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NUR 265 Exam 4 Study Guide.
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NUR 265 Exam 4 Study GuideEMERGENCY CARE
- Main reasons people seek emergency care include: Pain (main reason), Abdominal Pain, Chest pain, h/a,
Difficulty breathing, fever, Injury (especially in elderly population)
- EMTs can provide basic life support interventions such as AEDs, O2
- Paramedics can provide advanced life support interventions such as cardiac monitoring, advanced airway
management (intubation) IV access
- Staff and pt safety are major concerns in ER/ED setting
a. Staff: Disease transmission and physical safety when dealing with agitated or aggressive pts. always use
standard precautions. De-escalate situations if able, notify security, know exit routes.
b. Patient:
1. Identification: use identifiers such as ID bracelet. Two unique identifiers (name/DOB/SSN etc) unknown pts
use unique identification system such as Jane/John Doe.
2. Safety: Early identification of falls risk. Older adults should always have all side rails up, bed should be in
lowest position and call light w/in reach. Teach them to call out if they need assistance. Reorient pt as needed.
3.Skin integrity: Take measures that maintain skin integrity.
-Death in ER:
1. Medical examiner required if:
a. Trauma
b. Suspected homicide or abuse
DO NOT clean skin, leave all IV lines & tubing in place. The body can be covered with linen. The face may be
exposed for viewing.
- Triage:
Emergent (life threatening) Urgent (needs quick but not Non urgent (can wait a few hours)
immediate treatment)
Resp distress, active bleeding, Severe abdominal pain, fractures Simple fractures, skin rash, colds.
chest pain w/ diaphoresis, stroke, (displaced/closed or multiple) new
unstable VS onset of resp. infections
-Primary Survey and Resuscitation Interventions (ABCDE)
(A) Airway/cervical Spine.
Spontaneously breathing: Non-rebreather mask
Vent Assistance needed: Bag valve mask + 100% Oxygen. ***if GCS <8 then mechanically vent***
Manually align neck + spine to neutral position, use jaw thrust method.
(B) Breathing
Assess Resp status (lung sounds, resp effort, chest expansion etc)
If CPR is needed d/c vent and bag pt manually
(C) Circulation
Assess cardiac status
Ensure IV access (16 gauge in AC usually best) RL or NS usual.
External hemorrhage: apply direct pressure, if direct pressure fails, a tourniquet should be considered
(D) Disability
Rapid Assessment of neuro status GCS is common, is pt Alert, responsive to voice, responsive to pain or
unresponsive?
(E) Exposure
Expose and examine for any bleeding.
Always remove clothing w/ scissors cutting away (burns, or when moving limbs can cause injury) Cover
any viscera w/ moist sterile dressing/gauze
Prevent hypothermia by covering pt with blankets, use of heating devices or by infusing warm solutions.
-Secondary Survey and resuscitation interventions are used to identify other injuries or medical issues that may
be managed or that might affect the course of treatment. It usually involves a head to toe assessment and
This study source was downloaded by 100000849580189 from CourseHero.com on 07-18-2023 03:17:38 GMT -05:00
placement of gastric tubes, catheters and diagnostic studies.
https://www.coursehero.com/file/32230577/NUR-265-Exam-4-Study-Guidedocx/
, MASS CASUALTIES
Red Tag (class I) Yellow Tag (class II) Green Tag (class III) Black Tag (class IV)
Immediate threat to life Urgent: Require treatment Nonurgent: Can wait Allowed/expected to die.
eg. Airway obstruction, but not an immediate several hours. Eg. Eg. Massive bleeding,
shock, SOB, angina threat to life. Eg. Open Sprains, closed fractures, excessive full thickness
fractures (with distal abrasions, contusions. burns, high cervical
pulse), large wounds trauma (C3-5), massive
head trauma
-In mass casualties, medically stable pts may be discharged early. Eg: admit for observation, diagnostic
procedures, expected discharge, no critical change in condition x3 days, can be cared for at another facility such
as a rehab/long term care.
ANTHRAX
- Gram positive bacterial Infection.
- Prodromal stage difficult to distinguish from influenza or cold. In fulminant stage (late stage) s/s include s/s
associated w/ resp distress as there is massive edema and destruction of lung cells.
- Prophylaxis, treat w/ AB such as Cipro, Doxycycline, Amoxicilin.
- Exposure, treat w/ same as above AND/OR Rifampin, Clindamycin, Vancomycin. IV AB x7 days if response
is good then oral x60 days.
HEAT RELATED INJURIES
HEAT EXHAUSTION
-Older Adults: Avoid alcohol and caffeine, use sun screen, have rest/break periods when in hot environment
-Heat exhaustion primarily caused by dehydration. If left untreated can lead to heat stroke.
s/s:
- No significant elevation in body temp
- flu like symptoms.
- Orthostatic hypotension, tachycardia and confusion
Management:
- Stop any physical activity
- Move to a cool place and use cooling measures such as placing cold packs on neck, chest, abdomen and groin
- Remove any restrictive clothing
- Orally rehydrate using sports drink AND NOT water. DO NOT give salt tablets.
- Rehydrate using IV NS + monitor electrolytes.
HEAT STROKE
- True medical emergency. Body temp may exceed 104 F
s/s:
- elevated body temp
- skin hot and dry there MAY OR MAY NOT be sweating
- changes in mental status
- hypotension, tachycardia, tachypnea
Management:
- NPO DO NOT GIVE ANYTHING BY MOUTH a/r risk for aspiration
- NO ASA or any antipyretics
- O2 as needed
- IV NS and insert indwelling cath.
- External cooling: cold packs on neck, chest, abdomen, axilla and groin. d/c cooling when temp is 102 F.
- if pt begins to shiver parental benzo
- Rectal probe to assess temp Q15min
This study source was downloaded by 100000849580189 from CourseHero.com on 07-18-2023 03:17:38 GMT -05:00
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