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Test 2: Lewis Ch. 68 Emergency and Disaster nursing

Terms in this set (42)

Triage system
identifies and categorizes patients so that the most critical are treated first
Emergency Severity Index
five level triage system that incorporates concepts of illness severity and resource utilization to determine who should be treated first
Emergency Severity Index level 1
Stability of vital functions (ABCs): Unstable

Life threat or organ threat: obvious

How soon patient should be seen by HCP: Immediately

Expected resource intensity: high resource intensity, staff at bedside continuously, often mobilization of team response

Examples: Cardiac arrest, intubated trauma patient, overdose with bradypnea, severe respiratory distress
Emergency Severity Index level 2
Stability of vital functions (ABCs): threatened

Life threat or organ threat: likely but not always obvious

How soon patient should be seen by HCP: within 10 minutes

Expected resource intensity: high resource intensity, multiple, often complex diagnostic studies, frequent consultation, continuous monitoring

Examples: chest pain probably resulting from ischemia, multiple trauma unless responsive
Emergency Severity Index level 3
Stability of vital functions (ABCs): stable

Life threat or organ threat: unlikely but possible

How soon patient should be seen by HCP: up to 1 hr

Expected resource intensity: medium to high resource intensity, multiple diagnostic studies or brief observation, complex procedure

Examples: Abdominal pain or gynecologic disorders unless in severe distress, hip fracture in older patient
Emergency Severity Index Level 4
Stability of vital functions (ABCs): Stable

Life threat or organ threat: No

How soon patient should be seen by HCP: Could be delayed

Expected resource intensity: Low resource intensity, one simple diagnostic study or simple procedure

Examples: Closed extremity trauma, simple laceration, cystitis
Emergency Severity Index Level 5
Stability of vital functions (ABCs): Stable

Life threat or organ threat: No

How soon patient should be seen by HCP: Could be delayed

Expected resource intensity: low resource intensity, examination only

Examples: cold symptoms, minor burn, recheck prescription refill
Primary survey
focuses on airway, breathing, circulation, disability, exposure, facilitation of adjuncts and family, and other resuscitation aids
A - alertness and airway
determine level of consciousness by assessing the patient's response to verbal and/or painful stimuli

A - alert
V - responsiveness to voice
P - responsive to pain
U - unresponsive
B - breathing
Conditions causing breathing changes

fractured ribs, pneumothorax, penetrating injury, allergic reactions, pulmonary emboli, and asthma attacks
C - circulation
restore circulation to limbs that's circulation had been restricted to prevent bleeding
A - alert and airway assessment
- catastrophic external bleeding
- AVPU
- respiratory distress
- airway for patency
- check for loose teeth or foreign bodies
- bleeding, vomitus, or edema
A - alert and airway interventions
- control bleeding with direct pressure and pressure dressings
- open airway
- use jaw-thrust maneuver
- remove or suction any foreign bodies
- insert oropharyngeal or nasopharyngeal airway, cricothyroidectomy
- rapid sequence intubation
- immobilize cervical spine using rigid cervical collar and cervical immobilization device
B - breathing assessment
- ventilation
- scan chest for signs of breathing
- look for paradoxic movement of the chest wall during inspiration and expiration
- note use of accessory muscles or abdominal muscles
- observe and count respiratory rate
- note color of nail beds, mucous membranes, skin
- auscultate lungs
- assess for jugular venous distension and position of trachea
B - breathing interventions
- give supplemental O2 via appropriate delivery system
- ventilate with bag-valve-mask with 100% O2 if respiration are inadequate or absent
- prepare to intubate of severe respiratory distress or arrest
- have suction available
- if absent breath sounds, prepare for needle thoracostomy and chest tube insertion
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