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Emergency Nursing
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
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.
These may require minimal care or life support measures, education of patient and significant others, appropriate referral and knowledge of legal implications
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
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.
Principles of Emergency Care
Triage
Means to sort out or sift out
Emergency Nurses Association ( guidelines for triage ) Level I – resuscitation
Level II – Emergent
Level III- Urgent
Level IV- less urgent
Level V - Nonurgent
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
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
As a triage nurse in a busy emergency department, it is your responsibility to prioritize patients who present for care
Based on your understanding of the triage process, assign each of the following patients according to the four color coded disaster triage system
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
Answer
SERIOUS
S. Milby is a three year old who bit through her lip when she fell off her bicycle
She is frightened and crying
Answer
MINIMAL
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
ANSWER
CRITICAL
Assess and Intervene
ABCD method
Primary Survey
Airway
Breathing
Circulation Disability Exposure
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.
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
Ethical Issues in the Emergency Department
Unexpected Death
Organ and Tissue Donation
Airway obstruction
Hemorrhage
Hypovolemic shock
Wounds Trauma
Environmental Emergencies Poisoning Substance Abuse Violence, Abuse and Neglect Psychiatric Emergencies
Airway Obstruction
ADVANCED CARDIAC LIFE SUPPORT.pptCardiopulmonary-Cerebral Resuscitation.ppt..\articlesadult_choking_small.wmvadult_cpr_small.wmv
Airway Obstruction
Hemorrhage
Hemorrhage
Results in the reduction of circulating blood volume
Minor bleeding Signs and Symptoms
Control of External Hemorrhage
Control of Internal Bleeding
Hypovolemic Shock
Shock
Is a condition in which there is loss of circulating blood volume
Management
Airway Patent AIRWAY
Breathing Maintaining Breathing
Circulation Restoration of circulating blood volume
Wounds
Wounds
Involving injury to soft tissue from minor tears to severe crushing injuries
Management
Wound Cleansing Primary Closure Delayed Primary Closure Tetanus prophylaxis
Trauma
Trauma
an unintentional or intentional wound or injury inflicted on the body from a mechanism which the body cannot protect itself.
Forensic Evidence Injury Prevention Multiple Trauma
Assessment and Diagnostic Findings Gross evidence of trauma may be slight or
absent
Management
To determine the extent of injuries and to establish priorities.
Intraabdominal Injuries
Penetrating
Blunt trauma
Assessment and Diagnostic Findings Adominal Assessment Peritoneal irritation Hypotension and symptoms of shock
Internal Bleeding Intraperitoneal Injury Genitourinary Injury
Management
Airway
Breathing
Circulation
Crush Injuries
Assessment and Diagnostic Findings Hypovolemic shock Paralysis of the body part Erythema and blistering of skin Damaged body part Renal dysfunction
Fractures
Management
Assessment of Airway, Breathing and Circulation
Environmental Emergencies
Heat Stroke
Is acute medical emergency caused by failure of the heat regulating mechanisms of the body
Frostbite
Is trauma from exposure to freezing temperature and actual freezing of the intracellular fluid and fluids in the intercellular spacess
Hypothermia
Is a condition in which the core ( internal ) temperature is 35 degree centigrade or less as a result of exposure to cold.
Near Drowning
Is defined as survival for at least 24 hours after submersion that caused a respiratory arrest
Decompression Sickness
Occurs in patients who have engaged in diving , high altitude flying, or flying in commercial aircraft within 24 hours after diving.
Anaphylactic Reaction
Is acute systemic hypersensitivity reaction that occurs within seconds or minutes after exposure to certain foreign substances
Poisoning
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.
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
Ingested ( Swallowed ) Poisons Carbon Monoxide Poisoning Skin contamination Poisoning Food poisoning
Substance Abuse
Is the misuse or specific substances to alter mood or behavior
Drug and Alcohol Abuse
Acute Alcohol Intoxication Alcohol Withdrawal Syndrome/ Delirium
Tremens
Violence, Abuse and Neglect
Assessing for Abuse, Maltreatment and Neglect I noticed that you have
Sexual Assault
Psychiatric Emergencies
Overactive Patients Violent behavior Posttraumatic Stress Disorder Underactive or Depressed Patients Suicidal Patients
EMERGENCY NURSING
The Specialty of Emergency Nursing
Specific body system
Specific disease process/problem
Specific age group
Specific population, such as women’s health care or mental health
CORE
The scope of emergency practice involves the* ASSESSMENT* ANALYSIS* NURSING DIAGNOSIS * OUTCOME IDENTIFICATION* PLANNING* IMPLEMENTATION OF * INTERVENTIONS*EVALAUTION
Independent and Collaborative
DIMENSIONS
Responsibilities Functions Roles Skills
BOUNDARIES
Internal and External
INTERSECTIONS
Professional and Governmental groups
Major Trauma
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 )
Type of injury
Blunt injury Penetrating injuries
Oxygen delivery and consumption
Neuroendocrine stress response
Systemic Inflammatory Response syndrome
Multiple Organ Dysfucntion Syndrome
Coagulopathy
Hypothermia
Psychologic Response
Assessment
History and Risk factors Mechanism of injury Intoxicants Preexisting medical conditions Last meal Initial subjective presentation Initial objective presentation
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
Collaborative Management
Airway management Oxygen Fluid management- Crystalloids- ColloidsColloids Packed red blood cells Gastric intubation Urinary drainage
Pharmacotheraphy- Antibiotics- Analgesics and Anxiolytics
Nutrition theraphy
Surgery
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
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
Fear related to potentially threatening situation
Risk for injury Posttrauma syndrome
TRAUMATIC BRAIN INJURY
PRIMARY BRAIN INJURIES
Contusion Diffuse axonal injuries Concussion
Secondary brain injuries
Intrinsic
Extrinsic
Diagnostic tests
Skull X-ray Cervical spine X-ray Computed tomography ( CT ) MRI Cerebral angiography EEG Serum laboratory studies
Collaborative Mangement
Surgical intervention Management of intracranial pressure of dynamics Reduction of ICP by CSF drainage Hyperventilation Monitoring jugular venous oxygen saturation Diuresis theraphy
Maintenance of blood pressure to maintain cerebral perfusion pressure
Reduction of metabolic demand Modifying nursing care activites that raise
ICP Nutrition Rehabilitation
Nursing Diagnoses
Impaired gas exchange Risk for infection Decreased adaptivecapacity Ineffective thermoregulation Risk for disuse syndrome
CHEST TRAUMA
Collaborative Management
Oxygen theraphy Intubation Mechanical ventilation Blood replacement Chest tubes
Analgesia Pleural decompression Stabilization and fixation of flail chest Thoracotomy
Nursing Diagnoses
Risk for fluid volume deficit
Near Drowning
Is a survival of more than 24 hr following drowning
Near drowning with aspiration ( wet ) Near drowning without aspiration ( dry )
Collaborative Management
Oxygen therapy Endotracheal intubation Positive end-expiratory pressure ( PEEP ) Bronchoscopy Extracorporeal membrane oxygenation Rewarming for hypothermia Pharmacotheraphy
Fluid and electrolyte management Neurologic support Management of event that precipitated the
near drowning
Impaired gas exchange Hypothermia Risk for infection
Cardiac Trauma
Diagnostic Tests
Chest X-ray Troponin Cardiac Enzymes ECG MUGA
Echocardiography TEE
Collaborative Management
Treatment of dysrhythnias Relief of acute pain Immediate corrective surgical repair Treatment of shcok Treatment of myocardial failure
Nursing Diagnoses
Altered Tissue perfusion
Acute Cardiac Tamponade
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 ).
Etiology
Trauma Iatrogenic Infection Carcinoma Nontraumatichemorrhage Left ventricular hemorrhage
Assessment
Beck’s triad – distended neckveins,hypotension, muffled heart tones
Collaborative
Pericardicentesis Surgical Procedure Fluid Resuscitation Inotropic agents Oxygen,intubation,mechanical ventilation
Nursing Diagnoses
Decreased Cardiac Output
Renal and Lower Urinary Tract Trauma
Pelvic Fracture
Acute Spinal Cord Injury
Abdominal Trauma