Emergency, Terrorism, and Disaster Nursing Flashcards
Triage assessment questions
Is the patient dying?
Is this a patient who should not wait to be seen?
Put these patients ESI 1 or 2
Normal VS for ESI 3 or below;
Primary survey “A”
ABCDE
Airway: with Cspine stabilization or immobilization
-seizures, near-drowning, anaphylaxis, foreign body obstruction, or cardiopulmonary arrest; open airway using jaw-thrust maneuver->suction->insert airway–>intubate. Vent pt using 100% oxygen before intubation
rapid sequence intubation
is the preferred prpcedure for securing an unprotected airway in the ED. It involves the use of sedation (midazolam [Versed]) or anesthesia (etomidate [Amidate]) and paralysis (succinylcholine [Anectine]) apply cricoid pressure
Airway Emergency Assessment and Interventions
clear and open airway assess for obstructed airway assess for respiratory distress check for loose teeth or foreign objects assess for bleeding, vomitus, or edema
suction
jaw thrust maneuver
artificial airway
c spine immobilization
Primary Survey “B”
fractured ribs, pneumothorax, penetrating injury, allergic reactions, pulmonary emboli, and asthma attacks. Watch for dyspnea (PE), paradoxic or asymmetric chest wall mvmt (flail chest), decreased or absent breath sounds on the affected side (pneumothorax), visible wound to chest wall (penetrating injury), cyanosis (asthma), tachycardia and hypotension
Breathing Assessment and Interventions
Assess ventilation look for paradoxic mvmt of chest wall note use of accessory muscles listen for air bein expired through nose and mouth feel for air being expelled observe and count RR note color of nail beds, MM, skin auscultate lungs assess JVD and position of trachea
Give O2 (often 100% via non-rebreather)
vent with bag-valve-mask with 100% o2 if respirations are inadequate or absent.
prepare to intubate if respiratory arrest
have suction available
if absent breath sounds, prepare for needle thoracostomy and chest tube insertion
What do you do as an ED nurse if breath sounds are absent?
think about mechanically venting, or preparing for needle thoracostomy and chest tube insertion
Primary Survey “C”
Circulation: Heart, intact blood vessels and adequate blood volume. ** Altered Mental Status and delayed cap refill (>3sec) are the most significant signs of circulatory shock.
Circulation Assessment and Interventions
check carotid and femoral pulse palpate pulse for quality and rate assess color, temp, and moisture of skin check cap refill assess for external bleeding measure BP
if no pulse, initiate CPR
If shock symptoms or if pt is hypotensive, start two large-bore (14-16 gauge) IVs and initiate infusions of NS or LR
Control bleedings with direct pressure and sterile dressing
administer PRBC’s (warmed if rapid infusion, and don’t forget to replenish clotting factors too!)
consider use of a pneumatic antishock garment or pelvic splint in the presence of pelvic fracture with hypotension.
Obtain blood samples for type and crossmatch
Primary Survey “D”
DIsability: conduct a brief neuro exam–> pt’s LOC determines the degree of disability. GCS
assess pupils for size, shape, equality, and reactivity.
Inspect extremities for any obvious deformities and splint them if found.
Assess pain (PQRST)
Primary Survey “E”
Exposure/Environmental Control
Remove all trauma patient’s clothing to preform a thorough physical assessment. Once the patient is exposed, it is important to limit heat loss, prevent hypothermia, and maintain privacy by using warming blankets, overhead warmers, and warmed IV fluids
Life Threatening Conditions Identified During Primary Survey related to AIRWAY
inhalation injury
obstruction (partial or complete) from foreign bodies, vomitus, or tongue
penetrating wounds and/or trauma to upper airway structures
Life Threatening Conditions Identified During Primary Survey related to BREATHING
anaphylaxis
flail chest with pulmonary contusion
hemothorax
pneumothorax
Life Threatening Conditions Identified During Primary Survey related to CIRCULATION
MI pericardial tamponade shock (massive burns, hypovolemia) uncontrolled external hemorrhage hypothermia
Life Threatening Conditions Identified During Primary Survey related to DISABILITY
head injury
stroke
Secondary survey
the secondary survey begins after addressing each step of the primary survey and initiating any lifesaving interventions. The secondary survey is a brief, systematic process that aims to id ALL injuries.
Secondary Survey Steps: “FFFGHI”
Full set of VS Focused Adjuncts Facilitate family presence Give comfort measures History and Head to toe Assessment Inspect posterior surfaces
What are the actions to take during the Focused Adjuncts aspect of the secondary survey?
determine HR and rhythm. Initiate ECG, O2 sat, and end-tidal CO2 monitoring foley gastric tube obtain blood for labs arrange for diagnostic studies provide tetanus prophylaxis
What is the mnemonic to use during the History and Head to Toe assessment aspect of the secondary survey?
AMPLE
Allergies, Med Hx, Past Health HX, Last Meal, and Events/Environment preceding illness or injury
Post-cardiac arrest hypothermia
Therapeutic hypothermia for 24 hours following resuscitation improves mortality and neurologic outcomes in many patients. It should be considered for all patients who are comatose or who do not follow commands after resuscitation.
Therapeutic hypothermia
three phases: induction, maintenance, and rewarming
Induction phase of therapeutic hypothermia
goal core temp is 89.6-93.2. Achieve this through infusion of cold NS and cooling devices (Arctic Sun, Blanketrol). Patients require invasive monitoring (arterial and central pressures) and continuous assessment while receiving this therapy.
non-heart-beating donation
corneas, heart valves, skin, bone, and kidneys can be harvested from patients after death.
So you are cooling a person with heat stroke and they start to shiver. What do you do?
Administer Chlorapromazine (Thorazine) IV. Shivering increases core temp due to associated heated generated by muscle activity, so you should stop the shivering with meds. Antipyretics are not appropriate in this situation because the elevated temp is not due to infection.
Monitor for rhabdomyolysis (the muscle breakdown leads to myoglobinuria which places the kidneys at risk of acute failiure). Watch for tea-colored urine.
What happens physiologically if a person is hypothermic?
As core temp drops, BMR decreases two or three times. The cold myocardium is irritable and vulnerable to dysrhythmias. Decreased renal blood flow decreases GFR, which reduces water reabsorption, leading to dehydration. Hct increases as vascular volume decreases-cold, thick blood forms thrombuses–>risk for stroke, MI, PE, renal emboli
Shivering stops at core temps below 86. BMR, HR, and RR may be so slow that they are difficult to detect. reflexes are absent and pupils are fixed and dilated. The cause of death is typically refractory vfib.
Interventions for hypothermia
remove pt from cold environment
manage and maintain ABC’s
Provide high flow O2 via non-rebreather mask or BVM
rewarm patient (warming blanket, warm iv fluids, heated, humidified O2, warmed lavage)
**Warm central trunk first to limit rewarming shock
Immersion syndrome
occurs with immersion in cold water. This leads to stimulation of the vagus nerve and potentially fatal dysrhythmias (bradycardia and cardiac arrest)
