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Adult 2 - Final Exam Study Guide
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N460-Adult Health-Final Exam Study GuideUnit 1
Nursing Care of the Adult Client with an Emergency/Trauma
Objectives 1,2,4.5
Objective 1: Discuss similarities and differences in triage management in the emergency
room and a disaster situation.
o Emergency Room Triage
Most critically ill assigned highest priority
o Disaster Situation Triage
Treatments based on likelihood of survival
Objective 2: Discuss severity indices related to triage, trauma scoring and injury severity
scoring.
o Emergency Triage
Level 1- Resuscitation
Level 2- Emergent (10 min)
Level 3- Urgent (30 min)
Level 4- Semi Urgent (60 min)
Level 5- Nonurgent (120 min)
o Disaster Triage
Priority 1 (Immediate)- Red
Priority 2 (Delayed)- Yellow
Priority 3 (Minimal)- Green
Priority 4 (Expectant)- Black
Objective 4: Discuss triage skills and principles: assessment, history taking, and
facilitating appropriate use of emergency services, collection of forensic evidence.
Primary survey- focuses on stabilizing life-threatening conditions
ABCDEs
Airway with c-spine immobilization
Neurological disability
Expose and evacuate
Secondary survey- after primary survey is completed and life-threatening
insults are addressed
Health history and assessment
Diagnostics and labs
Monitoring devices
Splint fractures
Cleanse wounds
Other interventions
Documentation
Full set of vitals
Complaint with hx
Past medical history
Neurologic assessment
Allergies
Daily medications
Weight
, Domestic violence assessment
Objective 5: Identify the appropriate assessment data, nursing, diagnoses, and nursing
plan of care related to the client with: airway obstruction, hemorrhage, intra-abdominal
injuries/crush injuries, chest injuries (rib fractures/flail chest), pulmonary injuries
(tension pneumothorax, sucking/open pneumothorax), cardiac injury ( cardiac
tamponade), and environmental emergencies (heat stroke, hypothermia, and frostbite)
A) Intra-abdominal injuries:
Can be blunt or penetrating trauma
Blunt Trauma:
-MVC, falls, blows or explosions. Organs may be ruptured or lacerated from force involved. The
spleen and liver are organs commonly injured and there is often hemorrhage with injuries to
these 2 organs.
-Blunt trauma is often associated with other injuries and may be difficult to detect.
Penetrating Trauma:
Stab wounds: liver, small bowel, diaphragm, or colon
-If the knife is still in the abdomen after pt. has been stabbed—leave knife in abdomen
tamponading bleeding that may be occurring in abdominal cavity
Gunshot wounds: small bowel, colon, liver, and abdominal vascular structures
-Bullets can bounce off bones causing more internal injuries than you think look for entry/exit
wound. Get an X-ray or CT if unable to find 2 holes.
Assessment:
Guarding & splinting of abdomen—may be very painful
Hard, distended abdomenblood and bowel contents leaking into abdominal cavity
Decreased or absent bowel sounds may be an early sign of intra-peritoneal
involvement
Wounds over abdomen bruising, abrasions, penetrating injuries (think about organ
that lies beneath)
Pain over scapula with injury to spleen (referred pain)
Pain over right shoulder w/ laceration to liver
N/V intra-abdominal pressure or foreign content that spilled into abdominal space from
bullet/knife
Bloody urine—Assess UOP! Do NOT insert a catheter when having bloody meatus
(unless female is on period) otherwise contraindicated could be kidney/bladder or pelvic
crush injury.
Signs of hypovolemic shock***: decreased LOC, tachypnea (RR > 20), tachycardia (HR
> 100) , hypotension (systolic < 100), and decreased pulse pressure, decreased UOP—
(so measure it), cool/clammy skin, delayed cap refill
-Be aware that clients with intra-abdominal injuries have the potential for injury in multiple sites.
Delayed reaction can lead to massive blood loss into abdominal cavity and assessment of the
injury is vital. If excessive bleeding does occur it can lead to hypovolemic shock. Most common
cause of shock is hypovolemic shock.
Management-Nursing plan of care:
, ABCs with c-spine immobilization—you can maintain these without doctor’s orders.
Reassess ABCs—external bleeding needs to be under control—goes along with
circulation
Control internal hemorrhage
IV fluids: for possible blood loss
NPO & NG tube—NPO because major injuries may need tests run/surgery. NG tube for
decompression and do NOT place NG tube with facial fractures—could end up in brain.
Prep for diagnostic procedures—CT/US and damage control surgery
Diagnostics-Labs-Meds
Laboratory studies: UOP, UA, CBC (type/screen) and H/H—trauma pts. may need
blood, WBC will generally be elevated
Abdominal CT and ultra sound (bedside in ER)
Diagnostic peritoneal lavage—done if hospital doesn’t have means to CT/X-ray/US—so
seldom done—but basically incision to abdominal cavity-infuse NS and allow to drain
back out, if bleeding will be bloody output.
Sinography
IV fluids, tetanus and broad spectrum antibiotics
Nursing Diagnoses:
Acute pain r/t abdominal trauma
Ineffective breathing pattern r/t abdominal distention or pain
Deficient fluid volume r/t hemorrhage/hypovolemia
Dysfunctional GI motility r/t decreased perfusion
Disturbed body image r/t scarring/amputation
Risk for infection
B) Chest injuries:
Rib fractures
-Usually caused by blunt trauma, very painful at risk for pneumonia and atelectasis because
you have ribs broken in several different places and not breathing as well, coughing or
mobilizing secretions
Assessment:
Inspect the chest for bruising on one side or other, symmetrical rise and fall of chest
Observe chest wall movement
Listen to breath sounds
Palpate for any pain or crepitus
Check O2 sat—get O2 on them
Chest x-ray to see which ribs are fractured
Nursing plan of care:
Pain management: NSAIDS, intercostal nerve blocks, thoracic epidural analgesia, narcotics
(watch for respiratory depression, altered pain receptors in brain, and constipation)
-Incentive spirometry to prevent pneumonia has been shown to decrease incidence of
pneumonia in critical care hospital. Also decreased mortality by improving lung function
Flail Chest:
-When 3 or more adjacent ribs are fractured at 2 or more sites, resulting in free-floating rib
segments which causes chest to have asymmetrical rise/fall with respirations- paradoxical
breathing (chest wall moves in on inspiration and out on expiration)
, -Usually a complication of blunt chest trauma from steering wheel. Flail chest causes instability
of chest wall due to multiple rib fractures
Assessment:
Asymmetrical and uncoordinated movement of thorax
Rapid, shallow respirations, poor air movement
Palpation of crepitus of ribs cracking sound heard around bones/joints due to
presence of air
Nursing plan of care:
-ABCs, humidified O2, IV fluids, endotracheal intubation and ventilation (esp. if it’s severe
enough along with unstable sternum)
Diagnostics-Labs-Meds
Chest x-ray
ABGs—see how they are breathing
Pulse ox
Pain management: PCA, intercostal nerve block, epidural analgesia, administration of
narcotics
Nursing Diagnoses for Chest injuries:
Ineffective breathing pattern r/t trauma
Impaired gas exchange r/t loss of lung function esp. with flail segments
Impaired spontaneous ventilation-paradoxical breathing
Fear r/t not being able to breath
Anxiety—have tachypnea
C) Pulmonary Injuries:
Pneumothorax: air in the pleural space that results in complete or partial collapse of the lung
2 types: sucking/open pneumothorax in which there is a chest wound and pleural space is
exposed to positive atmospheric pressure and tension pneumothorax—air in pleural space
and cannot escape
Tension pneumothorax (closed)
Parietal or visceral pleural integrity is compromised—ex. broken rib, usually no external wound
associated with it
Rapid accumulation of air in pleura space
Severely high intra-pleural pressure
Shift of mediastinum
MEDICAL EMERGENCY—causes decreased CO (pressure can cause decreased
venous return) and as a result of decreased CO hypoxemia
Pts can deteriorate quickly
Assessment:
-cyanosis, air hunger (gasping for breath), agitation/scared, tracheal deviation to unaffected side
(trachea and even heart can be displaced from all the pressure), SQ emphysema, and neck
vein distention cause there is not good venous return.
Nursing plan of care:
Prepare for needle decompression—done ASAP- perform in 2nd intercostal space, mid-
clavicular line with 14 gauge needle—this decreases tension because air is released
Prepare for chest tube after needle decompression to keep lung inflated and get
remaining air out
Continuous client monitoring
Diagnostics-Medications: (all of this done after needle decompression)
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