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Emergency Nursing

Emergency Nursing

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Page 1: Emergency Nursing

Emergency Nursing

Page 2: Emergency Nursing
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Objectives

Discuss the unique challenges of nursing practice in an emergency care setting

List the most common type of trauma and interventions to prevent trauma.

Identify the components of an initial trauma assessment

Describe the collaborative management of trauma patient

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Historical Perspectives

Emergency nursing was officially recognized as a specialty in 1970

According to ENA, the definition of Emergency Nursing includes

The assessment , diagnosis and treatment of perceived actual or potential , sudden or urgent, physical or psychosocial problems that are primarily episodic or acute.

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These may require minimal care or life support measures, education of patient and significant others, appropriate referral and knowledge of legal implications

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Characteristics of Emergency Nursing Practice

Assessment , analysis , nursing diagnosis, planning, implementation and evaluation of human responses of individuals in all age groups

Care that is complicated by limited access to medical history and the episodic nature of the health care

Triage and prioritization

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Emergency operations preparedness Stabilization and resuscitation Crisis intervention for unique patient

populations such as sexual assault survivors. Provision of care in uncontrolled or un

predictable environments Consistency as much as possible across the

continuum of care.

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Principles of Emergency Care

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Triage

Means to sort out or sift out

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Emergency Nurses Association ( guidelines for triage ) Level I – resuscitation

Level II – Emergent

Level III- Urgent

Level IV- less urgent

Level V - Nonurgent

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Four Color – Coded Disaster Triage System Black – Dead

Red- Critical or Life threatening

Yellow- Serious

Green - Minimal policies on disposition and managent

of DEM patients.doc

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Triage Category Systems

RED- Critical...... Likely to survive with immediate simple care

BLUE - Catastrophic Survives with extensive care or poor prognosis...

YELLOW - Urgent..... Survives with care given in few hours

GREEN - Minor ..... Survives with care delayed hours to days

BLACK - Dead

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As a triage nurse in a busy emergency department, it is your responsibility to prioritize patients who present for care

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Based on your understanding of the triage process, assign each of the following patients according to the four color coded disaster triage system

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Mr. P. Pascual is a 28 year old who fell off a roof while working.

He has a wrist fracture, several small lacerations, and a swollen ankle.

He is awake , alert and complaining of pain

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Answer

SERIOUS

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S. Milby is a three year old who bit through her lip when she fell off her bicycle

She is frightened and crying

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Answer

MINIMAL

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Mr. M is a 62 year old who suffered a heart attack.

Paramedics were called to Mr. M’s house where defibrillation for ventricular fibrillation was necessary.

He has just arrived at the emergency department .

His blood pressure is 100/60 He is diaphoretic and pale

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ANSWER

CRITICAL

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Assess and Intervene

ABCD method

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Primary Survey

Airway

Breathing

Circulation Disability Exposure

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Secondary Survey

Complete health history and head to toe assessment

Diagnostic and laboratory testing Insertion or application of monitoring devices Splinting of suspected fractures Cleansing , closure and dressing or wounds.

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Issues in Emergency nursing care Documentation of consent and Privacy Violence in the Emergency Department Restraints Mandatory Reporting Evidence . Collection and Preservation Providing Holistic Care

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Ethical Issues in the Emergency Department

Unexpected Death

Organ and Tissue Donation

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Airway obstruction

Hemorrhage

Hypovolemic shock

Wounds Trauma

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Environmental Emergencies Poisoning Substance Abuse Violence, Abuse and Neglect Psychiatric Emergencies

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Airway Obstruction

ADVANCED CARDIAC LIFE SUPPORT.pptCardiopulmonary-Cerebral Resuscitation.ppt..\articlesadult_choking_small.wmvadult_cpr_small.wmv

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Airway Obstruction

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Hemorrhage

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Hemorrhage

Results in the reduction of circulating blood volume

Minor bleeding Signs and Symptoms

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Control of External Hemorrhage

Control of Internal Bleeding

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Hypovolemic Shock

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Shock

Is a condition in which there is loss of circulating blood volume

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Management

Airway Patent AIRWAY

Breathing Maintaining Breathing

Circulation Restoration of circulating blood volume

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Wounds

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Wounds

Involving injury to soft tissue from minor tears to severe crushing injuries

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Management

Wound Cleansing Primary Closure Delayed Primary Closure Tetanus prophylaxis

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Trauma

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Trauma

an unintentional or intentional wound or injury inflicted on the body from a mechanism which the body cannot protect itself.

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Forensic Evidence Injury Prevention Multiple Trauma

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Assessment and Diagnostic Findings Gross evidence of trauma may be slight or

absent

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Management

To determine the extent of injuries and to establish priorities.

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Intraabdominal Injuries

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Penetrating

Blunt trauma

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Assessment and Diagnostic Findings Adominal Assessment Peritoneal irritation Hypotension and symptoms of shock

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Internal Bleeding Intraperitoneal Injury Genitourinary Injury

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Management

Airway

Breathing

Circulation

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Crush Injuries

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Assessment and Diagnostic Findings Hypovolemic shock Paralysis of the body part Erythema and blistering of skin Damaged body part Renal dysfunction

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Fractures

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Management

Assessment of Airway, Breathing and Circulation

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Environmental Emergencies

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Heat Stroke

Is acute medical emergency caused by failure of the heat regulating mechanisms of the body

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Frostbite

Is trauma from exposure to freezing temperature and actual freezing of the intracellular fluid and fluids in the intercellular spacess

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Hypothermia

Is a condition in which the core ( internal ) temperature is 35 degree centigrade or less as a result of exposure to cold.

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Near Drowning

Is defined as survival for at least 24 hours after submersion that caused a respiratory arrest

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Decompression Sickness

Occurs in patients who have engaged in diving , high altitude flying, or flying in commercial aircraft within 24 hours after diving.

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Anaphylactic Reaction

Is acute systemic hypersensitivity reaction that occurs within seconds or minutes after exposure to certain foreign substances

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Poisoning

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Is any substance that, when ingested, inhaled, absorbed applied to the skin, or produced within the body in relatively small amounts, injures the body by its chemical action.

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Emergency Treatment

To remove or inactivate the poison before it is absorbed.

To provide supportive care in maintaining vital organ systems

To administer a specific antidote to neutralize a specific poison

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Ingested ( Swallowed ) Poisons Carbon Monoxide Poisoning Skin contamination Poisoning Food poisoning

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Substance Abuse

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Is the misuse or specific substances to alter mood or behavior

Drug and Alcohol Abuse

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Acute Alcohol Intoxication Alcohol Withdrawal Syndrome/ Delirium

Tremens

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Violence, Abuse and Neglect

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Assessing for Abuse, Maltreatment and Neglect I noticed that you have

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Sexual Assault

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Psychiatric Emergencies

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Overactive Patients Violent behavior Posttraumatic Stress Disorder Underactive or Depressed Patients Suicidal Patients

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EMERGENCY NURSING

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The Specialty of Emergency Nursing

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Specific body system

Specific disease process/problem

Specific age group

Specific population, such as women’s health care or mental health

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CORE

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The scope of emergency practice involves the* ASSESSMENT* ANALYSIS* NURSING DIAGNOSIS * OUTCOME IDENTIFICATION* PLANNING* IMPLEMENTATION OF * INTERVENTIONS*EVALAUTION

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Independent and Collaborative

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DIMENSIONS

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Responsibilities Functions Roles Skills

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BOUNDARIES

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Internal and External

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INTERSECTIONS

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Professional and Governmental groups

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Major Trauma

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Mechanisms of injury

Knowledge of the object producing the injury ( motor vehicle,handgun )

Type of energy released ( kinetic, thermal, chemical Force of energy ( velocity of vehicle or missile ) Use of protective devices ( seat belts, air bags ,

helmets )

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Type of injury

Blunt injury Penetrating injuries

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Oxygen delivery and consumption

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Neuroendocrine stress response

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Systemic Inflammatory Response syndrome

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Multiple Organ Dysfucntion Syndrome

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Coagulopathy

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Hypothermia

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Psychologic Response

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Assessment

History and Risk factors Mechanism of injury Intoxicants Preexisting medical conditions Last meal Initial subjective presentation Initial objective presentation

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Diagnostic Tests

Complete Blood Count Blood chemistries Arterial blood gas ( ABG ) analysis Oximetry Type and cross-match Blood alcohol, toxicology screen Urinalysis X-ray Computed tomography

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Collaborative Management

Airway management Oxygen Fluid management- Crystalloids- ColloidsColloids Packed red blood cells Gastric intubation Urinary drainage

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Pharmacotheraphy- Antibiotics- Analgesics and Anxiolytics

Nutrition theraphy

Surgery

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Nursing Diagnoses

Fluid volume deficit related to active loss secondary to physical injury

Altered protection related to clotting factor alterations ; decreased hemoglobin level.

Risk for infection related to inadequate primary defenses secondary to physical trauma or surgery

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Impaired tissue integrity related to mechanical factors

Hypothermia related to exposure at the scene of injury

Altered nutrition ;less than body requirements , related to increased need secondary to hypermetabolic posttrauma site

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Fear related to potentially threatening situation

Risk for injury Posttrauma syndrome

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TRAUMATIC BRAIN INJURY

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PRIMARY BRAIN INJURIES

Contusion Diffuse axonal injuries Concussion

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Secondary brain injuries

Intrinsic

Extrinsic

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Diagnostic tests

Skull X-ray Cervical spine X-ray Computed tomography ( CT ) MRI Cerebral angiography EEG Serum laboratory studies

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Collaborative Mangement

Surgical intervention Management of intracranial pressure of dynamics Reduction of ICP by CSF drainage Hyperventilation Monitoring jugular venous oxygen saturation Diuresis theraphy

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Maintenance of blood pressure to maintain cerebral perfusion pressure

Reduction of metabolic demand Modifying nursing care activites that raise

ICP Nutrition Rehabilitation

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Nursing Diagnoses

Impaired gas exchange Risk for infection Decreased adaptivecapacity Ineffective thermoregulation Risk for disuse syndrome

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CHEST TRAUMA

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Collaborative Management

Oxygen theraphy Intubation Mechanical ventilation Blood replacement Chest tubes

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Analgesia Pleural decompression Stabilization and fixation of flail chest Thoracotomy

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Nursing Diagnoses

Risk for fluid volume deficit

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Near Drowning

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Is a survival of more than 24 hr following drowning

Near drowning with aspiration ( wet ) Near drowning without aspiration ( dry )

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Collaborative Management

Oxygen therapy Endotracheal intubation Positive end-expiratory pressure ( PEEP ) Bronchoscopy Extracorporeal membrane oxygenation Rewarming for hypothermia Pharmacotheraphy

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Fluid and electrolyte management Neurologic support Management of event that precipitated the

near drowning

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Impaired gas exchange Hypothermia Risk for infection

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Cardiac Trauma

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Diagnostic Tests

Chest X-ray Troponin Cardiac Enzymes ECG MUGA

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Echocardiography TEE

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Collaborative Management

Treatment of dysrhythnias Relief of acute pain Immediate corrective surgical repair Treatment of shcok Treatment of myocardial failure

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Nursing Diagnoses

Altered Tissue perfusion

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Acute Cardiac Tamponade

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Is a sudden accumulation of blood , fluid, clots, pus , and /or gas in the pericardial space, which copresses the heart and interferes with both ventricular filling ( diastole ) and ejection ( systole ).

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Etiology

Trauma Iatrogenic Infection Carcinoma Nontraumatichemorrhage Left ventricular hemorrhage

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Assessment

Beck’s triad – distended neckveins,hypotension, muffled heart tones

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Collaborative

Pericardicentesis Surgical Procedure Fluid Resuscitation Inotropic agents Oxygen,intubation,mechanical ventilation

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Nursing Diagnoses

Decreased Cardiac Output

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Renal and Lower Urinary Tract Trauma

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Pelvic Fracture

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Acute Spinal Cord Injury

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Abdominal Trauma