Unit 1: Foundations of nursing care for adults
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| "Triage" | Client with the highest acuity needs recieves the quickest tx
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| Triage framework | Emergent, Urgent, Nonurgent
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| Emergent (part of triage) | Life- or limb-threatening situation
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| Urgent (part of triage) | Client should be treated soon, but that the risk posed is not life-threatening
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| Nonurgent (part of triage) | Generally can wait for an extended length of time without serious deterioration
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| Triage under mass casualty conditions | Military form that is implemented w a focus of achieving the greatest good for the greatest # of people
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| Emergent (class 1) | Red tag; immediate threat to life
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| Urgent (class 2) | Yellow tag; major injuries requiring immediate tx
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| Non urgent (class 3) | Green tag; minor injuries, no immediate tx
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| Expectant (class 4) | Black tag; expected/alllowed to die
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| Primary Survey | Rapid assessment of life-threatening conditions, no longer than 60 secs to perform
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| What guides the primary survey? | ABCDE
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| ABCDE stands for? | Airway/cervical spine, Breathing, Circulation, Disability. Exposure
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| 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
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| 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
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| If client unresponsive w trauma suspicion, how do you open airway? | Modified jaw thrust maneuver
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| 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
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| How do you clear the airway of obstructions manually? | Finger-sweep method; vomit/teeth/blood/foreign object
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| Breathing | Assess once a patent airway is achieved
-LS
-Observe chest movement/effort
-Rate/depth of respirations
-Chest trauma?
-Trachea position
-JVD
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| If breathing is not present/ inadequate? | Bag valve mask.. or CPR until one is found
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| Circulation | HR, BP, perfusion
-precursors to shock
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| 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
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| Inadequate circulation can cause | Shock; hypotension, tachycardia, eventual tissue ischemia + necrosis
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| Interventions for shock | O2, pressuring to bleeding, elevate feet, IV fluids/blood, VS, support.
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| Disability | Determines client's LOC
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| What is a good method to determine disability/LOC? | AVPU; alert, response to voice, response to pain, unresponsive
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| Glasgow coma scale | Eye opening, verbal response, motor response
-3-15 (low is bad)
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| Exposure | Remove client's clothing, always removed for a resuscitation attempt
-Hypothermia is a concern; vasoconstriction & impaired O2
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| To prevent hypothermia | -Remove wet clothing
-cover w/ blankets, heat lamp
-^ room temp
-warm IV fluids
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| Poisoning | Exposure to a toxic agent
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| 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
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| Rapid response team; pg. 13 | Respond to emergency situations; respiratory/cardiac arrest, stroke
-SBAR
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| Cardiac emergency; 1. Cardiac arrest | Sudden cesation of cardiac function usually caused by ventricular fibrillation or asystole
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| What is ventricular fibrilation? (VF) | Fluttering of ventricles causing loss of consciousness, pulselessness, & no breathing
-Need defibrillation
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| 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
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| Ventricular Asystole | Complete absence of electrical activity & ventricular movement of the heart
-Complete cardiac arrest
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| Pulseless electrical activity (PEA) | A rhythm that appears to have electrical activity but is not sufficient to stimulate effective cardiac contractions
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| What is BLS? (pg. 14) | Basic life support; involves hands on approach to assess/manage airway, breathing, circulation
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| What is ACLS? | Advanced cardiac life support; builds on BLS assessment/management
-cardiac monitoring
-invasive airway management
-electrical (defib)
-IV access, etc.
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| What is PALS? | Pediatric advanced life support; builds on BLS for neonatal & pediatric assessment/management
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| 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)
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| 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
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| Examples of catecholamines | Epinephrine, dopamine, dobutamine
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| Receptors; Alpha 1 | Activation of receptors in arterioles of skin, viscera & mucous membranes, & veins lead to vasoconstriction
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| Beta 1 receptors | Heart stimulation
-^ HR
-^ myocardial contractility
-^ rate of conduction through AV node
-release of renin d/t activation of kidney receptors
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| 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
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| Dopamine receptors | Activation of receptors in the kidney= renal blood vessels dilate
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| Epinephrine acts on which receptors? | Alpha 1, beta 1, beta 2; good for emergencies.. like cardiac arrest
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| Dopamine (Intropin) which receptors? | Dopamine, Beta1, Alpha 1
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| Dobutamine (Dobutrex) which receptors? | Beta1
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| Adverse effects of Epi (pg. 18) | -vasoconstriction can lead to htn crisis
-beta 1 can cause dysrthythmias, possible angina
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| Adverse effects of Dopamine | -beta 1; dysrhythmias & angina
-high doses = extravasation.. necrosis
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| Dobutamine adverse effects | Increased HR
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| Pregnancy risk category __ for dpi, dopa and dobutamine | C
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| How do tricyclic antidepressants effect EPI? | Block the uptake of epi = which prolongs and intensifies effects
-might need lower dose
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| How do MAOIS effect EPI? | prolong and intensify epi; avoid use of MAOIs
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| Extravasation can be tx w/ ? | Local injection of an alpha-adrenergic blocking agent; phentolamine
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