Care of the person who experiences trauma (BIG MOTHER FUCKING DECK) Flashcards by Carmen Burg

Q

What is the purpose of the triage system?

A

To ensure that the level and quality of care that is delivered to the community is commensurate with objective clinical criteria

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Q

Explain the Australasian triage scale and the 5 categories

A

Immediately life-threatening (category1)
Imminently life-threatening (category2)
Potentially life-threatening or important time- critical treatment or severe pain (category 3)
Potentially life-serious or situational urgency or significant complexity (category 4)
Less urgent (category5)

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Q

Name factors that influence the triage role

A

Physical environment
Time constraints
Language use
Nonverbal behaviours
Cultural diversity
Nature of the health concern
Expectations and assumptions
Emotions

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Q

What are impartant factors when checking airways?

A

Check patency

Check obstruction

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Q

What are important factors when checking Breathing?

A

Check for respiratory distress

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Q

What should you look out for when checking circulation?

A

Heart rate
Pulse characteristics
Skin indicators
Oral intake
Output

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Q

What should you look out for when checking Disability?

A

GCS

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Q

what is AVPU and when is it used?

A

when checking disability
A = alert
V = Responds to voice
P = Responds to pain - purposefully, non-purposefully, withdrawal/flexor response, extensor response
U = Unresponsive

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Q

What happens in a secondary survey?

A

Full set or vital signs
Give comfort measures
History and head to toe
Individualised aspects
IDC
BGL
physical

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Q

What differs between rural and remote triage?

A

Lack of safety net
Time issues
Triage process may occur outside hospital setting
Personal safety
Lack of anonymity
Decisions may carry enormous financial or social ramifications to patients and family
Knowledge of the community

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Q

What are the different types of emergency presentations

A

Burns
Submersion
Environmental emergencies
Spinal and head injuries
Anaphylaxis

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Q

what are the 3 Types of burns

not thickness

A

Thermal
Chemical
Electrical

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Q

Explain the characteristics and the thickness of different burns

A

– Superficial (epidermis): skin may pink to red and
dry, painful
– Partial thickness (epidermis and dermis): skin bright pink and blisters, painful
– Full thickness (epidermis, dermis, underlying tissues): skin appears waxy, dry, leathery, charred, no pain

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Q

What are the predisposing factors of burns

A

Age

under 3 yrs.- safety issues
3-14 yrs. – flame burns most common - 15-60 yrs. – domestic or industrial
over 60 yrs. – medical problems

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Q

Describe a primary survey of a burn

A

Airway – possible smoke inhalation
Breathing – possible carbon monoxide poisoning
Circulation – haemodynamic stability
Disability – neurological and spinal status
Exposure – temperature, wound severity (size, depth, location, patients age

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Q

Explain a secondary survey of a burn

A

Nature of the incident
Mechanisms of injury
Pertinent medical history – pre-existing disease
Current medications
Allergies
Tetanus immunisation

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Q

How do we measure the extent of a burn?

A

Every body part is broken down into a percentage

The rule of 9’s

The Lund and browder method is the recommended method as there is a table for different ages

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Q

Why is the burn percentage important to us?

A

The Australian nz burns association relies on accurate burn measurement for referral

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Q

What are some burns referral criteria?

A

Burns greater than 10%
Burns of special areas
Full thickness burs greater than 5%
Electrical burns
Chemical burns
Burns associated with inhalation injury
Burns at the extremes of age
Burns on people with pre existing medical disorders
Any burn patient with associated trauma

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Q

How is a partial thickness burn assessed for depth?

A

Sensation - Normal or increased sensitivity to pain and temperature
Colour - Red, will blanch with pressure indicating good capillary return
Blisters - Large, thick walled, will increase in size
Texture - Normal to firm

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Q

How is a full thickness burn assessed for depth?

A

Sensation - Anaesthetic to pain and temperature
Colour - White, brown, black, red. If red, does not blanch with pressure
Blisters - Usually none. If present, thin walled and do not increase with size
Texture - Firm to leathery. Eschar

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Q

What are some types of minor burns?

A

Sunburn

Scald burn - exposure to moist heat

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Q

What are some types of a major burns?

A

Includes all burns of the hands, face, eyes, ears, feet, and perineum, all electrical injuries, multiple traumas, and all clients that are considered high risk
Partial thickness burns of greater than 25% of the total body surface
Full thickness burns of 10% or greater of the total body surface area

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Q

Explain what happens in the Integumentary system in a major burn event

A

Integumentary

skin loss
sensory loss
decreased temp

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How can you tell if a burn wound is infected or at risk of infection?

– Increased sloughing of burn tissue – Increased edema around wound edges – Partial-thickness wound converting to full- thickness wound – Black or brown areas of discoloration

What is the recommended parameters for fluid resuscitation and for what burns is this necessary?

* Necessary in all burns >15% TBSA * Hourly urine0.5mL-1mL/kg/hr * HR <120 beats/min

What needs to be considered for respiratory management for a burn?

``` • TCDB every 2 hours - Prepare for intubation • Maintain adequate tissue oxygenation with least amount of inspired oxygen necessary • Continuous assessment of ABGS • PEEP may be used ```

What do we do for pain management if a burn?

* Do not administer IM analgesia * IV/CVC inserted * sliding scale order – e.g. Morphine infusion 5-25mg/hr with 2mg bolus prn – PCA * Change to oral medication when tolerating food and fluids

What types of surgery is done for burns?

* Escharotomy * SurgicalDebridement * Grafting

Explain escharotomy

A scalpel or electrocautery incision through the full thickness eschar, usually performed at a burn centre, to restore circulation to compromised extremities Removal of eschar

Explain burn contracture

Skin and scaring heals to tight

What nursing issues are associated with burns?

Distancing oneself from patients pain Engaging with the patients pain Seeking social support Core role reconstruction

What is a submersion injury?

Results when a person becomes hypoxia due to submersion

What is the pathogenisis of submersion?

Immediate struggle sometimes surprise inhalation or breath holding

What is a wet drowning?

Vigorous breathing and water down into the lungs leads to aspiration

What is a dry drowning?

The laryngeal spasm closes the airway leads to aspiration

What happens when fresh water is aspirated?

Water leaks rapidly to the capillary bed

What happens when salt water is aspirated?

Fluid is dragged into the the alveoli

What does surfactant destruction lead to?

Pulmonary oedema

What is the treatment and assessment of a submersion?

• Manage and maintain ABC • If ABC secure assess – Tachycardia is common after near drowning – CNS can range from coma to agitation to alert some may be lethargic, confused or irritable – Resp assessment note rate rhythm cyanosis, frothy sputum – Temp can be low grade in the first few hours – Exclude other possible pathologies such as MI, Arrhythmia, Neurological epilepsy, head injury ,spinal injury, Alcohol and drug intox, Environmental hypothermia

What is a thermoregulation issue?

Imbalance of temp

What is internal heat input?

Eating or drinking | Muscle contraction

What is external heat input?

Shower | engines

What are the types of heat output?

Conduction Convection Radiation Evaporation

Where is the thermoregulation centre?

The hypothalamus

How does the thermoregulation centre work?

Peripheral receptors send signals to the essential receptors in the hypothalamus which then sends the reponse

In smooth muscles what happens in thermoregulation? Describe the difference between cold and hot

Cold - muscles contract causing vasoconstriction - Less heat is carried from core to surface - extremities can turn blue and get frostbite Hot - muscles relax causing vasodilatation - more heat is carried from core to surface - surface heat is lost by convection and radiation - skin turns red

What happens in sweat glands in thermoregulation? Describe the difference between cold and hot

Cold - no sweat Hot - Glands excrete sweat to suface - sweat cools body and evaporates

In erector pili muscles what happens in thermoregulation? Describe the difference between cold and hot

Cold - Muscles contract raising the skin hairs which traps an insulating layer of still warm air next to the skin (goosebumps) Hot - muscles relax lowering skin hairs allowing air to flow over skin

What do skeletal muscles do for thermoregulation? Describe the difference between cold and hot

Cold - shivering, muscles contract and relax repeatedly generating heat by friction Hot - no shivering

Explain hypothermia

Hypothermia is a marked cooling of core body temperature ``` It produces depression of the • CNS and respiratory systems, • vasoconstriction • alterations in micro circulation coagulation • and ischemia tissue damage ```

What happens to metabolism the in hypothermia?

* Initial ↑ in basal metabolic rate which results in tachycardia, vasoconstriction and shivering * As metabolism slows oxygen deprivation occurs * The metabolism movesto anaerobic producing lactate and resulting in metabolic acidosis

What happens in the CVS in hypothermia?

* ↑ HR, ↑ B/P, ↑ CO * Shunting of blood from peripheries to central organs * As temp falls to 32°C myocardial activity is suppressed resulting in bradycardia * As myocardial activity is further depressed CO falls with the result less perfusion to vital organs

What happens in the respiratory system in hypothermia?

increased resp rate as hypothermia worsens the medulla becomes depressed and respiratory function is depressed Metabolically there is less CO2 being produced but there is less capacity to remove CO2 via the lungs and respiratory acidosis results

What is the management of hypothermia?

Rewarming to raise temperature by 0.5 - 1 degree Celsius /hour

What are the different types of rewarming?

Passive and active

Explain Passive rewarming

* Remove wet clothing * Replace with warm blankets * Increase room temperature * Eliminate drafts * Minimal handling * Warm oral fluids

Explain Active rewarming

* Immersion in heated water * Use of radiant heat * Devices such as Bair hugger * Use of space blankets * Cover the persons head (50 -60% of radiant heat loss occurs above the shoulders)

What is hyperthermia?

Diagnosed when the core body temp is higher than 40

What is the signs and symptoms of hyperthermia?

Heat cramps • Severe muscle cramps • Thirst ``` Heat exhaustion • Pale or grey skin • Fatigue weakness • Sweating++ • Altered mental state • Hypotension • Tachycardia • Thready pulse • Temp >37.8 but <40C ```

What is the management of hyperthermia?

``` Remove from danger Stabilise ABC, record temp Remove excessive clothing Cool – cold packs to axial / groin spray with water and fan Immerse part of body in cool/iced water Continue to monitor ABC may need Oxygen and / or ventilation, cardiac monitor Slow re hydration to prevent hyponatraemia ```

How are head injuries described?

Open or closed

What happens in raised ICP?

Blood or CSF or brain tissue swell and raise the pressure in the skull

What is used to regulate and maintain ICP?

• Monro-Kellie doctrine – If one component increases, another must decrease to maintain ICP. • Normal ICP 5 to 15 mmHg – Elevated if >20 mm Hg sustained

What compensatory actions does the body do for increased ICP?

– Changes in CSF volume – Changes in intracranial blood volume – Changes in tissue brain volume

Explain what happens in the cardiovascular system in a major burn event

``` Third spacing decreased BP Increased HR Decreased RBC's Decreased cardiac output Decreased tissue perfusion ```

Explain what happens in the respiratory system in a major burn event

``` Hypoxia Increased respiration Rhonchi Decreased ciliary movement Airway obstruction ```

Explain what happens in the GI system in a major burn event

``` Hyperacidity Ileus Melena Hematemesis Increased abdominal girth ```

Explain what happens in the urinary system in a major burn event

``` Decreased GFR Increased creatinin increased BUN Increased Specific gravity increased uric acid increased myoglobinuria ```

Explain what happens in the immune system in a major burn event

``` Decreased T-Cells Decreased B-cells Increased WBC's Decreased proteins Phagacytosis ```

Explain what happens in the metabolic system in a major burn event

``` increased catabolism decreased anabolism weightloss acidosis hyperglycemia ```

What do the adrenal and thyroid glands do for thermoregulation? Describe the difference between cold and hot

Cold - Glands excrete adrenaline and thyroxine which increased metabolic rate Hot - glands stop secreting adrenaline and thyroxine

What behaviours do people do for thermoregulation?

Cold - huddling up - curling up - finding shelter - putting on more clothes Hot - Stretching out - finding shade - swimming - removing clothes

What happens to the neurological system in hypothermia

alteration in mentalstate, ↑anxiety, muscle incoordination, weakness and confusion

What treatment can you do to actively internally rewarm a hypothermic patient?

* Heated humidified air or oxygen * Heated/warmed IV fluids * CP bypass diverts blood flow via a pump oxygenator and heat exchanger * Continuous arteriovenous rewarming via a femoral catheter

Explain the 4 stages of increased ICP

– Stage 1:total compensation – Stage 2: ↓compensation; risk for ↑ICP – Stage 3: failing compensation; clinical manifestations of ↑ICP (Cushing’s triad) – Stage 4: imminent → death

What are the clinical manifestations of raised ICP? Give 3 examples

• Change in level of consciousness • Change in vital signs – Cushing’s triad (widened pulse pressure, bradycardia, irregular respirations) – Change in body temperature ``` • Ocular signs – Unilateral pupil dilation – Sluggish or no response to light – Inability to move eye upward – Eyelid ptosis ``` Headache Vomiting

Regarding increased ICP what motor manifestations can occur?

↓ In motor function – Hemiparesis/hemiplegia – Decerebrate posturing (extensor) • Indicates more serious damage – Decorticate posturing (flexor)

What diagnostic studies are done for determining head and spinal injuries?

* CTscan/MRI/PET * EEG * Cerebral angiography GCS

Where can you place an ICP monitoring device?

``` Epidural intraparenchymal subarachnoid ventricular subdural ```

What treatments are used for spinal or head injuries?

``` • Treat under lying cause. • Adequate oxygenation –PaO2 >100mmHg – PaCO2 35-45 mm Hg – Intubation – Mechanical ventilation • Surgery ```

Give an example of 3 drug therapies that are used for head injuries?

– Mannitol (Osmitrol) • Plasma expansion • Osmotic effect • Monitor fluid and electrolyte status. – Hypertonic saline • Moves water out of cells and into blood. • Monitor BP and serum sodium levels. – Corticosteroids • Vasogenic edema • Monitor fluid intake, serum sodium and glucose levels. • Concurrent antacids, H2 receptor blockers, proton pump inhibitors ``` – Antiseizure medications – Antipyretics – Sedatives – Analgesics – Barbiturates ```

What nursing assessments can you do for a patient affected by a head injury?

``` • Subjective data • Level of consciousness (LOC) • Glasgow Coma Scale – Eye opening – Best verbal response – Best motor response ```

What does one dilated and one normal pupil mean?

compressed cranial nerve 3

What do bilateral dilation of pupils mean?

Ominous sign

What do pinpoint pupils mean?

Damage to pons or drugs

What cranial nerve assessments can you do?

– Eye movements – Corneal reflex – Oculocephalic reflex (doll’s eye reflex) – Oculovestibular (caloric stimulation)

What nursing interventions can you do for respiratory functioning of head injuries?

``` – Maintain patent airway. – Elevate head of bed 30 degrees. – Suctioning needs – Minimize abdominal distention. – Monitor ABGs. – Maintain ventilatory support. ```

What nursing interventions can you do for pain management of head and spinal injuries?

``` – Opioids – Propofol (Diprivan) – Dexmedetomidine (Precedex) – Neuromuscular blocking agents – Benzodiazepines ```

What nursing interventions can you do for fluid and electrolyte imbalances patients with head and spinal injuries?

– Monitor IV fluids. – Daily electrolytes – Monitor for DI or SIADH

How can you visually assess for a head injury?

* Bruising * Swelling * Lacerations * Bleeding

What are the different classifications of spinal cord injuries?

Traumatic and non traumatic

What can cause a traumatic spinal injury?

vehicle accidents, sporting accidents, falls and assaults with weapons.

What can cause a non-traumatic spinal injury?

- cervical spondylosis - myelitis - osteoporosis - tumours - vascular disease

What nursing management can you do for a spinal cord injury?

* Immobilisation to prevent further injury. * Thermoregulation. * Bowel and bladder management. * Reduce spascity. * Prevent pressure areas. * Prevent resp complications * Assist with nutritional needs. * Control pain * Promote mobility and maintain suppleness of joints and muscle tone. * Psychological support

What is a hypersensitive reaction?

Hypersensitivity describes an increased immune response to the presence of an allergen known as an antigen, which can potentially cause harm to the person

What are the signs and symptoms of anaphylactic shock?

* Rapid onset from seconds (can be up to one hour). * Rash, urticaria, pruritus. * Angioedema especially of the head, face, neck and upper airway. * Flushing * Chills * Diaphoresis * Laryngeal spasm (hoarseness, stridor) * Bronchospasm (wheeze or poor air entry) * Hypotension * Tachycardia * Arrhythmias * Cardio- pulmonary arrest

What is the treatment and management of anaphylactic shock?

* Secure patent airway, relieve obstruction * Remove allergen i.e. stinger, infusion etc * Adrenaline * Administer high flow oxygen via a non rebreather mask may require nebulised bronchodilator * Provide warmth * Corticosteroid * Administer histamine * Maintain BP with fluid, volume expanders, vasopressors

Explain the triad of death

Sever blood loss leads to 1. low body temp which leads to decreased coagulation which leads to 2. Blood clotting problems which increase lactic acid in the blood which leads to 3. Acidic blood which decreases heart performance And repeat steps 1-3 indefinitely until you save the patient