Term
| Emergency care is guided by the principle of ABCDE, what does ABCDE stand for? |
|
Definition
Airway
Breathing
Circulation
Disability
Exposure |
|
|
Term
| Which is the most important in ABCDE principle? |
|
Definition
|
|
Term
| If the clients ability to maintain an airway is lost, it is important to inspect what findings? |
|
Definition
Blood
Broken Teeth
Vomitus
Or other foreign materials in the airway that may cuase an obstruction. |
|
|
Term
| if a client is unresponsive without suspicion of trauma what technique is used? |
|
Definition
| Head-tilt-chin-lift-maneuver |
|
|
Term
| How is a Head-tilt-chin-lift-maneuver performed? |
|
Definition
| The nurse should assume a position at the head of the client, place one hand on the forhead, an the other on the chin,te head should be tilted while the chinis lifted superiorly. this lifts the tongue out of the laryngopharynx and providesfor a patent airway. |
|
|
Term
| when Can a head-tilt-chin-lift manuever not be used? |
|
Definition
| it must not be performed on clients who have potential cervical spine injury. |
|
|
Term
| when dealing with a patient who is unresponsive with suspicion of trauma what tecnique os used? |
|
Definition
| Modified jaw thrust manuever |
|
|
Term
| how is modified jaw thrust manuever tecnique done? |
|
Definition
| The nurse should assume a position at the head of the client, and place both hands on the side of the clients head. locate the connection between the maxilla and the mandible. lift the jaw superiorly while maintaining alignment of the cervical spine. |
|
|
Term
| what is a bag valve mask?when is it used |
|
Definition
| bag valve mask with 100% oxygen source is indicated for the clients who need additional support during resusitation. |
|
|
Term
| Breathing assessment includes what? |
|
Definition
auscultation of breath sounds
observation of chest expansion and resp effort
notation of Rate and depth of resp
identification of chest trauma |
|
|
Term
| what should be assessed for CIRCULATION? |
|
Definition
Heart rate
blood pressure
perfusion |
|
|
Term
| What interventioncould be done to restoring effectivecirculation? |
|
Definition
CPR
hemorrhage control(direct pressure should be applied to external bleeding)
obtaining IV
infusions of fluids or blood |
|
|
Term
|
Definition
| IV access should be achieved with large bore line in the antecubital fossa(bend of the elbow). Lactated ringers(LR) and 0.9% normal saline (NS) are typical resusitation fluids. |
|
|
Term
| How does shock develop?and what happens? |
|
Definition
| Shock may develop if circulation is compromised. shock is the body's responce to inadequate tissue perfusion and oxygenation. It manifests with qn increased heart rate and hypotension and may result in tissue ischemia and necrosis |
|
|
Term
| what are the interventions to alleviate shock?remember all |
|
Definition
administer oxygen
apply pressure (external bleeding)
elevate feet to shunt blood to vital organs
administer blood/fluids as ordered
monitor VS
remian with the client and provide reassurance and support for anxiety. |
|
|
Term
|
Definition
|
|
Term
| for the ABCDE D is for disabilty what does it fall under? |
|
Definition
| disability is a rapid assessment of a client NEUROLOGICAL status |
|
|
Term
For abcde
what is Disability Mnemonic |
|
Definition
A:alert
V:responsive to voice
P: Responisve to Pain
U; Unresponsive
Or the Glasgow come scale
|
|
|
Term
for ABCDE
explain what to do for EXPOSURE. |
|
Definition
remove clients clothing for fill assessment
look for evidence such ass bullets, drugs, weapons
hypothermia |
|
|
Term
| why is hypothermia such looked at in exposure for ABCDE/ |
|
Definition
leads to vasoconstriction and impaired oxygenation
|
|
|
Term
how to prevent hypothermia?
|
|
Definition
remove wet clothing from client
cover client with blankets
increase the temperature of the room
infuse warmed fluids as ordered |
|
|
Term
traige used in a tragic loss(huricane , many people)
what are classes? |
|
Definition
emergent /class1 red tag-life threatining injury
urgent/class2 -yellow tagmajor injuries
nonurgent /class3 -green tag minor injuries
expectant/class4 - black tag should or is dead |
|
|
Term
| interventions for sprains? |
|
Definition
refreain from weight bearing
apply ice to decrease imflammation
apply compression dressing to minimize swelling
elevate effected limb |
|
|
Term
|
Definition
tachypnea
tachycardia
hypotension
seizures
anxiety
abberant behavior
disorientation
coma |
|
|
Term
| intervention for heat stroke |
|
Definition
rapid cooling
remove clients clothing
place ice pack over major arteries(axillae,chest,groin,neck)
wet client body,fan on high
submerge body in cold water |
|
|
Term
|
Definition
| frost nip does not lead to tissue injury and is easily irreersable iwth application of warmth |
|
|
Term
|
Definition
| present with a white, waxy appearnce to the skin and permanent tissue injury can occur |
|
|
Term
|
Definition
| burns may result from ELECTRICAL CURRENT, CHEMICALS,RADIATION, OR FLAMES |
|
|
Term
|
Definition
remove agent
perform assessment
cover client and maintain npo
elevate extremeties
perform head to toe
administ fluids and tetanus toxoid |
|
|
Term
QUESTION
a client presents to the emergency department after being involved in a motor vehicle crash and is unresponsive. the nurse should open the airway with wat technique?
A. head tilt chin life
B. modified jaw thrust
C. hyperextention of the head and placemnt of an endotracheal tube
D. flexion of the head and placemnt of an endotracheal tube |
|
Definition
B is correct
think about crash and is in the emergency..
remember if no trauma seen or occured then head tilt chin lift if trauma /injury like fallen , crash, figthing may suspect some sort of ijnury or trauma best to use modified jaw thrust |
|
|
Term
QUESTION2
what techniques can be used to provide manual ventillation for a client who is not breathing or who is breathing inadequatly? |
|
Definition
| bag valve mask with supplemental at 100% of oxygen or Cpr |
|
|
