ED, trauma, disaster and critical care nursing – Flashcards
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Who is the ANA?
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the american nurses association
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What is the ANA definition of emergency nursing?
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the care of individuals across the lifespan with perceived or actual physical or emotional alterations of health that are undiagnosed or require further interventions. Emergency nursing care is episodic, primary, typically short-term and occurs in a variety of settings
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traits of an emergency nurse
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rapidly recognize and tx life threatening illness and injury, able to make rapid decisions, prioritize care and act with autonomy, able to provide pt centered care in a chaotic environment
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Who is the ENA
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emergency nurses association - they are a specialty nursing organization aimed at advancing emergency nursing practice, they provide standards of care for nurses working in ED, scope of practice and position statements (STANDARDS FOR BEST PRACTICE)
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What is BCEN?
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Board of Certification for Emergency Nurses - they provide/process testing for nurses to become nationally certified in emergency nursing and subspecialties
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What is CEN?
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Certified Emergency Nurse
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What is CPEN?
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Certified Ped Emergency Nurse
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What is CTRN?
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Certified transport Registered Nurse
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What is CFRN?
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Certified Flight Registered Nurse
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ANCP?
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Acute Care Nurse Practitioner and is an advanced practice
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CNS
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Clinical Nurse Specialist - an advanced practice
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What are some of the reasons so many people end up in the ER?
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access to care, aging pop., complex care and readmissions, mental health, substance abuse, EMTALA
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What is EMTALA?
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Emergency Medical Treatment and Labor Act - a federal law that says hospitals cannot refuse to serve pt if it is an emergency, if they are transferred they cannot go to a less qualified facility, IF it is not an emergency they can be DC or referred to outside resources
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What are the 3 main stages of pt coming into to ED for evaluation?
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1) assessment/triage 2) evaluation/intervention - stabilization 3) disposition ( discharge, admission, transfer, deceased)
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What is ESI
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Emergency Serverity Index is used to triage pts and determines their next step for tx. has a 1-5 scale and uses the illness severity to use resources appropriately, it is a national system make so that everyone with the same 5 pt should come out with the same triage order
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What is ESI 1-2?
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pt goes to a room
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What is ESI 3?
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This is the most difficult one bc it is not classified, these pt need more evaluation to determine next steps
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What is ESI 4-5?
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Fast track for care
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What is the main emphasis on a successful ED?
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FLOW OF THE DEPARTMENT
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What is the definition of triage?
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process of rapidly determining pt acuity, it is a critical assessment skill for emergency, categorize pt so the most critical is tx first using ESI
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ESI 1
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you are doing CPR here
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ESI 2
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ALOC, severe pain
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ESI 3
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" multiples" need more than one resource (xray, CT scan, MRI, cath lab, IV fluid therapy, etc.)
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ESI 4
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Resource - this pt need one main resource (xray, ct scan, MRI, cath lab, IV fluid therapy etc.)
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ESI 5
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This pt needs no resources
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Who is an admit in ESI triage system?
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1&2
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TNCC assessment?
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Trauma Nurse Core Course - assessment and prioritize. This system is divided into 3 phases - primary assessment, secondary survey and tertiary survey
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Describe the primary survey of the TNCC assessment
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focuses on airway, breathing, circulation, disability (neuro) and exposure (temp) (ABCDE), identifies life threatening conditions, if the conditions are r/t ABCDE interventions are started STAT and before moving to the next step. It includes airway with c-spine and/or immobilization. s/s - dyspnea, cant vocalize, foreign body airway, trauma to face or neck
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What parameters do we use for airway?
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MAINTAIN an airway using the least invasive first (DO NOT LOSE THE AIRWAY ONCE YOU HAVE IT ESTABLISHED), suction and/or remove foreign body, insert NG or oropharyngeal airway, ET tube
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Parameters for breathing in TNCC
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assess the WORK of breathing, rate, depth, effort, equal rise and fall, cyanosis, asymmetrical/paradoxical movement, decrease or absent BS, retractions, tripoding, gasping, grunting
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compromised breathing tx in primary TNCC
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02, BVM with 100% 02, monitor response (BVM BEST ON 10ML, NC BEST ON 4ML)
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s/s for compromised circulation TNCC primary
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skin signs, pulses (check CENTRAL pulses, peripheral may be absent due to injury or vasoconstriction) carotid in adult, brachial in infant
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Emergency tx circulation impairment TNCC primary
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chest compressions, IV/IO access - large bore if vol concerns, initiate aggressive fluid resuscitation using NS or LR as indicated
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Primary survey TNCC disability
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is measured by a pt consciousness - use AVPU, GCS, pupils
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What is AVPU
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alert, responsive to voice, responsive to pain, unresponsive
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What is GCS
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glascow coma scale - more specific than AVPU evaluation
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Primary survey exposure/environmental TNCC
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remove all clothes and do full physical assessment, prevent heal loss, GET TEMPS
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SECONDARY ASSESSMENT TNCC
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a brief systematic process to identify all injuries, full VS, application of devices (cardiac monitor, continuous 02 monitor), ETCO2, get history (SAMPLE), head to toe FOCUSED assessment
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What is SAMPLE?
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Use it to get pt history - s/s, allergies, meds, past med hx, last oral intake, event leading up to
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TERTIARY ASSESSMENT TNCC
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pertinent lab and diagnostic studies, detailed assessment of affected systems, consultation if applicable
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What is CDA
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Clinical decision area - this is liscenced space in the ER for pt that need to be observed for 24 hours but they have not signs for admission, there is a state agency that determines this area
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examples of pt who might go to CDA
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DM, chest pain but with normal troponin, 'ON THE FENCE PTS", not critically ill, do not need specialized units
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What are some advantages of CDA
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avoid the risk of admitting someone who doesn't need admitting, cost, avoids discharging someone who was not fully stable
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What are disadvantages of CDA?
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The space, take up a staff nurse, can only be used for these pt
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define heat exhaustion
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prolonged exposure to heat - this patients looks like a hot pt - HOT AND SWEAT- tired, sweaty, n/v, anxiety, hypotension, tachycardia, increase temp (99.6-104) - HOT AND WET
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tx for heat exhaustion
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stop activity, cooling measures, monitor, IV fluids, elderly or people with chronic illness may require admission
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define heat stroke
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most serious form of heat stress due to failure of hypothalamic thermoregulatory processes - core temp rises > 104, ALOC, NO SWEATING, circulatory collapse - HOT AND DRY
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Tx. heat stroke
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MEDICAL EMERGENCY - ABCs, cooling measures - prevent shivering, IV fluids for vol and lyte replacement, monitor for rhabdomyolysis (muscle breakdown that clogs the kidneys - urine will be very orange)
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Define hypothermia
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core temp <95, there is a mild, mod and severe
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risk factors for hypothermia
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elderly, very young, drugs (antipsychotics), ETOH, ALOC, sepsis, spinal cord injury (they cannot shiver), IF CORE TEMP IS <86, THIS IS LIFE THREATENING
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Mild hypothermia
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93.2-96.8 - shivering, lethargic, confusion, rational to irrational behavior, minor heart rate changes
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Moderate hypothermia
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86-93.2 - rigid, bradycardia, bradypnea, blood pressure by Doppler, metabolic and resp acidosis, hypovolemia, shivering disappears at 86
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Severe hypothermia
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<86 - the person looks dead, bradycardia, asystole, v fib
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tx for hypothermia
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warm pt to at least 90 before pronouncing dead (YOUR NOT DEAD UNTIL YOUR WARM AND DEAD) manage and maintain ABCs, rewarm pt slowly or they can go into shock and vfib, correct dehydration and acidosis, tx cardiac dysrhythmias
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tx mild hypothermia
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passive or active external rewarming - move pt to warm, dry place, remove damp clothes, place warm blanket on them or active external rewarming - body to body contact, fluid or air filled warming blankets, radiant heat lamps
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moderate to severe hypothermia tx
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active CORE rewarming - use heated humidified 02, warmed IV fluids, warm blankets, warm peritoneal, gastric or colonic lavage, USE NS OR LR - NO FLUIDS WITH SUGAR, WARM THE CORE FIRST BC IF YOU THINK THE PERIPHERAL IS WARMED THE CORE CAN STILL BE TOO COLD AND WILL SPREAD AGAIN TO PERIPHERAL, remember when rewarming that the pt will vasodilate but will have the same amt of fluid in their body so monitor bp closely
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Define a submersion injury
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when a person becomes hypoxic as the result of submersion in substance , usually water
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define drowning
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death from suffocation after submersion in fluid (you can drown without fluid in your lungs due to laryngospasm)
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Steps for submersion injury into ED
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Initial assessment (abcde), address hypoxia, mechanical ventilation with PEEP or CPAP to improve gas exchange when pulmonary edema is present, preserve neuro fxn and manage cerebral edema, monitor and manage fluids, lytes and acid base balance, rewarm if indicated
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PEEP
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Positive end expiratory pressure - keep the alveoli from closing all the way
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CPAP
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Continuous positive arterial pressure - keeps alveoli from closing all the way shut
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who is at the greatest risk for animal bites?
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children
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what is the most common animal bites
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dogs and cats followed by wild or domestic rodents
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complications of animal bites
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infection, rabies, mechanical destruction of skin, muscle, tendons, blood vessels or bone
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about dog bites
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usually in the extremities, rabies is a concern, can have significant tissue damage and death in children
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about cat bites
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deep puncture wounds can involve tendons and joint capsules, has a greater incidence of infection than dogs
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What is rabies
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a virus and there are 3 strains, it overwhelms the brain until it dies
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about human bites
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puncture wounds or lacerations, HIGH risk infection, oral bacterial flora, hep virus
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What is the Milwaukee protocol
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it is for rabies and puts pt in an induced coma so that the body can try and fight the rabies virus
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tx animal and human bites
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clean with copious irrigation, debride, tetanus prophylaxis, analgesics, prophylactic antibiotics for wounds with risks for infections (wound over joints, less than 6-12 hours old, puncture wounds, bites on hand or foot), leave puncture wounds open, loose sutures for lacerations, splint wounds that are over joints
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Rabies prophylaxis
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essential with animal bites, no cure once the symptoms appear and when they do it is too late and is fatal, initial injection of rabies immune globulin, then series of five injections of human diploid cell rabies vaccine on days 0, 3, 7, 14 and 28 (relatively painless especially compared to the old ones that were very painful and give in arm just like flu or tetanus shot)
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define poisoning
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chemicals that harm the body accidentally, occupationally, recreationally, or intentionally, severity depends on the type, concentration and route of exposure
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management of poisoning
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↓ absorption, ↑ elimination, implement toxin specific interventions per poison control center
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how to decrease absorption of poisons
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GASTRIC LAVAGE - intubate before lavage, if ALOC or ↓ gag reflex, perform within 2 hours of ingestion, don't if the poison is caustic agents, sharp objects, nontoxic substances. ACTIVATED CHARCOAL - MOST EFFECTIVE tx, orally or gastric tube within 60 min of ingestion, don't do if no BS, paralytic ileus, or toxin poorly absorbed by charcoal, can also neutralize antidotes so do not give shorty after charcoal WE ONLY TX POISONING WITH WHATEVER POISON CONTROLS TELLS US TO.
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How to tx toxins in the eyes
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dermal cleansing/eye irrigation - skin and ocular decontamination with water or saline, decontamination takes priority over all else except BLS
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What are enhanced elimination options
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cathartics (sorbitol) - give with first dose of charcoal to stimulate intestinal motility/increase elimination, whole bowel irrigation
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tx for blood poisoning
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hemodialysis/hemoperfusion - reserved for severe acidosis, urine alkalinization, chelating agents, antidotes, ASA od,
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3 reasons for violence toward others
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organic dz, psychosis, antisocial behavior, our number one priority is to keep pt and staff safe
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What is family and intimate partner violence
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pattern of coercive behavior in a relationship, involves fear, humiliation, intimidation, neglect, and/or intentional physical, emotional, financial or sexual injury, found in all professions, cultures, socioeconomic groups, ages, genders mostly in women, elderly and children, and screening for violence is required in ED
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what interventions do we take with family and intimate partner violence
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report abuse, make sure they are safe, make referrals, provide emotional support, inform victims about options
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What are the 5 natural disasters?
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natural, chemical/hazmat, terrorism/bioterrorism, nuclear, incendiary/bombing
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AACNs definition of "critical care nursing"
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specialty within nursing that deals specifically with human responses to life-threatening problems. A critical care nurse is a licensed professional nurse who is responsible for ensuring the acutely and critically ill patients and their families receive optimal care
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Define critically ill pt
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pt who are high risk for actual or potential-life threatening health problems, the more critical the more vulnerable the pt is to be unstable and need vigilant nursing care
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What is required by a critical care nurse
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comprehensive knowledge of illness/injury, ability to anticipate complications, advanced assessment skills, ability to act independently and collaboratively, advanced technological knowledge and skill, provide pt and family centered care for complex pt pop.
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What type of care is critical care?
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step down, progressive
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Who is AACN
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American Association of Critical Care Nurse. The largest specialty nursing organization in the world, representing >500,000 nurses who care for acutely and critically ill pt, dedicated to providing members with the knowledge and resources necessary to provide optimal care to critically ill pt. manages national cert exams and renewal processes for MOST critical care nurses
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What is CCRN
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critical care registered nurse
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PCCN
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progressive care nursing certification
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CMC
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cardiac medicine subspecialty
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CSC
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cardiac surgery subspecialty
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CNML
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clinical nurse manager and leader
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What level education is required for advanced practices?
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Masters
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ACNPC
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acute care nurse practitioner certification (ADVANCED PRACTICE)
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CCNS
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Critical care clinical nurse specialist (ADVANCED PRACTICE)
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Parameters for critical care
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pt with life threatening or potentially life threatening problems
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Common reasons for being in critical care
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physiologically unstable, risk for serious complications, need for invasive intervention and frequent assessment, requires intensive and complicated nursing support
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What are some common examples of "complicated nursing support needs?
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hemodynamic monitoring, mechanical ventilation, circulatory assistive devices, intracranial pressure monitoring, med titration (vasoactive, sedation, fibrinolytics) continuous renal replacement therapy.
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What is hemodynamic monitoring?
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the measurement of pressure, flow and oxygenation within the cardiovascular system
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Invasive pressure monitoring
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art line (continuous invasive blood pressure monitoring), CVP - right atrial pressure (swan ganz -preload), pulmonary artery (intracardiac pressure & CO), SVO2 and ScVo2 (tissue oxygenation)
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explain reading a CVP pressure
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There is an A, C and V waves. A is atrial contraction, X is atrial relaxation, C wave is bulging of the closed tricuspid valve into the right atrium during ventricular, Y is opening of the tricuspid valve and filling of the ventricle
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describe a swan ganz
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it is a pulmonary artery catheter with 5 lumens that go to different parts of the heart, there is a balloon at the end that reads the pulmonary artery wedge pressure when inflated, there is a thermistor on the end that measures PA temp and thermodilution cardiac output when solution is cooler than the body temp
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what are 2 circulatory assist devices
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intra-aortic balloon pump and ventricular assist device
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What is a biventricular assist device/
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for a pt waiting for bypass surgery
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What are the two modes of ventilation
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pressure OR volume
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types of ventilation modes? (THREE PEEPS)
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Tidal vol, high pressure limit, rate, I:E, PEEP
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What is the normal amt of air a pt breathes in 1 min?
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500
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What things should you think about when a HIGH pressure alarm goes off
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secretions, coughing, gagging, pt fighting the ventilator (asynchomy), condensation in the tubing, increased resistance (bronchospasm), decreased compliance (pulmonary edema, pneumothorax),
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What to think about when a LOW pressure alarm goes off
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total or partial vent disconnect, loss of airway (total or partial extubation), ET tub/trach cuff leak (pulmonary edema, pneumothorax)
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What to think about with apnea alarm
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resp arrest, oversedation, change in pt condition, loss of airway (total or partial extubation)
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What is involved in the nurse management of mechanical ventilation
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maintain and assess correct placement and cuff inflation, monitor 02 and ventilation, maintain patency of tube, give sedative and analgesics, facilitate communication, educate family and pt
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What is DOPE for trouble shooting mechanical ventilation and advance airway
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Displaced tube (check tube placement, cuff inflation), Obstruction (suction airway), Pneumothorax (assess lung sounds, equal chest rise and fall), Equipment failure (assess the equipment from the patient toward the machine - if needed d/c from vent and hand ventilate)
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what are some common complications of positive pressure ventilation
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cardiovascular system issues, pulmonary (barotrauma, volutrauma, ventilator associated pneumonia), na and h2o imbalance, neuro system, gastro system, musculoskeletal system, psychosocial needs
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common problems with critical care pt
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nutrition, anxiety, pain, impaired communication, sensory perceptual problems, skin integrity, DVTs, sleep problems
