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Disaster Triage and Nursing
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Disaster Triage and Nursing

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Questions and Answers

What color tag should be assigned to a patient with a penetrating head wound, burns over 60% of the body, and agonal respirations?

  • Red Tag
  • Green Tag
  • Yellow Tag
  • Black Tag (correct)
  • Which sign or symptom is associated with Blast Lung?

  • Bone fractures
  • Skin irritation
  • Hemodynamic instability (correct)
  • Abdominal pain
  • What condition is characterized by tympanic membrane rupture and is the most frequent injury from a pressure wave?

  • Spinal cord injury
  • Tympanic membrane rupture (correct)
  • Pulmonary contusion
  • Concussion
  • What action should a nurse take regarding a patient with an open abdominal injury and confusion?

    <p>Stop the bleeding and start normal saline</p> Signup and view all the answers

    Which patient assessment should the ER triage nurse prioritize in a multiple car crash scenario?

    <p>A patient w/ deviated trachea</p> Signup and view all the answers

    What is the primary diagnosis for a patient with a human bite and an unknown last tetanus shot?

    <p>Risk for infection related to human bite organisms</p> Signup and view all the answers

    Which disease has an incubation period of 12 days?

    <p>Smallpox</p> Signup and view all the answers

    Which tag is assigned to stable abdominal wounds with no airway compromise?

    <p>Yellow Tag</p> Signup and view all the answers

    What nursing diagnosis applies to a patient with difficulty maintaining an airway due to hemorrhage in the oral cavity?

    <p>Ineffective airway clearance</p> Signup and view all the answers

    Which of the following symptoms is NOT associated with nerve gas exposure?

    <p>Constipation</p> Signup and view all the answers

    What is the initial step that medical personnel should take at the scene of a disaster?

    <p>Triaging patients</p> Signup and view all the answers

    When decontamination begins, which action should be prioritized?

    <p>Double bagging all waste</p> Signup and view all the answers

    Which medication is appropriate for treating a heroin overdose?

    <p>Naloxone</p> Signup and view all the answers

    Which assessment finding in a patient who has taken an excessive amount of ASA indicates toxicity?

    <p>Tinnitus</p> Signup and view all the answers

    What is the priority intervention for a patient presenting with hyperthermia and a temperature of 105°F?

    <p>Place a cooling blanket on the patient</p> Signup and view all the answers

    Which of the following conditions would be classified as 'green' in a disaster triage scenario?

    <p>A broken thumb from falling debris</p> Signup and view all the answers

    Which interventions should be prioritized for a patient who has ingested poison?

    <p>Remove or inactivate the poison ASAP</p> Signup and view all the answers

    What clinical manifestations might indicate carbon monoxide poisoning?

    <p>Skin color ranges from pink to red with confusion</p> Signup and view all the answers

    When treating a snake bite, what is the first priority action?

    <p>Remove any restrictive items around the bite site</p> Signup and view all the answers

    What is an essential nursing management practice for hemorrhage patients?

    <p>Ensure patients have at least 2 large-bore IVs</p> Signup and view all the answers

    When assessing a patient for heat stroke, which symptoms indicate a worsening condition?

    <p>Confusion, elevated body temperature, and dry skin</p> Signup and view all the answers

    What is the priority intervention for a patient who has ingested poison?

    <p>Remove or inactivate poison ASAP</p> Signup and view all the answers

    Which medication can be used as a reversal agent for sedatives such as diazepam and lorazepam?

    <p>Flumazenil</p> Signup and view all the answers

    What should NOT be used in the initial management of snake bites within the first 6-8 hours?

    <p>Ice</p> Signup and view all the answers

    Which clinical manifestation is commonly associated with carbon monoxide poisoning?

    <p>Confusion and headache</p> Signup and view all the answers

    Which assessment finding is characteristic of a patient experiencing hemorrhage?

    <p>Clammy and decreased blood pressure</p> Signup and view all the answers

    Which symptoms are commonly associated with a person experiencing dyspnea following a blast injury?

    <p>Hypoxia and cough</p> Signup and view all the answers

    What is the possible consequence of a sucking chest wound in a patient?

    <p>Increased risk of cardiac arrest</p> Signup and view all the answers

    Which tag classification should be assigned to a patient with upper extremity fractures and minor burns?

    <p>Green Tag</p> Signup and view all the answers

    When dealing with a pandemic situation, healthcare providers are most concerned about reporting what to the CDC?

    <p>Increase in certain diseases in a normally healthy population</p> Signup and view all the answers

    Which of the following is a hallmark sign of anthrax during a clinical assessment?

    <p>Hemorrhaging mediastinum</p> Signup and view all the answers

    What is the primary nursing consideration for a patient with an open abdominal wound experiencing confusion?

    <p>Establish a clear airway and control bleeding</p> Signup and view all the answers

    What should be the focus of management for a patient who has sustained a blast injury resulting in tympanic membrane rupture?

    <p>Ensuring respiratory support</p> Signup and view all the answers

    What is the expected response by a nurse to a patient post-disaster who desires to resume normal activities?

    <p>Assess readiness and guide gradually returning to normalcy</p> Signup and view all the answers

    Which symptom is considered a clinical manifestation of internal bleeding?

    <p>Increased pulse rate</p> Signup and view all the answers

    What is the first action a nurse should take when decontamination begins?

    <p>Double bag all waste</p> Signup and view all the answers

    Which condition requires a vaccine after exposure as a precaution in bioterrorism management?

    <p>Smallpox</p> Signup and view all the answers

    What is the priority intervention for a patient presenting with frostbite of the lower extremities?

    <p>Soak feet in warm water for 30-40 minutes</p> Signup and view all the answers

    In a disaster triage scenario, which condition would be classified as a 'green' or minor priority?

    <p>A broken thumb from falling debris</p> Signup and view all the answers

    What should a nurse do first when there is a chemical spill on workers?

    <p>Continually flush the skin with water</p> Signup and view all the answers

    Which medication should be administered to a patient experiencing a heroin overdose?

    <p>Naloxone</p> Signup and view all the answers

    Which symptom is NOT associated with nerve gas exposure?

    <p>Constipation</p> Signup and view all the answers

    Study Notes

    Disaster Triage

    • Black Tag: Penetrating head wound, burns over 60% of the body, agonal respirations, no blood pressure, fixed and dilated pupils
    • Red Tag: Sucking chest wound, shock, hemothorax, asphyxia, incomplete amputations, open fractures
    • Yellow Tag: Stable abdominal wounds, soft tissue injuries, maxillofacial wounds without airway compromise
    • Green Tag: Upper extremity fractures, minor burns, sprains, behavioral disorders
    • Involved/White Tag: No apparent injuries but involved in the situation

    Disaster Nursing

    • Blast Lung: Dyspnea, hypoxia, tachypnea, apnea, cough, chest pain, hemodynamic instability
    • Tympanic Membrane Rupture: Most frequent injury from a pressure wave with symptoms of hearing loss, tinnitus, pain, dizziness, and otorrhea
    • Head Injury: Most common cause of post-blast deaths, usually caused by falling debris or the blast itself
    • Anthrax: Hallmark sign of anthrax is mediastinum hemorrhaging, incubation period varies
    • Smallpox: Incubation period is 12 days
    • Acute Radiation Syndrome: Probable survivors have no initial symptoms or minimal symptoms (nausea and vomiting)
    • CISM Components: Education, Field support, Defusing, Debriefing, Demobilization, Follow-up
    • Open Abdominal Injury: Priority is to stop bleeding and start normal saline solution, do not force oral fluids
    • Priority Assessment in ER: Deviated trachea, unequal pupils, ecchymosis in flank area, tachycardia
    • Human Bite: Priority diagnosis is risk for infection related to organisms in human bite
    • Hemorrhage in Oral Cavity: Nursing diagnosis is ineffective airway clearance
    • Disaster Scene Initial Step: Triaging
    • Nerve Gas Exposure: Symptoms include visual disturbances, flaccid muscles, nausea and vomiting, not constipation
    • Decontamination Priority: Double bag all waste, collect all water used in decontamination, cover the floor
    • Improbable Radiation Survivor: Bloody diarrhea
    • Cutaneous Anthrax Treatment: Cleanse skin with soap and water
    • Botulism Treatment: Mechanical ventilation
    • Chemical Spill on Workers: Continuously flush the skin with water
    • Heroin Overdose Medication: Naloxone
    • Emergency Triage in ER: Stridor and oxygen level of 75%
    • Priority Assessment in ER: Patient with multiple injuries from an MVA
    • CISM Defusing Component: Learning to identify stress reactions and how to manage them
    • "Green" Tag in Disaster Triage: Broken thumb from falling debris
    • Bioterrorism Agent requiring vaccine after exposure: Smallpox
    • ASA Overdose Clinical Manifestation: Tinnitus
    • External Hemorrhage Priority Intervention: Stop the bleeding
    • Hyperthermia Priority Intervention: Place a cooling blanket on the patient
    • Frostbite Intervention: Soak feet in warm water for 30-40 minutes at a time
    • Internal Bleeding Clinical Manifestation: Increased pulse rate
    • Frostbite Avoidance: Avoid ETOH and caffeine
    • Poison Ingestion Priority Intervention: Remove or inactivate poison ASAP
    • Carbon Monoxide Poisoning Clinical Manifestations: Skin color ranges from pink to red, confused, headache, decreased LOC, muscular weakness, palpitation, dizziness
    • Snake Bite Priority Intervention: Remove restrictive items
    • Nurse's Role in Disaster: Do the greatest good for the person you can save, not save everyone
    • Sedative Reversal Agent: Flumazenil
    • Lye and White Phosphorus: Do not wear gloves when rinsing off
    • Snake Bite Treatment: Antivenom most effective within 4 hours of bite, measure arm to monitor swelling, take a picture to document, DO NOT USE: ice, tourniquets, heparin, or steroids in the first 6-8 hours.

    Hemorrhage

    • Nursing Management: Two large-bore IVs (18 gauge preferred, 20 gauge okay), type and cross-match blood, IV fluids (NS or Lactated Ringers), platelets to help clot
    • Clinical Manifestations: Clammy skin, decreased blood pressure, rigid abdomen
    • Heat Stroke Progression: Confusion, delirium, elevated body temperature with hot dry skin, no sweating, decreased blood pressure, increased respiratory rate, and heart rate

    Disaster Triage Tags

    • Black Tag: Penetrating head wound, over 60% body burns, agonal respirations, no blood pressure, fixed and dilated pupils.
    • Red Tag: Sucking chest wound, shock, hemothorax, asphyxia, incomplete amputations, open fractures.
    • Yellow Tag: Stable abdominal wounds, soft tissue injuries, maxillofacial wounds without airway compromise.
    • Green Tag: Upper extremity fractures, minor burns, sprains, behavioral disorders.
    • Involved/White Tag: Individuals involved in an event but have no apparent injuries.

    Disaster Health Care

    • CDC Reporting: Health care providers should report an increase in certain diseases in a normally healthy population.

    Blast Lung

    • Signs and Symptoms: Dyspnea, hypoxia, tachypnea, apnea, cough, chest pain, hemodynamic instability.

    Tympanic Membrane Rupture

    • Most frequent injury from a pressure wave.
    • Signs and Symptoms: Hearing loss, tinnitus, pain, dizziness, otorrhea.

    Head Injury

    • Most common cause of post-blast deaths, usually caused by falling debris or the blast itself.

    Anthrax

    • Hallmark Sign: Mediastinum hemorrhage.

    Smallpox

    • Incubation period is 12 days.

    Acute Radiation Syndrome

    • Probable Survivors: No initial symptoms or only minimal symptoms (nausea, vomiting).

    Post-Disaster Patient Care

    • Encourage patients to return to normal activities.

    Critical Incident Stress Management (CISM)

    • Components: Education, Field support, Defusing, Debriefing, Demobilization, Follow-up.

    Open Abdominal Injury ER Nursing

    • Questionable Order: Force oral fluids.

    ER Triage Priorities

    • Highest Priority: Deviated trachea.
    • Other Priorities: Unequal pupils, ecchymosis in the flank area, tachycardia.

    ER Nursing - Open Abdominal Wounds

    • Priority: Stop the bleeding and start normal saline.

    Human Bite Wound

    • Priority Diagnosis: Risk for infection related to organisms in human bites.

    Oral Cavity Hemorrhage

    • Nursing Diagnosis: Ineffective airway clearance.

    Bioterrorism Agents

    • Botulism and anthrax can be disseminated.

    Disaster Scene Medical Personnel

    • Initial Step: Triaging.

    Nerve Gas Exposure

    • Symptoms: Visual disturbances, flaccid muscles, nausea and vomiting.
    • Not a symptom: Constipation.

    Decontamination

    • Priority Actions: Double bag all waste, collect all water used in decontamination, cover the floor.
    • Not a priority: Open air duct.

    Radiation Exposure

    • Improbable Survivor Symptom: Bloody diarrhea.

    Cutaneous Anthrax Treatment

    • Cleanse skin with soap and water.

    Botulism Treatment

    • Mechanical ventilation.

    Chemical Spill on Workers

    • First Action: Continually flush the skin with water.

    Heroin Overdose Medication

    • Naloxone.

    ER Triage Emergency Criteria

    • Emergency: Stridor, O2 saturation of 75%.

    ER Triage Priority Assessment

    • Highest Priority: Patient with multiple injuries from a motor vehicle accident (MVA).

    Critical Incident Stress Management: Defusing

    • Involves learning to identify stress reactions and how to manage them.

    Disaster Triage "Green" Tag Criteria

    • Broken thumb from falling debris.

    Smallpox Treatment

    • Requires a vaccine after exposure.

    Excessive Aspirin Ingestion

    • Clinical Manifestation: Tinnitus.

    External Hemorrhage Priority Intervention

    • Stop the bleeding.

    Hyperthermia Intervention

    • Place a cooling blanket on the patient.

    Lower Extremity Frostbite

    • Soak feet in warm water for 30-40 minutes at a time.

    Internal Bleeding

    • Clinical Manifestation: Increased pulse rate.

    Frostbite - Avoid

    • ETOH and caffeine.

    Poison Ingestion

    • Priority Intervention: Remove or inactivate the poison as soon as possible.

    Carbon Monoxide Poisoning

    • Clinical Manifestations: Skin color ranging from pink to red, confusion, headache, decreased level of consciousness, muscular weakness, palpitations, dizziness.

    Snake Bite

    • Priority: Remove restrictive items.

    Nurse's Role in Disaster Management

    • The nurse's role is NOT to do the greatest good for the person you can save. The role incorporates all individuals during a disaster.

    Sedative Reversal Agent

    • Flumazenil.

    Lye and White Phosphorus

    • Do not wear gloves when rinsing off.

    Snake Bite Treatment

    • Most Effective: Antivenom within 4 hours of the bite.
    • Measure arm: Monitor swelling. Take a picture to document.
    • Do NOT use: Ice, tourniquets, heparin, or steroids in the first 6-8 hours.

    Hemorrhage Nursing Management

    • Ensure two large-bore IVs: (18 gauge preferred, 20 gauge acceptable). Needed to administer blood.
    • Type and cross-match blood: For transfusion.
    • IV Fluids: Normal saline (NS) or Lactated Ringers.
    • Platelets: May be administered to help clot.

    Hemorrhage Clinical Manifestations

    • Clammy skin, decreased blood pressure.
    • Rigid abdomen.

    Heat Stroke Progression

    • Signs and Symptoms: Confusion, delirium, elevated body temperature with hot dry skin, no sweating, decreased blood pressure, increased respiratory rate, increased heart rate.

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    Description

    This quiz covers critical concepts in disaster triage and nursing care for various injuries and conditions. Participants will learn how to classify injuries using the triage tagging system and identify key injuries commonly seen in disaster situations. Perfect for nursing students and emergency responders.

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