AHN 447 Exam 3

What drugs may be used for muscle spasticity in patients with a SCI?

**tizanidine skeletal muscle relaxant helps control severe muscle spasticity This drug can cause severe drowsiness and sedation. **intrathecal baclofen (ITB) (Lioresal) therapy may be prescribed alternatively administered through a programmable pump that is implanted into the lower abdomen MONITOR FOR: sedation, fatigue, dizziness, and changes in mental status IF SUDDENLY WITHDRAWN, SEIZURES AND HALLUCINATIONS MAY OCCUR

When do the symptoms of a TIA typically resolve?

30-60 minutes

What is the difference between a complete and incomplete SCI?

A complete SCI is one in which the spinal cord has been damaged in a way that eliminates all innervation BELOW the level of the injury. Injuries that allow some function or movement BELOW the level of the injury are described as an incomplete SCI. Incomplete injuries are more common than complete SCIs.

How is multiple sclerosis (MS) diagnosed?

Abnormal CSF findings= elevated protein level & slight increase in WBC count CSF electrophoresis= reveals an increase in the myelin basic protein and the presence of increased immunoglobulins **IgG bands are seen in most pts with MS MRI of the brain and spinal cord demonstrates the presence of plaques MRI w/o contrast shows active lesions and reveals older lesions Assessment of CN function, coordination, strength, reflexes, and sensations are needed to diagnose MS

Explain care for the patient following a surgical spinal fusion.

After surgical spinal fusion, assess the pt's neurologic status and VS at least q hr for the first 4-6 hr and then, if the pt is stable, q 4 hr. Assess for complications of surgery, including worsening of motor or sensory function at or above the site of injury.

What postoperative interventions should the nurse implement for a patient after an anterior cervical diskectomy and fusion (ACDF)?

Assess Airway, Breathing, Circulation (FIRST PRIORITY) Check for bleeding and drainage at the incision site Monitor VS and neurologic status frequently Check for swallowing ability Assess the pt's ability to void Manage pain adequately Assist the pt with ambulation within a few hours of surgery, if he or she is stable

What assessments should the RN implement with a pt with a SCI?

Assess breath sounds every 2-4 hr during the first few days after SCI Monitor for changes in respiratory pattern or airway obstruction Perform respiratory assessment q 8-12 hr **O2 sat <92% and adventitious breath sounds may indicate pneumonia or atelectasis Evaluate HR, BP, and peripheral circulation **Multiple injuries may contribute to circulatory compromise from hemorrhagic hypovolemic shock Assess for indications of hemorrhage Assess LOC with GCS Assess pt's mobility and sensation Assess for bradycardia, hypotension, hypothermia, cardiac dysrhythmias **can occur b/c of loss of sympathetic input Monitor for s/s of autonomic. dysreflexia Assess for internal bleeding (abdominal distention, pain, paralytic ileus [may develop within 72 hrs of hospital admission]) Assess for swelling, redness, warmth, and decreased ROM **heterotropic ossification (HO) is a complication of prolonged immobility Observe for manifestations of neurogenic shock **This may occur within 24 hr after injury (especially in SCI above T6) Monitor pt at least hourly for: 1. Pulse ox <95% or symptoms of aspiration (stridor, garbled speech, or inability to clear airway) 2. Symptomatic bradycardia, including reduced level of consciousness and decreased urine output 3. Hypotension with SBP <90 or Map <65 NOTIFY HCP OF ANY OF THESE

What should you as the nurse teach a pt about prevention of heat-related illnesses?

Avoid alcohol and caffeine Prevent overexposure to the sun; use a sunscreen with an SPF of at least 30 with UVA and UVB protection Rest frequently and take breaks from being in a hot environment Plan to limit activity at the hottest time fo day Wear clothing suited to the environment. Lightweight, light-colored, and loose-fitting clothing is best 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

What should you teach a patient being discharged with a halo fixator?

Be aware that the weight of the halo alters balance. Be careful leaning forward or backward. Wear loose clothing. Bathe in the bathtub or take a sponge bath. Wash under the liner of the vest to prevent rashes or sores; use powders or lotions sparingly under the vest. Have someone change the liner if it becomes odorous. Support the head with a small pillow when sleeping to prevent unnecessary pressure and discomfort. Try to resume usual activities to the extent possible; keep as active as possible (the weight may cause weakness or fatigue). BUT avoid contact sports and swimming. Do NOT drive because vision is impaired with the device. Keep straws available for drinking fluids. Cut meats and other foods into small pieces to facilitate chewing and swallowing. Before going outside in cold temperature, wrap the pins with cloth to prevent the metal from getting cold. Have someone clean the pin sites as recommended by PHCP or hospital protocol. Observe the pin sites daily for redness, drainage, or loosening; report changes to PHCP. Increase fluids and fiber in the diet to prevent constipation. Use a position of comfort during sexual activity.

What discharge teaching should the nurse provide for a patient after an anterior cervical diskectomy and fusion (ACDF)?

Be sure that someone stays with the pt for the first few days after surgery Review drug therapy Teach care of the incision Review activity restrictions: **NO LIFTING **NO DRIVING UNTIL SURGEON PERMISSION **NO STRENUOUS ACTIVITIES Walk every day Call surgeon if symptoms of pain, numbness, or tingling worsen or if swallowing becomes difficult Wear brace or collar per surgeon's prescription

Why are patients with cervical cord injuries at risk for orthostatic hypotension?

Because of interrupted sympathetic innervation caused by the SCI, the blood vessels do not constrict quickly enough to push blood up into the brain. The resulting vasodilation causes dizziness or light-headedness and possible falls with syncope ("blackout").

What is blunt trauma? List some examples.

Blunt trauma results from impact forces Ex: motor vehicle crash, a fall, an assault with fists, kicks, or a baseball bat

What are some contributing factors to low back pain in older adults?

Changes in support structures: spinal stenosis, hypertrophy of the intraspinal ligaments, osteoarthritis, osteoporosis Changes in vertebral support and malalignment: scoliosis, lordosis Vascular changes: diminished blood supply to the spinal cord or cauda equina caused by arteriosclerosis, blood dycrasias intervertebral disk degeneration

What teaching should the RN educate a pt on preventing drowning?

Constantly observe people who cannot swim and are in or around water. Do not swim alone. Test the water depth before diving in head first; never dive in swallow water. Avoid alcoholic beverages when swimming and boating and while in proximity to water. Ensure that water rescue equipment such as life jackets, flotation devices, and rope is immediately available when around water.

What interventions should be performed for. a pt with heat-related illness?

Continue aggressive interventions to cool pt until RECTAL TEMP 102 F Give O2 by mask or NC IV access Administer 0.9% NS as prescribed Use a cooling blanket Do not give aspirin or any other antipyretics Insert a rectal probe to measure core body temperature q 15 min Insert an indwelling urinary drainage catheters Monitor VS frequently Administer muscle relaxants (benzodiazepines) if the pt begins to shiver Measure UOP and specific gravity Rapid cooling: --place ice packs on the neck, axillae, chest and groin --immerse the pt or wet the pt's body with cold water --fan rapidly to aid in evaporative cooling

What should the ER nurse assess for during the "D" of the ABCDE trauma resuscitation approach?

D= Disability The disability exam provides a rapid baseline assessment of neurological status. A simple method to evaluate LOC is the "AVPU" mnemonic A= Alert V= Responsive to Voice P= Responsive to Pain U= Unresponsive ALSO, you can use GCS to determine and document LOC GCS= pt is graded on eye opening, motor response, and verbal response Normal GCS= 15

What is the pt at risk for with a rib fracture?

DEEP CHEST INJURY (pulmonary contusion, pneumothorax, hemothorax)

What are the following drugs used for in the pt with a SCI? Dextran Atropine sulfate dopamine

Dextran, a plasma expander, may be used to increase capillary blood flow within the spinal cord and prevent or treat HYPOTENSION Atropine sulfate is used to treat bradycardia if the pulse rate falls below 50-60 bpm Dopamine is used for severe hypotension

How to prevent snakebites?

Do not keep venomous snakes as pets. Be extremely careful in locations where snakes may hide such as tall grass, rock piles, ledges and crevices, woodpiles, brush, boxes, and cabinets. Snakes are most active on warm nights. Don protective attire such as boots, heavy pants, and leather gloves. When walking or hiking, use a walking stick or trekking poles. Inspect suspicious areas before placing hands and feet in them. Do not harass snakes you may encounter. Striking distance can be up to two thirds the length of the snake. Even young snakes pose a threat; they are capable of envenomation from birth. Be aware that newly dead or decapitated snakes can inflict a bite for up to an hour after death because of persistence of the bite reflex. Do not transport the snake with the victim to the medical facility. Take a picture of the snack instead.

A critically injured trauma pt with an active hemorrhage enters the ER. How would this pt be classified in the triage system?

EMERGENT

A patient enters the ER with crushing substernal chest pain, SOB, and diaphoresis. How would this patient be classified in the triage system?

EMERGENT

During a mass triage, what color tags would the emergent, urgent, and nonurgent patients have?

Emergent= RED TAG Urgent= YELLOW TAG Nonurgent= GREEN TAG Expectant= BLACK TAG (expected and allowed to die)

What should you teach the pt with MS?

Emphasize the importance of avoiding rigorous activities that increase body temperature. **Increased body temperature may lead to increased fatigue, diminished motor ability, and decreased visual acuity. Teach he pt and family to keep the home environment as structured and free from clutter as possible. Teach the pt the importance of planning activities and allowing sufficient time to complete activities. An eye patch that is alternated from eye to eye every few hours usually relieves diplopia (double vision). Provide written instructions as a resource for the patient and caregivers at home. Emphasize the importance of avoid overexertion, stress, extremes of temperature (fever, hot baths, use of sauna baths, and hot tubs, overheating, and excessive chilling), humidity, and people with infections.

What is the highest-priority intervention when managing a trauma patient?

Establishing a patient airway is the highest-priority intervention when managing a trauma unless massive, life-threatening external hemorrhage.

What exercises should you teach to a patient with chronic or postoperative back pain?

Extension Exercises: 1. Stomach lying- lie face down with a pillow under your chest; lift legs straight up (alternate legs) 2. Upper trunk extension: lie face down with your arms at your sides and life your head and neck 3. Prone push-ups: lie face down on a mat and, keeping your body stiff, push up to extend your arms Flexion Exercises: 1. Pelvic tilt- lying on your back with your knees bent, tighten your abdominal muscles to push your lower back against the mat 2. semi-sit ups- lying on your back with your knees bent, raise your upper body at a 45 degree angle and hold this position for 5-10 seconds 3. Knee to chest- lying on your back with your knees bent, tighten your abdominal muscles to push your lower back against the mat. Now bring one or both knees to your chest and hold this position for 5-10 seconds

What is flail chest?

Flail chest is the result of fractures of at least 2 neighboring ribs in 2 or more places causing PARADOXICAL CHEST WALL MOVEMENT (inward movement of the thorax during inspiration, outward movement during expiration) It usually involves one side of the chest and results from blunt chest trauma.

What should teach a pt with a SCI about aging?

Follow guidelines for adult vaccination, particularly the flu and pneumococcus vaccinations. **Respiratory complications are the most common cause of death after SCI! For women, have Pap smears and mammograms as recommended. Take measures to prevent osteoporosis, such as increasing calcium intake, avoiding caffeine, and not smoking. Exercise against resistance can maintain muscle strength and slow muscle loss. **Women older than 50 yo often lose bone density, which can result in fractures. Practice meticulous skin care, including frequent repositioning, using pressure-reduction surfaces in bed and chairs/wheelchairs, and applying skin protective products. **As the person ages, skin becomes dry and less elastic, predisposing the patient to pressure injuries. Take measures to prevent constipation, such as drinking adequate fluids, eating a high-fiber diet, adding a stool softener or bowel stimulant daily, and establishing a regular time for bowel elimination. **Constipation is a problem for most pts with SCI. Modify activités if joint pain occurs; use a powered rather than a manual wheelchair. **Arthritis occurs in more than half of people older than 65 years old. Patients with SCI are more likely to develop arthritis as a result of added stress on the upper extremities when using a wheelchair.

What GCS score requires intubation?

GCS < 8 ETT & mechanical ventilation

What are the 5 primary mechanisms of injury for a SCI?

Hyperflexion--a sudden and forceful acceleration of the head forward, causing extreme flexion of the neck; ex: head-on motor vehicle collision Hyperextension--the head is suddenly accelerated and then decelerated; ex: vehicle collision where the vehicle is struck from behind or during falls when the pt's chin is struck Axial loading or vertical compression--vertical compression; ex: diving accidents Excessive rotation--turning of the head beyond normal range Penetrating trauma--ex: GSW

What should you do if a SCI patient begins experiencing autonomic dysreflexia (AD)?

If the pt experiences AD, raise the HOB IMMEDIATELY to help reduce the BP. Notify HCP IMMEDIATELY for drug therapy to quickly reduce BP. Determine the cause of AD and treat it promptly. If bladder extended, catheterize pt. Check catheter for kinks or obstruction. Assess for UTI or bladder stones Check for fecal impaction or other colorectal irritation Examine skin for new or worsening pressure injury symptoms Monitor BP q 10-15 minutes!!! Give nifedipine or nitrate as prescribed to lower BP as needed Check room temperature and bed coverings and adjust pt for comfort ***PRIORITY= PLACING PT IN A SITTING POSITION

What is the one exception to the ABCDE trauma resuscitation approach?

In the presence of massive, uncontrolled external bleeding, hemorrhage control techniques are the highest priority intervention In this situation, the sequence of priorities shifts to CAB, whereby the initial focus of resuscitation is to effectively stop the active bleeding.

How should you inspect for CSF leak in the pt who is postop following back surgery?

Inspect the surgical dressing for blood or CSF Clear drainage= CSF Blood and CSF may be mixed on the dressing, with the CSG being visible as a "halo" around the outer edges the dressing The loss of a large amount of CSF may cause the pt to report a sudden headache Report signs of any drainage on the dressing to the surgeon immediately Bulging at the incision site may be d/t a CSF leak or hematoma, both of which should be reported to the surgeon

When is intraosseous access a necessary approach?

Intraosseous access is an excellent initial approach for critically ill patients when veins cannot be rapidly accessed by the resuscitation team

What is the mechanism of injury (MOI)?

It describes how the pt's traumatic event occurred Ex: high-speed motor vehicle crash, a fall from a standing height, GSW to the torso

What is the drug ziconotide (Prialt) used for?

It is a drug that can be given for severe chronic back pain It is given by intrathecal (spinal) infusion with a surgically implanted pump selectively blocks calcium channels on nerves that usually transmit pain signals to the brain can be given with opioid analgesics BUT should NOT be given to pts with severe mental health/behavioral problems because it can cause psychosis If symptoms such as hallucinations or delusions occur, teach pts to stop the drug immediately and notify HCP.

What are the clinical manifestations of a pulmonary contusion?

MAY BE ASYMPTOMATIC AT FIRST decreased breath sounds or crackles and wheezes over the affected area bruising over the injury dry cough tachycardia tachypnea dullness to percussion bloody sputum initial CXR normal--CXR with opacities after several days *can lead to respiratory failure

What drugs are used to treat multiple sclerosis?

Many of these drugs are immunomodulators or antiinflammatory meds that can alter immunity and make patients vulnerable to secondary infection. Interferon beta-1a Interferon beta-1b (Betaseron, Extavia) Glatiramer acetate (Copaxone) Mitoxantrone (Novantrone) Natalizumab (Tysabri) Fingolimod (Gilenya), teriflunomide (Aubagio), dimethyl fumarate (Tecfidera) Corticosteroids (methylprednisone [Solu-Medrol])

What clinical manifestations are seen with hypothermia?

Mild (90-95 F): shivering, dysarthria (slurred speech), decreased muscle coordination, impaired cognition, diuresis (caused by shunting of blood to major organs) Moderate (82.4-90 F): muscle weakness, increased loss of coordination, acute confusion, apathy, incoherence, possible stupor, decreased clotting (caused by impaired platelet aggregation and thrombocytopenia) Severe (<82.4 F): bradycardia, severe hypotension, decreased RR, cardiac dysrhythmias (possible V fib or asystole), decreased neurologic reflexes, decreased pain responsiveness, acid-base imbalance

What interventions should you implement as the RN of a pt with flail chest?

Monitor the pt's VS and F&E balance (to intervene if shock or hypovolemia occurs) If he/she has a lung contusion, provide O2 prn and give IV fluids as prescribed Assess for and relieve pain with prescribed analgesics Provide psychosocial support

What should the RN know and implement for the pt in a halo fixator?

NEVER move or turn the pt by holding or pulling on the halo device. Do NOT adjust the screws holding the device in place. Check the skin frequently. Pressure is avoided if ONE finger can be inserted easily between the jacket and the pt's skin. Monitor the pt's neurological status for changes in movement or decreased strength. A special wrench is needed to loosen the vest in emergencies (ex: CPR). Tape the special wrench to the vest for easy access. Do NOT use sharp objects to relieve itching under the vest; skin damage and infection will slowly grow. Hospital policy is followed for pin-site care (may include use of NS). Vaseline dressings may also be used. Monitor for s/s of infection (ex: fever, purulent drainage from pin sites) and report any changes to HCP immediately. Provide d/c teaching.

A pt enters the ER with a general skin rash. How would this pt be classified in the triage system?

NONURGENT

A pt enters the ER with a simple fracture. How would this pt be classified in the triage system?

NONURGENT

A pt enters the ER with an ankle sprain. How would this pt be classified in the triage system?

NONURGENT

A pt enters the ER with cold symptoms. How would this pt be classified in the triage system?

NONURGENT

What should you teach the pt diagnosed with MS about fingolimod (Gilenya)?

PO immodulator This drug can be taken with or without food. Teach pts to monitor their HR every day b/c this drug can cause BRADYCARDIA, especially within the first 6 hrs after taking it. This drug inhibits immune cells and have antioxidant properties that protect brain and spinal cord cells MOST COMMON SIDE EFFECTS= FACIAL FLUSHING & GI DISTURBANCES Lab monitoring b/c this drug can cause a decrease in WBC count (predisposing pt to infection)

What is penetrating trauma? List some examples.

Penetrating trauma is caused by injury from sharp objects and projectiles Ex: wounds from knives, ice picks, bullets, pellets, fragments of metal or glass

What position should you place the pt in who has a pulmonary contusion?

Place the pt in moderate-Fowler's position. When side-lying, the "good lung down" position may be helpful.

How can you estimate SBP in an emergency situation?

Presence of a radial pulse= BP at least 80 mmHg systolic Presence of a femoral pulse= BP at least 70 mmHg systolic Presence of a carotid pulse= BP at least 60 mmHg systolic Remember: Head to Toe (60-70-80)

What are patients taking Natalizumab for MS at risk for developing?

Progressive multifocal leukoencephalopathy (PML)--an opportunistic viral infection PML is confirmed by MRI and examining CSF for causative pathogen. This drug causes damage to hepatic cells. **Monitor liver enzymes!!!

What ABG analysis would you expect to see in a pt with tension pneumothorax?

RESPIRATORY ALKALOSIS HYPOXIA

During the final component of the ABCDE resuscitation approach (Exposure), what should the nurse do?

Remove all clothing to allow for thorough assessment ALWAYS carefully cut away clothing with scissors Once clothing is removed, hypothermia (body temp < 95 F (36 C)) poses a risk to injured patients, especially those with burns and traumatic shock states

What is the nurse's role in the event of a facility fire?

Remove any pt or staff from immediate danger of the fire or smoke. D/c O2 for all pts who can breathe without it. For pts on life support, maintain their respiratory status manually until removed from the fire area. Direct ambulatory pts to walk to a safe location. If possible, ask ambulatory pts to help push wheelchair pts out of danger. Move bedridden pts from the fire area in bed, by stretcher, or in a wheelchair; if needed, have one or two staff members move pts on blankets or carry them. After everyone is out of danger, seek to contain the fire by closing doors and windows and using an ABC extinguisher if possible. Do not risk injury to yourself or staff members while moving patients or attempting to extinguish the fire.

How do you clear the airway of a pt with a cervical spine injury?

Respond by protecting the trauma pt's cervical spine by manually aligning the neck in a neutral, in-line position and using a jaw-thrust maneuver when establishing an airway.

What is spinal shock?

Spinal shock occurs immediately as the cord's response to the injury. The patient has complete but TEMPORARY loss of motor, sensory, reflex, and autonomic function that often lasts less than 48 hours but may continue for several weeks.

What interventions should be implemented for the pt with a SCI?

Suction pt as needed Encourage IS with non-mechanically ventilated pt Teach the pt who is tetraplegic to coordinate his or her cough effort with an assistant Maintain hydration through IV fluids Be sure to reduce potential causes for autonomic dysrelexia (AD) by preventing bladder and bowel distention, managing pain and room temperature, and monitoring for early VS changes. Regardless of the level of SCI, keep the pt in proper body alignment to prevent further cord injury or irritability. **Devices such as traction, orthoses, or collars may be used. Log roll pt to change position from supine to side lying Until the spinal column is stabilized, a jaw-thrust maneuver is preferable to a head-tilt maneuver to open the airway should the pt need airway intervention.

What are the main causes and risk factors for autonomic dysreflexia?

The causes of AD are typically GI, gynecologic-urologic (GU), and vascular stimulation. RFs: bladder distention UTI epididymitis or scrotal compression bowel distention bowel impaction irritation of hemorrhoids pain tight clothing contact with hard or sharp objects temperature fluctuations

What should the nurse teach the pt with MS about administering the interferons and glatiramer acetate at home?

The interferons and glatiramer acetate are subQ injections. Teach pts how to give and rotate the site of interferon-beta and glatiramer acetate injections b/c local injection site reactions are common. Teach pts receiving these drugs to avoid crowds and people with infections. Notify HCP if any s/s of infection occurs.

What is considered the level of injury in a pt with a SCI?

The level of injury is the LOWEST neurological segment with intact or normal motor AND sensory function.

What is the purpose of administering mitoaxantrone (Novantrone)

This is a chemotherapy drug. reduces neurologic disability decreases the frequency in clinical relapses in patients with secondary progressive, progressive-relapsing, or worsening relapsing-remitting MS

A pt enters the ER with a new onset of pneumonia. How would this pt be classified in the triage system?

URGENT

A pt enters the ER with a temperature >101 F (38.3 C). How would this pt be classified in the triage system?

URGENT

A pt enters the ER with a displaced fracture. How would this pt be classified in the triage system?

URGENT dislocations are also classified as urgent HOWEVER, simple fractures are classified as nonurgent

What would you teach a patient about preventing low back pain and injury?

Use safe maual handling practices, with specific attention to bending, lifting, and sitting. Assess the need for assistance with your household chores or other activities. Participate in a regular exercise program, especially one that promotes back strengthening, such as swimming and walking. Do not wear high-heeled shoes. Use good posture when sitting, standing, or walking. Avoid prolonged sitting or standing. Use a footstool or ergonomic chairs and tables to lessen back strain. Keep weight within 10% of ideal body weight. Ensure adequate calcium intake. Consider Vitamin D supplementation if serum levels are low. Stop smoking.

What is multiple sclerosis?

a chronic disease caused by immune, genetic, and/or infectious factors that affects the myelin and nerve fibers of the brain and spinal cord Diffuse random or patchy areas of plaque in the white matter of the CNS are the definitive finding Myelin is responsible for the electrochemical transmission of impulses between the brain and spinal cord and the rest of the body; demyelination can result in slowed or stopped impulse transmission remissions and exacerbations

What does the emergent triage imply?

a condition exists that poses an immediate threat to life or limb

What is a tension pneumothorax?

a life-threatening complication of pneumothorax in which air continues to ENTER the pleural space during iNSPIRATION but does NOT EXIT during EXPIRATION This leads to air collecting under pressure, completely collapsing the lung and compressing blood vessels, which limits blood return. This process leads to decreased filling of the heart and reduced cardiac output .

What should the ER nurse assess for/perform during the "C" of the ABCDE trauma resuscitation approach?

adequacy of HR, BP, and overall perfusion status CRT hemorrhage control IV access with fluid, blood, & drug administration **Common threats to circulation include cardiac arrest, myocardial dysfunction, and hemorrhage leading to shock state.

What is a pneumothorax?

air in the pleural space causing a loss of negative pressure in the chest cavity, which can lead to a COLLAPSED LUNG most often caused by blunt trauma The pneumothorax can be open or close. Open= [pleural cavity is exposed to outside air, as through an open wound in the chest wall Closed= when a pt with COPD has a spontaneous pneumothorax

What is autonomic dysreflexia?

aka autonomic hyperreflexia a potentially life-threatening condition in which noxious visceral or cutaneous stimuli cause a sudden, massive, uninhibited reflex sympathetic discharge in people with high-level SCI

What is hemothorax?

bleeding into the chest cavity A simple hemothorax is a blood loss of less than 1,000 mL into the chest cavity A massive hemothorax is a blood loss of more than 1,000 mL

What clinical manifestations are seen with heat stroke?

body temp >104 F (40 C) hot and dry skin (may or may not sweat) mental status changes (acute confusion, bizarre behavior, anxiety, loss of coordination, hallucinations, seizures, agitation, coma) VS changes (hypotension, tachycardia, tachypnea) electrolyte imbalances (sodium and K+) decreased renal function (oliguria) coagulopathy (abnormal clotting) pulmonary edema (crackles) **Cardiac troponin I is frequently elevated during nonexertional heat-related illnesses

What does the nonurgent triage imply?

can generally tolerate waiting several hours for health care services without a significant risk for clinical deterioration

How is pneumothorax treated?

chest tube needle thoracostomy (a large-bore needle is inserted by the HCP into the 2nd IC space in the midclavicular line of the affected side; a cx tube is then placed in the 4th IC space and attached to a water-seal drainage) --This is used for tension pneumothorax Pain control Pulmonary hygiene Open thoracotomy is needed when there is initial blood loss of 1,000 mL from the chest or persistent bleeding at the rate of 150-200 mL/hr over 3-4 hr

What should the ER nurse assess for during the "B" of the ABCDE trauma resuscitation approach?

determine whether or not ventilatory efforts are effective auscultate breath sounds evaluate chest expansion, respiratory effort, and any evidence of chest wall trauma or physical abnormalities **Both apneic pts and those with poor ventilatory effort need BVM ventilation for support until endotracheal intubation is performed and a mechanical ventilator is used.

What are rib fractures most often caused by?

direct blunt trauma to the chest wall (The force applied to the ribs fractures them and drives the bone ends into the chest)

How is external hemorrhage best controlled?

firm, direct pressure on the bleeding site with thick, dry dressing material the priority intervention is to ALWAYS STOP THE BLEEDING--before using blood products

What are some secondary injuries for a SCI?

hemorrhage ischemia hypovolemia impaired tissue perfusion from neurogenic shock local edema

What environmental factors put a patient at risk for heat-related illnesses?

high environmental temperatures (>95 F (35 C)) high humidity (>80%)

What are some postoperative complications of anterior cervical diskectomy and fusion (ACDF)?

hoarseness d/t laryngeal injury; may be temporary or permanent temporary dysphagia; may last few days to several months esophageal, tracheal, or vertebral artery injury wound infection injury to the spinal cord or nerve roots dura mater tears with associated CSF leaks pseudoarthrosis caused by nonunion of fusion graft and screw loosening if a fusion was performed

What is entailed in the second survey?

insertion of gastric tube for decompression of the GI tract to prevent vomiting and aspiration insertion of a urinary catheter to allow careful measure of urine output preparation for diagnostic studies comprehensive head-to-toe assessment splints applied to fractures

Paraplegia

involves ONLY the LOWER extremities, as seen in lower thoracic and lumbosacral injuries or lesions

Tetraplegia (or quadriplegia)

involves all 4 extremities

What prescribed drugs increase a pt's risk for heat-related illnesses?

lithium neuroleptics beta-adrenergic blockers anticholinergics ACE inhibitors diuretics

When should you notify HCP of excessive drainage with a chest tube?

more than 70 mL/hr >200 mL/hr can signal bleeding complication

What are the key features of multiple sclerosis?

muscle weakness and spasticity fatigue intention tremors dysmetria (inability to direct or limit movement) paresthesia hypalgesia (decreased sensitivity to pain) ataxia (decreased motor coordination) dysarthria (slurred speech) dysphagia (difficulty swallowing) diplopia (double vision) nystagmus (involuntary eye movements) scotomas (changes in peripheral vision) decreased vision and hearing acuity tinnitus, vertigo bowel and bladder dysfunction alterations in sexual function cognitive changes (memory loss, impaired judgement) depression **also, hyperactive DTRs, positive BABINSKI'S REFLEX, absent abd reflexes

What health status factors increase a pt's risk for heat-related illnesses?

obesity heart disease fever infection strenuous exercise seizures mental health disorders all degrees of burns (even sunburn)

What is the pathophysiology of a pulmonary contusion?

occurs most often by rapid deceleration during car crashes Hemorrhage and edema occur in and between the alveoli, reducing both lung movement and the area available for gas exchange. Localized inflammation can cause further damage. The pt becomes hypoxemia and dyspneic (SOB).

Who is at the highest risk for heat-related illnesses?

older adults (who have less body fluid volume and can easily become dehydrated) people with mental health/behavioral health conditions those who work outside homeless individuals users of illicit drugs athletes who engage in outdoor sports members of the military stationed in hot climates

How might the older adult present with a heat-related illness?

orthostatic hypotension tachycardia acute confusion

What clinical manifestations are most often seen with a flail chest?

paradoxical chest movement SOB cyanosis tachycardia hypOtension pain *work of breathing is increased from the paradoxical movement of the involved segment of the chest wall

What clinical manifestations would you expect to see in a pt with a hemothorax?

percussion on the involved side produces a dull sound respiratory distress diminished breath sounds

What are some complications of the use of halo fixators?

pin loosening local infection scarring osteomyelitis (cranial bone infection) subdural abscess instability

What does the urgent triage imply?

pt should be treated quickly but that an immediate threat to life does NOT exist at the moment Reassessment is needed

What are the clinical manifestations of pneumothorax (any type)?

reduced or absent breath sounds of the affected side on auscultation hyperresonance on percussion prominence of the involved side of the chest, which moves poorly with respirations open pneumo= tracheal deviation TOWARDS pneumothorax closed pneumo= tracheal deviation AWAY FROM pneumothorax --Tension pneumothorax (additional assessment findings): extreme respiratory distress and cyanosis distended neck veins hemodynamic instability

What are the clinical manifestations of autonomic dysreflexia?

sudden, significant rise in systolic and diastolic blood pressure accompanied by bradycardia profuse sweating ABOVE the level of lesion--especially in the face, neck, and shoulders goosebumps above or possibly below the level of the lesion flushing of the skin ABOVE the level of the lesion blurred vision spots in the patient's visual field nasal congestion onset of severe, throbbing headache flushing about the level of the lesion with pale skin below the level of the lesion feeling of apprehension

How is pneumothorax diagnosed?

symptoms CT scans CXR US

What is a transient ischemic attack (TIA)?

temporary neurologic dysfunction resulting from a brief interruption in cerebral blood flow typically a warning sign for an upcoming ischemic stroke

What is the primary survey?

the initial assessment of the trauma patient an organized system to rapidly identify and effectively manage immediate threats to life resuscitation efforts occur simultaneously with each element of the primary survey ABCDE A= Airway/Cervical spine B= Breathing C= Circulation D= Disability E= Exposure

What is a halo fixator?

the most commonly used device for immobilization of the CERVICAL SPINE This static device is affixed by four pins (or screw) into the outer aspect of the skull worn for 8-12 WEEKS!!!

How is hemothorax diagnosed?

visible on CXR confirmed with thoracentesis