NUR 3081 Trauma and ER graded A, Exams of Nursing

Download NUR 3081 Trauma and ER graded A and more Exams Nursing in PDF only on Docsity! RISNER Trauma/ER Nursing Notes Pgs. 111-119, 135-137, 622-624, 1161-1163, 1053-1055 ATI pgs. 9-24, 787-802 Emergency Room Nursing • Reasons people seek ED care o Abdominal pain o Chest pain o Breathing difficulty o Injuries (especially falls) o Headache o Fever o Pain (most common) • Triage o Process of rapidly determining patient acuity o Represents a critical assessment skill o Categorizes patients so most critical are treated first o “rapid assessment of who is going to die first without treatment” ▪ Most critical are treated first o 1.) Emergent ▪ Respiratory distress, chest pain, hemorrhage o 2.) Urgent ▪ Abdominal pain, fractures, soft tissue injuries o 3.) Non-urgent ▪ Skin rash, strains/sprains, “colds” • Primary Survey o Primary survey organizes order of approach to patient by: ▪ (A) Airway/Cervical Spine • Is patient still breathing? • Need to do CPR? • **TEST QUESTION – Must align cervical spine before any other care is done INCLUDING CPR o 1.) cervical spine alignment/stabilization o 2.) CPR ▪ (B) Breathing • Are they breathing on their own? ▪ (C) Circulation • What is their blood pressure? ▪ (D) Disability • Fractures? • What happened? ▪ (E) Exposure • Exposed to chemicals? • Gas burn? o **VERY IMPORTANT o Focuses on airway, breathing, circulation, disability and exposure (ABCDE) RISNER Trauma/ER Nursing Notes Pgs. 111-119, 135-137, 622-624, 1161-1163, 1053-1055 ATI pgs. 9-24, 787-802 o Identifies life-threatening conditions o If life-threatening conditions related to ABCD are identified during primary survey, interventions are started immediately and before proceeding to the next step of the survey o **Patient who has an MI will go before a patient that has a fall, patient with a fall will go before a patient with a 3 day cough ▪ Can’t go to step B without step A • Can’t get a BP unless patient is breathing o **Airway with cervical spine stabilization and/or immobilization ▪ Signs/symptoms in patient with compromised airway • Dyspnea • Inability to vocalize • Presence of foreign body in airway • Trauma to face or neck • **Stabilize the cervical spine, align spine, then airway!!! o Maintain airway: least to most invasive method ▪ Open airway using the jaw-thrust maneuver ▪ Suctions and/or remove foreign body ▪ Insert nasopharyngeal/oropharyngeal airway ▪ Endotracheal intubation o 1.) Stabilize/immobilize cervical spine ▪ Face, head, or neck trauma and/or significant upper torso injuries o 2.) Breathing ▪ Assess for dyspnea, cyanosis, paradoxic/asymmetric chest wall movement, decreased/absent breath sounds, tachycardia, hypotension • Many conditions cause breathing alterations including fractured ribs, pneumothorax, penetrating injury, allergic reactions, pulmonary emboli, and asthma attacks. • *NOTE: Usually breathing is one of the answers, but if there is a neck injury-neck injury trumps ▪ Life-threatening conditions, such as tension pneumothorax and flail chest, can severely and quickly compromise ventilation. ▪ Treatment • Administer high-flow O2 via a nonrebreather mask • Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for life-threatening conditions • Monitor patient response o 3.) Circulation ▪ Check central pulse (peripheral pulses may be absent because of injury or vasoconstriction) • If your patient is not breathing and there is no pulse = CPR ▪ If a pulse is felt, assess the quality and rate. ▪ Assess the skin for color, temperature, and moisture. RISNER Trauma/ER Nursing Notes Pgs. 111-119, 135-137, 622-624, 1161-1163, 1053-1055 ATI pgs. 9-24, 787-802 o Must recognize importance of hospital rituals in preparing the bereaved to grieve (e.g., collecting belongings, viewing the body) o Whenever possible, provide an area for privacy and, if appropriate, arrange for a visit from a chaplain. o Determine if patient could be candidate for non–heart beating donation ▪ Tissues and organs (e.g., corneas, heart valves, skin, bone, kidneys) can be harvested from patients after death • Gerontologic Considerations Emergency Care o Older adults are at high risk for injury—primarily from falls o Causes ▪ Generalized weakness ▪ Environmental hazards ▪ Orthostatic hypotension o Important to determine whether physical findings may have caused fall or may be due to fall • Things to Remember o Characterized by: ▪ Rapid change ▪ Multispecialty care ▪ Crowded, noisy conditions ▪ Crucial communications with ambulance staff, helicopter personnel ▪ Complex age and demographic range of patients o Patients have variety of heath care needs o Cultural considerations o Care of patients with mental illness o Disposition o Case management o Patient/family teaching Emergency Nursing – Poisons and Disaster Nursing • Poisons o Chemicals that harm the body accidentally, occupationally, recreationally, or intentionally o Severity depends on type, concentration, and route of exposure o Management ▪ Decrease absorption ▪ Enhance elimination ▪ Implement toxin-specific interventions per poison control center • Overdose of drugs – charcoal RISNER Trauma/ER Nursing Notes Pgs. 111-119, 135-137, 622-624, 1161-1163, 1053-1055 ATI pgs. 9-24, 787-802 o Pump stomach o Suction out o Laxative • Know antidotes o Ways to decrease absorption of poisons ▪ Activated charcoal, ▪ Dermal cleansing, ▪ Eye irrigation, ▪ Gastric lavage. • Nuclear enema: molasses or syrup and saline and milk of magnesium ▪ Whole-bowel irrigation ▪ Hemodialysis ▪ Urine alkalization ▪ Chelating agents ▪ Antidotes increases the elimination of poisons. o Ways to increase elimination of poisons ▪ The administration of cathartics (accelerates defecation) • Examples: o Lactulose, intense increasing of bulk of stool and force excretion o Castor oil o Aloe o Senna o Cascara sagrada o Sorbitol • Enhance elimination o Give with first dose of charcoal to stimulate intestinal motility/increase elimination ▪ Whole-bowel irrigation, ▪ Hemodialysis, ▪ Urine alkalization ▪ Chelating agents (chemicals or chemical compounds that react with heavy metals) ▪ Antidotes o Interventions ▪ Activated charcoal o Most effective intervention: administer orally or via gastric tube within 60 minutes of poison ingestion • Contraindications o Diminished bowel sounds o Paralytic ileus o Ingestion of substance poorly absorbed by charcoal o ***Charcoal can absorb and neutralize antidotes: do not give immediately before, with, or shortly after charcoal o ***Charcoal is only effective within an hour!!! RISNER Trauma/ER Nursing Notes Pgs. 111-119, 135-137, 622-624, 1161-1163, 1053-1055 ATI pgs. 9-24, 787-802 o Decontamination ▪ **Takes priority over all interventions except basic life support measures • Have to make sure patient is breathing BEFORE ANYTHING ELSE o Important Things To Remember ▪ Hemodialysis is reserved for patients who develop severe acidosis from ingestion of toxic substances (e.g., aspirin). ▪ Sodium bicarbonate administration raises the pH (>7.5), which is particularly effective for phenobarbital (anti-seizure) and salicylate poisoning. ▪ Vitamin C is added to IV fluids to enhance excretion of amphetamines and quinidine. ▪ Chelation therapy is considered for heavy metal poisoning (e.g., edetate calcium disodium [Calcium EDTA] for lead poisoning • Mass Casualty Incident (MCI) o Manmade or natural event or disaster that overwhelms community’s ability to respond with existing resources o MCIs usually involve large numbers (100+) of victims, physical and emotional suffering, and permanent changes within a community. o In addition, MCIs always require assistance from people and resources outside the affected community (e.g., American Red Cross, Federal Emergency Management Agency [FEMA]). o Triaging MCI: ▪ Triage of casualties differs from usual ED triage and is conducted in <15 seconds o Color Coded System ▪ System of colored tags designates both seriousness of injury and likelihood of survival • Green (minor injury) or yellow (non–life-threatening injury) tag indicates noncritical injury • Red tag indicates life-threatening injury • Blue tag indicates those who are expected to die • Black tag identifies the dead ▪ (In general, two thirds of victims will be tagged green or yellow and the remaining will be tagged red, blue, or black) o Casualties need to be treated and stabilized ▪ If known or suspected contamination, decontaminate at scene, then transport to hospitals o Many casualties will arrive at hospitals on their own (i.e., “walking wounded”) o Total number of casualties a hospital can expect is estimated by doubling number of casualties that arrive in first hour ▪ Generally 30% will require admission to hospital, and half of these will need surgery within 8 hours • If you have 100 come in the first hour, expect at least 200 RISNER Trauma/ER Nursing Notes Pgs. 111-119, 135-137, 622-624, 1161-1163, 1053-1055 ATI pgs. 9-24, 787-802 ▪ Pinpoint pupils ▪ Vomiting ▪ Unconsciousness o Preventing ▪ Drink enough ▪ No alcohol & caffeine ▪ Cool showering ▪ Wear light protection ▪ Do not stay in a closed car (?) ▪ Limit outdoor time o Treatments ▪ Treatment: stabilize patient’s ABCs and rapidly reduce temperature ▪ Cooling methods • Remove clothing • Cover with wet sheets • Place patient in front of large fan • Immerse in ice water bath • Slowly • Administer cool fluids or lavage with cool fluids • Ventilation with a BVM or intubation and mechanical ventilation may be required. ▪ These people are beyond nasal cannula • Intubation or 100% non-rebreather mask ▪ Safety comes first – sit them down or lay them down • Vitals • Cooling methods ▪ Fractures & Trauma o The emergency is what accompanies the fracture ▪ Circulation issues ▪ Third spacing ▪ Shock! o Classification ▪ Complete or incomplete • Complete – break is completely through the bone • Incomplete – bone is still in one piece ▪ Transverse ▪ Spiral ▪ Greenstick ▪ Comminuted ▪ Oblique ▪ Pathologic ▪ Stress o Clinical Manifestations RISNER Trauma/ER Nursing Notes Pgs. 111-119, 135-137, 622-624, 1161-1163, 1053-1055 ATI pgs. 9-24, 787-802 ▪ Localized pain ▪ Decreased function ▪ Inability to bear weight or use ▪ Guard against movement ▪ May or may not have deformity ▪ Immobilize if suspect fracture!!!! o Traction ▪ Purpose • Prevent or decrease pain and muscle spasm • Immobilize joint or part of body • Reduce fracture or dislocation • Treat a pathologic joint condition ▪ Pulling force to attain realignment – countertraction pulls in opposite direction ▪ Two most common types of traction • Skin traction o Short term (48-72 hours) o Tape, boots, or splints applied directly to skin o Traction weighs 5-10 pounds o Skin assessment and prevention of breakdown imperative • Skeletal traction o Long-term pull to maintain alignment o Pin or wire inserted into bone o Weights 5 to 45 lbs o Risk for infection o Complications of immobility ▪ Complications of immobility: • Can’t move • Can’t turn ▪ Nursing Care: • Maintain countertraction. o Elevate end of bed. • Maintain continuous traction. • Keep weights off the floor. • If traction is pulling patient toward end of bed, do NOT pull patient up in bed without removing weights first o REMOVE WEIGHTS FIRST PLEAAASE ▪ Hypothermia and Submersion Injuries o Core temperature <95º F (<35º C) o Risk factors ▪ Elderly ▪ Certain drugs – NSAIDs ▪ Alcohol – can’t self-regulate temp. ▪ Diabetes !) RISNER Trauma/ER Nursing Notes Pgs. 111-119, 135-137, 622-624, 1161-1163, 1053-1055 ATI pgs. 9-24, 787-802 o Core temperature <86º F (30º C) is potentially life threatening o Condition which occurs when the body starts losing heat more quickly than it can produce it resulting in the body temperature going down rapidly o Symptoms of Hypothermia ▪ Shivering ▪ Dizziness ▪ Feeling hungry ▪ Nausea ▪ Rapid breathing ▪ **Problems speaking ▪ Confusion ▪ Coordination difficulties ▪ Fatigue ▪ **Rapid heart rate ▪ Drowsiness ▪ ***Weak pulse (she said to notice this, probably test question! ▪ Shallow breathing o Wet clothing increases evaporative heat loss 5 times greater than normal; immersion in cold water (e.g., near drowning) increases evaporative heat loss 25 times greater than normal. o Hypothermia mimics cerebral or metabolic disturbances, causing ataxia, confusion, and withdrawal, so the patient may be misdiagnosed. o Types: ▪ Mild Hypothermia • 93.2 - 96.8 • Shivering • Lethargy • Confusion • Rational to irrational behavior • Minor heart rate changes o **Note that with hyperthermia – tachy ▪ Mild hypothermia – minimal changes • Treatments: o Mild hypothermia: passive or active external rewarming ▪ Passive external rewarming: move patient to warm, dry place; remove damp clothing; place warm blankets on patient ▪ Active external rewarming: body-to-body contact, fluid- or air-filled warming blankets, radiant heat lamps ▪ Moderate Hypothermia • 86 – 93.2 • Rigidity RISNER Trauma/ER Nursing Notes Pgs. 111-119, 135-137, 622-624, 1161-1163, 1053-1055 ATI pgs. 9-24, 787-802 ❖ Yellow Box (pg. 117) – clear the airway of any secretions or debris either with a suction catheter or manually if necessary. Protect the cervical spine in any trauma patient with the potential for spinal injury by manually aligning the neck in a neutral, in-line position and using a jaw-thrust maneuver when establishing an airway. Provide supplemental oxygen for all patients who require resuscitation. ❖ Yellow Box (pg. 117) – remove all clothing to allow for thorough assessment. Always cut away clothing with scissors o During resuscitation when rapid access to the patient’s body is critical o When manipulating a patient’s limbs to remove clothing could cause further injury o When thermal or chemical burns have caused fabrics to melt into the patient’s skin ❖ Yellow Box (pg.121) – assess the patient for orthostatic hypotension and tachycardia, especially the older adult who is predisposed to rapid dehydration. Older adults who are already dehydrated often experience acute confusion and are at risk for falls ❖ Yellow Box (pg. 122) – in regards to the patient with hyperthermia, after ensuring that the patient has a patent airway, effective breathing and adequate circulation, use rapid cooling as the first priority of care. Methods for rapidly cooling include: o Removing clothing o Placing ice packs on the neck, axillae, chest and groin o Immersing the victim in cold water o Wetting the patient’s body with cold water and then fanning rapidly to aid in cooling by evaporation o Drenching the victim with large amounts of icy water may be the fastest, most effective means to reduce core body temperature ❖ Yellow Box (pg. 132) – patients who are severely hypothermic are at high risk for cardiac arrest. Avoid using active external rewarming with heating devices because it is dangerous and contraindicated in this population due to rapid vasodilation ❖ Yellow Box (pg. 136) – do not attempt to get the water out of the near-drowning victim’s lungs; deliver abdominal or chest thrusts only if airway obstruction is suspected NCLEX PRACTICE QUESTIONS FROM TEXTBOOK: ▪ (pg. 112) The emergency department nurse is assigned to five clients waiting for orders to be implemented. Which client does the nurse assess first? A. 60 year old waiting for transport to the operating room for an emergency appendectomy B. 25 year old with a closed femur fracture who received pain medication 10 minutes ago RISNER Trauma/ER Nursing Notes Pgs. 111-119, 135-137, 622-624, 1161-1163, 1053-1055 ATI pgs. 9-24, 787-802 C. 30 year old with nausea and vomiting who has IV fluids infusing and is now sleeping D. 28 year old construction worker with a laceration on the arm that is waiting to be sutured ▪ (pg. 118) A trauma client has been brought to the emergency department after a motor vehicle crash. The client has severe injuries. What action does the nurse perform first? A. Start 2 large-bore IVs and run normal saline B. Apply oxygen and an oximeter probe to the client C. Stabilize the cervical spine and assess the airway D. Place pressure on a large bleeding wound to the forehead ▪ (pg. 122) An older client with heat exhaustion is being cooled with cool water spray and fanning. What assessment indicates to the nurse that the client needs hospitalization? A. The client is alert and oriented B. The client’s mucous membranes are dry and sticky C. The client reports weakness and nausea D. The client continues to sweat while being cooled ANSWERS: RISNER Trauma/ER Nursing Notes Pgs. 111-119, 135-137, 622-624, 1161-1163, 1053-1055 ATI pgs. 9-24, 787-802 • 112:A • 118:C • 122:B