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EMERGENCY NURSING
AMB UL A NCEAMBULANCE
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NURSES AND EDUCATION
Education is the most powerful
weapon which you can use to
change the world.Nelson Mandela
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SPECIFIC OBJECTIVES:At the end of the ER lecture discussion, the students will
be able to:
1. Define and explain emergency care nursing.
2. Identify the different functional requirements of anER department.
3. States the legal aspects involved in various
emergency situation.
4. Explain the Principles of ER care.
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SPECIFIC OBJECTIVES:
5. Discuss the process of assessment in various emergencysituations.
6. Utilize the nursing process in the care of patients in
emergency situation. 7. Formulate appropriate nursing diagnosis as to priority.
8. Evaluate outcome of the nursing care goals for each
situation.
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INTRODUCTION
Emergency Nursingis a nursing specialty in which nursescare for patients in the emergency or critical phase of theirillness or injury.
While this is common to many nursing specialties, the key
difference is that an emergency nurse is skilled at dealingwith people in the phase when a diagnosis has not beenmade and the cause of the problem is not known.
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emergency managementrefers to care to patientswith urgent and critical needs.
- Its philosophy include the concept that anemergency is whatever the patient or the
family considers it to be.- Large number of people seek emergency care for
serious life-threatening conditions.
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Emergency departmentsoften the first place wherevictims of family violence, abuse, or neglect go to seek for
help. Emergency Assessment:
A systematic approach to the assessment of anemergency patient is essential.
Often the most dramatic injury is not the most serious.
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Scope and practice of
Emergency Nursing
Specialized education
Expertise in assessing and identifying patients
health care problems
Establishes priorities, monitors acutely ill, andinjured patients
Nursing interventions are accomplished
independently
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Providing Holistic care
1. Patient-focused interventions
2. Family-focused interventions
*anxiety and denial
*remorse and guilt
*anger
*griefPsychological Considerations
Body trauma is an insult to physiologic and psychologicalhomeostasis, it requires both physiologic and psychological
healing.
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Approach to the Patient:
1. Understand and accept the basic anxieties of the acutelytraumatized patient. Be aware of the patient fear of
death, mutilation, and isolation.2. Personalize the situation as much as possible. Speak, react
and respond in a warm manner.
3. Give an explanation on a level that the patient can grasp.
An informed patient can cope withpsychological/physiologic stress in a more positive manner.
4. Accept the rights of the patient and family to have anddisplay their own feelings.
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Approach to the patient cont. . .
5. Maintain a calm and reassuring manner.
6. Understand and support the pts. feeling concerning loss ofcontrol( emotional, physical and intellectual).
7. Treat the unconscious patient as if conscious. Touch, callby name, and explain every procedure that is done. Avoid
making negative comments about pts condition.8. Orient the patient to person, time and place as soon as
he/she is conscious, reinforce by repeating thisinformation.
9. Bring the patient back to reality in a calm and reassuringmanner.
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Approach to family:
1. Inform where the patient is and give as much information
as possible about the treatment he/she is receiving.2. Recognize the anxiety of the family and allow them to talkabout their feelings. Allow the expressions of remorse,anger, guilt and criticism.
3. Deal with reality as gently and quickly as possible; avoidencouraging and supporting denial.
4. Assist the family to cope with sudden and unexpecteddeath.
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5. Some helpful measures include the following:
- Take the family to a private place.- Talk to all of the family together so they can mourn
together.
- Assure the family that everything possible was done:
inform them of the treatment rendered- Avoid volunteering unnecessary information ( patient was
drinking and etc.)
- Be recognizant of cultural and religious beliefs and needs.
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QUALITIES of an Emergency nurse:
has had specialized education, training, and experienceto gain expertise in assessing and identifying patientshealth care problems in crisis situations
establishes priorities
monitors and continuously assesses acutely ill andinjured patients
supports and attends to families
supervises allied health personnel
Teaches patients and families within a time-limitedhigh-pressured care environment.
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DELEGATION
A process by which responsibility andauthority for performing tasks aretransferred from one individual to anotherwho accepts that authority andresponsibility but remains accountable forthe task
5 Rs
- Right task
- Right circumstance
- Right person
- Right communication
- Right feedback
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Scope of Practice
RN
- Decision maker/ delegator
- Unstable patients
- Newly admitted or transferred patients- Health teachings or discharge teachings
- Blood transfusion/ chemotherapy/ central
catheters
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LPN/LVN
- Technical doers
- Stable patients with predictable outcomes- Wound care, traction, casts
- NGT and colostomy care
- Oral meds and parenteral (IM, SQ) therapies,
NO IV push- Data collection
CAN
- Stable patients
- Routine of care (eg. Ambulating, turning, I
and O, feeding, measurements of ht. and wt.)
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- Indirect activities: bed making,
transporting patients, stocking supplies)
Steps:
1. Define the task
2. Determine the delegate
3. Communicate expectations and outcomes4. Reach mutual agreement about the task
5. Monitor the task and provide guidance
6. Evaluate results
7. Provide feedback
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PRIORITIZATION
- decisions in which needs or problems require
immediate attention or action and which onescould be delayed at a later time if they are not
urgent
Principles
a. Needs that are life threatening or could result toharm if left untreated are high priorities
b. Actual problems have high priority than potential
problems
c. Problems identified by client are of higherpriority
d. Principles of Maslow or ABC may guide
decisions
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ISSUES IN EMERGENCY NURSING CARE
Documentation of consent
Consent to examine and treat the patient is part of the EDrecord.
Patient must consent to invasive procedure unless he/she isunconscious or in critical condition and unable to makedecisions.
If brought unconscious w/out family or friends, it must be
documented.
Limitin xp s t h lth isks
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Limiting exposure to health risks
> All health care providers should adhere strictly tostandard precautions for minimizing exposure.
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REMEMBER!!!
UNIVERSAL PRECAUTIONS:
The routine use of appropriate barrierprecautions to prevent skin and mucousmembrane exposure when contact with blood
or other body fluids of any individual mayoccur or is anticipated.
Universal Precautions apply to blood and toall other body fluids with potential for
spreading any infections.
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PRINCIPLES OF EMERGENCY CARE
TRIAGE
>trier, French word meaning, to sort.
>used to sort patients into groups based on the severity
of their health problems and the immediacy with whichthese problems must be treated.
>an advanced skill
Most of the patients entering an emergency department are
greeted by a triage nurse.
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Triage means to sort
Looks at medical needs and urgency of eachindividual patient
Sorting based on limited data acquisition
Also must consider resource availability
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Routine hospital triage directs all available resources to
the patients who are most critically ill, regardless of thepotential outcome.
Field triage hospital triage during a disaster.
>scarce resources must be used to benefit the mostpeople possible.
***this distinction affects triage decisions***
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POINTS TO REMEMBER ABOUT
TRIAGE CONSIDERATIONS
Identification of the patient
Assessment
Facilitation of treatment Communication
Legal liability
- Personal responsibility for ones own acts
- Reasonable care under the circumstances
- Care in accordance with accepted standards
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PERSONNEL IN THE TRIAGE SYSTEM
Emergency squad personnel
Nursing personnel
Physician staff
Hospital administration
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Ethical Justification
This is one of the few places where a "utilitarian rule" governsmedicine: the greater good of the greater number rather
than the particular good of the patient at hand. This rule isjustified only because of the clear necessity of general
public welfare in a crisis.A. Jonsen and K. Edwards, Resource Allocation in Ethics in
Medicine, Univ. of Washington School of Medicine,http://eduserv.hscer.washington.edu/bioethics/topics/resal
l.html
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TRIAGE SYSTEM CATEGORIES Emergent 1 have the highest priority
> life-threatening conditions and must be seen immediately.Conditions requiring immediate medical intervention. Any delay intx is potentially life or limb threatening.Condition such as : Airway compromise, cardiac arrest, Severeshock, cardiac arrest, cervical spine injury, multiplesystem trauma
Altered level of consciousness, eclampsia
Urgent serious health problems, but not immediately life-threatening ones; must be seen within an hour.
Non-urgent episodic illnesses that can be addressed within 24hours w/out increased morbidity
Fast-track requires simple first aid or basic primary care.
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Triage Categories Of Severity/Prioritization
Class I. Red Tag: Critical-top priorityLife-threatening but treatable injuries requiring
rapid medical attention- ARD, airway obstruction, shock, massive
hemorrhageRx: ABCs of resuscitation; Prioritize for transport Class II. Yellow Tag: Severe-Urgent care priority
Potentially serious injuries, but are stable enoughto wait a short while (within 1-2 hours) formedical treatment- Penetrating or abdominal wounds, major burns,closed head injuries with decreased LOC
Rx: ABCs of resuscitation; Prioritize for transport
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Class III. Green: Non-urgent- delayed priority- Minor injuries that can wait for longer
periods of time (2-6 hours) for treatment- Moderate burns, fractures, dislocations, eyeinjuries, lacerations, facial injuries withoutairway obstruction sprains, strains, contusionsRx: ABCs of resuscitation; Prioritize for
transport Black Tag:- Dead or still with life signs but injuries are
incompatible with survival in austereconditions
- Morgue at disaster site until bodies can bemoved
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AREAS OF TRIAGE
Disaster Scene
- Simple triage is used in a scene of mass
casualty; sort those who need critical attention
and immediate transport to the hospital and
those with less serious injuries
- Triage done to prioritize patients based on
severity of condition: treat as many as possible
when resources are insufficient for all to be
treated immediately
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Hospital
1. Triage team staff stations at the entrance
2. Rapid triage evaluation is made3. Clerk applies a stat record identification band, hand
the corresponding triage slip to the triage officer,
places the stat chart with the patient, logs the stat
medical record number, stat name number and the
patients name and the emergency department are
assignment
4. Patient is stabilized and leaves the ER after a rapid
reassessment to a treatment location and team in
the ER or another designated area for a more
thorough evaluation and assessment
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PROCESS OF TRIAGE
ASSESS AND INTERVENE**Priorities for patient with an emergent or urgenthealth problem
1. stabilization2. provision of critical treatments
3. prompt transfer to the appropriate setting(ICU, OR, General Care Unit)
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Why Should Planners Plan For Good Triage?
As a system tool, it provides a way to draworganization out of chaos.
Helps to get care to those who need it andwill benefit from it the most and speedsefficient patient evacuation.
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Why Should Planners Plan For Good Triage?
Helps in resourceplanningand allocation.
Provides an objective framework for
stressful and emotional decisions, helpingrescue workers to be more efficient andeffective.
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TRIAGE MOTTO:
Daily Emergencies
Do the best for each individual.
Disaster Settings
Do the greatest good for thegreatest number. Maximize
survival.
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2 Methodological approach to help identify andprioritize patient needs:
1. Primary Assessment
2. Secondary Assessment
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Systematic Approach to effectively establishing andtreating health priorities:
1. Primary surveyfocuses on stabilizing life-
threatening conditions, FIND ALL IMMEDIATETHREATS TO LIFE; 1.5 2minutes only
A Airway
- establish a patent airway
B BreathingAirway : Does the patient have an open airway?
Breathing : Is the patient breathing?
- Provide adequate ventilation, employingresuscitation measures when necessary. (Traumapatients must have the cervical spine protected andchest injuries assessed first)
Primary Assessment:
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y
1. The initial rapid assessment of the patient is meant toidentify life threatening problems (ABC)
1ststep is to determine if the patient is conscious. Ifconscious, the primary assessment can be performed at aglance.
A patient who is alert and talking indicates that there isbreathing and circulation.
A conscious patient indicates that circulation is adequateand enough blood being circulated to the brain.
If however the patient is not fully conscious, primaryassessment should proceed.
In a seriously ill or injured patient, it is recommended toadd 2 letters to the primary survey D- disability , E expose
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CONT.
C Circulation
- Evaluate and restore cardiac output bycontrolling hemorrhage, preventing and treatingshock, and maintaining or restoring effectivecirculation.
Circulation: Is there pulse? Is there profusebleeding?
D Disability
- Determine neurologic disability by assessingneurologic function using the Glasgow Coma Scale;apply a cervical collar
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Disability assess level of consciousness and pupils
Assess level of consciousness using AVPU scale:
- A is the patient alert?
- V Does the patient responds to the voice?
- P Does the patient respond to painful stimulus?
- U Is the patient unresponsive even to painfulstimulus?
E- Exposure
Remove clothing
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2. Secondary survey approach
a. Complete health history and head-to-toe assessment
Is a systematic, brief (2 to 3 minutes) examination of thepatient from head to toe of critical patients
It is to detect and prioritize additional injuries or todetect signs of underlying medical conditions.
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History1. If possible a brief history of the patients chief
complaint, accident, or illness is taken from the patient
or companion, relative , pre-hospital provider.2. What is the mechanism of injury circumstances,
forces, location, and time of injury?3. When did the symptoms appear?
4. Was the patient unconscious after the accident?5. How did the patient reach the hospital?6. What was the health status of the patient before the
accident or illness?7. Is there any hx of illness?8. Is the patient currently taking any medications?9. Does the patient have any allergy?10. Is the patient under a health care providers care?
( name of health provider)
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NURSING ALERT:
To obtain a good descriptive history, donot ask questions that can be answered byyes or no
b. Take the vital signs to establish complete baseline
information.c. Perform a Head to toe assessment including neuro
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d. Diagnostic and laboratory testing
e. Insertion or application of monitoring devices such as ECGelectrodes, arterial lines, or urinary catheter.
f. Bandaging and splinting of suspected fractures.
g. Cleaning and dressing of wounds.h. Performance of other necessary interventions based on theindividual patients condition.
i. Continual monitoring.
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If secondary survey reveals any of the following,
transport immediately:
- Tender distended abdomen
- Pelvic instability
- Bilateral femur fractures
Brief neuro exam:a. LOC (AVPU)
b. Motor- toes can be moved
c. Sensationcan feel touch to digits
d. Pupils PERL
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Transport Decision and Critical Intervention
- Critical trauma transported. All Rx done in transport
- Intervention to be done at scene:- Removal of airway obstruction
- Stop major bleeding
- Sealing sucking wounds
- Hyperventilate- Decompression of tension pneumothorax
Critical injuries can be simplified into 3 conditions:
a. Difficulty with respiration
b. Difficulty with circulation
c. Decreased LOC
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FUNCTIONAL REQUIREMENTS OF ANEMERGENCY DEPARTMENT
HOSPITAL POLICIES institutional
ED STAFF:
1. Head of the departments2. ER Supervisors
3. Head Nurse
4. Resident Doctors
5. Staff Nurse6. Nursing attendants, orderlies, handlers.
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EQUIPMENTS
EMERGENCY CART
defibrillator
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defibrillator
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LARYNGOSCOPE
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INTUBATION SET
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OXYGEN TANKS
SUCTION APPARATUS & SUCTION
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SUCTION APPARATUS & SUCTIONCATHETERS
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URINARY CATHETERS
IV FLUIDS IV CANNULA & IV
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IV FLUIDS, IV CANNULA & IVADMINISTRATION SET
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EMERGENCY MEDS & SYRINGES
CARDIOPULMONARY
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CARDIOPULMONARY
RESUSCITATION
Is a technique of basic life support for thepurpose of oxygenating the brain and
heart until appropriate.
Definitive medical treatment can restore
normal heart and ventilatory action.
Indications:
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Indications:
1. Cardiac Arrest
a. Ventricular fibrillation
b. Ventricular tachycardia
c. Asystole
2. Respiratory Arrest
a. Drowningb. Stroke
c. Foreign body obstruction
d. Smoke inhalation
e. Drug overdosef. Electricution/injury by lightning
g. Suffocation
h. Accident/injury
i. Coma
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Assessment:
Immediate loss of consciousness
Absence of palpable carotid or
femoral pulse; pulselessness in
large arteries
NURSING ALERT:The patient who has been
resuscitated is at risk for another
episode of cardiac arrest.
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Responsiveness/airway
Determine unresponsiveness: tap orgently shake patient while shouting,are you ok?
Place patient supine on a firm, flat
surface, kneel at the level ofpatients shoulder. If the patient hasa suspected head or neck trauma,the rescuer should move the patient
only if absolutely necessary.
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C P R
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PULSE SITES
ADULT CAROTID IN NECK
RADIAL IN WRIST
CHILD
CAROTID IN NECK
BRACHIAL IN ARM
INFANT
-BRACHIAL IN ARM
FEMORAL IN GROIN
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PULSE CHECKS
BE SURE PULSE IS ABSENT AND
BEGIN CPR
ADULT-AFTER 1 MINUTE OR 4
CYCLES OF 1 OR 2 MAN CPR CHILD & INFANT-AFTER 1 MINUTE
OR 20 CYCLES
AND EVERY FEW MINUTES
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COMPRESSIONS--ADULT
COMPRESS 1 1/2 - 2 INCHES GIVE 100 COMPRESSION'S PER
MINUTE FOR 1 OR 2 MAN CPR
USE 2 HANDS ON LOWER HALF OF
STERNUM CHECK CAROTID PULSE AFTER 1
MINUTE OF CPR
CHECK CAROTID PULSE DURING 2MAN CPR
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COMPRESSIONS--CHILD
COMPRESS 1/3 TO1/2 DEPTH OFCHEST
GIVE 100 COMPRESSION'S PER
MINUTE
USE THE HEAL OF 1 HAND ON THELOWER HALF OF THE STERNUM
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COMPRESSIONS--INFANT
COMPRESS 1/3 TO 1/2 DEPTH OFCHEST
USE 2 THUMBS AROUND THE CHEST
GIVE 100 COMPRESSION'S PER
MINUTE
USE 2 FINGERS 1 FINGER BELOW THE
NIPPLE LINE
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COMPRESSION RATIOS
ADULT
15 : 2 FOR 2 RESCUERS
15 : 2 FOR 1 RESCUER
CHILD
5 : 1 RATIO
INFANT
5 : 1 RATIO
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COMPLICATIONS OF CPR
PUNCTURED LUNG
LIVER LACERATION
FRACTURED RIBS/STERNUM
GASTRIC DISTENTION
GIVE SLOW EVEN BREATHS
PROPER HAND POSITION TO MINIMIZE
RIB FRACTURES
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AHA 2005
ACLS GUIDELINESIncreased Emphasis On:
Effective CPRPush hard and push fast
Chest compressions
Trauma:
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Trauma:Initial Management Priorities
A B C
Airway:- assess
- establish
- maintain
Breathing:- assess
- support
Circulation:
- assess
- access
- stop hemorrhage
- resuscitate
Airway
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AirwayNew Old
5 cycles of CPR/ 2 min prior tophoning 911 for infants/children
No jaw thrust (lay people)
Health care providers may usehead-chin tilt in injured patientsif jaw thrust fails
1 min of CPR prior tophoning 911 forinfants/children
Jaw thrust only forinjured patients
(both health careproviders and laypeople)
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BREATHING
ALL rescue breaths over 1 s, with adequate volume toproduce visible chest rise
Lay people: check for normalbreathing in adults
Normal (not deep) breath prior to AR
Continuous cycles when intubated only
8-10 resps per min when intubated (q 6-8 s) No rescue breathing without compressions for lay people
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BREATHING - OLD
Rescue breaths over 1-2 s
Varying tidal volumes suggested
10-12 resps/min once intubated
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CIRCULATION - NEW Single compression to ventilation ratio for ALL single
rescuers for ALL victims (excluding newborns) 30:2 (100/min)
5 cycles (2 min) CPR in between rhythm checks
Health care providers (2 rescuer):
Adults 30:2
Infants/children 15:2
CIRCULATION
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CIRCULATIONNEW OLD
Limit interruptions incompressions
Rescuers may use one or twohands for child CPR
Unwitnessed arrests: mayconsider 5 cycles of CPR prior todefibrillation (or response time >4 min)
Minimizations in interruptionsnot emphasized
Adult: 15:2
Infant and child: 5:1
Rhythm and pulse checks afterdefibrillation
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LEGAL ASPECTS IN EMERGENCY NURSING
LAW the sum total of rules and regulationsby which society is governed.
- it is man-made and regulates socialconduct in a formal and binding way.
CONSENT free and rational act thatpresupposes knowledge of the thing towhich the consent is being given by aperson who is legally capable to giveconsent.
NATURE OF CONSENT
i h i i i b i
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- is an authorization given, by a patient or a personauthorized by law to give the consent in the patients behalf
- secured by the nurse upon admission- usually for diagnostic procedures and initial treatment
deemed necessary by the medical staff.
- substantiated by a written authorization as a proof
against any liability that may arise due to an alleged unlawfultouching of a patient.
INFORMED CONSENT
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- Hayt and Hayt states that It is established principleof law that every human being of adult years and sound mind
has the right to determine what shall be done with his ownbody.
- he may choose whether to be treated or not and towhat extent, no matter how necessary the medical care, or
how imminent the danger to his life or health if he fails tosubmit to treatment.
ESSENTIAL ELEMENTS OF INFORMED CONSENT:
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1. diagnosis and explanation of the condition
2. fair explanation of the procedures to be done and used
and the consequences3. a description of alternative treatments or procedures
4. description of the benefits to be expected
5. material rights if any
6. prognosis, if the recommended care, procedure, isrefused
PROOF OF CONSENT
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- a written consent should be signed to show that theprocedures the one consented to and that the person
understands the nature of the procedure, the risks involvedand the possible consequences.
Who must consent?
- the patient
- another person gives consent if patient is incompetent,minor, or mentally ill or physically unable and is not in anemergency case
CONSENT IN EMERGENCY SITUATION:
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- No consent is necessary because inaction at such timemay cause greater injury.
LEGAL LIABILITY
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LEGAL LIABILITY Nurses are governed by civil and criminal law in roles as
providers of services, employees of institutions, and privatecitizens.
A nurse has a personal and legal obligation to provide astandard of client care expected of a reasonably competent
professional nurse. Professional nurses are held responsible for harm resultingfrom their negligent acts, or their failure to act.
R ibili i f h h i
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Responsibilities of the nurse to the patient:
PRIMARY RESPONSIBILITY: To give patient the kind ofcare his/her condition needs regardless of his/her race,creed, color, nationality or status.
Patients care must be based on needs, the physicians
orders, and the ailment; and shall involve the patient andallows the family to participate. (9thed. Professional Nsg inthe Phils by Venzon).
Nurses are advised to be familiar with the patients Bill ofRi hts d bs its p isi s
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Rights and observe its provisions.
The nurse may only repeat what the doctor wishes to
disclose, if the patient insist on knowing what the diagnosisis all about.
Confidentiality whatever info gathered by the nurseduring the course of caring for the patient shall always be
treated with CONFIDENTIALITY
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Confidential information may be revealed only when:
1. The patient permits such revelations as in claim forhospitalization, insurance benefits.
2. The case is medico-legal such as attempted suicide,gunshot wounds w/c have to be reported to the localpolice or NBI
3. Patient is ill of communicable disease and public safetymay be jeopardized; and
4. Given to members of the health team if information is
relevant to his care.
L l S f d
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Legal Safeguards Systematic reporting system for incidents or unusual
occurrences. Proper documentationNurses Bill of Rights Legal defense in a negligent action is when nurses know
and attain the standard of care in giving service and thatthey have documented the care they have given in aconcise and accurate manner.
NURSINGASSESSMENTS
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N NG E MEN PURPOSES:
Surveying the clients health status and risk factors for aparticular health problems
Identifying latent or occult (undetected) disease
Screening for a specific disease, such as diabetes orhypertension.
Identifying risks for particular health problem
Determining functional impact of disease (humanresponse to actual or potential health problems)
Evaluating the effectiveness of the health care plan
Health history
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Health history
Purposes:Elicits a detailed, accurate, and chronological
health record as seen in the clients perspective.
Connect with the client and develop goodrapport, provides insight into the clientsfunctional status, and helps focus and guidesubsequent physical examinations.
Ph i l E i ti
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Physical Examination
Physical examination is the secondcomponent of a complete nursing healthassessment. History findings help focus
the physical examination. Practice and adhere to standard
precautions throughout the entirephysical assessment.
ASSESSMENT TECHNIQUES
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ASSESSMENT TECHNIQUES
Inspection
an important assessment point (but commonly forgotten)Inspection employs the senses of vision and smell to
observe the client.
Auscultation
Involves listening (usually through a stethoscope) tosounds produced in the body, particularly the heart,lungs, blood vessels, stomach, and intestines.
A doppler ultrasonic stethoscope and an acoustic
stethoscope can be used to amplify body sound.
Palpation
Different parts of the hand are used to detect
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Different parts of the hand are used to detectcharacteristics of pulsation, vibrations, texture, shape,temperature, and movement.
Confirm and amplify findings observed during inspection.
Light palpation is always done first. Using finger pads,provide superficial and delicate palpation to explore skintexture and moisture; overt, large or deep masses; andfluid, muscle guarding, and superficial tenderness.
Deep palpation, uses the hand to explore internalstructures.
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Percussion
Sharply tapping the body surface with thefingers, hands, or a rubber reflex hammerproduces sounds whose quality depends on thedensity of underlying structures (organ borders,fluid, gas)Used to elicit tenderness and to assess reflexes.
Supportive Studies
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Supportive Studies
Laboratory Studies3 categories
Urinalysis
Hematology
Blood chemistry Diagnostic Studies
Performed during routine physical examinations and
assist in diagnosing disease.
Nurses responsibility
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Nurse s responsibility The nurse is responsible for the patient during the pretest,
intratest,posttest periods. Facility policies, procedures, and protocols for collecting,
handling, and transporting specimens should be followed atall times.
The nurse must educate the client concerning preparationfor the diagnostic test
Obtain written consent if necessary
Ensure clients safety during the procedure
Assist with the procedure if necessary Monitor for complications after the diagnostic test
Standard precaution must be adhered to at all times.
COMMON TYPES OF EMERGENCIES
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COMMON TYPES OF EMERGENCIES
CARDIAC EMERGENCIES/CHEST TRAUMA
RESPIRATORY EMERGENCIES
CNS EMERGENCIES
CARDIAC EMERGENCIES
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CHEST PAIN
ACUTE CORONARY
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ACUTE CORONARYSYNDROME
UNSTABLE ANGINA
MYOCARDIAL INFARCTION
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ANGINA PECTORIS
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ANGINA PECTORIS
1. Transient paroxysmal chest pain produced by insufficient blood flow to the myocardium resultingin myocardial ischemia.
2. Risk Factors
2.1 CAD
2.2 Atherosclerosis
2.3 HPN
2.4 Diabetes Mellitus ( DM )
2.5 Severe Anemia
2.6 Severe Aortic Insufficiency
3. Precipitating Factors
3.1 Physical Exertion
3.2 Consumption of Heavy Meal
3.3 Extremely Cold Weather
3.4 Strong Emotions
3.5 Cigarette Smoking
3.6 Sexual Activity
ASSESSMENT FINDINGS FOR ANGINA
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PECTORIS
4.
Assessment Findings
4.1Pain : Substernal with possibleradiation to the neck, jaw, backand arms but relieved by rest.
4.2 Palpitations and Tachycardia4.3 Dyspnea
4.4 Diaphoresis
4.5 Increased Serum Lipid Levels
4.6 Diagnostic Tests
a. ECG : Segment depressionand I wave inversion during chestpain
b. Stress Test : Abnormal ECGduring exercise
CHEST PAIN-ANGINA PECTORIS Clinical syndrome usually characterized by episodes or
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Clinical syndrome usually characterized by episodes orparoxysms of pain or pressure in the anterior chest.
Cause is usually insufficient coronary blood flow w/c resultsin a decreased oxygen supply to meet an increasedmyocardial demand for oxygen in response to physicalexertion or emotional stress.
Pain is often felt deep in the chest behind the upper ormiddle 3rdof the sternum (retrosternal area).
Pain is poorly localized and may radiate to the neck, jaw,shoulders, and inner aspects of the upper arms, usually theleft arm.
Tightness or a heavy, choking, or strangling sensation thathas a vise-like, insistent quality.
NURSING PROCESS
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Assessments: PQRST
P Position/LocationWhere is your pain located?Can you point to it?
-ProvocationWhat are you doing when the pain began?
Q- QualityHow would you describe the pain?
Is it like the pain you had before?- Quantity
Has the pain been constant?
R Radiation
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Can you feel the pain anywhere else?
- ReliefDid anything make the pain better?
S Severity
use pain rating scale
- SymptomsDid you notice any other symptoms with
the pain?
T Timing
How long ago did the pain start?
Nu sin Di n sis
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Nursing Diagnosis
1. Ineffective myocardial tissue perfusion secondary to
CAD as evidenced by chest pain.2. Anxiety related to fear of death
3. Deficient knowledge about the underlying disease andmethods for avoiding complications.
4. Noncompliance, ineffective management of therapeuticregimen related to failure to accept necessary lifestylechanges.
Planning and goals
1 Immediate and appropriate treatment when angina
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1. Immediate and appropriate treatment when anginaoccurs
2. Prevention of angina3. Reduction of anxiety
4. Awareness of the disease process
5. Understanding of the prescribed care,adherence to the self-care program, and absence ofcomplications.
Nursing Interventions
1. Treating angina
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> Stop activities, sit or rest in a semi-fowler position.
>Assess the angina
>Measure the vital signs
>Observe for signs of respiratory
distress>Nitroglycerin-can be repeated up to 3doses if chest pain is unchanged or lessened but stillpresent.
>Oxygen therapy-Administer oxygen.>For significant pain despite treatment,transfer to ICU
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2. Reducing anxiety-Provide emotional support.3. Preventing pain
4. Promoting home and community-based care.
Allow patient to notify physician immediately if pain occurs andpersists despite rest and medication>teaching patients self-care
Myocardial Infarction
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y Refers to the process by w/c areas of the myocardial cells
in the heart are permanently destroyed.
Caused by a reduced blood flow to the coronary artery dueto occlusion of an artery.
Due to profound imbalance existing between myocardialoxygen supply and demand.
Causes:
vasospasm of a coronary artery
Decreased oxygen supply
Increased demand of oxygen
MYOCARDIAL INFARCTION
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1. Death of myocardial cells from
inadquate oxygenation often causedby a sudden complete blockage ofcoronary artery; characterized bylocalized formation of necrosis (tissue destruction ) with subsequent
healing by scar formation andfibrosis.
2.. Risk Factors
a. Atheresoclerotic CAD
b. Thrombus formationc. Hypertension
d. Diabetes Mellitus
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NURSING PROCESS Assessment:
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Assessment:
Use systematic assessment w/c includes a careful history,
particularly as it relates to symptoms.Chest pain or discomfort- Substernal pain with radiation to the neck, jaw,
or back,;severe, crushing excruciating pain unrelieved by rest or nitrates.
Difficulty of breathing (dyspnea)
Nausea and vomiting
Skin : cool, clammy and ashen
f. Initial increase in Bp and pulse with gradual drop in blood pressure
Palpitations
Unusual fatigue
Faintness (syncope)Sweating (diaphoresis)
Nursing Diagnosis:
Ineffective cardiopulmonary tissue perfusion related to
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p y preduced coronary blood flow from coronary thrombus andatherosclerotic plaque.
Potential impaired gas exchange related to fluid overloadfrom left ventricular dysfunction
Potential altered peripheral tissue perfusion related todecreased cardiac output from left ventriculardysfunction
Anxiety related to fear of death
Deficient knowledge about post-MI self-care
Planning and goals:
Relief of pain or ischemic signs and symptoms
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Prevention of further myocardial damage
Absence of respiratory dysfunctionMaitenance or attainment of adequate tissue perfusion
by decreasing the hearts workload
Reduced anxiety
Adherence to the self-care programAbsence or early recognition of complications.
NURSING INTERVENTIONS FOR PATIENTS WITH
MYOCARDIAL INFARCTION
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MYOCARDIAL INFARCTION
Establish patent IV Line. Provide Pain relief.
Administer oxygen needed.
Provide bed rest with semi-fowlers position.
Monitor ECG and hemodynamic procedures. Administer antiarrythmic drugs as ordered.
Perform cardiac and lung assessments.
Monitor urine output and report output < 30 cc/hr.
Maintain full liquid diet with gradual increase to soft; low sodium Maintain quiet environment.
Transport to CCU soonest possible
Nursing Interventions
Relieving pain and other signs and symptoms of ischemia
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Improving respiratory function
Promoting adequate tissue perfusionReducing anxiety
Monitoring and managing potential complications
Promoting home and community-based care.
CARDIAC TAMPONADE
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CARDIAC TAMPONADE
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Compression of the heart as a result of fluid within thepericardial sac (pericardial effusion)
Usually caused by blunt or penetrating trauma to the chest.
Penetrating wound to the heart is associated with high
mortality.
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INTRA-ABDOMINAL INJURIES
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PENETRATING TRAUMA-
Stabbing wound site generally indicates whichorgans are affected. Wound severity depends onsize (width, shape and length) of the knife orinstrument used.
BLUNT TRAUMA occurs from direct impact of the forceto the abdominal wall, and/or thoracic area. Organs of theabdomen most often injured are the more solid organs thekidney, liver, spleen. May sustain pneumothorax,hemothorax,flail chest, myocardial bruising with the blunttrauma to the chest.
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STAB WOUND/GUNSHOT WOUND
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Are serious and usually requires surgery
High incidence of injury to hollow organ particularly smallbowel
Liver is the most frequently injured solid organ
High velocity missile create extensive tissue damage.
All abdominal gunshot wounds that cross the peritoneumrequire surgical exploration
Stab wound may be managed non operatively.
ASSESSMENT: Assess and treat client for life threatening injuries- respiratory status
d h h
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and hemorrhage.
Attempt to determine the type of force that caused the injury.
If the weapon or object producing the penetrating wound is still inplace, do not remove it. Object may not be removed until client is insurgery where bleeding and organ damage are more accessible for
repair
Remove the client's clothing and inspect the entire body for injuries.Penetrating injuries may not be bleeding or obvious initially. Carefullylogroll the client on his side and inspect back and trunk for injury.
Check the pulses in each extremity and evaluate the blood pressure inthe upper and lower extremity.
If abdominal trauma caused damage to the aorta, there may be
decrease in the blood pressure in the lower extremities
ASSESSMENT:
Carefully assess the thorax and continue to evaluate quality
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Carefully assess the thorax and continue to evaluate qualityof respirations. Frequent assessment of the quality and
presence of breath sounds, evaluate changes of breathsounds.
Asymmetry of the chest wall movement may indicatehemothorax or pneumothorax.
The presence of puncture penetrating wounds of the thoraxand fractured ribs may precipitate pneumothorax andatelectasis.
Observe for c changes in respirations and level of
consciousness that are indicative of hypoxia. Paradoxical movement of the chest wall indicate multiple rib
fractures and flail chest.
RESPIRATORY EMERGENCIES
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ACUTE RESPIRATORY DISTRESS
ACUTE RESPIRATORY DISTRESS SYNDROME(ARDS)
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Previously called, ADULT RESPIRATORY DISTRESS
SYNDROME Characterized by sudden and progressive pulmonary edema,
increasing bilateral infiltrates, hypoxemia, and reduced lungcompliance.
Acute phase:rapid onset of severe dyspnea that usuallyoccurs 12 to 48 hours after the initiating event.
Hypoxia is a condition characterized by an inadequateamount of oxygen.
Hypoxemia decrease oxygen saturation of the blood;generally occus when PO2 is below 50mmhg
Nursing Diagnosis:
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Hypoxia Potential Complications: respiratory failure,
inadequate cardiac output, dysrhythmia.Ineffective Airway Clearance related to ineffective cough orinability to remove airway secretions.
Ineffective breath patterns related to hyperventilation,
hypoventilation, CNS depressions of respiratory system.Impaired Gas exchange related alveolar hypoventilation orperfusion
Activity intolerance related to inadequate oxygen for ADL.
Anxiety related to breathlessness
Nursing Management
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Goal : to maintain good pulmonary hygiene and prevent
hypoxic episode general measures:Assess patency of airway (first priority)Position client to maintain patent airway.
A. unconscious client position on side with the chinextended notify physician and remain with client.B. conscious client elevate the head of the bed andposition on side as well.
Close monitoringUse of respiratory modalities (O2administration, chest physiotheraphy,endotracheal intubation, nebulizer therapy,
mechanical vent suctioning etc )
Nursing Management cont.
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Positioning to improve ventilation and perfusion in the
lungs and enhance secretion drainage.Explain procedure to reduce anxiety
Rest is essential to reduce oxygen consumption,decreasing oxygen needs.
Encourage cough and deep breathing exercise.Suction client as indicated by amount of sputum and
ability to cough
Maintain adequate fluid intake to keep secretions
liquified.
PULMONARY EMBOLISM
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PULMONARY EMBOLISM
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Refers to the obstruction of the pulmonary artery or one ofits branches by a thrombus that originates somewhere inthe venous system or in the right side of the heart.
The severity of the problem depends on the size of theemboli
The right lobe mostly frequent involved
Of the clients who die, die within 2 hours.
Clinical Manifestation
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Dyspnea Sudden, sharp, substernalchest pain
Coughing with hemoptysis
Tachycardia
Symptoms of hypoxia
Nursing Management
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Bed rest
Minimizing the risk of pulmonary embolism Preventing thrombus formation
Assessing potential for pulmonary embolism
Monitoring thrombolytic therapy
Managing pain
Managing oxygen therapy
Relieving anxiety
Monitoring for complications Providing postoperative nursing care
Promoting home and community-based care
STATUS ASTHMATICUS
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STATUS ASTHMATICUS
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Is severe and persistent asthma that does not respond toconventional therapy.
Attacks can last longer than 24 hours
The basic characteristics in asthma decrease the diameter
of the bronchi and are apparent in status asthmaticus.Constriction of the bronchiolar smooth muscle
Swelling of the bronchial mucosa
Thickened secretions
Clinical manifestations
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Clinical manifestations
Cough Shortness of breath
Expiratory wheezing
Symptoms of hypoxia
Retractions
Tachycardia
Increased anxiety, restlessness
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Nursing Management
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Position pt. on high back rest
Constant monitoring for the first 12 to 24 hours or untilstatus asthmaticus is under control.
Assessment of skin turgor to identify signs of dehydration
Fluid intake is essential to combat dehydration, to loosen
secretions, and facilitate expectoration. Conservation of patients energy
Non allergenic pillow should be used.
SMOKE INHALATION
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SMOKE INHALATION Inhalation injury is the leading cause of death in fire
victims
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victims.
Causes pulmonary damage:
Indicators:
History indicating that the burn occurred in anenclosed area
Burns of the face or neckSinged nasal hair
Hoarseness, voice change, dry cough, stridor, sootysputum
Bloody sputumLabored breathing or tachypnea and other signs of
reduced oxygen levels
Erythema and blistering of the oral or pharyngeal
mucosa
CNS EMERGENCIES
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CEREBRO-VASCULAR ACCIDENT (CVA)
CEREBRO-VASCULAR ACCIDENT (CVA) a.k.aSTROKE
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Sudden lost of brain function resulting from the disruptionof the blood supply to a part of the brain.
Most common site: middle cerebral artery
DRUG OVERDOSE
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DRUG OVERDOSE
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UNCONSCIOUS
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SHOCK
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Shockcharacterized by inadequate blood flow and tissue
perfusion
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Clinical Manifestation:
Restlessness- apprehensive
Increase pulse rate, weak and thready
Tachycardia to bradycardia
Urine output decreased - oliguria
Continued decrease blood pressure
Decrease sensory perception
Cool, moist skin
Rapid shallow respirationslabored, irregular respirations. Skin color pallor o cyanotic
Classification of shock
1.Hypovolemicredusced venous returndue to reduced blood
volume 15 to 25% reduction on vol.
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conditons such as hemorrhage, Burns, severe fluid loss,
dehydration
Treatment: Administer volume replacement, whole blood,
volume expander
2.Cardiogenicheart is unable to pump effectively and
circulate the intravascular vol.
Conditons: MI, Dysrhytmias, CHF
Treatment: Monitor EKG, medication to increase cardiac
output, digitalis and dopamine
3. Neurogenicalteration in the destribution of the blood volume. Increase
venous capacity due to a loss of peripheral vasomotor tone.
C dit S i l d i j
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Conditons: Spinal cord injury
4. Septicdilation of blood vessels by humoral or vasoactive substances
ConditionsOverwhelming infection, generally gram negative and positive
Treatment: Evaluate for origin of infection
5. Vasogenic (anaphylactic)antigen-antibody reaction with release of
histamine causing vasodilation
Conditions: Transfusion reactions, insect bites, side effectso of
medications, allergies to food
Treatment: Maintain airway problem with laryngeal edema ( chest tightnessoccur)
Oxygen as indicated,
epinephrine and benadryl IV
Nursing Interventions:
identify and correct cause of shock
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identify and correct cause of shock
maintain adequate respiratory function maintain adequate circulation
Blood volume
Cardiac output
Vascular tone Position in supine with legs elevated
Maintain patent airway
Provide supplemental Oxygen as ordered
Establish life line
Monitor blood pressure closely in individuals at increased risk.
SHOCK
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SEIZURES
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DISASTER NURSING
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DISASTER Any patient-generating incident that overloads
either existing personnel supplies and
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either existing personnel, supplies, andequipment, or is any patient-generating incident inwhich back-up supplies and personnel are notavailable in a reasonable amount of time
An occurrence, either natural or man-madecauses human suffering and creates human
needs that victims cannot alleviate withoutassistance.
Forces overwhelm a community.
Services are compromised.
Outside assistance is required. Is a result of vast ecological breakdown in the
relation between humans and their environment,as serious or sudden event on such scale that thestricken community needs extraordinary efforts to
co e with outside hel or international aid
MAJOR DISASTER
- any hurricane, tornado, storm, flood, high water, wind-
driven water tidal wave earthquake drought fire
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driven water, tidal wave, earthquake, drought, fire,
explosion, or any other catastrophe, which, in thedetermination of the President, causes damage of
sufficient severity and magnitude to warrant major disaster
assistance above and beyond local/state emergency
services by the government to supplement the effort and
available resources of local governments and private releif
organizations in alleviating the damage, loss, hardship, or
suffering caused by a disaster
State of Emergency
Any various types of catastrophes included in the
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y yp p
definition of a major disaster which requires
Federal emergency assistance to supplement
State and Local efforts to save lives and protect
property, public health and safety, or to avert or
lessen the threat of a disaster
Disaster Categories
Multiple patient incident
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- an incident that generates at least two, but fewer
than 10 patients- self-limiting and can be handled effectively withoutrequiring aid from resources outside the community
Multiple casualty incident
- generates 10 but fewer than 100 casualties andnecessitates total community and perhaps stateinvolvement eg. Airplane crashes, storms, floods
Mass casualty incident
- generates more than 100 victims; additional aidand assistance is required; occur infrequently butmust be anticipated in disaster planning
eg. Wars, major hurricanes, major earthquakes
Types of Disaster
1 E t l Di t t id th h it l
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1. External Disastersoccurs outside the hospital;
natural or man-madea. Natural- floods, earhtquakes, tornadoes, etc.
b. Man-made- war, fire, transportation accidents,
food contamination
2. Internal Disasters- occurs within an institution,such as hospital fire or bomb threat
Characteristics of Disaster Agents
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Predictability Frequency
Controllability/Mitigation
Time: speed, duration
Scope
Intensity
Community Implications
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Natural Disaster: Tsunami
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Nuclear Attack
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Epidemiology of a Disaster
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Agent - the physical items that actually causesthe injury or destruction
Hosthumankind (age, immunization status,
preexisting health status, degree of mobility,
emotional stability
Environmentfactors affecting outcome of a
disaster
a. Physicaltime, weather conditions, food
and water, functioning of utilities
b. Chemicalleakage of stored chemicals,
food
c. Biologicaloccur or increase as a result
of contaminated water, improper waste
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, p p
disposal, insect or rodent proliferation,improper food storage
d. Socialcontribute to the individuals
support system (loss of family members,
change in roles, questioning of religious
beliefs)
Factors that influence response to disaster
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1. Situationalwarning time before a disaster occurs,
nature and severity of a disaster, physical proximity
and closeness to the victims affected
2. Personalpsychological proximity, coping ability,
losses, role overload, previous disaster experience
Stages of a Disaster
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1. Warning stage
- Provide sufficient time for preparing to handle
the potential event
- Minimize loss of lives and mitigate damage
- Disaster plans are activated, emergencyoperations centers are established, and the
affected area is evaluated or provided with in-
place protection
- Problems: communication, doubt, adaptation
2. Impact Stagestaying alive (primary objective)
Few seconds to minutesearthquake, explosion
Few days or weeksfloods, heat waves
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Several monthsdroughts, epidemics
3. Inventory StageSurvivors assesses the effectsof the event and identify what must be done next; aperiod of isolation in which mitigative actions arerequired to prevent additional loss of life
4. Rescue StageHelp arrives to rescue survivorsand to help the injured
5. Remedy Stage - Recovery activities are beinginitiated
6. Recovery StageEncompasses total recoveryfrom the impact and resulting situation; requiresholistic recovery and development of adaptivebehavior to produce lasting changes
Four Stages of the Victims Emotional Response
Denial deny the magnitude of the problem
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Denialdeny the magnitude of the problem,
understand the problem but seem unaffectedemotionally
Strong emotional responseregards the problem as
overwhelming and unbearable; retell or relive the
experience over and over; weeping, restlessness,anger, sadness, passivity,sweating
Acceptancemakes a concetrated effort to solve the
problem; feels more hopeful and confident
Recoveryfrom crisis reaction; feel back to normaland routines become important again; sense of well-
being restored; decision ability returns; carries out
plans
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Common Problems at Mass Casualty Incidents
Failure in adequate alerting
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Failure in adequate alerting
Lack of rapid primary stabilization of patients Failure to move, collect, and organize patients
rapidly at a suitable location
Use of overly time-consuming and inappropriate
care methods Premature commencement of transportation
Improper use of personnel in the field
Lack of proper distribution of patients, which results
in improper use of medical facilities
Lack of recognizable EMS command in the field
Role of the Nurse at the Disaster Site
I f t
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Insure safety
First Aid
Emergency care
Role of the Nurse in a Shelter Objective: temporary means of caring Assessment Planing:
24/7 nursing and ancillary coverage
Supplies Implementation Evaluation
Role of the CHN in a Community Setting After a
Disaster
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Goal: Achieve the best possible level of health
for persons in a community after a disaster Primary Prevention Secondary Prevention Tertiary Prevention
NURSES ROLES IN DISASTERS
D t i it d f th t
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Determine magnitude of the event
Define health needs of the affected groups
Establish priorities and objectives
Identify actual and potential public healthproblems
Determine resources needed to respond to theneeds identified
Collaborate with other professional disciplines,governmental and non-governmental agencies
Maintain a unified chain of command Communication
ADVANTAGES OF TRIAGE
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Helps to bring order and organization to achaotic scene.
It identifies and provides care to those who
are in greatest need
Helps make the difficult decisions easier Assure that resources are used in the
most effective manner
May take some of the emotional burden
away from those doing triage
WHY IS DISASTER TRIAGE NEEDED
Inadequate resource to meet immediate needs
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Infrastructure limitations
Inadequate hazard preparation
Limited transport capabilities
Multiple agencies responding
Hospital Resources Overwhelmed
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Questions/Comments
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Thank you very
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much!