Exam (elaborations)
NUR 211 ED & Trauma Exam 4 Questions and Answers 2024/2025(A+ GRADED 100% VERIFIED).
- Course
- NUR 211
- Institution
- Excelsior College
NUR 211 ED & Trauma Exam 4 Questions and Answers 2024/2025(A+ GRADED 100% VERIFIED).
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NUR 211 ED & Trauma Exam 4black tarp - ANS expected to die
green tarp - ANS least injured, walk away
yellow tarp - ANS need to be seen w/in 6-12 hrs
red tarp - ANS life threatening injuries with good chance of survival IF treated immediately
for the patient exposed to hazardous chemicals the first step is always - ANS decontamination
EMTALA means that - ANS all clients get stabilized in ER regardless of insurance coverage
consent in AL - ANS § They must be competent (able to make decisions), at age of consent (14
or GED or married or pregnant or divorced)
§ Emergency consent can be used if patient is unable to consent, would likely give consent, and
it is an emergency
primary survey vs. secondary survey - ANS o For very sick client
o Rapid assessment to find life-threatening conditions
o Focuses on airway, breathing, circulation, disability, and exposure (ABCDE)
o Based off measures we can see quickly
- secondary survey is the head to toe
primary survey: airway - ANS § Airway with cervical spine stabilization and/or immobilization,
assess chest injuries
· S/s in patient with compromised airway
o Dyspnea
o Ability to vocalize (airway is good)
o Foreign body
o Facial or neck trauma
· Maintain airway
o Do jaw thrust not head tilt on traumatized pt
primary survey: breathing - ANS · Dyspnea
· Cyanosis
· Paradoxical/asymmetric chest wall movement
· Decreased or absent BS
· Tachycardia
· Hypotension
, -Administer high-flow O2 via a non rebreather mask
-Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for life-threatening conditions
-Monitor patient response
-Insertion of chest tube, reestablish integrity of chest
primary survey: circulation - ANS •Check central pulse (peripheral pulses may be absent
because of injury or vasoconstriction)
-Assess skin for S/S shock
-Insert two large-bore IV catheters - Type & Cross
-Initiate aggressive fluid resuscitation using Normal Saline or Lactated Ringer's solution
-Manage hypothermia
-Check peripheral pulses- closed reductions of fractures if pulseless
primary survey: disability - ANS •Measured by patient's level of consciousness
-AVPU
•A = alert
•V = responsive to voice
•P = responsive to pain
•U = unresponsive
-Glasgow Coma Scale: Assess arousal aspect of patient's consciousness
-Pupils: Size, shape, response to light, equality
-Motor & sensory Evaluation of spine
primary survey: exposure and environmental control - ANS -Remove clothing
-Provide temperature control—avoid hypothermia
primary survey acronym - ANS ABCDE
airway
breathing
circulation
disability
exposure and environmental control
secondary survey acronym - ANS FGHI
full set of vitals/five interventions/family presence
give comfort measures
history and heat-to-toe
inspect posterior surfaces (logroll)
full set of vitals - ANS •Blood pressure (bilateral)
•Heart rate
•Respiratory rate
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