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