Podcast
Questions and Answers
During a primary survey of a trauma patient, which assessment finding requires the most immediate intervention by the nurse?
During a primary survey of a trauma patient, which assessment finding requires the most immediate intervention by the nurse?
- Patient's skin is cool and clammy to touch.
- Patient has shallow, labored respirations. (correct)
- Patient reports pain at the site of injury.
- Patient responds to verbal stimuli but is confused.
A patient involved in a motor vehicle accident is being assessed using the AVPU scale. The patient opens their eyes and responds when the nurse shouts their name. How should the nurse document this patient's level of consciousness?
A patient involved in a motor vehicle accident is being assessed using the AVPU scale. The patient opens their eyes and responds when the nurse shouts their name. How should the nurse document this patient's level of consciousness?
- Verbal (correct)
- Unresponsive
- Painful
- Alert
When performing the 'A' (Airway) assessment in the ABCDE primary survey, which intervention should the nurse prioritize for a patient with suspected cervical spine injury?
When performing the 'A' (Airway) assessment in the ABCDE primary survey, which intervention should the nurse prioritize for a patient with suspected cervical spine injury?
- Suctioning the airway to remove secretions.
- Performing a chin-lift maneuver to open the airway.
- Inserting an oropharyngeal airway.
- Utilizing a jaw-thrust maneuver to open the airway. (correct)
During the 'B' (Breathing) assessment of the ABCDE primary survey, the nurse observes asymmetrical chest rise and diminished breath sounds on the left side. Which condition should the nurse suspect?
During the 'B' (Breathing) assessment of the ABCDE primary survey, the nurse observes asymmetrical chest rise and diminished breath sounds on the left side. Which condition should the nurse suspect?
In the 'C' (Circulation) assessment of the ABCDE primary survey, the nurse finds a weak and rapid radial pulse. What is the most appropriate next step for the nurse to assess?
In the 'C' (Circulation) assessment of the ABCDE primary survey, the nurse finds a weak and rapid radial pulse. What is the most appropriate next step for the nurse to assess?
A patient with a head injury has a Glasgow Coma Scale (GCS) score of 10. Which nursing intervention is most critical based on this score?
A patient with a head injury has a Glasgow Coma Scale (GCS) score of 10. Which nursing intervention is most critical based on this score?
During the 'E' (Exposure) step of the ABCDE survey, the nurse removes a trauma patient's clothing. What is the priority nursing action after exposure?
During the 'E' (Exposure) step of the ABCDE survey, the nurse removes a trauma patient's clothing. What is the priority nursing action after exposure?
In a secondary survey of a trauma patient, the nurse is assessing the abdomen. Which finding would be most concerning and require immediate further investigation?
In a secondary survey of a trauma patient, the nurse is assessing the abdomen. Which finding would be most concerning and require immediate further investigation?
A patient presents with signs of hypovolemic shock following a severe laceration. Which intervention should the nurse prioritize?
A patient presents with signs of hypovolemic shock following a severe laceration. Which intervention should the nurse prioritize?
A patient has a deep laceration to the forearm with active bleeding. Direct pressure and elevation have not stopped the bleeding. What is the next appropriate step the nurse should take?
A patient has a deep laceration to the forearm with active bleeding. Direct pressure and elevation have not stopped the bleeding. What is the next appropriate step the nurse should take?
A patient has experienced a traumatic amputation of their left hand. What is the correct procedure for managing the amputated part?
A patient has experienced a traumatic amputation of their left hand. What is the correct procedure for managing the amputated part?
A patient arrives in the emergency department with a knife impaled in their chest. What is the priority nursing action regarding the impaled object?
A patient arrives in the emergency department with a knife impaled in their chest. What is the priority nursing action regarding the impaled object?
A patient with a deep puncture wound is being assessed for tetanus risk. Which factor is most critical in determining the need for tetanus immunoglobulin?
A patient with a deep puncture wound is being assessed for tetanus risk. Which factor is most critical in determining the need for tetanus immunoglobulin?
A patient is suspected of having a spinal cord injury after a fall. Which assessment finding is most indicative of potential spinal cord damage at the L4-L5 level?
A patient is suspected of having a spinal cord injury after a fall. Which assessment finding is most indicative of potential spinal cord damage at the L4-L5 level?
A patient with a chest injury is showing signs of a tension pneumothorax. Which assessment finding is most characteristic of this condition?
A patient with a chest injury is showing signs of a tension pneumothorax. Which assessment finding is most characteristic of this condition?
A patient has fractured ribs and is diagnosed with flail chest. What is the primary concern related to flail chest?
A patient has fractured ribs and is diagnosed with flail chest. What is the primary concern related to flail chest?
A patient with a suspected abdominal injury after a car accident is being assessed. Which assessment finding is most indicative of potential spleen or liver injury?
A patient with a suspected abdominal injury after a car accident is being assessed. Which assessment finding is most indicative of potential spleen or liver injury?
A patient with a fractured femur is at risk for complications related to orthopedic trauma. Which complication should the nurse monitor for most closely in the immediate post-injury period?
A patient with a fractured femur is at risk for complications related to orthopedic trauma. Which complication should the nurse monitor for most closely in the immediate post-injury period?
A patient is admitted with full thickness burns over 40% of their body. During the initial resuscitation phase, which intervention is the highest priority?
A patient is admitted with full thickness burns over 40% of their body. During the initial resuscitation phase, which intervention is the highest priority?
A patient with extensive burns develops hypothermia. What is the most appropriate method to rewarm this patient?
A patient with extensive burns develops hypothermia. What is the most appropriate method to rewarm this patient?
A patient is found outside in cold weather, shivering and confused, with a body temperature of 92°F (33.3°C). What is the priority nursing intervention?
A patient is found outside in cold weather, shivering and confused, with a body temperature of 92°F (33.3°C). What is the priority nursing intervention?
A patient with frostbite to their toes is being treated in the emergency department. What should the nurse avoid doing when caring for the affected area?
A patient with frostbite to their toes is being treated in the emergency department. What should the nurse avoid doing when caring for the affected area?
A patient presents with heat exhaustion. Initial assessment findings include diaphoresis, dizziness, and a temperature of 102°F (38.9°C). What is the priority nursing intervention?
A patient presents with heat exhaustion. Initial assessment findings include diaphoresis, dizziness, and a temperature of 102°F (38.9°C). What is the priority nursing intervention?
A patient is suspected of opioid overdose. Which medication should the nurse prepare to administer immediately?
A patient is suspected of opioid overdose. Which medication should the nurse prepare to administer immediately?
A patient inhaled chlorine gas. What is the priority nursing intervention?
A patient inhaled chlorine gas. What is the priority nursing intervention?
A patient is bitten by a coral snake. What is the most appropriate first aid measure?
A patient is bitten by a coral snake. What is the most appropriate first aid measure?
A patient is rescued from a near-drowning incident after being submerged for approximately 30 minutes in cold water. What is the most important factor guiding resuscitation efforts?
A patient is rescued from a near-drowning incident after being submerged for approximately 30 minutes in cold water. What is the most important factor guiding resuscitation efforts?
In a disaster triage situation, which patient should be prioritized as 'immediate' (red tag) according to START triage?
In a disaster triage situation, which patient should be prioritized as 'immediate' (red tag) according to START triage?
During a disaster response, the nurse is asked to triage patients. Which principle of disaster triage is most important to remember?
During a disaster response, the nurse is asked to triage patients. Which principle of disaster triage is most important to remember?
Which bioterrorism agent is known to cause symmetrical descending paralysis and is considered a neurotoxin?
Which bioterrorism agent is known to cause symmetrical descending paralysis and is considered a neurotoxin?
A public health nurse is educating the community about anthrax. Which statement is most accurate regarding anthrax transmission?
A public health nurse is educating the community about anthrax. Which statement is most accurate regarding anthrax transmission?
For which bioterrorism agent is droplet precautions necessary to prevent person-to-person spread?
For which bioterrorism agent is droplet precautions necessary to prevent person-to-person spread?
A patient comes to the emergency department with altered mental status, inability to sweat, and hot, dry skin after being outside on a hot day. These are late signs of which heat-related illness?
A patient comes to the emergency department with altered mental status, inability to sweat, and hot, dry skin after being outside on a hot day. These are late signs of which heat-related illness?
During the primary survey of a trauma patient, the nurse uses the AVPU scale. Which patient response indicates the highest priority for immediate intervention?
During the primary survey of a trauma patient, the nurse uses the AVPU scale. Which patient response indicates the highest priority for immediate intervention?
A patient with a suspected cervical spine injury requires airway management. Which method of opening the airway is most appropriate to minimize further injury?
A patient with a suspected cervical spine injury requires airway management. Which method of opening the airway is most appropriate to minimize further injury?
During the 'Breathing' assessment of the ABCDE survey, a nurse observes shallow respirations and cyanosis in a trauma patient. What is the immediate priority nursing intervention?
During the 'Breathing' assessment of the ABCDE survey, a nurse observes shallow respirations and cyanosis in a trauma patient. What is the immediate priority nursing intervention?
In assessing 'Circulation' during a primary survey, the nurse notes absent radial pulses. What is the most appropriate site to assess for a central pulse to confirm circulation?
In assessing 'Circulation' during a primary survey, the nurse notes absent radial pulses. What is the most appropriate site to assess for a central pulse to confirm circulation?
A patient with a head injury has a Glasgow Coma Scale (GCS) score of 8. Which nursing intervention is of the highest priority based on this score?
A patient with a head injury has a Glasgow Coma Scale (GCS) score of 8. Which nursing intervention is of the highest priority based on this score?
During the 'Exposure' phase of the ABCDE survey, after removing a trauma patient's clothing, what is the most critical next step to prevent hypothermia?
During the 'Exposure' phase of the ABCDE survey, after removing a trauma patient's clothing, what is the most critical next step to prevent hypothermia?
In a secondary survey, the nurse palpates a trauma patient's abdomen and notes rigidity and tenderness. Which potential injury should the nurse suspect based on these findings?
In a secondary survey, the nurse palpates a trauma patient's abdomen and notes rigidity and tenderness. Which potential injury should the nurse suspect based on these findings?
A patient is showing signs of hypovolemic shock due to significant blood loss. Which intervention is the most critical for the nurse to implement initially?
A patient is showing signs of hypovolemic shock due to significant blood loss. Which intervention is the most critical for the nurse to implement initially?
A patient has a deep laceration to the leg with uncontrolled bleeding despite direct pressure. What is the next appropriate step in managing this bleeding?
A patient has a deep laceration to the leg with uncontrolled bleeding despite direct pressure. What is the next appropriate step in managing this bleeding?
A patient presents with a partial amputation of the finger. What is the correct initial management of the amputated part to maximize the chances of successful reattachment?
A patient presents with a partial amputation of the finger. What is the correct initial management of the amputated part to maximize the chances of successful reattachment?
A patient arrives in the emergency department with a knife impaled in their abdomen. What is the most important principle to follow when managing an impaled object?
A patient arrives in the emergency department with a knife impaled in their abdomen. What is the most important principle to follow when managing an impaled object?
When assessing a patient with a puncture wound for tetanus risk, which aspect of the wound is most critical in determining the need for tetanus immunoglobulin (TIG)?
When assessing a patient with a puncture wound for tetanus risk, which aspect of the wound is most critical in determining the need for tetanus immunoglobulin (TIG)?
A trauma patient is suspected of having a spinal cord injury at the L4-L5 level. Which assessment finding would be most indicative of injury at this level?
A trauma patient is suspected of having a spinal cord injury at the L4-L5 level. Which assessment finding would be most indicative of injury at this level?
A patient with a chest injury is showing signs of tension pneumothorax. Which assessment finding is most indicative of this life-threatening condition?
A patient with a chest injury is showing signs of tension pneumothorax. Which assessment finding is most indicative of this life-threatening condition?
A patient with fractured ribs develops flail chest. What is the primary physiological concern associated with flail chest that the nurse should monitor for?
A patient with fractured ribs develops flail chest. What is the primary physiological concern associated with flail chest that the nurse should monitor for?
In a patient with suspected abdominal trauma, which assessment finding is most concerning for potential spleen or liver injury?
In a patient with suspected abdominal trauma, which assessment finding is most concerning for potential spleen or liver injury?
A patient with a fractured femur is at risk for fat embolism syndrome (FES). Which early sign should the nurse monitor for most closely?
A patient with a fractured femur is at risk for fat embolism syndrome (FES). Which early sign should the nurse monitor for most closely?
A patient with full thickness burns over 50% of their body is in the resuscitation phase. What is the highest priority intervention in the first 24 hours?
A patient with full thickness burns over 50% of their body is in the resuscitation phase. What is the highest priority intervention in the first 24 hours?
A patient with extensive burns develops hypothermia. What is the most appropriate method to rewarm this patient, considering their burn injuries?
A patient with extensive burns develops hypothermia. What is the most appropriate method to rewarm this patient, considering their burn injuries?
A patient with frostbite to the toes is being treated. Which action should the nurse avoid during the rewarming process to prevent further tissue damage?
A patient with frostbite to the toes is being treated. Which action should the nurse avoid during the rewarming process to prevent further tissue damage?
A patient presents with heat exhaustion. Initial findings include diaphoresis, dizziness, and a temperature of 102.5°F (39.2°C). What is the priority nursing intervention?
A patient presents with heat exhaustion. Initial findings include diaphoresis, dizziness, and a temperature of 102.5°F (39.2°C). What is the priority nursing intervention?
A patient is suspected of opioid overdose. Which medication is the antidote and should be prepared for immediate administration?
A patient is suspected of opioid overdose. Which medication is the antidote and should be prepared for immediate administration?
A patient has inhaled chlorine gas. What is the immediate priority nursing intervention in managing this inhalation injury?
A patient has inhaled chlorine gas. What is the immediate priority nursing intervention in managing this inhalation injury?
A patient is bitten by a coral snake. What is the most appropriate first aid measure at the scene?
A patient is bitten by a coral snake. What is the most appropriate first aid measure at the scene?
A patient is rescued from cold water after being submerged for 35 minutes. What is the most important factor guiding resuscitation efforts in this near-drowning scenario?
A patient is rescued from cold water after being submerged for 35 minutes. What is the most important factor guiding resuscitation efforts in this near-drowning scenario?
In a disaster triage situation, which patient should be tagged as 'immediate' (red tag) according to START triage principles?
In a disaster triage situation, which patient should be tagged as 'immediate' (red tag) according to START triage principles?
During disaster triage, what is the overarching ethical principle that guides resource allocation when there are more casualties than resources?
During disaster triage, what is the overarching ethical principle that guides resource allocation when there are more casualties than resources?
Which bioterrorism agent is known to cause symmetrical descending paralysis and is a potent neurotoxin?
Which bioterrorism agent is known to cause symmetrical descending paralysis and is a potent neurotoxin?
Which statement is most accurate regarding anthrax transmission and public health risk?
Which statement is most accurate regarding anthrax transmission and public health risk?
For which bioterrorism agent is droplet precautions necessary to prevent person-to-person spread in a healthcare setting?
For which bioterrorism agent is droplet precautions necessary to prevent person-to-person spread in a healthcare setting?
A patient is found unresponsive with hot, dry skin, altered mental status, and inability to sweat after being in extreme heat. These are late signs of which heat-related illness?
A patient is found unresponsive with hot, dry skin, altered mental status, and inability to sweat after being in extreme heat. These are late signs of which heat-related illness?
A nurse is caring for a patient with suspected heatstroke. Which of the following cooling methods is most appropriate and rapidly effective?
A nurse is caring for a patient with suspected heatstroke. Which of the following cooling methods is most appropriate and rapidly effective?
A patient who ingested a toxic substance is alert and oriented. What is the initial nursing action regarding gastrointestinal decontamination?
A patient who ingested a toxic substance is alert and oriented. What is the initial nursing action regarding gastrointestinal decontamination?
Following a disaster, a nurse is assigned to a long-term care facility. What is a key consideration for disaster preparedness in this setting?
Following a disaster, a nurse is assigned to a long-term care facility. What is a key consideration for disaster preparedness in this setting?
During a disaster drill, the nurse is asked to identify patients who should be discharged to create bed space. Which patient is most appropriate for discharge?
During a disaster drill, the nurse is asked to identify patients who should be discharged to create bed space. Which patient is most appropriate for discharge?
A nurse is educating community members about disaster preparedness. Which action is most crucial for individual and family disaster planning?
A nurse is educating community members about disaster preparedness. Which action is most crucial for individual and family disaster planning?
Which of the following assessment findings in a trauma patient would necessitate immediate intervention by the nurse to ensure patient safety and best outcome?
Which of the following assessment findings in a trauma patient would necessitate immediate intervention by the nurse to ensure patient safety and best outcome?
In managing a patient with severe trauma, which nursing action demonstrates effective prioritization and delegation in a busy emergency department?
In managing a patient with severe trauma, which nursing action demonstrates effective prioritization and delegation in a busy emergency department?
Flashcards
Triage: Primary Survey
Triage: Primary Survey
Initial assessment to recognize life-threatening conditions and determine priorities of care in critically ill or injured patients.
AVPU Scale
AVPU Scale
A scale used to determine a patient's level of alertness. Stands for Alert, Verbal, Painful, Unresponsive.
ABCDE Assessment
ABCDE Assessment
A systematic approach to assess and manage critical conditions. Stands for Airway, Breathing, Circulation, Disability, Exposure.
Airway Management
Airway Management
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Assessing Breathing
Assessing Breathing
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Assessing Circulation
Assessing Circulation
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Assessing Disability
Assessing Disability
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Assessing Exposure
Assessing Exposure
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Secondary Survey
Secondary Survey
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Shock
Shock
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Triage
Triage
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Disaster
Disaster
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Disaster Preparedness
Disaster Preparedness
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Botulism
Botulism
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Prioritize a patient in acute pain with tissue trauma
Prioritize a patient in acute pain with tissue trauma
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Prioritization: burns
Prioritization: burns
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GCS score range
GCS score range
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Triage prioritization
Triage prioritization
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Patient safety
Patient safety
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Prevent heat loss
Prevent heat loss
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Hypothermia symptoms
Hypothermia symptoms
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What is frostbite?
What is frostbite?
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Analgesics - rewarming
Analgesics - rewarming
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Hyperthermia signs
Hyperthermia signs
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Managing Hyperthermia
Managing Hyperthermia
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Poison entry routes
Poison entry routes
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Poisoning, consult with...
Poisoning, consult with...
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Snakebite first aid
Snakebite first aid
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Near-drowning priorities
Near-drowning priorities
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Bioterrorism awareness
Bioterrorism awareness
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Examples of Agents
Examples of Agents
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Study Notes
Triage Primary Survey
- Triage’s initial assessment identifies life-threatening conditions to prioritize patient care
- AVPU scale is used to quickly determine the patient's level of alertness
- ALERT: Patient is alert
- VERBAL: Patient responds to verbal stimuli.
- PAINFUL: Patient responds to painful stimuli.
- UNRESPONSIVE: Patient does not respond to any stimuli.
- ABCDE assessment follows AVPU to continue assessing the patient
ABCDE Assessment
- The ABCDE assessment includes Airway, Breathing, Circulation, Disability, and Exposure.
ABCDE - Airway
- Use the chin-lift maneuver to open the airway
- Use the jaw-thrust maneuver to open the airway when a head or neck injury is present
- Ensure the neck is not hyperextended, flexed, or rotated until a spinal injury is ruled out
- Check for airway obstruction by tongue, teeth, blood, emesis, edema, and foreign objects
- Interventions include removing the obstruction, suctioning, or inserting an airway
ABCDE - Breathing
- After the airway is controlled, monitor for spontaneous breathing
- Note the rate and depth of breathing, chest rise symmetry, and use of accessory muscles
- Auscultate lung sounds
- Next, position the patient, and utilize supplemental O2 or BiPAP if necessary
- Use a mouth-to-face mask or bag-valve face mask for patients with no spontaneous breathing
- Endotracheal intubation can help maintain the airway and protect lungs from aspiration
ABCDE - Circulation
- Palpate the carotid or femoral pulse to assess quality and rate
- Evaluate skin temperature, color, and moisture
- Stop external bleeding with pressure or a tourniquet, as a last resort
- Look for signs of internal bleeding, shock, and burn injuries that can compromise circulation
- Insert a large bore IV for fluid resuscitation
- Monitor vital signs
- Initiate cardiac compressions if there is no pulse
ABCDE - Disability
- Use the Glasgow Coma Scale (GCS) to perform a quick neurological assessment for CNS injuries
- The GCS scale assesses the patient on a scale of 3-15 and looks at motor, verbal, and eye-opening responses
- Any GCS score under 13 requires immediate treatment
- Patients with GCS scores of 8 or lower have the highest morbidity and mortality
ABCDE - Exposure
- Remove the patient’s clothing
- Ensure you respect the patient's dignity during the exposure assessment
- Keep the patient covered to prevent heat loss and shivering
- Look for injuries, bleeding, signs of illness, and medical alert bands
Secondary Survey
- Identify any non-life-threatening issues or medical problems that need intervention
- Inspect and palpate of all major body areas assessing for the following:
- Deformity
- Bruising
- Open wounds, bleeding, and pain
- Lacerations, bleeding, and pupil assessment
- Breath sounds in all fields, wounds, and foreign bodies
- Bowel sounds, tenderness or rigidity, and wounds, bruising
- Lacerations, wounds, injuries, deformities, tenderness, pulses, and capillary refill
SHOCK
- Shock involves progressively decreasing blood pressure, leading to inadequate tissue perfusion
- Types of shock include:
- Hypovolemic
- Cardiogenic
- Obstructive
- Distributive
- Anaphylactic
- Septic
- Neurogenic
Major Trauma
- Penetrating trauma is an open injury caused by sharp objects or projectiles like bullets or explosion fragments
- Blunt trauma is a closed injury where the skin surface remains intact, but internal injuries can occur
- Surface trauma includes closed wounds such as contusions (bruising) and hematomas
- Open wounds
- Abrasions- scraping away of epidermal and dermal skin layers - risk of pain and infection
- Puncture wounds- extent of damage to organs is difficult to estimate
- Lacerations-snagging or tearing of tissue that is variable in depth
- Avulsions-full thickness skin loss often seen in machine, lawnmower, and power tool accidents
- Open wounds
Trauma - Amputation
- Amputation is a partial or complete severing of a body part
- Control the bleeding by applying direct pressure and raising the affected area
- A tourniquet can be applied only as a last resort
- Cover the stump with sterile saline-moistened gauze, cover with dry gauze, and secure in place with an elastic bandage
- Send the amputated parts in for reattachment
- Rinse with saline, wrap in sterile gauze, and place in a bag
- Put the bag on ice to keep it cool without causing further damage
TRAUMA
- Do not remove impaled objects unless they obstruct the airway
- Removing an impaled object can cause further injury and/or uncontrollable bleeding
- Apply a bulky dressing around the object to stabilize it
- Tetanus is caused by Clostridium tetani spores entering the body through wounds
- The spores produce toxins that affect the Central Nervous System.
- Adults aged 19 and above need a tetanus vaccine booster every 10 years or sooner if they sustain a deep cut or burn
- Symptoms include muscle contractions and spasms, including lockjaw
- Maintain an open airway
- Administer human tetanus immune globulin IM
Head Trauma
- Head trauma from sharp blows can shift intracranial contents, leading to brain tissue contusions
- The initial injury is irreversible
- The secondary phase involves Intracerebral bleeding and edema that can cause issues with increased intracranial pressure (ICP)
Spinal Trauma
- Spinal trauma typically results from MVAs, sports injuries, falls, and assaults
- Treat all patients with spinal trauma as though they have a spinal injury until proven otherwise
- Do not move the patient because it can displace injured bones and damage the spinal cord
- Stabilize the back and neck with a C-collar and backboard until the injury is ruled out
- Cervical Spine injuries are especially vulnerable
- Neurological signs and symptoms are as follows:
- S3-S5 or above - Patient unable to tighten anus
- L4-L5 or above - Patient unable to flex foot and extend toes
- L2-L4 or above - Patient unable to extend and flex legs
- C5-C7 or above - Patient unable to extend and flex arms
Chest Trauma
- Chest trauma can cause injury to the heart and lungs
- Hemothorax is bleeding into the intrapleural space
- Pneumothorax is air in the intrapleural space
- Tension pneumothorax happens when air is trapped during exhalation, putting pressure on the unaffected lung and heart
- A flail chest involves at least two fractures on a rib, resulting in a loose segment
- Myocardial contusion involves bruising of the heart
- Cardiac tamponade involves blood or fluid buildup in the pericardial sac, increasing pressure on the heart and preventing proper filling and contraction
Abdominal Trauma
- In abdominal trauma, organs are at risk of injury because of limited bony protection
- Injury to the spleen or liver can cause rapid blood loss and hypovolemic shock
- Bladder rupture may result in urine leaking into the abdomen
Orthopedic Trauma
- In orthopedic trauma, fractured bones can result in blood loss, compromised circulation, and possible infection
- Joint dislocations can cause neurovascular compromise
- Delayed fracture reduction can cause avascular necrosis and death of tissue and bone
- Splint limbs as they lie to prevent damage during transport
Trauma – Nursing Process
- Data collection should include:
- Mechanism of injury
- LOC/GCS score, pupil assessment
- Movement of extremities
- Identification of all injuries and its associated complications
- Vital signs
- Head-to-toe assessment performed after primary/secondary survey
- Nursing diagnoses and interventions include:
- Acute pain is related to tissue trauma - Use RICE (Rest, Ice, Compression, Elevation) and analgesics
- Ineffective breathing pattern - open the airway
- Risk for bleeding related to trauma-Apply direct pressure
- Risk for ineffective cerebral tissue perfusion is related to Cerebral edema-Assess neuro status, Elevate head 30-45 degrees, Midline head position
- Risk for Aspiration related to neck injury-Suction - Log roll to the side if vomiting
- Impaired physical mobility related to neck and bone injury - Assess neurovascular function, Immobilization, Remove jewelry
- Decreased cardiac output-Monitor vital and oxygen saturation
- Deficient fluid volume related to hemorrhage-Monitor signs of hypovolemic shock- Administer IV fluids & Ultrasound
- Risk for infection related to tissue trauma-Irrigate open wounds, provide wound care, and administer Tetanus Toxoid
Burns
- Refer to chapter 55 for a full review of burns
- Burns can lead to fluid/electrolyte loss, infection, and/or ineffective temperature regulation
- Treatment includes ABCDE + "F" (fluid resuscitation)
- Airway/breathing interventions- Manage any inhalation injury
- Keep the head elevated by 30 degrees, provide supplemental O2, administer IV fluids, keep the patient warm, and administer analgesics
- Treatment depends on the depth of the burn
Hypothermia
- Normal body temperature is 98.6F
- Hypothermia happens when the core body temperature drops below 95F
- The body is unable to regulate its temperature and generate body heat, resulting in a loss of body heat
- Defining characteristics based on temperature:
- Below 95: patient will be alert, shivering, cold skin, poor coordination, slurred speech, and irritability
- Below 91.4: Includes cardiac arrhythmias and cyanosis
- Below 89.6: Shivering stops, muscle activity declines/rigid, lethargic, disoriented, hallucinations, dilated pupils, and hypotension
- Below 82.4: hypoventilation (3-4 breaths per min), bradycardia, v fib, and absent tendon reflexes
- Below 80.6- no vitals, fixed and dilated pupils, v fib or asystole, and appears deceased
- The determination of death is made only after rewarming the core to above 90F
- Initial treatment includes rewarming, stabilizing vital functions, and preventing further heat loss
- If temp is over 82.4F, passive rewarming is suggested by setting room temperature to 70-75F, wrapping the patient in a warm dry blanket, and covering the patient's head with a warm towel
- If temp is below 82.4F, then active rewarming is needed with heating blankets and radiant heat. Includes the administration of oxygen and fluids along with warm gastric lavage
- Monitor temperature with a rectal probe
- Avoid using cardiac medications because vasodilation can cause cardiac overload
Frostbite
- Frostnip happens when exposed body parts become very cold but not frozen
- The patient may not experience pain
- Skin becomes pale and blanched
- Rewarming can happen easily with contact and warm objects
- In Frostbite, the body part becomes frozen
- Extremities are at an increased risk
- Affected tissue will be hard and frozen
- When rewarmed, the tissue will appear deep red and feel hot and dry
- The degree of the injury is dependent on the duration of exposure, temperature, and wind velocity
- Do not rub the area, cover it with a dry sterile dressing to protect it from further injury
- No weight bearing on the affected extremity - elevate to the level of the heart
- Analgesics can be used with rewarming
Hyperthermia
- Children and older adults including those that have cardiac complications are more at risk
- Thermoregulation (sweating and dilation of blood vessels) break down
- Heat builds up and cannot be released
- Antipyretics will not work in this case
- Early signs (temp 100.4-102.2F): diaphoresis, cool, clammy skin, alert, irritable, and poor judgment. dizziness, weakness, headache, vomiting, diarrhea, and tachycardia
- Late signs(temp 106F or higher): An inability to sweat, hot/dry/flushed skin, altered mental status, seizures. coma, and hypotension
- The three different forms of Illness from heat exposure include:
Heat cramps are painful cramps in the legs or abdomen occurring after exercise.
- Prevent by loss of salt and water from sweating
- Administer rest and hydration for cramps Heat Exhaustion is when water and electrolytes are lost due to heavy sweating causing Hypovolemia and dehydration
- Elevated body temp to 100.4-102.2F
Heatstroke: Symptoms of heat exhaustion are untreated, heatstroke can develop.
- Altered mental status with inability to sweat or Altered mental status as key symptoms
- A rapid rise in body temperature rises rapidly to 106F or high
- Is a deadly condition with the need for monitoring in the ICU
- Nursing Diagnoses and Interventions:
- Patient has hyperthermia related to hot temperature:
- Remove them from environment- Remove clothing
- Mist- spray cool water while fanning the patient
- Deficient fluid volume related to hypovolemia
- Hydrate the patient with oral fluids if alert: if hypotensive give IV fluids
- Patient has hyperthermia related to hot temperature:
Poisoning
- Poisons can enter the body by ingestion, inhalation, injections, absorption, or venomous bites
- The goal is identification of the poison and treatment
- Ingested poisons make up 1/3 of all poisoning and mostly ingested are drugs. Other examples can be cleaners, soaps, insecticides, acids, or alkalis
- Treatment includes Naloxone (Narcan) for opioid overdose
- Inhaled poisons, such as carbon monoxide that can produce a profound hypoxia, chlorine, gas, and/ or pesticides
- Administer Oxygen and supply with fresh air and give 02
- With injected poison use cold compression, elevate, remove jewelry, or contact the poison specialist for treatment
Near Drowning
- Drowning is a state of death caused by asphyxia after going underwater
- Near-drowning is a state in which the patient has temporary survival once going underwater.
- Underwater, the victim will start to hold their breath
- Results in aspiration of water and possibly laryngospasm
- Dry Drowning cold water causes laryngospasm and nerve stimulation causing hypoxia
- Preventative treatments are to learn to swim and avoid doing drugs/alcohol
Psychiatric Emergencies
- Pyschiatric Emergencies is when a personal can no longer maintain there coping skills
- Mood and behavior can change causing harmful thoughts to themselves and others
- This can result into life Threatening behaviors to the patient
- Be careful when caring for the patient and avoid stressful areas, give them space
Disaster Response
- A disaster is any event that overwhelms existing personnel, facilities, equipment, and capabilities of response agencies
- Examples include fires, explosions, terrorist acts, weather events, etc.
- Response must include community and hospitals
- The plan must deal with victims, death, family, and staff and community
- Facility must conduct disaster drills, and know your role
- If disaster occur, hospitals may call you in
- In Long term facilities, provide protection up to 96 hours
Bioterrorism Agents
- Using substances to attack- evaluated by CDC
- Early recognition, treatment, and prevention will save lives
- There are many agents that exist such as Anthax, Bothlism, and Pague
Anthrax
- Anthrax is spore forming bacteria
- Animal that are exposed cause humans to contract when close to contaminated animals
- The contact can be Cutaneous or Pulmonary or GI and no transmission is to one another
- To identify, use the signs and symptom of blistering, soreness, fever, chills, cough, confusion. nausea, headache. pain sweats or body sores
- Treat with vaccine with antibiotics and supportive care
Botulism
- Botullism is the illness that is the most lethal that blocks neurotransmitter
- Colorless and odorless and blocks neurotransmission that prevents acetylcholine release causing skeletal muscle
- No transmission to other just through improper process from food and wounds
- Signs consist of afebrile, symmetrical paralysis, clear Mentation symptoms ( dry), dizziness, sore throat.
- Give antitoxin and maintain airway/clean services
Plague
- transmitted through the bite of an infectious flea or from direct contact with fluids
- The most serious for will transmit from Person to Person
- Symptoms include fever. headache, weakness, pneumonia with bloody mucus from shortness of breath, chest pain, and cough
- Use Droplet precaution if you assist .
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