CM 4 Review

A&Ox4 (also AAOx4 - awake,alert and oriented)

refers to someone who is alert and oriented to person,place, time and event. Does the person being evaluated understand who they are, where they are, approximate date or part of the day, and what is happening?

Blunt Trauma

results from impact forces such as those sustained in a motor vehicle crash; a fall; or an assault with fists, kicks, or a baseball bat.

Basic Metabolic Panel (BMP)

series of blood tests that measure certain components of blood, including glucose, calcium, and electrolytes

Compensatory Stage of Shock

stage of shock occurs when MAP decreases by 10 to 15 mm Hg from baseline. Kidney and hormonal compensatory mechanisms are activated because cardiovascular responses alone are not enough to maintain MAP and supply oxygen to vital organs. triggers the release of renin, antidiuretic hormone (ADH), aldosterone, epinephrine, and norepinephrine to start kidney compensation. Signs and symptoms of this stage include changes resulting from decreased tissue perfusion. Subjective changes include thirst and anxiety. Objective changes include restlessness, tachycardia, increased respiratory rate, decreased urine output, falling systolic blood pressure, rising diastolic blood pressure, narrowing pulse pressure, cool extremities, and a decrease in oxygen saturation. Comparing these changes with the values and observations obtained earlier is critical to identifying this stage of shock.

Progressive Stage of Shock

stage of shock occurs when there is a sustained decrease in MAP of more than 20 mm Hg from baseline. Compensatory mechanisms are functioning but can no longer deliver sufficient oxygen, even to vital organs. Vital organs develop hypoxia, and less vital organs become anoxic (no oxygen) and ischemic (cell dysfunction or death from lack of oxygen).

Refractory

stage of shock occurs when too much cell death and tissue damage result from too little oxygen reaching the tissues. Vital organs have extensive damage and cannot respond effectively to interventions, and shock continues. So much damage has occurred with release of metabolites and enzymes that damage to vital organs continues despite interventions. The sequence of cell damage caused by the massive release of toxic metabolites and enzymes is termed multiple organ dysfunction syndrome (MODS). Signs are a rapid loss of consciousness; nonpalpable pulse; cold, dusky extremities; slow, shallow respirations; and unmeasurable oxygen saturation. Therapy, including fluid replacement, is not effective in saving the patient's life, even if the cause of shock is corrected and MAP temporarily returns to normal.

Level II Trauma Center

typically located in community hospitals • Provides care to most injured patients • Transfers patient if needs exceed resource capabilities

Level III Trauma Center

typically located in community hospitals • Stabilizes patients with major injuries • Transfers patient if needs exceed resource capabilities

12ml/hr

The pharmacy provides milrinone (Primacor) 50mg in 200ml D5W. What is the correct rate for a milrinone (Primacor) infusion of 0.5mcg/kg/min for a client who weighs 220 pounds? 10ml/hr 12ml/hr 8ml/hr 15ml/hr

Glascow Coma Scale (GCS)

an evaluation tool used to determine level of consciousness, which assigns point values for eyes, verbal and motor functions. 3 being the worse score and 15 being the best. 7 or below is considered to be comatose

D

"Members of the team know their boundaries and ask for help before resuscitation attempt worsens." Match this statement with the most appropriate element of team dynamics listed. A. Knowledge sharing B. Summarizing and reevaluation C. Constructive intervention D. Knowing your limitations

20

A sustained ICP of greater than __ mm Hg is considered detrimental to the brain because neurons begin to die. Periodic increases in pressure occur with straining during defecation, coughing, or sneezing but do not harm the uninjured brain.

D

1. The nurse is caring for a client with hypovolemic shock. Which new assessment finding indicates to the nurse that interventions are currently effective? A. Oxygen saturation remains unchanged. B. Core body temperature has increased to 99°F (37.2°C). C. The client correctly states the month and year. D. Serum lactate and serum potassium levels are declining.

A

1. What is the nurse's priority action for the unconscious patient who is breathing who has been brought to the ED? A. Assess breath sounds and respiratory efforts B. Establish vascular access with a large-bore catheter C. Remove clothing to perform a complete physical assessment D. Evaluate level of consciousness (LOC) using the Glasgow Coma Sale (GCS)

A,B,D,E,H

A client in the progressive stage of hypovolemic shock has all of the following signs, symptoms, or changes. Which signs will the nurse attribute to ongoing compensatory mechanisms? Select all that apply. A. Increasing pallor B. Increasing thirst C. Increasing confusion D. Increasing heart rate E. Increasing respiratory rate F. Decreasing systolic blood pressure G. Decreasing blood pH H. Decreasing urine output

B

2. A client is admitted with a suspected cervical spinal cord injury. What is the nurse's priority action for this client? A. Assess cardiac sounds. B. Manage the client's airway. C. Check oxygen saturation level. D. Perform a neurologic assessment.

A

2. After assessing four clients, which will the triage nurse identify to be seen first in the ED? A. Client with fever of 101.2°F B. Client who reports slurred speech C. Client who reports bilateral ear pain D. Client with urinary burning and frequency

A

2. The nurse is caring for a patient in the initial stage of hypovolemic shock. What assessment data will the nurse anticipate? A. Heart rate 118 beats/min B. 2+ pedal pulses C. Bilateral fine crackles in lung bases D. BP change from 100/60 to 100/40 mm Hg

Lactic acid (lactate) (arterial)

3-7 mg/dL 0.3-0.8 mmol/L (arterial)

A,C,D

3. The nurse is assessing a client with septic shock. What assessment data indicate a progression of shock? Select all that apply. A. BP change from 86/50 to 100/64 mm Hg B. Heart rate change from 98 to 76 beats/min C. Cool and clammy skin D. Petechiae along the gum line E. Urine output 45 mL/hr

A

What priority complication would the nurse suspect when assessing a patient with an electrical burn that has an entrance wound on the right shoulder and an exit wound through the left side of the ribs? A. Cardiac dysrhythmias B. Fractured ribs C. Kidney failure D. Gastrointestinal ileus

C

On entry to the ED of a client who fell from a roof, what is the nurse's priority action? A. Place nasal cannula to administer oxygen. B. Apply pressure to small bleeding wounds. C. Assess airway and stabilize cervical spine. D. Initiate large-bore IV to infuse normal saline.

Cushing triad

a classic but very late sign of increased ICP, consists of severe hypertension, a widened pulse pressure (increasing difference between systolic and diastolic values), and bradycardia. This triad of cardiovascular changes usually indicates imminent death.

2

One nurse has not reported their findings of no breath sounds heard on the right side of the chest during a trauma admission. Which is the best action the team leader should take? 1. "Who is suppose to be covering the chest?" 2. "Team member X, what are the breath sounds?" 3. "Replace team member X, I need to know about the patient's breath sounds." 4. "Can the team member documenter check the breath sounds?"

Fentanyl

Opioids such as __________ may be used with ventilated patients to decrease pain and control restlessness if the agitation is caused by pain. This drug has fewer effects on blood pressure and heart rate than morphine and therefore may be a safer agent to manage pain for the TBI patient.

90

Cardiovascular dysfunction results from disruption of sympathetic fibers of the autonomic nervous system (ANS), especially if the injury is above the sixth thoracic vertebra. Bradycardia, hypotension, and hypothermia occur because of loss of sympathetic input. These changes may lead to cardiac dysrhythmias. A systolic blood pressure below ___ mm Hg requires treatment because lack of perfusion to the spinal cord could worsen the patient's condition.

ICP

Check pupils of TBI patients for size and reaction to light, particularly if the patient is unable to follow directions, to assess changes in level of consciousness. Document any changes in pupil size, shape, and reactivity and notify the Rapid Response Team or primary health care provider immediately because they could indicate an increase in ____!

3

After receiving a change-of-shift report, which patient should the RN assess first? 1. The patient is up ad lib and c/o headache 2/10. 2. The newly admitted patient with a stage IV pressure ulcer on the coccyx from another facility. The patient is denies pain and is cooperating with staying off their back. 3. The patient who is a 2 day post-op with an abdominal wound and VS: 110/70; 120; 22; pulse ox 95% on RA and temp 39 celsius. 4. The patient who needs to be medicated with multiple analgesics before a scheduled dressing change.

Initial stage of shock

Be aware that increased heart and respiratory rates or a slight increase in diastolic blood pressure may be the only sign of this stage of shock.

Inotropic Agents for Hypovolemic Shock

Directly stimulate beta-adrenergic receptors on the heart muscle, improving contractility. Examples: Dobutamine Milrinone Assess for chest pain because these drugs increase myocardial oxygen consumption and can cause angina or infarction. Monitor for transient hypotension as both drugs may cause vascular dilation. Assess blood pressure every 15 min because hypertension is a symptom of overdose.

TBI

For any patient having a ____, assess for signs of increased ICP, hypotension, hypoxemia (decreased blood level of oxygen), hypercarbia, or hypocarbia. Be aware that subtle changes in blood pressure, consciousness, and pupillary reaction to light can be very informative about neurologic deterioration! Hypercarbia can cause cerebral vasodilation and contribute to elevated ICP. Hypocarbia is caused by hyperventilation and can lead to profound vasoconstriction with resulting ischemia.

osmotic

For the patient receiving either _________ or loop diuretics, monitor for intake and output, severe dehydration, and indications of acute renal failure, weakness, edema, and changes in urine output. Serum electrolyte and osmolarity levels are measured every 6 hours.

30 to 45

HOB elevation in patients with TBI is at ____ TO _____ degrees to prevent aspiration. However, if increasing head elevation significantly lowers systemic blood pressure, the patient does not benefit from drainage of venous blood or CSF out of the skull from this position.

C

How long would the nurse expect a patient's partial-thickness wound to heal by epithelialization? A. 24 hours B. 2 to 3 days C. 5 to 7 days D. 48 hours

Vasoconstrictors for hypovolemic shock

Improve mean arterial pressure by increasing peripheral resistance, increasing venous return, and increasing myocardial contractility. Examples: Norepinephrine Phenylephrine HCl Assess patient for chest pain because these drugs increase myocardial consumption and can cause angina or ischemia. Monitor urine output hourly because higher doses decrease kidney perfusion and urine output. Assess blood pressure every 15 min because hypertension is a symptom of overdose. Assess patient for headache because headache is an early symptom of drug excess. Assess every 30 min for extravasation; check extremities for color and perfusion because if the drug gets into the tissues, it can cause severe vasoconstriction, tissue ischemia, and tissue necrosis. Assess for chest pain because the drug can cause rapid onset of vasoconstriction in the myocardium and impair cardiac oxygenation.

Agents That Enhance Myocardial Perfusion in Hypovolemic Shock

Improve myocardial perfusion by dilating coronary arteries rapidly for a short time. Examples: Sodium nitroprusside Nitroglycerin Protect drug container from light because light degrades the drug quickly. Assess blood pressure at least every 15 min because the drug can cause systemic vasodilation and hypotension, especially in older adults.

neurogenic shock

In _________________, loss of blood vessel tone (dilation) after severe cord injury may result in hypoperfusion

incomplete spinal cord injury

Injuries that allow some function or movement below the level of the injury are described as an

neuro check

Level of Consciousness (LOC) Pupillary Checks Movement and Strength of Extremities Sensation in Extremities Vital Signs

Drug Alert

Monitor the patient closely because drugs that dilate coronary blood vessels, such as nitroprusside and nitroglycerin, can cause systemic vasodilation and increase shock if the patient is volume depleted. Drugs that increase heart muscle contraction increase heart oxygen consumption and can cause angina or infarction.

A: Airway/cervical spine

Part of the Primary Survey Establish a patent airway by positioning, suctioning, and administering oxygen as needed. Protect the cervical spine by maintaining alignment; use a jaw-thrust maneuver if there is a risk for spinal injury. If the Glasgow Coma Scale (GCS) score is 8 or lower or the patient is at risk for airway compromise, prepare for endotracheal intubation and mechanical ventilation.

B: Breathing

Part of the Primary Survey: 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.

D: Disability

Part of the Primary Survey: Evaluate the patient's level of consciousness (LOC) using the GCS. Re-evaluate the patient's LOC frequently.

C: Circulation

Part of the Primary Survey: 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 severe, uncontrollable extremity hemorrhage, wound packing, and/or use of a hemostatic dressing.

MILD TBI

Physical Findings-No evidence of brain damage on a CT or MRI scan. • Appears dazed or stunned • Loss of consciousness (if any) <30 minutes • Headache • Nausea • Vomiting • Balance or gait problems • Dizziness • Visual problems • Fatigue • Sensitivity to light • Sensitivity to noise Cognitive Findings • Feeling mentally foggy • Feeling slowed down • Difficulty concentrating • Difficulty remembering • Amnesia about the events around the time of injury Sleep Disturbances • Drowsiness • Sleeping less than usual • Sleeping more than usual • Trouble falling asleep Emotional Changes • Irritability • Sadness • Nervousness • More "emotional" • Depression

E: Exposure

Remove all clothing for a complete physical assessment. Prevent hypothermia (e.g., cover the patient with blankets, use heating devices, infuse warm solutions).

D

Safe and Effective Care Environment The nurse is caring for a client with hypovolemic shock who is bleeding from a traumatic injury to the upper chest wall. What is the priority nursing action? A. Insert a large-bore IV catheter. B. Administer supplemental oxygen. C. Elevate the client's feet, keeping the head flat. D. Apply direct pressure to the area of overt bleeding.

TBI

Some patients with ___ experience seizure activity as a result of primary or secondary brain injury. Be sure to initiate Seizure Precautions according to your agency's policy and procedure.

3, 4

The 48 y-o client is admitted with encephalopathy with history of alcohol abuse, hypertension, and smoker for 30 years. The client is awakes to loud verbal stiumuli, oriented to name, and falls asleep. VS: 150/80; 80; 18; pulse ox 95% on room air; temp 37.2. Which prescribed medications due at this time should the nurse administer? Select all that apply. 1. Docusate sodium 100mg PO 2. Lisinopril 10 mg PO 3. Nicotine Patch topical 4. Vancomycin 500 mg IVPB 5. Losarten 100mg /Hydrochlorothiazide 12.5mg 1 tab PO.

3

The 70 year-old patient has been alert, oriented x 4 and participating in the physical therapy sessions to increase their strength with walking. The patient is now disoriented to place, date, and situation. Which set of assessments should the nurse do next? 1. Auscultate the heart, rhythm and rate; assess the patient's capillary refill and pulses of all extremities and vital signs. 2. Assess the patient's level of consciousness, assess the patient's pupils reaction to light; inspect and auscultate the patient's abdomen and palpate for tenderness, lesions and/or distention and vital signs. 3. Assess the patient's pupils reaction to light, assess grips, assess the dorsiflexion and plantar flexion; assess for pain; auscultate lung and heart sounds; and vital signs. 4. Assess the patient's pain and inquire if the patient is experiencing dizziness, headaches, weakness and/or incooridnation; and vital signs.

1

The client involved in a MVA has a closed head injury, cardiac contusion, and has an ICP line with the reading 22, BP 140/50 (80);heart rate 45; breathing 24, pulse ox 94% FiO2 40% on the ventilator, AC 16, Vt 350 and PEEP 5. The client is responsive to pain, restless, and moving all extremities. Which orders should the nurse hold and clarify with the physician? Select all that apply. 1. IV infusion of 0.45% at 75 ml/hr 2. Give 25 gm of Mannitol IVPB every 4 hours 3. Lacosamide (Vimpat) 100mg in 0.9% NS 50ml IVPB 4. Increase the propofol drip to maintain RASS at 0- 1. 5. Give dexamethasone 4mg IVP every 6 hrs.

1;4;5

The client with a history DM, HTN, CAD, and recent head trauma due to a fall. The client's BNP is 1500, sodium 142, potassium 3.9, magnesium 2.0, glucose 155. The client has a sliding scale insulin order, receiving dobutamine drip at 10mcg/kg/min, and furosemide (lasix) drip at 40mg/hr. Which clinical finding indicates the client is improving? 1. Urine output increased from 50ml/hr to 200ml/hr 2. Cardiac Index 1.5 3. BNP 1800 4. Cardiac index 2.9 5. Weight loss of 2kg from yesterday

PRIMARY SURVEY

The initial assessment of the trauma patient is called the Consist of: airway/cervical spine (A); breathing (B); circulation (C); disability (D); and exposure (E) There is one notable exception to the standard ABCDE trauma resuscitation approach. Lessons learned from the military and continued research have made it clear that in the presence of massive, uncontrolled external bleeding, hemorrhage control techniques are the highest-priority intervention

LOC

The most important variable to assess with any brain injury is _____! A decrease in arousal, increased sleepiness, and increased restlessness or combativeness are all signs of declining neurologic status. Report any of these signs and symptoms immediately to the primary health care provider or Rapid Response Team!

A

The nurse is assessing the client who was in a motor vehicle accident with a T5 injury. Which finding indicates the patient may have spinal shock? A. Onset of weakness and loss of sensation of both legs B. New onset of anxiety and restlessness C. Decerebrate posturing D. Awake, but confused, disoriented to place and situation.

A;C;E

The nurse is preparing to provide care to a group of clients. On which specific areas should the nurse focus in order to prioritize the clients' care needs? Select all that apply. A. Noting which clients have particular safety needs B. Noting time when the attending physicians make rounds C. Identifying clients with specific medication times D. Noting number of licensed staff assigned for the shift E. Asking if any clients have complex issues

C

The nurse is reviewing the laboratory profile of a client with hypovolemic shock. What laboratory value will the nurse anticipate? A. pH 7.51 B. PaO 2 106 mm Hg C. PaCO 2 49 mm Hg D. Lactate 0.4 mmol/L

D

The nurse receives report on a client who was in a house fire tonight, while the client did not suffer any skin burns, their carboxyhemoglobin level is 40%. The nurse recognizes which assessment will not be reliable in this client? A. Pain level B. Hemoglobin level C. Reddish-brown urine color D. Pulse Oximetry

ALL

The nurse reported the following to oncoming nurse: Mr. OO 35 y/o was admitted early at 0600 c/o back pain (one hour ago). No history of medical/surgical problems, NKA, AxOx4, PERRLA @ 3mm, equal strong grips, and his assessment is okay except the movement of legs. The client reports that he can't move legs. His dorsal flex and plantar reflexes are weak and equal, c/o numbness and tingling of the left leg from foot to hip area. Dorsalis pedis pulses 2+, cap refill<3 seconds and color normal for ethnicity of both legs. His wife is at the bedside and complaining about the techs not responding quick enough when the call light is used. Pt is incontinent with urine. Which statements are correct related to what is missing from the nurse's report? 1. What admission orders have been done. 2. Vital signs and most recent lab results. 3. History of the back pain, recent injuries, type of job, and home medication for pain. 4. How long has pt been unable to move legs and urine incontinence. 5. What is the patient's skin condtion and use of briefs 6. Pain management since admission, last pain medicaton given, and what is ordered.

B (250/1.5)

The order is Vancomycin 1000mg in 250 ml to run over 1hour and 30 minutes. What is the correct rate to set the pump? A. 147ml/hr B. 167ml/hr C. 166ml/hr D. 146ml/hr

4000 mL at a rate of 500 mL/hr ; 4000 mL at a rate of 250 mL/hr

The patient is burned 25% of body most full thickness wounds. The pt weighs 80 kg. What amount of the fluid is needed for the first 8 hours and what rate per hour to infuse? Place answers in answer 1 box. Then figure how much fluid is needed for the next 16 hours and rate per hour to infuse? Place answers in the box provided. The answer should be written as: ________ ml at rate of ____ ml/hr.

cervical

The patient with a __________ SCI is at high risk for respiratory compromise. The initial and priority assessment focuses on the patient's ABCs ( a irway, b reathing, and c irculation). After an airway is established, assess the patient's breathing pattern.

secondary survey

The resuscitation team also performs a more comprehensive head-to-toe assessment, known as the ____________________, to identify other injuries or medical issues that need to be managed or that might affect the course of treatment. includes insertion of a 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, and preparation for diagnostic studies.

4

The team is admitting a patient involved in a MVA with multiple fractures and is awake and alert at the scene but is now unresponsive. What assessments should be done first? 1. Circulation, Airway, Breathing, and start two large bore IV's 2. Alertness, breathing, circulation, disability, exposure 3. Complete neurological exam to identify if the patient is truly unresponsive. 4. Airway and Alertness, breathing, circulation, disability, exposure

2,3,5

The trauma patient arrived to the emergency room with shortness of breath, heart sounds muffled, and jugular venous distention. VS: 98/50; heart rate 120, respiratory rate 30, and pulse ox 88% on 100% non-rebreather. Which action(s) should be taken next? Select all that apply. 1. Prepare for intubation 2. Provide pain medication 4 mg IVP. 3. Notify the ER provider stat 4. Complete a secondary survey 5. Prepare for chest tube insertion

cervical

The upper __________ spinal nerves innervate the diaphragm to control breathing. Monitor all TBI patients for respiratory problems and diaphragmatic breathing, as well as for diminished or absent reflexes in the airway (cough and gag). The first priority is the assessment of the patient's ABCs

late signs of increased ICP

These manifestations include severe headache, nausea, vomiting (often projectile), and seizures.

Level I Trauma Center

Usually located in large teaching hospitals in densely populated areas Provides a full continuum of trauma services for adult and/or pediatric patients Conducting research is a requirement for trauma center verification

Level IV Trauma Center

Usually located in rural and remote areas Provides basic trauma patient stabilization and advanced life support within resource capabilities Arranges transfer to higher trauma center levels as necessary

C

What is the priority focus of prehospital care for a client with a chemical injury burn? A. Preventing infection B. Airway control C. Decontamination D. Fluid balance

B, E

What mechanism of injury will the nurse document for a client in a motor vehicle accident whose airbag deployed when the car struck a tree at 40 miles per hour? Select all that apply. A. Blast B. Blunt C. Laceration D. Penetration E. Acceleration-deceleration

D

What would be the nurse's best action when a patient with a burn injury develops a brassy cough, incresed difficulty swallowing, and progressive hoarseness? A. Instruct the AP to check vital signs every 15 minutes. B. Place the patient on continuous pulse oximetry. C. Establish a second IV access. D. Activate the Rapid Response Team.

D

When teaching a community group about burn prevention, which education will the nurse include? A. "Have a smoke detector in one central spot in the home." B. "If you use home oxygen, turn it down when you are smoking." C. "Set your water heater temperature below 160°F (71°C.)." D. "Plan several ways of escape from the home in case the primary exit is blocked."

A, B, D, E

Which are the priorities of care when providing care for a patient with a burn injury during the emergent phase? Select all that apply. A. Maintaining body temperature B. Securing the airway C. Maintaining nutrition status D. Supporting circulation and perfusion E. Keeping the patient comfortable with analgesics F. Psychosocial adjustment

A,C,D,E,F

Which assessment findings would the ER nurse expect when a patient has a smoke-related inhalation injury? A. Shortness of breath B. Cherry red skin C. Cough D. Soot around the nose or mouth E. Hoarseness of speech F. Singed nasal hairs

D

Which client does the oncoming ED nurse see first when assigned to care for four clients? A. 21-year-old with a skin rash who has been waiting 2 hours to see a provider B. 30-year-old with influenza who has infusing IV fluids and is resting quietly C. 47-year-old who fell off of a curb, resulting in a sprained ankle D. 56-year-old reporting chest pain and diaphoresis that started 30 minutes prior

1;2;3;4

Which early assessment findings support the nurse's concern that a client is experiencing hypovolemic shock? Select all that apply. 1. restlessness 2. Slight increase in pulse 3. Slight decrease in blood pressure 4. Normal respirations 5. Dry, warm skin

D

Which is the best action for the nurse to take prior to changing the dressing of a patient with a burn injury? A. Instruct the AP to give the patient a complete bath. B. Leave the wound open to air for 30 minutes. C. Allow the patient to rest and nap for an hour. D. Give pain medication 30 minutes before the dressing change.

A,C,D,E,F

Which teaching strategies would the nurse include when instructing patients about how to prevent burn injuries? Select all that apply. A. When space heaters are used, keep flammable objects away from them. B. Hot water heaters should be set below 150 degrees F (65.5C). C. Never add a flammable substance to an open flame. D. Use sunscreen and protective clothes to avoid sunburn. E. If using home oxygen, do not smoke in the room where the oxygen is in use. F. Avoid smoking when drinking alcohol or taking drugs that induce sleep.

C

Why is allowing for complete chest recoil important when performing high-quality CPR? A. There will be a reduction of rescuer fatigue B. It will reduce the risk of rib fractures C. The heart will adequately refill between compressions D. The rate of chest compressions will increase

Potassium

With dehydration and an acidotic state, this electrolyte will be INCREASED

Hematocrit and hemoglobin

With dehydration and fluid shift these labs will be INCREASED, except with hemorrhage

Pinpoint; herniation; fixed

______ and nonresponsive pupils are indicative of brainstem dysfunction at the level of the pons. Asymmetric (uneven) pupils, loss of light reaction, or unilateral or bilateral dilated pupils are treated as __________ of the brain from increased ICP until proven differently. Pupils that are _______ (nonreactive) and dilated are a poor prognostic sign. Patients with this problem are sometimes referred to as having "blown" pupils.

Lidocaine

________ given IV or endotracheally may be used to suppress the cough reflex; coughing increases ICP

Furosemide

________, a loop diuretic, is often used as adjunctive therapy to reduce the incidence of rebound from mannitol. It also enhances the therapeutic action of mannitol, reduces edema and blood volume, decreases sodium uptake by the brain, and decreases the production of CSF at the choroid plexus.

Mannitol

________, an osmotic diuretic, is often used to treat cerebral edema by pulling water out of the extracellular space of the edematous brain tissue. It is most effective when given in boluses rather than as a continuous infusion.

Paraplegia, paraparesis

_________ (paralysis) and _________ (weakness) involve only the lower extremities, as seen in lower thoracic and lumbosacral injuries or lesions.

Carbon dioxide

__________ ________ is a very potent vasodilator that can contribute to increases in ICP. Cerebral ischemia caused by even transiently decreased oxygen and either high or low carbon dioxide levels contributes to secondary brain injury.

Tetraplegia, quadriparesis

____________(also called quadriplegia) (paralysis) and ___________ (weakness) involve all four extremities, as seen with cervical cord and upper thoracic injury.

Propofol and midazolam

_____________ AND ____________ (GABA-receptor agonists) provide sedation to decrease ICP but are not as effective for pain control. Most mechanically ventilated patients receive a combination of these drugs.

Pulmonary contusion

a potentially lethal injury, is a common chest injury and occurs most often by rapid deceleration during car crashes After a contusion, respiratory failure can develop immediately or over time. Patients may be asymptomatic at first and can later develop various degrees of respiratory failure and possibly pneumonia. These patients often have decreased breath sounds or crackles and wheezes over the affected area. Other symptoms include bruising over the injury, dry cough, tachycardia, tachypnea, and dullness to percussion. Management includes maintenance of ventilation and oxygenation. Provide oxygen, give IV fluids as prescribed, and place the patient in a moderate-Fowler position. If a high FiO 2 is needed, oxygen may be administered using a high-flow nasal cannula (HFNC). When side-lying, the "good lung down" position may be helpful.

CBC (complete blood count)

a set of tests that include all WBC, RBC and platelet measurements.

arterial blood gases (ABGs)

a test performed on arterial blood to determine levels of oxygen, carbon dioxide, and other gases present

emergent (resuscitation) phase

burn injury that begins at the onset of injury and continues for about 24 to 48 hours During this phase, the injury is evaluated and priorities of care are determined based on extent and severity of the burn. The priorities of care during this phase include (1) securing the airway, (2) supporting circulation and perfusion, (3) maintaining body temperature, (4) keeping the patient comfortable with analgesics, and (5) providing emotional support.

Chest Trauma

can be treated with basic resuscitation, intubation, or chest tube placement.

Spinal Shock

also called spinal shock syndrome, 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. Spinal shock is not the same as neurogenic shock.

Glasgow Coma Scale (GCS)

an assessment that scores eye opening, verbal response, and motor response. The lowest score is 3, which indicates a totally unresponsive patient; a normal score is 15

Hypotension

defined as a mean arterial pressure less than 70 mm Hg

Hypoxemia

defined as a partial pressure of arterial oxygen (PaO 2) less than 80 mm Hg

complete spinal cord injury

injury in which there is complete loss of sensation and muscle control below the level of the injury

Penetrating Trauma

is caused by injury from sharp objects and projectiles. Examples are wounds from knives, ice picks, other comparable implements, and bullets (gunshot wounds [GSWs]) or pellets. Fragments of metal, glass, or other materials that become airborne in an explosion (shrapnel) can also produce this type of trauma

10 to 15 mm Hg

normal level of intracranial pressure (ICP) is

rehabilitative (restorative)

phase begins with wound closure and ends when the patient achieves his or her highest level of functioning. The emphasis is on the psychosocial adjustment of the patient, the prevention of scars and contractures, and the resumption of preburn activity, including resuming work, family, and social roles. This phase may take years or even last a lifetime, depending on the degree and impact of burn(s).

acute (healing)

phase of burn injury begins about 36 to 48 hours after injury, when the fluid shift resolves, and lasts until wound closure is complete. During this phase, the nurse coordinates interprofessional care that is directed toward continued assessment and maintenance of the cardiovascular and respiratory systems, as well as toward nutrition status, burn wound care to preserve tissue integrity, pain control, and psychosocial interventions.

PERLA

pupils equal, react to light and accommodation

Patient with Hypovolemic Shock

• Ensure a patent airway. • Insert an IV catheter or maintain an established catheter. A large-bore catheter is suggested. • Administer oxygen to maintain O2 saturation at 92% to 96%; supplemental oxygen is no longer recommended if saturation is normal (Chu et al., 2018). • Elevate the patient's feet, keeping his or her head flat or elevated to no more than a 30-degree angle. • Examine the patient for overt bleeding. • If overt bleeding is present, apply direct pressure to the site. • Administer drugs as prescribed. • Increase the rate of IV fluid delivery. • Do not leave the patient.