Exam 2 Topics

h/x = history; r/x = risk; a/x = assessment; t/x = treatment

Pathophysiological changes associated with major burns

Skin is burned → release of cytokines → histamines & prostaglandins released → vasdilation & increased capillary permeability → possible edema

Also divided intro 3 zones:

• Coagulation zone: closest to injury

  • Lots of coagulated proteins & v blood flow

  • Tissue loss

• Stasis zone: damage may be reversed

  • Still damage & v blood flow

• Hyperemia zone:

  • High released of histamine & prostaglandins

  • Most likely to be resuscitated

Major changes:

• Infection r/x

• Malnourished due to increased metabolic needs

• Dehydrated + edema

• ^ Potassium levels in blood stream

• Possible rhabdomyolosis → AKI

• Very stressing on the patient

Connections:

• Hypermetabolic state starting 4 days after up to 3 years

  • Involve dieticians

  • Possible hyperglycemia from stress

  • Early enteral feeding & avoid parenteral nutrition

  • Make sure to meet nutrient needs:

    • Protein, carbs, fat

    • Glutamate, Vitamin C, zinc, selenium

• Mobility & passive ROM are limitedd due to sedation, pain meds, edema, & wound dressings

  • Early mobility incentivised

• Possible perfusion to skin and organs → shock

  • Hypovolemia, ^ systemic vascular resistance and v CO, ^ HR

  • cold-clammy skin

  • Confused

  • No urine output

Evaluation of burn fluid resuscitation effectiveness

Monitor albumin levels

Evaluation if fluid administrations are effective:

• Urine output > 0.5 mL/kg/hr

  • If they have rhabdo/AKI must be >1 mL/kg/hr

  • Urinary catheter may be needed

• base deficit less than 2 → mantains good pH lvs

• Systolic BP >90

• No AMS

• Good HR

• Good lactate levels

Classification of Burns

Superficial: dmg to only epidermis

• Sunburn

Superficial Partial: dmg to epidermis & superficial dermis

• Pink or red

• Blistering & wet

Deep Partial: deep in dermis

• Nonblanchable, dry

• White/yellow

Depth:

1. epidermis; sunburns

2. Epi + dermis

3. Epi + dermis; requires skin grafting

4. Epi + dermis + fat layer

5. Epi + dermis + fat + muscle layer

6. Epi + dermis + fat + muscle + bone layer

TBSA:

• Minor: <10%

• Major: >20%

Successful burn fluid resuscitation

Calculate Fluid needs:

• ABA: TBSA x kg/8 = mL/hr

  • 40-80kg only

• Rule of 10s: TBSA x 10 = mL/hr

  • if >80kg; every 10kg add 100mL/hr

• Parkland: 2-4 mL x kg x TBSA = mL

  • Deliver half first 8hr

  • Rest over next 16 hr

Refer to other flashcard for effectiveness

Nursing management of clients with severe burns

First BSI is put

Then ABCDE are performed along with the:

• Secondary survey:

  • H/x of events

    • if happened in a closed space → r/x for inhalation injuries

  • Health h/x

  • Head-to-toe

  • Depth, size, severity of burn

• Check if they are at risk for further injury:

  • Compartment syndrome:

    • Mainly from peripheral edema & burned skin constriction

  • Hypothermia

• Analyze VS & determine need for fluids

  • v BP & ^ HR indicated hypovolemia → need for fluids

  • 500mL LR are recommended

• Calculate TBSA (rule of 9s)

• Severe burns need usage of urine output & fluid efficacy is evaluated

  • Also NG/gastric tube for decompression

• Debridement or excision of nonviable tissue

Stages of wound healing

1. Hemostasis:

• Clotting cascade is initiated → fibrin mesh → vasoconstriction → prevents bleeding & invasion of pathogens

2. Inflammation:

• Removal of pathogens, dmged cells, debris → vasodilation → hyperemia + edema → immune cells enter (neutrophils) → cytokines release → macrophages phagocytosis

3. Proliferation: day 3-10 and lasts weeks

• nutrients brought to help wounds → epithelialization → fibroblasts proliferate → granulation tissue develops & vascular repair

4. Tissue remodeling: day 21-year

• collagen is brought to strengthen the wound → wound edges are contractice to help close → fibroblasts are aptototized to smooth and mature the wound → angiogenesis stops → b.f. returns to normal levels

Skin layers and their functions:

Epidermis:

• Made up of 4-5 layers

  • Soles of feet require 5 layers to be thick

• Protects, waterproofs, influences skin color

• Contains normal flora:

  • Staph. epidermitis

  • Staph. aureus

  • Cutibacterium acnes

Dermis:

• Made up of 2 layers

• Sweat glands, hair, hair follicles, muscle, sensory neurons, blood & lymphatic vessels

Hypodermis:

• “Subcutaneous fascia”

• Adipose lobules & connective tissue, hair follicles, sensory neuron, b.v.

Areas of thickeness:

• Thick: palms & soles

• Thin: eyelids, axilla, ge nitals, mucous membranes

  • With children more and >50 years

Stages of wound infection:

Via the wound infection continuum:

1. Contamination: micro-organisms in wound, but not yet causing infection

2. Colonization: replicating micro-organisms that yet dont cause infection response

3. Local infection: redness, drainage, pain

• Topical antibiotics

1. Spreading infection: infection beyound wound; cellulitis of leg w/diabetic foot ulcer

• Topical + Systemic antibiotics

• Erythema, swelling of lymphnodes

• Malaise & anorexia

1. Systemic Infection: Invasion of micro-organisms into blood stream → sepsis → affects organs

• Topical + Systemic antibiotics

From local → systemic: biofilm formed over wound, making antibiotics more resistant and not easily removed.

Effects of smoking on wound healing:

Smoking/Tobacco:

• Nicotine → vasoconstriction

  • Fibronolysis is decreased → blood more viscous & v blood flow

• Tobacco → catecholamine (epi) release → reduce blood flow

• Carbon monoxide levels are increased → v O2 levels

• v immune system → impairs ability for wounds to heal

Moisture-associated skin damage (MASD) risk factors:

Incontinence → IAD from urine and stool

Skin folds → trap moisture → ^ risk of breakdown

Being hospitalized in the ICU cause a higher risk

Aging-related factors that impair pressure injury healing

Decreased perfusion, v tissue sensitivity, & lower protein levels

• Limited mobility due to possible HF → SOB when ambulating → may lead to prolongued sitting and ^ psi in bony areas (ischial tuberosities)

• Possible depression & social isolation may increase impairment of pressure injury healing

Psoriasis and associated psychosocial complications

Inflammatory skin condition causes redness, itching, flaring & painful skin

• Dry thick raised patches (scaly/plaque like appearance)

• In scalp, elbows, knees, and ocurs from overactive immune response

• Some may feel embarassed or self-conscious → frustration. hesitation to socialize, avoiding public → social isolation & v QOL

• May be woried that their infection may contaminate others or worse around others

Priority nursing assessment and triage for skin disorders and wounds

Always look for signs that require immediate action:

• Anaphylaxis → airway & CV compromise

• Acute infection → worsen and spreads

• Severe rash → serious allergic reactions or systemic illness

• Mucous membrane involvement → serious skin reaction

• Skin breakdown → ^ delayed healing & infection r/x

• Signs of sepsis → TIME

  • T: Temp: fever/hypothermia

  • I: infection: UTI, pneumonia, rash

  • M: Mental decline

  • E: Extremely ill:

    • Rapid/shallow breathing

    • Tachy

    • Pale & clammy skin

    • Extreme pain

    • Lightheaded + dizzy

Skin disorder A/x: assess for changes in normal skin like:

• Alterations:

  • Rash, redness, dry/cracked skin, blisters

  • Discoloration, itching, warmth, pain, drainage

  • Swelling, fever, resp distress

• Health h/x:

  • Previous skin conditions

  • Current meds (AXAs, NSAIDs, antiseizures, chemo meds [EFGR inhibitors])

Wound A/x:

• Document characteristics:

  • Location, size

  • Wound bed: appearance, color, granulation, slough, eschar

  • Wound edges

  • Undermining: Tissue destruction under intact skin around wound

  • Tunneling

  • Drainage: #, color, odor & consistency

    • Use COCA a/x:

      • Color, odor, consitency, amount

      • Sanguineous, serosanguineous, purulent

  • Pain

  • Surrounding skin

• Signs of infection:

  • Local: red, warm, swelling, pain, odor, size, drainage

  • Systemic: fever, chills, ^ HR, ^ RR, v BP, malaise, confusion (uncs)

    • Possible signs of sepsis⭐

Vital Signs & Pain:

• Fever → infection

• ^ HR → infection, stress, pain

• ^ RR → infection, pain

• ^ BP → pain, anxiety

• v BP → possible severe infection, shock, anaphylaxis

Triaging:

• Highest priority

  • Poor breathing, throat tight, wheezing, low BP, anaphylaxis

• Then: infection or sepsis risk

  • Fever, worse wound, purulent drainage, abnormal VS, TIME

• After: delayed wound healing

  • Poor perfusion, DM, nutrition (v protein)

  • Incontient, moisture, pressure

  • Friction/Shearing

  • Immunosuppressive meds

  • Smoking or Obese

Systemic Causes of chronic wounds:

Diabetes → v collagen formation, v b.f., X immunity

malnutrition

connective tissue disease like RA

CVD/PAD

Obese,DM, Smoking

Recognition of shingles (herpes zoster)

Painful fluid-filled blsitering onesided rash in body or face; scab over w/in 7-10 days:

• Itching, tingling, or burning: may occur before or w/rash

• May be elevated

• Caused by varicella zoster (chickenpox)

Preop r/x factors for hypoxemia, bleeding & DVT

Hypoxemia: low O2 in blood

• Obstructive sleep apnea → makes intubation difficult, more O2 is needed & at higher risk for pulmonary complications

• Pulmonary disorders → lowers resp reserve & o2

• Smoking h/x

• >65 years

• SOB

• Sedatives or opioids

• General anesthesia

Bleeding:

• Abnormal CBC, HgB (<12), Hct (<36%) → anemia or low blood levels

• Abnormal PT (11-13.5), INR (>1.1), aPTT (>35)

• Platelets <150k

• Surgery w/expected blood loss: hip replacement

• Meds

• Hypothermia (<35 C)

DVT:

• Orthopedic, thoracic, neuro surgery

• Cental venous access devices

• Prolonged operative time

• Anesthesia

• Immobility

• Poor pain control → reduces early ambulation possibilities

Postoperative hemorrhage and hypovolemic shock interventions

Postop hemorrhage:

• ABC

• Check VS frequently

  • Q5-15 mins for 1st hr

• A/x surgical site, dressing drains, & tubes

• I&Os

• Notify provider if excessive bleeding

• Maintain IV & prepare blood/IV fluids

• Keep them warm to prevent hypothermia

• Monitro hgb, hct, ptts, PT/INR, aPTT

Hypovolemic Shock:

• Call help

• Maintain airway & provide O2

• Place them supine unless not

• Monitor VS

• Start/maintain large-bore IV access

• IV fluids/blood

• I&O

• Monitor AMS

Essential postoperative discharge education

Discharge begins at admission

• Deep breathing excercises + early ambulation

  • Diaphragmatic breathing, leg exercises, frequent repositioning & coughing helps prevent complications

• Maintain adequate nutrition

• Follow med regimen + any new meds needed

• Possible lifestyle modifications

• Wound care & dressing changes

• Follow-up care

Preoperative teaching and breathing exercises

Teaching topics:

• NPO or clear liquids

• What meds to hold

• Shower, antiseptic wash or bowel prep

• Explain where patient may go before and after

• Explain the tubes, drains, IVs, monitors

• Teach how pain will be a/x and t/x

• Teach turning, repositioning & early ambulation

• Encourage patient asking question and coping mechanisms

• Reinforce planned procedure instructions

Breathing Exercises:

• Help prevent atelectasis, pneumonia, poor o2, secretions

• Diaphragmatic breathing:

  • Lie supine/in a chair → place hands over stomach → breath gently & deeply via nose → allow lower bely to rise while keeping chest relaxed → slowly pursed lip exhale (blowing candles) → pull stomach gently toward spine while exhaking → repeat x5

  • Belly rises when breathing in & belly pulls inwards when breathing out

• Deep Breathing:

  • Sit back → inhale via nose for 4 secs → hold breath for 8 secs → exhale via pursed lip for 8 secs → relax briefly → repeat 3x

• Incentive Spirometer:

  • sit upright or in edge of bed → set goal marker → hold device upright → place in moutjh & seal lips → inhale slowly & deep → watch piston rise → hold breath for as long as possible or >5 secs → exhale slowly → rest few secs → repeat 10 times and QHR while awake

• Coughing & Splinting

  • Hold pillow/blanket firmly over incision → take deep breath → cough → repeat PRN

Preop education

Refer to flashcard 19

QSEN Competencies in Perioperative Nursing

1. Patient-Centered Care:

• a/x fears, anxiety, pain, support systems

• Teaching + HIPAA

• Cultural preferences addressed + interpreter PRN

2. Teamwork & Collaboration:

• Communicate allergies, alert labs, & r/x factors

• Hand-off reports & Collaborate on any pt needs

• Verify informed consent

• Confirm correct pt site

3. EBP:

• Follow surgical checklist

• Standard + sterile precuations

• Early ambulation, SCD, NPO edu, breathing exercises

4. QI:

• Prevent surgical site infections & wrong-site surgery

• v falls, postop issues

• Monitor possible infections or safety risks

5. Safety:

• Preop: identity, consent, allergics, procedure, surgical site, labs, NPO, meds

• Intra: sterile field, positioning injury, monitor complications, complete time-out

• Postop: maintain airway, VS, pain, fall, bleeding DVT infection, prevention, wounds

6. Informatics:

• Document all patient info

  • a/x, VS, pain, wounds, drains, I&O

  • Allergies, labs, meds, h/x

  • Informed consent verification

  • Surgical-checklist completions

SBAR Communication:

S: Intro, confirm right pt, surgeon, procedure & site

B: Client med and surgical h/x, allergies, labs, x-rays, comorbidities

A: Any abnormal results, allergics, h/x relevant to procedure, prosthetics, family, important info

R: Prevention of allergic reactions (meds/latex), positioning, prevent surgical complications

Purpose and priorities of the preoperative assessment

• Client history

• VS & O2

• Allergies: food, meds, latex, iodine

• Head-toe, height, weight

• Meds: OCT, herbal supplements, prescription

  • Blood thinners, NSAIDs, diabetic meds, weight loss meds

• Diagnostics

• NPO/clear liquid

• Mental status

• Risk for complication

  • Aspirating, infection, DVT, psi injuries, resp depression

• Informed consent & correct pt, procedure & site

Priority postoperative assessment following femur fracture repair

1. AB

• Airway, Respiration, SaO2, breath sounds, chest wall movement, cough ability

• General anesthesia pt’s require frequent resp a/x

2. Circulation & Bleeding:

• ^ HR, v BP trends

• Cool, pale clammy skin

• Restless, Poor orientation, confusion

• Excessive drainage or bloody

• Urine output <30mL/hr → hypovolemia indication

• Hematomas

3. Neurovascular a/x (6 P’s)

• Pain, Pallor, Pulselessnes, Parathesia, Paralysis, Poikilothermia

4. Pain A/x:

• General pain assessment

• Signs of opioid resp depression

• Worsening pain may signify bleeding, swelling, DVT, ischemia

5. DVT risk:

• Assess for calf pain, warmth, erythema, edema

• Bilateral leg sizes & mobility level

6. Wound/Dressing/Drain a/x:

• Drainage/bleeding

• #,color

• Redness, swelling, tenderness, purulent drainage

• Hematoma signs near site

7. Fluids/Labs/KIdney:

• I&O (>30mL/hr), IV fluids

• Hgb & Hct, Electrolyes, BUN & Creatinine

8. Mobility & Safety

Preoperative medications and nursing responsibilities

IV fluids, sedatives, antibiotics, antiemetics, opioids, antacids, anxiolytics

• Either right before the client before going to surgical site or 20-30 mins before

• Educate the effects of preop meds

• Raise side rails up after meds taken effect

• Enema if patient is going to abd/pelvic surgey; evening or day of

• DONT TAKE BB AS THEY INTERACT W/ANESTHESIA

  • v BP & impaired circulation

Recognition of malignant hyperthermia

Genetic disorder triggered via anesthesia; life-threatening when recieivn anesthetics & succinylcholine

• Ask ab personal/family h/x of it

• Early s/s:

  • ^ HR, ^ RR, arrythmias, hyperkalemia, hypercarbia, rigidity

  • May also occur postoperatively

• STOP meds causing it → 100% O2 → Dantrolene IV

Fall risk factors in the postoperative client

• Older age >65

• Anesthesia & meds delay AOx4

• Confusion or poor judgment

• Post op delirium (uncs):

  • From anesthetics, dehydration, hypoxia, blood loss, E+ imbalance

• Sedatives, opioids, anesthsia

• Weakness or v mobility

• Sensory deficits

• Arthritic joints or limited mobility

  • Deconditioning

• v BP (ortho hypo, med-induced, blood loss, blood pooling)

• Hypovolemia

• Pain

• Devices

• Incontinence or urgent voiding needs

• Fall h/x

Assessment standard in transplant nursing practice

This assessment helps:

• Prepar donor/recepient for process

• Identifies risks/complications

• Monitor recovery, graft rejection, immunosuppressive effects/Adverse effects

• Support systems

Assessment Area	What the Nurse Monitors
Vital signs	Fever, blood pressure changes, tachycardia, or instability
Graft function	Signs that the transplanted organ is not working properly
Laboratory values	Evidence of inflammation or organ malfunction
Fluid status	Intake/output, urine output, IV fluids, blood products if ordered
Bleeding	Especially important for certain organs, such as liver transplant
Infection	Increased risk due to immunosuppressive medications
Acute graft rejection	Early findings vary by organ or tissue transplanted
Medication effects	Side effects and adherence to immunosuppressive therapy
Support system	Caregiver availability before, during, and after transplant
Psychosocial/financial needs	Stress, questions, worries, and need for resources

Type	Timing
Hyperacute rejection	Minutes to hours after transplant
Acute rejection	Days to weeks after transplant
Chronic rejection	Months to years after transplant

Possible signs of rejection:

• Evidence of acute inflammation in lab studies

• Organ malfunction

  • Example: elevated BUN after kidney transplant

• Clinical changes in graft function

  • Example: excessive bleeding after liver transplant

• Chronic rejection findings may include:

  • Nausea

  • Jaundice

  • Itching

  • Recurrent infections

  • Fatigue

  • Weight gain

  • Anemia

Immediate Postoperative Priority

During the first 24 hours after transplant, the nurse’s assessment focuses on:

1. Preventing complications

2. Recognizing acute graft rejection

3. Monitoring vital signs regularly

4. Responding immediately to abnormal findings

5. Monitoring for general postoperative complications, such as:

   • Atelectasis

   • Hemorrhage

   • Blood clots

   • Ileus

   • Infection

Professional performance standards in transplant nursing

Standard Area	Meaning in Transplant Nursing
Ethics	Protect donor and recipient rights, support informed consent, and respect client choices.
Evidence-Based Practice	Use current transplant guidelines and best practices to prevent complications.
Communication	Clearly communicate with the client, family, caregivers, and transplant team.
Collaboration	Work with providers, pharmacists, dietitians, physical therapists, case managers, and social workers.
Resource Utilization	Help clients access financial, social, educational, and follow-up care resources.
Advocacy	Support the needs, safety, and well-being of both donors and recipients.
Education	Teach clients and caregivers about the transplant process, recovery, medications, rejection, and complications.
Regulatory Practice	Follow federal and state regulations related to organ and tissue donation.

Professional practice evaluation in transplant nursing

The transplant nurse evaluates whether they:

• Follow transplant nursing standards and regulations

• Provide safe care to both donor and recipient

• Communicate effectively with the interprofessional team

• Teach clients and caregivers clearly

• Recognize complications, such as graft rejection or infection

• Monitor immunosuppressive medication effects

• Advocate for client needs and informed decision-making

• Use evidence-based interventions

• Support emotional, caregiver, and financial needs

• Improve practice through feedback, education, and experience

Emergency Operations Plan (EOP) and disaster preparedness

A disaster event must be meticulously coordinated in the hospital

• preparation, training, resource planning, need for experienced staff members

• hazard vulnerability analysis: i/x risks to facility/community

  • tells hospital what disasters are most likely

• Before, participate in disaster drills

• High level of comms, excellent triage skills, seamless transition of care

• EOP: wrriten plan for responding to a disaster

  • Helps respond quickly

  • Establishes roles

  • Mobilizes staff

  • Manages & allocates supplies

  • Protects everyone

Nurses role in Disaster:

• Predisaster:

  • risk assessment

  • disaster planning

  • drills, education

• Response:

  • Activates plan, triage, care, communicate needs

  • I/x safe shelter, food, water, & sanitation

• Recovery:

  • Continue care, monitor patients, assist with support, reunite families, help with mental health, debrief, revise plan

Chemical disaster decontamination procedures

Nurse should wear gown, gloves, & mask → identify chemical type

Process:

1. Contaminated patient enters hot zone

2. Patient is triaged and placed in holding area

3. Remove & discard contaminated clothes

4. Shower & dry

5. Provide clean clothes

6. Move patient to cold zone

7. Evaluated for discharge

8. Discharge OR hospitalized

Disaster triage: black-tag classification

Attached to those who died

Qualities:

• No spontaneous breathing and after positioning airway, no improvement noted

• AGONAL RESPIRATIONS; apnea

Disaster triage: red-tag classification

Given to those who may survive treatment

• Neurological injuries, shock states, major burns

• CPR, hemorrhage addressed

• Qualities:

  • RR>30, needs airway positioning,

  • Absent radial pulse or capillary refill >2 secs

  • Altered mental status

Disaster triage: green-tag classification

Minor injuries

• They are able to respond to commands, have peripheral pulses, no resp distress, no hemorrhage signs

• Lacerations, contusions, sprains, strains

• Qualities:

  • Follows commands

  • ABLE TO WALK

Media communication during disasters and emergency response

When a disaster occurs, new media calls for info

• Individuals assigned to provide info

• Notifies them on policies:

  • Staff needs to report to duty during disaster

  • Process for communicating authorities, equipment supplies, vendors, other facilities

• Nurses refrain from sharing in social media; facility manages that

Therapeutic communication with families during critical illness

Keep client & family at center of decision making

• Include their preferences, needs, concerns, and participation

• Encourage them to be present during medical procedures (CPR)

PREPARED MODEL:

• P: Prepare to discuss issues in advance if time is available

• R: Relate to patient & family

• E: Elicit patient and caregiver wishes

• P: Provide edu related to patient & family needs

• A: Acknowledge emotions & concerns

• R: Realistic hope should be fostered

  • Wish for peaceful death

• E: Encourage questions & continue to be available for communication

• D: Document

Discharge planning and care of sexual assault survivors

Care:

• Understand patient’s fear of being stigmatized

• SANE is assigned to patient

  • They provide emotional supprot, evaluates injuries, carries forensic exams, collect evidence via rape kit

  • TIME is essence, collect evicence as sson as possible

  • Must obtain consent before

  • Educate patient to not change clothes or void before exam

• Forensic photographer may be contacted

• Possible emergency contraception given: ulipristal acetate

• Assess patient for HIV/STI → Posteexposure prophylaxis 72 hrs of assault

Discharging Patient that Experience sexual assault:

• Provide bathing facility

• Give food, drinks, grooming kits, phone access, replacement clothing after

• Assess safety issues before returning home

• Verbal & written edu to follow-up

• Eduate on new meds, law agencies, and support systems

Priority nursing actions during sexual assault forensic care

1. Ensure private room for safety & privacy

2. Triage to severe distress

3. Use SANE nurse

4. Emotion support

5. Obtain concsent

6. Preserve evidence

7. Collect forensic evidence

8. Maintain chain of custody

9. A/x & document injuries via pictures

10. A/x STI & HIV risk

11. Initiate HIV PEPE PRN

12. Offer emergency contraception PRN

13. Discharge support

SBAR

SBAR helps prevent communication errors in the ED

Primary survey versus secondary survey in emergency care

Survey	Purpose	Focus
Primary survey	Rapidly identify and treat life-threatening problems	ABCDE: airway, breathing, circulation, disability, exposure
Secondary survey	Find additional injuries or problems after the client is stabilized	More complete head-to-toe assessment and history

PRIMARY

Step	What to Assess
A — Airway	Check for airway obstruction, aspiration, swelling, trauma, or foreign body.
B — Breathing	Assess respiratory distress, respiratory rate, oxygen saturation, stridor, wheezing, and chest rise.
C — Circulation	Assess pulse, heart function, bleeding, hemorrhage, and signs of shock.
D — Disability	Assess neurologic status using AVPU: Alert, responds to Voice, responds to Pain, Unresponsive.
E — Exposure	Expose client to assess injuries while preserving evidence such as clothing, weapons, drugs, or bullets.

SECONDARY

Focus includes:

• Full head-to-toe assessment

• Vital signs and reassessment

• Pain assessment

• History of the event/injury

• Identification of less obvious injuries

• Ongoing monitoring for changes

• Assessment after interventions, such as intubation or fluids

Example: A client’s airway problem may improve after intubation, but later the nurse may find a collapsed lung during the secondary survey.

SBAR communication… again

refer to other flashcards

ABCDE assessment

Step	What to Assess
A — Airway	Check for airway obstruction, aspiration, swelling, trauma, or foreign body.
B — Breathing	Assess respiratory distress, respiratory rate, oxygen saturation, stridor, wheezing, and chest rise.
C — Circulation	Assess pulse, heart function, bleeding, hemorrhage, and signs of shock.
D — Disability	Assess neurologic status using AVPU: Alert, responds to Voice, responds to Pain, Unresponsive.
E — Exposure	Expose client to assess injuries while preserving evidence such as clothing, weapons, drugs, or bullets.

End-of-life communication in emergency care

• Communicate with the team first

  • Discuss the client’s condition with the provider and team before speaking with the family.

  • This helps everyone give the same clear information.

• Use a provider + nurse approach

  • The provider explains the medical details.

  • The nurse stays with the family to provide emotional support and answer questions.

• Give information in small parts

  • Do not overwhelm the family with everything at once.

  • Allow time for them to process each part of the information.

• Be honest, but compassionate

  • Do not give false hope.

  • Use clear, gentle language.

• Use therapeutic communication

  • Speak calmly.

  • Listen actively.

  • Allow silence.

  • Acknowledge emotions and concerns.

• Provide emotional and practical support

  • Explain what is happening.

  • Help the family understand the next steps.

  • Offer presence and reassurance.

• Keep communication ongoing

  • Give frequent updates.

  • Repeat information as needed.

  • Allow the family to ask questions.

• Respect wishes and decisions

  • Consider advance directives.

  • Respect end-of-life choices.

  • Support palliative care or withdrawal of life support decisions when appropriate.

• Support family presence when appropriate

  • Family may find comfort being present during resuscitation or end-of-life care.

  • This can help them understand the efforts made and allow them to say goodbye.

• Document communication

  • Record what was discussed.

  • Include decisions made, questions asked, and support provided.

Breaking Bad News

When telling a family that a client is dying or has died:

• The nurse and provider should share the news together

• The provider answers technical questions

• The nurse provides empathy, support, and presence

• Information should be shared in small pieces

• The family should be allowed time to understand each part

• Do not give false hope

• Continue to support the family after the news is shared

Stress management and prevention of nurse burnout

• Practice mindfulness

  • Focus on the present moment to reduce stress and anxiety.

• Use diaphragmatic breathing

  • Slow, deep breathing can help calm the nervous system during or after stressful situations.

• Perform relaxation exercises

  • Use stretching, guided relaxation, or quiet time to decompress.

• Practice compassion for self and others

  • Avoid harsh self-criticism and recognize that difficult emotions are normal in high-acuity care.

• Participate in recreational activities

  • Hobbies and enjoyable activities outside of work help restore energy.

• Decrease social media use

  • Limiting stressful or negative content can reduce emotional overload.

• Participate in peer-support sessions

  • Talking with coworkers who understand the clinical environment can reduce isolation.

• Meet basic physical needs

  • Prioritize food, fluids, rest, and sleep.

• Build positive workplace relationships

  • Supportive relationships with coworkers help create resilience.

• Balance work and life

  • Make time away from work for rest, relationships, and personal needs.

• Develop emotional intelligence

  • Recognize and manage emotions while communicating effectively with others.

To prevent burnout, nurses should:

• Practice regular self-care

• Seek support from peers, preceptors, mentors, or leadership

• Participate in debriefing after stressful events

• Maintain healthy boundaries

• Continue learning to build confidence and competence

• Use teamwork and ask for help when needed

• Advocate for safe staffing and a respectful work environment

• Recognize early signs of emotional exhaustion

• Use employee assistance or mental health resources when needed

Types of emphysema and risk for pneumothorax

Risk factors:

• Blunt chest trauma

• Penetrating wounds

• Closed/occluded chest tube

• Uncs with less pulmonary reserves (v elasticity & thicker alveoli)

• COPD

Tension Pneumothorax risk factor:

• Central venous catheter placement

• Positive pressure mechanical ventilation

  • due to high volumes of O2 or overexpansion

• Lung biopsy, tracheostomy, bronchospy, intercostal nerve block, pacemaker, CPR

Types:

• Centrilobular/Centriacinar: most common; affects upper lobes

  • long term smoking

• Panlobular/Panacinar: entire lung lobule uniformly; more severe in lower lobes

  • alpha-1-antrytripsin deficiency

• Paraseptal/Distal Acinar: outermost lungs

  • Pneumothorax

• Subcutaneous Emphysema: escapes into tissue beneath skin

  • causes crepitus & swelling

Physiology of open pneumothorax

Air movies in and out of a wound in the chest wall

Secondary spontaneous pneumothorax and COPD

Caused by already establised diseases: COPD, asthma, cystic fibrosis, or interstitial lung disease, or TB/Pneumonia

• Sharp chest pain, SOB, tachy, chest tightness

• COPD → ruptures weak blebs → makes SSP life-threatening

  • D/x via chest-xray then CT scan

  • Thoracostomy

Characteristics of nonallergic asthma

No hypersensitivity to allergens

• Normal IgE levels

• Happens later in life

Positive response to corticosteroids

Persistence of manifestations

Triggers:

• tobacco, airpollction, odors

• Cold, dry air, weather changes

• Viral infections: cold, flu, bronchitis

• Vigorous exercise or high stress

• GERD

Lobar pneumonia

Bacterial lung infection → inflammation & fluid consolidation throughout all lobes

S/s:

• Fever, chills, chest pain when breathing/coughing

• rust-colored phlegm

• SOB

• Fatigue & confusion (uncs)

Pathophysiology of bronchospasm in asthma

Bronchospasm occurs when there is Inflammation, edema, and excess mucus

Risk factors for status asthmaticus

Previous intubation ⭐

Poorly controlled disease

Non-adherence to meds

Heavy exposure to infections or allergens

H/x if CAD

Typical pneumonias

Streptococcus pneumoniae

S/s:

• High fever & chills

• Cough w/phlegm

• Sharp breathing/coughing chest pain

• SOB, ^HR, sweat, fatigue

D/x:

• Chest x-ray → dense localized shadow

Risk factors for emphysema/COPD

SMOKING or airway pollution

COPD complications and associated risks

Increased risk for pneumonia, pneumothorax, ARDS

May also lead to straining of heart → pulmonary HTN, cor pulmonale, A-fib

Pneumothorax considerations in older adults

Caused by:

• COPD, emphysema, interstitial lung disease

s/s:

• Atypical

• Lower dyspnea levels

• O2 Sat at 93-94%

Causes of noncardiogenic pulmonary edema

Kidney injury

ARDS, sepsis, Drowning, high altitude, pancreatitis

Age-related respiratory changes and asthma assessment

Physiological changes in the respiratory system can mimic the presence of airway obstruction

• v elasticity, narrow airway, weak muscle, stiffer alveoli

• Utlilize Spirometry to determine extent of airflow limitation

Common clinical manifestations of COPD

Dyspnea when doing physical acitivites, Sputum production, Chronic cough, wheezing, tight chest

• Possible weight gain (edema) & loss (later stages)

Systemic effects:

• Weight loss, Muscle dysfunction, Poor nutrition, weight gain

Patient education for pulmonary edema secondary to heart disease

Adhere to diuretics

Monitor daily weight

• >3 lbs a day → report

Low sodium diet

• <2k

Fluid restriction