Deck 69: Nursing Management: Emergency, Terrorism, and Disaster Nursing

Question 1

An older man arrives in triage disoriented and tachypneic. His skin is hot and dry. His wife states that he was fine earlier today. The nurse's next priority would be to

A) obtain a detailed medical history from his wife.
B) assess his vital signs, including a rectal temperature.
C) determine the kind of insurance he has before treating him.
D) start supplemental oxygen and have the ED physician see him.

Answer 1

The patient had been assessed through the steps of triage and the primary survey has also been done. Other information including the history of patient and insurance of the patient can be conducted later but this is not priority of the nurse.
Hence, the options (a) and (c) are incorrect.
The nurse cannot start the treatment until full assessment of the patient has been done and the physician has ordered the nurse to administer medications or oxygen to the patient.
Hence, the option (d) is incorrect.
After the primary survey, the next priority of the is to obtain full set of vital signs which includes the core temperature of the patient that can be measured rectally.
Hence, the option (b) is correct.

Question 2

Patient Profile
D.F., a 20-yr-old Hispanic female trauma patient, is brought to the ED in an ambulance. She was the driver in a motor vehicle collision and was not wearing a seat belt. Two children in the car were pronounced dead at the scene. The paramedics stated that there was significant damage to the car on the driver's side.
Subjective Data
• Patient asks, "What happened Where am I "
• Complains of shortness of breath and leg pain
Objective Data
Physical Examination
• Vital signs: blood pressure 85/40 mm Hg, heart rate 140 beats/min, respiratory rate 36 breaths/min; O₂ saturation 85% with 100% non rebreather mask
• Decreased breath sounds on left side of chest
• Asymmetric chest wall movement
• Glasgow Coma Score = 14; pupils slightly unequal
• Badly deformed left lower leg with significant swelling and a pedal pulse by Doppler only
• 4-cm head laceration, bleeding controlled
1. What are D.F.'s most likely life-threatening injuries
2. Priority Decision: What is the priority of care for D.F.
3. Priority Decision: What interventions does this patient need immediately
4. What other interventions should you consider
5. Delegation Decision: What activities could you delegate to unlicensed assistive personnel (UAP)
6. Several family members have arrived in the ED, including the mother of one of the children who died. The second child who died was the patient's child. How should you approach the family
7. Priority Decision: Based on assessment data presented, what are the priority nursing diagnoses Are there any collaborative problems
8. Evidence-Based Practice: What are the best practice guidelines for fluid resuscitation in patients who are experiencing hypovolemic shock

Answer 2

1.
The most likely life-threatening injuries of D.F. include decreased blood pressure, breath shortness, and increased respiratory rate, increased heart rate, decreased oxygen saturation, and decreased breath sounds on left part of the chest and asymmetric movement of chest.
2.
The priority of care for D.F. is to maintain her breathing because her airway is open which creates a life-threatening breathing problem for her.
3.
D.F. needs the following interventions on priority basis:
• Providing mechanical ventilation and intubation for maintaining adequate oxygenation and effective breathing
• Allowing for drainage by placing a left pleural chest tube
4.
Other important nursing interventions that should be considered for D.F. include:
• Inserting two large intravenous catheters for administration of medications and replacement of blood
• Elevating the head of the bead to 30degrees for normalising the intracranial pressure
• Immobilizing the extremities after establishment of adequate oxygenation and ventilation
• Monitoring the patient continually for vital signs, consciousness level, sounds of lungs, cardiac rhythm, capillary refill and urinary output
5.
The unlicensed assistive personnel (UAP) can be delegated to assist in immobilizing the lower extremities of patient, to obtain blood for testing, to clean the head lacerations, to measure and record the nasogastric and urinary output and to record vital signs.
6.
The death of children is a great loss for which the families should be provided adequate support. It is better to ask the family for the requirement of the clergy. The feelings of the family members should be properly acknowledged to make them feel comfortable. The family should be informed regarding the changes in the condition of the patient or regarding changes in the collaborative care of the patient. Additional support including counsellor, clergy member and family member should be available when the patients are being told about the children status.
7.
The priority nursing diagnosis includes risk for ineffective perfusion of cerebral tissue, risk for peripheral neurovascular dysfunction, acute pain, anxiety, fear and ineffective pattern of breathing. The collaborative problems include infection, embolism of fat, increased intracranial pressure, shock and haemorrhage.
8.
Colloids and crystalloids play a role in resuscitation of fluid. Colloids are used for expanding volumes as the molecule size of colloids can keep them in the vascular space for long time. However, the cost of the colloids is much higher and there is less proof in support of improving resuscitation with colloids. The volume and type of fluid which is being lost by the patient and clinical status of the patient determine the choice of fluid for resuscitation.

Question 3

Situation
You are a registered nurse, employed as a charge nurse at a subacute rehabilitation facility. It is midnight and you are driving home from work when you see a motor vehicle collision with a person at the side of the road waving and yelling for help. You stop and call 911 to report the incident. What do you do next
Ethical/Legal Points for Consideration
• As a licensed health care provider, you are under no legal obligation to stop and render aid.
• If you do stop, you assume an obligation not to leave the scene until sufficiently trained first responders arrive and assume control.
• Between 50 and 75 yr ago, many states moved to encourage trained health care providers to stop and render aid by passing "Good Samaritan" statutes. These statutes, which vary somewhat from state to state, offer immunity from lawsuit for bystanders who offer aid in emergencies except in the case of gross negligence.
• A Good Samaritan must not be in the place of employment or under employment conditions.
• An example of gross negligence might be refusing to assist someone who obviously had a serious hemorrhage in favor of a person with a minor injury because the bleeding person looked old and disheveled.
• Immunity covers only the scene of the accident and not subsequent care under the supervision of health care providers.
• If there is a national disaster, an act of terrorism, or a major emergent need for health care personnel, you may be required to go to an assigned site to offer aid. You would not be covered by the Good Samaritan Act under these circumstances.
1. What factors do you think contribute to a health care provider's decision whether to stop to provide aid
2. What basic aid would you feel comfortable providing if you do not have an emergency or trauma background
3. Would your professional liability (malpractice) insurance cover you if someone claimed that you acted negligently while providing assistance

Answer 3

NO ANSWER

Question 4

Apply the steps in triage, the primary survey, and the secondary survey to a patient experiencing a medical, surgical, or traumatic emergency.

Question 5

You are working in a 12-bed intensive care unit and have been assigned to care for the following two patients. There is one UAP available to help as needed.
Patients
R.K. is a 72-year-old white man who was admitted with a massive stroke after collapsing on the street. He is unresponsive, even to painful stimuli. He has an oral endotracheal (ET) tube in place and is receiving mechanical ventilation (assist-control mode, FIO₂ 70%, VT 700 mL, respiratory rate 16 breaths/min, PEEP 5 cm H 2 O). His chest x-ray revealed right lower lung consolidation. A subclavian central line was placed to monitor CVP and administer fluids. IV antibiotics have been started. His cardiac rhythm on admission was atrial fibrillation with a rapid ventricular response. He is receiving IV diltiazem (Cardizem) and his ventricular response has slowed to 84 bpm. His temperature is elevated despite receiving acetaminophen q 4 hr. He is also receiving enteral feeding at 25 mL/hr via small-bore nasogastric feeding tube and has an external condom catheter for urinary drainage.
J.N. is a 55-year-old white man who was admitted 24 hours ago after emergent surgery for an acutely ischemic bowel. The surgical procedure involved extensive abdominal surgery to repair a perforated colon, irrigate the abdominal cavity, and provide hemostasis. During surgery his systolic BP dropped to 70 mm Hg. Seven units of packed red blood cells and 4 L of 0.9% saline were infused. His pulmonary status worsened within 12 hours of admission to the ICU, requiring an emergent ET intubation. He developed a pneumothorax after intubation and a left-side chest tube was placed at that time. His hypoxemia has rapidly progressed and is currently refractory to 100% FIO₂ and high levels of PEEP. His laboratory test results indicate kidney and liver failure. He has an advance directive that indicates he does not want to be kept alive by artificial means, but he has a full code status. He is currently sedated, paralyzed, and unable to communicate. His urinary catheter is draining concentrated urine 30 mL/hr. He has a central line in place and is receiving 0.9% saline at 125 mL/hr. His most recent ABGs are as follows: pH 7.12, PaO₂ 50 mm Hg, PaCO₂ 62 mm Hg, HCO 3 17 mEq/L, and O₂ saturation 84%. His PaO₂ /FIO₂ ratio is 200 and his chest x-ray shows worsening bilateral interstitial infiltrates compatible with an ARDS pattern.
Priority Decision: After receiving report, which patient should you see first Provide rationale.

Question 6

A patient has a core temperature of 90° F (32.2° C). The most appropriate rewarming technique would be

A) passive rewarming with warm blankets.
B) active internal rewarming using warmed IV fluids.
C) passive rewarming using air-filled warming blankets.
D) active external rewarming by submersing in a warm bath.

Question 7

Relate the pathophysiology to the assessment and collaborative care of select environmental emergencies (e.g., hyperthermia, hypothermia, submersion injury, bites).

Question 8

You are working in a 12-bed intensive care unit and have been assigned to care for the following two patients. There is one UAP available to help as needed.
Patients
R)K. is a 72-year-old white man who was admitted with a massive stroke after collapsing on the street. He is unresponsive, even to painful stimuli. He has an oral endotracheal (ET) tube in place and is receiving mechanical ventilation (assist-control mode, FIO₂ 70%, VT 700 mL, respiratory rate 16 breaths/min, PEEP 5 cm H 2 O). His chest x-ray revealed right lower lung consolidation. A subclavian central line was placed to monitor CVP and administer fluids. IV antibiotics have been started. His cardiac rhythm on admission was atrial fibrillation with a rapid ventricular response. He is receiving IV diltiazem (Cardizem) and his ventricular response has slowed to 84 bpm. His temperature is elevated despite receiving acetaminophen q 4 hr. He is also receiving enteral feeding at 25 mL/hr via small-bore nasogastric feeding tube and has an external condom catheter for urinary drainage.
J)N. is a 55-year-old white man who was admitted 24 hours ago after emergent surgery for an acutely ischemic bowel. The surgical procedure involved extensive abdominal surgery to repair a perforated colon, irrigate the abdominal cavity, and provide hemostasis. During surgery his systolic BP dropped to 70 mm Hg. Seven units of packed red blood cells and 4 L of 0.9% saline were infused. His pulmonary status worsened within 12 hours of admission to the ICU, requiring an emergent ET intubation. He developed a pneumothorax after intubation and a left-side chest tube was placed at that time. His hypoxemia has rapidly progressed and is currently refractory to 100% FIO₂ and high levels of PEEP. His laboratory test results indicate kidney and liver failure. He has an advance directive that indicates he does not want to be kept alive by artificial means, but he has a full code status. He is currently sedated, paralyzed, and unable to communicate. His urinary catheter is draining concentrated urine 30 mL/hr. He has a central line in place and is receiving 0.9% saline at 125 mL/hr. His most recent ABGs are as follows: pH 7.12, PaO₂ 50 mm Hg, PaCO₂ 62 mm Hg, HCO 3 17 mEq/L, and O₂ saturation 84%. His PaO₂ /FIO₂ ratio is 200 and his chest x-ray shows worsening bilateral interstitial infiltrates compatible with an ARDS pattern.
Delegation Decision: Which tasks could you delegate to the UAP (select all that apply)

A) Record vital signs on R.K. and J.N.
B) Suction R.K. and J.N.'s ET tubes as needed.
C) Titrate the diltiazem IV drip downward based on R.K.'s heart rate.
D) Talk to J.N.'s family regarding his advance directive and current code status.

Question 9

Effective interventions to decrease absorption or increase elimination of an ingested poison include which of the following (select all that apply)

A) Hemodialysis
B) Milk dilution
C) Eye irrigation
D) Gastric lavage
E) Activated charcoal

Question 10

Relate the pathophysiology to the assessment and collaborative care of select toxicologic emergencies.

Question 11

An older woman arrives in the ED complaining of severe pain in her right shoulder. The nurse notes that her clothes are soiled with urine and feces. She tells the nurse that she lives with her son and that she "fell." She is tearful and asks you if she can be admitted. What possibility should the nurse consider

A) Paranoia
B) Possible cancer
C) Family violence
D) Orthostatic hypotension

Question 12

Select appropriate nursing interventions for victims of violence.

Question 13

You are working in a 12-bed intensive care unit and have been assigned to care for the following two patients. There is one UAP available to help as needed.
Patients
R)K. is a 72-year-old white man who was admitted with a massive stroke after collapsing on the street. He is unresponsive, even to painful stimuli. He has an oral endotracheal (ET) tube in place and is receiving mechanical ventilation (assist-control mode, FIO₂ 70%, VT 700 mL, respiratory rate 16 breaths/min, PEEP 5 cm H 2 O). His chest x-ray revealed right lower lung consolidation. A subclavian central line was placed to monitor CVP and administer fluids. IV antibiotics have been started. His cardiac rhythm on admission was atrial fibrillation with a rapid ventricular response. He is receiving IV diltiazem (Cardizem) and his ventricular response has slowed to 84 bpm. His temperature is elevated despite receiving acetaminophen q 4 hr. He is also receiving enteral feeding at 25 mL/hr via small-bore nasogastric feeding tube and has an external condom catheter for urinary drainage.
J)N. is a 55-year-old white man who was admitted 24 hours ago after emergent surgery for an acutely ischemic bowel. The surgical procedure involved extensive abdominal surgery to repair a perforated colon, irrigate the abdominal cavity, and provide hemostasis. During surgery his systolic BP dropped to 70 mm Hg. Seven units of packed red blood cells and 4 L of 0.9% saline were infused. His pulmonary status worsened within 12 hours of admission to the ICU, requiring an emergent ET intubation. He developed a pneumothorax after intubation and a left-side chest tube was placed at that time. His hypoxemia has rapidly progressed and is currently refractory to 100% FIO₂ and high levels of PEEP. His laboratory test results indicate kidney and liver failure. He has an advance directive that indicates he does not want to be kept alive by artificial means, but he has a full code status. He is currently sedated, paralyzed, and unable to communicate. His urinary catheter is draining concentrated urine 30 mL/hr. He has a central line in place and is receiving 0.9% saline at 125 mL/hr. His most recent ABGs are as follows: pH 7.12, PaO₂ 50 mm Hg, PaCO₂ 62 mm Hg, HCO 3 17 mEq/L, and O₂ saturation 84%. His PaO₂ /FIO₂ ratio is 200 and his chest x-ray shows worsening bilateral interstitial infiltrates compatible with an ARDS pattern.
R)K.'s lungs are clear to auscultation. Evaluation of his gastrointestinal status reveals minimal bowel sounds and a gastric residual of 200 mL even after his emesis. You elevate the head of his bed to 60 degrees, hold the tube feeding, and notify his health care provider.
Which intervention would you expect the health care provider to order for R.K.

A) Morphine sulfate 2 mg IV stat
B) Metoclopramide (Reglan) 10 mg IV q6hr
C) Restart enteral tube feeding while maintaining HOB elevation at 90 degrees
D) Hold enteral tube feeding for 1 hour and restart with half-strength fluids at same rate

Question 14

A chemical explosion occurs at a nearby industrial site. The first responders report that victims are being decontaminated at the scene and approximately 125 workers will need medical evaluation and care. The nurse receiving this report should know that this will first require activation of

A) a code blue alert.
B) a disaster medical assistance team.
C) the local police and fire departments.
D) the hospital's emergency response plan.

Question 15

Differentiate among the responsibilities of health care providers, the community, and select federal agencies in emergency and mass casualty incident preparedness.

Question 16

You are working in a 12-bed intensive care unit and have been assigned to care for the following two patients. There is one UAP available to help as needed.
Patients
R)K. is a 72-year-old white man who was admitted with a massive stroke after collapsing on the street. He is unresponsive, even to painful stimuli. He has an oral endotracheal (ET) tube in place and is receiving mechanical ventilation (assist-control mode, FIO₂ 70%, VT 700 mL, respiratory rate 16 breaths/min, PEEP 5 cm H 2 O). His chest x-ray revealed right lower lung consolidation. A subclavian central line was placed to monitor CVP and administer fluids. IV antibiotics have been started. His cardiac rhythm on admission was atrial fibrillation with a rapid ventricular response. He is receiving IV diltiazem (Cardizem) and his ventricular response has slowed to 84 bpm. His temperature is elevated despite receiving acetaminophen q 4 hr. He is also receiving enteral feeding at 25 mL/hr via small-bore nasogastric feeding tube and has an external condom catheter for urinary drainage.
J)N. is a 55-year-old white man who was admitted 24 hours ago after emergent surgery for an acutely ischemic bowel. The surgical procedure involved extensive abdominal surgery to repair a perforated colon, irrigate the abdominal cavity, and provide hemostasis. During surgery his systolic BP dropped to 70 mm Hg. Seven units of packed red blood cells and 4 L of 0.9% saline were infused. His pulmonary status worsened within 12 hours of admission to the ICU, requiring an emergent ET intubation. He developed a pneumothorax after intubation and a left-side chest tube was placed at that time. His hypoxemia has rapidly progressed and is currently refractory to 100% FIO₂ and high levels of PEEP. His laboratory test results indicate kidney and liver failure. He has an advance directive that indicates he does not want to be kept alive by artificial means, but he has a full code status. He is currently sedated, paralyzed, and unable to communicate. His urinary catheter is draining concentrated urine 30 mL/hr. He has a central line in place and is receiving 0.9% saline at 125 mL/hr. His most recent ABGs are as follows: pH 7.12, PaO₂ 50 mm Hg, PaCO₂ 62 mm Hg, HCO 3 17 mEq/L, and O₂ saturation 84%. His PaO₂ /FIO₂ ratio is 200 and his chest x-ray shows worsening bilateral interstitial infiltrates compatible with an ARDS pattern.
R)K.'s lungs are clear to auscultation. Evaluation of his gastrointestinal status reveals minimal bowel sounds and a gastric residual of 200 mL even after his emesis. You elevate the head of his bed to 60 degrees, hold the tube feeding, and notify his health care provider.
J)N.'s ABG results reflect a worsening of his ARDS. You correctly identify that these results demonstrate

A) uncompensated respiratory acidosis.
B) uncompensated respiratory alkalosis.
C) partially compensated respiratory acidosis.
D) partially compensated respiratory alkalosis.

Question 17

You are working in a 12-bed intensive care unit and have been assigned to care for the following two patients. There is one UAP available to help as needed.
Patients
R)K. is a 72-year-old white man who was admitted with a massive stroke after collapsing on the street. He is unresponsive, even to painful stimuli. He has an oral endotracheal (ET) tube in place and is receiving mechanical ventilation (assist-control mode, FIO₂ 70%, VT 700 mL, respiratory rate 16 breaths/min, PEEP 5 cm H 2 O). His chest x-ray revealed right lower lung consolidation. A subclavian central line was placed to monitor CVP and administer fluids. IV antibiotics have been started. His cardiac rhythm on admission was atrial fibrillation with a rapid ventricular response. He is receiving IV diltiazem (Cardizem) and his ventricular response has slowed to 84 bpm. His temperature is elevated despite receiving acetaminophen q 4 hr. He is also receiving enteral feeding at 25 mL/hr via small-bore nasogastric feeding tube and has an external condom catheter for urinary drainage.
J)N. is a 55-year-old white man who was admitted 24 hours ago after emergent surgery for an acutely ischemic bowel. The surgical procedure involved extensive abdominal surgery to repair a perforated colon, irrigate the abdominal cavity, and provide hemostasis. During surgery his systolic BP dropped to 70 mm Hg. Seven units of packed red blood cells and 4 L of 0.9% saline were infused. His pulmonary status worsened within 12 hours of admission to the ICU, requiring an emergent ET intubation. He developed a pneumothorax after intubation and a left-side chest tube was placed at that time. His hypoxemia has rapidly progressed and is currently refractory to 100% FIO₂ and high levels of PEEP. His laboratory test results indicate kidney and liver failure. He has an advance directive that indicates he does not want to be kept alive by artificial means, but he has a full code status. He is currently sedated, paralyzed, and unable to communicate. His urinary catheter is draining concentrated urine 30 mL/hr. He has a central line in place and is receiving 0.9% saline at 125 mL/hr. His most recent ABGs are as follows: pH 7.12, PaO₂ 50 mm Hg, PaCO₂ 62 mm Hg, HCO 3 17 mEq/L, and O₂ saturation 84%. His PaO₂ /FIO₂ ratio is 200 and his chest x-ray shows worsening bilateral interstitial infiltrates compatible with an ARDS pattern.
R)K.'s lungs are clear to auscultation. Evaluation of his gastrointestinal status reveals minimal bowel sounds and a gastric residual of 200 mL even after his emesis. You elevate the head of his bed to 60 degrees, hold the tube feeding, and notify his health care provider.
Management Decision: You walk into J.N.'s room and find his wife whispering in his ear with her hand on the ventilator tubing, appearing to be ready to disconnect him from life support. What is your best initial action

A) Ask J.N.'s wife to leave the room immediately.
B) Report the incident to the charge nurse and security immediately.
C) Ask J.N.'s wife if you could talk to her about her husband's condition.
D) Report the incident to J.N.'s health care provider to address J.N.'s code status.