Emergency Nursing and Trauma
A standardized five-level system of ED triage to identify acuity and resource use of clients
What is the Emergency Severity Index
States that the 3 components (brain tissue, blood and CSF) must stay at a constant volume in the closed skull structure
What is the Monroe Kellie doctrine
Type of head injury often associated with a tear in the dura and subsequent CSF leakage
What is a basilar skull fracture
Characterized by decreased tissue perfusion and impaired cellular metabolism
What is Shock?
Types of distributive shock
What is Septic, Neurogenic, Anaphylactic
Gun shot wounds and stab wounds are examples of this type of injury
What is penetrating injury
Assessment tool used to determine disability during the primary survey
What is Level of Consciousness, Glasgow Coma Scale
A client with a ventriculostomy for ICP monitoring develops a high fever and leukocytosis. What complication do you suspect?
Infection/Meningitis!
Occurs when the hearts ability to contract and pump blood is impaired leading to inadequate supply to heart and tissues
What is cardiogenic shock
The first drug of choice in anaphylactic shock
What is epinephrine?
The nurse is concerned about what conditions in patients with rib fractures
What is diminished ventilation, atelectasis, hypoxemia, punctured lung (pneumothorax)
A client arrives to the emergency department after being hit by a car while riding their bicycle. What should the nurses assess first?
Airway!
Early clinical manifestations of increased intracranial pressure
What is change in level of consciousness, restlessness, drowsiness, increased respiratory effort, purposeless movements, pupillary changes, unilateral weakness, headache
Normal range of ICP
What is 10-20
Priority treatment for hypovolemic and septic shock
What is Volume expansion and fluid resuscitation
The failure of two or more organ systems in the irreversible stage of shock
What is MODS
Referred pain could indicate this type of intraabdominal injury
What is Spleen, liver or intraperitoneal injury
Clinical manifestations of a tension pneumothorax
What is dyspnea, marked tachycardia, tracheal deviation, decreased or absent breath sounds on the affected side, neck vein distention, cyanosis, hypotension, agitation, and profuse diaphoresis
Optimal client body position to manage increased ICP
Head of bed 30-45 degrees head in neutral position
Caused by a decrease in ADH. Results in increased urine output and , low urine osmololity, hypernatremia.
What is diabetes insipidus
The stage of shock characterized by hypotension, low MAP, increasing lethargy, delirium and decreased capillary refill.
What is the progressive stage
The clinical manifestations of neurogenic shock
The components of the primary survey
What is A= airway
B=Breathing
C=circulation
D=Disability
E= Exposure and Environmental Control
Manifestations include paradoxical movement of the chest and shallow respirations with tachycardia
What is flail chest
Abnormal motor responses to stimuli indicating increased intracranial pressure
What is decerebrate and decorticate postures
Reference point to level the transducer of ventriculostomy to monitor ICP
What is the Foramen of Monroe
Cerebral ischemia occurs in this stage of shock
What is the refractory stage
The actions taken during the first hour in treatment of sepsis according to the surviving sepsis campaign bundle
Measure lactate level, obtain blood cultures, administer broad spectrum antibiotics, begin rapid fluid resuscitation (hypotension or lactate >= 4), administer vasopressors