Emergency Nursing
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35 terms
Terms | Definitions |
|---|---|
 Assessment in the Emergency Department | ABCDE FGHI A airway, B breathing, C circulation, D neuro, E exposure, F full vitals including catheter, ng, labs, G give comfort, H head to toe asssesment, I inspection |
| Priorities | Airway breathing circulation Focus assessment based on severity of problem |
| General Assessment | control bleeding, prevent infection, limit mobility immobilize spine until spine injury ruled out, evaluate LOC, start infusion, give tetanus, antibx, surgical prep |
| 3 types of Trauma | Blunt, Penetrating,Crushing |
| Blunt | no open wound, assess for internal injury |
| Penetrating | open wound, control bleeding |
| Crushing | compression, assess and splint |
| Treatment | get pt. history as able, ABCs, control bleeding, Labs, H/H, wbc, amylase to rule out liver injury, pain, Splint,monitor, wound care, document |
| Hemorrhage | provide fluid replacement Normal Saline or Lactated Ringers, look for at color of skin, pain in left shoulder can indicate injury to spleen or right side could be liver, CT, apply pressure to stop bleeding, last resort is a tourniquet |
| Anaphylaxis | hypersensitive reaction that occurs in seconds S/S respiratory, itching, edema, decrease in blood pressure, vasodilation |
| Tx anaphylaxis | ABCs and epinephrine |
| Heat Stroke | failure of body temperature to regulate, temp. over 105, no sweating (anhydros), dry skin, low bp, tachypnea and tachycardia |
| Tx Heat Stroke | decrease temperature as soon as possible, sponging, cooling blanket, ice, lavage, VS, IV, IOs,O2 assess |
| Hypothermia | internal core less than 95 degrees frostbite, shivering,pulmonary edema, organs shut down, white mottled skin and pain do not massage or allow pt. to walk |
| Tx Hypothermia | ABCs rewarm heating blanket, lavage, warm O2, heater Do not massage...... let blood warm naturally |
| Poisoning | can be ingested, inhaled, applied for corrosive poison give water or milk, activated charcoal, cathartic when possible, antagonist, antidote |
| Tx for Poisoning | ABCs, labs, antidote, lavage with charcoal, diuresis, dialysis |
| Hypovolemic Shock | loss of blood, fluid or plasma that causes inadequate perfusion |
| Tx Hypovolemic Shock | with Central Venus Pressure, IV arterial line, catheter, oxygen, elevate legs, increase fluids rapidly |
| Cardiac Shock | heart loses abitity to pump, poor cognition, weak pulse, low bp, tachypnea, oliguria Tx underlying cause |
| Septic Shock | body system failure related to infection, treat with massive antibiotics, cardiac decomp, decreased loc, crackles, cold clammy skin |
| Meds for shock | Dopamine force heart to increase output, Inocor increases muscle contraction and vasodilation, Adrenalin dilates bronchioles, Nipride for peripheral vasodilation often used with Dopamine |
| Sexual assault, Abuse and Neglect | Skilled interview, detailed documentation, photos with permission, privacy, mandatory reporting |
| Meds for Sexual needs | Antibiotics for STDs, gonorrhea, syphyllis, rocephin, vibramycin Emergency contraception |
| Job of Triage Nurse | sorts patients into groups based on severity emergent, urgent, non-urgent, fast tracked meaning simple first aid or primary care |
| Triage Nurse | collects vitals, history, and series of questions to screen patients Course of present illness, what brought pt. here, pt. history, ask what meds, allergies, last meal eaten |
| Issues of Emergency Nursing Care | document consent, need to consent to be treated or if unconcious and no family members document this constantly document pt. condition, when treatments completed, pt. condition at discharge Keep pt. family informed and allow family to stay with pt. if possible |
| Nurses intial job is to | stablize the patient's life threatening condition Then get brief health history, meds, allergies, med. hist, rapid head to toe assessment, testing, monitoring devices, IV, foley insertion, splinting, wound care |
| Tretment Priorities | Establish airway, Control Hemorrhage, Prevent hypovolemic shock, assess for neck injury, eval. for other injuries, splint. Assign highest priority to most lethal injury |
| Rember Nurses are protected with | Good Samaritan status |
| Most common clinical sign of neglect | malnutrition and dehydration |
| Signs of Hypovolemic Shock | early slight increase in pulse pt. becomes tachy` |
| Common Causes of hypovolemia | burns, gastro bleeding, hemothorax, severe vomiting, severe diarrhea, diabet acidosis, diuretic therapy |
| Nursing Interventions for Hypovolemia | CVP to assess response to fluid replacement, monitor bp, ABGs, admin. fluids at a rapid rate, ECG, vitals,ABGs, pulse, elevate legs above heart unless contraindicated. |
| Medications for shock | dopamine forces heart to contract, Inocor increase myocaridal contractility, epinephrine bronchiol dilation Nitropussin or Nipride for Cardiogenic shock give w. dop. |
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