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
Emergency Nursing P2
| Question | Answer |
|---|---|
| is a life threatening condition due to INADEQUATE PERFUSION | Shock |
| Stages of Shock | Compensatory Progressive Refractory |
| Body tries to compensate for low perfusion -normal BP -Inc. HR and RR | Compensatory |
| Compensatory begins to fail Hypotachytachy | Progressive |
| Types of Shock | Hypovolemic Cardiogenic Obstructive Distributive |
| MOST COMMON and has a problem with fluid/blood loss Hypotachytachy, weak pulse, delayed capillary refill, cool and clammy skin, Oliguria | Hypovolemic shock |
| First thing to do in Hypovolemic Shock | Stop the main cause of fluid/blood loss |
| Fluid Resuscitation in Hypovolemic Shock | Isotonic: LRS, Gauge 18 |
| Gauge for Blood Transfusion and Fluid Resuscitation | Gauge 14, 16, 18 |
| Gauge for Adults | Gauge 20, 22 |
| Gauge for Pedia | Gauge 24, 26 |
| Position for patient in Shock | Modified Trendelenburg = inc. the perfusion Trendelenburg = risk for inc. ICP |
| Heart cant pump enough blood (Heart Failure) | Cardiogenic shock |
| Assessments for Cardiogenic shock | Hypoperfusion crackles (blood backs up to lungs) jugular vein distention (blood backs up to systemic circulation) edema |
| Interventions as prescribed in Cardiogenic Shock | Inotropes: Dobutamine (inc. contractility) Diuretics: Furosemide (Lasix) (morning to prevent nocturia/sleep disturbances-6AM) WOF: Hypokalemia and Hypotension |
| Physical obstruction to blood flow | Obstructive |
| Action for Obstructive Shock | Treat the underlying cause = WOF: Risk for bleeding |
| Main cause of Obstructive Shock | Pulmonary Embolism |
| In Obstructive Shock, administer thrombolytics and anticoagulant | Thrombolytics - Urokinase, Streptokinase, Alteplase Anticoagulant - Warfarin-Vit K, Heparin-Protamine Sulfate |
| Type of shock which defines vasodilation of blood vessels | Distributive |
| Types of Distributive Shock | Neurogenic Anaphylactic Septic |
| ONLY shock that has NO COMPENSATORY MECHANISM spinal cord injury > loss of SNS function > Vasodilation of blood vessels hypotension, bradycardia | Neurogenic Shock Meds: Vasopressors - constrict blood vessels (Norepinephrine: inc. BP) Atropine - Inc. HR |
| IgE: Allergy = Ellergy, allergeeeeeee Allergic reaction > histamine release > vasodilation of blood vessels and airway constriction hypotension, stridor, angioedema, urticaria (rash/hives) | Anaphylactic Shock Meds Antihistamine: Diphenhydramine Corticosteroids: for inflammation (angioedema) |
| Infection > septicemia > Vasodilation of blood vessels hypotension, fever and chills | Septic Shock Collect blood cultures (do detect the type or organism) > administer antibiotics or antivirals > prevent resistance |
| Disaster set up by American Heart Association | Cardiopulmonary Resuscitation (CPR) |
| in CPR, check what pulse | Carotid pulse no more than 10 secs |
| (+) pulse, (-) breathing | Rescue Breathe |
| Recovery position after CPR | Side lying |
| When to stop CPR | Scene is Unsafe Emergency response has arrived you are exhausted spontaneous circulation has returned |
| Measuring the Neurological Function | Disability |
| Rapid Assessment of LOC (Yes/No) | AVPU Alert Verbal Response Pain Response Unresponsiveness |
| More detailed compared to AVPU | GCS E 4 V 5 M 6 |
| Fully exposing the patient to detect hidden problems examples: hidden wounds bruising and bleeding deformities and fractures thermal problems | Exposure |
| is a life threatening condition due to inadequate thermoregulation prolonged exposure to high temperature failure of HYPOTHALAMUS to regulate body temperature | Heat Stroke |
| Assessment in Heat Stroke | HEAT Hot and dry skin Elevated HR, RR, TEMP (40.6 'C or greater) Altered level of consciousness >seizure Throw Up (Vomit) |
| In heat stroke, apply ice pack in what part of the body | axilla, groin, chest |
| Accessible: Surface | Axilla, temporal |
| Accurate: Core | Rectal: most accurate: contraindicated with hemorrhoids Oral: Second Option if there is hemorrhoids Tympanic |
| Core body temperature <35'C | Hypothermia |
| Assessments in Hypothermia | CHILLS Cyanosis - peripheral and central due to vasoconstriction Heart Arrythmia - slows the electrical activities of the Heart Inability to talk LOC dec. Low VS - coldness slows metabolism Shivering (EARLIEST AND COMMON SIGN) |
| Absence of Sweat | Anhidrosis |
| in Hypothermia, because of arrythmia, monitor | ECG, LOC - give 02 Dry the pt completely |
| Hypothermia Intervention, put the patient in | Bair Hugger |
| Partial Separation of surgical wound/sutures Cause: Inc. Abdominal pressure (straining coughing, sneezing) | Dehiscence |
| In Dehiscence, what will you do to reduce pressure | splinting |
| Exit of organ, complete separation of wounds with organ protrusion Cause: worsening dehiscence | Evisceration management: supine with bended knees, never push back the organs |
| Comes from the french word TRIER which means TO SORT patient accordingly to severity of condition | TRIAGE |
| Direct all available resources to the mostly illed patient "what makes you worst, makes you first" | Hospital |
| Scarce of resources | Disaster |
| Do the greatest good for the greatest number of people | Utilitarianism |
| EMERGENT OR IMMEDIATE airway and breathing problems uncontrolled bleeding Unstable patient with life threatening conditions > 30 RR >2 capillary refill | RED Treatment: 15-30 mins |
| URGENT or DELAYED controlled wound/bleeding MAXILLOFACIAL wounds without airway compromise fractures without hemorrhage Stable at the moment but can deteriorate later if left untreated | YELLOW Treatment: <2 hours |
| MINIMAL or WALKING WOUNDED minor cuts, abrasions, lacerations anxiety minor injuries | GREEN Treatment: > 24 hours hrs |
| DEAD or EXPECTANT shallow and apneic breathing devastating head injury fixed and dilated pupil unlikely to survive injuries are too entensive | BLACK |
Created by:
lessuy