Podcast
Questions and Answers
Which of the following is the priority nursing intervention in the primary survey?
Which of the following is the priority nursing intervention in the primary survey?
- Controlling bleeding
- Maintaining a patent airway (correct)
- Assessing level of consciousness
- Evaluating circulation
A patient with a known spinal injury requires airway management. Which maneuver is most appropriate to open the airway?
A patient with a known spinal injury requires airway management. Which maneuver is most appropriate to open the airway?
- Jaw-thrust maneuver (correct)
- Heimlich maneuver
- Log roll maneuver
- Head-tilt, chin-lift maneuver
During triage in the emergency department, which patient requires immediate intervention?
During triage in the emergency department, which patient requires immediate intervention?
- A patient with a stable closed fracture of the tibia.
- A patient complaining of a headache and dizziness.
- A patient exhibiting signs of respiratory distress. (correct)
- A patient with a minor laceration on their arm.
A patient is suspected of being in the progressive stage of shock. Which assessment finding supports this suspicion?
A patient is suspected of being in the progressive stage of shock. Which assessment finding supports this suspicion?
Which type of shock is caused by a severe allergic reaction?
Which type of shock is caused by a severe allergic reaction?
What is a key difference between pneumothorax and hemothorax?
What is a key difference between pneumothorax and hemothorax?
What is a priority nursing intervention for a patient with a tension pneumothorax?
What is a priority nursing intervention for a patient with a tension pneumothorax?
A patient is being treated for a snakebite. Which intervention is contraindicated?
A patient is being treated for a snakebite. Which intervention is contraindicated?
What is the primary treatment for tetanus?
What is the primary treatment for tetanus?
Which finding in a trauma patient indicates the need for immediate intervention to reduce intracranial pressure (ICP)?
Which finding in a trauma patient indicates the need for immediate intervention to reduce intracranial pressure (ICP)?
What is the Glasgow Coma Scale (GCS) used for in trauma patients?
What is the Glasgow Coma Scale (GCS) used for in trauma patients?
A patient is suspected of having a spinal cord injury. At what level of injury would the nurse be most concerned about respiratory effort?
A patient is suspected of having a spinal cord injury. At what level of injury would the nurse be most concerned about respiratory effort?
A nurse is preparing to administer epinephrine to a patient experiencing anaphylaxis. Which route is most appropriate?
A nurse is preparing to administer epinephrine to a patient experiencing anaphylaxis. Which route is most appropriate?
Following a disaster, a nurse is assigned to triage. A patient presents with burns covering most of the body, is non-responsive, and has shallow, agonal respirations. What triage category would this patient fall under?
Following a disaster, a nurse is assigned to triage. A patient presents with burns covering most of the body, is non-responsive, and has shallow, agonal respirations. What triage category would this patient fall under?
Following exposure to anthrax, which antibiotic is typically recommended as a first-line treatment?
Following exposure to anthrax, which antibiotic is typically recommended as a first-line treatment?
Which of the following would the nurse recognize as a sign/symptom of botulism?
Which of the following would the nurse recognize as a sign/symptom of botulism?
A patient has a deep partial-thickness burn. What finding would the nurse expect to see?
A patient has a deep partial-thickness burn. What finding would the nurse expect to see?
Which action is the most important when caring for a patient that has just been exposed to a nerve agent, such as sarin?
Which action is the most important when caring for a patient that has just been exposed to a nerve agent, such as sarin?
If a patient is suspected of smallpox, how should the client be isolated?
If a patient is suspected of smallpox, how should the client be isolated?
What findings are associated with heat stroke?
What findings are associated with heat stroke?
A patient presents to the emergency room after being stung by a bee and having an allergic reaction. The patient is experiencing urticaria along with swelling of the tongue. What medication should be given first?
A patient presents to the emergency room after being stung by a bee and having an allergic reaction. The patient is experiencing urticaria along with swelling of the tongue. What medication should be given first?
The nurse is caring for a patient who is experiencing hypothermia with a body temperature of 85°F (29.4°C). What assessment finding would the nurse expect to see?
The nurse is caring for a patient who is experiencing hypothermia with a body temperature of 85°F (29.4°C). What assessment finding would the nurse expect to see?
Which of the following best describes 'triage' in the context of disaster response:
Which of the following best describes 'triage' in the context of disaster response:
During the secondary survey of a major trauma client the nurse assesses crepitus (audible or palpable crunching) in the chest area. What is the clinical significance of this finding?
During the secondary survey of a major trauma client the nurse assesses crepitus (audible or palpable crunching) in the chest area. What is the clinical significance of this finding?
During the primary survey of a trauma patient, what is the rationale for avoiding hyperextension, flexion, or rotation of the neck?
During the primary survey of a trauma patient, what is the rationale for avoiding hyperextension, flexion, or rotation of the neck?
A patient in shock is ordered IV fluids, what is the best catheter to use when administering IV fluids for resuscitation?
A patient in shock is ordered IV fluids, what is the best catheter to use when administering IV fluids for resuscitation?
The nurse assesses a patient and finds that the patient is alert and responds to verbal stimuli. How should the nurse document this finding in the patient's chart?
The nurse assesses a patient and finds that the patient is alert and responds to verbal stimuli. How should the nurse document this finding in the patient's chart?
When assessing a patient with a musculoskeletal injury during the secondary survey, what finding requires immediate intervention?
When assessing a patient with a musculoskeletal injury during the secondary survey, what finding requires immediate intervention?
Following a bee sting, a patient develops generalized itching, urticaria, and tongue swelling. What type of shock is the patient most likely experiencing?
Following a bee sting, a patient develops generalized itching, urticaria, and tongue swelling. What type of shock is the patient most likely experiencing?
A patient is in the progressive stage of hypovolemic shock. What is most likely causing the patient's health to deteriorate?
A patient is in the progressive stage of hypovolemic shock. What is most likely causing the patient's health to deteriorate?
A patient with anaphylactic shock is experiencing bronchoconstriction. What would the nurse expect to hear when auscultating lung sounds?
A patient with anaphylactic shock is experiencing bronchoconstriction. What would the nurse expect to hear when auscultating lung sounds?
What is an important preventative measure a nurse can take to minimize the risk of latex allergy in the workplace?
What is an important preventative measure a nurse can take to minimize the risk of latex allergy in the workplace?
What is the best way to maintain a patient's body temperature when trying to prevent shock from blood loss?
What is the best way to maintain a patient's body temperature when trying to prevent shock from blood loss?
When providing direct pressure to a bleeding wound and elevating the injured extremity, the bleeding persists. What should the next step be?
When providing direct pressure to a bleeding wound and elevating the injured extremity, the bleeding persists. What should the next step be?
A patient possibly has hypovolemic shock. What finding would the nurse expect to see?
A patient possibly has hypovolemic shock. What finding would the nurse expect to see?
For a patient with a deep laceration to the arm, what nursing intervention takes priority?
For a patient with a deep laceration to the arm, what nursing intervention takes priority?
A trauma client experiences a sudden deceleration injury. What would be priority?
A trauma client experiences a sudden deceleration injury. What would be priority?
Why is it important to know if a trauma victim takes epinephrine?
Why is it important to know if a trauma victim takes epinephrine?
After administering epinephrine, what findings would suggest it was effective?
After administering epinephrine, what findings would suggest it was effective?
To help keep the airways clear of the patient, what position should you place the patient in during an allergic reaction?
To help keep the airways clear of the patient, what position should you place the patient in during an allergic reaction?
Besides administering oxygen, what action promotes breathing during an allergic reaction?
Besides administering oxygen, what action promotes breathing during an allergic reaction?
What is a medication that can be used as a second-line therapy as part of an anaphylaxis treatment plan?
What is a medication that can be used as a second-line therapy as part of an anaphylaxis treatment plan?
What is the most important thing to monitor while rewarming a client with hypothermia?
What is the most important thing to monitor while rewarming a client with hypothermia?
Below what temperature do interventions say cardiac drugs be given sparingly to hypothermia patients?
Below what temperature do interventions say cardiac drugs be given sparingly to hypothermia patients?
If a patient is alert, what fluids should be given to a patient experiencing heat exhaustion?
If a patient is alert, what fluids should be given to a patient experiencing heat exhaustion?
What is a key manifestation in heatstroke?
What is a key manifestation in heatstroke?
A client is admitted and needs decontamination. What method is recommended to surfaces contaminated against smallpox?
A client is admitted and needs decontamination. What method is recommended to surfaces contaminated against smallpox?
In a biological attack known as anthrax, what can improve the chances of survival?
In a biological attack known as anthrax, what can improve the chances of survival?
What is the most likely form of anthrax after a biological attack?
What is the most likely form of anthrax after a biological attack?
During the primary survey of a trauma patient, after addressing the airway, what is the next priority?
During the primary survey of a trauma patient, after addressing the airway, what is the next priority?
A patient who has been involved in a motor vehicle accident is complaining of chest pain and difficulty breathing. Upon assessment, the nurse notes absent breath sounds on the right side. What condition should the nurse suspect?
A patient who has been involved in a motor vehicle accident is complaining of chest pain and difficulty breathing. Upon assessment, the nurse notes absent breath sounds on the right side. What condition should the nurse suspect?
What physical assessment findings would be most indicative of a patient experiencing cardiac tamponade?
What physical assessment findings would be most indicative of a patient experiencing cardiac tamponade?
A patient presents to the emergency department with an open wound sustained while gardening. The patient's immunization history is unknown. What intervention is most appropriate regarding tetanus prophylaxis?
A patient presents to the emergency department with an open wound sustained while gardening. The patient's immunization history is unknown. What intervention is most appropriate regarding tetanus prophylaxis?
A patient exposed to anthrax would most likely contract which form of the disease?
A patient exposed to anthrax would most likely contract which form of the disease?
A patient exhibiting signs and symptoms including ptosis, blurred vision, difficulty swallowing and generalized muscle weakness is suspected to have been exposed to what?
A patient exhibiting signs and symptoms including ptosis, blurred vision, difficulty swallowing and generalized muscle weakness is suspected to have been exposed to what?
A nurse performing triage after a large explosion identifies which client as emergent (red triage tag)?
A nurse performing triage after a large explosion identifies which client as emergent (red triage tag)?
What is the best description of the purpose of triage during a disaster:
What is the best description of the purpose of triage during a disaster:
A trauma patient in the ED is restless and anxious. The client has a Weak, rapid, thready pulse and exhibits cold and clammy skin. The client is likely experiencing what?
A trauma patient in the ED is restless and anxious. The client has a Weak, rapid, thready pulse and exhibits cold and clammy skin. The client is likely experiencing what?
A nurse is caring for a client experiencing hypovolemic shock secondary to severe blood loss after a trauma. Which nursing intervention is most appropriate to implement?
A nurse is caring for a client experiencing hypovolemic shock secondary to severe blood loss after a trauma. Which nursing intervention is most appropriate to implement?
A client who is in hypovolemic shock is not responding and is deteriorating. What clinical indicator is most likely causing the client's health to deteriorate?
A client who is in hypovolemic shock is not responding and is deteriorating. What clinical indicator is most likely causing the client's health to deteriorate?
A client is experiencing shock and is prescribed IV fluids. The nurse knows to avoid which IV fluid administration in cardiogenic shock:
A client is experiencing shock and is prescribed IV fluids. The nurse knows to avoid which IV fluid administration in cardiogenic shock:
A client has a deep partial-thickness thermal burn injury and is experiencing burn shock. When providing wound care, the nurse knows that wet dressings are:
A client has a deep partial-thickness thermal burn injury and is experiencing burn shock. When providing wound care, the nurse knows that wet dressings are:
A client is suspected of Tetanus in an open wound. The nurse will monitor for which primary sign?
A client is suspected of Tetanus in an open wound. The nurse will monitor for which primary sign?
The nurse is assessing a client with a spinal cord injury and notes the level is at C5 or above. The nurse priorities is carefully assessing what:
The nurse is assessing a client with a spinal cord injury and notes the level is at C5 or above. The nurse priorities is carefully assessing what:
A client is coding when the nurse notes they are profound hypothermia and needs cardiac drugs. What temperature does the nurse know that cardiac drugs should be given sparingy?
A client is coding when the nurse notes they are profound hypothermia and needs cardiac drugs. What temperature does the nurse know that cardiac drugs should be given sparingy?
A bioterrorism attack with smallpox breaks out at a local convention. What contamination method can be used on surfaces?
A bioterrorism attack with smallpox breaks out at a local convention. What contamination method can be used on surfaces?
Hypothermia is occuring when the clients body drops below what temperature?
Hypothermia is occuring when the clients body drops below what temperature?
The skin protects the body by preventing:
The skin protects the body by preventing:
A patient is admitted to the hospital and confined to rooms that are under negative atmospheric pressure and equipped with with high-efficiency particulate air (HEPA) firation and has Smallpox, what kind of precautions should the staff take?
A patient is admitted to the hospital and confined to rooms that are under negative atmospheric pressure and equipped with with high-efficiency particulate air (HEPA) firation and has Smallpox, what kind of precautions should the staff take?
What best describes distributive shock?
What best describes distributive shock?
A client has sustained a bee or wasp sting, what method should the nurse uses to remove the stinger?
A client has sustained a bee or wasp sting, what method should the nurse uses to remove the stinger?
What priority information should the nurse get when assessing a client with poisoning?
What priority information should the nurse get when assessing a client with poisoning?
Which is not true regarding shock?
Which is not true regarding shock?
What assessment is extremely important in clients with facial burns?
What assessment is extremely important in clients with facial burns?
A patient presents with cool, clammy skin, rapid heart rate, and decreasing blood pressure. These findings are most indicative of which condition?
A patient presents with cool, clammy skin, rapid heart rate, and decreasing blood pressure. These findings are most indicative of which condition?
A patient with a gunshot wound to the abdomen is restless and showing signs of shock. What is the most appropriate initial intravenous fluid for resuscitation?
A patient with a gunshot wound to the abdomen is restless and showing signs of shock. What is the most appropriate initial intravenous fluid for resuscitation?
A patient with a pneumothorax is experiencing increasing respiratory distress. Which of the following assessment findings would differentiate a tension pneumothorax from a simple pneumothorax?
A patient with a pneumothorax is experiencing increasing respiratory distress. Which of the following assessment findings would differentiate a tension pneumothorax from a simple pneumothorax?
A patient presents with a sucking chest wound after a stabbing. What is the most appropriate immediate intervention?
A patient presents with a sucking chest wound after a stabbing. What is the most appropriate immediate intervention?
A patient in the emergency department has an open fracture with significant soft tissue damage. The patient's immunization history is unavailable. Which intervention is most appropriate to prevent tetanus?
A patient in the emergency department has an open fracture with significant soft tissue damage. The patient's immunization history is unavailable. Which intervention is most appropriate to prevent tetanus?
A patient is diagnosed with tetanus. Which of the following nursing interventions is essential to manage the patient's condition?
A patient is diagnosed with tetanus. Which of the following nursing interventions is essential to manage the patient's condition?
During the primary survey of a trauma patient, the nurse notes that the patient is responsive to pain but confused. According to the AVPU scale, how should the nurse document this level of consciousness?
During the primary survey of a trauma patient, the nurse notes that the patient is responsive to pain but confused. According to the AVPU scale, how should the nurse document this level of consciousness?
A patient involved in a motor vehicle accident is being triaged. The patient has an open femur fracture, is alert and oriented, and has stable vital signs. How should this patient be categorized during triage?
A patient involved in a motor vehicle accident is being triaged. The patient has an open femur fracture, is alert and oriented, and has stable vital signs. How should this patient be categorized during triage?
A patient with septic shock has received a bolus of intravenous fluids, but their blood pressure remains low. Which intervention should be considered next?
A patient with septic shock has received a bolus of intravenous fluids, but their blood pressure remains low. Which intervention should be considered next?
During the ABCDE assessment, which assessment finding would take priority?
During the ABCDE assessment, which assessment finding would take priority?
A nurse is assessing a patient at risk for hypovolemic shock. What is the rationale for assessing skin temperature and moisture?
A nurse is assessing a patient at risk for hypovolemic shock. What is the rationale for assessing skin temperature and moisture?
A patient that is diagnosed with tetanus will most likely have what manifestations?
A patient that is diagnosed with tetanus will most likely have what manifestations?
During a primary survey, what takes priority after airway?
During a primary survey, what takes priority after airway?
A patient has air trapped in the lungs during expiration, putting pressure on other unaffected parts. This best describes what condition?
A patient has air trapped in the lungs during expiration, putting pressure on other unaffected parts. This best describes what condition?
A patient has an open femur fracture. Regarding tetanus, what steps would be taken if the patient is unknown?
A patient has an open femur fracture. Regarding tetanus, what steps would be taken if the patient is unknown?
A patient present to the ER and the nurse recognizes the patient is going to decompensate quickly and reuires immediate intervention. How should the nurse categorize this patient?
A patient present to the ER and the nurse recognizes the patient is going to decompensate quickly and reuires immediate intervention. How should the nurse categorize this patient?
Which of the following is most likely to progress shock, possibly causing death?
Which of the following is most likely to progress shock, possibly causing death?
A patient requires the jaw-thrust maneuver to open a client's airway. What is this useful for?
A patient requires the jaw-thrust maneuver to open a client's airway. What is this useful for?
When assessing circulation, what should be assessed in the primary survey?
When assessing circulation, what should be assessed in the primary survey?
To protect from heatloss, what should the nurse do as part of the exposure portion of the primary assessment?
To protect from heatloss, what should the nurse do as part of the exposure portion of the primary assessment?
What is a finding of chest trauma?
What is a finding of chest trauma?
Sharp blows to the head can shift intracranial contents causing what?
Sharp blows to the head can shift intracranial contents causing what?
What is common with clostridium tetani?
What is common with clostridium tetani?
What is the focus with spinal trauma?
What is the focus with spinal trauma?
What can be a cause of hypovolemic shock?
What can be a cause of hypovolemic shock?
A patient is going into shock. What does the body do to try to compensate?
A patient is going into shock. What does the body do to try to compensate?
What does distributive shock include?
What does distributive shock include?
What is a key concept with the Near-drowning client
What is a key concept with the Near-drowning client
What intervention can be taken in a disaster for mild hyperthermia related to exposure to a hot environment?
What intervention can be taken in a disaster for mild hyperthermia related to exposure to a hot environment?
In carbon monoxide poisoning, what occurs in the body?
In carbon monoxide poisoning, what occurs in the body?
What should be avoided for snake bites?
What should be avoided for snake bites?
In a disaster, what does nursing do
In a disaster, what does nursing do
If a community is exposed to anthrax, what could have taken place?
If a community is exposed to anthrax, what could have taken place?
A patient presents with a triad of afebrile, symmetrical descending paralysis, clear mentation. What disease is this?
A patient presents with a triad of afebrile, symmetrical descending paralysis, clear mentation. What disease is this?
What is a droplet precaution that can be taken with plague?
What is a droplet precaution that can be taken with plague?
What is the purpose of the secondary patient survey?
What is the purpose of the secondary patient survey?
Flashcards
Shock
Shock
A condition of acute circulatory failure leading to inadequate tissue perfusion and decreased blood pressure.
Phases of Shock
Phases of Shock
Compensated, progressive, and decompensated.
Types of Shock
Types of Shock
Hypovolemic, Cardiogenic, Obstructive, Distributive.
Hypovolemic Shock
Hypovolemic Shock
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Cardiogenic Shock
Cardiogenic Shock
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Obstructive Shock
Obstructive Shock
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Treating Shock
Treating Shock
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Nursing for Shock
Nursing for Shock
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Pneumothorax
Pneumothorax
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Cardiac Tamponade
Cardiac Tamponade
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Hemothorax
Hemothorax
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Tetanus
Tetanus
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Primary Survey Components
Primary Survey Components
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What to assess first?
What to assess first?
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Purpose of Primary Survey
Purpose of Primary Survey
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Airway Assessment
Airway Assessment
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Airway maneuver w/Spinal Injury
Airway maneuver w/Spinal Injury
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Check Airway For:
Check Airway For:
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Airway Adjuncts
Airway Adjuncts
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Advanced Airway Adjuncts
Advanced Airway Adjuncts
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Breathing Assessment
Breathing Assessment
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Assisted Ventilation
Assisted Ventilation
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Disability Assessment Purpose
Disability Assessment Purpose
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Levels of Consciousness
Levels of Consciousness
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Secondary Survey Assessment
Secondary Survey Assessment
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Anaphylaxis
Anaphylaxis
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Abrasion
Abrasion
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Laceration
Laceration
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AVPU
AVPU
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Anaphylactic Shock Nursing Interventions
Anaphylactic Shock Nursing Interventions
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Hypothermia
Hypothermia
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Heatstroke
Heatstroke
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Triage
Triage
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Nursing Interventions for Hyperthermia
Nursing Interventions for Hyperthermia
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Distributive Shock
Distributive Shock
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Controlling hemorrhage
Controlling hemorrhage
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Hypothermia in near-drowning
Hypothermia in near-drowning
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Head Trauma
Head Trauma
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Penetrating Chest Trauma
Penetrating Chest Trauma
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Using a blanket in shock
Using a blanket in shock
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Major Trauma
Major Trauma
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Epinephrine for anaphylaxis
Epinephrine for anaphylaxis
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Antihistamines for anaphylaxis
Antihistamines for anaphylaxis
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Neck and back stabilization
Neck and back stabilization
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Burn depth
Burn depth
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If the bone is fractured.
If the bone is fractured.
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Primary Survey
Primary Survey
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If the patient is injured.
If the patient is injured.
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Botulism interventions
Botulism interventions
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Spinal Shock
Spinal Shock
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Pneumothorax and Hemothorax
Pneumothorax and Hemothorax
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Neurogenic Shock
Neurogenic Shock
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Septic Shock
Septic Shock
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Secondary Survey
Secondary Survey
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Tension Pneumothorax
Tension Pneumothorax
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Tetanus Cause
Tetanus Cause
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Nursing intervention for Impalement
Nursing intervention for Impalement
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Disability
Disability
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Nursing care for breathing
Nursing care for breathing
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Nursing care for circulation
Nursing care for circulation
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GCS
GCS
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Exposure considerations
Exposure considerations
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Study Notes
Primary Survey
- Guides the recognition of life-threatening conditions and determination of care priorities.
- It involves assessing airway, breathing, circulation, and disability.
Primary Survey: Airway
- Critical first step.
- Avoid neck hyperextension, flexion, or rotation until spinal injury is ruled out.
- Use the jaw-thrust maneuver instead of the chin-lift maneuver during CPR if a spinal injury is suspected.
- Inspect the airway for obstructions such as loose teeth, foreign objects, bleeding, and vomitus and suction to clear obstructions.
- Airway adjuncts like nasopharyngeal and oropharyngeal airways are used to maintain an open airway.
- Advanced adjuncts like endotracheal intubation or cricothyroidotomy are performed by trained personnel when additional airway support is required.
Primary Survey: Breathing
- Follows the airway assessment.
- Involves assessing spontaneous breathing, respiratory rate, and depth
- The nurse auscultates for breath sounds bilaterally to determine respiratory need.
- Interventions are performed before proceeding if not breathing.
- Mouth-to-face mask or bag-valve face mask ventilation can be performed.
- Endotracheal intubation is preferred in unconscious patients as it protects the lungs from aspiration.
Primary Survey: Circulation
- Assesses by palpating the carotid pulse for quality and rate.
- Includes an inspection of the skin for color and temperature.
- External bleeding is controlled by external pressure and elevation if possible.
- Life-threatening conditions that can compromise circulation are assessed, and interventions are provided before proceeding.
- Large-gauge IV cannulas (16 or 18 gauge) are initiated for fluid resuscitation.
- CPR must be initiated if the patient does not have a pulse.
- Vital signs need to be check and recorded when a pulse can be palpated.
Primary Survey: Disability/Central Nervous System
- Determines the level of consciousness to detect serious central nervous system injury.
- Level of consciousness ranges from alert (A), responds to verbal stimuli (V), responds to painful stimuli (P), or unresponsive (U).
- For painful stimuli, periorbital pressure or pressure on the lateral outer aspect of the second or third interphalangeal joint can be applied.
- Observe and record the response to pain.
- Assess movement of all extremities.
Secondary Survey
- Conducted for victims of severe trauma.
- Identifies medical or injury problems not immediately life-threatening but require treatment.
- Major body areas like the head, spine, chest, abdomen, and musculoskeletal system are quickly examined.
- The patient’s clothing is removed, and each major body area is inspected and palpated for deformity, bruising, open wounds, bleeding, and pain.
Components of Secondary Survey
- Head: Inspect for lacerations and bleeding from orifices, check pupil size and response to light.
- Chest: Auscultate for breath sounds in all lung fields, inspect for lacerations, wounds, and foreign bodies.
- Abdomen: Auscultate for bowel sounds in all four quadrants, palpate for tenderness and rigidity, inspect for lacerations, wounds and foreign bodies, and inspect for ecchymosis.
- Extremities: Inspect for lacerations, wounds, and foreign bodies, inspect for injuries and deformities, palpate for pulses and evaluate temperature and capillary refill, and compare the left to the right extremities.
Medication Errors in the ED
- Medication administration is a common nursing intervention with medication errors being the most frequently reported error.
- The ED nurse is interrupted on average 3.3 times per hour, with 27.5% of these interruptions happening during medication administration.
- Temporary staff have been shown to make more medication errors, resulting in a greater patient harm than permanent staff members.
- Contributing factors include ED overcrowding, high volume of medications given, complicated patients, verbal orders, time constraints, interruptions, and distractions.
- Implementations include use of the five rights of medication administration, minimizing distractions, and double-checking medications with another nurse.
Types of Shock
- Shock is acute peripheral circulatory failure, causing decreasing blood pressure and tissue perfusion.
- Three phases: compensated, progressive, and decompensated.
- Compensated shock involves an adaptational phase to changes in blood circulation.
- Inadequate tissue and cell perfusion results in compensatory mechanisms failing. The third decompensated stage of shock patients no longer respond to treatment.
- Four types: hypovolemic, cardiogenic, obstructive, and distributive.
- Hypovolemic shock results from a decrease in the circulating blood volume.
- Cardiogenic shock is due to cardiac malfunction or failure.
- Obstructive shock results from a blockage of blood flow in the cardiovascular circuit outside of the heart.
- Distributive shock is caused by excessive dilation of the venules and arterioles.
Anaphylaxis
- Severe allergic reaction that occurs suddenly after contact with an allergen.
- Results from chemical mediators releasing from mast cells and basophils.
- Vasodilation and capillary leakage induced by released mediators leads to hypotension and vascular collapse.
Anaphylaxis Pathophysiology
- Form of distributive
- No blood loss occurs.
- Excessive vasodilation
- The bronchi constrict, making airflow increasingly difficult
- Increased fluid and mucus production in the bronchial passages
- Oxygen deprivation due to fluid-filled alveoli and constricted bronchi
- Hypotension with vasodilation
- Decreased level of consciousness due to decreased oxygenation
- Respiratory distress with stridor and cyanosis due to fluid and constricted airways
Anaphylaxis Signs and Symptoms of an Allergic Reaction
- Generalized itching and flushing
- Urticaria (hives)
- Swelling of the lips, tongue, or uvula
- Dyspnea
- Bronchospasm, wheezing, and stridor
- Chest tightness and cough
- Crampy abdominal pain and vomiting
- Anxiety
- Hypotension
Nursing Process Data Collection for Shock and Anaphylaxis
- The patient at risk for shock should be monitored for signs/symptoms that are common to all shock types
- Notes the patient's initial level of consciousness, and monitors for subsequent changes
- Decline in consciousness indicates a need for intervention
- Pulses indicate the strength of the heart’s contractions and should be assessed frequently
- Blood pressure indicates a change in blood volume, changes occur rapidly, skin temperatures and color can change
- Blood loss activates a sympathetic nervous system in the “flight-or-fight”, skin becomes cool and clammy
- Blood shunted to vital organs due to peripheral blood vessels constricting
- Insufficient skin circulation is pale, white, or ashen
- Skin can be seen in the nail beds, conjunctiva of the eye, or mucous membranes
- Capillary refill is checked on the nailbeds to evaluate arterial circulation to an extremity
Hypovolemic/Hypoxia Nursing Interventions
- Maintain vital signs that are within the normal baseline range
- Obtain frequent vital signs to monitor patient status
- Administer oxygen for over 90% saturation
- Isotonic IV fluids will aid in maintaining blood pressure
- Monitor output and intake in order to monitor fluid
- Patients bleeding will receive directed pressure
- Elevate the limb when possible
- Monitor signs, record the data, and report indications for advancing shock
- Monitor fluid intake as ordered
Allergy Nursing Interventions
- Administer epinephrine IM for allergy ABC
- Give antihistamines to control allergic rash and pruritus
- Steroids are tapered to prevent returning symptoms
Major Trauma
- Identified as the fifth leading cause of mortality in the United States
- Under the age of 34 and over the age of 70
- Injury may be a singular vital organ or multiple systems.
Gerontological Issues/Major Trauma
- Falls are a high risk group
- Initial assessment will require questions and an assessment to see if the patient has indications of prior abuse. resolution will take longer in elderly with injuries
- Elder with trauma injuries requires the nurse to see if there are additional indicators with similar injury indicators.
- There is a report when there are abuse indications
- Not prove
Sharp/Blunt Trauma Injuries
- Penetrating or open injuries are caused by sharp objects like glass or knives, with projectiles such as bullets
- Blunt or closed injuries have an intact skin surface trauma beyond the force extends to underlying structures
Gunshot Wound Injuries
- Trajectory of the bullet depends on mass projection, tissue, speed and range.
- Documentation of findings are not to label wounds as exit or entry points
- Near the level of the diaphragm need to be evaluated to see if they hit the abdomen
Surface Trauma
- Surface trauma includes trauma that does not affect/break skin vs. any open injury
- Closes injuries cause bruising and hematosis
- Open injuries include scraping the skin (abrasions), narrow object cause, loss of full-thickness skin and open wounds caused by snags and tearing of tissue
Surface Trauma: Abrasions
- Scraping of the epidermis and dermal layers with very little bleeding
- Very painful due to the inflamed nerve ending, ground dirt can increase the risk of infection
Surface Trauma: Puncture Wounds.
- Narrow object high-velocity
- Entrance wounds deceptive and hard to estimate damage underlying or organs
- Located wounds are chest or abdomen
Head Trauma
- sharp blows to cause shifting of content in the brain
- first phase not reversable
- Second phase leads to intererebral bleeding and edema, directed at reducing ICP
- spinal cord injuries come from accidents often for men from 16 to 30
- the spine gets injured patients need neck support in the spinal cord in trauma to see possible spinal damag
Chest Trauma
- can cause life threating injuries such as tamponade
- can lacerate lung tissue to cause change negative that cause pressure in air or blood pressure
Abdominal Trauma
- Organs are venerable from injury due to limited bony protection
- Liver or spleen can rapidly loss volume and hypovolemic shock
- Organs can be injured due to severe/blunt or penetrating trauma
- if urinary bladder ruptures then urine and blood is detected from the urinary meatus or perinium.
Orthopedic Trauma
- Fractured bones cause loss of blood, circulation and mobility
- fractures disrupt the pelvic veins
- Fractures of large bones cause loss of significant blood
- Delayed fracture reduction reduces blood vessels vessels
The Spinal Trauma Scale
- Assess pupils in their reactivity, and monitor extremities when it comes to the spinal cord.
- Patients major chest injuries can have dramatic symptoms with cyanosis
Nursing and Planning of Spine, Trauma, and Chest
- Give oxygen that is supplementary as part of a breathing technique
- Immobilized to allow healing
- Interventions will show success and have normal extremity function.
Burns
- Burns disrupt barriers that allow bacteria prevent electrolyte conservation
- injuries that result in major altered functions
- depend the degree
- and other associated smoke inhalation
- patients include smoke inhalation
Skin Care
- facial burns are elevated in order to reduce swelling
- loss of skin due is to not able to regain heat on their own
- Super facial is on the surface
- Partial is on the inner dermis and epidermis and has all-thickness all layers
Heat Stroke
- Hypothalamus does not work for over hypertherimia
- When these mechanisms are overwhelmed, the disaster arises and is not reversed
Three Forms of Hyperthimia.
- Over exposure from heat can result in several symptoms and progress
- Heat Cramps include muscle spasms
- Heat exhaustion occurs when the body causes fluid due to swelling, treatable with fluids.
- Heat stroke is not treated or reversed, and could can altered mental status high fever and death.
Poisoning
- Poison are introduced by the body through any pathway
- Poisons cause cellular structure, change functions
- Assess the mental capacity
Poisoning Process
- Recognition of the process and then assess
- Look at bodily clues
- Check for tracking signs
- See burns around area IV
Nursing Dx and Planning
- Risk for injury and absorption expected to be successful
- Access the poison control with details
- Not access to the airway through the injection process
- Given through airway or fresh area
- Resp. to monitor
Injected Poison
- Pose challenging problems and are difficult to remove
- local cause tissue due to problems
Insect Bites Or Stings
- Causes anaphylaxis in the most
- Limited pain heat in most
- Treatment applies to sting/bite, cellulitis to occur later
Black widow
- Is in the shape of a bird abdomen, which is common in the US
- Spreading of large muscle groups, etc
Brown recluse Spider.
- Lives in dry areas
- Cause severe damage
- Fever or chills
Snakebites
- Have venom
- Leave marks
- Discoloration
- Burning
Near drownings
- Is death from submersion lack of oxygen, surviving may show hypoxia
- The reflex overriding their breath
- There is water inspiration through laryngospasms
Drowning
- Is secondary after being immersed, hypothermia makes a challenge in the body and can be fatal
Nursing and Drowning
- Respiratory, hypoxia makes challenge for those with drowned patient
- Aggressive efforts from cold water as they decrease when body temperature in not up to 32.
Trauma Nursing
- Assessing trauma helps make a better outcome to keep that safe for all.
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