Care of Patients Experiencing Urgent Alterations in Health- Chapter 16 VOCABULARY

nursing fundamentals

A national network of services that provides coordinated aid and medical assistance from primary response to definitive care

emergency medical services (EMS) is obtained

process of classifying a group of patients according to the severity of injury and need of care is called

Triage.

basic emergency procedure for life support

cardiopulmonary resuscitation (CPR)

legal protection for those who give first aid in an emergency situation

Good Samaritan laws

An immediate life-threatening situation of the highest priority

abnormal circulation

An immediate or life threatening situation is when there is an (2)

absent or abnormal pulse

While seeking help, continue the primary survey by assessing the patient’s what?

circulation, airway, and breath-ing (CAB)

What maneuver should be used to ensure the victim’s airway is open?

head-tilt/chin-lift maneuver unless you believe them to have a neck injury

What maneuver should be used if you suspect the victim has a cervical spine injury?

Jaw-thrust maneuver

What signs may indicate a potential head or spinal cord injury?

decrease the level of consciousness

abnormal pupil reaction,

lack of movement in the arms or the legs

what are the two purposes of CPR?

1. To keep the blood circulating and carrying oxygen to the brain, the heart, and other parts of the body

2. To keep the airway open, and the lungs supplied with oxygen when breathing has stopped

The state in which vital functions, such as heartbeat and respiration, have ceased is referred to as?

Clinical death

the irreversible loss of all organ function in the body, including the brain

Brain death

the irreversible damage to body cells due to prolonged lack of oxygen is called?

Biological death

what is the first organ damaged by a lack of oxygen?

The brain

Clinical death may be reversed if CPR is started within how many minutes of cardiopulmonary arrest?

4 minuets

Brain death most likely occurs within how many minutes if CPR isn’t initiated?

10 minuets

An irreversible form of unconsciousness characterized by a complete loss of brain stem function while the heart may continue to beat.

Brain death

brain death is sometimes referred to as

Irreversible coma

What is the initial assessment task in determining the need for CPR?

determine responsiveness

(shake and ask “are you okay?”)

For the most successful treatment of cardiac arrest, CPR and the use of an AED should be initiated within how many minutes

the first 3 to 5 minutes

The immediate, initial assistance given to a person who is injured or has become ill is called?

First aid

Which assessment is the highest priority when caring for multiple victims after a motor vehicle accident?

Orientation

Spinal cord injury

Musculoskeletal injuries

Absent or abnormal pulse

Absent or abnormal pulse

Absent or abnormal pulse

Assessment of life-threatening problems is the priority in an emergency situation. An immediate life-threatening situation of highest priority is abnormal circulation; an absent or abnormal pulse.

Wrong answer rational
Orientation

Assessing a victim’s orientation should be done after assessing for life-threatening injuries. A decreasing level of consciousness, abnormal pupil reaction, and lack of movement in the arms or the legs are indicative of a possible injury to the head or spinal cord.

Spinal cord injury

After the initial assessment for life-threatening problems, assess the victim for indications of skull injury and brain or spinal cord damage, all of which necessitate immediate interventions.

Musculoskeletal injuries

Assessment of musculoskeletal injuries is not the first assessment the nurse would complete.

The absence of a pulse confirms the presence of sudden cessation of functional circulation confirms

cardiac arrest

Complications of external chest compressions include

lacerated liver

fractured ribs

fractured sternum,

bruising or bleeding of the liver, the lungs, and the spleen

The rescuer at the victim’s head is referred to

as the?

ventilator

the rescuer at the victim’s chest is referred to as the

compressor

In two-rescuer cardiopulmonary resuscitation who determines responsiveness

the ventilator

Who assesses for pulseslessness

the ventilator

If the victim has a pulse, the ventilator should initiate rescue breathing at a rate of

one breath every 6 to 8 seconds, or 8 to 10 times/min

what is the compression rate for 2 person CPR

The com-pression: ventilation ratio for two-person CPR is 30 chest compressions for every 2 breaths. Exhalation occurs during chest compressions. The compression rate for two-person CPR is at least 100 per minute.

what is the compression rate for 1 person CPR

The rescuers should switch positions every ____ cycles of 2 minutes to continue effective CPR.

5

(The switch is initiated by the rescuer performing chest compressions at the end of a 30:2 sequence.)

For the purpose of basic life support, an infant is defined as anyone younger than

1 year of age,

compression rate for child and infant

The sequence of compressions to ventilation is 30:2 (30 compressions to 2 breaths). If there are two health care provider rescuers, the sequence is 15:2 (15 compressions to 2 breaths).

a child is defined as anyone between age

1 year and puberty

Where do you check for a pulse on a child and infant?

Check for circulation by assessing the pulse on the

Child carotid artery

Infant brachial artery

• If the victim has a pulse, the ventilator should initiate rescue breathing at a rate of one breath every 6 to 8 seconds, or 8 to 10 times/min, for an adult victim.

• The compression rate for two-person CPR is at least 100 per minute.

The switch is initiated by the rescuer performing chest compressions at the end of a 30:2 sequence.

• infant and child

• If there is a pulse, continue rescue breathing at a rate of one breath every 6 to 8 seconds.

• If there is no pulse or the pulse is less than 60 beats/min, begin to perform external cardiac compressions.

infant The breastbone is compressed to a depth of at least one third the diameter of the chest, or 1.5 inches (4 cm), at a rate of at least 100 times/min.

infant The sequence of compressions to ventilation is 30:2 (30 compressions to 2 breaths). If there are two health care provider rescuers, the sequence is 15:2 (15 compressions to 2 breaths)

When performing cardiac compressions on a child, do the following:

1. Compress the chest with the heel of one hand at the nipple line at a depth of at least one-third the diameter of the chest, or 2 inches (5 cm), at least 100 times/min. Make sure that the fingers do not touch the ribs.

2. Keep the compressions smooth, allowing the chest to return to the natural position after each compression.

3. The sequence is 30 compressions to 2 breaths. If two health care providers are performing the rescue, the sequence is 15:2 (15 compressions to 2 ventilations).

Perform mouth-to-mouth ventilation only until help arrives.

Mouth-to-mouth ventilation is only indicated if the patient has a pulse. In this instance, since the patient is pulseless, mouth-to-mouth ventilation is not appropriate.

The compression rate for two-person CPR is at least 120 per minute.

The compression rate for two-person CPR is at least 100 per minute.

stridor (harsh sound during respirations, high-pitched and resembling the blowing of wind, caused by obstruction of the air passage)

Shock is an abnormal condition of inadequate blood flow to the body’s peripheral tissues (decreased tissue perfusion)

slightly bluish, grayish, slatelike, or dark purple discoloration of the skin, especially of the lips and nail beds, caused by an excess of deoxygenated hemoglobin in the blood

cyanosis

abnormal rapidity of heart action, usually defined as a heart rate of more than 100 beats/min in an adult

tachycardia

an exaggerated hypersensitivity reaction to a previously encountered antigen.

Anaphylaxis

What type of shock occurs due to the sudden decrease in the amount of circulating blood caused by the sudden release of histamine, which creates capillary hyperpermeability, which causes the release of plasma through the capillary walls.

Anaphylaxis shock

This type of shock results from poor heart function, which results from various cardiovascular abnormalities. The heart is unable to maintain sufficient blood pressure for all body parts.

Cardiogenic Shock

This type of shock occurs due to decreased fluid volume, which can result from bleeding, prolonged vomiting, diarrhea, or fluid loss. It may be caused by surgery, trauma, or burns.

Hypovolemic shock (hemorrhagic shock)

This type of shock occurs when the nervous system fails to maintain normal contraction of the blood vessels. Common causes include spinal anesthesia, quadriplegia, or medications that promote vasodilation. It happens when blood pressure drops because there isn't enough blood to fill the dilated blood vessels.

Neurogenic Shock

This type of shock is caused by the nervous system’s reaction to an emotional stimulus. Blood vessels temporarily dilate, decreasing blood flow to the brain, which can result in unconsciousness, or syncope.

Psychogenic Shock Syncope

This type of shock occurs due to a severe infection. Toxins produced by microorganisms lead to fluid loss through the walls of blood vessels. It is commonly observed in individuals with various infections, such as:

- Urinary tract infections or wound infections

- Patients who have recently undergone surgery

- Individuals receiving chemotherapy

- Those with conditions that compromise the immune system, such as AIDS

Septic Shock

Shock is related to the inability of the body to maintain what?

circulatory homeostasis.

The average adult has approximately how much blood circulating in their bloodstream?

5 to 6 L (8 to 12 pints)

what is a Danger of venous bleeding is

entrance of air into the severed vein which creates a risk for air embolism

An abnormal circulatory condition in which air travels through the bloodstream and becomes lodged in a blood vessel

air embolism (

Location of the following arteries:

Brachial

Carotid

Femoral

Radial

Brachial (in the medial aspect of the upper arm)

Carotid (on either side of the neck)

Femoral (in the upper thigh and groin)

Radial (in the medial aspect of the lower arm)

hemoptysis

Expectorate blood

hematemesis

or vomit blood

melena

Dark, tarry stool

hematuria

blood in the urine

Nursing interventions for internal bleeding include:

• Lay on a flat surface with legs elevated 6 to 12 inches, if this is not contraindicated.

• Initiate treatment for shock.

• Place a cold compress or ice on the area of the suspected injury.

  • Do not apply the ice directly to the skin because it can damage the tissue.

  • Place a towel or clean cloth between the ice and the skin

an injury to the internal or external soft tissues of the body

wound

3 steps for wound treatment

1. stop the bleeding

2. treat shock

3. prevent infection

ecchymoses

discolorations of an area of the skin or mucous membrane caused by the extravasation of blood into the subcutaneous tissues; also called bruises

injuries that do not break the skin, are caused by a blow, and are characterized by edema, discoloration, and pain

Contusions

• Closed fracture: The skin overlying the injury is intact.

• Open or compound fractures: An open wound exists over the fracture site. Often the affected bone is visible as it protrudes through the skin.

• Comminuted fracture: The bone is shattered into two or more fragments or pieces.

• Spiral fracture: Results from a twisting force.

• Impacted fracture: Results from trauma that causes the bone ends to jam together.

• Greenstick fracture: An incomplete break, occurring most commonly in children because their bones are more pliable.

• Compressed fracture: To the vertebrae as the result of pressure.

• Depression fracture: Results from blunt trauma to a flat bone, causing an indentation in the bone.

• Displaced fracture: Fracture in which the ends of the bones are not in alignment with each other.

• Oblique fracture: Break runs diagonally across the bone, at approximately a 45-degree angle to the shaft of the bone.

• Crepitus: a grating sound caused by the broken bones scraping against each other

• Crepitus: a grating sound caused by the broken bones scraping against each other

Deep partial-thickness burns (also classified as sec-ond-degree burns) fully involve the first layer of skin (epidermis), as well as some of the underlying tissue (dermis); scarring from vesicles and infection is pos-sible.

Full-thickness burns (also classified as third-degree burns) involve destruction of the skin and underly-ing tissue, including fat, muscle, and bone.