TraumaDisasterNotes2010 - Module 15 Nursing Care of the...

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Module 15: Nursing Care of the Individual Experiencing Shock/Trauma/Disaster: Critical Care Concepts- p. 1821-1843 2010 Emergency and Disaster Care Notes Most clients with life-threatening or potentially life-threatening problems are transported to the emergency department (ED). Sequence for care based on a prioritization process known as triage Triage normally performed by nurses as clients enter the emergency department; also performed by emergency medical personnel or first responders outside of hospital when there are multiple casualties. In the hospital setting, triage- vital assessment skill needed by emergency nurse which facilitates rapid determination of client’s acuity level; facilitates treatment of clients who have a threat to life, vision, or limb before treating other clients Categorizes so most critical are treated first Emergency Severity Index: (Fig 69-1) Five-level triage system that incorporates illness severity and resource utilization Emergency Severity Index (ESI)- 5-level triage system that provides standardized approach to triage/guides initiation of appropriate interventions by prioritizing clients based on urgent needs or threat to life. See table 69-2 page 1822. PRIMARY SURVEY - Assessment of a client in emergency room; begins with primary survey focusing on airway, breathing, circulation, and disability; identifies life-threatening conditions and facilitates immediate intervention as each step is performed. See following summary of risk factors, key assessment findings that nurse looks for, and immediate response required. See Table 6-3 page 1824 .; *Recognize causes of life threatening injury Tab 69-4 p.1825 Airway- with cervical spine stabilization and/or immobilization : RNSG 2432 1
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Risk factors – facial trauma, vomiting, tongue in airway, seizures, near-drowning, anaphylaxis, foreign body obstruction, cardiopulmonary arrest Assessment findings : dyspnea, inability to vocalize, visible foreign body in the mouth or airway, and trauma to the face or neck. Airway interventions progress rapidly from the least to the most invasive and may progress from opening the airway by jaw-thrust maneuver, suctioning and/or removal of foreign body, rapid – sequence intubation/insertion of a nasopharyngeal or oropharyngeal airway, to endotracheal intubation or cricothyroidotomy as needed. See page 1823 Cervical spine must be stabilized with rigid cervical collar or other means of immobilization in clients with face, head, or neck trauma and/or significant upper torso injuries. Page 1823. Breathing alterations : Risk factors - fractured ribs, pneumothorax, penetrating injury, allergic reactions, pulmonary emboli, asthma, tension pneumothorax, and flail chest Assessment findings : Look listen & feel, estimate respiratory rate - dyspnea, rapid/slow/shallow/deep/irregular respirations, absence of nasal/oral air flow, use of accessory or abdominal muscles, paradoxical or asymmetric chest wall movement,
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TraumaDisasterNotes2010 - Module 15 Nursing Care of the...

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