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NURS 2400 1st Test Review
(ED, Burn, Restraints)
Terms in this set (38)
How often do you document restraints?
What to do when you suspect abuse?
Report it to provider, Adult Protective Services, Division of Child and Family Service, and/or law enforcement as mandated by law.
What is a restraint?
Direct application of physical force to an individual, without the individual's permission, to restrict his or her freedom of movement. The physical force may be human, mechanical devices, or a combination thereof.
what is not a restraint?
Medical devices applied to prevent further medical issues, Restraining leg for a patient on a intra aortic balloon pump, Restraining a patients arm after implantable pacer placement, Restraining a patients arm after fistula placement, Any procedure where movement can cause bleeding, displacement.
Identify steps before restraining someone?
1. Conduct assessment
2. implement appropriate alternatives based on assessment
3. When alternatives are not effective an RN can initiate restraint but must obtain an order within an hour.
4. A physician order is required for restraint
5. Remove restraints when the indications for use are resolved.
6. Order renewal is required for each calendar day of use.
What is the priority intervention for patient brought to E.R. that does not have airway?
Placement of artificial airway
Nursing intervention for narcotic overdose
Immediate intervention for pt with heatstroke
ABC's, and then reduce temperature rapidly, through various cooling methods:
-cool sheets, towels, or sponging with cool water.
-Ice to neck, groin, chest, and axillae
-iced lavage of stomach or colon
-immersion in cold water bath.
Reasons for restraint use
-to improve pt's wellbeing by preventing removal of iv lines, endotracheal tubes, feeding tubes, or to prevent injury of patients who are temporarily mentally incapacitated after surgery or procedure.
What EMTALA means?
Emergency Medical Treatment And Labor Act EMTALA is a
federal law that requires hospital emergency departments to
medically screen every patient who seeks emergency care and to
stabilize or transfer those with medical emergencies, regardless of
health insurance status or ability to pay
What needs to be on orders for restraint?
-alternatives measures that were attempted and were ineffective
-specific time period (up to 24hrs)
-types of restraint used
-A face-to-face eval of the pt within 12 hrs of restraint application is required & before order renewal
-Ordering physician must consult attending and document cconsultation
During a mass casualty, which injury receives care first?
a. Abdominal evisceration
b. Open fracture of the left forearm
c. Sprained ankle
d. Sucking chest wound
d. D(This casualty is a red tag, or emergent, because it can be quickly resolved until further help can be given.)
Know what and what not to do when someone gets shanked.
Do not remove shank!
-if viscera is protruding cover with sterile and moist saline dressing.
S/S of heat stroke
-hot dry skin
-anhidrosis (inability to sweat)
Nursing interventions for pt who has been poisoned
-ABC's (airway damage from corrosive poisons)
-ventilation and oxygenation are essential
-Monitor : ECG, vital signs, and neuro status
-Urinary catheter to monitor renal function
-measures to remove toxin or decrease absorption
(gastric lavage, ipecac, activated charcoal, cathartic)
s/s of CO poisoning
CNS symptoms. (pulse ox is not valid, skin color not reliable)
Simple Parkland Formula
Half of calculated fluid is administered in first 8 hrs after injury, the next half is administered the next 16 hrs.
What type of fluid do we use for burn resuscitation
Lacted ringers solution through a large-bore cannula in peripheral vein
Know nursing interventions for pt who sustained burns around their face.
-Secure and protect airway
-inhalation injury should be suspected with facial burns
-administer 100% oxygen
-early intubation before edema has obstructed larynx
-blood sampling and blood pressure monitoring may require arterial line.
Know how to administer px meds to burn pt
-IV pain medications in small doses and titrated to effect.
-Do not administer Intramuscular/Subq medications
Know risks of electrical burn
-Deep tissue injuries may not be visible on initial clinical presentation but in many circumstances should be assumed as present and timely intervention initiated.
-Pediatric electrical burns occur at home
-adult electrical burns occur in workplace.
Know nurse interventions for pt who received chemical burns
-do not waste time looking for neutralizing agent, focus on removing chemical from pt
Know what to do if the nurse receives call from poison center control asking for info.
Give the information
Pt who has large burn on the body what manifestations will you see
-Hypovolemia (large fluid shifts leading to low bp)
-Edema (monitor for compartment syndrome)
-Hyperkalemia immediately after burn injury (due to cell death leading to release of potassium) (monitor EKG)
-Hypokalemia may occur later with fluid shifts and inadequate potassium replacement.
-Hyponatremia (from plasma loss)
-Inhalation injury (Airway, Breathing symptoms)
-Kidney alterations (Dark urine=notify provider)
What kind of burns get you admitted to the burn unit.
Know when burn pt is no longer at risk for infection.
when wound is closed
When burn pt has burgundy colored urine
Notify provider immediately
Best way to prevent infection in burn patient
Nursing interventions for pt who is hypothermic
-remove wet clothing, and rewarm
-Rewarming (Controlled but rapid rewarming)
-active core rewarming:
(Cardiopulmonary bypass, warm fluid administration, warm humidified oxygen, warm peritoneal lavage.)
-passive external rewarming:
Warm blankets and over the bed heaters
note: Cold blood returning from the extremities has high
levels of lactic acid and can cause potential cardiac
dysrhythmias and electrolyte disturbances (EKG MONITORING)
Risk for pt who has central line
S/s for superficial burn
-pain is soothed by cooling
-reddened, blanches with pressure
-minimal or no edema
Know priority for er nurse or any nurse
Nursing interventions for pt with frost bite
-Controlled but rapid rewarming 37 to 40 C circulating bath for 30-40min intervals
-analgesics for pain
-do not massage or handle (if feet are involved, do not walk)
Know side effects of ketoralac (select all that apply)
NSAID, GI Bleeding, Kidney Damage, Fluid retention
Pt arrives in e.r. After trauma, what part of assessment on trauma victim would take highest priority.
Airway, Breathing and then Circulation
s/s of pt that may becoming violent
-Pacing or restlessness
-clenched fist, loud speech
How to de-escalate violent patient.
-Respect personal space
-Do not challenge agitated
-Begin verbal communication
-Identify wants and feelings
-Be short and to the point
-Listen to the patient
-Set clear limits
Trauma patient interventions
-Requires a team approach
-Determine extent of injuries and establish priorities
-Assume cervical spine injury
-Injuries interfering with vital physiologic function have highest priority (ABC's)
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