Emergency and Disaster Nursing Exam 2 with Complete Solution

Scope and Practice of Emergency Nursing - ANSWER -emergent, urgent, and critical care needs -an emergency is whatever the pt or family considers it to be -the emergency nurse has special training, education, experience, and expertise in assessing and identifying health care problems in crisis situations Emergency Nursing - ANSWER -pts with life threatening or potentially life-threatening problems enter the hospital through the ED Triage - ANSWER -process of rapidly determining patient acuity -represents a critical assessment skill -triage process: pt who have a threat to life, vision, or limb are treated before another pts -triage system: categorizes pt so most critical are treated first -pt and family focused Initial Assessment - ANSWER -a systematic process -divided into 2 phases: primary and secondary -must follow safety guidelines for protection of pt and staff Pedi Assessment Triangle - ANSWER -appearance (#1) -work of breathing -circulation (color) Emergency Airway Management - ANSWER -open the airway- keep it open -airway is everything; without one nothing matters -establishing and maintaining a patent airway -ensuring effective oxygenation and ventilation Head Tilt-Chin Lift Maneuver - ANSWER Indications: -unresponsive -NO spinal injury -unable to protect airway Contraindications: -responsive -possible spine injury Advantages: -no equipment -Noninvasive Disadvantages: -hazardous to spinal injury -no protection from aspiration Jaw Thrust Manuever - ANSWER Indications: -unresponsive -possible spine injury -unable to protect airway Contraindications: -resistance to opening mouth Advantages: -used with spine injury or cervical collar -no special equipment required Disadvantages: -cannot maintain if pt becomes responsive or combative -difficult to maintain for extended time -difficult to use with bag mask ventilation -thumb must remain in place -requires second rescuer -no protection against aspiration Emergency Nursing - ANSWER Pt=primary survey focuses (ABCD) -A: airway with cervical spine stabilization and/or immobilization -B: breathing -C: circulation -D: disability (quick neuro check; AVPU) -don't move on until the previous has been taken care of -identifies LIFE THREATENING conditions AVPU - ANSWER -A: ALERT -V: RESPONSIVE TO VOICE -P: RESPONSIVE TO PAIN -U: UNRESPONSIVE Secondary Survey - ANSWER -Definition: brief, systematic process to identify all injuries -EFGHI -E: exposure/environmental control -F: full set of vitals/ five interventions/ facilitate family presence -G: give comfort measures (pharm and nonpharm) -H: history and head to toe assessment -I: inspect entire body -Evaluate need for tetanus prophylaxis -provide ongoing monitoring (BP, O2, HR, primary survey) -prepare to send Death in ED - ANSWER -must recognize importance of hospital rituals in preparing the bereaved to grieve -determine if pt could be candidate for non-heart beating donation -call medical examiner (have SBAR and hx ready) Gerontologic Considerations: Emergency Care - ANSWER Elderly @ high risk for injury: -decreased visual acuity and peripheral vision -hearing loss (esp high frequency sounds) -pre existing disease and med use -dementia and cognitive impairment -main injury with elderly: falls -are findings b/c fall or did they cause the fall FYI: anyone who dies within 24hrs of arrival is a careeners case; leave in all tubes - ANSWER ... After Death: - ANSWER -clean room -clean pt -remove unneeded equipment -cover in warm blanket -bring chairs/kleenex -turn lights down GI Emergency - ANSWER -Upper GI: esophagus, stomach, dudenum -Lower GI: jejunum, ileum, colon, rectum Peptic Ulcer Disease (PUD) - ANSWER -causes upper GI bleed -causes: overuse of NSAIDs (#1), helicobacter pylori Stress Related Erosive Syndrome (SRES) - ANSWER -can prevent -causes upper GI bleed -high risk for: post op, trauma, shock, burns, acute neuro disease, vent dependence Medical Emergencies - ANSWER -Esophageal Varices: vessels in esophagus that become engorged -@ risk for: eating d/o (V). alcoholics -s/s: portal HTN -Gastric Perforation -s/s: sudden severe upper abd pain, radiates to R shoulder, rebound tenderness, rigidity -sets you up for sepsis Heat Exhaustion - ANSWER -prolonged exposure to heat -occurs when body is unable to cool itself -sxms may be vague -general malaise, N, V, fatigue, light headed, diaphoresis, mild confusion, hypoTN -temp of 99.6-104.0