Chapter 13: nursing care of patients w/ emergent conditions and disaster/bioterrorism response Flashcards
(65 cards)
1
Q
Primary survey: abcde
A
a = airway
b = breathing
c = circulation
d = disability
e = exposure: remove clothing, look for injuries and medical alert jewelry
2
Q
secondary survey
A
- for patient w/ severe trauma
- identifies non life threatening injuries
- rapid head to toe assessment
- keep covered and warm
3
Q
shock
A
- circulatory failure
- decreased cellular perfusion
- treatment: control bleeding, vital signs, keep warm, IV fluids
4
Q
types of shock
A
hypovolemic
cardiogenic
obstructive
distributive
5
Q
shock nursing care
A
- control bleeding
- monitor vital signs
- give oxygen as ordered
- give iv fluids as ordered
- keep warm
- give medications as ordered
6
Q
anaphylaxis
A
- severe allergies reaction to protein/drug
- sudden
- distributive shock
- signs and symptoms: respiratory distress (wheezing), hypotension, decreased consciousness
7
Q
anaphylaxis treatment
A
- airway
- oxygen
- epinephrine
- antihistamines
- steroids
8
Q
shock nursing diagnoses
A
- risk for shock
- risk for ineffective peripheral tissue perfusion
- risk for allergic reaction
- ineffective airway clearance
9
Q
major trauma
A
- mechanism of injury
- penetrating (open) injuries
- blunt (closed) injuries
10
Q
mechanism of injury
A
transfers environmental energy to person
11
Q
penetrating (open) injuries
A
sharp object, projectiles
12
Q
blunt (closed) injuries
A
trauma extends to surrounding structures
13
Q
surface trauma
A
closed wound
open wound
14
Q
closed wound
A
contusion, hematoma
15
Q
open wound
A
- abrasion, puncture, laceration
- avulsion, amputation
16
Q
tetanus
A
- cause: bacillus clostridium tetani
- spores enter open wound and active
17
Q
signs and symptoms of tetanus
A
- jaw spasm (lockjaw)
- abdominal rigidity
- dysphagia, dyspnea
- muscle stiffness
- seizures
- death
18
Q
tetanus vaccinations
A
boosters every 10 years
19
Q
treatment for tetanus
A
- hospitalization
- airway maintenance
- human tetanus immune globulin (intramuscular)
- muscle spasm control
- wound care
- tetanus toxoid booster
20
Q
head trauma
A
first phase
second phase
21
Q
first phase of head trauma
A
initial injury
22
Q
second phase of head trauma
A
- involve intracerebral bleeding and edema
- increased intracranial pressure (ICP)
23
Q
signs and symptoms of ICP
A
- headache
- nausea/vomiting
- change in LOC
24
Q
late signs and symptoms of ICP
A
- dilated, nonreactive pupils
- unresponsive
- abnormal posturing
- decreased pulse rate, widening pulse pressure
- changes in respiratory pattern
25
head trauma treatment: decrease ICP
- oxygen
- head elevated 30-45 degrees
- head midline
26
spine trauma
- suspect w/ all trauma pts
- stabilize spine (neck/back) until injury ruled out
- maintain airway
27
chest trauma: heart and lung damage
- pericardial tamponade
- hemothorax
- tension pneumothorax
- flail chest
28
treatment for chest trauma
- oxygen
- chest tube as needed (PRN)
- surgery
29
abdominal trauma
- spleen, liver, bladder, intestinal damage
- monitor for shock
- abdominal distention
- IV fluids
- surgery
30
orthopedic trauma
- emergency care: "splint it as it lies"
- fractures
- joint dislocations
- treatment
31
treatment for orthopedic trauma
- immobilize
- elevate
- ice
- open/closed reduction
- pain control
32
majo trauma assessment
- identify mechanism of injury
- vital signs
- pain level
- glascow coma scale
33
major trauma nursing diagnoses
- acute pain
- risk for ineffective cerebral tissue perfusion
- ineffective breathing pattern
- ineffective airway clearance
- impaired physical mobility
- decreased cardiac output
- deficient fluid volume
- risk for infection -
34
major trauma nursing care
closed wound
open wound
monitor vital signs
35
closed wound
elevation, ice, rest
36
open wound
control bleeding
cover w/ sterile (dry/saline soaked) dressing
clean w/ sterile saline
tetanus immunization within 5 years
37
burns
- primary survey: ABCDE
-airway/respiratory monitoring
- treatment
38
treatment for burns
- oxygen
- IV fluid resuscitation
- temperature regulation
- pain control
- wound care/infection control: silver sulfadiazine
39
hypothermia
- core temp below 95 degrees Fahrenheit
- rewarming (active/passing)
- stabilizing vital functions
- prevent further heat loss
40
frostnip vs frostbite
- frostnip: extremities cold, not frozen
- frostbite: extremities frozen. protect, never rub. dry, sterile dressing. no weight bearing. elevate.
41
hyperthermia
- heat cramps
- heat exhaustion
- heatstroke
- treatment
42
heat cramps
muscle spasms
43
heat exhaustion
- excessive sweating
- hypovolemia
44
heatstroke
- inability to sweat
- temp 106 degrees Fahrenheit
45
treatment for hyperthermia
- cool environment
- loosen clothing
- oral or IV fluids/electrolytes
46
poisoning and drug overdose
- ingested
- inhaled
- injected drugs, stings
- venom bites
- treatment
47
poisoning and drug overdose: ingested
drugs
plants
chemicals
48
poisoning and drug overdose: inhaled
natural gas
carbon monoxide
chlorine
49
treatment for poisoning and drug overdose
- identify substance
- contact poison control center
- treat as indicated
50
near drowning
- water submersion w/ survival
- respiratory failure
- neurological injury
51
treatment for near drowning
primary survey: abcde
airway, oxygen
rewarm
52
nursing diagnosis for near drowning
ineffective tissue perfusion related to severe anoxia
53
disaster response
- overwhelming event
- institutional disaster plan activated
- casualties are triaged
- disaster drills
54
bioterrorism agents
bacteria
viruses
toxins
55
anthrax
- bacterial disease
- three forms
- no isolation; use standard precautions
- fatal if not treated
- antibiotic therapy
56
three forms of anthrax
inhalation
cutaneous
gastrointestinal
57
botulism
- caused by clostridium botulinum
- most potent lethal toxin known
- potent neurotoxin
- paralytic illness: blocks neurotransmission
- not contagious
58
botulism signs and sympms
- classic triad of botulism:
1. afebrile
2. symmetrical descending flaccid paralysis w/ prominent bulbar palsies
- clear mentation
59
botulism treatment: trivalent ABE quine antitoxin
prevents progression of disease
60
supportive care for botulism treatment
monitor airway, gag reflex, cough, swallowing, oxygenation
61
botulism infection control
- standard precautions: wash exposed clothes, shower if aerosol exposure, use 0.1% hypochlorite bleach solution for surfaces
62
plague
- coccobacillus yersinia pestis
- biological attack: primary pneumonic plague
- incubation per8iod 2-4 days
63
plague signs and symptoms
- high fever, chills
- headache
- chest discomfort
- dyspnea
- cough, hemoptysis
- GI symptoms
- rapidly progressive respiratory failure and sepsis 2-4 days after onset
64
treatment for plague
antibiotics
65
