Help
Options
Didn't know it?
click below
click below
Knew it?
click below
click below
Don't Know
Remaining cards (0)
Know
retry
shuffle
restart
0:00
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
Chapter 2
Unit 1: Foundations of nursing care for adults
| Question | Answer |
|---|---|
| "Triage" | Client with the highest acuity needs recieves the quickest tx |
| Triage framework | Emergent, Urgent, Nonurgent |
| Emergent (part of triage) | Life- or limb-threatening situation |
| Urgent (part of triage) | Client should be treated soon, but that the risk posed is not life-threatening |
| Nonurgent (part of triage) | Generally can wait for an extended length of time without serious deterioration |
| Triage under mass casualty conditions | Military form that is implemented w a focus of achieving the greatest good for the greatest # of people |
| Emergent (class 1) | Red tag; immediate threat to life |
| Urgent (class 2) | Yellow tag; major injuries requiring immediate tx |
| Non urgent (class 3) | Green tag; minor injuries, no immediate tx |
| Expectant (class 4) | Black tag; expected/alllowed to die |
| Primary Survey | Rapid assessment of life-threatening conditions, no longer than 60 secs to perform |
| What guides the primary survey? | ABCDE |
| ABCDE stands for? | Airway/cervical spine, Breathing, Circulation, Disability. Exposure |
| Airway/cervical spine | If client is awake/responsive; airway is open. If loses airway; inspect mouth for foreign objects, blood, teeth, etc. If client is unresponsive w/o trauma suspicion; head-tilt, chin-lift maneuver |
| Head-tilt, chin-lift, why? | Most effective way to open client's airway. Do NOT perform if suspected cervical spine injury 1 hand on forehead, other on chin; tilt head while lifting chin This lifts the tongue out of the laryngopharynx= patent airway |
| If client unresponsive w trauma suspicion, how do you open airway? | Modified jaw thrust maneuver |
| How do you do the modified jaw thrust manuever? | Both hands on either side of client's head, find connection between maxilla and mandible, lift jaw superiorly while maintaining alignment of the cervical spine |
| How do you clear the airway of obstructions manually? | Finger-sweep method; vomit/teeth/blood/foreign object |
| Breathing | Assess once a patent airway is achieved -LS -Observe chest movement/effort -Rate/depth of respirations -Chest trauma? -Trachea position -JVD |
| If breathing is not present/ inadequate? | Bag valve mask.. or CPR until one is found |
| Circulation | HR, BP, perfusion -precursors to shock |
| Interventions to achieve circulation | -CPR -Assess for external bleeding; pressure to visible bleeding site, apply a tourniquet distal to a traumatic amputation -IV assess; large bore both AC's, isotonic fluids/blood |
| Inadequate circulation can cause | Shock; hypotension, tachycardia, eventual tissue ischemia + necrosis |
| Interventions for shock | O2, pressuring to bleeding, elevate feet, IV fluids/blood, VS, support. |
| Disability | Determines client's LOC |
| What is a good method to determine disability/LOC? | AVPU; alert, response to voice, response to pain, unresponsive |
| Glasgow coma scale | Eye opening, verbal response, motor response -3-15 (low is bad) |
| Exposure | Remove client's clothing, always removed for a resuscitation attempt -Hypothermia is a concern; vasoconstriction & impaired O2 |
| To prevent hypothermia | -Remove wet clothing -cover w/ blankets, heat lamp -^ room temp -warm IV fluids |
| Poisoning | Exposure to a toxic agent |
| Interventions to manage exposure to or ingestion of a toxic substance | -o2, ventilation, ect. -monitor circulation -IV fluids -VS -assess tissue edema q15-30 for snake bites/spider -opioids for pain -ABGs, BG, coagulation -Valium IV if seizures -Reverse heroin/toxicity w. narcan -dialysis |
| Rapid response team; pg. 13 | Respond to emergency situations; respiratory/cardiac arrest, stroke -SBAR |
| Cardiac emergency; 1. Cardiac arrest | Sudden cesation of cardiac function usually caused by ventricular fibrillation or asystole |
| What is ventricular fibrilation? (VF) | Fluttering of ventricles causing loss of consciousness, pulselessness, & no breathing -Need defibrillation |
| Pulseless ventricular tachycardia (VT) | Irritable firing of ectopic ventricular beats at a rate of 140-180/min -Will become unconscious overtime and deteriorate in VF |
| Ventricular Asystole | Complete absence of electrical activity & ventricular movement of the heart -Complete cardiac arrest |
| Pulseless electrical activity (PEA) | A rhythm that appears to have electrical activity but is not sufficient to stimulate effective cardiac contractions |
| What is BLS? (pg. 14) | Basic life support; involves hands on approach to assess/manage airway, breathing, circulation |
| What is ACLS? | Advanced cardiac life support; builds on BLS assessment/management -cardiac monitoring -invasive airway management -electrical (defib) -IV access, etc. |
| What is PALS? | Pediatric advanced life support; builds on BLS for neonatal & pediatric assessment/management |
| Administer IV antidysrhythmic meds according to ACLS guidelines; (pg.14) | Epi 1 mg IV push q3-5 min OR Vasopressin 40 units IV x1 only (switch to epi if no response) |
| Post resuscitation; pharmacological management (pg. 16) | IV meds that cause a catecholamine adrenergic agonist effect -cannot be taken by the oral route; can't cross the BBB, short duration of action |
| Examples of catecholamines | Epinephrine, dopamine, dobutamine |
| Receptors; Alpha 1 | Activation of receptors in arterioles of skin, viscera & mucous membranes, & veins lead to vasoconstriction |
| Beta 1 receptors | Heart stimulation -^ HR -^ myocardial contractility -^ rate of conduction through AV node -release of renin d/t activation of kidney receptors |
| Beta 2 receptors | Activate receptors in arterioles of the heart, lungs, skeletal muscles = vasodilation -bronchial stimulation = bronchodilation -uterine smooth muscle= relax uterus -liver= glycogenolysis -Skeletal muscle receptors; muscle contraction |
| Dopamine receptors | Activation of receptors in the kidney= renal blood vessels dilate |
| Epinephrine acts on which receptors? | Alpha 1, beta 1, beta 2; good for emergencies.. like cardiac arrest |
| Dopamine (Intropin) which receptors? | Dopamine, Beta1, Alpha 1 |
| Dobutamine (Dobutrex) which receptors? | Beta1 |
| Adverse effects of Epi (pg. 18) | -vasoconstriction can lead to htn crisis -beta 1 can cause dysrthythmias, possible angina |
| Adverse effects of Dopamine | -beta 1; dysrhythmias & angina -high doses = extravasation.. necrosis |
| Dobutamine adverse effects | Increased HR |
| Pregnancy risk category __ for dpi, dopa and dobutamine | C |
| How do tricyclic antidepressants effect EPI? | Block the uptake of epi = which prolongs and intensifies effects -might need lower dose |
| How do MAOIS effect EPI? | prolong and intensify epi; avoid use of MAOIs |
| Extravasation can be tx w/ ? | Local injection of an alpha-adrenergic blocking agent; phentolamine |
Created by:
mary.scott260!
Popular Nursing sets