juniperk's version from 2018-04-29 23:59


Question Answer
How often should an assessment be done on the 5 levels?Resuscitation- continuous nursing surveillance. Emergent- reassessed at least every 15 minutes. Urgent- every 30 minutes. Less urgent- reassessed every 60 minutes. Nonurgent- every 120 minutes.
What does the nurse in triage collect?1. VS (pain) 2. Current Hx (PMH) 3. Neurological assessment 4. weight 5 allergies 6. Domestic violence screening 7. necessary dx finding.
What is primary survey?Focuses on stabilizing life-threatening conditions.
What is the neurological assessment?AVPU Alert, Verbal, Pain, Unresponsive
What is the secondary survey?Complete health hx 2. Head-to-Toe assessment 3. Dx and lab testing 4. Monitoring devices 5. Splinting of suspected fx 6. Cleansing, closures, and dressing of wounds 6. Other necessary interventions
What are the signs and symptoms of shock?Cool, moist skin, decreasing BP, increasing HR, delayed cap refill, and decreasing urine volume
Patient's who are hemorrhaging are at risk for what? caused by what?At risk for cardiac arrest caused by hypovolemia.
Whenever a patient is hemorrhaging (int or ext) what is needed for management?Fluid (isotonic electrolyte solutions e.g LR NS) and blood replacement.
What are the symptoms of internal bleeding?Tachycardia 2. decreasing BP 3. apprehension 4. cool and moist skin 5. delayed cap refill
What position should a patient with internal bleeding maintain?Supine.
What is primary closure?Wound is sutured or stapled with local or moderate sedation.
What is delayed primary closure? What should be done?Needed if tissue has been lost or there is a high potential for infection. A thin layer of gauze covered by an occlusive dressing should be used. Splint in a functional position to prevent motion and decrease contracture.
What is the protocol for removing clothing from a patient who has experienced trauma?The nurse must be careful not to cut through or disrupt any tears, holes, blood strains, or dirt. Place each piece of clothing in individual paper bag. If wet, it should be hung to dry. Do not give to familites. Valuables are inventories.
What type of state is the body in immediately following a multiple trauma injury?The body is hypermetabolic, hypercoagulable, and severly stressed.
What is the priority management in pts with multiple injuries?1. Airway/ventilation 2. Control hemorrhage 3. Prevent/treat hypovolemic shock 4. Assess for head and neck injuries 5. Evaluate other injuries 6. Splint fx & then reassess pulses and neurovascular status 7. Perform more thorough assessment
What will the WBC and the amylase/lipase level reflect in intrabdominal injuries?WBC elevation. Amylase/Lipase increase might suggest pancreatic injury or perforation of the GI tract.
In addition to ABCs, what else is a crush injury observed for?Acute renal insuffiiciency. Severe muscular damage may cause rhabdomyolysis resulting in acute tubular necrosis.
Crushed- Serum lactic acid might show what?increased
What is the most serious of heat induced illnesess?Heat stroke
What are the signs of heat stroke?CNS dysfunction (confusion, behavior, coma, seizures), elevated temp, hot dry skin, anihidrosis, tachypnea, hypotension, and tachycardia.
What are the signs of heat exhaustion?high temp, headaches, anxiety, syncope, profuse diaphoresis, goosebumps, orthostasis.
Tx for pt with heat strokeCirculation, AIRWAY, breathing. IV access for fluid. Remove pt clothes, reduce core temp to 102 asap within an hour.
What metabolic state might a patient with heat stroke be in? what electrolyte imbalance?Hypokalemia and metabolic acidosis. Sodium bicarbonate to correct acidosis.
How are frozen exgtremities warmed?Placed in a circulating bath for 30-40 minutes. DO NOT MASSAGE!
Once a frozen extremity is warmed what next?Part is protected from further injury and is elevated to help control swelling. Steril gauze is placed between digits. Hourly active motion to any affected digits
What are 2 lab findings in a frozen injuryhyperkalemia (released from damaged cells) and hypovolemia.
What is the basic life support that are priority in a hypothermic ptCAB
What should you monitor for when pt's temperature is being raised from 88 to 90FVentricular fibrillation

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