Emergency Nursing Principles And Management (2)

Question 0

Triage under mass casualty conditions

Answer 0

Military form of triage that focuses on achieving the greatest food for the greatest number of people.

Tag colors:

Red: emergent
Urgent: yellow
Nonurgent: green
Expectant: black

Question 1

Triage under usual conditions

Answer 1

Ensures that pts with highest acuity needs receive the quickest tx.

Emergent, urgent, nonurgent model

Emergent: life or limb threatening situation

Urgent: pt should be tx soon but the risk posed is not life threatening

Nonurgent: generally can wait for an extended length of time without serious deterioration

Question 2

Emergent or class 1

Answer 2

Identified with a red tag indicating an immediate threat to life

Question 3

Urgent or class 2

Answer 3

Identified with a yellow tag indicating major injuries that require immediate tx.

Question 4

Nonurgent or class 2

Answer 4

Identified with a green tag indicating minor injuries that do not require immediate tx.

Question 5

Expectant or class 4

Answer 5

Identified with a black tag indicating one who is expected and allowed to die

Question 6

Primary survey

Answer 6

Rapid assessment of life threatening conditions.

Should take no longer than 60 seconds to perform.

Standard precautions : gloves, gown, eye protection, face mask, show covers must be worn to prevent contamination with bodily fluids.

ABCDE principle guides the primary survey

Question 7

ABCDE principle

Answer 7

Emergency care is guided by the principle of ABCDE.

AIRWAY/cervical spine: most important step in performing the primary survey. If a patent airway is not established, the subsequent steps of the primary surgery are futile.

BREATHING: once a patent airway is achieved, the presence and effectiveness of breathing should be assessed.

CIRCULATION: once adequate ventilation is accomplished, circulation is assessed. Assess HR, BP, and perfusion.

DISABILITY: disability is a quick assessment to determine the pt's LOC 
A: alert 
V: responsive to voice 
P: responsive to pain 
U: unresponsive 

Glasgow coma scale : eye opening, verbal response, motor response
-score of 3 is unresponsive and score of 15 indicates a pt within normal limits neurologically

EXPOSURE: removes the pt’s clothing for a complete physical assessment
-clothing is always removed during a resuscitation situation to assess for additional injuries

Question 8

Antivenin antidote

Answer 8

Based on type and severity of snake bite within 4 to 12 hours

Question 9

Antidotes for ingested poison (3)

Answer 9

• activated charcoal
• gastric lavage and aspiration
• whole-bowel irrigation

Syrup of ipecac is no longer recommended

Question 10

What to give to reverse heroin and other opiate toxicity ?

Answer 10

Naloxone (narcan)

Question 11

Cardiac arrest

Answer 11

The sudden cessation of cardiac function caused most commonly by ventricular fibrillation or ventricular systole.

Question 12

Ventricular fibrillation

Answer 12

A fluttering of the ventricles causing loss of consciousness, pulselessness and no breathing. This requires collaborative care to defibrillate immediately using ACLS protocol.

Question 13

Pulseless ventricular tachycardia (VT)

Answer 13

An irritable firing of ectopic ventricular beats at a rate of 140 to 180/min. The client over time will become unconscious and deteriorate into VF.

Question 14

Ventricular asystole

Answer 14

A complete absence of electrical activity and ventricular movement of the heart.
Pt is in complete cardiac arrest and requires implementation of BLS and ACLS protocol.

Question 15

Pulseless electrical activity (PEA)

Answer 15

A rhythm that appears to have electrical activity but is not sufficient to stimulate effective cardiac contractions and requires implementation of BLS and ACLS.

Question 16

How to maintain patent airway in unconscious pt without suspicious of trauma..

Answer 16

If pt is unresponsive without suspicion of trauma : airway should be opened with head-tilt/chin-lift maneuver (most effective manual technique for opening an airway)
DO NOT perform this on a pt with a potential cervical spine injury

Question 17

How to maintain airway in unconscious pt with suspicion of trauma

Answer 17

Airway should be opened using modified jaw thrust maneuver.

Airway can be maintained using airway adjuncts: oropharyngeal or nasopharyngeal airway.

Question 18

ACLS protocols for Ventricular fibrillation (VF) or ventricular tachycardia (VT)

Answer 18

-initiate CPR components of BLS
-defibrillate according to BLS guidelines
-establish IV access
-administer IV antidysrhythmic medications
(Epinephrine 1mg IV push every 3 to 5 min or vasopressin 40 units IV x 1 only) switch to epinephrine is no response

Consider following medications :

• Amiodarone hydrochloride (Cordarone)
• Lidocaine hydrochloride (Xylocaine)
• magnesium sulfate
• Procainamide (Procan SR)
• Vasopressin