- Shuffle
Toggle OnToggle Off
- Alphabetize
Toggle OnToggle Off
- Front First
Toggle OnToggle Off
- Both Sides
Toggle OnToggle Off
Front
How to study your flashcards.
Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key
Up/Down arrow keys: Flip the card between the front and back.down keyup key
H key: Show hint (3rd side).h key
PLAY BUTTON
PLAY BUTTON
20 Cards in this Set
- Front
- Back
|
what components does the primary survey focus on
|
A airway
B breathing C circulation D disability E exposure/environment |
|
signs & symptoms of airway compromise
|
dyspnea
inability to vocalize drooling presence of foreign body in airway trauma to face or neck |
|
ways to maintain airway (least invasive to most invasive)
|
jaw thrust maneuver
suction and/or remove foreign body insert NG/oropharyneal airway endotracheal intubation |
|
what should be assessed for breathing phase of primary survey
|
assess for SOB
tachycardia cyanosis paradoxical/asymmetric chest wall movement decreased/absent breath sounds on one side not other hypotension |
|
interventions for breathing part of primary survey
|
administer high flow O2 (100% via nonrebreather mask
Bag-valve mask ventilation w/100% O2 and intubation for life-threatening conditions monitor pt response |
|
assessment for circulation part of primary survey
|
check central pulses (carotid, apical, femoral)
assess skin for color, temp, moisture assess mental status & capillary refill |
|
interventions for circulation part of primary survey
|
insert 2 large-bore IV catheters
initiate aggressive fluid resuscitation using NS or LR |
|
assessment for disability part of primary survey
|
AVPU
Glasgow Coma Scale Pupils (PERRLA) |
|
what happens in exposure/ environment part of secondary survey
|
all clothing is removed
provide temperature control |
|
explain the importance of knowing the mechanism of injury in the assessment and care of the patient
|
it's important to know the mechanism so you know how to treat the patient.
|
|
collaborative management of head injury to prevent/treat secondary injury
|
Preventing secondary injury – blood that’s caustic to brain tissue, pneumonia include:
• Timely diagnosis • Surgery if necessary Frequent neurological assessment and report any changes to PCP Use calm, gentle approach Maintain normothermia Pain management Infection control CT scan surgery placement of ICP monitor Prophylactic seizure meds, control glucose, antibiotics to prevent infection |
|
identify the use of the Glasgow Coma Scale in predicting severity of injury
|
Evaluates opening of the eyes, verbal response and motor response.
Highest score possible is 15 The higher the score the higher the brain function Lowest possible score 3 Score of 8 or less is poor prognosis Nurses must document technique used to illicit response so that each new nurse can be able to tell if the response is changed (worse or better) by using the same technique. |
|
identify the components & significance of Cushing's Triad.
|
Components: systolic hypertension, decreased pulse and altered respiration patter.
Significance: with increased ICP compensatory mechanisms begin to fail and there is a loss of autoregulation. the systolic BP rises in an attempt to maintain cerebral perfusion. This causes the triad. |
|
explain the rationale for the measures used to prevent & treat increased ICP
|
monitor airway
hyperoxygenate prior to suctioning head in midline neutral position & HOB greater than 30 degrees to promote venous drainage avoid clustering nursing activities avoid overstimulation of client |
|
identify immobilization techniques used to prevent secondary injury in SCI patients
|
skeletal traction to stabilize or bring spine back into proper alignment
halo w/ or w/o vest surgery to reduce fracture or decompress spinal cord |
|
treatment priorities during acute phase of SCI
|
airway mgmt
hemodynamic monitoring ECG assess for signs of decr tissue perfusion (decr BP, confusion, diminished/absent peripheral pulses) prevent DVTs |
|
discuss effects of SCI r/t ongoing mgmt during subacute & transitional phase of injury
|
autonomic dysreflexia can occur just as pt is recovering from spinal shock
incr hypertension can cause MI or retinal & cerebral hemorrhage orthostatic hypotension common |
|
common causes of autonomic dysreflexia
|
prevent distention of bladder & bowel
keep clothes, appliances loose good nail care prevent/treat pressure ulcers |
|
common symptoms of autonomic dysreflexia
|
sudden rise in BP
seeing spots/blurred vision pounding headache nasal stuffiness facial flushing red blotches on chest excessive sweating above level of injury goose bumps cool, clammy skin nausea anxiety bradycardia |
|
emergency interventions for autonomic dysreflexia
|
raise HOB
remove any abdominal binder or other restrictive devices rapid acting antihypertensives - Procardia (nifedipine), nitroglycerin |
