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essential to nursing
- ability to recognize an emergent condition, prioritize, and provide quick(rapid) assessment and interventions.
- for appropriate level of care.
- most important.
- dont flex or extend neck.
components of primary survey
neuro logic test is preformed
a condition of acute peripheral circulatory failure, decreasing b/p and failing tissue perfusion.
4 types of shock
- hypovolemic-decrease blood volume.
- cardiogenic-heart failure.
- obstructive-blocked blood flow outside heart,reduced oxygen.
- distributive-dilation of venules and artyerioles, decreased b/p.
- maintain open airway
- control bleeding
- supine position
- record v/s
- give iv fluid
- give no food or drinks till no surgery
- injury to spleenand liver can cause rapid loss of blood leading to hypovolemic shock.
- intra abd. hemorrhage
glasgo coma scale (GCS)
- used to rate a pt level of consciousness.
- score lower then 13 may indicate the need for immediate treatment.
- dialated or nonreactive pupils indicate increased ICP and a need for immediate intervention. INTER CRANIAL PRESSURE
- score 8 or lower is death
- partial thickness burn: superficial(epidermas of skin) or deep(entire epidermal layer& dermis).
- -clean w/steralsaline, cover with 1/8inch layer of anti infective cream(silver sulfadiazine), cover w/dry bulky fluffy dressing.
- full thickness burn: involves all skin layers and subcutaneous tissue.
- occurs when the body looses so much water and electrolytes thru heavy sweating that hypovolemia occurs.
- lead to heat stroke if heat exhaustion not treated.
- s/s cool clammy skin, grey face,irritability,poor judgment.
- body temp is normal or slightly elevated 100.4-102.2
- other signs dizzy vomit diarrhea weak and fiat.
- heat exhaustion not treated.
- sign unable to sweat.
- can develop seizures.
- hot dry flush skin.
- temp 106F
- seizues, cerebral ischemia, renal failure,late cardic decoprensation and GI bleeding. (effects heart,renal, brain, intestines.)
- 1/3caused by cleaners,soaps, insecticides,acids,alkalis
- cant make pt vomit d/t burning of gastric poison.
- syrup to make you vomit, no longer recommended.
- servour cases use activated charcoal.
anxiety lead to panic
- complete disorganization/loss of control.
- pt in panic is terrified and needs external controls to avoid harm.
- most common result is manic depressive(bipolar) disorder.
- exhibits bizarre, extreme, hyperactive behaviors.
- high risk of injury to self and others.
- drug Haldol 5
heighten psychiatric emergency
use of alcohol and illicit drugs.
bio terrorism small box
- breakout in community, disease3.
- small pox caused by variola virus, an orthopoxvirus unque to humans.
- small pox fatality 30%.
- rash occurs 2-3 days later first on face and for arms.
- pustules(airborne) wear N95 mask.