Med Surg 3: Test 1

Carbon Monoxide Poisoning

*1-10*: normal *11-20(mild)*: HA, flushing, decreased visual acuity, decrease cerbral functioning, slight breathlessness *21-40(moderate)*: HA, N/V, drowsy, tinnitus, confusion, pale to reddish/purple skin, low bp, increase and irregular HB, depressed ST *41-60(severe)*: coma, seizures, cardiopulmonary instability *61-80(fatal)*: death

The nurse in an ER triage. Priority patient is...

A client with chest pain who states that just ate pizza w/ spicy sauce.

Client in ER has frostbite to R hand. Which finding would the nurse note on assessment of the client's hand?

A white color to the skin, which is insensitive to touch

A patient has a core temp of 90 F. the most appropriate rewarming technique would be...

Active internal warming using IV fluid

Ingested entire bottle of chewable vitamins, suicide, which intervention first?

Administer activated charcoal

When assessing the pt. with a multi-lumen central line, the nurse notices that the cap is off one of the lines on assessment. The pt. is in respiratory distress and the vital signs show hypotension and tachycardia. What is the nurse's priory action?

Administer oxygen

Lung injury associated with burns

*Lower* -High degree of suspicion if patient was trapped in a fire in an enclosed space or clothing caught fire -Presence of facial burns or singed nasal or facial hair -Dyspnea -Carbonaceous sputum -Wheezing -Hoarseness -Altered mental status *Upper* -Blisters, edema -Hoarseness -Difficulty swallowing -Copious secretions -Stridor -Substernal & intercostal retractions -Total airway obstruction

Decontamination

*dont assume decontamination* 1. removal of patients clothing/jewelry and then rinsing the patient with water 2. thorough soap and water wash and rinse

CVA care

-Comply with hand hygiene requirements. -Bathe ICU patients over 2 months of age with a chlorhexidine preparation on a daily basis. -Scrub the access port or hub with friction immediately prior to each use with an appropriate antiseptic (chlorhexidine, povidone iodine, an iodophor, or 70% alcohol). -Use only sterile devices to access catheters. Immediately replace dressings that are wet, soiled, or dislodged. -Perform routine dressing changes using aseptic technique with clean or sterile gloves. -Change administrations sets for continuous infusions no more frequently than every 4 days, but at least every 7 days. -Promptly remove unnecessary central lines Perform daily audits to assess whether each central line is still needed

Nutrition for Burns

-Early & aggressive nutritional support w/in several hours of burn injury can decrease complications & mortality, optimize burn wound healing, & minimize the negative effects of hypermetabolism & catabolism -Basal metabolic rate is 40-100x higher than normal w/ burn injury -Maintain NPO status until bowel sounds are heard, & then advance to clear liquids as prescribed -Provide diet high in protein, carbohydrates, fats, & vitamins, w/ major burns requiring more than 5000 calories/day -Monitor calorie intake & daily weights -Failure to supply adequate calories & protein leads to malnutrition & delayed healing

Airway Management

-Early endotracheal intubation to reduce need for emergency tracheostomy (extubation when edema resolves in approx 3-6 days) -Escharotomy is circumferential burns to neck &/or chest -If no intubation, 100% humidified O2 & place in high fowler's -Encourage TCDB

Triage

1. *Red Tag*: Chance of Survival but serious (sucking chest wound, shock hemothrorax, pneumo, asphyxia) 2. *Yellow Tag*: Major injuries that don't need immediate attention (stable ab wounds, serious without airway compromise) 3. *Green Tag*: Minor injuries that can be delayed hours or days of treatment(fractures, minor burns) 4. *Black Tag*: Not likely to survive so just don't help them

Deadly 6 of trauma

1. Airway 2. Cardiac tamponade 3. Tension pneumoathorax 4. Hemothorax 5. Sucking chest wound 6. Flail chest

An older man arrives in triage disorientated and dyspneic. His skin is hot and dry. His wife states that he was fine earlier today. The nurse's next priority would be to..?

Assess his vital signs (1st step of nursing process)

What assessment parameter will the nurse address during secondary survey?

BP and HR

Acute phase vs rehab phase

*ACUTE* (1) Wound care -Goals prevent infection & promote wound re-epithelialization (2) Excision & grafting (3) Pain management (4) Physical & occupational therapy -Passive & active ROM performed on all joints (5) Nutritional therapy -Goals provide adequate calories & protein to promote healing *REHAB* 1.Begins when the patient's wounds have healed & he/she is engaging in some level of self 2. Happens as early as 2 weeks or as long as 7-8 months after a major burn injury (1) work toward resuming a functional role in society (2) rehabilitate from any functional and cosmetic post-burn reconstructive surgery that may be necessary 3. Complications: -Joint contractures an abnormal condition of a joint characterized by flexion & fixation; happens if adequate ROM is not started & new tissue shortens

Common Poisons

*Acetaminophen/Tylenol* -Activated charcoal, n-acetylcysteine *Acids/Alkalis* -Minor: immediate dilution(water/milk) -Major: Activated charcoal, gastric lavage, hemodyalisis, supportive care *Bleaches* -washing of exposed skin, dilution, gastric lavage *Carbon Monoxide* -100% O2 NRB mask *Tricyclic antidepressants* -multidose activated charcoal, gastric lavage, supportive care NEVER INDUCE VOMITING

Trauma patients are triaged how?

*Primary Survey*: -always check for hemorrhage first(Ultrasound for hidden blood loss) -Airway, breathing, circulation(Compression or Fluids), disability(LOC), exposure(undress), facilitation(VS) *Secondary*: -History, head to toe, *check posterior (log roll)*

Phases of Blast Injury

*Primary*: results from pressure wave *Secondary*: results from debris from the scene or shrapnel from the bomb *Tertiary*: pressure wave hat causes the victim to be thrown *Quaternary*: presenting conditions exacerbated by the force of the blast or by potential injury complications *Quinary*: hyper inflammatory state commonly seen in bystanders near the blast and due to toxics substances

2 types of suction

*Water* -column of water to control the amount of suction from the wall regulator -amount of water is what controls the suction -An increase in suction does not result in an increase in negative pressure to the system because any excess suction merely draws in air through the vent on top of the 3rd chamber *Dry* -contains no water

Classification of a burn

*depth, extent, location, and patient risk factors* -small= <10 TBSA(cover with clean, cool, tap water dampened towel) -large= >10 TBSA(CAB) Go to burn center -partial thickness >10% TBSA -face, hands, feet, perineum, gentalia, major joints -3rd degree burns -electrical burns including lightning, chemical, inhalation -pre-existing medical disorders that could complicate management -people who require special social, emotional, or long term rehab intervention

Thermal Burns

*most common* -scald burns happen in bathroom or cooking

Burn injury depth

*partial thickness* -superficial: red, blanching, pain, mild swelling -deep: blisters, red, shiny, wet, severe pain cause by injury to nerve, edema *full thickness* -dry, waxy, white, leather, or hard skin. -thrombosed vessels -insensitivity to pain -muscle, tendon, bone NEED SURGICAL INTERVENTION

Ebola

*recently travel outside the country???* -infection with virus of family filoviradae, genoa ebolavirus -contact -isolate, proper ppe, only necessary tests LIMIT EXPOSURE TO PEOPLE

Hemorrhage

*stopping bleeding is essential* -main cause of shock -Hidden blood: retroperitoneum, pelvis, chest, and thighs 1. Volume Replacement(LR, Normal Saline, PRBC) 2. Control External Hemorrhage(firm pressure, tourniquet) 3. Control Internal Hemorrhage(Blood products rapidly) -tachycardia, low BP, thirst, cool moist skin, delayed cap refill

What are effective interventions to decrease absorption or increase elimination of ingestion poison?

- Activated charcoal - Gastric lavage - Hemodialysis

Client being brought back to ER w/ patient thickness burns to his face, neck, arms, chest. The nurse should...

- Assess for airway patency - Administer O2 as prescribe - Elevate extremities if no fractures of present

A nurse is working on a disaster response team and is triaging pts. Which of the following is a color code of green?

- Client with a fractured arm - Client with a first-degree burn to the forearm

Which interventions should the nurse perform before using non open-suctioning technique for a patient with an RT tube?

- Hyper-oxygenate the pt. for 30 sec - Perform hand hygiene before performing the procedure - Perform a cardiopulmonary assessment

ESI

-*ESI1*: unstable, immediate assistance (cardiac arrest, severe respiratory distress, intubated trauma) -*ESI2*: threatened condition, within 10 minutes need assistance (chest pain from ischemia, multiple trauma) -*ESI3*: Stable, up to 1 hour need assistance (abdominal pain or gyno, hip fracture) -*ESI4*: stable, could be delayed (closed extremity trauma, simple laceration) -*ESI5*: stable, could be delayed examination only (cold symptoms, minor burns)

Location of burn issues

-*face/neck/chest/back*: breathing issues/airway -*hands, feet, joints, eyes*: self care and future functioning -*hands and feet*: challenge to manage due to vascular and nerve supply systems -*nose and ears*: high risk for infection because skin is very thin -*butt and perinium*: infection from urine/feces contamination

Most common type of chemical restraints?

-Ativan -halidol

Complications of Central Venous

-Catheter Occlusion:change position raise arm cough, 10ml syringe -embolism: o2, clamp catheter, left side with head down -infection -pneumo: o2, semi fowlers, chest tube -catheter migration: fluoroscopy

Wound Care

-Cleansing and gentle debridement (using scissors & forceps) during a regular shower or w/ patient in bed -Once daily shower & dressing change w/ an evening dressing change in the patient's room are often routine in burn centers -Extensive, surgical debridement done in OR -Patients find 1st wound care to be both physically & mentally demanding; provide emotional support & begin to build trust during this activity -INFECTION can cause further tissue injury & possible sepsis --Source of infection is likely the patient's own normal flora, mostly from skin, respiratory, & GI systems -Always wear PPE and use sterile gloves when applying ointments & sterile dressings -Permanent skin coverage is the primary goal autograft (patient's own skin) or allograft (cadaver skin) is generally used; newer biosynthetic options are now available

Emergent phase of burn management

-Emergent (resuscitative) phase is time required to resolve the immediate, life-threatening problems resulting from burn injury -Lasts up to 72 hrs from the time the burn occurred -Primary concerns *onset of hypovolemic shock & edema formation* *Fluid/electrolyte shifts*: -hyperkalemia, hyponatremia= hypovolemeic shock (high HR low BP) -intravascular volume depletion: Colloidal osmotic pressure decreases w/ progressive loss of protein from the vascular space results in more fluid shifting out of vascular space into the interstitial spaces third spacing *inflammation and healing*: begins within 1st 6-12 hrs after injury *Greater risk for infection* S/S: hypovolemic shock, paralytic ileus/decrease bowel shivering, frightened

Nursing Management Chest Tubes

-Monitor the patient's clinical status. Assess vital signs, lung sounds, and pain. -Assess for manifestations of re-accumulation of air and fluid in the chest (decreased or absent breath sounds), significant bleeding (>100mL/hr), chest drainage site infection (drainage, erythema, fever, elevated WBC) or poor wound healing. Notify HCP for management plan. -Evaluate for subcutaneous emphysema at chest tube site. -Encourage the patient to breathe deeply periodically to facilitate lung expansions and encourage range-of-motion exercises to the shoulder on the affected side. Encourage use of incentive spirometry every hour while awake to prevent atelectasis or pneumonia. -Never elevate the drainage system to the level of the patient's chest because this will cause fluid to drain back into the lungs. Secure the unit to the drainage stand. Change the unit if the collection chamber is full. -Do not try and empty it. Mark the time of measurement and the fluid level on the drainage unit according to the unit standards. Report any change in the quantity or characteristics of drainage (e.g. clear yellow to bloody) to the HCP and record the change. *Notify HCP if >100mL/hr of drainage.* -Check the position of the chest drainage container. If the drainage system is overturned and the water seal is disrupted, return it to an upright position and encourage the patient to take a few deep breaths, followed by forced exhalations and cough maneuvers. -If the drainage system breaks, place the distal end of the chest tubing connection in a sterile water container at a 2-cm level as an emergency water seal. -Milking or stripping chest tubes is no longer recommended. Position tubing so that drainage flows freely to negate need for milking or stripping.

Burn Control

-PREVENT HYPOTHERMIA: cool large burns no more than 10 min -do not immerse body part in cool water -never cover with ice -gently remove as much burned clothing as possible -wrap pt in dry clean sheet or blanket to prevent further contamination to burn

Patient Burn Risk Factors

-Pre-existing heart, lung, or kidney disease = poorer prognosis for recovery -Diabetes or PVD = poor healing, especially w/ foot or leg burns -General physical weakness from chronic disease = challenging for pt to fully recover -Also, a burn patient who also sustained injuries such as fractures, head injuries, or other trauma will also have a more difficult recovery

Healing Education

-Tell patients who have more heavily pigmented skin that is will take longer for it to regain its color because manyof the melanocytes have been destroyed -Scarring: discoloration(fades over time) and contour(fitted garments to make it flat) -itching: water based moisturizers and short term use of antihistamines

What must be obtained when being transferred to another facility?

-consent from patient -acceptance from facility and physician -appropriate modes of transportation

.emotional response

-fear -anxiety -anger -guilt -hopefulness -depression

Idications for Central venous access devices

-med administration -nutrtional replacement -blood samples -blood transfusions -renal failure -shock, burns -hemodynamic monitoring

When is giving consent not needed in emergency nursing?

-needed for invasive procedures -If UNCONSCIOUS or unable to make decisions: 2 providers

Types of Airways

-oropharyngeal -endotracheal intubation -cricothyroidectomy

Education on Warfare agents

-plan a meeting place -where to go if an evacuation is necessary -determine when and who to turn off water, gas, electricity, at main switches -locate safe spot in the home for each type of disaster -replace stored water supply every 3 months and store food every 6 months -back of stuff

Nuclear Radiation Exposure

-traige outside -strict isolation -floors and vents covered/sealed -waste double bagged- thrown in yellow/magenta containers -PPE(water resistant gowns, two pairs of gloves, masks, caps, goggles, booties -doximetry devices

Small Pox

-transmitted in air droplets and handling contaminated material -s/s begin 7-17 days after exposer: fever, back pain, vomiting, malaise, HA, papules 9th day *vaccine can cause you to get small pox*

drawing blood from CVA

-wash hands -Identify the patient and explain the procedure to the patient and/or family member -Stop Infusion: If fluid is infusing through a single lumen catheter, stop the infusion. For multi‐lumen catheter; stop and clamp all other infusions. *Exception: Do not stop vasoactive medication infusions. Consider looking for an alternate blood draw site.* -Using aseptic technique disconnect the tubing from the injection cap. Attach a new luer lock device onto the tubing and set it aside. -Scrub the hub with alcoholic chlorhexidine preparation, 70% alcohol, or povidone-iodine (twist back and forth). Completely air dry 30 seconds. -Flush the line with Normal Saline -Withdraw waste -multi specimen draw: order tubes *blue, red, gold, light green, purple, gray* -Keep the Line by flushing using a push/pause flushing method. -Restart Infusion

Core body temp of 86.6. What action is most important?

Administer warmed IV fluids

What is the triad of death?

Hypothermia Coaguability Acidosis

Client undergoing fluid replacement after being burned 25% of body 12 hour ago. Nursing assessment reveals BP 90/50, pulse 110, urine output 20 ml over past hour. The nurse reporting findings insists...

Increasing the amount of IUV LR solution being administered per hr.

The nurse is unable to flush a central venous access device and suspects occlusion. The best nursing interventions would be to?

Instruct the pt. to change positions, raise arm, and cough

A 71 y/o woman arrives in the ER after ingesting acetaminophen. What is most important to ask?

What time did you take the medication?

Chemical Burns

Result of contact with acids, alkalis, organic compounds -acids: hydrochloric acid, oxalic, and hydrofluoric acid -alkali: oven and drain cleaners, and heavy industrial cleaners(harder to manage since they adhere to tissue causing protein hydrolysis and liquefaction -organic compounds: chemical disinfectants(phenols), gasoline Tx: 1. Best treated by quickly removing any chemical particles or powder from the skin 2. Remove all clothing containing the chemical because the burning process continues while the chemical is in contact with the skin 3. Flush affected area w/ copious amounts of water to irrigate the skin anywhere from 20 minutes to 2 hours post exposure 4. Tape water is acceptable for flushing eyes exposed to chemicals

The nurse scheduled to care for burn client scheduled for an escharotomy procedure being performed for 3rd degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy?

Return of distal pulses

Safety of Chest tubes

SAFETY: - Keep all tubing below chest level -Keep all tubing together -NEVER disconnect a chest tube -Do not clamp chest tubes (except when full; change quickly) -You may disconnect for suction -of no tidaling: drainage system is blocked -suspect a system leak with continuous bubbling

Nerve Agents

Sarin and Soman Action: inhibition of cholinesterase S/S: increased secretions, GI motility, diarrhea, bronchospasm TX: soap and water, supportive care, benzodiazapines, pralidoxime, atropine

Students end of school party...drinking alcohol, eating snacks, swimming. A student was found floating in pool. What action first?

Securing the airway and providing ventilation

Airway Obstruction

Signs: -*early*: not speaking, breathing or coughing; neck in hands -*late*: hypoxia, cyanosis, loss of consciousness Management: -*breath and cough spontaneously*: forceful coughing -*inffective cough, high pitched*: act as if complete airway obstruction Establishing an Airway -reposition head -head tilt/chin lift, jaw thrust, insertion of equipment

Rules of Nine

arms and legs are circumferential

Biologic Warfare Agents

biologic or chemical substance that can cause mass destruction or fatality -used for sabotage or may be used by global terrorists with intentions to enable global objectives -anthrax, smallpox, botulism, plaque, tularemia, hemorrhagic fever, ebola

Fasciotomy

compartment syndrome

Incident Command System

federally mandated command structure that coordinates personnel, facilitates, equipment, and communication in any emergency situation -HICS: hospital emergency preparedness coordinated who oversees and coordinates all efforts surrounding the event

Doximetry devices

measures how much exposure you are getting being around nuclear radiation

Preventing VAP

CLOSED SUCTION TECHNIQUE

Drug Care for Burns

*Analgesics & Sedatives:* -IV pain medications early in post burn period -Morphine, hydromorphone, fentanyl, ketorolac *Tetanus Immunization* Update always with burns -Routinely given to all burn patients d/t likelihood of anaerobic burn wound contamination -If patient has not received an active immunization w/in 10 years before the burn injury, tetanus immunoglobulin should be considered *Antimicrobial Agents:* -Topical antimicrobial agents may be used -Systemic antibiotics not routine used because burn eschar has little or no blood supply; also increases risk of developing multidrug resistant organisms *Venous Thromboembolism (VTE) Prophylaxis:* -If there are no contraindications, it is recommended that low-molecular weight heparin (enoxaparin: not kidney friendly 1 time a day) or low-dose unfractionated heparin(kidney friendly 2 times a day) be started as oon as it is considered safe

Anthrax

*Bacillus Anthracis* -contracted through digestive system, abrasion on skin, or inhalation -blood test detects -TX: antibiotics(ciprofloxacin, doxycycline, penicillin

Emergent Phase Complications

*Cardiovascular* -dysrhythmias and hypovolemic shock -increased risk for VTE -blood thickness increases because of fluid loss *resp* -no correlation btw TBSA and inhalation injury *cardiopulm* -preexisting lung/heart disease increased risk for complications -fluid replacement to vigorous =HF or pulmonary edema *urinary* -Acute tubular necrosis secondary to hypovolemia

Chest Tubes

*Chest tubes are inserted to reestablish negative pressure and allow for proper lung expansion* -12 french to 40 french 3 Compartments 1. collection chamber: receives fluid and from the pleural or medialstinal space 2. water sealed chamber: contains 2 cm of water and acts as a 1 way valve -brisk bubbling often occurs with a pneumo(coughing, sneezing, exhalation) -bubbling ceases when air leaks resolves(negative pressure restored**) -tidaling is normal 3. suction control champer: applies suction to chest drainage

Botulism

*Clostridium Botulinum* -found in soil and spread through air and food, person to person -neuro s/s 12-36 hours on food; 24-72 hours on inhalation(can progress to paralysis -early: antitoxin(induces vomit and enema)

Teaching to reduce Burn Injury

*Flame or Contact* -regular home fire drills -never leave hot water unattended while cooking -never use gasoline or other flammable liquids to start a fire *Scald* -lower hot water tempt to lowest point (120) -check temp with back of hand after running bath water -supervise bathing *Inhalation* -smoke/CO detectors *Chemical* -containers labeled correctly *Electrical* -avoid or repair frayed wiring -avoid outdoors during lightening -protective eyewear and gloves

Cold Related Emergencies

*Frostbite*(localized) -vasoconstriction--> results in edema 1. superficial: involves skin and subq tissue(ears, nose, fingers, and toes) --waxy pale yellow to blue, crunchy frozen, tingling, numbness --immerse in water (37-40 C) 2. Deep: muscle, bone, tendon --white, hard insensitive to touch --immerse in water, IV analgesia *Hypothermia*(systemic) -<35 C -GOAL manage & maintain ABCs, rewarm the patient, correct dehydration & acidosis, and treat cardiac dysrhythmias 1. Mild: 34-36- shivering, lethargic, confusion, minor HR changes 2. Medium: 32-34- rigidity, bradycardia, slowed RR, metabolic/resp acidosis 3. extreme: <32- appears dead, HR RR slowed way down, reflex absent, pupils fixed

Poisonings

*Gastic Lavage*:Involves insertion of large diameter (36-42 Fr) gastric tube for irrigation of copious amounts of saline -elevate HOB, intubate if altered LOC, within 1 hour of ingestion *activated charcoal*: Many toxins adhere to charcoal & pass through GI tract rather than being absorbed into the circulation -50-100g for adults -contraindications: diminished bowel, paralytic ileum, ingestions of substance poorly absorbed by charcoal *skin/ocular decontamination*: Involves removal of toxins from skin & eyes using copious amounts of water or saline -wear PPE *Hemodialysis*:Reserved for patients who develop severe acidosis from ingestion of toxic substances (e.g. Aspirin)

Suctioning procedures for patient on mechanic ventilation

*General measures for open- and closed- suction techniques* -Gather all equipment -Wash hands and don PPE -Explain procedure and patient's role in assisting with secretion removal by coughing -Monitor patient's cardiopulmonary status (eg. VS, ECG, LOC) before, during, and after the procedure -Turn on suction and set vacuum to 100-120mmHg *Open-suction technique* -Open sterile catheter package using the inside of the package as a sterile field. NOTE: suction catheter should be no wider than ½ the diameter of the ET tube -Fill the sterile solution container with sterile normal saline or water. -Don sterile gloves. -Pick up sterile suction catheter with dominant hand. Using non-dominant hand, secure the connecting tube (to suction) to the suction catheter. -Check equipment for proper functioning by suctioning a small volume of sterile saline solution from the container. *Closed-suction technique* -Connect the suction tubing to the closed suction port. -Hyper-oxygenate the patient -for 30 secs -With suction off, gently and quickly insert the catheter using the dominant hand. When you meet resistance, pull back ½". -Apply continuous or intermittent suction using the non-dominant thumb. Withdraw the catheter over 10 secs or less. -Hyper-oxygenate for 30 secs as described above. -If secretions remain and the patient has tolerated the procedure, perform 2 or 3 suction passes as described above. Reconnect the patient to the ventilator.

Heat Related Emergencies

*Heat Cramps*: muscle contractions -thirst -rest and sodium and water replacement *Heat Exhaustion*: -Fatigue, N/V, thirst, hypotension/tachy, dilated pupils, confusion, diaphoresis, pale ashen skin -Cool room, moist sheet, ABC's, fluid and electrolytes *Heatstroke*:failure of thermo-regulatory processes -Most serious -Increase in sweating, vasodilation, and RR deplete fluids/electrolytes; core temp rapidly increases within 10-15 min(>105.3) -ABC, temp reduction, fluid/electrolytes *Control Shivering*: IV chiropromazine

Stings & Bites

*Hymenopteran*: bees, yeloow jackets, hornets, wasps, fire ants -mild discomfort to life threatening anaphylaxis -S/S delayed up to 48 hrs: stinging, swelling, itching, HA, fever, wheezing, hypotension -Mild: elevation, cool compress, oral antihistamines -Severe: IM/IV antihistamines(diphenhydramine), SC(epi), or coricosteroids(dexomethasone) -Teaching: remove with scraping motion NO TWEESERS *Tick Bites* 1. Lyme: appear within days -flu like(stiff neck, HA, fatigue), bulls eye rash--> meningitis, monarticular arthritis -TX: *cefriaxone* 2. Rocky: -pink macular rash on palm, wrist, soles, feet, ankles within 10 days -TX: *doxycycline* 3. TICK paralysis: 5-7 days -flaccid ascending paralysis -removal or dies/paralysis *Animal/human bites* -Most significant problems are infection and mechanical destruction of skin, muscle, tendons, blood vessels, & bone -Tetanus prophylaxis, analgesics, irrigation

One week after thoracotomy, a pt. with chest tubes to water seal drainage has an air leak in the closed chest drainage system. Which pt. assessment warrants follow up nursing actions?

Chest tube with a loose-fitting dressing

FEMA Levels of Disasters

1. Level 1: Massive Disaster involves significant damage and results in a presidential declaration with major federal involvement and full engagement of federal, regional, and national resources 2. Level 2: moderate disaster that is likely to result in a a presidential declaration of an emergency with moderate federal assistance 3. Level 3: minor disaster that involves a minimal level of damage, but could result in a presidential declaration of a emergency

Inhalation injury suspected. What would the nurse anticipate being prescribed to client

100% O2 via a tight fitting non-rebreather mask

Nurse is making a home visit to elderly client during winter. Nurse notices client has oven on with oven door open used as a form of heat. Which intervention is the most important?

Have a meeting with the client and family, warn them on the fire and safety risks of using the oven for heat.

A nurse is performing triage in the ER department. Who should she see first?

32 y/o patient with dug overdose, unresponsive, poor respiratory effort

Client burned in explosion. Burn initially affected entire face (anterior half of head and anterior torso). There were circumferential burns to both lower half of both arms. Burns on posterior surface of the head and upper half of the posterior torso. What % of the body is burned?

36%

Which type of graft utilizes the client's own skin for wound coverage?

Autograph

Forensic Evidence

Clothing: place individually in paper bag -*have them sign when taking evidence off your hands* -never leave evidence alone

The nurse notes tidaling of the water level in the tube submerged in the water-seal chamber in a pt. with closed chest tube drainage. The nurse should...?

Continue to monitor pt. (normal finding)

Disaster documentation

Disaster Tags: numbered and include triage priority, name, address, age, location, and description of injuries, tx or meds given -placed with patient AT ALL TIMES

Which action is most important for the nurse to take when caring for a pt. with a subclavian triple-lumen catheter?

During removal of the catheter, have the pt. perform the Valsalva maneuver

You are working in the ED with your preceptor, who is a triage nurse. A 24 year-old male arrives and states "I think I have food poisoning. I've been vomiting all night and now I have diarrhea." The patient reports abdominal cramping that he rates as 6/10. He denies fever or chills. Vital signs: T = 97.8, HR = 94, RR = 16, BP = 121/74.

ESI 3

What must be done no matter what if the patients comes to the ED according to EMTALA?

Everyone must see a provider when they come to an ER -Nurses are *Not* Providers

When older woman walks in soiled, claims she fell, what should the nurse suspect?

Family violence

Fluid Therapy

Parkland (Baxter) formula: *4ml/kg/%TBSA burn* 2. If electrical burn then require both fluids & mannitol (osmotic diuretic) to increase UO & overcome high levels of myoglobin & hemoglobin in urine 3. Assess for adequacy of fluid resuscitation using clinical parameters: -Urine output 0.5-1.0mL/kg/hr; 75-100mL/hr for electric burns -Cardiac parameters MAP >65, SBP >90, HR <120 *Parkland (Baxter) Formula* 1. 4mL/kg x % of TBSA = total fluid requirements for 1st 24 hrs 2. Use Lactated Ringers 3. Application: -½ of total in 1st 8 hrs -¼ of total in 2nd 8 hrs -¼ of total in 3rd 8 hrs 4. Example: -For a 70-kg patient w/ 50% TBSA burn: 4mL x 70 kg x 50 = 14,000mL in 24 hrs 7000mL (1/2) given in 1st 8 hrs 3500mL (1/4) given in the 2nd 8 hrs 3500mL (1/4) given in the 3rd 8 hrs

A male pt. w/ multiple injuries is brought to the ED by ambulance. He has had his airway stabilized and is breathing on his own...hemorrhage vital signs?

Rapid Pulse Hypotension

Smoke/Inhalation Burns

Rapid initial and ongoing assessment is critical--> airway compromise and pulmonary edema can develop over 1st 12-24 hours *asphyxiation*: carbon monoxide (CO) or hydrogen cyanide -O2 delivery of or consumption by tissues is impaired results in hypoxia & carboxyhemoglobin (hemoglobin combined w/ CO *Upper Airway Injury*: mouth, oropharynx, larynx -redness, blistering, edema, swelling -can constrict from outside *Lower Airway Injury*: trachea, bronchioles, and alveoli -tissue damage -pulmonary edema may not appear until 12-48 hours after-->ARDS Tx: 1. Watching closely for signs of respiratory distress 2. If CO poisoning is suspected treated w/ 100% humidified O2

Submersion Injuries

Regardless of what type of fluid is aspirated, the end result can be acute respiratory distress syndrome -hypotonic fresh water -hypertonic salt water *Goal correct hypoxia and fluid imbalances, support basic physiologic functions, and rewarm if hypothermia is present*

Electrical

results from intense heat generated from an electrical current *direct damage to nerves and vessels causing tissue anorexia and death* -below the surface--> pass through brain, heart, kidneys, etc. -at risk for dysrhythmias or cardiac arrest, metabolic acidosis, and myoglbinuria 1.flash injury: -An electrical flash generates light & heat w/o current flow & usually causes a thermal burn of exposed areas d/t the heat generated, or a flame burn from ignition of clothing -Have few complications & patients generally require shorter lengths of hospital stay 2. Conductive Injury: -Occur when current overcomes the skin's resistance & travels through the body -Conduction of electricity through nerves & vessels & along the outside of bones generates heat, causing damage to adjacent tissues -Entrance & exit wounds or contact points can help identify the probably current path & therefore anticipated tissues 3. Lightning injury: -Result from a direct strike, a high-voltage DC injury, or a side flash wherein the current discharges from an object nearby through the air to an adjacent object or person -Respiratory & cardiac arrest common