pengantar KGD

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    Ita Yuanita

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    Non trauma and trauma room

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    EMERGENCY NURSING the delivery of specialized care to variety of ill or

    injured patient. Such as pt may be unstable, have

    complex needs, required intensive and vigilant nrsgcare

    practice of episodic, primary, critical and acute

    nursing care of all ages who experience physical

    emotional or psychological alterations in health.

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    Priorities

    Major Goals1. To preserve life

    2. To prevent deterioration before more definitive

    treatment can be given.3. To restore the patient to useful living

    ***injuries to face, neck and chest that impairs

    respiration are the highest priorities

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    Five key ethical principles (after Beauchamp and

    Childress 1989) Respect for the individual

    The need to ensure confidentiality and privacy

    Respect for the autonomy of the individual

    The need to ensure appropiate consent is given by the patient or relative Beneficence/non malfeasance

    The need to ensure that decisions regarding treatment for the individualpatient are designed to be of benefit to patient, not merely to avoid harm

    Honesty

    That individual patients and families are given honest information regardingprogress and prognosis

    Justice

    Equity od access rather then postcode service

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    PATIENTS SAFETY WHO/JCI Infection control

    Correct patients identification

    Effective communication (read back, repeat back)

    High alert medication (look like, sound like drugs)

    Prevent patients fall

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    Role and responsibleliety of

    emergency nurse

    MAKING SURE THAT ALL PATIENTS AND MEMBER

    OF THEIR FAMILIES RECEIVE CLOSE ATTENTION

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    Role of Emergency NursesAdcovate

    Surveillance

    Safety officer Patient care

    Triage

    Risk Communication Forensics supervisor

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    SC AHEC Sept. 10, 2004

    Functional roles of emergency nurses

    Functional role Triage Charge Nurse

    Emergent Care ChargeNurse

    Urgent Area ChargeNurse

    Minor TreatmentLeader

    Minor Treatment AreaCharge Nurse

    Structural Position Triage Charge Nurse

    Senior ED RN Urgent Area Charge RN

    Nurse Practitioner

    Medical/Surgical Nurse

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    CONDITIONS OF EMERGENCY ROOM

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    Triage Is a method of prioritizing patient care according to

    the type of illness or injury and the urgency of thepatient's condition

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    Tr iage Rating Systems: 3 Categories

    a. Emergent (red)conditions requiring IMMEDIATE CARE and

    intervention because of increased risk of mortality or threat to

    life, limb or vision.

    B-burns

    C-chest pain-cardiac arrestR-respiratory distress

    H-hemorrhage sec. to ectopic pregnancy

    M-major blunt or penetrating trauma

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    ENA guidelines for triage based on 5

    tier system: Level I : Resuscitation - this level includes patients

    who need immediate nursing and medical attention,such as those with cardiopulmonary arrest, majortrauma, severe respiration distress and seizures

    Level II: Emergent - these patients need imadiatenursing assessment and rapid treatment. Patients whomay be assessed as level II include those with headinjuries, chest pain, stroke, asthma, and sexual assaulinjuries

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    Level III : Urgent - these patients need quick attention,but can wait as long as 30 minutes for assessment andtreatment. Such as patient might report to ED withsign of infection, mild respiratory distress or moderatepain

    Level IV : less urgent - patients in this category can

    wait up to 1 hours for assessment and treatment; theymay include earache, those with chronic back pain,upper respiratory symptoms and mild headache

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    NURSING RESPONSIBI L I TIES

    Assessment:

    a.Primary Assessmentrapid initial assessment of the

    symptoms to determine life threatening conditions

    while simultaneously intervening.

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    PRIMARY SurveyCirculation

    adequate circulation to maintain cellular tissue perfusion.

    Abnormal : bradycardia or tachycardia. cool, pale and

    diaphoresis, obvious uncontrolled external bleeding, decrease

    LOC

    Assess LOC, using mnemonic : A Very Practical Use(AVPU)

    A = alert, oriented patientV = responds to VoiceP = respond to PainU = Unresponsive Patient

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    Primary Survey Airway

    with C spine immobilization, patent airway, ability to speak,

    foreign body, chest expansion

    Nursing diagnosis : ineffective airways clearance, risk for

    aspiration, impaired ventilation spontaneous

    Interventions : chin-lift / jaw thrust, suctioning, intubation,

    cricothyroidectomy, tracheostomy, cervical spine neutral

    position.

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    Nursing diagnosis : Decreased cardiac output, risk forshock

    Interventions :

    direct pressure to control external bleeding

    IV access

    CPR

    Pericardiocentesis-aspiration of blood from pericardial sac AutotransfusionBT of one s own blood

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    PRIMARY SURVEY

    Breathing- effectiveness of breathing and ventilation ability.Abnormal : apnea, weak, shallow/labored respiration

    diminished /absent breath sounds

    unequal chest expansion

    retractions/ paroxysmal chest wall movementtracheal deviation

    Open chest wound

    Examples : chest trauma

    Subcutaneous emphysema

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    Nursing diagnosis : ineffective airways clearance,

    ineffective breathing pattern, Impaired gas exchange,

    impaired ventilation spontaneous

    Nursing interventions

    1. Oxygen therapy

    2. Chest tube insertion, intubation

    3. Pressure dressing on a flail segment of the ribs

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    Disability

    complete a brief neurological assessment todetermine baseline functioning, potential life

    threatening complications, LOC.

    Abnormal: Unresponsive

    altered pupils : fixed pupils,

    papillary respons abnormalities.

    Expose- remove all clothing from the client to facilitate a

    thorough complete secondary assessment

    examination.

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    Get other assessment aids : cardiac monitor, pulse

    oxi,urinary catheter, NGT, lab. studies: CBC,

    electrolytes, Fibrin degradation products

    (coagulation), amylase, lactate; renal studies ;blood type and crossmatch; toxicology studies.

    History

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    References Emergency Preparedness and Response.

    Explosions and Blast Injuries: A Primer forClinicians.http://www.cdc.gov/masstrauma/preparedness/primer.htm#key

    Lippincott. Emergency Nursing Made

    Incredibly Easy!

    http://www.cdc.gov/masstrauma/preparedness/primer.htmhttp://www.cdc.gov/masstrauma/preparedness/primer.htmhttp://www.cdc.gov/masstrauma/preparedness/primer.htmhttp://www.cdc.gov/masstrauma/preparedness/primer.htm