Emergency Nursing Notes

EMERGENCY NURSING

Care given to patients with urgent and critical needs

Also for non-urgent cases or whatever the patient or family considers an emergency

Serious life-threatening cardiac conditions (Myocardial infarction, Acute heart failure, Pulmonary edema Cardiac dysrhythmias)

The Emergency Nurse Applies the ADPIE on the human

responses of individuals in all age groups whose care is made difficult by the limited access to past medical history and the episodic nature of their 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 and unpredictable environments.

Consistency as much as possible across the continuum of care

The Nursing Process Provides logical framework for problem

solving in this environment Nursing assessment must be continuous,

and nursing diagnoses change with the patient’s condition

Although a patient may have several diagnoses at a given time, the focus is on the most life-threatening ones

Both independent and interdependent nursing interventions are required

Emergency Nursing in Disasters The emergency nurse must expand his or

her knowledge base to encompass recognizing & treating patients exposed to biologic and other terror weapons

The emergency nurse must anticipate nursing care in the event of a mass casualty incident.

Documentation of Consent Consent to examine and treat the patient

is part of the ER record. The patient must consent to invasive

procedures unless he or she is unconscious or in critical condition and unable to make decisions.

If the patient is unconscious and brought to the ER without family or friends, this fact should be documented

After treatment, a notation is made on the record about the patient’s condition on discharge or transfer and about instructions given to the patient and family for follow-up care.

Exposure to Health Risks All emergency health care providers

should adhere strictly to standard precautions for minimizing exposure.

Early identification and adherence to transmission-based precautions for patients who are potentially infectious is crucial.

ER nurses are usually fitted with a personal high-efficiency particulate air (HEPA)-filter mask apparatus to use when treating patients with airborne diseases.

Providing Holistic Care Sudden illness or trauma is a stress to

physiologic and psychosocial homeostasis that requires physiologic & psychological healing.

When confronted with trauma, severe disfigurement, severe illness, or sudden death, the family experiences several stages of crisis beginning with anxiety, and progress through denial, remorse & guilt, anger, grief & reconciliation.

The initial goal for the patient and family is anxiety reduction, a prerequisite to recovering the ability to cope.

Assessment of the patient and family’s psychological function includes evaluating emotional expression, degree of anxiety, and cognitive functioning.

Nursing Diagnoses Possible nursing diagnoses include: Anxiety

related to uncertain potential outcomes of the illness or trauma and ineffective individual coping related to acute situational crises

Possible diagnoses for the family include: Anticipatory grieving and alterations in family processes related to acute situational crises

Patient-Focused Interventions Those caring for the patient should act

confidently and competently to relieve anxiety.

Reacting and responding to the patient in a warm manner promotes a sense of security.

Explanations should be given on a level that the patient can understand, because an informed patient is better able to cope positively with stress.

Human contact & reassuring words reduce the panic of the severely injured person and aid in dispelling the fear of the unknown.

The unconscious patient should be treated as if conscious (i.e. touching, calling by name, explaining procedures)

As the patient regains consciousness, the nurse should orient the patient by stating his or her name, the date, and the location.

Family-Focused Interventions The family is kept informed about where

the patient is, how he or she is doing, and the care that is being given.

Allowing the family to stay with the patient, when possible, also helps allay their anxieties.

Compiled Notes of Bernie C. Butac 1 | P a g e

Additional interventions are based on the assessment of the stage of crisis that the family is experiencing.

Helping Them Cope With Sudden Death Take the family to a private place. Talk to the family together, so they can

mourn together. Reassure the family that everything

possible was done; inform them of the treatment rendered.

Show the family that you care by touching, offering coffee, and offering the services of the chaplain.

Helping Them Cope With Sudden Death Encourage family members to support

each other & to express emotions freely. Avoid giving sedation to family members;

this may mask or delay the grieving process, which is necessary to achieve emotional equilibrium and to prevent prolonged depression.

Encourage the family to view the body if they wish; this action helps integrate the loss.

Spend time with the family, listening to them and identifying any needs that they may have.

Allow family members to talk about the deceased and what he or she meant to them; this permits ventilation of feelings of loss.

Avoid volunteering unnecessary information.

Discharge Planning Instructions for continuing care are given

to the patient and the family or significant others.

All instructions should be given not only verbally but also in writing, so that the patient can refer to them later.

Instructions should include information about prescribed medications, treatments, diet, activity, and contact info as well as follow-up appointments.

Principles of Emergency Room Care

Triage: comes from the French word trier, which means "to sort;” A method to quickly evaluate and categorize the patients requiring the most emergent medical attention.

ER Triage Emergent (immediate): patients have

the highest priority; must be seen immediately

Urgent (delayed or minor): patients have serious health problems, but not immediately life-threatening ones; seen w/in 1 hour

Non-urgent (minor or support): patients have episodic illnesses addressed within 24 hours.

Determination of Priority in ER Triage: Classified based on principle to benefit the largest number of people

Determination of Priority in Field Triage Critical clients are given lowest priority Victims who require minimal care and can be

of help to others are treated first. 1. Red – Emergent (immediate)2. Yellow – Immediate (delayed) 3. Green – Urgent (minor) 4. Blue – Fast track or psychological support

needed5. Black – Patient is dead or progressing

rapidly towards death

Triage Tags should be used on all calls involving 3 or more patients.

The general placement location should be on one of the patient’s arms.

When a triage tag has been utilized, remember to document the tag number in the history portion of your run report.

“E”– Cart Located in designated areas where medical

emergencies and resuscitation is needed Purpose: to maximize the efficiency in

locating medications/supplies needed for emergency situations.

Drawer 5: Contains respiratory supplies such as oxygen tubing, a flow meter, a face shield, and a bag-valve-mask device for delivering artificial respirations

Drawer 4: Contains suction supplies & gloves

Drawer 3: Contains intravenous fluids Drawer 2: Contains equipment for

establishing IV access, tubes for laboratory tests, and syringes to flush medication lines.

Drawer 1: Contains medications needed during a code such as epinephrine, atropine, lidocaine, CaCl2 and NaHCO3

The back of the cart usually houses the cardiac board.

Assessment and Intervention in the ERThe Primary Survey: Focuses on stabilizing life-threatening conditions; employs the ABCD Method

The ABCD Method A irway - Establish the airway B reathing - Provide adequate ventilation C irculation - Evaluate & restore cardiac

output by controlling hemorrhage, preventing & treating shock, and maintaining or restoring effective circulation

D isability - Determine neurologic disability by assessing neuro function using the Glasgow Coma Scale

Eye Eye opening opening responseresponse

SpontaneousSpontaneousTo voiceTo voiceTo painTo painNoneNone

44332211

Verbal Verbal responseresponse

OrientedOrientedConfusedConfusedInappropriate wordsInappropriate wordsIncomprehensible Incomprehensible soundssounds

5544332211


NoneNone

Motor Motor responseresponse

Obeys commandObeys commandLocalizes painLocalizes painWithdrawsWithdrawsFlexionFlexionExtensionExtensionNoneNone

665544332211

Assess and Intervene: The Secondary Survey includes: A complete health history & head-to-toe

assessment Diagnostic & laboratory testing Application of monitoring devices Splinting of suspected fractures Cleaning & dressing of wounds Performance of other necessary interventions

based on the patient’s condition.

Airway Obstruction

An acute upper airway obstruction is a blockage of the upper airway, which can be in the trachea, laryngeal (voice box), or bronchi areas

Causes: Viral and bacterial infections, fire or inhalation burns, chemical burns and reactions, allergic reactions, foreign bodies, and trauma.

o In adults, aspiration of a bolus of meat is the most common cause.

o In children, small toys, buttons, coins, and other objects are commonly aspired in addition to food.

Clinical Manifestations1. Choking2. Apprehensive appearance3. Inspiratory & expiratory stridor4. Labored breathing5. Flaring of nostrils6. Use of accessory muscles (suprasternal &

intercostal retractions)7. ñ anxiety, restlessness, confusion8. Cyanosis & loss of consciousness develops as

hypoxia worsens.

Assessment and Diagnostics Involves simply asking whether the patient is

choking & requires help If unconscious, inspection of the oropharynx

may reveal the object. X-rays, laryngoscopy, or bronchoscopy may

also be performed. For elderly patients, sedatives & hypnotic

medications, diseases affecting motor coordination, & mental dysfunction are risk factors for asphyxiation of food.

Victims cannot speak, breath or cough. If victim can breathe spontaneously, partial

obstruction should be suspected; the victim is encouraged to cough it out.

If the patient has a weak cough, stridor, DOB & cyanosis, do the Heimlich.

After the obstruction is removed, rescue breathing is initiated; if the patient has no pulse, start cardiac compressions.

Head-Tilt-Chin-Lift Maneuver1. Place the patient on a firm, flat surface.2. Open the airway by placing one hand on

the victim’s forehead, and apply firm backward pressure with the palm to tilt the head back.

3. Place the fingers of the other hand under the bony part of the lower jaw near the chin and lift up.

4. Bring the chin and teeth forward to support the jaw.

Jaw-Thrust Maneuver1. Place the patient on a firm, flat surface.2. Open the airway by placing one hand on

each side of the victim’s jaw, followed by grasping and lifting the angles, thus displacing the mandible forward.

Oropharyngeal Airway InsertionA semicircular tube or tube-like plastic device inserted over the back of the tongue into the lower pharynx Used in a patient who is breathing spontaneously but unconscious.

ET Intubation: Indications1. To establish an airway for patients who

cannot be adequately intubated with an oropharyngeal airway.

2. To bypass an upper airway obstruction3. To prevent aspiration4. To permit connection of the patient to a

resuscitation bag or mech. ventilator5. To facilitate removal of tracheobronchial

secretions

Cricothyroidotomy Used in the following emergencies in w/c ET

intubation is contraindicated:1. Extensive maxillofacial trauma2. Cervical spine injuries3. Laryngospasm4. Laryngeal edema5. Hemorrhage into neck tissue6. Laryngeal obstruction

Nursing Diagnoses For Airway Obstruction1. Ineffective airway clearance due to

obstruction of the tongue, object, or fluids (blood, saliva)

2. Ineffective breathing pattern due to obstruction or injury

Hemorrhage

Bleeding that may be external, internal or both

External: Laceration, avulsion, GSW, stab wound

Internal: Bleeding in body cavities and internal organs

Assessment


Results in reduction of circulating blood vol., w/c is the principal cause of shock

Signs and symptoms of shock:1. Cool, moist skin2. Hypotension3. Tachycardia4. Delayed capillary refill5. Oliguria

Management Fluid Replacement Two large-bore intravenous cannulae are

inserted to provide a means for fluid and blood replacement, and blood samples are obtained for analysis, typing, & cross-matching.

Replacement fluids may include isotonic solutions (LRS, NSS), colloid, and blood component therapy.

• Packed RBCs are infused when there is massive hemorrhage

• In emergencies, O(-) blood is used for women of child-bearing age.

• O(+) blood is used for men and postmenopausal women.

• Additional platelets and clotting factors are give when large amounts of blood is needed.

Control of External Hemorrhage Physical assessment is done to identify area

of the hemorrhage. Direct, firm pressure is applied over the

bleeding area or the involved artery. A firm pressure dressing is applied, and the

injured part is elevated to stop venous & capillary bleeding if possible.

If the injured area is an extremity, it is immobilized to control blood loss.

Control of Bleeding: Tourniquets Applied only as a last resort just proximal to

the wound and tied tightly enough to control arterial blood flow; tag the client with a “T” stating the location and the time applied

Loosened periodically to prevent irreparable vascular on neuro damage

If still with arterial bleeding, remove tourniquet and apply pressure dressing

If traumatically amputated, the tourniquet remains in place until the OR.

Control of Internal Bleeding Watch out for tachycardia, hypotension, thirst,

apprehension, cool and moist skin, or delayed capillary refill.

Packed RBC are administered at a rapid rate, and the patient is prepped for OR.

Arterial blood is obtained to evaluate pulmonary perfusion & to establish baseline hemodynamic parameters

Patient is maintained in a supine position and closely monitored.

Hypovolemic Shock

A condition where there is loss of effective circulating blood volume due to rapid fluid loss that can result to multi-organ failure

Causes

1. Massive external or internal bleeding2. Traumatic, vascular, GI and pregnancy

related3. Burns

Nursing Diagnoses for Hypovolemic Shock1. Altered tissue perfusion related to failing

circulation2. Impaired gas exchange related to a V-P

imbalance 3. Decreased cardiac output related to

decreased circulating blood volume

Clinical Manifestations1. Weakness, lightheadedness, and

confusion2. Tachycardia3. Tachypnea4. Decrease in pulse pressure5. Cool clammy skin6. Delayed capillary refill

Hypovolemic Shock: Management1. Rapid blood and fluid replacement; blood

component therapy optimizes cardiac preload, correct hypotension, & maintain tissue perfusion

2. Large-bore intravenous needles or catheters are inserted into peripheral vv.

3. A central venous pressure catheter may also be inserted in or near the RA.

4. LRS approximates plasma electrolyte composition and osmolarity

5. A Foley catheter is inserted to record urinary output every hour; urine volume indicates adequacy of kidney perfusion

6. Ongoing nursing surveillance of the total patient is maintained to assess the patient’s response to treatment; a flow sheet is used to document parameters

7. Lactic acidosis is a common side effect & causes poor cardiac performance

Wounds

A type of physical trauma wherein the skin is torn, cut or punctured (open wound), or where blunt force trauma causes a contusion (closed wound).

Specifically refers to a sharp injury which damages the dermis of the skin.

Types of Wounds 1. Open (Incised wound, Laceration,

Abrasion, Puncture wound, Gunshot wound)

2. Closed (Contusion, Hematoma, Crushing injury)

Incised Wound A clean cut by a sharp edged object such as

glass or metal. As the blood vessels at the wound edges are

cut straight across, there may be profuse bleeding

Laceration Ripping forces or rough brushing against a

surface which can cause rough tears in the skin or lacerations.


Laceration wounds are usually bigger and can cause more tissue damage due to the size of the wound.

Abrasion Superficial wounds that occur at the surface

of the skin. Friction burns and slides can cause abrasion Characteristic in the way that only the top

most layer of the skin is scrapped off. Bleeding is not profuse though wounds

Puncture Wound Small entry site Though not large in surface area, wounds are

deep and can cause great internal damage.

Gunshot Wound (GSW) Caused by firing bullets or any other small

arms. Have a clean entry site but a large and

ragged exit site.

Contusion a.k.a. bruise: Caused by blunt force trauma that damages tissue under the skin

Hematoma: Also called a blood tumor Caused by damage to a blood vessel that in

turn causes blood to collect under the skin Caused by a great or extreme amount of force

applied over a long period of timePatterned Wound: Wound representing the outline of the object (e.g. steering wheel) causing the wound

Management: Wound Cleansing 1 . Hair around wound may be shaved.2 . NSS is used to irrigate the wound.3 . Betadine & hydrogen peroxide are only used

for initial cleaning & aren’t allowed to get deep into the wound without thorough rinsing.

4 . Use local or regional block anesthetics if indicated.

Wound Management 1 . Use of antibiotics depends on how the injury

occurred, the age of the wound, & the risk for contamination

2 . Site is immobilized & elevated to limit accumulation of fluid

3 . Tetanus prophylaxis is administered based on the condition of the wound and the immunization status

Wound Healing: By First Intention Occurs when tissue is cleanly incised and re-

approximated and healing occurs without complications.

The incisional defect re-epithelizes rapidly and matrix deposition seals the defect.

Wound Healing: By Second Intention Healing occurs in open wounds. When the wound edges are not approximated

and it heals with formation of granulation tissue, contraction and eventual spontaneous migration of epithelial cells.

Wound Healing: By Third Intention

Occurs when a wound is allowed to heal open for a few days and then closed as if primarily.

Such wounds are left open initially because of gross contamination.

Trauma

The unintentional or intentional wound or injury inflicted on the body from a mechanism against w/c the body cannot protect itself

Leading cause of death in children and in adults younger than 44 y/o

Alcohol & drug abuse are implicated in both blunt & penetrating trauma

Collection of Forensic Evidence: Included in documentation are the ff:1. Descriptions of all wounds2. Mechanism of injury3. Time of events4. Collection of evidence5. Statements made by the patient

If suicide or homicide is suspected in a deceased patient, the medical examiner will examine the body on site or have it moved to the medico-legal office for autopsy.

All tubes & lines are left in place. Patient’s hands are covered with paper bags

to protect evidence.

Injury Prevention Components 1. Education: Provide information and

materials to help prevent violence, and to maintain safety at home and in vehicles.

2. Legislation: Provide universal safety measures without infringing on rights (Seatbelt Law).

3. Automatic Protection: Provide safety without requiring personal intervention (Airbags, seatbelts).

High incidence of injury to hollow organs, particularly the small intestines

The liver is the most frequently injured solid organ.

High velocity missiles create extensive tissue damage.

Intra-abdominal Injuries: Blunt (MVA, falls, blows)Associated with extra-abdominal injuries to chest, head, extremityIncidence of delayed & trauma-related complications is higherLeads to massive blood loss into the peritoneal cavityTrauma: Assessment

1. Inspection of abdomen for signs of injury (bruises, abrasions)

2. Auscultation of bowel sounds3. Watch out for signs of peritoneal

irritation like distention, involuntary guarding, tenderness, pain, muscular rigidity, or rebound tenderness together with absent BS.

Trauma: Diagnostic Findings1. Urinalysis to detect hematuria


2. Serial hematocrit to detect presence or absence of bleeding

3. WBC count to detect elevation associated with trauma

4. Serum amylase to detect pancreatic or GIT injury

PE for Internal Bleeding Inspect body for bluish discoloration,

asymmetry, abrasion, & contusion FAST (Focused Assessment for

Sonographic Examination of the Trauma Patient) exam through CT scan to assess hemodynamically unstable patients and detect intraperitoneal bleeding

Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen.

Pain in the right shoulder can result from a laceration of the liver.

Administration of opioids is avoided during the observation period.

Trauma: Genitourinary Injury A rectal or vaginal exam is done to determine

any injury to the pelvis, bladder, and intestinal wall.

To decompress the bladder & monitor urine output, a Foley catheter is inserted AFTER DRE.

A high-riding prostate gland indicates a potential urethral injury.

Trauma: Management of Intra-abdominal Injuries1. A patent airway is maintained.2. Bleeding is controlled by applying direct

pressure to any external bleeding wounds & by occlusion of any chest wounds.

3. Circulating blood vol. is maintained with intravenous fluid replacement including blood component therapy.

4. In blunt trauma, cervical spine immobilization is maintained until cervical x-rays have been obtained & injury is ruled out.

5. All wounds are located, counted & documented.

6. If abdominal viscera protrude, the area is covered with sterile, moist saline dressing to prevent drying.

7. Oral fluids are withheld and stomach contents are aspirated with an NGT in anticipation of surgery.Tetanus and broad-spectrum antibiotics are given as prescribed.

8. If still with evidence of shock, blood loss, free air under the diaphragm, evisceration, hematuria or suspected abdominal injury, transport to OR.

Trauma: Crushing Injuries Occur when a person is caught between

objects, run over by a moving vehicle, or compressed by machinery

Watch out for hypovolemic shock from extravasation of blood & plasma into injured tissues after compression has been released.

Crushing Injuries: Assessment Watch out for paralysis of a body part,

erythema & blistering of skin, damaged part appearing swollen, tense & hard.

Renal dysfunction is secondary to prolonged hypotension.

Myoglobinuria is secondary to muscle damage causing ARF.

In conjunction with ABC’s, the patient is observed for acute renal insufficiency

Major soft tissue injuries are splinted early to control bleeding and pain.

A ò serum lactic acid concentration to <2.5 mmol/L indicates successful resuscitation.

If an extremity is involved, it is elevated to relieve swelling & pressure.

A fasciotomy is done to restore neurovascular function.

Medications for pain & anxiety are given as prescribed, and the patient is transported to the OR for debridement & fracture repair

Trauma: Multiple Injuries Requires a team approach with one person

responsible for coordinating the treatment Immediately after injury, the body is

hypermetabolic, hypercoagulable, and severely stressed.

Mortality is related to the severity & the number of systems involved.

Multiple Injuries: Nursing Responsibilities1. Assessing & monitoring the patient2. Ensuring venous access3. Administering prescribed meds4. Collecting laboratory specimens5. Documenting activities and the patient’s

response 6. Gross evidence may be slight or absent; the

injury regarded as the least significant may be the most lethal.

7. Determine the extent of injuries & establish priorities of treatment (ABC’s)

8. Establish airway & ventilation.9. Control hemorrhage.10. Prevent & treat hypovolemic shock & monitor

intake & output.11. Assess for head & neck injuries. 12. Evaluate for other injuries – reassess head &

neck, chest; assess abdomen, back & extremities.

13. Splint fractures.14. Carry out a more thorough and ongoing

examination & assessment.

FRACTURES

When a client is being examined for a fracture, the body part is handled gently & as little as possible.

Clothing is cut off to visualize the body & assessment is done for pain over or near a bone, swelling, & circulatory disturbance, ecchymosis, tenderness & crepitation.

Management of Fractures


ABCD Method & evaluation for abdominal injuries is performed BEFORE an extremity is treated unless a pulseless extremity is seen.

If the extremity is pulseless, repositioning of the extremity to proper alignment is required.

Pulseless Extremities If the pulseless extremity involves a fractured

hip or femur, a Hare traction may be applied to assist w/ alignment.

If repositioning is ineffective in restoring the pulse, a rapid total body assessment is completed, followed by a transfer to the operating room for arteriography and possible arterial repair.

Management of Fractures After the 1° survey, the 2° survey is done

using a head-to-toe approach. Observe for lacerations, swelling &

deformities including angulation, shortening, rotation, & symmetry.

Palpate all peripheral pulses. Assess extremity for coolness, blanching,

decreased sensation & motor function.

Splinting of Extremities Before moving the patient, a splint is applied

to immobilize the joint above & below the fracture

Relieves pain, restores circulation, prevents further tissue injury

Procedure:1. One hand is placed distal to the fracture &

some traction is applied while the other hand is placed beneath the fracture for support.

2. The splint should extend beyond the joints adjacent to the fracture.

3. Upper extremities must be splinted in a functional position.

4. If a fracture is open, moist, sterile dressing is applied.

5. Check the vascular status by assessing color, temperature, pulse, and blanching of the nail bed.

6. If there is neurovascular compromise, the splint is removed and reapplied.

7. Investigate complaints of pain or pressure.

People at Risk: those not acclimatized to heat elderly and very young people those unable to care for themselves those w/ chronic & debilitating dse those taking tranquilizers, diuretics,

anticholinergics, and beta blockers. exertional heat stroke occurs in healthy

individuals during sports or work activities.

Heat Stroke An acute medical emergency caused by

failure of the heat-regulating mechanisms. Usually occurs during extended heat waves,

especially when accompanied by high humidity

Pathophysiology

Hyperthermia results because of inadequate heat loss, which can also cause death.

Most heat-related deaths occur in the elderly, because their circulatory systems are unable to compensate for the stress imposed by heat

Elderly people have ò ability to perspire as well as a ò thirst mechanism to compensate for heat.

Assessment Causes thermal injury at the cellular level,

resulting to widespread damage to the heart, liver, kidney, and blood coagulation

Watch out for profound CNS dysfunction (confusion, delirium, bizarre behavior, coma), ñ body temperature (>40.6°C), hot, dry skin, anhidrosis, tachypnea, hypotension, and tachycardia.

Management The primary goal is to reduce the high

temperature as quickly as possible, because mortality is directly related to the duration of hyperthermia.

Simultaneous treatment focuses on stabilizing oxygenation using the ABC’s of basic life support.

After clothing is removed, core temperature is reduced to 39°C ASAP by one or more of the ff methods:

1. Cool sheets & towels or continuous sponging with cool H2O

2. Ice applied to neck, groin, chest, & axillae while spraying with tepid water; cooling blankets

3. Iced saline lavage of stomach or colon if temperature does not decrease

4. Immersion in cold water bath

During cooling, the patient is massaged to promote circulation and maintain cutaneous vasodilation.

An electric fan is positioned so that it blows on the patient to augment heat dissipation by convection and evaporation.

Client’s core temperature is constantly monitored w/ a thermometer placed in the rectum, bladder, or esophagus

Avoid hypothermia; prevent spontaneous recurrence of hyperthermia

Nursing Interventions Monitor vital signs, ECG, CVP and level of

responsiveness Administer 100% oxygen to meet tissue

needs exaggerated by the hypermetabolic condition.

NSS or LRS is initiated to replace fluid losses and maintain circulation

Urine output is monitored to detect acute tubular necrosis from rhabdomyolysis.

Blood specimens are obtained to detect DIC and to estimate thermal hypoxic injury to the liver, heart, and muscle tissue

Dialysis is done for renal failure. Give benzodiazepines or chlorpromazine for

seizures; K for hypokalemia; Na bicarbonate for metabolic acidosis


Nurse Teachings Advise client to avoid immediate exposure to

high temperature (10am-2pm). Emphasize importance of adequate fluid

intake, wearing loose clothing, and reducing activity in hot weather.

Monitor weight and fluid losses during workouts; replace fluids

Use a gradual approach to physical conditioning; allow acclimatization

FROSTBITE Trauma from exposure to freezing

temperatures that results to actual freezing of the tissue fluids in the cell and intracellular spaces

Results in cellular and vascular damage Body parts most frequently affected are the

feet, hands, nose and ears Ranges from 1st (erythema) to 4th degree (full-

depth tissue destruction)

Assessment Frozen extremity may be cold, hard, and

insensitive to touch Appears white or mottled blue-white Extent of injury from exposure to cold is not

initially known; assess for concomitant injury History includes environmental temperature

duration of exposure, humidity, and presence of wet conditions

Management The goal is to restore normal body

temperature; controlled yet rapid rewarming is instituted

Constrictive clothing and jewelry that could impair circulation are removed.

Patient should NOT be allowed to ambulate if the lower extremities are involved.

Place extremity in a 37° to 40°C circulating bath for 30- to 40-min.

Repeat treatment until circulation is effectively restored.

Early rewarming ò amount of tissue loss. Analgesic is given during rewarming since

process may be very painful. Avoid handling of body part to prevent further

injury. ELEVATE to prevent further swelling. Sterile gauze or cotton is placed between

affected fingers or toes to prevent maceration.

A foot cradle is used to prevent contact with bedclothes.

Blebs are left intact and not ruptured, especially if they are hemorrhagic.

Risk for infection is great; strict aseptic technique is used during dressing changes, and tetanus prophylaxis & anti-inflammatory medications are given

Whirlpool bath for affected extremity to aid circulation, debride necrotic tissue and prevent infection

Escharotomy to prevent further tissue damage, allow normal circulation and permit joint motion; fasciotomy

After rewarming, hourly active motion of affected digits is done to promote maximal restoration of function and to prevent contractures.

Refreezing is avoided Avoid tobacco, alcohol, and caffeine because

of vasoconstrictive effects which further reduce the already deficient blood supply to injured tissues.

Hypothermia A condition in which core temperature is 35°C

or less as a result of exposure to cold Occurs when patient loses ability to maintain

body temperature Urban hypothermia is associated with a high

mortality rate affected are the elderly, infants, patients with concurrent illnesses, and the homeless.

Alcohol ingestion ñ susceptibility due to systemic vasodilation.

Trauma victims are at risk resulting from treatment with cold fluids, unwarmed oxygen, and exposure during examination.

Hypothermia takes precedence in treatment over frostbite.

Assessment Watch out for progressive deterioration, with

apathy, poor judgment, ataxia, dysarthria, drowsiness, pulmonary edema, acid-base abnormalities, coagulopathy & coma

Shivering may be suppressed below 32.2°C due to ineffective mechanism

Peripheral pulses are weak and become undetectable; cardiac irregularities, hypoxemia and acidosis may occur.

Management: Monitoring VS, CVP, urine output, arterial blood gas

levels, blood chemistry and chest xray are frequently evaluated.

Body temp is monitored with a rectal, esophageal, or bladder thermometer.

Continuous ECG monitoring is done because cold-induced myocardial irritability can lead to v. fibrillation.

Management: Core Rewarming Include cardiopulmonary bypass, warm fluid

administration, warm humidified oxygen by ventilator, and warm peritoneal lavage

Done for severe hypothermia Monitoring for ventricular fibrillation as the

patient passes through 31° to 32°C is essential.

Management: Passive External Rewarming Includes the use of warm blankets or over-

the-bed heaters Increases blood flow to the acidotic, anaerobic

extremities


Cold blood returning to the core can cause cardiac dysrhythmias & electrolyte imbalances

Supportive Care External cardiac compression Defibrillation of v. fibrillation (ineffective if

core temp is <31°C) Mechanical ventilation and heated, humidified

oxygen Warmed IVF to correct hypotension and

maintain urine output and core rewarming Sodium bicarbonate to correct metabolic

acidosis if necessary Antiarrhythmic medications Insertion of Foley catheter to monitor fluid

status

Near-Drowning Survival for at least 24 hours after submersion Most common consequence is hypoxemia One of the leading causes of death in children

younger than 14 y/o; children younger than 4 y/o account for 40% of all drownings

Risk Factors1. Alcohol ingestion2. Inability to swim3. Diving injuries4. Hypothermia5. Exhaustion

Rescue Successful resuscitation with full neurologic

recovery has occurred in drowning victims after prolonged submersion in cold water.

After surviving submersion, ARDS resulting in hypoxia, hypercarbia, & respiratory or metabolic acidosis can occur.

Pathophysiology Fresh water aspiration results in loss of

surfactant, hence the inability to expand the lungs.

Salt water aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs.

Treatment Goals Maintaining cerebral perfusion and adequate

oxygenation to prevent further damage to vital organs

Immediate CPR is the factor with the greatest influence on survival

Prevention of hypoxia by ensuring an adequate airway and respiration, thus improving ventilation and oxygenation

Management ABG analyses are performed to evaluate O2,

CO2, HCO3 and pH If the patient is not breathing spontaneously,

ET intubation with positive-pressure ventilation improves oxygenation, prevents aspiration, and corrects intrapulmonary shunting and V-P abnormalities

If the patient is breathing spontaneously, supplemental O2 may be given by mask

Because of submersion, the patient is usually hypothermic; use a rectal probe to assess

Prescribed warming procedures such as corporeal rewarming, warmed PD, inhalation of warmed aerosolized O2, and torso warming depends on the severity & duration of hypothermia.

Intravascular volume expansion & inotropic agents are used to manage hypotension & impaired tissue perfusion; ECG monitoring is done to monitor dysrhythmias.

A Foley catheter is used to measure output; NGT intubation is used to decompress the stomach & prevent aspiration of gastric contents.

Close monitoring continues with serial VS, serial ABG’s, ECG monitoring, ICP assessments, serum electrolyte levels, I & O, & serial CXR.

Complications include hypoxic or ischemic cerebral injury, ARDS, pulmonary damage 2° to aspiration, & cardiac arrest.

Decompression Sickness (DCS) Occurs in patients who have engaged in

diving, high-altitude flying, or flying in a commercial aircraft 24 hrs after diving

Results from nitrogen bubbles trapped in joint or muscle spaces, resulting in musculoskeletal pain, numbness, & hyperesthesia

Bubbles can become emboli in the bloodstream & cause stroke, paralysis, or death.

A rapid history & recompression is done ASAP & may necessitate a low altitude flight to the nearest hyperbaric chamber.

Assessment Evidence of rapid ascent, loss of air in the

tank, buddy breathing, recent alcohol intake or lack of sleep, or a flight within 24 hours after diving are risk factors.

Signs and symptoms: 1. Joint/extremity pain2. numbness, hypesthesia3. loss of ROM4. neuro Sx mimicking CVA5. CP arrest in severe cases

Management A patient airway and adequate ventilation are

established & 100% O2 is given throughout treatment & transport

A CXR is obtained to identify aspiration, and at least 1 IV line is started with LRS or NSS.

If a head injury is suspected, the head of the bed is lowered.

Wet clothing is removed and the patient is kept warm.

Transfer to the closest hyperbaric chamber is done.

Antibiotics may be prescribed if aspiration is suspected.

Anaphylaxis An acute systemic hypersensitivity reaction

that occurs w/in seconds or min. after exposure to foreign substances such as medications & other agents


Repeated administration of oral & parenteral therapeutic agents may cause this when initially only a mild allergic response occurred

Pathophysiology Antigen-antibody interaction Antigen – allergen Antibody – IgE previously sensitized basophils

and mast cells Release of mediators like histamine and

prostaglandin cause the systemic reactions

Causes Penicillins – most common Contrast media Bee stings Food

Anaphylaxis Signs and Symptoms1. Respiratory Signs:

nasal congestion itching, sneezing, coughing bronchospasm & laryngeal edema chest tightness, dyspnea wheezing & cyanosis

2. Skin: flushing with sense of warmth & diffuse

erythema; generalized itching over entire body

(systemic reaction) urticaria (hives); massive facial angioedema (with

accompanying upper respiratory edema)

3. Cardiovascular: Tachycardia or bradycardia Peripheral vascular collapse

indicated by pallor, imperceptible pulse, ò BP, circulatory failure, coma & death

4. GIT: nausea & vomiting colicky abdominal pains, diarrhea

Anaphylaxis Management Establish an airway & ventilation while

another gives epinephrine. Early ET intubation avoids loss of the airway,

& oropharyngeal suction removes secretions. If glottal edema occurs, a crico-thyroidotomy

is used to provide an airway.

Anaphylaxis: Epinephrine Administration Subcutaneous injection for mild, generalized

symptoms IM injection for more severe & progressive

reactions with the possibility of vascular collapse

IV route for rare instances where there is LOC & severe cardiovascular collapse; may cause dysrhythmias

Anaphylaxis: Additional Treatments Antihistamines are given to block further

histamine release

Aminophylline by slow IV trans-fusion for severe bronchospasm & wheezing refractory to treatment

Albuterol inhalers or humidified treatment to ò bronchoconstriction

Crystalloids, colloids, or vasopressors for prolonged hypotension

Isoproterenol or dopamine for reduced cardiac output; O2 to enhance tissue perfusion

IV benzodiazepines for seizure control; corticosteroids for prolonged reaction with persistent hypotension or bronchospasm

Anaphylaxis Prevention Be aware of the danger signs of anaphylaxis. Ask the patient about previous allergies (e.g.

allergies to eggs) Before giving antigenic agents, ask caregiver

whether agent was received at an earlier time.

Avoid giving medications to patients with allergic disorders unless necessary.

Perform a skin test before administration of certain agents; have epinephrine readily available.

If dealing with outpatients, keep them in the clinic for at least 30 min after injection of any agent.

Caution patients who are highly sensitive to carry medical kits.

Encourage wearing of medical IDs.

Poisoning: Ingested Poisons May be corrosive (alkaline and acid agents

that cause tissue destruction) Alkaline products: Lye, drain and toilet bowl

cleaners, bleach, non-phosphate detergents, button batteries

Acid products: toilet bowl and metal cleaners, battery acid

Poisoning Management Control the airway, ventilation and

oxygenation. ECG, VS, and neurologic status are monitored

for changes. Shock resulting from the cardio-depressant

action of the ingested substance, or from ò circulating blood volume due to ñ capillary permeability, is treated.

A Foley catheter is inserted to monitor renal function and blood examinations are done to test for poison concentration.

The amount, time since ingestion, signs and symptoms, age and weight and health history are determined.

Patient who ingested a corrosive poison is given water or milk to drink for dilution (not attempted if patient has acute airway obstruction, or if with evidence of gastric or esophageal burn or perforation.

The following procedures may be done: Ipecac syrup to induce vomiting in the alert

patient Gastric lavage for the obtunded patient;

aspirate is tested Activated charcoal administration if poison

can be absorbed by it Cathartic, when appropriate


Ingested Poison Warnings Vomiting is NEVER induced after ingestion of

caustic substances or petroleum distillates. The area poison control center should be

called if an unknown toxic agent has been taken or if it is necessary to identify an antidote for a known toxic agent.

Gastric Lavage Guidelines1. Remove dentures and inspect for loose

teeth.2. Measure the distance between the bridge

of the nose and the xiphoid process and mark tube with indelible pencil or tape.

3. Lubricate tube with KY-Jelly.4. If comatose, patient is intubated with

cuffed nasotracheal or endotracheal tube before placement of NGT.

5. Place patient in a left lateral position with head lowered 15°.

6. Pass the tube orally while keeping the head in neutral position. Pass tube to marking (50 cm).

7. Aspirate gastric contents with the syringe attached to the tube before instilling water/antidote & save specimen.

8. Remove syringe and attach funnel to the end of the tube or use a 50mL syringe to instill solution into tube.

9. Elevate funnel above patient’s head and 150-200mL of solution into it.

10. Lower funnel and siphon the gastric contents, or connect to suction.

11. Save the samples of the first two washings.

12. Repeat the lavage until the returns are clear and no particulate matter is seen.

13. The stomach may be left empty, and an absorbent or saline cathartic is instilled and allowed to remain inside.

14. Pinch out the tube during removal or suction while withdrawing and keep head lower than the body.

15. Warn patient that stools will turn black from the charcoal.

Management The specific chemical is given as early as

possible to reverse effects. Procedures include administration of charcoal,

diuresis, dialysis, and hemoperfusion. If poisoning is due to a suicide attempt,

psychiatric evaluation is requested; if accidental, home poison-proofing directions are given

Inhaled Poisons: CO Poisoning A result of industrial or household incidents,

or attempted suicide Implicated in more deaths than any other

toxins, except alcohol. CO exerts its toxic effects by binding to

circulating hemoglobin, reducing its oxygen-carrying capacity. Hemoglobin absorbs CO 200x more readily than O2.

Carboxyhemoglobin doesn’t have O2

CNS symptoms predominate with CO toxicity. Watch out for headache, muscle weakness, palpitation, dizziness, and confusion, which rapidly leads to coma.

Skin color ranges from cherry-red to pale and is not a reliable sign.

Pulse oximetry will record false (+)’s.

CO Poisoning Management Goal: to reverse cerebral and myocardial

hypoxia and hasten elimination of CO by:1. Carrying the patient to fresh air

immediately and opening doors and windows

2. Loosening all tight clothing 3. Initiate CPR if required; give O2.4. Prevent chilling; wrap in blankets.5. Keep patient as quiet as possible.6. Do NOT give alcohol in any form.7. Upon arrival at the ER, analyze

carboxyhemoglobin levels and give 100% O2 until level is <5%.

8. Watch out for psychoses, spastic paralysis, ataxia, visual disturbances, and deterioration in mental status and behavior which may be symptoms of brain damage.

9. If accidental poisoning occurs, the DOH should be informed so that the dwelling could be inspected.

Food Poisoning A sudden illness that occurs after ingestion of

contaminated food or drink Some of the most common diseases are

infections caused by bacteria, such as Campylobacter, Salmonella, Shigella, E. coli O157:H7, Listeria, and botulism

Campylobacter A bacterium that causes acute diarrhea Transmitted through ingestion of

contaminated food, water, or unpasteurized milk, or through contact with infected infants, pets or wild animals.

Salmonella Transmitted by drinking unpasteurized milk or

by eating undercooked poultry and poultry products such as eggs

Any food prepared on surfaces contaminated by raw chicken or turkey can also become tainted

May also stem from food contaminated by a food worker

Shigella Transmitted through feces. It causes

dysentery, an infection of the intestines causing severe diarrhea. The disease generally occurs in tropical or temperate climates, especially under conditions of crowding, where personal hygiene is poor

E. Coli O157:H7 Associated with eating undercooked,

contaminated ground beef. Drinking unpasteurized milk and swimming in or


drinking sewage-contaminated water can also cause infection

Listeria found in many types of uncooked foods, such

as meats and vegetables, as well as in processed foods that become contaminated after processing, such as soft cheeses (such as feta and crumbled blue cheese) and cold cuts.

Unpasteurized milk or foods made from unpasteurized milk may also be sources of listeria infection

Botulism Linked to home-canned foods with a low acid

content Foods include asparagus, green beans, beets,

and corn. Other sources include chopped garlic in oil,

chili peppers, tomatoes, improperly handled baked potatoes cooked in aluminum foil, and home-canned or fermented fish (such as sardines)

Food Poisoning: MC Foods Honey should NOT be given to children

younger than 12 months of age, as it can contain spores of C. botulinum and is known to cause infant botulism

Staphylococcus aureus in spaghetti Bacillus cereus in fried rice Toxins in mushrooms, shellfish, including the

puffer fish

Assessment1. How soon after eating did the symptoms

occur?2. What was eaten in the previous meal? Did

the food have an unusual odor or taste?3. Did anyone else become ill from eating

the same food? 4. Did vomiting occur? What was the

appearance of the vomit?5. Did diarrhea occur?6. Any other neurologic symptoms?7. Does the patient have a fever?8. What is the client’s appearance?

Management Determine the source and type of food

poisoning. Food, gastric contents, vomitus, serum and

feces are collected for examination. Patient’s VS, sensorium and muscular activity

are closely monitored. Support the respiratory system and assess

fluid and electrolyte balance; watch out for lethargy, ñPR, fever, oliguria, anuria, hypotension, and delirium.

Administer IV antiemetic medications for mild nausea, give sips of weak tea, carbonated drinks, or tap water.

Clear liquids for 12 to 24 hrs after nausea and vomiting subside, and then progressed to a low-residue bland diet.

Burns Alteration in skin and underlying tissues as a

result of: Too much exposure to sun and UV Direct contact with heat and burning

object Hot water and liquids Chemicals

Factors considered when assessing the severity of a burn: depth of the burn and size the part of the body burned the age of the client, and the client's previous and past medical history

“Rule of Nines” Chart

Assessment of Damage Lund & Browder Method: Assigns percentage

of BSA for various anatomic parts; more precise method of estimating the extent of burn

Palm Method: The size of the palm (approximately 1% of BSA) can be used to assess the extent of burn injury in patients with scattered burn.

Factors considered when assessing the severity of a burn: depth of the burn and size the part of the body burned the age of the client, and the client's previous and past medical history

Depth of Burns: Superficial burn The epidermal layer is damaged and hurt Wound is quite painful. Skin is characteristically red and dry. Redness generally subsides within 24 to 48

hours Scarring does not occur

Depth of Burns: Deep partial thickness Burns affect the dermal layer of the skin. The injured skin is red or mottled, possibly

weepy with vesicles or blisters and considerable swelling.

When healing is complete, the skin is usually somewhat discoloredTightening and contracture may develop.

Depth of Burns: Full thickness burn the injury extends all the way through the

subcutaneous tissue sometimes to muscle and bone no regeneration can occur skin is leathery and charred. The surface is dry and edema is present.

Part of the Body Burned Special attention to the hands, head, neck,

chest, ears, face, perineum and feet


Prevention of contractures in these areas is crucial to good healing.

Any time there is soot around the nose or mouth, burned nasal hairs, stridor, hoarseness, decreased breath sounds, upper airway damage should be suspected.

Burns in the Extremes of Age In pediatric clients under age 2, the

immunologic response to stress and trauma is not fully developed, and a burn injury can be overwhelming.

In the elderly, these responses are diminished and the person's general health may be compromised by existing medical problems.

Burn ManagementMaintenance of Airway Patency

A. Assess the airway. B. Auscultate the trachea, and monitor for

adventitious breath sounds or decreased breath sounds.

C. If client is dyspneic or if there is carbon monoxide poisoning, a high liter flow of 8 to 10 liters of oxygen is recommended.

D. If compromise is suspected, the victim may be intubated and ventilated.

Indications for intubation are airway obstruction and a PaO2 of less than 60 mm Hg.

The continuous monitoring by means of a pulse oximeter assists in assuring adequate oxygenation.

E. The client's level of consciousness should be carefully monitored. Burn victims are most often alert, oriented and cooperative even with extensive injuries.

Fluid Resuscitation The maximum loss of fluid occurs within 12 to

18 hours after the burn. The total quantity of fluid required to correct

this volume deficit is replaced in the first 24 hours following the burn injury.

The amount of fluid required to correct the deficit is calculated to be 2 to 4 mL per cent burn per kilogram of body weight.

Administration of the fluids takes place over a 24-hour period with half the amount given in the first 8 hours and the remainder over the next 16 hours.

Fluid Loss Management

1. Consensus Formula: 2-4 mL x body weight (kg.) x % body surface area burned. Half to be given in first 8 hours, remaining half to be given over next 16 hours.

2. Evans Formula Colloids: 0.5 mL x body weight (kg.) x

%BSA burned Electrolytes: 1.5 mL x body weight (kg) x

% BSA burned Glucose: 2000 mL for insensible loss

Day 1: Half to be given in the first 8 hours; remaining half over next 16 hours

3. Parkland Formula Lactated Ringer’s Solution: 4 mL x

body weight (kg) x % BSA burned Day 1: Half to be given in first 8 hours;

half to be given over next 16 hours Day 2: Varies. Colloid is added (e.g.

albumin, dextran)

Burn Management Obtain laboratory data Monitor urine output and vital signs Administer tetanus antitoxin/toxoid Hypertonic Saline Solution Goal: to increase serum sodium level and

osmolarity to reduce edema and prevent pulmonary complications

Concentrated solutions of sodium chloride (NaCl) and lactate are given sufficiently to maintain a desired volume of urinary output.

Phases of Burn Care: Emergent1. Airway2. Breathing3. Circulation4. Disability5. Exposure6. Fluid Resuscitation

Assess for Acute Respiratory Failure Assess for Acute Renal Failure Assess for Distributive Shock Assess for Compartment Syndrome (Assess

peripheral pulse, capillary refill.) Assess for Paralytic Ileus (Auscultate bowel

sounds, abdominal distention.) Assess for Curling’s Ulcer (Assess gastric pH,

occult blood in stools.)

Burn Care: Acute Phase Begins 48 to 72 hours post-injury Assess for edema, jugular vein distention,

crackles, increased arterial pressure Use asepsis & reverse isolation. Give high-calorie, high-protein diet Assess the graft sites. Report signs of poor

healing, graft take or trauma. Prevent flexed position in burned areas. Burn Care: Rehabilitation Phase Wound healing, psychosocial support, and

restoring maximal functional activity remain priorities.

Chemical Burn Most chemicals that cause burns are either

strong acids or bases The severity of a chemical burn is determined

by the mechanism of action, the penetrating strength and concentration, & the amount and duration of exposure of the skin to the chemical.

Management The skin should be continuously drenched

immediately with running water from a shower, hose or faucet as the patient’s clothing is removed.


The skin of the health care professional assisting should also be appropriately protected.

Chemical Poison Warnings Water should NOT be applied on burns from

lye or white phosphorus because of a potential for an explosion or for deepening of the burn.

All evidence of these chemicals should be brushed off the patient before any flushing.

Management Determine the identity and characteristics of

the chemical agent for future treatment. The standard burn treatment for the size &

location of the wound (antimicrobials, debridement, tetanus toxoid) is instituted.

The patient may require plastic surgery for further wound management

The patient is instructed to have the affected area re-examined at 24 & 72 hours and in 7 days because of the risk of under-estimating the extent & depth of these types of injuries.


Emergency Nursing Notes

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