Exam (elaborations)
N450 Assessment 2 (1)
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N450 Assessment 2 (1)
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N450 Assessment 2ED Triage - ANS-Process of quickly sorting patients and assigning right resources in the right
place and right time
ESI 1 - ANS-Unstable
ESI 2 - ANS-Threatened
ESI 3-5 - ANS-Stable
ABCDE - ANS-Airway
Breathing
Circulation
Disability
Exposure/Environment
Nursing Interventions for Alertness/Airway - ANS-Control Bleeding
Open airway
Jaw thrust
Suction airway
Nasal/Oral airway or intubation
Cervical Spine immobilization
Nursing Interventions for Breathing - ANS-Administer O2
Intubate
Suction
Alertness/Airway Assessment - ANS-Assess:
Catastrophic external bleeding
LOC
Respiratory distress
Patency: Foreign objects/loose teeth
Breathing Assessment - ANS-Ventilation
Use of accessory muscles
Respiratory rate
Color of skin
Auscultate lungs
JVD and trachea position
Airflow does not ensure adequate.... - ANS-ventilation
,Circulation Assessment - ANS-Palpate carotid or femoral
Pulse rate and quality
Skin color, temp, dry/moist
Capillary refill
BP
Nursing Interventions for Circulation - ANS-CPR/ACLS
Prep for central venous access
Administer IV fluids/blood products
Control bleeding
If patient is hypotensive insert ______ large bore IVs, and start 0.9% normal saline or lactated
ringers - ANS-two
Disability Assessment - ANS-LOC w/ Glasgow Coma Scale
Pupils
Glasgow Coma Scale - ANS-Eye opening 4
Verbal response 5
Motor response 6
GCS 8 or less - ANS-severe brain injury
GCS 9-12 - ANS-moderate brain injury
GCS 13-15 - ANS-mild head injury
Exposure/Environment Assessment - ANS-Remove clothing for complete assessment
Nursing Interventions for Exposure/Environment - ANS-Prevent heat loss by keeping patient
covered or infusing warmed IV fluids
Stabilize impaled objects
Protect patient's privacy
DO NOT remove _________ objects - ANS-impaled
Facilitate Adjunctive Monitoring/Family Presence Assessment - ANS-Evaluate VS and POx
Discuss family preference for involvement during invasive procedures and/or CPR
Nursing Interventions for Family Presence - ANS-Monitor VS
Establish healthcare team
Secondary Survey - ANS-head to toe assessment starting at head.
, Touch, smell, looking all areas.
SAMPLE - ANS-Symptoms
Allergies
Medications
Pertinent history
Last meal or intake
Events or factors
Logroll - ANS-Method of turning a person in one movement without bending the spine, 3-4
people. One person keeps head in place
Who is at high risk for injury? - ANS-Older adults
Who is at high risk for hyperthermia? - ANS-Elderly, mentally ill, and very young
Hyperthermia - ANS-99.6-105.8
Nursing Interventions for Heat Exhaustion - ANS-Start PO or IV fluids 0.9% saline
Cool patient
Monitor VS
Nursing Interventions for Heat Stroke - ANS-High flow O2
Start IV 0.9% NS
*EKG Monitor
Rapidly Cool Patient
Nursing interventions for Frostbite - ANS-DO NOT RUB
Warm under warm water
Treat like a burn
Hypothermia - ANS-below 95 deg F
Shivering stops at _____ - ANS-86 deg F
Who's at greatest risk for animal bites? - ANS-Children
Complications of Animal Bites - ANS-Infection (RABIES)
Destruction of skin
Human Bites increase risk for... - ANS-infection
Treatment of Human Bites - ANS-Clean site
Start antibiotics
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