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NUR 213 ( LATEST 2024 / 2025 ) FINAL 5 | A+ RATED GUIDE | QUESTIONS AND ANSWERS (SOLVED)
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NUR 213 ( LATEST 2024 / 2025 ) FINAL 5 | A+ RATED GUIDE | QUESTIONS AND ANSWERS (SOLVED)
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NUR 213 FINAL 51. salt triage
Answer
Sort, Assess, Lifesaving Interventions, Treatment and/or Trans- port•First priority
Those who cannot follow commands and have obvious life threatening injuries•Second priority
Those who can follow commands but cannot walk•Third priority
Those who are able to walk•In response to the lack of scientific data regarding the efficacy of
mass casualty triage systems, the Centers for Disease Control and Prevention (CDC) formed an
interdisciplinary advisory committee to review existing disaster triage models. The advisory
committee developed the Sort, Assess, Lifesaving Interventions, Treatment, and/or Transport
(SALT) model by combining the best features of the existing systems. Sort, Assess, Lifesaving
Inter- ventions, Treatment, and/or Transport can be used to triage both adults and children.
Sort, Assess, Lifesaving Interventions, Treatment, and/or Transport is endorsed
by several national organizations, including the American College of Emergency Physicians, the
American College of Surgeons Committee on Trauma, the American Trauma Society, and the
National Association of EMS Physicians.SALT stands for Sort, Assess, Lifesaving
Interventions, Treatment, and/or Transport. The first step is to address the "walking wounded."
Those who are able to walk are prioritized last; those who cannot follow a command or have an
obvious life threat are prioritized first; and those who can follow a command but are unable to
walk are prioritized second. The next step is to make lifesaving interventions before assigning a
patient to a triage category. Lifesaving interventions include control of major hemorrhage,
opening the airway and providing two breaths for child casualties, decompression of a tension
pneumothorax, and the use of auto injector antidotes. Finally, triage categories are assigned
(delayed, immediate, or expectant) based on breathing, peripheral pulses, respiratory distress,
and hemorrhage control. The SALT system of triage is different from the other systems in that
there is a grey or "Expectant" category. This category means that the patient may have a life-
threatening injury, but current resources are not available to meet the need. As resources
become available, this "Expectant" category of patients should be re-evaluated frequently. It is a
different method of triage in that there are two phases; a global sorting based on the ability to
follow commands and walk, and a triage category assignment based on response to lifesaving
interventions. Regardless of the system used, the primary goal of disaster triage is to maximize
the number of survivors.Many casualties will present to the hospital within the first 2 hours of
the event. Patients usually arrive at the hospital in two waves. Wave 1 arrives in approximately
15 to 30 minutes. These patients are the walking wounded who were able to self-extricate
themselves from the scene and make it to the hospital on their own. Past disasters have shown
that 80% to 85% of all disaster casualties will bypass the EMS system and arrive at the hospital
on their own. Wave 2 will follow in 30 to 45 minutes. This second group
needed assistance for extrication from the scene and were transported by EMS. They are usually
more seriously injured than the patients in the first wave.
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,2. Mass Casualty triage
Answer
¡Red/Immediate
Life-threatening, treatable with immedi- ate attention
Airway obstruction, MI, hemorrhage, severe abdominal injury, tension pneumothorax, shock,
head injury, threatened loss of limb¡Yellow/Delayed
Poten- tially serious but stable enough to wait a short while for medical treatment
Fractures, burns < 20%, soft tissue injuries min. bleeding, torso wounds w/o shock, facial injury
w/o airway involvement¡Green/Minimal
Minor injuries can wait for longer periods of time
Ambulatory, minor burns, sprains, lacerations¡Black/Expectant
Dead, No VS, injuries incompatible with survival
Full thickness burns > 50% TBSA, no pulse or breathing after airway opened, high SCI,
transcranial GSW-Inside the hospital setting, part of mass casualty triage includes relocating
and discharging patients to create more beds for those who are high priority. This is evident and
can even be seen with the surge during the COVID pandemic with hospitals diverting ambulances
and not having any beds for other emergent patients
3. prerenal, intrarenal, postrenal AKI
Answer
prerenal- 60-70%. Sudden and severe drop
in blood pressure (shock) or interruption of blood flow to the kidneys from severe injury or
illness. Causes dehydration, hypovolemic shock, vomiting and diarrhea, surgery, diuretics, heart
failure, vasodilation- (meds, anaphylaxis, sepsis)Leads to decrease in GFR
Intrarenal- Direct damage to the kidneys by inflammation, toxins, drugs, infection, or reduced
blood supply. Causes acute glomerulonephritis, pyelonephritis, allergic response to
radiocontrast media, diabetic nephropathy, nephrotoxic agents (amino- glycosides, NSAIDs,
ACE inhibitors, Vancomycin), DIC, hypertensionAcute tubular necrosis (most common)
postrenal- from Obstruction problems- BPH, prostate, bladder cancer, strictures, fecal
impaction, kidney stones
4. clinical manifestations of AKI
Answer
Azotemia
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, Urea, nitrogen, creatinine waste in bloodIncreased BUN and creatinineMay or may not have
oliguriaFluid overload and electrolyte imbalances (increased K and phosphorus, decreased Ca
and Na)Meta- bolic acidosisEdemaAnemiaUremia
excess urea in blood causing renal decline and involving multiple body systemsAnorexia,
NVDConfusion, lethargySeizures or coma
5. priority for peritoneal dialysis
Answer
Before - take weight, warm solutionPeritonitis- Key signs to report- fever, tachycardia, cloudy
drainageDeadly Key signs- crackles, rapid R, dyspnea, First action raise HOBInsufficient
outflow- Assess patient ab- domen distention and constipationAssess device, catheter kinks and
obstructions, INTERVENTION reposition to side lying position
Contraindications- -History of multiple abdominal surgeries (scar tissue and damage to peritoneal
membrane)-Chronic abdominal conditions. Ex
pancreatitis, diverticuli- tis, crohns-Recurrent abdominal wall or inguinal hernias-Obesity-Pre-
existing back problems or vertebral disease-Severe COPD (lungs wont be able to expand
Complications- -Catheter infection & peritonitis
S&S cloudy effluent, increased WBCs, redness, swelling, drainage (Chronic infections may
switch to HD)-Abdom- inal pain and/or distention-Hyperglycemia & increase triglyceride levels
r/t glucose in dialysate-Outflow problems. Ex
kinked catheter, catheter migration, constipa- tion-Respiratory compromise-Protein loss
6. · Hemodialysis complications clinical manifestations
Answer
-Hypotension
(Dur- ing & Post Treatment) Light-headedness, NV, seizures, vision changes, & chest
pain(During Tx, fluid removal rate decreased & add NS therapy)
-Muscle cramps, HA, NV, dizziness, & malaise(During Tx, the filtration rate might be slowed or
NS bolus)
-Systemic infection is a concern; Higher risk of Hep B, Hep C & HIV; Multiple blood
transfusions, immune system depression, & underlying disease processes
-Dialysis dementia
Answer
Progressive, potentially fatal neurological complication from long-term dialysis; May be due to
aluminum present in phosphate binders
-Localized AV fistula/graft complication
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