NURS 4406 EXAM 1 REVIEW
NURS 4406 EXAM 1 REVIEW
• Principles of Emergency Care Nursing (5-8)
o Emergency Nursing Principles (2-3)
▪ Triage, primary survey, ABCDE, poisoning, rapid response team, cardiac emergency, post-resuscitation
▪ Prioritization
• ABCDE Principle
Airway/Cervical - Most important step of primary survey
Spine - Patent airway is not established can result in hypoxia, brain injury, or death within 3
– 5 min
- Unresponsive without suspicion of trauma opened with head-tilt/chin-lift maneuver
- Unresponsive with suspicion of trauma open with modified jaw thrust maneuver
- Inspect opened airway for blood, teeth, vomit, & secretions
- Administer bag valve mask at 100% O2 for additional support
- Use a nonrebreather mask for clients breathing spontaneously
Breathing - Assess for presence & effectiveness of breathing
- Listen to breath sounds, monitor chest expansion, effort, rate & depth
- If client if not breathing or breathing inadequately manual ventilation should be
performed via bag valve mask with supplemental O2
Circulation - Assess HR, BP, Peripheral pulses, & cap refill
- Cardiac arrest, myocardial dysfunction & hemorrhage are precursors to shock &
ineffective circulation
- Asses for external bleeding, apply direct pressure
- Obtain IV access with a large bore IV & infuse isotonic solutions (LR)
- Shock signs: Hypotension, increased HR
- To reverse shock give O2, apply pressure to wound, elevate legs, give fluids,
remain with client to decrease anxiety
Disability - Assessment to determines clients LOC
- AVPU: Alert, responsive to Voice, responsive to Pain, Unresponsive
- Determine Glasgow Coma Scale
- Repeat neuro assessment frequently
Exposure - Remove clothes for a complete physical assessment
- Preserve items such as clothes, bullets, drugs, weapons
- Warm client up to prevent hypothermia ( core temp < 95)
▪ Primary/Secondary Surveys (2-3)
• Primary
o Rapid assessment of life-threatening conditions
o Complete systematically so life-threatening conditions aren’t missed
o Standard precautions should be used – gloves, gown, eye protection, face mask, & shoe covers
o Use the ABCDE for guidance
• Secondary
o F: Full set of vitals, obtain labs, insert catheter, x-ray, EKG, contact family
o G: Give comfort measures – pain management, reposition, assess pain, console, reassure,
provide support
o H: Head to toe assessment, allergies, PMH, current medications, last meal, exposure
o I: Inspect posterior for bruising, injuries, and rectal tone
▪ Triage & Patient Centered Care (1-2)
Nonacute -Nonlife threatening
- Delay in doing interventions does not negatively impact client
outcome
Acute - Low potential to become life threatening
- Necessary interventions are scheduled, expected, & typical
,NURS 4406 EXAM 1 REVIEW
Critical - Potential to become life threatening
- Quick response & rapid response needed to stop threat
from becoming life threatening
Imminent - Life threatening
, NURS 4406 EXAM 1 REVIEW
Death - Interventions are needed immediately
• 3 Level Assessment • 5 Level Assessment
o Emergent: Care is needed now due o Level 1: Resuscitation
to life threatening injuries o Level 2: Emergent
o Urgent: 30 min window to provide o Level 3: Urgent
care, bad injuries but not yet fatal o Level 4: Less urgent
o Non-Urgent: Minor injuries; not priority o Level 5: Non-urgent
• Perfusion (8-12)
o Hemodynamic Monitoring (2-3)
▪ Clinical Manifestations
• Serious or critical illness • Acute kidney injury
• Heart failure • ARDS
• Post CABG clients • Burn or trauma injury
▪ Nursing Interventions
• Arterial Line insertion
o Perform Allen’s test prior
▪ Occlude both radial & ulnar arteries and release one at a time
▪ Must have positive Allen’s test prior to insertion
o Place client in supine or Trendelenburg position for insertion and sedate
o Obtain chest x-ray after insertion to confirm placement
o Monitor respiratory and cardiac status
▪ Management of arterial line
• Observe wave forms, changes in form can indicate catheter migration or displacement
• To obtain readings from catheter place client in supine position with HOB elevated 15-30°evel
transducer at phlebostatic axis before readings and with all position changes
• Zero system to atmospheric pressure
• Compare findings to physical assessment
▪ Evaluation of Hemodynamic Pressures
• Proximal lumen • Balloon Inflation
o Measures right atrial pressure (CVP) o Intermittently used for PAWP
o Infuse IVF o When not in use shout be left deflated
o Obtain venous blood samples and locked
• Distal lumen • Thermistor
o Measures PAPs (PA o Measures temperature differences
systolic/diastolic, mean PAP, & PA between right atrium & PA to
wedge pressure determine CO
o NOT for IVF
•
NURS 4406 EXAM 1 REVIEW
• Principles of Emergency Care Nursing (5-8)
o Emergency Nursing Principles (2-3)
▪ Triage, primary survey, ABCDE, poisoning, rapid response team, cardiac emergency, post-resuscitation
▪ Prioritization
• ABCDE Principle
Airway/Cervical - Most important step of primary survey
Spine - Patent airway is not established can result in hypoxia, brain injury, or death within 3
– 5 min
- Unresponsive without suspicion of trauma opened with head-tilt/chin-lift maneuver
- Unresponsive with suspicion of trauma open with modified jaw thrust maneuver
- Inspect opened airway for blood, teeth, vomit, & secretions
- Administer bag valve mask at 100% O2 for additional support
- Use a nonrebreather mask for clients breathing spontaneously
Breathing - Assess for presence & effectiveness of breathing
- Listen to breath sounds, monitor chest expansion, effort, rate & depth
- If client if not breathing or breathing inadequately manual ventilation should be
performed via bag valve mask with supplemental O2
Circulation - Assess HR, BP, Peripheral pulses, & cap refill
- Cardiac arrest, myocardial dysfunction & hemorrhage are precursors to shock &
ineffective circulation
- Asses for external bleeding, apply direct pressure
- Obtain IV access with a large bore IV & infuse isotonic solutions (LR)
- Shock signs: Hypotension, increased HR
- To reverse shock give O2, apply pressure to wound, elevate legs, give fluids,
remain with client to decrease anxiety
Disability - Assessment to determines clients LOC
- AVPU: Alert, responsive to Voice, responsive to Pain, Unresponsive
- Determine Glasgow Coma Scale
- Repeat neuro assessment frequently
Exposure - Remove clothes for a complete physical assessment
- Preserve items such as clothes, bullets, drugs, weapons
- Warm client up to prevent hypothermia ( core temp < 95)
▪ Primary/Secondary Surveys (2-3)
• Primary
o Rapid assessment of life-threatening conditions
o Complete systematically so life-threatening conditions aren’t missed
o Standard precautions should be used – gloves, gown, eye protection, face mask, & shoe covers
o Use the ABCDE for guidance
• Secondary
o F: Full set of vitals, obtain labs, insert catheter, x-ray, EKG, contact family
o G: Give comfort measures – pain management, reposition, assess pain, console, reassure,
provide support
o H: Head to toe assessment, allergies, PMH, current medications, last meal, exposure
o I: Inspect posterior for bruising, injuries, and rectal tone
▪ Triage & Patient Centered Care (1-2)
Nonacute -Nonlife threatening
- Delay in doing interventions does not negatively impact client
outcome
Acute - Low potential to become life threatening
- Necessary interventions are scheduled, expected, & typical
,NURS 4406 EXAM 1 REVIEW
Critical - Potential to become life threatening
- Quick response & rapid response needed to stop threat
from becoming life threatening
Imminent - Life threatening
, NURS 4406 EXAM 1 REVIEW
Death - Interventions are needed immediately
• 3 Level Assessment • 5 Level Assessment
o Emergent: Care is needed now due o Level 1: Resuscitation
to life threatening injuries o Level 2: Emergent
o Urgent: 30 min window to provide o Level 3: Urgent
care, bad injuries but not yet fatal o Level 4: Less urgent
o Non-Urgent: Minor injuries; not priority o Level 5: Non-urgent
• Perfusion (8-12)
o Hemodynamic Monitoring (2-3)
▪ Clinical Manifestations
• Serious or critical illness • Acute kidney injury
• Heart failure • ARDS
• Post CABG clients • Burn or trauma injury
▪ Nursing Interventions
• Arterial Line insertion
o Perform Allen’s test prior
▪ Occlude both radial & ulnar arteries and release one at a time
▪ Must have positive Allen’s test prior to insertion
o Place client in supine or Trendelenburg position for insertion and sedate
o Obtain chest x-ray after insertion to confirm placement
o Monitor respiratory and cardiac status
▪ Management of arterial line
• Observe wave forms, changes in form can indicate catheter migration or displacement
• To obtain readings from catheter place client in supine position with HOB elevated 15-30°evel
transducer at phlebostatic axis before readings and with all position changes
• Zero system to atmospheric pressure
• Compare findings to physical assessment
▪ Evaluation of Hemodynamic Pressures
• Proximal lumen • Balloon Inflation
o Measures right atrial pressure (CVP) o Intermittently used for PAWP
o Infuse IVF o When not in use shout be left deflated
o Obtain venous blood samples and locked
• Distal lumen • Thermistor
o Measures PAPs (PA o Measures temperature differences
systolic/diastolic, mean PAP, & PA between right atrium & PA to
wedge pressure determine CO
o NOT for IVF
•
