Nursing Quiz on Inhalation Injury and Emergencies

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Questions and Answers

Inhalation injury may cause ______ nasal hairs.

singed

For cyanide poisoning, ______ is a pharmacological antidote used.

Hydroxocobalamin

A common nursing diagnosis for inhalation injury is ______ Gas Exchange.

Impaired

A sign of airway obstruction may include ______ and hoarseness.

stridor Signup and view all the answers

Smoke inhalation can cause airway ______, soot, and mucus obstruction.

edema Signup and view all the answers

Oxygen therapy is used to compensate for increased oxygen ______.

demand Signup and view all the answers

Epinephrine is administered to reduce the body's allergic ______.

response Signup and view all the answers

Continuous monitoring of vital signs includes tracking ______, heart rate, and respiratory rate.

blood pressure Signup and view all the answers

A beta-agonist like albuterol is used to relieve breathing ______.

symptoms Signup and view all the answers

Common causes of head injuries include road traffic accidents, falls, and ______.

sports injuries Signup and view all the answers

Thoracic emergencies can involve conditions such as pneumothorax and ______.

hemothorax Signup and view all the answers

Patients should avoid foods like nuts and ______ to prevent allergic reactions.

seafood Signup and view all the answers

Nursing interventions for anaphylaxis include teaching the patient about the use of an epinephrine ______.

auto-injector Signup and view all the answers

In the event of a foreign body obstruction, a person with partial obstruction might exhibit signs such as coughing, choking, and ______.

dyspnea Signup and view all the answers

A complete obstruction is indicated when a person is unable to cough, speak, or ______.

breathe Signup and view all the answers

Signs of hypoxia during the assessment of circulation include ______ or cyanosis.

pallor Signup and view all the answers

The upper respiratory tract includes the nose, nasal cavity, pharynx, larynx, and ______.

mouth Signup and view all the answers

Common causes of foreign body obstruction include food-related items, foreign objects, and ______ conditions.

medical Signup and view all the answers

When assessing airway status, it is important to perform a visual inspection for visible ______.

obstructions Signup and view all the answers

Smoke inhalation can lead to serious effects on the respiratory tract including inflammation and ______ damage.

tissue Signup and view all the answers

In managing respiratory emergencies, the priority is to secure the ______, which allows air to enter the lungs.

airway Signup and view all the answers

Study Notes

Nursing Care of Clients in Emergency Situations - Medical Emergencies

Clients in emergency situations require immediate nursing care.
Medical emergencies demand swift and appropriate responses.

Airway, Breathing, Circulation

An open airway allows air to enter the lungs for breathing.
If the airway is blocked, breathing is impossible.
Quickly check an unconscious person for breathing using the Look, Listen, and Feel (LLF) technique. This shouldn't take longer than 10 seconds.
Assess pulse, bleeding, shock, skin color, and temperature.

Foreign Body Obstruction

Foreign body obstruction (choking) is a significant medical issue, leading to varying degrees of asphyxiation or oxygen deprivation.
Causes of foreign body obstruction include food items, foreign objects, medical/physical conditions, behavioral factors, aspiration, and developmental factors.
The upper respiratory tract includes the nasal cavity, pharynx, larynx, and mouth.
Masses or edema can obstruct the upper respiratory tract.
Foreign body obstruction can be partial or complete.

Partial Obstruction Signs/Symptoms

Cough
Gagging
Choking
Drooling
Dyspnea when speaking
Inspiratory stridor

Complete Obstruction Signs/Symptoms

Inability to cough, speak, or breathe
Cyanosis
Unresponsiveness

Foreign Body Obstruction Assessment

Assess airway status (signs and symptoms).
Perform visual inspection (look for visible obstructions).
Do not perform a blind finger sweep.
Observe chest movement (breathing).
Assess for hypoxia (pallor or cyanosis, circulation).

Ineffective Airway Clearance

Related to airway obstruction by a foreign body.
Evidenced by inability to speak or cough, absent/diminished breath sounds, or cyanosis/choking gestures.

Impaired Gas Exchange

Related to complete or partial airway blockage, impairing oxygen and carbon dioxide exchange.
Evidenced by decreased oxygen saturation, cyanosis (lips, skin, or nail beds), or altered mental status.

Planning for Foreign Body Obstruction

Remove upper airway obstruction.
Restore clear airway.
Return to normal breathing pattern.

Interventions for Foreign Body Obstruction

Children (<1 year old): 5 back blows followed by 5 chest thrusts (Heimlich maneuver)
Adults (>1 year old): 5 abdominal thrusts.
Laryngoscopy (removal by forceps or suction).
Cardiopulmonary resuscitation (CPR).

Pharmacologic Management for Foreign Body Obstruction

Epinephrine: For anaphylaxis reactions.
Oxygen therapy: For acute respiratory distress.
Antibiotics: For aspiration pneumonia (e.g., piperacillin-tazobactam, meropenem).
Anxiolytics: For anxiety (e.g., lorazepam, diazepam).
Corticosteroids: For inflammation/injury to airways (e.g., methylprednisolone, dexamethasone).
Bronchodilators: For bronchospasm/wheezing (e.g., albuterol, salmeterol).

Patient and Family Education for Foreign Body Obstruction

Childproofing.
Safe eating habits.
Toy safety.
Heimlich maneuver.

Evaluation for Foreign Body Obstruction

Airway is clear, breathing restored.
Stable vital signs (oxygen saturation ≥ 95%).
No signs of infection/further complications.
Patient/family understands prevention strategies

Inhalation Injury

Damage to the respiratory tract from heat, smoke, or chemical irritants during inhalation
Types include thermal injury, chemical injury, and smoke inhalation

Thermal Injury

Damage caused by hot gases, steam, or flames.
Large heat capacity of air dissipates heat before it reaches lower respiratory tract.

Chemical Injury

Damage from inhaling toxic substances, fumes, or vapors.
Severity depends on chemical type and solubility.

Smoke Inhalation

Caused by breathing in complex mixture of hot gases, particulate matter, and toxic chemicals during a fire.
Leading cause of death in fire-related injuries.

Effects of Inhalation Injury on the Respiratory Tract

Upper airway: Thermal burns cause swelling, redness, and tissue damage, potentially leading to airway obstruction and breathing difficulties.
Lower airway and lungs: Toxic gases/smoke cause inflammation, bronchospasm, and fluid accumulation (pulmonary edema), impairing oxygen exchange and lung function.
Mucociliary clearance: Toxins damage the mucociliary escalator, reducing mucus clearance and increasing infection risk.
Chemical injury: Combustion products (e.g., carbon monoxide, cyanide) impair oxygen delivery, leading to hypoxia and tissue damage.

Inhalation Injury Signs and Symptoms

Upper airway: Hoarseness, stridor, wheezing, sore throat, difficulty swallowing, facial/neck swelling
Lower airway: Cough (potentially black/sooty), dyspnea (shortness of breath), tachypnea (rapid breathing), chest tightness, wheezing.
Physical: Soot/burns around the mouth/nose, singed nasal hairs, visible burns in the mouth/throat.

Nursing Diagnosis for Inhalation Injury

Ineffective airway clearance (caused by airway edema, soot, mucus obstruction).
Interventions: Assess for stridor/hoarseness, High Fowler position, humidified oxygen, prepare for intubation if necessary.
Impaired gas exchange (caused by carbon monoxide or cyanide poisoning, alveolar damage).
Interventions: Administer 100% oxygen via non-rebreather mask, monitor oxygen saturation and ABGs, use antidotes if toxic exposure is confirmed.

Assessment & Diagnostic Tests for Inhalation Injury

History and physical examination
Arterial blood gas (ABG)
Carboxyhemoglobin levels
Cyanide levels
Complete blood count (CBC)
Chest X-ray
Chest CT scan
Bronchoscopy

Pharmacologic Management for Inhalation Injury

Oxygen therapy
Antidotes for toxic gas exposure (e.g., hydroxocobalamin for cyanide poisoning, sodium thiosulfate as alternative).
Bronchodilators (e.g., albuterol, ipratropium)
Anti-inflammatory agents (e.g., dexamethasone)

Patient Education for Inhalation Injury

Medication adherence
Hydration and nutrition
Avoidance of respiratory irritants

Anaphylaxis

Acute hypersensitivity reaction, life-threatening.
Rapidly evolving, generalized, multi-system allergic reaction.
Causes: Food allergies (cow’s milk, eggs, peanuts, shellfish, tree nuts, wheat, seeds), medications, stinging insects, latex, other substances.

Risk Factors for Anaphylaxis

Previous anaphylaxis episode
Allergy history
Asthma
Family history of anaphylaxis
Underlying health conditions

Signs and Symptoms of Anaphylaxis

Airway: Shortness of breath, difficulty breathing, inability to swallow
Skin: Hives, redness, itchy rash, swelling
Stomach: Cramps, diarrhea, nausea/vomiting
Heart: Drop in blood pressure, increased heart rate, weak pulse, feeling faint

Stages of Anaphylaxis

Stage one (mild): Mild symptoms
Stage two (moderate): Increasing symptoms
Stage three (severe): Significant symptoms
Stage four (life-threatening): Severe symptoms that can be life-threatening

Diagnostic Assessment for Anaphylaxis

History (particular foods, latex, medications, insect stings)
Blood tests
Skin tests

Nursing Diagnosis for Anaphylaxis

Ineffective airway clearance (due to swelling and bronchospasm).
Impaired gas exchange (reduced oxygen supply due to airway obstruction/bronchospasm).

Treatment Planning for Anaphylaxis

Goals: Maintain patent airway, stabilize blood pressure, reduce allergic reaction severity, prevent further allergen exposure, educate on anaphylaxis management.

Interventions for Anaphylaxis

Immediate: Administer epinephrine IM (first-line treatment, 0.3–0.5 mg intramuscularly, repeated every 5–15 minutes), Ensure airway patency (if necessary intubation), Provide oxygen therapy, Start IV access and fluid resuscitation; Continuously monitor vital signs (BP, HR, RR), oxygen saturation, and level of consciousness.
Other treatments may include antihistamines and/or corticosteroids IV as indicated.

Foods to Avoid (Diet and Nutrition) for Allergies

Nuts
Seafood
Dairy products
Processed foods containing allergen (unless specifically labeled allergen-free)

Patient Education (Anaphylaxis)

Avoid identified allergens.
Proper use of epinephrine auto-injecters (e.g., EpiPen).
Recognize early signs of an allergic reaction and seek emergency care when needed.

Evaluation for Asthma

Patient maintains a patent airway and oxygen saturation ≥ 95%.
Blood pressure is stabilized, and cardiovascular function is restored.
Anaphylaxis symptoms resolved without recurrence.
Patient and family demonstrate understanding of prevention and management strategies.

Head Injury

Trauma to the scalp, skull, or brain, from mild bump/bruise to severe brain injury.

Common Causes of Head Injury

Road traffic accidents (RTAs), Falls, Sports injuries, Violence/assault, Industrial/workplace accidents

Types of Physical Trauma

Penetrating: Injury caused by a foreign object piercing the skin, damages underlying tissues, resulting in an open wound (gunshot, explosive devices, stab wounds)
Blunt: Injury by forceful impact, falls, or physical attack with a dull object; contusion, abrasion, laceration, or fracture

Prehospital Assessment for Head Injury

Gathering patient history prior to arrival (mechanism of injury, visible injuries, current interventions, patient's age and sex)
Assessing patient vitals.
Evaluating existing injuries to determine possible life-threatening injuries.

Airway Assessment for Head Injury

Check for patency by talking with the patient.
Establish if responsive to questions.

Circulation Assessment for Head Injury

Check for bleeding, visualize for external bleeding, or signs of shock (pallor, cold/diaphoretic skin)
Take carotid and femoral pulse.

Disability Assessment for Head Injury

Perform Glasgow Coma Scale (GCS) assessment (eye opening, verbal responses, motor responses).

Exposure Assessment for Head Injury

Removing all clothing/covering to assess full extent of injury.
Maintaining warmth to prevent hypothermia.

Further History of Head Injury

Assess past medical/surgical history, medications, and allergies.
Delineate the events that led to the injury.

Nursing Diagnoses for Head Injuries

Acute pain
Impaired skin integrity
Impaired physical mobility (due to fracture)
Risk for infection (related to open wounds)

Planning for Head Injury

Maintain patient stability, prevent secondary injuries, manage pain, and promote functional independence.
Immediate interventions: Spinal immobilization, airway management, blood pressure stabilization. Implement interventions to prevent complications like pressure ulcers, monitor for respiratory complications and ensure bowel/bladder management.

Implementation for Head Injury

Emergency care
Surgical intervention (as needed)
Critical care (including mechanical ventilation, hemodynamic monitoring, specialized medications)
Rehabilitation (physical therapy, occupational therapy, speech therapy, psychological support)

Medical-Surgical Management for Head Injury

Medical management: Provide medications like analgesics (opioids or NSAIDs), Encourage non-pharmacological techniques for pain management (relaxation, breathing exercises), Maintain aseptic wound care, and monitor closely for infection.
Surgical management: If needed, surgical procedures (to repair tissues, control bleeding, remove foreign objects).

Pharmacologic Management for Head Injury

Pain control (e.g., morphine, ibuprofen, acetaminophen)
Prevent infection (e.g., cefazolin, ciprofloxacin)
Anti-inflammatory drugs (ketorolac, prednisone).
Other medications as needed.

Diet and Nutrition for Head Injury

Small, frequent meals
High-calorie diet
Balanced macronutrients
Increased hydration
Focus on foods high in protein to encourage healing

Patient Education for Head Injury

Understand injury details
Promote self-care
Prevent complications
Support recovery
Medication purpose
Pain assessment
Follow-up checkups

Evaluation for Head Injury

Vital sign monitoring
Pain assessment
Wound care
Functional assessment (with mobility assessment)
Psychological assessment

Thoracic Emergency

Acute, life-threatening conditions involving chest cavity and vital organs (lungs, heart, blood vessels).

Types of Thoracic Injuries

Pneumothorax
Hemothorax
Flail chest

Pneumothorax

Air fills the pleural space, causing lung collapse.

Hemothorax

Blood accumulates in the pleural space.

Flail Chest

Portion of the ribcage detaches due to multiple rib fractures.

Causes of Thoracic Injuries

Cardiac conditions (myocardial infarction)
Motor vehicle accidents (MVAs)
Cardiac tamponade
Severe pneumonia
Pulmonary embolism

Signs and Symptoms of Thoracic Injuries

Hypo-tension
Pallor/Diaphoresis
Shortness of breath
Delayed capillary refill
Hypoxia

Nursing Diagnoses for Thoracic Injuries

Ineffective breathing pattern
Impaired gas exchange
Acute pain

Planning for Thoracic Injuries

Stabilizing patient condition, restoring effective breathing, addressing underlying causes,
Immediate interventions: Stabilization of vital signs, airway management, treatment of any obvious injuries.
Prevent complications (pressure ulcers), and ensure bowel/bladder management.
Long-term goals: Rehabilitation planning (physical therapy, occupational therapy, speech therapy, psychological support).

Implementation for Thoracic Injuries

Emergency care (stabilize vitals)
Surgical intervention (as needed)
Critical care (including ventilation, monitoring, and specialized medications)
Rehabilitation (involving physical, occupational, and psychological support).

Medical-Surgical Management for Thoracic Injuries

Medical: Medications and fluids
Surgical: Tube thoracostomy, thoracotomy, pericardiocentesis, embolectomy/thrombolytic therapy.

Pharmacologic Management for Thoracic Injury

Pain control (e.g., opioids, NSAIDs) -Support for cardiac function and dysrhythmias through ECG monitoring and pericardiocentesis as needed.

Patient Education for Thoracic Injuries

Explaining the diagnosis (simple terms)
Describing symptoms
Reassuring patient about treatment and outcomes
Teach use of oxygen therapy (nasal cannula, mask)
Importance of not smoking near O2 equipment.
Teach diaphragmatic breathing techniques
Importance of following-up care (chest X-rays/other evaluations)
Contact information for healthcare team

Evaluation for Thoracic Injuries

Patient maintaining patent airway with oxygen saturation ≥ 95%.
Blood pressure stabilized.
Cardiovascular function restored.
Symptoms resolved without recurrence.
Understanding of prevention/management strategies demonstrated.

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Description

Test your knowledge on inhalation injuries and respiratory emergencies in nursing. This quiz covers pharmacological interventions, nursing diagnoses, and critical signs to monitor. Enhance your understanding of crucial nursing interventions in acute care settings.