exam 3 Flashcards

Question

Describe principles of emergency care, including triage, assessment and intervening.

Answer 1

● TRIAGE: sorts patients by hierarchy based on: ○ Severity of health problems ○ Immediacy with which these problems must be treated ● Triage nurse collects data and classifies the illnesses/injuries to ensure the patients most in need of care do not needlessly wait ● Protocols may be initiated in the triage area ● ED triages differ from disaster triage in that patients who are the most critically ill receive the most resources, regardless of potential outcome ● Three categories: ○ Emergent: Highest priority ○ Urgent: Serious health problems but not life threatening ○ Nonurgent: Episodic illness ● Emergency severity index (ESI) assigns patients to five levels: ○ Level 1 (most urgent) to Level 5 (least urgent) ○ Level 1: Immediate life saving interventions ● Assessment: ○ Primary Survey: Focus on stabilizing life-threatening conditions: ■ A: airway: establish patent airway ■ B: breathing: provide adequate ventilation ■ C: circulation: evaluate and restore cardiac output; control hemorrhage, prevent and treat shock ■ D: disability: determine neurologic status; AVPU mnemonic (alert, verbal, pain, unresponsive), patient has neuro problem not able to communicate or unresponsive ■ E: exposure: undress to assess wounds or areas of injury. Make sure we don’t miss any areas ○ Secondary Survey ■ Health history: Very important ● History including current trauma, indoor and outdoor, what happened leading up to these injuries. Patients status before the injury or illness ■ Head-to-toe assessment: reassess airway, breathing, VS ■ Diagnostic and lab testing ■ Monitoring devices: ECG, arterial lines, urinary catheters ■ Splinting of suspected fractures ■ Cleansing, closure, dressing wounds ■ Performance of other interventions based on patients condition

Answer 2

``` . Airway Obstruction: ● Partial and complete obstruction ● Oropharyngeal or nasopharyngeal airway insertion ● Endotracheal intubation ● King tube or laryngeal mask ● Cricothyroidotomy ● Maintain Ventilation: ○ Ensure that the patient has equal bilateral breath sounds ○ Monitor pulse ox ``` b. Hemorrhage: Control Bleeding · Fluid replacement: IV access · Monitor VS, neuro, circulation and pulses · External: Easier to control · Internal: May need dx testing to find out where the bleed is c. Trauma: Chest · Injury prevention: o Education o Legislation o Automatic protection · Multiple trauma: Single catastrophic even that causes life-threatening injuries to at least 2 distinct organs or organ systems · Injuries interfering with vital physiologic function have highest priority: Brain and spinal cord · Chest Trauma o Blunt: Caused by impact or force from an object o Penetrating: Body is pierce by an object o Pneumothorax o Cardiac Tamponade o Subcuteneous Emphysema o Pathologic states: § Hypoxemia § Hypovolemia § Cardiac Failure o Life threatening: Impaired ventilation and perfusion leading to acute renal failure, hypovolemic shock, and death o Assessment: § Rapid Assessment- ABCDE · Airway: · Breathing: · Circulation: · Disability: · Exposure: § General assessment: Undress patient completely to avoid missing injuries · CXR, CT scan · Lab: CBC, clotting studies, electrolytes · O2 sat, ABGs · ECG o Medical Management: § Goal: Restore & maintain cardiopulmonary function § Establish airway & ventilation § Treat shock with colloids, crystalloids, blood § Chest tube often needed to achieve rapid and continuing re-expansion of lungs, drains fluid, blood, and air. § May require exploratory surgery if management isn’t enough Pain management to help with chest expansion

Answer 3

● Ostomy ○ Colostomy vs ileostomy - how they differ in characteristics and nursing care ■ Colostomy: ● surgical opening into the colon to allow drainage of contents through a stoma (large intestine: sigmoid, transverse, descending, ascending) ● Depending on placement, determines the type of fecal matter ● Permanent or temporary ● Can be trained ■ Ileostomy: ● surgical opening into the ileum of the small intestine ● Large amounts of digestive enzymes are found in the waste ● Permanent of temporary ● Continuous output, so there should never be constipated ● Nursing care of both Ostomy types ○ Empty the pouch when it is 1/3-1/2 full ○ Empty before activity and bedtime ○ Never put anything in the stoma unless instructed by provider ○ Change appliance system 1-2 times a week and prn, in the morning another gathering all supplies ○ Always wipe the tail of the pouch after emptying ○ May use lubricating deodorizer ○ Clean stoma and peri-stomal skin with warm water only w/ wash cloth or paper towels ○ Apply barrier ring (if needed), then wafer (cut to size), then apply pouch to wafer ● Post-operative ostomy assessment, nursing care, and priority interventions ○ Assessment ■ Monitor Ostomy output ● Occurs in 24-48 hours after surgery for ileostomy ● 3-6 days after surgery for colostomy ■ Monitor stoma ● Pink to bright red ● Shiny ○ Nursing care ■ Monitor fluid loss (large volume lost in this early period) ■ Record I&O ■ Monitor electrolyte and lab values ■ Administer electrolyte replacement ■ Bloody drainage initially ■ May still have stool and mucous from rectum initially ■ Monitor/manage gas pain ■ Manage NG suction ■ Provide emotional support ○ Priority interventions ■ Determine a regular schedule for changing the pouch to avoid leakage ■ Reinforce ostomy care education ■ Management of drainage from stoma and monitoring the nature of the drainage ■ How to use stoma appliances ■ Monitor for Peri-stomal skin irritation ● Caused by leakage due to pouching system that does not fit will ● Apply a solid skin barrier component ■ Diarrhea ● Can lead to dehydration and electrolyte imbalance, so monitor lab values ● Replacement of fluids and electrolytes when needed ● Use of anti-diarrheal agents ■ Ensure the pouching system is fitted properly to prevent leakage and skin irritation ■ Stoma stenosis ● Monitor for circular scar tissue that forms at stoma site ● May be surgically release ● Monitor for complications ○ Discharge education for colostomy and ileostomy ■ Patient is able to empty, change and apply ■ Education on when to call the doctor ● s/s of infection/complications ● Bowel Obstruction

Answer 4

○ Small bowel obstruction clinical manifestations ■ Initial symptoms ● Cramps pain (wavelike and colicky) ● Hypoactive/absent bowel sounds ● Vomiting ● Dehydration ● Abdominal distention ● Complete blockage ○ Reverse direction of intestinal contents ○ Large bowel obstruction clinical manifestations ■ Symptoms develop and progress much slower than small bowel obstruction ● Constipation may be ONLY symptom ■ As it progresses ● Obvious distention ● Crampy lower abdominal pain

Answer 5

■ Used to decompress the stomach when there is an intestinal obstruction/lieu’s ■ Hooks up to suction to remove gastric contents when needed ■ Used to administer nutrition or medication when oral intake is not tolerate ○ NG nursing care ■ Assess/monitor output ■ Monitor function of NG ■ Assess fluid and electrolyte imbalances ■ Monitor nutritional status ■ Assess for resolution ■ Frequent oral care (every 4 hours) ■ Can also offer water or mouth wash to swish every hour ■ Keep nostrils clear ■ Lubricant can be applied to mouth and nose to help with discomfort of the tube ■ If the NG tube comes out DO NOT put it back in!! Call the provider ○ NG assessment ■ To check placement attach an empty syringe and instill air, then pull back to withdraw stomach contents and us a pH strip to double check that it is stomach contents ● If it is positive, indicates correct placement

Answer 6

○ Know clinical manifestations of Crohn’s and ulcerative colitis ■ Crohn's disease clinical manifestations ● Insidious onset ● RLQ abdominal pain that is NOT relieved with a BM ● Chronic diarrhea ● Cramps abdominal pain after meals ● Abdominal tenderness and spasms ● Steatorrhea ● Anorexia, weight loss, nutritional deficiencies ■ Ulcerative Colitis clinical manifestations ● LLQ pain ● Chronic diarrhea ● Stool with mucus, pus, or blood ● Frequent stools, 6+ a day ● Intermittent tenesmus (feeling of Im-complete defection) ● Anorexia, weight loss ○ Client education (discharge teaching) for Crohn’s and UC ■ Maintain normal elimination patterns ■ Determine relationship between BM and certain foods/activities/emotional stressors ■ Determine frequency, character, consistency, and amount of BM ■ Administer anti-diarrheal ○ Relieving pain ■ Assess character and onset of pain ■ Administer analgesic ■ Encourage non-pharm interventions ○ Maintain optimal nutrition ■ May need parenteral nutrition ■ Record I&O and DW ■ Encourage small, frequent, low-residue food ○ Promote rest ■ Intermittent rest periods and activity as tolerate ■ Passive exercises and joint ROM if needed ○ Reduce anxiety ■ Encourage expression of feelings and questions ■ Provide education about medical management/surgery ○ Prevent skin breakdown ■ Assess skin frequently ■ Provide perianal care (apply skin barrier prn) ■ Use pressure relieving devices ■ Consult with wound care prn ○ Monitor and manage potential complications ■ Monitor lytes, dysrhythmias, change in LOC, hypotension, rectal bleeding, s/s or perforation and obstruction ○ Know potential complications associated with inflammatory bowel disease and how to monitor/manage ■ Malnutrition and dyhydration ■ Increase risk of colon cancer ■ Bowel obstruction and perforation ■ Ulcers and fistula ■ Anal fissures ■ Cancers

Answer 7

○ Risk factors of colorectal cancer ■ Older age (65-75) ■ Family history ■ Men ■ African American or Ashkenazi ○ Clinical manifestations ■ Determined by location, stage, and function of affected intestinal segment ■ Change in bowel habits (most common) ■ Blood in stool ■ Dull abdominal pain, melena (R side) ■ Obstruction, bright red blood in stool (L sided) ■ Tenesmus, rectal pain, alternating constipation and diarrhea, blood in stool (rectal) ○ Prevention: She said to remember that screening is very important! ■ EARLY SCREENING ■ All adults begin periodic colonoscopy screening at age 50 ■ Home test kits ■ Smoking cessation ■ Physical activity, diet, weight reduction

Answer 8

``` ○ Any form of tobacco use ○ Excessive ETOH use ○ HPV infection ○ Hx of head and neck cancer ○ Men ```

Answer 9

``` ○ Nursing management ■ Prevention of aspiration pneumonia ■ Low Fowler/Fowler position ■ Use of IS 10x/day ■ Sitting up in chair when able ■ Nebulizer treatments ■ Assess for regurgitation and dyspnea ■ Maintain NG tube ● Usually to low intermittent suction ● DO NOT manipulate ● DO NOT replace if displaced ■ NPO ■ Maintaining Adequate Nutrition ● Diet advanced as tolerated ● After meals, remain un right for at least 2 hours ● Encourage food intake, appetite may be poor ● Avoid Boost of Ensure (promotes dumping syndrome) ```

Answer 10

``` ○ Maintains airway clearance ○ Fowler position ○ Assess for s/s of resp distress (She said this is the main thing, knowing that we just took out part of the neck and need to assess breathing and swallowing!) ○ Removal of secretions to prevent pneumonia ○ Cough and deep breathing ○ Suction PRN ○ Relieve pain ○ Assess pain level (PCA if needed) ○ Providing wound care ○ Management of wound vacs and dressings and s/s of infection ○ Maintaining adequate nutrition ○ Assess ability to chew ○ Diet modification PRN ○ Oral care after eating to prevent infection ○ Maintaining physical mobility ■ Weakness of shoulder ■ Exercise to promote maximal shoulder function and neck motion ○ Monitor/manage potential complications ■ Hemorrhage ○ Frequent VS ○ Avoid valsalva maneuver ○ Chyle fistula ○ Assess chest tube drainage ```

Answer 11

``` ■ Assess for lower facial paralysis and difficulty swallowing ○ Speech therapy ■ Promote effective communication ■ Establish communication plan pre op ■ SLP therapy ■ Supporting patient self esteem and needs of caregivers ○ Pre op teaching ○ Support change in body image ■ Coping skills ■ Support groups ```

exam 3 Flashcards

(35 cards)