Exam (elaborations)
RN LASALLE ACHIEVE STUDY GUIDE TEST MAP EXAM 3 GET a A+ ON YOUR EXAM
- Course
- NUR 425
- Institution
- La Salle University
TEST MAP ADULT HEALTH 2 LASALLE BSN,RN EXAM 3
[Show more]
Seller
Follow
Content preview
Emergency Nursing & Trauma1. What systems are used for triage in the emergency department?
Triage: used to sort patients into groups based on the severity of their health problems
and the immediacy with which these problems must be treated; used for rapid
assessment and decision-making preferably in less than 5 minutes
Three Category Scale
Categorizes patients as emergent, urgent, or nonurgent
Emergency Severity Index
Assigns patients into 5 levels based on acuity and resource need
o Level 1- resuscitation
o Level 2- emergent
o Level 3- urgent
o Level 4- less urgent
o Level 5- nonurgent
Canadian Triage & Acute Scale
Assigns patients into 5 levels and includes time parameters for how frequently
patients are reassessed
o Level 1- resuscitation + continuous nursing surveillance
o Level 2- emergent + reassessed every 15 minutes
o Level 3- urgent + reassessed every 30 minutes
o Level 4- less urgent + reassessed every 60 minutes
o Level 5- nonurgent + reassessed every 120 minutes
Triage Bypass
Moves patient directly to an open bed in the ED to reduce waiting times
Receiving nurse performs initial assessment & vital signs
Team Triage
Triage nurse works with a physician or APN within the triage area
Can move patients to diagnostics and possible discharge without fully admission
to the ED
,2. What are the components (assessment and interventions) of the primary and
secondary survey?
Primary Assessment
Focuses on stabilizing life/limb threatening conditions; rapid assessment
o Airway- ensure airway is patent
o Breathing- provide adequate ventilation
o Circulation-restore cardiac output, control hemorrhage, prevent & treat
shock
o Disability- assess neurologic function using the Glascow Coma Scale or
AVPU mnemonic
Alert
Verbal responsiveness
Pain responsiveness
Unresponsive
o Exposure- undress to assess any wounds or areas of injury
Secondary Assessment
A more throughout assessment that focuses on diagnosis & treatment
Health history
Head-to-toe assessment
Diagnostics & lab testing
Monitoring devices
Splinting fractures
Wound care
3. What methods should the nurse utilize to determine neurologic function in a client
who experienced a trauma?
Glascow Coma Scale
Assesses neurological status in acute medical or trauma patients
Contains 3 components
o Eye opening response
o Verbal response
o Motor response
A sore of ≤ 8 indicates a comatose state
, 4. What are the different causes and types of traumas?
Trauma: an intentional or unintentional wound or injury inflicted on the body from a
mechanism against which the body cannot protect itself
Multiple Trauma: a single catastrophic event that causes life-threatening injuries to at
least two distinct organs or organ systems
Triad of mortality
o Hypothermia
o Metabolic acidosis
o Coagulopathy
Types
Blunt- injury of the body by forceful impact, falls, or physical attack with a dull
object
Penetrating- involves an object or surface piercing the skin, causing an open
wound
Management
Establish airway and ventilation
Control hemorrhage
Prevent and treat hypovolemic shock
Assess for head & neck injuries
Evaluate for other injuries
Splint fractures and reassess pulses & neurovascular status (if applicable)
Perform secondary assessment and diagnostic studies
5. What are the clinical manifestations associated with abdominal trauma?
Assessment & Diagnostic Findings
Gross injuries
o Bruises, abrasions, or penetrating trauma
Absent bowel sounds
Internal hemorrhage
o Blueish discoloration of back and flanks
o Hypotension & other signs of shock
Intraperitoneal injury
o Tenderness or rebound tenderness
o Guarding
o Abdominal distension/rigidity
o Referred pain
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller mooret7. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $20.49. You're not tied to anything after your purchase.
Can Stuvia be trusted?
4.6 stars on Google & Trustpilot (+1000 reviews)
67866 documents were sold in the last 30 days
Founded in 2010, the go-to place to buy study notes for 14 years now