Professional Nursing 3 Exam 2: Rasmussen
Parkland Formula
(4mL/kg/% TBSA)
Priority Assessment/Interventions for Burns in ED
1. secure airway 2. support circulation and organ perfusion by fluid replacement 3.keep patient comfortable with analgesics 4. prevent infection through carful wound care 5. maintain body temperature 6. provide emotional support Assessment of the respiratory system is most critical to prevent life-threatening complications
Acute Phase
36 to 48 hours after injury when the fluid shift resolves until wound closure -continued assessment and maintenance of the cardiovascular and respiratory systems and toward GI and nutrition status, burn wound care, pain control, and psychosocial interventions
S/S of Flail Chest
Anxious, short of breath, in pain
Cardiac Damage Test
EKG
Delegation of Mechanical Ventilators
Five Rights of Delegation 1. right task 2. right circumstance 3. right person 4. right direction/communication 5. right supervision
Positioning to Prevent Contractures - Chart 26-6
Head and Neck: hyperextension-no pillow, place a towel roll under neck or should, neck splint Posterior Neck: flexion-turn head from side to side Upper Chest and Chest: should retraction-supine, fold towel under spine, between scapulae Lateral Trunk: flexion to uninvolved side-supine with arm on affected side over head Anterior Shoulder: abduction and external rotation-upper arms at 90 degrees of abduction from the lateral aspect of the trunk Posterior Shoulder: slight flexion and interior rotation-arms slightly behind midline Axilla: abduction with 10 to 15 degree, forward flexion and external rotation-support abducted arm with suspension from IV pole or beside table, axilla splint Elbow: extension and supination-keep joint in extended position Wrist: 30 to 45 degree of extension-use splint Fingers: 70 to 90 degree, extension-use a splint Ankle: 90 degree of dorsiflexion, padded footboard or splint with heels free of pressure Legs: 15 to 20 degrees of abduction-place small pillow between legs Hip: extension and neutral rotation-patient supine with lower extremity extended, trochanter roll, use foam edge along lateral aspect of thigh
Nurse's Role in Fire
Remove any patient or staff immediate danger or smoke Discontinue oxygen for patients who can breathe without it Maintain life support manually until removed for fire area Ambulatory patients walk to safety Ask ambulatory patients to assist pushing wheelchairs Move bedridden patients by bed, stretcher, or wheelchairs After everyone is out of danger seek to contain fire, close windows and doors and using ABC fire extinguisher Do not risk injury to yourself or staff
Rule of Nines
The body is divided into areas that are multiples of 9% Head = 4.5% anterior and 4.5% posterior Arms = 4.5% anterior and 4.5% posterior Legs = 9% anterior and 9% posterior Trunk = 18% anterior and 18% posterior
Tension Pneumothroax
air continues to enter pleural cavity space during inspiration and does not exit during expiration
Pneumothroax
air in the pleural space causing a loss of negative pressure in the chest cavity, a rise in chest pressure, and reduction in vital capacity which can lead to lung collapse
Rehab Phase of Burns
begins with wound closure and ends when patient achieves highest level of functioning -psychosocial/emotional needs prevention of scars and contractures, resumption of preborn activities, resuming work, family, and social roles visits form friends and short public appearances before discharge -patient education dressing changes, s/s of infection, drug regimen, proper use of prosthetic and positioning devices, correct application and care of pressure garments, comfort measures to reduce puritius, and follow-up appointment dates
Expected (and allowed) to die or dead (Class VI)
black tag
PTSD
can lead to multiple characteristic psychological and previously enjoyable events, detachment, rapid heart rate, and insomnia
Level II Trauma Center
capable of providing care to the vast majority of injured patients -play a significant role in injury management, education, prevention, and emergency preparedness planning
Level I Trauma Center
capable of providing leadership and total collaborative care for every aspect of injury, from prevention to rehab -offer professional and community education programs, conduct research, and participate in system planning -located in large teaching hospitals and severe dense population areas
Tension Pneumothroax: Interventions
chest tube therapy needle thoracostomy monitor chest tube drainage, vital signs, blood loss, intake and output assess patient response to chest tube and infuse fluids and blood as prescribed serial chest x-rays
Emergent Triage
condition poses an immediate threat to life or limb
acute respiratory distress syndrome (ARDS): complications
decreased gas exchange and oxygenation refractory hypoxemia
External Pacemaker
delivered through thoracic muscles requires large amounts of electricity used only in emergencies
acute respiratory distress syndrome (ARDS): care of a patient
determine if increased work of breathing is present (hyperpnea, noisy, respiration, cyanosis, pallor, and retraction) document sweating, respiratory efforts, and changes in mental status
Drug Therapy: Contractibility
digoxin (lanoxin)
Symptoms of PE
dyspnea sharp, stabbing chest pain apprehension, restlessness feeling of impending doom cough hemoptysis
Address before discharge of burns
early patient assessment financial assessment evaluation of family resources weekly discharge planning meeting psychological referral home care designation of caregiver develop teaching plan training for wound care rehab referral home assessment medical equipment public health nursing referral evaluation of community resources visit to referral agency re-entry programs long-term care placement environmental interventions auditory testing speech therapy prosthetic rehab
Temporary Pacemaker
energy provided by external battery pacl
Debriefing: Type I
entails bringing in critical incident stress debriefing (CISD) teams to provide sessions for small groups of staff to promote effective coping strategies
Internal Disaster
event occurring inside a health care facility or campus that could endanger the safety of patients or staff
External Disaster
event outside the facility or campus, somewhere in the community which requires the activation of the facility's emergency management plan
Intubation Procedures
expectations are to maintain a patent airway, provide a way to remove secretions, provide ventialtion and oxygen
Resuscitation Phase
first-phase begins at the onset of injury and continues for 24 to 48 hours 1. secure the airway 2. support circulation and organ perfusion by fluid replacement 3. keep comfortable with analgesics 4. prevent infection through wound care 5. maintain body temperature 6. provide emotional support
Chronic or Recurrent
fixed rate- constant rate demand mode- fires at preset rate inhibited-no fire triggered-triggered and fires
Acute Stress Disorder
focuses on dissociative symptoms such as numbing, reduced awareness, depersonalization, derealization, or amnesia, experienced within the first month of a traumatic event
Triage Nurse
gatekeeper in emergency care system -requires appropriate training and experience in both emergency nursing and triage decision-making concepts to develop and expert knowledge base and provide ongoing mentoring and quality improvement feedback -initiation of care while patient is on stretcher in hall of a crowded ED
Nonurgent
generally tolerate waiting several hours without a significant risk for clinical deterioration -sprains and strains, simple fractures, "cold" symptoms, and general skin rashes
Nonurgent or "walking wounded" (Class III)
green tag minor injuries can be managed in a delay fashion(generally more than 2 hours) closed fractures, sprains, strains, abrasions, and contusions
Flail Chest: Interventions
humidified oxygen, pain management, deep breathing and positioning, secretion clearance by suction or cough
Pulmonary Embolism: Interventions
implementing oxygen therapy administer anticoagulants or fibrinoytic therapy for tissue perfusion monitor response to interventions provide pychosocial support
Carbon Monoxide Poisoning S/S
increased threshold to visual stimuli increased blood flow to vital organs headache decreased cerebral function decreased visual acuity slight breathlessness tinnitus nausea drowsiness vertigo altered mental state confusion stupor irritability low BP increases irregular HR depressed ST-segment and dysrhythmias pale to reddish-purple skin soma convulsions cardiopulmonary instability death
Debriefing: Type II
involves an administrative review of staff and system performance during the event to determine whether opportunities for improvement in the emergency management plan exists
Ventilator Bundle Sets
keep HOB at least 30 degrees oral care done per policy (usually brush teeth every 8 hours, rinse every 2 hours) ulcer prophylaxis prevent aspiration pulmonary hygiene **These have greatly reduced VAP overall**
Epicardial Pacemaker
lead or leads are passed through the chest wall from an external power source and attached directly to the heart
Decreased Cardiac Output S/S
lightheadedness fatigue low urine output
Canadian Triage Acuity Scale (CTAS)
lists of descriptors are used to establish levels
Cardioversion
new-onset of AF, stable AF that is resistant to medication therapy if onset is more than 48 hours, must take anticoagulants for 4-6 weeks if onset is unknown a TEE can be performed
Level IV Trauma Center
offer advance life support care in rural or remote settings that do not have ready access to a higher level trauma center
Triage
organized system for sorting or classifying patients into priority levels, depending on illness or injury severity -highest acuity receives the quickest evaluation treatment, and prioritized resource utilization
Pulmonary Embolism: care of a patient
oxygen by nasal cannula or mask reassure correct measures are begin taken place in high fowler's apply tele obtain IV access continuous pulse ox resp status every 30 min assess cardiac status prescribed tests are obtained immediately examine thorax for petechiae administer anticoagulants assess for bleeding handle patient gently institute bleeding precautions
Flail Chest: Priority Assessment
paradoxical chest movement, dyspnea, cyanosis, tachycardia, and hypotension
Synchronous Intermittent Mandatory Ventilation (SIMV)
patient breaths between the machines preset breaths/minute rate the machine initially set on and SIMV rate of 12, the patient receives 12 breaths/minute respiratory rate is a combo of vent and spontaneous breaths provider usually decreases at 1 to 2 breaths/minute
Level III Trauma Center
primary focus is initial injury stabilization and patient transfer -some major injuries may be admitted for care
Aflutter
rapid regular beats that usually results in tachycardia
Emergent Triage (Class I)
red tag immediate life-threatening airway obstruction or shock
P Waves
represents artrial depolarizations indicates an ectopic focus has fired when the shape of the pwave changes
Pressure Support Ventilation (PSV)
respiratory effort is augmented by a predetermined pressure assist from the vent as weaning ensues the amount of pressure applied to inspiration gradually decreases another weaning method includes maintaining pressure but gradually decrease the vent's preset breaths/min
Urgent Triage
should be treated quickly but immediate threat to life does not exist at the moment -new onset of pneumonia, renal colic, complex lacerations not associated with major hemorrhage, displaced fractures or dislocations, and temp greater than 101
Event Resolution
staff and supply availability to meet ongoing operational needs -taking inventory and restocking the ED are high-priority assignments -teamwork and interprofessional collaboration between ED and central supply are essential to resolving stock availability
acute respiratory distress syndrome (ARDS): interventions
support and provide oxygen prevent complications, support lungs ventilation, positioning, ECMO antibiotics for infection vitamins C and E, N-acetylcysteine, nitric oxide, and surfactant replacement conservative fluid therapy
Vtach
sustained ventricular tachy, usually 140 to 180 breaths/minute or more
Signs of PE
tachypnea crackles friction rub tachycardia S3 or S4 diaphoresis low-grade fever petechiae chest and armpit decreased O2
T-Piece Technique
taken off vent for short periods of time (5 to 10 min) to allow spontaneous breathing vent is replaced with a T-piece or CPAP prescribed FiO2 may be higher for a patient on the T-piece than the vent weaning happens as the patient can tolerate progressively longer than a vent nighttime weaning is not attempted until the patient can maintain spontaneous respirations most of the day
Rehabilitation Phase
technically begins when wound closure and ends when patient achieves their highest level of functioning -emphasis is on psychosocial adjustments of the patients - prevention of scars and contractures -resumption of work, family, and social roles
Endocardial Pacemaker
threaded through a large central vein lodged in right ventricle, right atrium, or both
ET Tube
through nose and mouth into trachea rests 2 cm above the carnia verify placement by end-tidal carbon dioxide levels and chest xray priority actions is maintaining patent airway assess placement, cuff leak, breath sounds, indications of adequate gas exchange and oxygenation, and chest wall movement
Pain medications for burn victims
topical drugs -silver sulfadiazine -collagenase -mafenide -gentamicin sulfate -polymyxin -acticoat -polymem -aquacel ag -nitrofurazone -mepilex ag Broad-spectrum antibiotics
Medications for PE
unfractioned heparin low-molecular-weight heparin **enoxaprin (lovenox) or fondaparinux (arixtra)
Emergency Severity Index (ESI)
uses an algorithm that fosters rapid, reliable, and clinically pertinent categorization of patients into five groups, level I (emergent) to level V (Nonurgent)
Afib
wavy baseline with irregular ventricualr rhythm
Class II
yellow tag can wait a short time (30 minutes to 2 hours) open fractures with a distal pule and large wounds