Adult 3 test 2 pt. 1

Bee and wasps

venom injected through stings; most can sting repeatedly when distrubed; only honey bees can sting just once

Lightning strike interventions

- at risk for multi-system trauma -inital care includes spine stabilization, with ABCs (CPR if needed) - victims of lightning are not electrically charged- the resucer is not in danger for physical contact -hospital care- ECG, mechanical ventilation, thorough physical and diagnostic assessment, CT scan, creatine (skeletal muscle damage) - treat and assess burn wounds -tetanus prophylaxis -may need transfer to a burn center

Heat related illness prevention

-Avoid alcohol and caffeine -use SPF over 30 with UVA and UVB protection -rest and take breaks -limit activity at the hottest time of the day -wear clothing suited for the environment (lightweight, light-colored, loose-fitting) -Pay attention to your personal physical limitations-modify activities accordingly -take cool baths or showers to help reduce body temperature -stay indoors in air-conditioned buildings if possible -ask a neighbor, friend, or family member to check on the older adult at least twice a day during a heat wave

Secondary survey

-Done after the immediate life threats are dealt with - performs a more comprehensive head-to-toe assessment, known as the ____ _____ to identify other injuries or medical issues that need to managed or that might affect the course of treatment -splints may be applied to fractured extremities and temporary dressings will be placed over wounds

Care of the patient with PE

-apply oxygen -reassure the pt -place in high fowlers -apply ECG -Obtain venous access -assess oxygenation continuously with pulse ox - assess resp status Q30min (lung sounds, rate, rhythm, and ease of respirations, check skin color and cap refill, check position of the trachea) -assess cardiac status by comparing B/P is R and L arms, pulse checks for quality, checking cardiac monitor for arrhythmias, checking for distention of neck veins -ensure that prescribed chest imaging and lab tests are obtained immediately (CBC, platelet count, PT, PTT, d-dimer, ABG) -examine thorax for petechiae -administer prescribed anticoagulants -assess for bleeding Adminster heparin, lovenox, alteplase

Key features of heat stroke

-body temp over 104 -hot, dry skin that may or may not perspire -mental status changes- acute confusion, bizarre behavior, anxiety, loss of coordination, hallucinations, agitation, seizures, coma -vital sign changes- hypotension, tachycardia, tachypenia -electrolyte imbalances-Na and K - decreased renal function (olguria) -pulmonary edema (crackles)

High-altitude illness or high altitude disease

-bodys exposure to low partial pressure of oxygen at high elevations -at risk if living above 2500 feet (less oxygen avaliable) -cause is an interaction of environmental and genetic factors -more at risk are those who are obese, chronic illnesses, cardiovascular problems, dehydrated, and alcohol consuptions - Increases the RR to improve the oxygen delivery (hypoxic-ventilatory response) -increased RR causes hypocapnia (decreased carbon dioxide) and respiratory alkalosis -within 24 to 48 hourse the kidneys excrete the excess bicarbonate to return the pH to normal and the RR then increases again - sympathetic nervous system then increases the HR, BP, and cardiac output -pulmonary artery pressure rises due to generalized hypoxia-induced pulmonary vasocontriction -cerebral flow increases to maintain cerebral oxygen delivery -hypoxia induces red blood cell production -increased RBCs and hemoglobin (can develop into polycythemia) -ascend slowly

Teamwork and Interprofessional Collaboration

-collaboration with professional and ancillary staff who function in support roles -radiology, ultrasound technicians, RTs, laboratory techs, social workers, case managers, CNAs, and clerks -accountable for communication of pertinent staff considerations, patient needs, and restrictions to support staff -good communication with nurses from inpatient units is necessary -hand off communication should include: Situation- reason for being in the Ed and admitting diagnosis Pertinent medical history, including implantable devices and any history of organ transplant Assessment and diagnostic findings, critical results Transmission based precautions and safety concerns as indicated (allergies, fall risk) Interventions provided in the ED and response to those interventions -Standardized approach to hand-off using SBAR

Chest tube placement and care

-covered with airtight dressings -gravity to drain the pleural space Stationary chest tube drainage systems-use water-seal mechanism that acts as a one-way valve to prevent air of liquid from moving back into the chest cavity

Heat related illness

-environmental temp over 95 degrees and high humidity -heat stroke and heat exhaustion -at risk populations are older adults, people with mental health/behavioral conditions, those who work outside, homeless individuals, illicit drug users, athletes who engage in outdoor sports, and members of the military stationed in hot climates -health can also increase the risk: obesity, heart disease, fever, infection, strenuous exercise, seizures, mental health disorders, all degrees of burns, the use of prescribed drugs (lithium, neuroleptics, beta-adrenergic blockers, anticholinergics, ACE inhibitors, and diuretics)

Lightening strike

-most common young adult males -most occur during the summer months during the afternoon or early evening -Can happen to anyone without adequate shelter- golfers, hikers, campers, beach-goers, and swimmers -attracted to anything wet on the body -produces injury by directly striking a victim, splashing off a nearby object, or traveling through the ground -many people are left with permanent disabilities -injuries are preventable- stay indoors during electrical storms Assessment; both cardiopulmonary and nervous are affected -caridopulmonary arrest is the most lethal (provide care first) - can cause serious myocardial injury (ECG) -angina and dysthrythmias -inital appearance of mottled skin and decreased to absent peripheral pulses due to arterial vasospasm CNS- immediate but temporary paralysis aka keraunoparalysis - affects the lower limbs more than the upper limbs - resolves within hours - other S&S and complications: cataracts, tympanic membrane rupture, cerebral hemorrhage, depression, post traumatic stress disorder, skin burns (most are superficial-may have full thickness burns, charring, ad contact burns from metal objects)

Action alert- patient safety

-move slowly from supine to upright position with ambulating -confirm side rails are up and locked on stretchers -call light is within reach -fall risk is clearly communicated to visitors and staff members -older adults should always have the side rails up and the bed in the lowest position -reorient the patient frequently and re-assess mental status -undiagnosed delirium increases the risk for mortality for older adults who are admitted to the hospital -assess the need for a family member or someone who may need to stay with the patient

Lighting strike prevention

-observe weather forecasts when planning to be outside -seek shelter when you hear thunder- nearest building, enclosed vehicle- do not stand under an isolated tall tree or structure (ski lift, flagpole, boat mast, powerline) in an open area such as a field, ridge, or hilltop; lightening seeks the highest point. A stand of dense trees offers better protection -leave water immediately (including an indoor shower or bathtub) and move away from open bodies of water -avoid metal objects such as chairs or bleachers; put down tools, fishing rods, garden equipment, golf clubs, and umbrellas; stand clear of fences, exposed pipes, motorcycles, bicycles, tractors, and gold carts - if camping in a tent, stay away from the metal tent poles and wet walls -once inside a building, stay away from open doors, windows, fireplaces, metal fixtures, and plumbing -turn off electrical equipment, including computers, televisions, and stereos - Stay off the hard-wired telephone, lightening can enter through the telephone line and produce head and neck trauma, including cataracts and tympanic membrane disruption. death can result. - if you are caught out in the open and cannot seek shelter, attempt to move to lower ground such as a ravine or valley; stay away from any tall trees or objects that could result in a lightning strike splashing over to you; place insulating material between you and the ground - a lighting strike is imminent if your hair stands on end, you see blue halos around objects and you hear high-pitched or crackling noises. if you cannot move away from the area immediately, crouch on the balls of your feet and tuck your head down to minimise the target size; do not lie on the ground or have hand contact with the ground

Bee and wasp first aid/prehospital care

-remove stinger with tweezers or by gently scraping and apply ice pack -ensure ABCs -if there is a history of allergic reaction to stings or has wheezing, facial swelling, and respiratory distress, epinephrine should be given immediately - should carry an epi pen (follow with an antihistamine)

Drowning first aid/emergency care

-safe rescue of the person and rescuers - spine stabilization with a board or flotation device should be considered for those at high risk of spine trauma -time is of the essence -rapid rescue for the best benefit -initiate airway clearance and ventillary support measures-deliver rescue breaths as soon as possible (even in the water) -if hypothermia is a concern, handle the victim gently to prevent vfib Do not try to get the water out of the lungs by delivering abdominal or chest thrusts Hospital care: -airway and caridopulmonary support -oxygen administration, ET tube, CPR, defibrillation -gastric decompression with NG or OG to prevent aspiration -typically has a distended abdomen which impairs diaphram movement and decreases lung ventilation -full spectrum of critical care may be needed to manage to pathological complications of drowning, including pulmonary edema, infection, acute respiratory distress syndrome (ARDS), and CNS impairment

Heat stroke

-true medical emergency in which the body temp exceeds 104 - high mortality rate & thermoregulations fail and cannot adjust for a critical elevation in temp -if not treated or the pt does not response, organ dysfunction and death can result Exertional heat stroke- sudden onset and if often the result of strenuous physical activity Classic heat stroke- non exertional heat stroke-occurs over a period of time as a result of chronic exposure to a hot humid environment Assessment: temp over 104, presence of sweating does not rule out heat stroke, mental status changes occur as a result of thermal injury to the brain and are hallmark findings in heat stroke (confusion, bizarre behavior, seizures, or even coma) The patient may have hypotension, tachycardia, and tachypnea. Cardiac troponin 1 is frequently elevated during non-exertional heat-related illnesses-cost effective to predict severity and organ damage at the beginning of heat stroke Planning/Implmentation: -do not give food or liquid by mouth due to vomiting and aspiration (neurologic impairment) -immediate care using advanced life support is essential -first priority is to monitor and support the patients airway, breathing, and circulatory status -provide high concentration oxygen therapy -start several IV lines with NS and insert a urinary catheter -continue interventions to cool the pt until the rectal temp is 102 -External cooling methods include cooling blankets and ice packs -internal cooling methods include iced gastric and bladder lavage -use a continuous core temperature monitoring device (rectal or esophageal) or a temperature-monitoring urinary bladder catheter to prevent hypothermia -if shivering occurs during the cooling process give a paternal benzodiazepine such as diazepam (Valium). Lorazepam (ativan) is an alternative agent. -seizures can increase body temp further - also treated with IV benzodiazepine -once stabilized administered to ICU is needed to monitor for complications such as multisystem organ dysfunction syndrome and severe electrolyte imbalances

A

A client at the urgent care reports being stung, but not seeing the stinging insect. The electronic health record indicates a history of allergies to bee stings. What is the appropriate nursing action? A.Prepare to administer epinephrine IM, oral diphenhydramine, and oxygen. B.Remove the stinger, apply ice to the sting site, administer oral diphenhydramine. C.Obtain vital signs, administer oxygen, prepare to administer epinephrine IV. D.Establish an IV infusion with normal saline, apply heat to the sting site, administer acetaminophen.

C

A client phones the telehealth nurse reporting nausea and development of a throbbing headache while on a climbing expedition. Which teaching will the nurse provide first? A.Rest to regain strength B.Drink water to rehydrate C.Descend to a lower altitude D.Take acetazolamine if available

B

A flight nurse is preparing to care for a client who has been involved in a serious motor vehicle crash. When the helicopter lands, what is the nurse priority action?

moderate hypothermia

32-35 Active external and core (internal) rewarming methods -external heat with heating blankets can cause after drop (continued decrease in core body temperature after removal from the cold environment) by producing vasodilation - Rewarm pts trunk: core rewarming includes warm IV fluids, heated oxygen or inspired gas to prevent further heat loss via the respiratory tract; and heated peritoneal, pleural, gastric, or bladder lavage. S&S: muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, stupor, decreased clotting (impaired platelet aggregation and thrombocytopenia)

refractory hypoxemia

= *inability to improve oxygenation with increases in oxygen concentration* *hallmark* of *acute respiratory distress syndrome (ARDS)* - progressive form of acute respiratory failure that has *high mortality rate*

Chest tube care

Clamp when there is an airleak, you need to change canisters, or the canister is damaged. Change the dressing once per shift or when it is visable soiled Can clamp if there is no longer a need for the chest tube (the lung is fully inflated again) but giving it time to see if more draining will need to take place If the tube becomes dislodged clamp the tubes and if the tubes come out make sure to put an occlusive dressing on and cover 3/4 sides with tape

Reg tag

Classified as emergent (immediate threat to life) ex; airway obstruction or shock

DMAT

Disaster Medical Assistance Team made up of civilian medical, paraprofessional, and support personnel that is deployed to a disaster area with enough medical equipment and supplies to sustain operations for 72 hours -relief services ranging from primary health care and triage to evacuation and staffing to assist health care facilities that have been overwhelmed with casualties -licenses are valid in all states

D

After a mass casualty event, the nurse is triaging clients in the field. Which client is correctly classified? A. 38 year old with an open femur fracture: black tag B. 42 year old with multiple abrasions and contusions: yellow tag C. 54 year old with third degree burns over 90% of the body: green tag D. 61 year old who is having difficulty breathing and wheezing: red tag

Intrapulmonary causes of ventilatory failure

Airway disease: COPD, asthma Ventilation-persfusion (V/Q) mismatch: Pulmonary embolism, pneumothroax, ARDS, Amyloidosis, pulmonary edema, interstitial fibrosis

Tuberculosis

An infectious disease that may affect almost all tissues of the body, especially the lungs -caused by mycobacterium tuberculosis -one of the most common bacterial infections worldwide -transmitted through aerosolation (coughs, laughs, sneezes, whistles, or sings) -normal immunity prevents the development of active TB -bacillus multiplies freely when it reaches a susceptible site (bronchi or alveoli) S&S: fatigue, lethargy, nausea, anorexia, weightloss, irregular menses, blood-tinged cough, chest tightness, aching chest pain, low-grade fever-may have night sweats (weeks or months) Diagnostics: chest x-ra, sputum cultures of blood or respiratory secretions

Valium

Anxiolytic- Benzodiazepine- sedative -treat anxiety, muscle spasms, and seizures Contraindicated in pts with myasthenia gravis, severe respiratory insufficiency, severe hepatic insufficiency, and sleep apnea -do not take with medications such as antihistamines that can make your drowsy or cause respiratory depression

Brown recluse first aid/pre hospital

Apply cold compress over the site of the bite Do not apply heat because it increases enzyme activity and potentially worsens the wound Elevate affected extremity, provide local wound care and rest

Black widow first aid and prehospital care

Apply ice pack to decrease action of neurotoxin montior for systemic toxicity; support ABCs Transport to acute care facility as soon as possible

Black widow collaborative care

Assessment: Look for: -description of bite as nearly painless to sharply painful -tiny papule or small, red punctate mark - systemic complications, which usually develop within an hours of bite and involve neuromuscular system -concerns that may include sever abdominal pain, muscle rigidity and spasm, hypertension, nausea, vomiting. This may initially incorrectly diagnosed as an acute abdomen Hospital care: -monitor older adults, especially those with CV disease, for complications of hypertension -monitor vital signs, especially blood pressure and respiratory function -observe for seizures related to rapidly rising blood pressure -administer opioid pain medication and muscle relaxants (Diazepam) as ordered -administer tetanus prophylaxis as needed -monitor for signs of pulmonary edema, uncontrollable hypertension, respiratory arrest and/or shock -administer antivenom as ordered. Monitor for signs of anaphylaxis and serum sickness -contact regional poision control for specific advice on antivenom dosing and medical management

Bee and wasp interprofessional collaborative care

Assessment: Look for: wheal-flare skin reactions; swelling can be extensive and involve an entire limb or body area - hives, itching, and swelling of lips and tongue -monitor for anaphylaxis (respiratory distress, bronchospasm, laryngeal edema, hypotension, decreased mental status, and cardiac dysrhythmias) - systemic effects develop based on venom load and sensitivity- nausea, generalized edema, vomiting, diarrhea, destruction of red and white blood cells and platelets, damage to the blood vessel walls, acute kidney injury, renal failure, liver injury, cardiac complications, and multisystem organ failure Hospital care: -administer oxygen -continuously monitor cardiac function and blood pressure -administer antihistamines, albuterol, and corticosteroids as ordered -be certain that advanced life support drugs and resuscitation equipment are readily available -observe patients who have sustained multiple stings for several hours. Be prepared to admit to CC if toxic venom effects are noted - carry epi pen and wear medical alert tag

Pit viper collaborative care

Assessment: look for: -puncture wound in skin -pain, swelling, redness, and/or bruising around bites -vesicles or hemorrhagic bullae that may form later -patient identification of minty, rubbery, or metallic taste - tingling or paresthesias on scalp, face, and lips -muscle twitching, weakness -nasuea and vomitting -hypotension, seizures -clotting abnormalities or DIC Hospital care: -obtain complete history of event (snake apperance, time of bite, prehospital interventions, and any past snakebites or antivenom therapy) -give supplemental oxygeen -insert two large bore IVs -infuse NS or LR -continously monitor heart function and blood pressure -provide opioids to decrease pain -obtain coagulation panel, CBC, CK, type and cross match, urinalysis -obtain ECG -mark, measure, and record circumference of bitten extremity q15-30 minutes -contact regional poison control for specific advice on antivenom dosing and medical management -if indicated, administer Crotalidae, Polyvalent Immune Fab (CroFab) as ordered

Brown recluse collaborative care

Assessment: look for: Central bite mark, may appear as a bleb or vesicle with edema and erythema -description of bite as painless, stinging, or sharp -center of bite to become bluish-purple - central part of the wound to become dark and necrotic over the following 1-3 days (red white and blue sign) -systematic toxicity, which rarely occurs (rash, fever, chills, nausea, vomiting, malaise, joint pain) -Rare: sever systemic complications (loxoscelism), which may include hemolytic anemia, thrombocytopenia, DIC, and death Hospital care: -rare -supportive care measures -topical antiseptic and sterile dressings can be applies -antibiotics may be needed -administer tetanus prohylaxis -for extensive wounds- debridement and skin grafting

Coral snake collaborative care

Assessment: look for: Weakness, cranial nerve deficits (ptosis, diplopia, swallowing difficulty), altered level of consciousness, and respiratory paralysis -pain at the site, which may be described as mild and transient -difficult to find fang marks Hospital care: - identify snake as a coral snake if possible. If the snake cannot be identifired, treat as if venom were injected - be aware that toxic effects of venom may be delayed up to 13 hours and then produce rapid clinical deterioration -monitor for elevation in CK level from muscle breakdown and myoglobinuria -continually monitor cardiac function, blood pressure, and pulse oximetry. Be prepared to admit to a critical care unit -Be prepared to provide aggressive airway managemet if respiratory insufficiency or severe neurologic impairment occurs -provide interventions to decrease risk for aspiration -antivenom is not manufactured in the US. Supportive care is recommended - teach the patient that effects of a severe bite can persist for many days -contact regional poison control for specific advice on patient management

Emergency care of the patient with heat stroke

At the scene -ensure a patent airway -remove the patient from the hot environment -remove the patients clothing -pour or spray cold water on the patients body and scalp -fan the patient -if ice is avaliable-place ice in cloth or bags and position the packs on the patients scalp, groin, neck, and in the armpits -contact emergency services At the hospital -give oxygen by mask of NC- be prepared for intubation -start at least one large bore IV -Administer NS as prescribed-use cooled solutions if avaliable -use a cooling blanket -do not give aspirin or other antipyretics -insert a rectal probe to measure core body temperature continuously - insert urinary catheter -monitor vital signs frequently -obtain baseline lab tests: electrolytes, cardiac enzymes, liver enzymes, and CBC -administer muscle relaxants (benzodizepines) if the patient begins to shiver -measure urine output and specific gravity to determine fluid needs -stop cooling interventions when core body temperature is 102 -obtain urinalysis and monitor urine

Coral Snakes

Bands of black, red, and yellow that encircle the snakes body Small maxillary fangs

Hypothermia

Cote temp below 95 Predisposing conditions: cold-water immersion, acute illness, traumatic injury, shock, immobilization, cold weather, advanced age, selected medications, alcohol intoxication and substance abuse, malnutrition, hypothyroidism, inadequate clothing or shelter Divided into three categories

CroFab

Crotalidae polyvalent immune Fab copperhead/rattlesnake bites After reconstitution infuse the dose intravenously over 60 minutes. The infusion should proceed slowly over the first 10 minutes with careful observation for any allergic reaction- can increase if there is not reaction Recommended inital dose is 4-6 vials - staring dose may vary from a minimum of 4 to a max of 12 Monitor for: Bleeding, fever, swollen glands, rash itching, joint pain Allergies to papayas, papain, pineapples, sheep, horses, dustmites, or latex

HAP

Definition: -onset/diagnosis occurs <48 hours after admission in a patient with specific risk factors: in hospital >48 hours in the past 90 days, living in a nursing home or assisted-living facility, received IV therapy, wound care, antibiotics, chemotherapy in the past 30 days, seen at a hospital or dialysis clinic within the past 30 days -develops when a pts immunity cannot overcome the invading organisms -risk factors: older adult, chronic lung disease, presence of gram-negative colonization of the mouth, throat, and stomach, ALOC, recent aspiration event, ET tube, trach, or NG tube, poor nutritional status, reduced immunity (disease or drug therapy), uses drugs that increase gastric pH (histamine H2 blockers/antacids) or alkaline tube feeding, currently receiving mechanical ventilation (VAP) Management considerations: may have MDRO, critical hand hygiene Increased respiratory rate/SOB hypoxemia COugh Purlent, blood-tinged or rust-colored sputum Fever Pleuritic chest discomfort

Coral snake first aid/prehospital

Definitively identify the snake as a coral snake, if possible Encircle the affected extremity with an elastic bandage or roller gauze dressing (do not wrap so tightly that arterial flow is impeded); then splint. Leave on until the patient is treated at an acute care facility

High Altitude Pulmonary Edema

Delayed onset of symptoms-usually developing on 2nd or 3rd night after working strenuously for 1-2 days, Dyspnea and SOB (after significant rest), Crackles, fatigue, tachypnea, tachycardia at rest, hypotension, AMS -management= descend to a lower altitude -allow rest and acclimate at the current altitude Prevention and treatment- acetazolamide (Diamox, Apo-acetazolamide) to treat and prevent AMS -rids the body of excess fluid and induces metabolic acidosis which increases the RR and decreases the occurrences of periodic respiration during sleep at night. -take 24 hours before ascent and continue taking the first 2 days of the trip -moderate to severe treatment is dexamethasone (Decadron)- reduces cerebral edema by acting as an anti-inflammatory in the CNS - symptoms reoccur when the drug is stopped -early recognition of ataxia, change is LOC should descend to lower altitude, give supplemental oxygen, monitor airway

MOI

Describes how the patients traumatic event occurred Two most common are blunt and penetrating trauma

Drainage system management of chest tubes

Do not strip the chest tube. Keep drainage system lower than the level of the patients chest. Keep the chest tube as straight as possible from the bed to the suction unit, avoiding kinks and dependent loops. Extra tubing can be loosely coiled on the bed. Ensure that the chest tube is securely taped to the connector and that the connector is taped to the tubing going into the collection chamber. Assess bubbling in the water-seal chamber; should be gentle bubbling on patient's exhalation, forceful cough, and position changes Assess for tidaling (rise and fall of water in chamber three with breathing). Check water level in the water-seal chamber and keep at the level recommended by the manufacture Check water level in the suction control chamber and keep at the level prescribed by the surgeon (unless dry suction system is used) Clamp the chest tube only for brief periods to change the drainage system or when checking for air leaks Check and document amount, color, and characteristics of fluid in the collection chamber as often as needed according to the patients condition and agency policy Empty collection chamber or change the system before the drainage makes contact with the bottom of the tube When a sample of drainage is needed for culture or other laboratory test, obtain it from the chest tube; after cleaning chest tube, use a 20 gauge (or smaller) needle and draw up specimen into a syringe

Black tag

Does not apply Expectant expected and allowed to die Ex: head trauma, extensive full-thickness burns, high cervical spinal cord injury requiring mechanical vent

PE signs and symptoms

Dyspnea, sudden onset Sharp, stabbing chest pain Apprehension, restlessness Feeling of impending doom Cough Hemoptysis signs: tachypnea, crackles, pleural friction rub, tachycardia, S3 or S4 heart sound, diaphoresis, low grade fever, petechaie over chest and axillae, and decreased arterial oxygen saturation Cardiac: tachycardia, distended neck veins, syncope, cyanosis, and hypotension ECG changes- T-wave and ST segment changes as a left or right axis deviations RIght ventricular dysfunction and failure Anxious

Severe hypothermia

Extracoporeal rewarming methods such as cardiopulmonary bypass (fastest) or hemodialysis Monitor for early signs of complications that can occur after rewarming such as fluid, electrolyte, and metabolic abnormalities; ARDS; acute renal failure; and pneumonia "warm and dead" -avoid external rewarming S&S: bradycardia, severe hypotension, decreased RR, cardiac dysrhythmias (vfib/asystole), decreased neuro reflexes, decreased pain response, acid base imbalance

Black widow

Female shiny black with a red hourglass pattern on abdomen inhabit cool, damp environments such as log piles, vegetation, and rock; also live in barns, shed, and garages

Labs for PE

First leads to respiratory alkalosis (low PaCO2) on ABG. The Pa)2-FiO2 ratio falls as a result of shunting blood from the right side of the heart to the left without picking up oxygen from the lungs -causes the PaCO2 to rise resulting in respiratory acidosis from the buildup of lactic acid from tissue hypoxia Other labs: metabolic panel, troponin, brain natriuretic peptide, and a d-dimer

Rimfampin (RIF, Rifadin, Rimactance, Rofact)

First-in-line treatment for TB -Kills slower-growing organisms, even those that reside inside macrophages and caseating granulomas Nursing implications- warn pts to expect a orange-reddish staining of the skin/urine, and all other secretion's- soft contact lenses will become permanently stained -knowing the expected side effects decreases anxiety -use additional method of contraception besides birth control while taking the drug and for q month after stopping it -avoid drinking alcohol -report darkening or urine, a yellow appearance to the skin or whites of the eyes, and an increased tendency to bruise or bleed which are signs and symptoms of liver toxicity or failure -ask pt about all other drugs in use because this drug interacts with many other drugs

Isoniazid (INH, Hydrazide, PDP-Isoniazid)

First-in-line treatment of TB Kills actively growing mycobacteria outside the cell and inhibits the growth of dormant bacteria inside macrophages and caseating graulomas Nursing implications -avoid antacids and take the drug on an empty stomach (1 hour before meals or 2 hours after meals) to prevent slowing of drug absorption in the GI tract -teach the pt to avoid drinking alcoholic beverages due to liver damaging effects -Tell the pt to report darkening of the urine, a yellow appearance to the skin or whites of the eyes, and an increased tendency to bruise or bleed, which are signs and symptoms of liver toxicity or failure

D

Following management of a disaster, a patient care technician tells the nurse, "I keep seeing the faces of people that died when I close my eyes." What is the appropriate nursing response? A."The memories will fade eventually; it's just so fresh right now." B."Can you take a few days off to rest and try to feel better?" C."If we just lean on each other, we will get stronger and get through this." D."I will go with you to the occupational nurse who can help you explore your feelings."

Acceleration-deceleration

Forces involved in a high-speed crashes or falls from a great height, produces injury by tearing, shearing, and compressing anatomic structures. Trauma to the bones, blood vessels, and soft tissue occurs

Pulmonary angiography

Gold standard for PE diagnosis CT-PA or helical CT can also be used -diagnosis pulmonary abnormalities

Moderate

Grades of pit viper envenomation: Fang marks and swelling progressing beyond the site of the bite; systemic signs and symptoms such as nausea, vomiting, paresthesias, or hypotension

Severe

Grades of pit viper envenomation: Fang marks present with marked swelling of the extremity; subcutaneous ecchymosis; severe symptoms, including manifestations of coagulopathy

None

Grades of pit viper envenomation: Fang marks, but no local or systemic reactions

Minimal

Grades of pit viper envenomation: Fang marks, local swelling and pain, but no systemic reactions

Paramedics

Interdisciplinary team members: -advanced life support providers who can perform advanced techniques which may include cardiac monitoring, advanced airway management and intubation, needle decompression, establishing IV or IO access, and administering drugs en route -key source for valuable pt data

Prehospital care providers

Interdisciplinary team members: -first care givers that a pt see before transport to the ED -skill level of EMS is determined locally

Emergency medical technicians

Interdisciplinary team members: -offer basic life support interventions such as oxygen, basic wound care, splinting, spinal immobilization, and monitoring of vital signs -some carry AEDs and may be able to administer selected drugs such as a Epipen, narcan, or nitro -for patients who need care beyond this paramedics are dispatched

Psychiatric crisis nurse team

Interdisciplinary team members: -pts who visit the ED for their acute problems also may have chronic mental health disorders -pts experiencing an acute psychiatric crisis situation as their primary problems such as a suicide attempt secondary to severe depression or a new onset of psychosis -the availability of mental health/behavioral health nurses can improve the quality of care delivered to these pts who need specialized interventions in the ED -evaluated patients with emotional behaviors or mental illness and facilitated the follow-up treatment plan, including possible admission to an appropriate psych facility -interact with pt and families when sudden illness, serious injury, or death of a loved one may have caused a crisis --on site interventions can help patients and families cope with these changes in their lives -some EDs may have a specialized area to treat these pts with a video monitor, door locks, solid ceilings, and a secured area to retain pt belongings, metal detectors, panic alarms, and elimination of any items or room features that could pose a safety risk

Emergency medicine physician

Interdisciplinary team members: -specialized education and training in emergency pt management -directs overall care in the department

Forensic nurse examiners

Interdisciplinary team members: -obtain pt histories -collect forensic evidence -offer counseling and follow-up care For victims of rape, child abuse, and domestic violence aka IPV -recognize evidence of abuse and when to intervene on the patient's behalf Those who specialize in helping victims of sexual assault are called sexual assault nurse examiners (SANE) or sexual assault forensic examiners (SAFE) Interventions: safety plan or how to escape a violent relationship, document injuries, and collect physical and photographic evidence. May also provide testimony in court as to what was observed during the exam and information about the type of care provided

Drowning

Leading cause of accidental death in the US -suffers primary respiratory impairment from submersion or immersion in water Prevention is key: observe those who cannot swim around water, do not swim alone, don't dive into shallow water, avoid alcohol, ensure life jackets are available -amount of water is a key factor -fresh water surfactant reduces surface tension within the alveoli, increases lung compliance and alveolar radius, decreases the work of breathing- surfactant loss destabilizes the alveoli and leads to increased airway resistance -Salt water -hypertonic- creates as osmotic gradient that draws protein rich fluid from the vacular space into the alveoli -fresh and salt cause pulmonary edema -most important factors are duration and severity of hypoxia -bradycardia, reduced cardiac output, vasoconstriction of the vessels in the intestine, skeletal muscles, and kidneys - thought to reduce myocardial oxygen use and enhance blood flow to the heart and cerebral tissues (diving reflex) -cause should be determined

First degree frost bite

Least severe type - involves hyperemia (increased blood flow) of the effected area and formation of edema

Immediately notify physician or rapid response team

Management of chest tube drainage systems: Tracheal deviation Sudden onset or increased intensity of dyspnea O2 less that 90% Drainage greater than 70 ml/hr Visible eyelets on chest tube Chest tube falls out of the patient chest (first, cover the area with dry sterile gauze) Chest tube disconnects from the drainage system (first, put end of tube in a container of sterile water and keep below the level of the patients chest) Drainage in tube stops (in the first 24 hours)

Pit viper first aid/pre hospital care

Move to safety, away from snake Call for immediate emergency assistance Encourage rest to decrease venom circulation Remove jewlery and constrictive clothing Take photos of snake from a safe distance to aid in identification Immobilize affected extremity in position of function-maintain at level of the heart Keep patient warm, provide calm environment Do not incise or suck wound, apply ice, or use a touniquet

Extrapulmonary causes of ventilatory failure

Neuromuscular disorders: Myasthenia gravis, Gillian-barre syndrome, poliomyelitis, spinal cord injuries affecting nerves to intercostal muscles Central nervous system dysfunction: stroke, increased intracranial pressure, meningitis Chemical depression: opioid analgesics, sedatives, anesthetic, kyphoscoliosis, massive obesity, sleep apnea, external obstruction/constriction

Green tag

Nonurgent Minor injuries that do not require immediate treatment AKA the walking wounded EX: closed fractures, sprains, strains, abrasions, and contusions wait more than 2 hours for care may evacuate themselves from the scene and go to the hospital make up the greatest number (can overwhelm the system) -makes it difficult to know the actual number of casualties and may carry contaminants (nuclear, biologic, chemical to the hospital)

Peak airway pressure

PIP -pressure used by the ventialtor to deliver a set tidal volume at a given lung complaiance -PIP value appear on the display of the ventilator -highest pressure is reached during inspiration --trends in PIP reflect changes in resistance of the lungs and resisitance in the ventilarory -increased PIP means increased airway resistance in the patient or the ventilator tubing (bronchospasm or pinched tubing, patinent biting the ET tube), increased secretions, pulmonary edema, or decreased pulmonayr complaiace -upper pressure limit is set to prevent barotrauma -when limit is reached the high pressure alarm sounds and the remaining volume is not given

Maintaining patient and staff safety in the ED

Patient identification- provide ID bracelet for each patient, use two unique identifiers, use a special identification system for patients with an unknown identity Injury prevention for patients- keep rails up on stretcher, keep stretcher in the lowest position, remind pt to use the call light, reorient the confused patient frequently, if pt is confused ask a family member or significant other to remain with the pt, and implement measures to protect skin integrity for patients at risk for skin breakdown Risk for errors and adverse events- obtain a thorough pt and family history, check for medical bracelet or necklace, search pts belongings for weapons or other harmful items such as drugs and drug paraphernalia when he or she has an altered mental status Injury prevention to staff- use standard precautions at all times, anticipate hostile, violent patient, family, and/or visitor behavior. Plan and practice options if violence occurs, including assistance from the security department

Patient safety

Patient identification: identification bracelet at the ED -for unconscious pts without ID or emergent trauma patients they are assigned a Jane/John doe tag -always verify the identity using two identifies before each intervention and before medication administration EX: name, birth date, agency identification number, home telephone number or address, and/or social security number Fall Prevention: identify those at risk for falls - implement appropriate fall precautions and safety measures -pain medication, sedation, or lower-extremity cast application can increase the risk of falls - can occur in those with medical conditions or drugs that cause syncope -many older adults experience orthostatic hypotension as a side effect of cardiovascular drugs - can become dizzy -provide nutrition, hygiene, privacy, and basic health needs to those who have to wait along time in the ED (can cause increased pain in those with back pain or arthritis) Protecting skin integrity: assess the skin frequently and implement preventive interventions -promote clean, dry skin for incontinent patients, mobility techniques that decrease shearing forces Potential for medical errors of adverse events: -obtain essential and accurate medical history information -survey for wearing a medical alert bracelet or necklace on those with ALOC -two person search of patient belongings may have medication containers, name of the doc, name of the pharmacy, family contact person or med list -these help gather medication history to improve timeliness and accuracy of the information recorded -help determine the diagnosis and influence the overall emergency treatment plan -automated electronic tracking systems to locate patients Hospital acquired infection: older adults are more at risk for urinary tract or respiratory infections -those who are immune suppressed-especially those on chronic steroid therapy or immune modulators -wash hand and use hand sanitizer to prevent pathogen transmission

Near drowning

Previously defined as recovery after submersion -no longer used

Breathing

Primary survey: -after airway is secured - determines whether or not ventilatory efforts are effective not whether the patient is breathing - listen to breath sounds, evaluate chest expansion, respiratory effort, and any evidence of chest wall trauma or physical abnormalities - apneic patients and those with poor ventilatory effort need BVM ventilation for support until ET and vent is obtained -if CPR is needed- vent is disconnected and the patient is manually ventilated with a BVM -lung compliance can be assessed through sensing the degree of difficulty in ventilating the patient with the BVM Interventions: Assess breath sounds and respiratory effort Observe for chest wall trauma or other physical abnormality Prepare for chest decompression if needed Prepare to assist ventilations if needed

Circulation

Primary survey: -after effective ventilation is secured -adequacy of heart rate, blood pressure, and overall perfusion Common threats include cardiac arrest, myocardial dysfunction, and hemorrhage leading to a shock state -interventions are targeted at restoring effective circulation through cardiopulmonary resuscitation, hemorrhage control, IV vascular access with fluid and blood administration as necessary and drug therapy -IV with a large bore (16 gauge) -peripheral IV lines in the antecubital area -additional access may be needed with femoral, subclavian, or jugular sites using large-bore (8.5 Fr) CVC - IOs -LR and normal saline are the crystalloids of choice for resuscitation (hypertonic saline may be used in some situations such as head trauma) - fluids and blood should be warmed before administration to prevent hypothermia -anticipate the need for rapid blood component administration in a hemorrhagic shock state using packed red blood cells, FFP, a platelets to replace blood loss and prevent coagulopathy -priority is to stop the bleeding Interventions: monitor vital signs, especially blood pressure and pulse maintain vascular access with a large-bore catheter Use direct pressure for external bleeding; anticipate need for a tourniquet for sever, uncontrollable extremity hemorrhage and use of a hemostatic dressing

Airway / cervical spine

Primary survey: -anoxic brain injury without -____ is the highest priority intervention -nonrebreather mask is best for the spontaneous breathing patient -Bag-valve-mask with the appropriate airway adjunct and a 100% oxygen source for those who need ventilatory assistance -Glasgow coma scale of 8 or less requires ET tube and a vent Interventions: establish a patent airway by positioning, suctioning, and oxygen as needed Protect their cervical spine by maintaining alignment; use a jaw-thrust maneuver if there is a risk for spinal injury if the Glasgow coma scale is 8 or less or the patient is at risk for airway compromise, prepare for endotracheal intubation and mechanical ventilation

Exposure

Primary survey: -if evidence preservation is an issue, handle per policy -evidence may include articles of clothing, impaled objects, weapons, drugs, bullets -Examples of when evidence collection is needed: elder abuse, domestic violence, homicide, suicide, drug overdose, and assault -Once clothing is removed, hypothermia is a risk (temp less than 36) especially in those with burns and traumatic shock states Interventions: Remove all clothing for a complete physical assessment Prevent hypothermia (cover the patient with blankets, use heating devices, and infuse warm solutions) -Remove all clothing to allow for through assessment. Always careful to cut away clothing with scissors: -During resuscitation when rapid access to the patients body is critical -when manipulating a patient limbs to remove clothing could cause further injury - when thermal or chemical burns have cause fabrics to melt into the patients skin

Disability

Primary survey: -rapid baseline assessment of neurologic status -mnemonic AVPU A- alert V-responsive to voice P- responsive to pain U-unresponsive -Glasgow coma scale is also used (verbal response, eye opening, and motor response) -scored 3-15 Normal score is 15, lowest score is 3 (unresponsive) -metabolic abnormalities (hypoglycemia), hypoxia, neurologic injury and illicit drugs or alcohol can impair level of consciousness -frequently assess for rapid intervention Interventions: evaluate the patient's level of consciousness (LOC) using the GCS Reassess frequently

Primary Survey

The initial assessment of the trauma patient is called the ____ _____, which is an organized system to rapidly identify and effectively manage immediate threats to life. A- airway/cervical spine B-breathing C- circulation D- disability E- exposure Injuries identified in the primary survey are managed first Hemorrhage control move to highest priority if bleeding is present-- CAB instead of ABC

External hemorrhage

Primary survey: Circulation ___ ____ is quite obvious and is best controlled with firm, direct pressure on the bleeding site with thick, dry dressing material -Decreases blood flow for most wounds -tourniquets that occlude arterial blood flow to the injury should be used to manage severe, compressible bleeding from extremity trauma when direct pressure fails to achieve hemorrhage control; hemostatic dressings (speed the formation of a blood clot) are another essential tool to apply directly over the bleeding site in the management of life-threatening hemorrhage -internal hemorrhage is a more hidden complication that must be suspected in injured patients or those who present in a shock state B/P can quickly be estimated: Radial pulse: B/P at least 80 Femoral pulse: B/P at least 70 Carotid pulse: B/P at least 60 - by the time hypotension occurs compensatory mechanisms used by the body to attempt to maintain vital signs in a shock state have been exhausted

Moderate/severe hypothermia hospital care

Protect from further heat loss and handle gnetly to prevent vfib. -position in the supine position to prevent orthostatic changes in blood pressure from cardiovascular instability -follow standard ABCs -administer drugs with caution and/or spaced at longer intervals becuase metabolism is unpredictable -drugs can accumulate without obvious therapeutic eff3ect while the patient is cold but may become active and potentially lead to drug toxicity -withhold IV drugs except vasopressors until core remp is over 86 -Defibrillation attempts may be ineffective until the core temp is above 86 -one attempt is okay

Age related respiratory changes

Ribs less mobile Loss of elastic recoil Stiff alveoli Weakened respiratory muscles Decreased surface area for gas exchange Decreased cilia Decreased IgA Decreased O2 carrying capacity of the blood Decreased response to hypoxia/hypercapnia Total lung capacity stays about the same FEV drops

mild hypothermia

Shelter from the cold environment, remove all wet clothing, undergo passive or active external rewarming -apply warm clothing or blankets (passive) - heating blankets (monitor the skin every 15-30 min), warm packs, and convective air heater or warms to speed rewarming (active) -drink warm high carbohydrate liquids that do no contain alcohol or caffeine S&S: shivering, dysarthria (slurred speech), decreased muscle coordination, impaired cognition, diuresis

Third degree frost bite

Small blisters that contain dark fluid and an affected body part that is cool, numb, blue, or red and does not blanch -full-thickness and subacutaneous tissure necrosis occurs and requires debridement

D

The ED nurse receives communication about a major and catastrophic explosion that took place in a local city warehouse. How does the nurse classify this event? A.Epidemic B.Pandemic C.Internal disaster D.External disaster

D

The ED nurse who is just beginning a shift is assigned to care for four clients. Which client does the nurse assess first?

Hypothalamus

The ___ is the body's temperature regulation control center -both heat and cold sensitive neurons and receives different input from temperature sensors in the skin, spinal cord, abdominal viscera, and in or near the great vessels of the thorax -maintains the core body temperature to 37

A, B, C, D, E, G

The community health nurse is educating a client about frostbite prevention. Which factors will the nurse teach that are risk factors for developing frostbite? Select all that apply A. Dehydration B. Smoking history C. Previous frostbite D. Excessive fatigue E. Active smoker F. Wearing wool socks G. History of diabetes

A, C, D

The nurse is caring for a client who was attacked on a rooftop. The client was repeatedly kicked and then shot in the leg, which contributed to a fall from the five-story building. Which mechanism of injury with the nurse document? Select all that apply

B, C, D, E

The nurse is caring for a client who was brought to the emergency department after being found very ill on a mountain climb. Which assessment findings does the nurse recognize as symptoms of high-altitude pulmonary edema? select all that apply A. Respiratory acidosis B. Cyanosis of the lips C. Tachycardia at rest D. Bilateral crackles E. Persistant dry cough

A

The nurse is caring for a client who was camping overnight. The client is vomiting and has severe pain in the left foot. Blood pressure is 90/60, and the left lower leg is swollen and red. For which condition will the nurse assess as the priority? A.Snakebite B.Heat exhaustion C.Altitude sickness D. Brown recluse spider bite

C

The nurse is caring for a female client who has been seen at the ED multiple times recently for sexually transmitted infections and various physical concerns. When the client's boyfriend goes for coffee, what is the priority nursing action? A.Look for tattooing or 'branding' marks. B.Complete a psychosocial assessment. C.Ask, "Does anyone you know make you feel unsafe?" D.Follow agency policy for contacting local authorities to report the concern

D

The nurse is caring for an older adult client with heat exhaustion. Which assessment finding indicates to the nurse that the client may need hospitalization? A. Alert and oriented B. Reports nausea and weakness C. continues to sweat while being cooled D. Mucous membranes are dry and sticky

D

The nurse is performing triage after a mass shooting in a shopping mall. To which client does the nurse assign a black tag? A.21-year-old with confusion B.23-year-old with an open femur fracture C.26-year-old with uncontrollable anxiety D.29-year-old with full-thickness extremity burns

Pit viper (rattlesnakes, cottonmouths, copperheads)

Triangular head Two retractable curved fangs

Yellow tagged

Urgent Major injuries that require immediate treatment Ex: open fractures with a distal pulse and large wounds that need treatment within 30 minutes to 23 hours

Brown recluse patho

Venom causes cellular damage and impaired tissue integrity

Coral snake patho

Venom contains nerve and muscle toxins Blocks neurotransmission Toxic effects may be delayed up to 13 hours and the produce rapid clinical deterioration

pit viper pathophysiology

Venom immobilizes and aids in digestion of prey; may ne lethal Has local and systemic effects Enzymes break down human tissue proteins, alter tissue integrity

Black Widow Pathophysiology

Venom is neurotoxic; produces a syndrome known and latrodectism in which the venom causes neurotransmitter release from nerve terminals

D

Which client will the emergency nurse triage as the priority? A.21-year old with ankle fracture B.33-year old with with vomiting, flank pain, and a history of kidney stones C.49-year-old with profound weakness and 103° F fever D.59-year-old with sweating, jaw pain,, and pain in the left arm

C

While performing a history, a client becomes unconscious. What is the priority nursing action? A.Obtain vital signs. B.Assess the airway. C.Contact the ED physician. Evaluate the patient's level of consciousness.

Patient managment of chest tube drainage systems

___ ensure that the dressing on the chest around the tube is tight and intact. Depending on agency policy and the surgeons preference, reinforce or change loose dressings. Assess for difficulty breathing. Assess breathing effectiveness by pulse oximetry. Listen to breath sounds for each lung. Check alignment of trachea. Check tube insertion site for the condition of the skin. Palpate area for puffiness or crackling that may indicate subcutaneous emphysema. Observe site for signs of infection (redness, purulent drainage) or excessive bleeding. Check to see if tube eyelets are visible. Assess for pain and its location and intensity and administer drugs for pain as perscribed. Assist patient to deep breathe, cough, perform maximal sustained inhalations, and use IS. Reposition the patient who reports a burning pain in their chest.

Frost bite

____ ___ occurs when body tissue freezes and causes damage to tissue integrity- can be superficial, partial, or full thickness ____nip- a superficial cold injury that may produce pain, numbness, and pallor or a waxy appearance of the affected area by is easily relieved by applying warmth - common on the face, nose, finger, or toes- untreated can further develop -damage is determined after the part is thawed Interventions: recognition is essential to prevent further damage Hospital care: degrees of partial thickness to full thickness: rapid rewarding in a water bath at temp range of 104-108 -administer analgesics, IV opiates, IV rehydration, Ibuprofen 400mg-800mg PO every 8 hours to decrease thromboxane production -handle the injured areas gently and elevate them above the heart to decrease tissue edema -assess hourly for the development of compartment syndrome - early symptoms include increasing alteration in levels of comfort and paresthsias (compare with the unaffected extremity)- assess for pulses and muscle weakness -Destroys tissues and produces deep tetanus-prone wound- important to have a tetnus vaccine -apply loose nonadherent sterile dressings to the damages areas (avoid compression) -topical and systemic antibiotics can be used -debridement may be needed to evaluate tissue viability and provide wound management -amputation may be needed for those who develop gangrene or severe compartment syndrome Dry heat or massage should never be used- okay interventions include a rapid rewarming water bath to preserve tissue

Staff safety

____ ____ concerns center on the potential from transmission of a disease and on personal safety when dealing with aggressive, agitated, or violent patients and visitors -use of standard precautions -negative pressure room for TB or airborne pathogens-wear an air purifying respirator or specifically fitted facemask -security guard present -metal detectors for screening for weapons -strategically located panic buttons and remote door access controls to get help -Triage reception area with bullet proof glass and staff controlled door entry to the treatment area -canine units made up of specially trained officers and dogs to patrol high risk areas Hostile patient and visitor behaviors also pose injury risks to staff members. Be alert for volatile situations or people who demonstrate aggressive or violent tendencies through verbal abuse or acting out. Be sure to follow the hospital security plan, including identifying the nearest escape route, attempting de-escalation strategies before harm can occur, and notifying security and supervisory staff of the situation. Emergency visits resulting from gang or domestic violence can produce particularly hazardous conditions. Report all episodes of assaultive or violent behaviors through the hospital event documentation process so leaders and risk managers are aware of the scope of the problem and can plan safety strategies, including staff education, accordingly

Heat exhaustion

____ ____ is a syndrome resulting primarily from dehydration -caused by heavy perspiration and inadequate fluid and electrolyte intake during heat exposure over hours to days -profuse diaphoresis can lead to profound, even fatal dehydration and hyponatremia caused by excessive sodium lost in perspiration -if left untreated it can lead to heat stroke -Flu-like symptoms: headache, weakness, nausea, and or/vomiting -body temp may not be significantly elevated in this condition -may continue to perspire despite dehydration -assess for orthostatic hypotension and tachycardia -confusion -stop physical activity immediately and move to a cool place -use cooling measures- cold packs on neck, chest, abdomen, and groin -soak the victim is cool water or fan while spraying water on the skin -remove constrictive clothing -sports drinks or oral rehydration therapy can be provided. -drinking plain water can worsen the Na deficit- do not give salt tablets -if signs persist call an ambulance- -monitor vital signs, and rehydrate with IV NS if nausea or vomiting persists -draw blood for serum electrolytes -hospital admission is indicated for those with other health problems that are worsened by heat-related illness or those with severe dehydration and evidence of physiologic compromise

Pulmonary embolism

_____ ____ is a collection of particulate matter (solids, liquids, or air) that enters venous circulation and lodges in the pulmonary vessels. Large emboli obstruct pulmonary blood flow, leading to reduced gas exchange, reduced oxygenation, pulmonary tissue hypoxia, decreased perfusion, and potential death. -blood clot is the most common -Comes from a VTE or DVT (travels through the R side of the heart to the pulmonary artery, platelets collect which triggers the relaease of substances that cause blood vessel constriction- then causes pulmonary vessel constriction and pulmonary hypertension). The deoxygenated blood moves into arterial circulation causing hypoxemia Major risk factors: prolonged immobility, CVCs, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer, and trauma

Flail chest

_____ ____ is the result of fractures of at least two neighboring ribs in two or more places causing paradoxical chest wall movement (inward movement of the thorax during inspiration, with outward movement during expiration) -usually involves one side of the chest and results from blunt chest trauma (car crashes) -assess for underlying injuries -also can occur from bilateral separations of the ribs from their cartilage connections to each other anteriorly without an actual rib fracture -can occur as a complication of CPR -impaired gas exchange, coughing, and clearance of secretions are impaired -splinting further reduces the patients ability to exert the extra effort to breath and may contribute later to failure to wean -assess for dyspnea, cyanosis, tachycardia, and hypotension -pt is anxious, short of breath, and in pain WOB is increased -interventions: Humidified oxygen, pain management, promotion of lung expansion through deep breathing and positioning, and secretion clearance by coughing and tracheal suction -vent if needed, monitor ABG, hypoxemia/hypercapia=PEEP. -usually stabilized by positve presssure ventilation -monitor VS, fluid and electrolyte balance so hypovolemia or shock can be managed immediately

Ventilatory failure

a problem in oxygen intake (ventilation) & blood delivery (perfusion) that causes a ventilation-perfusion (V/Q) mismatch in which perfusion is normal but ventilation is inadequate. -Occurs when the chest pressure doesn't change enough to permit air movement into & out of the lungs. As a result, too litte oxygen reaches the alveoli & carbon dioxide is retained. Either inadequate oxygen intake or carbon dioxide retention leads to hypoxemia. -Usually results from any of these problems: a physical problem of the lungs or chest wall; a defect in the respiratory control center in the brain; or poor function of the respiratory muscles, especially the diaphragm. Causes of ventilatory failure are either extrapulmonary (involving nonpulmonary tissues but affecting respiratory function) or intrapulmonary (disorders of the respiratory tract) -Defined by a PaCO2 above 45 plus acidemia (pH less the 7.35) in pts who have otherwise healthy lungs

Rhabdomyolosis

can occur from lightening strikes circulation of by-products of skeletal muscle destruction that can lead to renal failure

ARDS

acute respiratory distress syndrome - severe, sudden lung injury caused by acute illness features: hypoxemia that persists even when 100% oxygen is given (refractory hypoxemia), decreased pulmonary compliance, dyspnea, noncardiac associated bilateral pulmonary edema, dense pulmonary infiltrates on X-ray -occurs after acute lung injury as a result of other conditions such as sepsis, burns, pancreatitis, trauma, and transfusion -trigger is systemic inflammatory response

Pentrating trauma

caused by an injury from sharp objects and projectiles Ex; wounds from knives, ice picks, bullets, pellets, metal, glass, shrapnel

Litchenberg figures or keraunographic markings

characteristic skin manifestation of lightning is the apperance of tree-like branching or ferning marks on the sking -not considered burns and are thought to be caused by the coagulation of blood cells in the capillaries

Bunt trauma

impact forces such as those sustained in a motor vehicle crash, a fall, or an assault with fists, kicks, or a baseball bat -blast effect from an exploding bomb can also cause

Second degree frost bite

large, clear fluid-filled blisters with partial-thickness skin necrosis

Brown recluse spiders

medium size, light brown, fiddle shaped mark from eyes down their back live in boxes, closets, basements, sheds, garages

Fourth degree frost bite

most severe -no blisters or edema -the part is numb, cold, and bloodless -full thickness necrosis extends into the muscle and bone -gangrene develops which may require amputation of the affected part (may develop over days to weeks)

Chest tube

placed in the pleural space to allow lung reexpansion -prevents air and fluid from returning to the chest Nursing care priorities: integrity of the system, promote comfort, ensure chest tube patency, and prevent complications