
o Increased or decreased HCT
o Oliguria
o Confused /agitated /restlessness
o Dry mucous membrane , loss of skin turgor
o Flattened neck veins

Hypovolemic shock

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The following are s/s of what?

o Warm dry skin , flushed
o Decreased CO
o Decreased right and left filling volumes
o Decreased SVR
o Bradycardic
o Hypothermia
o Decreased o2 (bradypnea)

Neurogenic shock

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List examples of obstructive shock

o Tension pneumothorax
o Cardiac tompanade
o Severe valvular disease

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List S/S of neurogenic shock

o Warm dry skin , flushed
o Decreased CO
o Decreased right and left filling volumes
o Decreased SVR
o Bradycardic
o Hypothermia
o Decreased o2 (bradypnea)

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All of the following are S/S of what?

***** Hypotension
* Tachycardia
* Dysrhythmias noted early (pvc’s, sinus tach)
* Vfib /vtach /cardiac arrest
* Muffled heart sounds
* Distended neck veins /JVD
* Hyperventilation/tachypnea= respiratory alkalosis
* Agitation/anxiety
* Decreased LOC
* SHOB /dyspnea
* Tracheal deviation toward the unaffected side hallmark sign
* Subcutaneous emphysema
* Cyanosis
* Absent breath sounds

Tension Pneumothorax

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List S/S of a tension pneumothorax

Hypotension
Tachycardia
Dysrhythmias noted early (pvc’s, sinus tach)
Vfib /vtach /cardiac arrest
Muffled heart sounds
Distended neck veins /JVD
Hyperventilation/tachypnea= respiratory alkalosis
Agitation/anxiety
Decreased LOC
SHOB /dyspnea
Tracheal deviation toward the unaffected side hallmark sign
Subcutaneous emphysema
Cyanosis
Absent breath sounds

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What needs to be done in a case of emergent pneumothorax?

A needle decompression performed to remove the air from the pleural space may be required.Large bore needle (14-16G)
Followed by chest tube insertion.

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Priority interventions for a chest tube

 Apply 100% non rebreather oxygen mask
 Prepare for intubation and mechanical ventilation
 Elevate head of the bed
 Encourage deep breathing and coughing q1-2 hrs
 Encourage ambulation as soon as possible
 Chest tube management - Never clamp the chest tube!
 Administer pain medications
 Assess LOC
 Collect ABG
 Assess for subcutaneous emphysema

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If chest tube becomes disconnected from drainage system…

immediately submerge the end of the chest tube in sterile was to preserve the water seal,

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If chest tube becomes dislodged from chest

Apply Vaseline gauze dressing and notify HCP immediately.

Steps of decontamination

1. Remove patients clothing and bagging clothing. Eliminating 60%-90% of continents ASAP 2. Wet the patients skin and wash with soap and water for 5-10 minute. Gently cleaning 3. Pay special attention to hair, face, hands, and other areas that were exposed but were not covered by clothing 4. Follow washing by copious rinsing of the patient with tepid water 5. Determine the level of PPE required for staff to wear 6. Controlling access to the decontamination site as well as the hospital 7. Having a container ready to receive contaminated clothes , valuables , and contaminated supplies 8. Ensuring screens are available for patient privacy 9. Ensuring collection system for water run off is available if needed

S.T.A.R.T | What does it stand for?

Simple Triage and Rapid Treatment

Spinal injury with total loss of motor and sensory function below the level of injury

Complete injury

Spinal injury with incomplete structural damage with some function preserved below the primary injury level.

Incomplete injury

* Type of incomplete SCI * Etiology: hyperextension injury with central cord swelling * Clinical manifestations: functional motor loss greater in arms than legs, bladder dysfunction, variable loss of sensation

Central cord syndrome

* Type if incomplete SCI * Etiology: acute anterior compression from bony fragments or acute disk herniation * Clinical manifestations: loss of motor function (paresis or paralysis), Pain, Temperature, Crude touch and pressure below the level of injury, preserved sense of proprioception (position sense), fine touch and pressure and vibration

Anterior cord syndrome

* Type of incomplete SCI * Etiology: acute compression * Clinical manifestations: loss of proprioception, fine touch and pressure and vibration, intact pain, temperature, and crude touch and pressure

Posterior Cord Syndrome

* Type of incomplete SCI * Etiology: Hemisection of the spinal cord resulting from penetrating injury (gunshot, knife injury), may result also from primary ischemia, infection, or hemorrhagic event * Clinical manifestation: * Ipisilateral loss of motor function, proprioception, and vibration, contralateral loss of pain and temperature

Brown-Sequard syndrome

on same side as the injury

Ipisilateral

on opposite side of injury

contralateral

# What level of SCI is this? Quadriplegia with loss of spontaneous respiratory function

C1-C4

# What level of SCI is this? Quadriplegia with possible phrenic nerve involvement

C4, C5

# What level of SCI is this? Quadriplegia with gross arm movements, phrenic nerve intact

C5, C6

# What level of SCI is this? Quadriplegia with biceps intact, diaphragmatic breathing

C6, C7

# What level of SCI is this? Quadriplegia with triceps, biceps, and wrist extension intact and some function of intrinsic hand muscles

C7, C8

# What level of SCI is this? Paraplegia with trunk and leg involvement, normal arm and hand movement

T1-T5

# What level of SCI is this? Paraplegia with fair ability to control balance and trunk, little or no voluntary bowel or bladder control

T6-T12

# What level of SCI is this? Cauda equina injury, variable motor and sensory loss in lower extremities; a reflexice bowel and bladder

Below L1

# What type of immobilization device is this? * Used to maintain cervical immobilization for specific types of cervical fractures. * Made up of a ring around the patients head attached to a special vest by 4 rods. * Titanium screws are screwed into the skull bone and attached to the halo device * Weights connect to the halo at the head of the bed over a pulley system

Halo traction device

# What type of immonilization/stabilization is this? * Used for spinal traction * U shaped tongs * Pressure controlled pins are inserted into the skull at opposite ends to permit longitudinal force to be applied to the axis of the spinal column. * Tongs are attached to weights using a pulley system at the head of bed

Gardner-wells tongs

* Occurs immediately after injury and applies to all phenomena surrounding spinal cord transection. This results in a complete but temporary loss or depression of spinal reflexes , sensory, motor and autonomic activity below the injury level. * Can last from 24 hrs to 1-6 weeks , return of reflex activity below level of injury indicate the end

Spinal Shock

# All of the following are clinical manifestations of what?  Flaccid paralysis of skeletal muscles  Absence of deep tendon reflexes  Impaired proprioception  Decreased visceral /somatic sensations  Penile reflex  Urinary/ fecal retention  Anhidrosis (absence of sweating)  Paralytic ileus

Spinal Shock

* Disruptive type of shock * Cardiac output decreased d/t the vessels lose tone, allowing blood to pool in the periphery and blood pressure to fall. * Only shock with Bradycardia

Neurogenic Shock

# All of these fall under what mass casuality color code? * Airway obstruction * MI * hemorrhage * Severe abdominal injury * Tension pneumothorax * Shock * Head injury * Threatened loss of limb

Red or immediate

# All of these fall under what mass casuality color code? * Fractures, burns < 20% * Soft tissue injuries minimal bleeding * Torso wounds w/o shock * Facial injury w/o airway involvement

Yellow or delayed

# All of these fall under what mass casuality color code? * Ambulatory * Minor burns * Sprains * Lacerations

Green or minimal

# All of these fall under what mass casuality color code? * Full thickness burns > 50% TBSA * No pulse * No breathing after airway open * High SCI * Transcranial GSW

Black or expectant

What should be done to open airway of c-spine is not cleared?

Jaw thrust

Hoarsness can indicate what?

Laryngeal injury or inhalation injury

How often does Joint Comission say emergency response plan should be practiced?

2 times a year

# All of the following are clinical manifestations of what? * Motor weakness * Numbness, Tingling, pain * Muscle atrophy * Decreased/absent DTR or Areflexia * Ascending flaccid paralysis from lower extremities over several days * Autonomic manifestations: sweating and tachycardia

Guillain-Barre Syndrome (GBS)

Cranial nerves to assess with GBS

VII, IX, X, XI, XII

Involvement of cranial nerve X can cause what?

 autonomic dysfunction  Cardiac Dysrythmias  Paroxysmal hypotension  Orthostatic Hypotension  Paralytic Ileus  Urinary Retention  Potential antidiuretic hormone

Maslow's Hierarchy of needs

5. Self Actualization 4. Self esteem 3. Love and belonging 2. Safety and security 1. Physiological needs

Priority Levels of care

* Level 1- ABC's * Level 2- Sudden change in VS and LOC * Level 3- Unstable metabolic disorders * Level 4- C/O pain, except chest pain * Level 5- Complex treatments and skills * Level 6- Discharge teaching and referral

Prioritization principals

* Systemic before local * Acute before chronic * Actual problems before potential problems * Recognize condition changes/emergencies (unstable) vs. expected findings (stable)

Elements of assertive communication between HCP's

* Establish trust * Use 'I' statements, you statements can indicate blame * State concerns –open, honest, direct * Focus on issue of conflict * Use 'CUS' method to get attention to problem (Concerned, Uncomfortable, Safety)

Conflict resolution steps and actions

* Strive for “win-win” * Identify the problem or issue * Generate a possible solution * Evaluate suggested solutions * Choose the best solution * Implement the solution chosen * Evaluate: Is the problem resolved?

Communication with families in a crisis

* Keep them updated * Allow to stay close * Appoint an advocate * Don’t use medical jargon * Give factual information

5 rights of delegation

* Right Task * Right Circumstance * Right Person * Right Direction/communication * Right Supervision/evaluation

5 key words for delegation

* P- Planning * A-Assessment * C-Collaboration * E- Evaluate * T- Teaching

Unprofessional behaviors

* blaming or criticizing other healthcare providers in the presence of patients i.e.“Sorry you didn’t get your pain medication, the night-shift was short staffed” * acting outside the scope of practice * accepting duties/responsibilities you are not prepared & competent for * diverting drugs/supplies * failing to safeguard a patient from incompetent practice of another nurse * falsifying documentation

Factors associated with professional commitment

* Strong belief in and acceptance of the profession's code, role, goals, values, and morals * Willingness to exert considerable personal effort on behalf of the profession * Strong desire to maintain membership in the profession * Pattern of behaviors congruent with the nurses' professional code of ethics

a pattern of coercive control founded on and supported by physical and/or sexual violence or threat of violence of an intimate partner.

Battering

Why do victims stay with abusers

* Period after leaving abuser at 75% greater risk of being killed by the partner. * Fear for their lives or lives of their children * Fear of retaliation by the partner * Fear of losing custody of their children * Lack of financial resources * Lack of a support network * Religious reasons * Having hope that the partner will change, and they can have good times again * Lack of attention to the danger

Nursing priorities for suspected child abuse

* Reporting to authorities when there is reason to suspect child abuse or neglect * Provide shelter and promote reassurance of safety * Stay with pt * Promote trust

# All of the following are S/S of what? * Re-expiernce the traumatic event * Flashbacks * Sustained high level of anxiety or arousal * General numbing of responsiveness * Intrusive recollections or nightmares * Amnesia to certain aspects of trauma * Depression * Survivors guilt * Anger * Substance abuse * Relationship problems * Suicidal thoughts

PTSD

List S/S of PTSD

* Re-expiernce the traumatic event * Flashbacks * Sustained high level of anxiety or arousal * General numbing of responsiveness * Intrusive recollections or nightmares * Amnesia to certain aspects of trauma * Depression * Survivors guilt * Anger * Substance abuse * Relationship problems * Suicidal thoughts

Treatment for PTSD

* Cognitive therapy * Prolonged exposure therapy * Group family therapy * Eye movement desensitization and reprocessing * Psychopharmacology

Medications used to treat PTSD

o SSRI (first line): paroxetine , sertraline o Tricyclic antidepressants: Amitriptyline (evlavil) o MOA inhibitors o Benzos, busprione , propranolol

Nursing priorities for PTSD

* Establish therapeutic relationship encourage patient to share feelings * Provide safe , non threatening , routine environment * Assess client for suicidal ideation , take precautions as needed * Use multiple strategies to decrease anxiety (music, imagery, relaxation, breathing techniques ) * If pt is a child involve caregivers in treatment

Root cause analysis process

1. Identify problem 2. Define problem 3. Understand problem 4. Identify root cause 5. Corrective action 6. Monitor Repeat

# What medication is this? * Purpose: control seizure disorders , neuropathic pain, restless legs syndrome * Action: Slowing the entrance of sodium and calcium back into the neuron, thus extending the time it takes for the nerve to return to its active state and slows the frequency of neuron firing * CNS effect: Somnolence, dizziness, ataxia, fatigue, nystagmus, peripheral edema diminish in time * Special considerations: Monitor plasma levels, do not admin within 2 hrs of antacids, renal dosing w/ renal impairment pt's, monitor for suicidal thoughts

Gabapentin

# What medication is this? * Purpose: decreased muscle spasticity * Action: inhibits reflexes * S/e : dizziness, weakness, confusion, headache, nausea, constipation, difficulty falling asleep, tiredness, frequent urination * A/E: visual / audio hallucinations, seizures * Special considerations: Monitor for s/s of overdose, do not give with MAO Inhibitors, alcohol, antihistamines, or opioid analgesics, can increase glucose, alkaline phosphate, AST, and ALT, needs to be d/c'd over 2 wks or more

Baclofen

# What medication is this? * Use: First drug of choice for BP – unresponsive to adequate fluid resuscitation * Effects: Increase BP, MAP, CVP, SVR, o Cardiac stimulation o peripheral vasoconstriction o renal and splanchnic vasoconstriction o Can increase or decrease cardiac output * Special considerations: o Administer via central line d/t risk of ischemia o Requires CVP monitoring o Monitor pt for dysrhythmias o Notify HCP if urine OP is <30 o Needs to be discontinued gradually

Vasopressors or Norepinephrine

# What medication is this? * Purpose: vasodilation of renal, mesenteric and coronary arteries * Typical dose 2-10 MCG/KG/MIN * S/e: Arrhythmias, hypotension, angina, palpitations * Toxicity: If excessive HTN occurs rate of infusion should be decreased or temporarily d/c’s until BP is decreased * Do not admin with beta blockers, general anesthetics, and phenytoin

Dopamine

* Action: peripheral vasoconstriction, increased cardiac contractility, smooth muscle relaxation * Used to treat: Hypotension associated with septic shock, severe allergic rxn, cardiac arrest, inhalation injury * S/E: angina, arrhythmias, HTN, Tachycardia, nervousness, restlessness, tremor * A/E: Paradoxical bronchospasms w/ excessive use of inhalers-If wheezing is heard hold med and notify HCP immediately * Can cause increased glucose * Dose 2-10mcg/min

Epinephrine

# What medication is this? * Action: arterial vasoconstriction- increases BP * Dose: 40-200 mcg/min

Phenylephrine

# What medication is this? * Action: increased cardiac contractility, mild vasodilation * Dose: 5-15 mcg/kg/min

Dobutamine | Inotropic

# What medication is this? * Action : black the action of the vagus nerve in the parasympathetic nervous system increasing HR * used in neurogenic shock to treat bradycardia

Atropine

# What medication is this? * Use: work by blocking epinephrine. * Effects: Lowers HR and decreases cardiac workload * Special considerations: * Do not give if HR is less than 60, remember to use apical pulse * Monitor for hypotension after 1st dose * Teach pt to rise slowly from seated or lying positions to avoid orthostatic hypotension * Use cautiously in pt’s w/ HF and asthma

Beta blockers

# What medication is this? * Use: lowers HR and BP , angina , dysrhythmias * Action: * S/e : o Ortho hypotension, dizziness, flushing,HA, Peripheral edema , constipation o Considerations: o avoid grape juice , elevate legs to & compression to reduce edema, to help with constipation give ( all F’s Fluids, fiber, fruits)

Calcium Channel blockers

# What medication is this? * Use: First line medication use to treat HTN, HF, MI. Used to treat cardiomyopathy * Effects: Reduces after-load, relaxes blood vessels, decreases BP * Special considerations: * Can cause K retention so be careful when administering K sparing diuretics, potassium supplements, and check labs * Do not give to pregnant pt * S/e : remember acronym ACE

ACE Inhibitors

# What medication is this? * Action: binds to cell receptors enhancing the effects of GABA., slows/ calms activity of the nerves in the brain * Uses: acute anxiety, sedation/muscle relaxant ,siezures, etoh * A/e: Drowsiness, lightheadedness, ataxia, visual disturbances, anger, restlessness, nausea , constipation, lethargy, apathy , dry mouth. * Considerations: * Monitor for s/s of withdrawals, not meant for long term use, must be tapered off,

Benzos | -zepam, -zolam

# What medication is this? * Action: inhibits uptake of serotonin – increased serotonin * Uses: depression, anxiety, ocd, eating disorders * S/e: Headache , tremors, difficulty sleeping, nausea, dry mouth/thirst, constipation, urinary retention, sexual dysfunction * A/e: serotonin syndrome * Considerations: * May take 4-6 weeks to take effect, take in the morning, first line for depression and anxiety

SSRI's | (-atlopram, -oxetine, -zodone)

Unit 4 exam Flashcards

(90 cards)