Shared Flashcard Set

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Triage
Semester 1
24
Nursing
Undergraduate 3
05/21/2013

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Cards

Term
What are some examples of triage cat 1
Definition
-Multi-trauma
-unconscious &/or severe head injury
-status epilepticus
-extreme dysponea eg severe asthma or acute pulmonary oedema
-cardio-pulmonary arrest
-open chest wounds
-major burns- >10% full thickness
-severe haemorrhage
Term
What are some examples of triage cat 2
Definition
-Chest pain or other symptoms suggestive of myocardial ischaemia, PE or aortic dissection
-severe abdo pain or other symptoms suggestive of ruptured aortic aneurysm
-altered LOC
-Fever, rash, headache ect suggestive of sepsis or meningitis
-severe skeletal trauma (femoral fracture, dislocated knee, amputations ect)
-severe pain
-multiple fractured ribs
-fractured cervical spine
-acute spinal injury with neurological deficit
-eye injuries
Term
What are some examples of triage cat 3
Definition
-moderately severe pain not suggestive of critical illness
-severe laceration without active haemorrhage
-head injury with transient LOC
-PR/PV bleeding
-compound fractures without neurovascular compromise
Term
What are some examples of triage cat 4
Definition
-minor trauma (severe sprains)
-migraine headache (with history)
-Earache
-Gastroenteritis
-Colles fracture or simple fractures
Term
What are some examples of triage cat 5
Definition
-Chronic lower back pain
-URTI, flu
-dressings
-sprains
-rash
Term
What is primary assessment
Definition
ABCDE
Term
What's involved in airway assessment?
Definition
observe for
-vocalisation
-tongue obstruction
-loose teeth or foreign objects
-bleeding
-vomitus or other secretions
-oedema
Term
What are airway interventions
Definition
-position supine
-assume cervical spinal injury pressent until proven otherwise
-open and clear airway (jaw thrust/chin lift, removal of foreign bodies, suctioning), insertion of nasal or oral airway, consider intubation.
Term
What's involved in breathing assessment?
Definition
Assess:
-spontaneous breathing
-chest rise and fall
-skin colour
-RR
-patterns of breathing
-soft tissue or bone injuries to chest wall
-use of accessory muscles
-bilateral breath sounds
-jugular veins and position of trachea
Term
What are some breathing interventions?
Definition
Breathing present- O2 high flow mask (12-15L)
Breathing absent- +ve pressure ventilation, intubate, high flow O2.
Breathing ineffective: identify life threatening conditions
Term
Examples of life threatening injuries that may compromise breathing:
Definition
Tension pneumothorax
open pneumothorax
flail chest with pulmonary contusion
hemothorax
Term
What are some examples of life threatening injuries that may compromise airway?
Definition
partial or complete airway obstruction
obstruction by tongue
penetrating wounds
blunt trauma to larynx pr other upper airway structures
Term
What is involved in circulatory assessment
Definition
-pulse quality, location and rate
-cap refill
-skin colour, temp and diaphoresis
-inspect for external bleeding
-assess LOC
-BP if adequate staff avaliable
Term
What are circulatory interventions
Definition
no pulse: initiate CPR (BLS, ALS)
pulse ineffective: control external bleeding, recognise shock, 2 large bore cannulas, fluid replacement, transfer for definitive care or OT.
Term
Estimating blood loss
Definition
response to bolus:
-rapid stabilization (<20% blood loss)
-transient response (20-40% blood loss, ongoing loss or inadequate fluid stabilization)
-No response (look for exsanguinating source, consider tamponade, myocardial contusion)
Term
Examples of life threatening conditions in relation to circulation:
Definition
uncontrolled bleeding
shock from haemorrhage
massive burns
pericardial tamponade
direct cardiac injury
Term
What's involved in disability assessment
Definition
AVPU (alert, responds to verbal, responds to pain, unresponsive)
Assess pupils for size, shape and reactivity to light
GCS
Term
What are disability interventions
Definition
if decreased LOC conduct further assessment in secondary survey
if pt not alert or vocalising monitor for compromise to airway and breathing
if GCS <9 will need intubation
if GCS <13 consider transfer
Term
What's involved in assessing exposure
Definition
undress pt, maintain normothermia, warm fluids. After performing primary survey and correcting any life threatening conditions proceed with careful sexamination.
Term
What is involved in secondary assessment?
Definition
-Obs, ECG, pulse oximetry, IDC, gastric tube, laboritory studies
-comfort measures (pain relief, verbal reassurance)
-History (allergies, meds, past illness, last meal, environment and events prior to injury)
-head to toe examination (inspection, auscultation, palpation)
Term
What is tertiary examination
Definition
24hrs after admission
head to toe
collect and review results: xray, scan, blood tests
Term
Who to immobilise
Definition
-pedestrian hit >30km/hr
-MVC > 60km/hr
-Fall >3m
-kicked/fall from moving horse
-hanging
-thrown from vehicle
-thrown over handlebars of bike
-severe electrical shock
-diving injury
-direct force to head or neck
-multiple trauma
-significant injury above clavicles
-trauma and unexplained hypotension
-neck tenderness
-limitations of neck movement due to pain
-neurological deficit
Term
NEXUS criteria for c-spinal injury clearance
Definition
fully alert- GCS 15
No posterior midline cervical spine tenderness
No motor or sensory deficit (weakness, numbness)
No evidence or intoxication
Term
Mental health triage
Definition
cat 1 (immediate)- definite danger to life (self or others)
cat 2 (10min)- probable risk of danger to self and others &/or physical restrained in ED &/or severe behavioural disturbances
Cat 3 (30min)possible danger to self, moderate behaviour disturbances, severe distress.
Cat 4 (60min)- moderate distress, semi-urgent mental health problem, under observation &/or no immediate threat to self or others
Cat 5 (120min)- no danger to self or others, no acute distress, no behavioural disturbances
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