H&I5 Exam 1

Clinical Judgement, Clotting, & O2/Gas Exchange: Bolded green = Question from SG ; Bolded Black = Bolded from PPT bc need to know ; Blue = meds/examples ; Purple & Pink = extra info

What are the 2 types of disasters?

• Natural

• Human-made

EX: earthquakes, hurricanes, tornadoes, and floods, wildfires

natural disaster

EX: structural collapses, multi-vehicle collisions, chemical spills, bioterrorism

human-made disaster

What are the 4 emotional phases experienced after a disaster?

• Heroic

• Honeymoon

• Disillusionment

• Reconstruction

A shell-shocked community responding to the emergency needs of food, water, and shelter

heroic

EX: First responders and survivors work together to rescue others during a flood

heroic example

A short-lived sense of optimism and relief at survival

honeymoon

EX: Survivors of a mass-casualty shooting discuss what they experienced during the event

honeymoon example

A coming to terms with reality, including the limits of available disaster assistance

disillusionment

EX: Optimism turns into discouragement and the need for substance abuse services may increase

disillusionment example

A phase of setbacks and grief, eventually leading to readjustment to new surroundings

reconstruction

EX: Students return to school following a hurricane

reconstruction example

What are the phases of the disaster management cycle?

• Prevention/mitigation

• Preparedness

• Response

• Recovery

What is CASPER?

Community assessment for public health emergency response!!!

• a framework to collect household-level data about a community

  • helps identify what a community needs

  • tracks changes in needs over time

  • supports funding requests

  • evals. how well disaster response efforts are working

Prevention/Mitigation

Involves assessing for potential threats and vulnerabilities to either stop a disaster from happening at all or to reduce the effects of a disaster if it were to occur

Preparedness

After all efforts have been made to prevent/decrease the effects of a disaster, the community must prepare to face or endure the disaster

Response

Actions taken during and immediately after a disaster

• local gov. will handle emergency 1st but if too overwhelmed —> involve state

• if local & state does not have enough resources —> call for federal gov.

Recovery

Begins when the threat no longer exists. . .

• rebuilding damaged/destroyed buildings

• resuming previous activ.

• establish "new norm" in the circumstances

• refer victims/workers to mental health services

Nurse’s role in Prevention/Mitigation

• Assessing the condition of buildings and other community structures

• Identifying at-risk and vulnerable populations within the community 

• If any threats or vulnerabilities are identified, arrange for repair or removal

Nurse’s role in Preparedness

• Leading annual emergency drills that include debriefing sessions

• Get community members ready for potential disasters.

• Developing personal, work, and family disaster plans 

• Identifying community evacuation routes​​​​​​

• Identifying emergency shelter locations, including those specifically for individuals with special health care needs

• Stockpiling food, water, medication, and first-aid supplies​​​​​​​

Nurse’s role in Response

• Activating the disaster plan

• Providing triage 

• Establishing disease surveillance if an outbreak or bioterrorism is suspected

• Evaluating any other public health needs that may arise

Nurse’s role in Recovery

• Provides nursing and medical care to disaster victims.

• Assist with reunification of families and conduct ongoing assessments of physical and mental health status.

• Evaluates the response and participates in the revision of the disaster preparedness plan to make improvements.

What is the definition of a mass casualty incident?

• A type of disaster where a large number of deaths/injuries occur in a short period of time and overwhelm the resources of the health care system.

• It may require the collaboration of numerous agencies and health care facilities as well as state, regional, and/or national resources.

How many domain competencies for disaster nursing?

Domain 1

Preparing & Planning

• actions taken to get ready for a disaster

Domain 2

Communication

• relaying important updates to disaster team members in a timely manner

Domain 3

Incident Management Systems

• structures in place to activate disaster response and execute disaster plans

Domain 4

Safety and Security

• use of basic infection control; reporting hazards

Domain 5

Assessment

• Conducting assessment and reporting findings

Domain 6

Intervention

• Providing care to victims based on acuity and availability of resources

Domain 7

Recovery

• Making referrals for ongoing care and debriefing

Domain 8

Law & Ethics

• Adherence to policies and procedures

What does it mean to have a “utilitarian approach” to mass casualty triage?

• You prioritize survivability, not severity.

• You allocate resources to those who can be saved with the resources available.

• You tag patients with catastrophic, non‑survivable injuries as EXPECTANT.

• You focus on IMMEDIATE patients who will die without rapid intervention but are still salvageable.

• The goal is maximizing total lives saved

What is a START system?

allows 1st responders to triage multiple victims in < 30 sec. based on respiration, perfusion, & mental status

EIDM

• Expectorant

• Immediate

• Delayed

• Minor

victim unlikely to survive

Expectorant

___?____ care / life-threatening

• pt needs action to save their life ASAP

Immediate

urgent care, can be delayed up to 1 hr

• they’re hurt but stable enough to wait

Delayed

delayed care, can delay up to 3 hrs

• minor injuries, can walk and self-care

Minor

What are the 2 types of debriefing after MCI/disaster?

• Crisis support team debriefing

• Administrative review debriefing

What are the benefits to crisis support team debriefing?

• Helps staff process emotional stress after the event

• Promotes healthy coping strategies

• Supports mental well‑being

• Reduces risk of burnout, PTSD, or moral distress

• Provides a safe space to talk about feelings, fears, and reactions

When do you use crisis support team debriefing?

immediately after or shortly following the incident, when emotions are high

What are the benefits to administrative review debriefing?

• Evaluates system performance and protocol effectiveness

• Identifies what worked well and what failed

• Highlights resource gaps, communication issues, or workflow problems

• Leads to updates and improvements in the emergency preparedness plan

• Strengthens future disaster response

When do you use administrative review debriefing?

after the event is stabilized & operations return to normal

Hemostasis

Process that stops bleeding at site of injury while maintaining normal blood flow elsewhere

What are the steps of hemostasis after tissue/vessel injury?

Vasoconstriction —> Activation of Platelets —> Platelet Plug Formation —> Clotting/Coagulation cascade (fibrin clot) —> Fibrinolysis (clot dissolution)

What happens during vasoconstriction?

Injured site tightens & blood flow is reduced to the area

What happens during activation of platelets?

1. Shape change → spiky + sticky

2. Granule release → ADP + TXA₂ recruit more platelets

3. GP IIb/IIIa exposed → fibrinogen bridges platelets

4. Aggregation → platelet plug forms

What happens during platelet plug formation?

1. Platelets stick to exposed collagen (adhesion)

2. Platelets activate + release chemicals

3. More platelets aggregate

4. Forms a temporary plug

What happens during clotting/coagulation cascade (fibrin clot)?

1. Clotting factors activate in a cascade

2. Fibrin strands form a mesh

3. Mesh stabilizes the platelet plug → solid clot

What happens during fibrinolysis (clot dissolution)?

1. tPA activates plasminogen → plasmin

2. Plasmin breaks down fibrin → clot dissolves

3. Fibrin pieces = FDPs (including D‑dimer)

4. Inhibitors prevent excessive clot breakdown

What are the different components to the clotting/coagulation cascade?

• Intrinsic pathway

• Extrinsic pathway

• Common pathway

Intrinsic pathway

starts from abnormalities inside the blood vessel

• triggered by internal vessel damage

Extrinsic pathway

starts quickly when tissue factor is exposed from an outside injury

• triggered by external trauma exposing tissue factor

Common pathway

both pathways merge —> leading to fibrin formation

Intrinsic Labs

• PTT or aPTT (partial prothrombin time)

• Measures activity of the intrinsic pathway

• Elevated: i.e., vit K deficiency, hemophilia, DIC, liver disease, heparin therapy

  • Heparin therapy

Extrinsic Labs

• PT (prothrombin time)

  • Measures the extrinsic coagulation pathway

  • Elevated value = missing clotting factors, liver disease, warfarin therapy, DIC, Vit.K deficiency

• INR (international normalize ratio)

  • Measures the extrinsic coagulation pathway

  • Elevated in patients receiving anticoagulation

  • Warfarin (Coumadin) therapy

    • 2 – 3 (prevent pulmonary emboli, venous thrombosis)

    • 3.5 – 4.0 (mechanical heart valves)

D-DIMER

• Test for a possible blood clot

• Indicator of fibrinolysis - Elevated implies clot formation occurred  & starting to breakdown. i.e., DIC, malignancy, pulmonary embolus or DVT

Problems w D-Dimer

Cannot be used alone to Dx a blood clot because elevated in other situation (recent surgery, malignancy)

What organs contribute to clotting processes?

• Liver

• Bone Marrow

• Blood Vessels (endothelium)

• Kidneys (indirect)

Liver role in clotting process

• Produces most clotting factors (II, V, VII, IX, X, fibrinogen)

• Produces proteins C & S (natural anticoagulants)

What if the liver fails in the clotting process?

• Prolonged PT/INR

• Easy bruising, bleeding

• Liver failure

Bone Marrow role in clotting process

• Produces platelets, which form the platelet plug

• 80% circulate, 20% stored in spleen

What if the bone marrow fails in the clotting process?

Thrombocytopenia → petechiae, purpura, bleeding

Blood Vessels (endothelium) role in clotting process

• Endothelium releases von Willebrand factor (vWF) → helps platelets stick

• Releases tissue factor (TF) → triggers extrinsic pathway

• Maintains an anti‑clotting surface under normal conditions

What if the blood vessels fail in the clotting process?

• vWF deficiency → poor platelet adhesion

• Endothelial damage → DIC trigger

Kidneys role in clotting process

• Produces erythropoietin that stimulates RBCs

• RBCs help platelets stick to vessel walls

What if the kidneys fail in the clotting process?

Anemia —> Poor hemostasis

Calcium role in clotting process

Cofactor in multiple steps in the coagulation cascade

• hypocalemia = poor clot formation

Vitamin K role in clotting process

Liver requires to activate factors II, VII, IX, & X

• Warfarin blocks this = prolonged PT/INR

Von Willebrand Factor (vWF) role in clotting process

Helps platelets adhere to collagen, carries factor VIII

Fibrinogen role in clotting process

Converted to fibrin by thrombin = forms mesh

• low in DIC & liver disease

What are platelets and what do they do?

____ are small blood cells that help stop bleeding by forming the platelet plug

• when activated, they stick to injured blood vessel walls —> forming the plug by aggregating (sticking together)

• they circulate in the blood 80% & are stored in the spleen 20%

What is thrombocytopenia?

Low platelet count (<150,000)

What platelet count is dangerous & why?

< 100,000 = major risk for bleeding

< 50,000 = risk for spontaneous bleeding/deadlly

What are the causes of thrombocytopenia?

• Bone marrow suppression

• Liver disease

• Hemorrhage

• Immune thrombocytopenia purpura (ITP)

Thrombocytopenia Patient Teaching

• Watch for bleeding “BED” (bruises, epistaxis, dots(petechiae)

• Avoid injury (soft toothbrush, electric razor, no contact sports, fall precautions)

• NO NSAIDS (meloxicam, aspirin, indomethacin, naprozen, ketorolac, ibuprofen, diclofenac)

• CALL DOC NOW if platelets <10,000, sudden severe HA, blood in stool/urine, vision changes

• NO ETOH, STAY HYDRATED, BLOW NOSE GENTLY

DVT (deep vein thrombosis)

Blood clots formed in deep veins, typically in LE

• blocks normal blood flow & can break loose causing a PE —> travels to lungs

DVT Risk Factors

• Trauma/surgery

• Hospitalization/immobility

• Replacement (hormone/oral contraceptives)

• Obesity

• Malignancy

• Birth (postpartum)

• Older age

• Smoking

• Infection/inflammation

• Sickness (CHF, stroke)

DVT S/S

• Unilateral (1 leg)

• Pain / Tenderness (calf/thigh)

• Swelling / Edema

• Warmth, Redness

• May be asymptomatic

What is Virchow’s Triad?

Explains why clots form

1. STASIS

2. ENDOTHELIAL INJURY

3. HYPERCOAGULABILITY

Stasis

Blood isn’t moving

• Blood flow slows down → clots form more easily

• Happens with immobility, long flights, bedrest, hospitalization

Endothelial Injury

Vessel wall damage

• Trauma, surgery, inflammation, central lines

• Damaged vessel wall exposes tissue → clotting begins

Hypercoagulability

Blood is “extra sticky”

• Hormones, cancer, pregnancy, smoking, genetic disorders

• Blood clots more easily than normal

How is DVT diagnosed? What is the gold-standard?

• Venous doppler

• D-dimer

  • high sensitivity, low specificity (use it to rule out)

DVT treatment

Heparin for anticoagulation

• goal is to prevent the clot from dislodging

DVT Complication

• PE (pulmonary embolism)

• Post-thrombotic syndrome

Why don’t we massage the leg with DVT?

increases risk of dislodging the clot

Patient teaching for DVT

• Do NOT rub leg

• Wear compression stockings

• Take anticoagulants as prescribed

Pulmonary Embolism

A blood clot that travels to the lungs & blocks a pulmonary artery = preventing gas exchange at alveoli

PE Risk Factors

~same as DVT~

• Trauma/surgery

• Hospitalization/immobility

• Replacement (hormone/oral contraceptives)

• Obesity

• Malignancy

• Birth (postpartum)

• Older age

• Smoking

• Infection/inflammation

• Sickness (CHF, stroke)

PE S/S

• Dyspnea (MC)

• Chest pain (pleuritic — worse with deep breathing)

• Tachycardia, tachypnea

• Cough, hemoptysis (blood-tinged)

• Low-grade fever

• Anxiety, sense of doom

• Triad — dyspnea, pleuritic pain, tachycardia

Gold standard for PE diagnosis & WHY

CT Pulmonary Angiogram (CTPA)

• direct visualization of the clot, fast, accurate, shows perfusion defects, & first-line test in most hospitals

When would we use a V/Q scan?

• Pt cannot receive contrast (contrast allergy or renal failure)

• Preggo

• Pt w suspected PE + iodine allergy

PE Nursing Interventions

• High-flow O₂ → keep SpO₂ ≥94%

• Anticoagulation Heparin → Warfarin

• Thrombolytics (massive PE only)

• Monitor for shock → vasopressors if needed (shock caused by right heart strain, decreasing preload and cardiac output causing shock)

PE Complications

• Right heart failure

• Sudden death

• Chronic thromboembolic pulmonary hypertension (CTEPH)

PE Patient Teaching

• “Call 911 if sudden SOB or chest pain”

• Avoid sitting still >1 hr

• No smoking

• Do NOT take other medications that alter clotting!

PE Treatment

• Anticoagulants (Heparin/Warfarin)

• Thrombolytics (tPA, alteplase, streptokinase)

• Embolectomy

• Vena Cava filter

Heparin

• Route of administration: IV 

• Lab monitored: aPTT

• Antidote: Protamine Sulfate

Enoxaparin (Lovenox)

• Route of administration: SQ 

• How it differs from regular Heparin: Enoxaparin is low-molecular-weight heparin (LMWH). Its duration is 2–4x as long, its response is more stable, less laboratory testing is needed, it is less likely to cause thrombocytopenia, and patients can be trained to give it SQ at home.