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EXAM 5 Flashcards

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1
Q

1 cause of death

A

trauma

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2
Q

first step in emergency

A

check the scene -this must be done before providing care

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3
Q

primary survey

A

A=airway (with cervical spine stabilization and immobilization),

B=breathing (rate, rhythm, and effort),

C=circulation (SBP of at least 90 with radial pulse, 60 with carotid or femoral pulse)

D=disability (neurological assessment – GCS (if less than 8, intubate),

E=exposure/environmental control (measures to keep the patient warm, removing clothing to assess for other injuries)

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4
Q

Secondary survey

A

F - full set of vitals , EKG, pulse ox, foley, NG/OG tube, labs

Give comfort

history head to toe

inspect posterior

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5
Q

ESI 1

A

unstable, needs immediate care, cardiac arrest, intubated trauma victim, severe overdose

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6
Q

ESI 2

A

threatened, needs care in minutes, chest pain, multiple trauma, child with fever and lethargy (bc meningitis), disruptive psychiatric patient, immunosuppressed patient

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7
Q

ESI 3

A

stable, needs care within 1hour, abdominal pain, GYN disorders

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8
Q

ESI 4

A

stable, care can be delayed, simple laceration, cystitis, typical migraine

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9
Q

ESI 5

A

stable, care can be delayed, cold symptoms, re-check, minor burns

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10
Q

black tag

A

expectant) are used for the deceased and for those whose injuries are so extensive that they will not be able to survive given the care that is available.

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11
Q

red tag

A

(immediate) are used to label those who cannot survive without immediate treatment but who have a chance of survival.

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12
Q

yellow tag

A

(observation) for those who require observation (and possible later re-triage). Their condition is stable for the moment and, they are not in immediate danger of death. These victims will still need hospital care and would be treated immediately under normal circumstances.

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13
Q

green tag

A

(wait) are reserved for the “walking wounded” who will need medical care at some point, after more critical injuries have been treated.

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14
Q

white tag

A

(dismiss) are given to those with minor injuries for whom a provider’s care is not required.

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15
Q

golden hour

A

refers to the first hour or initial time period following initial traumatic injury. Survival rates increase with proper care during the time soon after injury.

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16
Q

lethal triad

A

often cause deaths during the first 24 hours. The “lethal triad” are coagulopathy, acidosis, and hypothermia.

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17
Q

platinum 10 minutes

A

no patient should have more than 10 minutes of stabilization on the scene prior to transport to a trauma center.

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18
Q

coagulopathy

A

results from blood loss and tissue injury leading to an imbalance between clotting, anti-coagulation and fibrinolysis in the early stage of trauma which results in continued bleeding

due to hypothermia and acidosis

tx: fluid and warm blood products

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19
Q

acidosis

A

Lactic acid rapidly accumulates and cannot be cleared by the body causing a drop in pH.

promotes hypotension, impairs O2 delivery, leads to arrythmias, and liver cannot clear lactic acid

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20
Q

hypothermia

A

shivering, which inc metabolic demands and o2 consumption

leads to ischemia, dec contractiltiy, arrythmias, impaired clotting

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21
Q

focus of lethal triad care

A

correcting hypovolemia, preventing and treating shock, and maintenance of adequate oxygenation

warm fluids, transfusion, early intubation and ventilation, warm blankets, warm room

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22
Q

who should be notified

A

primary and secondary nurses
ED docs
EMT/ED techs
OR/anesthesia
Resp therapist
lab techs
radiology
ICU
security

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23
Q

9 nursing roles

A

Know facility’s role in emergency and disaster response

Know and use the chain of command

Locate facility’s emergency/disaster response plan

Know and demonstrate role in emergency/disaster response

Participate in drills

Demonstrate correct operation of equipment needed

Know personal limits in knowledge, skills

Apply creative problem-solving and flexible thinking

Take personal responsibility and contribute to solutions

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24
Q

red cross definition of disaster

A

an occurrence, either natural or man-made, that causes human suffering and creates human need that victims cannot alleviate without assistance - NEED OUTSIDE HELP

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25
stanhope and lancaster def of disaster
any human-made or natural event that causes destruction and devastation that cannot be relieved without assistance - NEED outside help
26
charge nurse role
use chain of command
27
4 phases of disaster response
Mitigation Preparedness Response Recovery
28
Langan and James’ 5 Stages of Disaster:
Non-disaster – before the treat of disaster becomes real. Time to plan and educate – this is mitigation. Pre-disaster – event is certain to occur but has not yet happened. Time to warn and evacuate – this is preparation. Impact – disaster is occurring, effects are felt Emergency – community comes to help of those affected, outside resources mobilized – this is response. Reconstruction – rebuilding, restoration, mitigation of effects – this is recovery.
29
when should preparation begin
at personal level
30
nurses role in preserving evidence 6
care for patient first contact law enforcement obtain specimens avoid damaging evidence bag and preserve evidence document
31
6 people more at risk for difficulty in responding and recovery from disaster
Extremes in age People dependent on treatment and care The disabled Economically disadvantaged People with mental health disorders People who have experienced previous emergency/disaster
32
5 risks to nurses in disaster
Physical harm Emotional distress Moral distress PTSD Burnout
33
1. What is substance recognized by body as foreign?
antigen
34
2. Cell-mediated response
stimulation of T-lymphocytes which recognize the foreign antigens, bind to them, and produce sensitized clones of the T-lymphocyte which migrate throughout the body to locate and bind to antigens.
35
3. Antibody-mediated (humoral) response
stimulation of B-lymphocytes which differentiate into plasma cells that produce antigen-specific antibodies that bind to the antigen and inactivate it. This is followed by inflammation and phagocytosis.
36
4. The human leukocyte antigen (HLA) system
found on chromosome 6 and helps the immune system determine what tissue is foreign
37
tissue typing
5. determine how much overlap there is between a potential donor’s and recipient’s HLA antigens and prevent hyperacute rejection
38
hyperacute rejection
when someone maybe was a match but then developed antihuman antibodies from transfusion, transplants, or pregnancy
39
AB immunoglobulin and antigen
AB antigens and no ig
40
O igb, antigens
no antigens and anti-a and anti b ig
41
3 living donor criteria
- 18 years or old - Physical/mentally fit - No HTN, diabetes, heart disease, HIV or TB
42
3 ethics with donation
- Must be fully informed of risks/complications - Voluntary - Pain is most common concern
43
required request laws
Request for donation is required by all hospitals using Medicaid and medicare
44
how to evaluate if someone is a donor
DMV designation and family consent
45
5 ways family is most likely to consent
1. They are not asked at the same time they are informed of the patient’s death, 2. They perceive the timing of the request is optimal, 3. They view the requestor as sensitive to their needs, 4. They are approached in a quiet, private place, and, 5. An organ procurement specialist makes the request
46
3 deceased donor contraindications
- Uncontrolled sepsis - Active hepatitis, HIV - Malignant tumor outside of primary brain tumor
47
11 organ recipient contraindications
- >70 years - Untreated cancer within 5 years - Active TB - HIV positive - Actie hepatitis - Substance abuse - Severe COPD - CAD - Ef<20% ( unless heart transp) - Psychosocial/behavioral issues - BMI >35
48
3 types of living donations
kidney, part of liver, BM
49
how to test for organ eligbility
- Tissue typing - Crossmatching (donor lymphocytes are mixed with serum of the recipient – if donor cells are destroyed, the test is positive and the transplant is contraindicated)
50
how to prevent donor complications
screening
51
3 benefits to living donor donations
less time waiting, time for recipient to plan, psych benefit to recipient(improves compliance)
52
if there is impending death, nurse must
nurse must contact OPO (life net) and regional organ donor bank AND must talk to the family
53
5 responsibilities for OPO
- Identifying and evaluating donor - Confirming brain death - Obtaining consent - Assisting with clinical management - Preserving and sending organs
54
9 nursing care for brain death
- MAP > 60 - Urine output >1mL/kg/hour - EF>45 - fluid replacement (to manage DI) - Thyroid hormone - Corticosteroids - Vasopressin minimum to maintain BP - Prevent acidosis with Na <150 and K+ >4.0 - Prevent hypothermia keep at 36.5
55
3 clinical care for withdrawing care
- Will death occur in an hour when removed from ventilation - If so, the patient is extubated, transported to the OR, team waits for 5 min of asystole, if death occurs within 60 min, the team begins organ recovery - IF patient maintains a heartbeat and continues to breathe after 60 min, the patient returns to the ICU
56
kidney transplant criteria
*when GFR is <30 BEFORE need for dialysis Criteria: blood type and 0 antigen mismatch Point system priority = time waiting, antigen mismatch quality, donation status, proximity
57
how is kidney transplant done
Donor kidney placed in right iliac fossa near bladder with a ureteral stent to maintain patiency
58
for all transplants, nursing actions are 7
DVT proph. (SCD) Early ambulation IS Deep breathing Coughing Hand hygiene Asepsis wound care
59
5 liver transplant criteria
- Blood typing - Body size - Urgency degree - MELD score (higher score means more sick) - Locally first
60
how is liver transplant done
T tube or biliary stent usually placed
61
6 contraindication? for heart transplant
- MUST be local regional - > 65 - Pulm HTN - Kidney/liver dysfun (no HF) - Insulin dep diabetes with neuropathy - smoking priority to patient on mechanical ventilation
62
tehcnique for heart transplant
biclaval
63
within 1st month after transplant, what is most common infection
HAI - CMV
64
how to prevent infection
Screening, vaccines, dental care, CL care, foley care, hand hygiene, face mask, no flowers and plants, wash/peel/cook veggies, avoid live vaccines, prophylaxis abx for dental care , coughing deep breathing, early ambulation, antiviral prophylaxis
65
when are opportunistic infections most common after transplants
2-6 months
66
if someone has CMV what is important
assessment of mouth and throat
67
s/s of CMV
leukopenia, fever, joint pain, fatigue, anorexia, abdominal pain, diarrhea, pneumonia, gastritis, colitis, hepatitis, retinitis, and endocarditis can develop.
68
when are community acquired infections most common
>6 months - pneumonia, rsv, influenza, UTI
69
3 nutrition for transplant
- need dietician consult - high calorie and high protein - enteral preffered
70
when is induction and maintenance used and what is induction
to prevent acute and chronic rejection of the graft, and to prevent and minimize the risk of infection or risk of drug toxicity. induction: heavy duty IV high dose immunosupressants placed before during or after
71
rabit ATG use moa SE 2 nursing
depletes lymphocytes fever, HA through cL with filter
72
if patient develops rejection s/s what is tx
antirejection Iv steroids
73
all organ trasnplant recipients recieving immunosupression,
should be ASSESSED for signs of rejection and for signs and symptoms of infection
74
4 patient education for transplants
1. Cannot take immunosupressants 2. New meds 3. Temp above 37.8 4. Weakness, SOB, sudden weight gain, swelling of hands and feet, not feeling right, aches and pains
75
prednisone/methyprednisolone MOA SE nursing
interferes with T cell differentiation to impair antigen recognition development of diabetes, Cushingnoid appearance, mood swings, Na and H2O retention, weight gain, dyslipidemia, osteoporosis, aseptic necrosis of the hip, muscle atrophy, gastric ulcers, cataracts. * Nursing: administer with food, monitor baseline BP, weight, and for signs of infection, teach the importance of regular eye exams, weight-bearing exercise, Ca supplements.
76
tacrolimus use MOA AE nursing
kidney bc less nephrotoxic for maintence inhibits cytokine production by T cells * AE: development of diabetes, diarrhea/vomiting, neurologic toxicity – headache, tremor, numbness/tingling, nephrotoxicity. Nursing - ORAL ADMIN PREFFERED - ON EMPTY STOMACH - Monitor BP, BG, renal function, if diabetes – treat that
77
cyclosporine class, moa, se, nursing
calcinueurin inhibitors for heart transplant inhibits t cell differentiation * SE: development of nephrotoxicity (is dose-related), kidney fibrosis, hypertension, dyslipidemia, hirsutism, neurologic toxicity is less common than with tacrolimus NARROW THERAPEUTIC WINDOW - Monitor drug levels - Monitor BP - Weight - Kindey function - NO grapefruit, no contrast, - If start new drug, ask doctor because of many interactions
78
mycophenolate mofetil class moa se education
antiproliferative agent – to inhibit B and T cell proliferation * SE: neutropenia, anemia, N/V/D, opportunistic infections * EMPTY STOMACH, DON’T CRUSH OR CHEW

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