Modifiable - ANSWER Can be changed
Nonmodifiable - ANSWER Cannot be changed
Aspects of Health - ANSWER Physical, Emotional, Social, Intellectual, Spiritual,
Occupational, Environmental
Social Environment - ANSWER Crime vs. Safety, poverty vs. Prosperity, peace vs.
Social unrest, and presence vs. Absence of support from social networks
Physical Environment - ANSWER Access to health care, sanitation, availability of
clean water, and geographic location
Triage Level 1 - ANSWER Resuscitation
Triage Level 2 - ANSWER Emergent
Triage Level 3 - ANSWER Urgent
Triage Level 4 - ANSWER Less Urgent
Triage Level 5 - ANSWER Nonurgent
Primary Survey - ANSWER Rapid assessment of life threatening conditions;
completed systematically; standard precautions; guided by ABCDE principle
ABCDE Principle - Airway - ANSWER Maintain airway, head-tilt/chin-lift if
unresponsive; DO NOT perform if potential cervical spine injury; if trauma
suspected use modified jaw thrust maneuver; bag valve mask with 100% O2 with
nonrebreather for spontaneous breathers
ABCDE Principle - Breathing - ANSWER If NOT breathing, manual vent with bag
valve mask or mouth to mouth
ABCDE Principle - Circulation - ANSWER HR, BP, pulses, cap refill; to restore
circulation: CPR, assess for internal bleed, hemorrhage control; IV access;
Isotonic fluids/blood; to alleviate shock: O2, pressure to bleed, elevate lower
extremities, IV fluids & blood, VS, stay with patient
ABCDE Principle - Disability - ANSWER Assess LOC; GCS; AVPU
,ABCDE Principle - Exposure - ANSWER Complete physical assessment; clothing
removed; hypothermia primary concern
Poisoning - ANSWER Medical emergency; history, type of poison; respiratory
support, circulation, restore fluids, BP/EKG; ingested poison use activated
charcoal, gastric lavage (done within 1 hour), aspiration; diazepam if seizures
occur
Rapid Response Team - ANSWER Respond to emergency when patient has
indications of rapid decline; early recognition before respiratory/cardiac arrest or
stroke occurs
Cardiac Arrest - ANSWER Cardiac emergency
Vfib/Pulseless VT - ANSWER Defibrillate, CPR, administer IV antidysrhythmic
(epinephrine, amiodarone, lidocaine, magnesium sulfate)
Ventricular Asystole - ANSWER Cardiac emergency
Pulseless Electrical Activity (PEA) & Asystole - ANSWER CPR, if shockable use
Defibrillator, IV access, Epinephrine IVP every 3-5 minutes
Epinephrine - ANSWER Stimulates alpha 1 (vasoconstrict), beta 1 (increases HR),
beta 2 (bronchodilator); used for superficial bleeding, increased BP, AV block,
cardiac arrest, & asthma; adverse effects include hypertension crisis,
dysrhythmias, angina
Dopamine - ANSWER Renal blood vessel dilation, beta 1 (increases HR); used for
shock, heart failure, acute kidney injury; adverse effects include dysrhythmias,
angina
Dobutamine - ANSWER Beta 1 (increases HR); used for heart failure
Cerebral Angiography - ANSWER Visualization of cerebral blood vessels, assess
blood flow in brain, identify aneurysms; do NOT perform if pregnant, NPO for 4-6
hours prior, assess allergy to shellfish or iodine, assess bleeding risk/use of
anticoagulants, assess BUN & Creatinine; monitor area for clotting after
procedure; void immediately after; may experience metallic taste or feeling of
warmth; movement restricted
CT Scan - ANSWER Cross section image of cranial cavity; supine, no jewelry; if
contrast dye used take precautions
EEG - ANSWER Identifies brain wave abnormalities, seizure activity & sleep
disorder; wash hair prior, be sleep deprived, expose to flashing lights or
hyperventilate for 3-4 minutes; avoid stimulants/sedatives 12-24 hours
,ICP Monitoring - ANSWER Performed by neurosurgeon in operating room, used
for increased ICP, GCS score of 8 or less, complication of infection.
Intraventricular Catheter - ANSWER Fluid filled catheter connected to sterile
drainage system inserted into burr hole, allows simultaneous drainage &
monitoring by transducer connected to monitor.
Subarachnoid screw or bolt - ANSWER Hollow threaded screw or bolt connected
to transducer, placed through burr hole.
Epidural or subdural sensor - ANSWER Fiber optic sensor inserted through burr
hole.
Signs and Symptoms of Increased ICP - ANSWER Irritability first sign, severe
headache, decreased level of consciousness, dilated/pinpoint pupils, altered
breathing pattern (Cheyne-stokes), hyperventilation, apnea, abnormal posturing.
Lumbar Puncture - ANSWER Withdraw CSF to diagnose MS, syphilis, meningitis.
Complications of Lumbar Puncture - ANSWER Headache from leaking CSF, give
opioids/pain meds, increase fluid intake.
MRI Preparation - ANSWER NPO 4-8 hours prior; remove jewelry, not
claustrophobic, give earplugs; with contrast dyes: assess for allergies for
shellfish; no metal implants (IUD, aneurysm clip, ortho joint, artificial heart valve,
pacemaker).
PET & SPECT Scan - ANSWER Nuclear medicine procedures produce 3D images
of head; images can be static (depicting vessels) or functional (depicting brain
activity); captures regional metabolic processes (tumor activity, dementia).
Radiation Risks - ANSWER Associated with imaging procedures like PET and
SPECT scans.
X-ray - ANSWER Reveal fracture or curvature; no pregnant patients, no jewelry.
Pain Assessment - ANSWER Location, quality, measures/intensity/severity,
timing/onset/duration, setting/how it affects daily life, associated manifestations,
aggravating/relieving factors.
Nonpharmacological Pain Management - ANSWER TENS, heat, cold, massage,
relaxation, imagery.
Nonopioid Pain Management - ANSWER For mild-moderate pain, 4g Tylenol,
monitor for salicylism (tinnitus, vertigo, decreased hearing), GI upset, bleeding.
, Opioid Pain Management - ANSWER For moderate-severe pain, around the clock
administration, causes constipation, hypotension, urinary retention,
nausea/vomiting, sedation, respiratory depression, have naloxone ready.
Meningitis - ANSWER Inflammation of meninges, viral most common and
resolves without treatment, fungal common in AIDS patients; bacterial is
contagious with high mortality.
Meningitis Prevention - ANSWER Hib vaccine, PPSV & MCV4 vaccine (college
students).
Signs and Symptoms of Meningitis - ANSWER Excruciating constant headache,
stiff neck, photophobia, fever and chills, nausea/vomiting, altered level of
consciousness, positive Kernig sign, positive Brudzinski sign, tachycardia,
seizure, red macular rash, irritable.
Diagnosis of Meningitis - ANSWER CSF analysis (cloudy=bacterial, clear=viral; +
= increased WBC, decreased protein, decreased glucose in bacterial); CT
scan/MRI to assess increased ICP.
Meningitis Medications - ANSWER Ceftriaxone or cefotaxime in combination with
vancomycin: antibiotics given until culture & sensitivity results available;
effective for bacterial infections.
Phenytoin - ANSWER Anticonvulsants given if ICP increases or experiences a
seizure.
Analgesics for Meningitis - ANSWER Acetaminophen, ibuprofen: non-opioid
analgesics for headache and/or fever to avoid masking changes in the level of
consciousness.
Prophylactic Antibiotics - ANSWER Ciprofloxacin, rifampin, or ceftriaxone: given
if in close contact with patient.
Complications of Meningitis - ANSWER Increased ICP; monitor level of
consciousness, pupillary changes, impaired extraocular movements; SIADH;
monitor for dilute blood and concentrated urine; septic emboli.
Nursing Considerations for Meningitis - ANSWER Isolation precautions, droplet
precautions until 24 hours.
Seizures - ANSWER Abrupt, abnormal, excessive uncontrolled electrical
discharge of neurons within the brain, altered level of consciousness, change in
motor and sensory ability/behavior.
Nonmodifiable - ANSWER Cannot be changed
Aspects of Health - ANSWER Physical, Emotional, Social, Intellectual, Spiritual,
Occupational, Environmental
Social Environment - ANSWER Crime vs. Safety, poverty vs. Prosperity, peace vs.
Social unrest, and presence vs. Absence of support from social networks
Physical Environment - ANSWER Access to health care, sanitation, availability of
clean water, and geographic location
Triage Level 1 - ANSWER Resuscitation
Triage Level 2 - ANSWER Emergent
Triage Level 3 - ANSWER Urgent
Triage Level 4 - ANSWER Less Urgent
Triage Level 5 - ANSWER Nonurgent
Primary Survey - ANSWER Rapid assessment of life threatening conditions;
completed systematically; standard precautions; guided by ABCDE principle
ABCDE Principle - Airway - ANSWER Maintain airway, head-tilt/chin-lift if
unresponsive; DO NOT perform if potential cervical spine injury; if trauma
suspected use modified jaw thrust maneuver; bag valve mask with 100% O2 with
nonrebreather for spontaneous breathers
ABCDE Principle - Breathing - ANSWER If NOT breathing, manual vent with bag
valve mask or mouth to mouth
ABCDE Principle - Circulation - ANSWER HR, BP, pulses, cap refill; to restore
circulation: CPR, assess for internal bleed, hemorrhage control; IV access;
Isotonic fluids/blood; to alleviate shock: O2, pressure to bleed, elevate lower
extremities, IV fluids & blood, VS, stay with patient
ABCDE Principle - Disability - ANSWER Assess LOC; GCS; AVPU
,ABCDE Principle - Exposure - ANSWER Complete physical assessment; clothing
removed; hypothermia primary concern
Poisoning - ANSWER Medical emergency; history, type of poison; respiratory
support, circulation, restore fluids, BP/EKG; ingested poison use activated
charcoal, gastric lavage (done within 1 hour), aspiration; diazepam if seizures
occur
Rapid Response Team - ANSWER Respond to emergency when patient has
indications of rapid decline; early recognition before respiratory/cardiac arrest or
stroke occurs
Cardiac Arrest - ANSWER Cardiac emergency
Vfib/Pulseless VT - ANSWER Defibrillate, CPR, administer IV antidysrhythmic
(epinephrine, amiodarone, lidocaine, magnesium sulfate)
Ventricular Asystole - ANSWER Cardiac emergency
Pulseless Electrical Activity (PEA) & Asystole - ANSWER CPR, if shockable use
Defibrillator, IV access, Epinephrine IVP every 3-5 minutes
Epinephrine - ANSWER Stimulates alpha 1 (vasoconstrict), beta 1 (increases HR),
beta 2 (bronchodilator); used for superficial bleeding, increased BP, AV block,
cardiac arrest, & asthma; adverse effects include hypertension crisis,
dysrhythmias, angina
Dopamine - ANSWER Renal blood vessel dilation, beta 1 (increases HR); used for
shock, heart failure, acute kidney injury; adverse effects include dysrhythmias,
angina
Dobutamine - ANSWER Beta 1 (increases HR); used for heart failure
Cerebral Angiography - ANSWER Visualization of cerebral blood vessels, assess
blood flow in brain, identify aneurysms; do NOT perform if pregnant, NPO for 4-6
hours prior, assess allergy to shellfish or iodine, assess bleeding risk/use of
anticoagulants, assess BUN & Creatinine; monitor area for clotting after
procedure; void immediately after; may experience metallic taste or feeling of
warmth; movement restricted
CT Scan - ANSWER Cross section image of cranial cavity; supine, no jewelry; if
contrast dye used take precautions
EEG - ANSWER Identifies brain wave abnormalities, seizure activity & sleep
disorder; wash hair prior, be sleep deprived, expose to flashing lights or
hyperventilate for 3-4 minutes; avoid stimulants/sedatives 12-24 hours
,ICP Monitoring - ANSWER Performed by neurosurgeon in operating room, used
for increased ICP, GCS score of 8 or less, complication of infection.
Intraventricular Catheter - ANSWER Fluid filled catheter connected to sterile
drainage system inserted into burr hole, allows simultaneous drainage &
monitoring by transducer connected to monitor.
Subarachnoid screw or bolt - ANSWER Hollow threaded screw or bolt connected
to transducer, placed through burr hole.
Epidural or subdural sensor - ANSWER Fiber optic sensor inserted through burr
hole.
Signs and Symptoms of Increased ICP - ANSWER Irritability first sign, severe
headache, decreased level of consciousness, dilated/pinpoint pupils, altered
breathing pattern (Cheyne-stokes), hyperventilation, apnea, abnormal posturing.
Lumbar Puncture - ANSWER Withdraw CSF to diagnose MS, syphilis, meningitis.
Complications of Lumbar Puncture - ANSWER Headache from leaking CSF, give
opioids/pain meds, increase fluid intake.
MRI Preparation - ANSWER NPO 4-8 hours prior; remove jewelry, not
claustrophobic, give earplugs; with contrast dyes: assess for allergies for
shellfish; no metal implants (IUD, aneurysm clip, ortho joint, artificial heart valve,
pacemaker).
PET & SPECT Scan - ANSWER Nuclear medicine procedures produce 3D images
of head; images can be static (depicting vessels) or functional (depicting brain
activity); captures regional metabolic processes (tumor activity, dementia).
Radiation Risks - ANSWER Associated with imaging procedures like PET and
SPECT scans.
X-ray - ANSWER Reveal fracture or curvature; no pregnant patients, no jewelry.
Pain Assessment - ANSWER Location, quality, measures/intensity/severity,
timing/onset/duration, setting/how it affects daily life, associated manifestations,
aggravating/relieving factors.
Nonpharmacological Pain Management - ANSWER TENS, heat, cold, massage,
relaxation, imagery.
Nonopioid Pain Management - ANSWER For mild-moderate pain, 4g Tylenol,
monitor for salicylism (tinnitus, vertigo, decreased hearing), GI upset, bleeding.
, Opioid Pain Management - ANSWER For moderate-severe pain, around the clock
administration, causes constipation, hypotension, urinary retention,
nausea/vomiting, sedation, respiratory depression, have naloxone ready.
Meningitis - ANSWER Inflammation of meninges, viral most common and
resolves without treatment, fungal common in AIDS patients; bacterial is
contagious with high mortality.
Meningitis Prevention - ANSWER Hib vaccine, PPSV & MCV4 vaccine (college
students).
Signs and Symptoms of Meningitis - ANSWER Excruciating constant headache,
stiff neck, photophobia, fever and chills, nausea/vomiting, altered level of
consciousness, positive Kernig sign, positive Brudzinski sign, tachycardia,
seizure, red macular rash, irritable.
Diagnosis of Meningitis - ANSWER CSF analysis (cloudy=bacterial, clear=viral; +
= increased WBC, decreased protein, decreased glucose in bacterial); CT
scan/MRI to assess increased ICP.
Meningitis Medications - ANSWER Ceftriaxone or cefotaxime in combination with
vancomycin: antibiotics given until culture & sensitivity results available;
effective for bacterial infections.
Phenytoin - ANSWER Anticonvulsants given if ICP increases or experiences a
seizure.
Analgesics for Meningitis - ANSWER Acetaminophen, ibuprofen: non-opioid
analgesics for headache and/or fever to avoid masking changes in the level of
consciousness.
Prophylactic Antibiotics - ANSWER Ciprofloxacin, rifampin, or ceftriaxone: given
if in close contact with patient.
Complications of Meningitis - ANSWER Increased ICP; monitor level of
consciousness, pupillary changes, impaired extraocular movements; SIADH;
monitor for dilute blood and concentrated urine; septic emboli.
Nursing Considerations for Meningitis - ANSWER Isolation precautions, droplet
precautions until 24 hours.
Seizures - ANSWER Abrupt, abnormal, excessive uncontrolled electrical
discharge of neurons within the brain, altered level of consciousness, change in
motor and sensory ability/behavior.
