Card Set Information
observe for what in basal skull fx?
bleeding from ears.
want to observe increased signs of bleeding.
SCI. avoid what stimuli?
ICU, care plan, contractures can be prevented by?
exercising 48 hours after injury, 5x a day. turning pt doesn't count.
head injury pts, thrash around bed, what you wanna do?
pad side rails.
C5 spinal cord injury, severe throbbing HA, what you wanna do?
Check indwelling catheter for patency
assess SCI. injury. What you suspect?
old female, decreased LOC, why did physician order, elevate HOB, avoid sharp hip flexion.
avoid impeding venous outflow.
anything that impedes venous outflow will increase ICP
what you expect to observe with spinal shock?
absence of reflexes along extremities
Glascow coma scale is measuring what?
severe brain injury, what test is used to confirm brain death?
cerebral blood flow studies
first is EEG - then cerebral blood flow study
you doing pin site care on traction. it comes off. what you do first?
ED 6yo. MVI. vitals are normal. what you trying to do now?
preserve brain homeostasis.
so you're preventing secondary injuries from happening.
diffuse axonal injury. what test can you do to observe brain structure?
13yo, ED, baseball, child comes awake 5 hours after, he can't remember shit. MRI no injury. What you suspect?
(no injury - won't be mild concussion bc he has been out for 5 hours)
80yo male fell. he's most as risk for?
(what comes out of a hematoma? embolis...so it's a matter of "what comes first")
Brain injury, what is a goal for this pt?
prevention of sleep deprivation.
sleep deprivation can irritate, increase ICP
major cause of death with people with SCI?
highest risk for TBI is in what age group?
older people. 75 or older.
spinal cord injury. you suspect muscle spasticity. What med can you expect to give?
ED, MVI, t1 spinal cord injruy. What is he at risk for d/t this?
decrease in BP and HR. You know it's neurogenic shock. What you wanna look out for?
abrupt onset of fever.
(think, they can't sweat either. SNS is damaged)
Autonomic dsyreflexia. What are the obj when caring for this?
removing the triggering stimulus.
burn pt, first systemic event after a burn injury is what?
burn victim, stabilized. If he has inadequate fluid resuscitation, what happens?
burn victim, 24% of body, pathopysiologic changes include what?
male pt, 16yo, burn rt hand/arm, superficial burn, nurse teach pt what about dressing changes?
check cap refill for circulation
burn unit, nurse has to monitor for what as the edema in the burns increases?
acute phase of burn, most important for nuse to monitor?
What occurs during the acute phase of a burn.
What is nursing goal during acute phase of burn?
to manage pain a proactive way for pt's comfort
caring for pt during acute phase of burn. you are responsible for what?
observe for infection
time to change dressings on burn pt. what can you do to reduce pain at this time?
go as fast as you can
care plan, open fx, what is priority nursing goal?
risk for infection.
you have a bone sticking out, what you at risk for? osteomyelitis.
hip fx, you tell pt to do what to prevent complications?
(to prevent DVT, you increase fluid).
nurse caring for pt with tibial fx. short leg cast is used for what?
amputation, when can pt stand up after surgery?
you can stand after the amputation. right after.
simple fx, teachings, what you tell pt?
do exercises of the unaffected muscles.
long arm cast. 12 hrs, arms hurts, analgesics did not relieve pain, what next?
rid of cast as fast as you can.
What situation is the family in when blaming each other about what happened to pt?
remorse and guilt
gunshot wound, most common hollow organ injury is what?
multiple trauma, after threats to life are corrected (airway, etc) then what's next?
rapid physical assessment. (then you look at "what happened" to the pt. the wounds, the situation).
rehab phase of burn injury.
patient and family education is priority in acute/rehab phase
burn vic is transitioning from acute to rehab, pt tells the nurse, "I can't wait to have surgery so I can look normal again". What do you say to that?
we'll talk about it after the scars heal.
high cervical spinal injury, what meds can you give to prevent further spinal cord damage?
automic dysreflexia. What are they going to present?
brady and hypotention
ICP, what symptoms would indicate increased ICP, leading to brain stem damage?
person fell. hit head, feels fine after. now has HA. you suspect epidural hematoma. What you expect they do next?
T2 SCI. neurogenic shock, you wanna monitor for what?
17 yo male, SCI, common cause is what?
SCI, altered mobility, what can you do to prevent DVT?
apply thigh elastic socks
discharge teaching, pt asks why autonomic dysreflexia is an emergency. Why?
Sudden increase in BP can increase ICP, bursting cerebral blood vessels
SCI, autonomic dysreflexia, what is priority?
place pt in safe position
SCI, prone to foot drop, use splints. splints are removed and reapplied how often?
every 2 hours
goal for quadriplegia include what?
maintain skin integrity.
suspected brain injury pt. what might MD order to prevent secondary injury?
you want to
heat stroke. you expect to see what?
(heat exhaustion - sweat. Heat stroke - no sweat)
swallowed toilet bowl cleaner. What you want to do?
suspected alcohol intox. what condition can mimic this?
sex assult vic. important for nurse to do what when assessing vic?
respect privacy and sensititvity.
admitted for depression. What you want to do?
ask pt is they have thought about taking their own life
pt coughing forcefully, choking. What do you do?
watch pt. do not intervene at this time.
fx left femur. What signs for potential fat emboli?
cyanosis, decreased O2
pt fell into hole. rt leg is shorter than lt leg, what you suspect?
dislocation of hip
why are dislocations and subluxations medical emergencies?
vascular necrosis my develop
hockey player. can't move left arm, arm looks longer than rt arm. What you suspect?
injury to wrist. 3rd degree strain. Why would MD order xray?
avulsion fx are associated with 3rd degree strains.
boy, bmx race, open fx, tibia. what grade is this?
pt has intra articular fx and MD splints injury. when man comes back, you want to let him know what?
post traumatic arthritis.
fallen, injure ankle, trimalleolar fracture. What is used to hold that in place?
post op ORIF ankle. comes back, find out bones didn't heal together. What complication is this?
neck of left femur fx. What is complication of that?
resp insufficiency. you expect what to be inserted?
oral pharengeal airway.
MVA, blunt trauma to abd. What action is appropriate.
immobilize on backboard.
What to immobilize until SCI is ruled out.
pt can't maintain patent airway d/t hemorrhage. What is nursing diagnosis?
ineffective airway clearance.
pt broken femur. cool moist skin, increased HR, falling BP. you suspect?
(hypovolemia through bleeding)
discharge teaching. how you give instructions
verbal and written
Talking about pts that talk about suicide. What is it about crisis intervention?
is used to determine suicide potential.
MVA, trapped burning vehicle. Est likelihood of survival. What is it based on?
age, depth, presence of inflammation
acute phase of burn, caution of fluid and elecs is because of what?
pt psycho resp. to burn injury
shifts in fluid
losses of fluid from large burn wounds
acute phase of burn. what intervention can you do to help pt cope more effectively?
promote truthful communication
assisting pt in practicing approp. strategies
give positive reinforcement.
rehab phase. what goals are important at this time?
increase understanding of follow up care
increase control of care
increase participation in daily living
adjustment to alterations in lifestyle.
school nurse. SPI. what are risk factors?
prevention of infection in burn pt. nurse instructor is discussing what phase of burn care
immediate resuscitative phase in burn injury. what does lab work look like?
hyperka+, hypona+, acidosis, increased HCT
electrical burn. thick eschar. what abx would you use?
partial thickness. proper intervention of separation of burns.
trim away the whatever
what faactors does nurse use to determine depth of burn?
cause of burn
deep partial thickness. nursing diagnosis priority
baby, boil water on chest. what do i do?
teaching elastic garment. how do you wear it?
partial thickness on chest and legs. smoke inhalation. what is priority
house fire. face, leftforearm
What lab value you closely monitor in burn?
partial thickness. why do we keep alignment in pt?
to prevent contractures
something about fat, weight and fluids.
your reserve fat has been catabolized so it can be used for fluid because you haven't been eating.
most burns occur?
neuro ICU. SCI. priority?
ineffective breathing patterns.
fx of nose. skin tear, mucus membrane. what type of fx?
long bone fx. careplan. what intervention to promote healing?
monitor color, temp,
edema, tenderness, muscle spasm, ecchymosis. ran 10 miles, now it hurts to stand. what is this?
2nd degree strain.
discharge after sprain to left ankle. what you tell him?
AKA comes for post op check. phantom pain. what can you do?
apply hot compress.
BKA. how you measure proper positioning and prevent contrax?
encourage pt turn side to side/prone
sling. clavicle fx. what you teach?
encourage some light activity. raise it up a little bit. ROM. prevent contrax.
What fx is at risk for volkmann's cx?
soccer player. leg hit from side while foot is planted on ground.
lateral collateral ligament injury.
hip fx, chest pain, increase HR and RR. thick white, sputum. what is it?
fx humerus. tachy, pale, confused.
something something fx.
place a pillow
broken hip. prevent complications. assess for what?
multi team do for amputees.
help achieve highest level of function
amputee. maintain what during care?
amputee. least likely to perform what?
place residual limb on pillow.
BKA. discharge teaching. what you teach?
amputee. discharged. assess for what?
pts, healed, nontender scar.
alchy withdrawal. prevent hallucinations.
turn lights down low
known poison. assist with gastic lavage. what position?
rewarming hypothermic pt. what can you expect to do?
you suspect internal bleeding when you see what?
increase pulse rate.
falling roof. test is see injury in peritoneal.
no identification. how you get consent?
document LOC and status.
acute alchy intox,
rape trauma sysndrome
acute stress reactx to life threatening situation
rape vic. sate of shock. guilt, humilitation. what phase?
acute disorganization phase.
rape vic, interventions are aimed at what?
sense of control of his or her life
who is high risk for suicide?
what do you document in relation to restraints?
pt's response to restraints.
ltc. weakness, lethargy. emergencies in elderly is different because?
altered response to treatment.
frostbite. homeless. rewarming.
place 100 degree circulation bath
stomach cramps, nausea, diarrhea. key to treatment of food poisoning.
determine source and type of food poisoning.