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Chapter 2

Unit 1: Foundations of nursing care for adults

"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!
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