CC2 Exam 1 Study Guide
primary survey ANS: rapid assessment of life threatening conditions
- standard precautions
- ABCs: airway, breathing, circulation
- disability
- exposure
airway ANS: assessment: mechanics and ventilation, are they breathing spontaneously?
- if a patient is awake/responsive airway is fine... put on nonrebreather
interventions:
- remove object with suction or finger sweep
- oropharyngeal (no gag reflex) or nasopharyngeal airway (no NG tube if head/face trauma)
- reposition, head tilt/chin lift
- GCS>8 INTUBATE
- CSPINE: any suspicion of cspine injury we need to maintain precautions with collar, extreme care when
rolling patient
breathing ANS: gas exchange, being able to use air properly
assessment:
- resp (lung sounds, chest rise, RR, O2 sat, JVD, chest trauma, trach position)
- watch for chest rising unequally: paradoxical flail chest: fluid enters lungs, 3+ fractured ribs, chest leans
to side, fixed with chest tube
interventions
- oxygen
- chest tube
,- needle decompression if they have a pneumothorax (large bore IV into chest and let some of that air
out)
circulation ANS: assess: HR, BP, peripheral pulses, cap refills, skin color, UO
- cardiac arrest and myocardial dysfunction and hemorrhage can lead to shock
interventions
- priority: identify uncontrolled bleeding and STOP BLEEDING
- replace blood volume lost (fluids, blood products)
- apply tourniquet distal to area if bleeding isnt controlled
- infection
disability ANS: assess: neuro status
- GCS: eyes (4) verbal (5) motor (6),
LESS THAN 8 INTUBATE
- AVPU: alert, verbal, pain, unresponsive
- pupil assessment
- constantly reassess
GCS scale ANS: Eyes (4)
- open spontaneously 4
- moves to speech 3
- moves to pain 2
- no response 1
Verbal (5)
- oriented x 3 5
- confused 4
,- inappropriate responses 3
- incomprehensible sound 2
- no verbal response 1
Motor (6)
- obeys commands 6
- moves to pain response 5
- withdrawals from pain 4
- decorticate 3
- decerebrate 2
- no response 1
exposure and environment ANS: - expose patient, anteriorly and posteriorly
- remove all items, jewelry, clothes, etc.
- maintain privacy and dignity
- preserve items of evidence
- hypothermia (<95) primary concern (maintain patients body heat)
prevention of hypothermia ANS: - remove wet clothing
- cover client with warm blankets
- increase temp in room
- use a heat lamp to provide additional warmth
- infuse warmed IV fluids
- 2 large bore IVs in antecubital fossa
secondary survey ANS: F: full sets of vitals, five adjuncts, family presence
, - contact, update, console family
G: give comfort measures: pain, reposition, padding
H: head to toe assessment, history, AMPLE (allergies, meds, prior med hx, last PO intake, events)
I: inspect posterior
emergency meds ANS: epinephrine
no max dose, given when theres no pulse
amiodarone
antiarrhythmic, afib, aflutter, recurrent vfib or vtach
magnesium sulfate
torsades de pointes
norepinephrine
vasopressor used when BP and volume are low, replace volume first, causes vasoconstriction to increase
BP
dopamine
positive inotrope, increases BP and HR, used when perfusion/CO are bad
disaster START triage ANS: "reverse triage"
- used in mass casualty situations
- allows the greater number of patients to be treated by utilizing resources more effectively
- assess and categorize immediately
black triage tag ANS: EXPECTANT
- victim unlikely to survive given severity of injuries
- palliative care and pain relief
- ex: obvious non survivable injury, respiratory arrest, airway repositioning doesnt work
primary survey ANS: rapid assessment of life threatening conditions
- standard precautions
- ABCs: airway, breathing, circulation
- disability
- exposure
airway ANS: assessment: mechanics and ventilation, are they breathing spontaneously?
- if a patient is awake/responsive airway is fine... put on nonrebreather
interventions:
- remove object with suction or finger sweep
- oropharyngeal (no gag reflex) or nasopharyngeal airway (no NG tube if head/face trauma)
- reposition, head tilt/chin lift
- GCS>8 INTUBATE
- CSPINE: any suspicion of cspine injury we need to maintain precautions with collar, extreme care when
rolling patient
breathing ANS: gas exchange, being able to use air properly
assessment:
- resp (lung sounds, chest rise, RR, O2 sat, JVD, chest trauma, trach position)
- watch for chest rising unequally: paradoxical flail chest: fluid enters lungs, 3+ fractured ribs, chest leans
to side, fixed with chest tube
interventions
- oxygen
- chest tube
,- needle decompression if they have a pneumothorax (large bore IV into chest and let some of that air
out)
circulation ANS: assess: HR, BP, peripheral pulses, cap refills, skin color, UO
- cardiac arrest and myocardial dysfunction and hemorrhage can lead to shock
interventions
- priority: identify uncontrolled bleeding and STOP BLEEDING
- replace blood volume lost (fluids, blood products)
- apply tourniquet distal to area if bleeding isnt controlled
- infection
disability ANS: assess: neuro status
- GCS: eyes (4) verbal (5) motor (6),
LESS THAN 8 INTUBATE
- AVPU: alert, verbal, pain, unresponsive
- pupil assessment
- constantly reassess
GCS scale ANS: Eyes (4)
- open spontaneously 4
- moves to speech 3
- moves to pain 2
- no response 1
Verbal (5)
- oriented x 3 5
- confused 4
,- inappropriate responses 3
- incomprehensible sound 2
- no verbal response 1
Motor (6)
- obeys commands 6
- moves to pain response 5
- withdrawals from pain 4
- decorticate 3
- decerebrate 2
- no response 1
exposure and environment ANS: - expose patient, anteriorly and posteriorly
- remove all items, jewelry, clothes, etc.
- maintain privacy and dignity
- preserve items of evidence
- hypothermia (<95) primary concern (maintain patients body heat)
prevention of hypothermia ANS: - remove wet clothing
- cover client with warm blankets
- increase temp in room
- use a heat lamp to provide additional warmth
- infuse warmed IV fluids
- 2 large bore IVs in antecubital fossa
secondary survey ANS: F: full sets of vitals, five adjuncts, family presence
, - contact, update, console family
G: give comfort measures: pain, reposition, padding
H: head to toe assessment, history, AMPLE (allergies, meds, prior med hx, last PO intake, events)
I: inspect posterior
emergency meds ANS: epinephrine
no max dose, given when theres no pulse
amiodarone
antiarrhythmic, afib, aflutter, recurrent vfib or vtach
magnesium sulfate
torsades de pointes
norepinephrine
vasopressor used when BP and volume are low, replace volume first, causes vasoconstriction to increase
BP
dopamine
positive inotrope, increases BP and HR, used when perfusion/CO are bad
disaster START triage ANS: "reverse triage"
- used in mass casualty situations
- allows the greater number of patients to be treated by utilizing resources more effectively
- assess and categorize immediately
black triage tag ANS: EXPECTANT
- victim unlikely to survive given severity of injuries
- palliative care and pain relief
- ex: obvious non survivable injury, respiratory arrest, airway repositioning doesnt work
