Complex Care Exam #2

Impact of Nursing on Homelessness in ED

-Maintain situational awareness

-Attend to personal safety needs

-Use standard precautions

-Demonstrate behaviors that promote trust and do not blur professional boundaries.

What are Forensic Nurse Examiners (RN-FNE)

-Educated nurses to collect pt evidence and offer care for pts of abuse, rape and violence.

-1:1 with the pt

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Psychiatric Nurses

-Evaluate pts with mental illnesses and they facilitate the care plan

-Can facilitate the admission into a mental facility

Who are the pre-hospital care team

EMT’s and Paramedics

Hand-off communication process from ED to next point of care

-Situation of patient

-Pertinent (relevant) Medical history

-Assessment and diagnostic findings

-Transmission-based precautions & safety concerns

-Interventions provided in the ED

Patient safety in the ED

-Fall risk

-Medical administration errors

-Patient misidentification

-Skin breakdown

ED training and certification

-BLS

-ALCS

-PALS (pediatric)

-Emergency nurse speciality certification

-Trauma Nursing Care Course

The act of sorting or classifying patients which identifies highest-acuity

Triage

Emergent vs Urgent vs Non urgent

Emergent → Immediate threat to life or limb

Urgent → Requires quick treatment but immediate threat to life does not exist at the moment

Non-urgent → Can wait several hours for care without significant risk.

Emergent Examples

-Vascular → No perfusion to limb leading to amputation

-Retinal detachment

-Chest pain with diaphoresis

-Hemorrhage

-Stroke

Urgent Examples

-Severe abdominal pain

-Displaced or multiple fractures

-Renal colic (kidney stones)

-Pneumonia

-Complex cuts or lesions

Non urgent Examples

-Simple fracture

-Rashes

-Strains and sprains

-STDS

When the provider determines whether the patient should be admitted to a hospital, transfered to a specialty care center, or discharged to home

Disposition

What are the factors that need to determined before disposition occours

-Assess psychosocial needs

-Consult with social services and rehab team

-Be alert for human trafficking

-Implement SBIRT

Case management tasks

-Arrange appropriate referral and follow-up

-Review ED census and trends

-Collaborate to find safe environments for patients or vulnerable populations

Specific death care for trauma deaths (suspected homicide & abuse cases)

-LEAVE ALL LINES IN PLACE

-Pt needs autopsy

-Use appropriate words such as death or died.

What is the leading cause of death in the US for individuals under 35 years old

Unintentional Trauma (accidents like motor vehicle crashes or poisoning)

Trauma Informed Care (TIC) 4 key principles

Model of care that ensures patient safety

1) Realizing the widespread affect of trauma

2) Recognize the signs and symptoms of trauma

3) Responding by fully integrating trauma knowledge into practices and procedures

4) seeking to actively resist retraumaization

Level 1 Trauma Centers

-Regional resource facility that provides leadership and total collaborative care from prevention through rehabilitation

-Large teaching hospitals that serve dense populations

Level 2 Trauma Centets

Community hospitals that can provide care to vast majority of injured patients

Level 3 Trauma Centers

Smaller, rural hospitals that focus on initial injury stabilization and patient transfer if necessary

Level 4 Trauma Centers

Rural remote settings that offers ACLS and transfers patient after stabilization

What are examples of mechanism of injuries (MOI)

-Blunt trauma

-Blast Effect

-Acceleration-deceleration

-Penetrating trauma

When do you not use ABCD(disability)E(exposure)

In presence of excessive bleeding (multiple gunshot or stab wounds) use CAB.

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Neurological Diagnostic Testing

-CerebralAngiogram

-Electroencephalography (EEG)

-Glasgow Coma Scale

-ICP Monitoring

-Lumbar Puncture

Test that is done to visual the cerebral circulation, it will detect blockages of arteries or veins in the head or neck.

Gold standard for intracranial vascular diseases

Cerebral Angiogram

Cerebral Angiogram need to knows

-Before → Asses for stroke and bleeding risk

-During → Instruct client to remain still (flushing may happen)

After → Frequent (15 min) neuro checks for 2 hours than every 1 hour for 6 hours. Asses for bleeding!!

Diagnostic tests that sees if it can detect seizures

Electroencephalography (EEG)

Electroencephalography (EEG) need to knows

-Before → reassure this is noninvasive, hold anti-seizure (Keppra, Tegretol, Topomax) and sedation medicine (benzos “pam + lam” & propofol)

-During → Monitor and evaluate pts response to noise and light

-After → Instruct client to resume their anti seizure meds, and help wash the gel out of their hair.

Glasgow Coma Scale

Less than 8 intubate

Device used to measure the pressure inside the skull

ICP monitoring

ICP monitoring need to knows

-Before → Shave and clean head by the insertion site

-During → Assist the in procedure and maintain aseptic technique

-After → Make sure the equipment is balanced and calibrated, prevent infection, frequent neuro and vital checks.

What are early vs late signs of increased ICP

Early → Decreased LOC, restlessness, confusion, report of headache and projectile vomiting.

Late → Posturing, syncope

Sticking a spinal needle into spinal cord to take in CSF for testing is called

Lumbar Puncture

Lumbar Puncture need to know

-Before → Order a CT, and asses for bleeding risk

-During → Maintain pt on side lying position

-After → Monitor headache, VS, neuro check, keep pt in reclined position for several hours, encourage oral fluid intake and walk the CSF to the lab (do not tube it)

Acceleration Vs Deceleration Injury

Most common way to acquire a TBI

-Acceleration → Back head hurt

Deceleration → Front head hurt

Primary vs Secondary Brain Injuries

Primary → Happens at time of injury

Secondary → Occurs after initial injury and worsens outcomes

Tear of the artery after a skull fracture is called

Epidural Hemorrhage (pt has acute and rapid decrease in mental status)

Worst headache they have ever had in their life (10/10) pain due to an aneurysm

Subarachnoid Hemorrhage

Thunder clap in their head, hearing aspect noted, severe head ache (deep blood vessel ruputured)

Intracerbral Hemorrhage

Venous bleed from a fall that is more chronic in nature is called

Subdual Hemorrhage

Subdural hemorrhage/hemotoma etiology

-Falls

-Motor vehicle crashes

-Colliding with a stationary or moving object

Subdural Hematoma Health Promotion

-Safe driving practices

-Avoid alcohol, drugs, marijuana

-Use helmets

-Environmental factors

-Fall prevention strategy

TBI/Brain Bleeds Assessment

-LOC

-Sleep disturbances

-Pupillary changes

-Emotional lability

ICP Drug

Mannitol (osomotic dirutic) “lasix for the brain”

-Pulls fluid off the brain

-Give in a bolus make sure there is a filter needle and tubing

-Do not use this on heart pts

-Insert foley, Monitory I & O’s, electrolytes, urine osmolarity

Generalized Seizures

Tonic Clonic → Typical seizure (3-5 minutes)

Myoclonic → very quick muscle jerk

Atonic → Loss of muscle tone than disoriented, probably fall or slump over

Partial Seizures

Simple → Aura, one body part moving

Complex → Amnesia, and they stare blanky

Etiology of Seizures

Primarily through seizures

5 seizure precautions

1) Padded side rails

2) Airway at the bedside

3) Suction at the bedside

4) Oxygen flow meter at the bedside

5) Maintain patent IV site

Medical Management for Seizures

-Keppra, Tegrotal, Topomax

-Make sure people take their seizure medication

-Surgical → vagal nerve stimulation and pacemaker for the brain

Nursing management for status Epilepticus

-Medical Emergency

-Stay with patient

-Put pt on side (avoid aspiration)

-Administer oxygen

-2 Large bore IVs

-IV fluids + Lorezapam

Patient Education for Seizures

-Make sure they take their medications daily

-Routine lab work

-Medical alert bracelet

-Know laws of when you can drive again

-Avoid alcohol or excessive fatigue

GBS is what type of disease

Autoimmune disease

GBS clinical manifestations

-Rapid, acute and progressive weakness of symmetric extremities → Ascending (bottom to top)

-Maximum weakness comes at 4-6 weeks

-Orthostatic hypotension

-Abnormal vagal response

-Facial flushing

Most important complication to monitor for GBS patients

Respiratory failure due to paralysis of nerves within the diaphragm or lungs.

Nursing Care for GBS patients

-Ventilator support

-Plasma exchange

-High does IVIG (most effective 2 weeks out)

-Respiratory, Neuro, & cardiac assessments

-Monitor for fever

-Enteral or parenteral nutrition

Rare autoimmune disease where antibodies attack the acetylcholine receptors which prevents muscles to be stimulated

Myasthenia Gravis

Clinical Manifestations of Myasthenia Gravis

-Cranial nerve impacts of eye movement, facial expressions, chewing, swallowing, talking or breathing.

-Eyelid drooping

-Blurred vision

Big concerns for patients who are experiencing a Myasthenia Gravis Crisis

Severe muscle weakness that leads to aspiration and pneumonia

Nursing care for Myasthenia Gravis

Anticholestrase Agents (neostigmine & donezipil)

When there is ischemia or hemorrhage into the brain that results in death of brain cells leading to a severity of loss of function.

Stroke (Leading cause of serious long-term disability in the US)

Non-modifiable risk factors for stroke

-Age → Over 55

-Sex → More common in males while more females die from it

-Ethnicity → African American

-Arteriovenous Malformation

Modifiable risk factors for stroke

-HTN

-Diabetes

-Afib

-Oral contraceptives

-Cocaine

-Alcohol

Secondary Prevention of stroke

-Carotid endarterectomy

-Anticoagulant therapy (heparin & warfarin)

-Antiplatelet (aspirin & plavix)

-Statins

-Prils

When a patient comes into the emergency room and is complaining about generalized weakness what is the first and then second thing you should do?

1) Get a blood sugar

2) Get a CT scan

Ischemic Stroke → Blocking blood flow

Thrombotic → Blood clot forms in artery (no movement)

Embolic → Plaque breaks away from one part of the body and clots on an artery (movment) “dysrithmias cause this most of times”

Hemorrhagic Stroke

A blood vessel bursts which allows for blood to seap into the brain and damage it until it clots off.

What are causes for ischemic strokes

-Atherosclerosis

-Cardiac dysrhythmias

-Valvular heart disease

-Coagulpathies

-Dissection of carotid arteris

What is the most common cause of hemorrhagic stroke

Hypertension

Intracerebral Hemorrhage, Subarachnoid Hemorrhage, Cerebral Aneurysm

Intracerebral Hemorrhage → Caused by HTN and forceful activity

Subarachnoid Hemorrhage → Caused by rupture of a cerebral aneurysm, trauma, or drug abuse

Cerebral Aneurysm → “Silent Killer”

Nursing Care for Strokes

-Manage blood pressure

-Place pt NPO

-Control fluids and electrolytes

-Manage ICP → implement seizure precautions, make sure neck is midline, HOB at 30 degrees.

Ischemic Stroke Medications

Tpa → Administered within 4 hours, medication screening if they are on other blood thinners, implement fall & bleeding precautions (major headache = internal bleeding).

-After stabilized do continuous treatment with anticoagulants like warfarin (INR 2-3), plavix and blood thinners like aspirin.

Hemorrhagic Stroke Medications

-Adminster vasopressors to maintain perfusion!!!

-Calcium channel blockers (nimodipine)→ for vasospasms

Surgical Interventions Ischemic vs Hemorrhagic

Hemorrhagic → Resection (cut and resew the vessel), preventative clipping of aneurysm’s, suck out hemotoma’s “evacuation”

Ischemic → Brain stents placed (used for pts not able to get tpa)

What are the 3 main assessments you need to do for Stroke patient

1) Cardiac

2) Respiratory

3) Neurologic

What is the best prevention for VTE

Get the patient up and moving right away!!

Right Brain vs Left Brain Stroke

-Right → Left side paralysis, impulsivity, personality changed.

-Left → Right side paralysis, slowed speech, slow and cautious.

Aphasia vs Dysarthria vs Dysphagia

-Aphasia → Affects a person’s ability to comprehend, speak, read, and write.

-Dysarthria → Lack of coordination in muscles associated with speech

-Dysphagia → Affects swallow ability

How often should a stroke patient be placed on their paralyzed side for

For only 30 minutes

GI & Urinary notes for stroke

-Constipation and urinary retention is common

-Give stool softness

-Get them mobile

-Make them use bathroom every hour instead of using catheters for urinary retention.

Short temporary impairment of the cerebral blood flow to a specific region of the brain that lasts for a few minutes.

Transient Ischemic Attacks (TIA)