Emergency Updated)

8/6/2019 Emergency Updated)

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EMERGENCY NURSING

Sonia D. Ygloria, RN,MAN


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OBJECTIVES

At the end of the lecture, the students will be

able to:

Describe emergency care as collaborative,holistic approach that includes the patient,the family and significant others

Discuss priority emergency measuresinstituted for any patient with an emergency

condition


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SCOPE AND PRACTICE OF EMERGENCY

NURSING

Had specialized education, training, experience,

and expertise in assessing and identifying

patients health care problems in crisis situations

Establishes prioritiesMonitors and continuously assesses acutely ill

and injured patients

Supports and attends to familiesSupervises allied health personnel

Teaches patients and families within a time

limited, high pressured care environment


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ISSUES IN EMERGENCY NURSING

CAREDocumentation of consent and privacy

Limiting exposure to health risks

Violence in the emergency department

Providing holistic care

- patient focused interventions

- family focused interventions


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EMERGENCY NURSING & THE

CONTINUUM OFCARE

Patient is rapidly assessed, treated, and

referred to the appropriate setting for on

going carePatients who receive emergency care are

discharged directly from the emergency

department to their homes

Emergency nurse must plan and facilitate the

patients discharge & follow- up care in the

home & community


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EMERGENCY CARE

Emergency Care- care that must be

rendered without delay

( Ex: several patients with diverse healthproblems- some life-threatening-some not-may present to the emergency department

simultaneously.)


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EMERGENCY NURSING

> practice of episodic, primary, critical and

acute nursing care of all ages who experience

physical,emotional or psychological alterationsin health.


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Care of theClient presenting to an Emergency

Department :

1. Triage classification of all clients presenting to

the emergency department.

Purpose: to prioritize treatment.


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Triage Rating Systems:

3 Categories

a. Emergent conditions requiring IMMEDIATECARE and intervention because of increased riskof mortality or threat to life, limb or vision.

B-burnsC-chest pain

C-cardiac arrestR-respiratory distress

H-hemorrhage sec. to ectopic pregnancyM-major blunt or penetrating trauma


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b. Urgent conditions that require care ASAP andgenerally within 1 hour because the conditionhas the potential for causing the deterioration of

health state if not treated ASAP. These clientswill have stable V/S but have acute illness andmust be treated to prevent morbidity.

F-fever

A-abd.painS-stable fracture

L-lacerations with controlled bleeding


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c. Non-urgent- require routine care that can bedelayed for more than 2 hours without thepossibility of deterioration; clients presenting

with non-urgent conditions frequently utilize theemergency dept. because they do not have aprimary care physician.

C-colds

S-sore throatT-tooth acheA-abrasions

R-rashes


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AIRWAY

- establish a patent airway

- withC

ervical spine immobilization, ability tospeak, foreign body, chest expansion.

TREATMENT:

chin-lift / jaw thrust, suctioning, intubation,cricothyroidectomy, tracheostomy, cervical

spine neutral position.


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BREATHING- effectiveness of breathing andventilation ability.

- provide adequate ventilation, employing

resuscitation measures when necessary.( trauma patients must have the cervical spineprotected and chest injuries assessed first.)

Abnormal : apnea, weak, shallow/labored respiration,diminished /absent breath sounds ,unequal chestexpansion, retractions/ paroxysmal chest wallmovement, tracheal deviation, Open chest wound,Sx of chest trauma, Subcutaneous emphysema


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TREATMENT:

1. Oxygen therapy

2.Chest tube insertion, intubation3. Pressure dressing on a flail segment of the

ribs


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CIRCULATION- adequate circulation to

maintain cellular tissue perfusion.

- evaluate and restore cardiac output bycontrolling hemorrhage, preventing andtreating shock, and maintaining or restoring

effective circulation. This includes the

prevention and management ofhypothermia.


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Abnormal :

bradycardia or tachycardia, cool, pale and

diaphoresis ,obvious uncontrolled externalbleeding,decrease LOC, Sx of hypovolemia,

pericardial tamponade, cardiac arrest


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TREATMENT

1. direct pressure to control external bleeding

2.IV access3.CPR

4. Pericardiocentesis-aspiration of blood from

pericardial sac5. Autotransfusion BT of ones own blood.


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DISABILITY complete a brief neurological

assessment to determine baseline

functioning, potential life threateningcomplications, LOC (glasgow coma scale)

- Determine neurologic disability by assessing

neurologic function using glasgow coma scale


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Abnormal:

Unresponsive altered pupils :

fixed pupils,papillary response abnormalities.


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EXPOSE- remove all clothing from the client to

facilitate a thorough complete secondary

assessment examination.

b.Secondary Assessment- a brief, systematic

head to toe assessment that identifies allinjuries. This includes the following:


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Complete health history and head-to-toeassessment

Diagnostic and laboratory testing

Insertion or application of monitoring devicessuch as ECG electrodes, arterial lines or urinarycatheters

Splinting of suspected fractures

Cleansing, closure and dressing wounds

Performance of other necessary intterventionsbased on the patient condition


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TREATMENT:

cervical immobilization is maintained at all

times as well as continual assessment ofhemodynamic and oxygen status.

Fahrenheit-provide measures to prevent body

heat loss at this time through the use ofwarmed IVF, warmed blankets or healing

lamps.


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Get V/S other assessment aids : cardiac

monitor, pulse oxi,urinary catheter, NGT,

laboratory studies:CBC, electrolytes, Fibrindegradation products (coagulation), amylase,lactate; renal studies ; blood type and

crossmatch; toxicology studies.

History- head to toe assessment :HPI / PMH /

FH /Meds


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Common Problems Seen in Emergency

Settings :

1. Airway obstruction- partial or complete

obstruction of the airway.

- life threatening medical emergency


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Pathophysiology:

airway

Partially/completely occluded

Hypoxia, hypercabia, resp.cardiac arrest

Permanent brain injury

Death (within 3-5 minutes)


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Manifestations:

Cant speak, breath or cough

Choking, apprehensive appearance,inspiratory and expiratory stridor, laboredbreathing, use of accessory muscles, flaringnostrils, increasing anxiety, restlessness andconfusion

absent air movement

O2 sat decreases rapidly

O2 deficit occurs in the brain

hypoxia


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Assessment & Diagnostic

findings:

Unconscious patient- inspection of oropharynx

-X-rays

- Laryngoscopy

- bronchoscopy


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Causes of Upper airway

obstruction

Aspiration of foreign bodies

AnaphylaxisViral or bacterial infection

Trauma

Inhalation or chemical burns


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(for elderly patients risk factors for

asphyxiation with mental dysfunction

( dementia, mental retardation) and parkinsonsdisease.


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Management

If the patient canBreath and cough spontaneously partial

obstruction should be suspected thevictim is encouraged to cough forcefully andto persist with spontaneous coughing andbreathing efforts as long as good airexchange exists.

If the patient..

Demonstrates a weak, ineffective cough, highpitched noise while inhaling, increasedrespiratory difficulty or cyanosis should be

managed


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Has no pulse- cardiac compressions are

instituted


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2.Tension pneumothorax- occurs when air

enters the pleural space through a tear

during inspiration and accumulates becauseit cannot escape during expiration.

3. Flail chest the force of impact to the chest

wall during injury causes the fracture of 3 or

more continuous ribs\ in 2 or more placesresulting in a floating segment.


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4. Uncontrolled hemorrhage- uncontrolled bleeding.

5. Motor Vehicle Accidents *MVA- blunt and multipletrauma.

Acceleration/deceleration forces increased velocityof a moving object followed by a reduction invelocity e.g. speed of a vehicle.

Compression forces- body parts are pressed againstimmobile objects due to explosive injury to air filled

organs *liver and spleen Shearing forces- a rotational force exerted around a

fixed site. Blunt trauma- fractures, lacerations,contusions, rupture or tearing of solid and holloworgans and major blood vessels.


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6. Penetrating injuries - stab wounds/GSW :

knives, pencils, forks; high velocity /high

energy missiles: guns,rifles,high pressureinjection devices.

7. Hypothermia a condition where the core

body temp. is 36C ( 96.8 F ) or less. Tx : ABC,

faster rewarming,Cordarone, D50-50 IV


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8. Frostbite injury caused by exposure to coldenvironment and conditions.

TREATMENT : Remove from the cold envt. before

thawing. Area not be rubbed mechanical frictioncan cause tissue damage;

Aloe vera topical inhibits platelet aggregation :thromboxane inhibiting effect.

Tetanus prophylaxis:Topical and parenteral antibiotics ,

Oral and parenteral analgesics.


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9. Heat exhaustion- vasomotor collapse

sustained from prolonged exposure to heat.

TREATMENT :Rest in cool

shaded area TSB,

direct fans toward patientFluid and Electrolyte replacement


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10.HEATSTROKE an extremely elevated core bodytemperature caused by a failure of thehypothalamus-perspiration regulating mechanism;

carries 70% mortality rate.Tx :

Aggressive cooling measures to institute

Full body exposure and cooling by evaporation

Prevent shivering

Cardiac monitor

Ice water gastric and peritoneal lavage


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Prevent over correction

hypothermia and cerebral edema

IV NSS, do not use LR because liver is unable tometabolize lactate.

U.O.

ABC

s Meds: Thorazine 10-25mg preventshivering Mannitol Solu-Medrol.


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11. Drowning and Near drowning drowning isdeath caused by asphyxia and aspiration aftersubmersion in water; near drowning is risk of

death occurring within 24 hours.Tx : ABC

CBC, ABG

Fresh water drowning electrolytes decreasedSalt water drowning electrolytes increased

XRay bilateral infiltrate


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Cardiac monitor

ET intubation

Correct hypoxia and cyanosisI and O

Antibiotics,Epinephrine,Lidocaine,At SO4

Bronchodilators,NaHCO3,Steroids


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12. BITES dog,cat, rodent, human, insect/bee,spider, tick, snake; a break in the continuity ofthe skin caused by a bite from an animal, insect

or human.Tx : Meticulous wound careDevitalized tissue should be debrided and topical

antibiotic ointment.IV antibiotics severe human and animal bite

Rabies prophylaxis-animal bite

Carnivores-rabies positive : raccoons, bats, wildanimals


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Herbivorous rabies negative : mice, rodents

Venomous bites black widow spiders,

poisonous snakesAnti venom tx: constricting band/ice to slow

the circulation and spread of venom to

circulation.

*Wound should be left open and a bulkydressing is applied-dry sterile dressing.

*ABC,V/S,LOCMuscle relaxants Animal control


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13. POISONINGS substances that are harmful

: inhaled, ingested *food, drug, overdose or

acquired by contact *insecticidesC

arbonmonoxide inhalation, Food poisoning Drug

overdose: ASA overstimulation of resp.

center and metabolic acidosis-

hyperventilation,hyperthermia,hyperglycemias Insecticide

surface absorption


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Treatment:

ABC,

IV accessNarcan-Naloxone antagonist for resp.

depression due to narcotic overdose

Flumazanil-for Benzodiazepine ingestion

Gastric lavageNGT Vomiting isC/I Antidotes: Ipecac, activated

charcoal


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14. Electrocution injury sustained by electric

current

Treatment :ABC, Spine immobility,Local wound care Meds :

NaHCO 3 , Mannitol, Tetanus, Lidocaine,

Amiodarone and Epinephrine End of

Emergency Nursing


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VIOLENCE,ABUSEAND NEGLECT

Manifestations:

- Physical injuries ( unexplained bruises,

lacerations, abrasions, head injuries orfractures)

- Health problems ( anxiety, insomnia,

gastrointestinal symptoms that are related to

stress)

- Malnutrition and dehydration- common

manifestations of neglect


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Assessment and Diagnostic findings:

- Careful history- screening process

- Asking questions in private- General appearance and interactions with

significant others

- Examination of the entire surface area of thebody

- Mental status


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Management:

- Safety and welfare of the patient

SEXUAL ASSAULT

- Rape- forced sexual acts, especially if these

acts involve vaginal or anal penetration


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Assessment:

- Rape trauma syndrome

phases of psychological reactions:- Acute disorganization phase - which may

manifest an expressed state in which shock,

disbelief, fear, guilt, humiliation, anger and

other such emotions are encountered

- Phase of denial and unwillingness to talk

about the incident


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- Phase of reorganization- the incident is put intoperspective. Victims never fully recover and goon to develop chronic stress disorders and

phobias

Management:

- Sympathetic support to reduce the patients

emotional trauma- Gather evidence for possible legal proceedings

- Patient should never left alone


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- Physical examination

- Specimen collection

- Treating potential consequences of rape* prophylaxis against STDs- ceftriaxone

- follow-up care ( counselling)


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PSYCHIATRICEMERGENCIES

- Urgent , serious disturbance of behavior,

affect or thought that makes the patient

unable to cope with life situations andinterpersonal relationships.

manifestations:

- Overactive or violent

- underactive or depressed

- suicidal


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Overactive patients

Manifestations:

- disturbed, uncooperative and paranoidbehavior

- Anxious

- Panicky

- Intense nervousness- Depression

- crying


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Assessment:- Obtaining accurate history to identify events

leading to crisis

- Past mental illness- Hospitalizations

- Injuries- Serious illnesses

- Use of alcohol or drugs- Crises in interpersonal relationships- Intrapsychic conflicts


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Manifestations of abnormal thoughts andbehavior:

Hypoglycemia, drug or alcohol toxicity, stroke,

seizure disorder, head injury

Management:

-security should be nearby

-restraints ( last resort)

- Approaching the patient ( therapeutic andcalming effect)


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Introduce your self by name

Tell the patient I am here to help you

Repeat the patients name from time to time Speak in one thought sentences and be

consistent

Give the patient space and time to slow down

Show interest in listen to, encourage the patientto talk about personal thoughts and feelings

Offer appropriate and honest explanations


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- Medications

* psychotropic agent ( thorazine and

haloperidol) act specifically againstpsychotic symptoms of thoughtfragmentation and perceptual and behavioral

aberrations.


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VIOLENT BEHAVIOR

- Usually episodic, is a means of expressing

feelings of anger, fear or hopelessness- Frequently lose control when intoxicated with

alcohol or drugs


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POSTRAUMATICSTRESS DISORDER

- Development of characteristic symptoms

after a psychologically stressful event that isconsidered outside the range of normalexperience (rape, combat, motor vehicle

crash, natural catastrophe, terrorist attack)


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Manifestations:

-Intrusive thoughts

- Dreams

- Phobic avoidance reaction ( avoidance ofactivities that arouse recollection of thetraumatic event

- Heightened vigilance

- Exaggerated startle reaction

- Generalized anxiety

- Societal withdrawal


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Assessment:

- Evaluation of the patients pretrauma history,the trauma itself and postrauma functioning

Management:

- Organize and begin to integrate the experience

- Emergency management focuses on the patientspresenting behavior

- Crisis intervention strategies


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UNDERACTIVE OR DEPRESSED PATIENTS- Mood disturbance

Manifestations:- Sadness- Apathy

- Feelings of worthlessness

- Self blame- Suicidal thoughts- Desire to escape


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- Avoidance of simple problems

- Anorexia

- Weight lose- Decreased interest in sex

- Sleeplessness

- Ceaseless activity or reduction in activity


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SUICIDAL PATIENTS- An act that stems from depression and can be

viewed as a cry for help and intervention

Specific signs and symptoms of potential suicide:- Communication of suicidal intent

- History of previous suicide attempt- Family history of suicide

- Loss of a parent at an early age- Specific plan for suicide- A means to carry out the plan


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Emergency management:

- Focuses on treating the consequences of

suicide attempt and preventing further self-injury


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DISASTERNURSING

Disasters

- defined as any destructive event that disruptsthe normal functioning of a community

- Ecologic disruptions, or emergencies of aseverity and magnitude that result in deaths,injuries, illness and property damage thatcannot be effectively managed

- Event that require extraordinary effortsbeyond those needed to respond to everydayemergencies


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CLASSIFICATION OF DISASTER

a. Natural ( caused by natural or environmental

forces) result of an ecological disruption orthreat that exceeds the adjustment capacityof the affected community

b. Man-made ( human generated) direct

causes are identifiable human actions,deliberate or otherwise


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Categories of human- generated disasters:a. Complex emergencies ( combination of forces

such as drought, famine, disease and political

unrest that displace millions of people fromtheir homes)b. Technological disasters ( large number of

people, property, community infrastructure andeconomic welfare are directly and adversely

affected by major industrial accidents;unplanned release of nuclear energy; fires orexplosions from hazardous substances such asfuels, chemicals or nuclear materials


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c. Disasters that are not caused by natural

hazards but occur in human settlements.


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Hospital Emergency Incident

Command System

- Local organization that coordinatespersonnel, facilities, equipment and

communication in any emergency situation- Becomes the center of operations for

organization, planning and transport ofpatients in the event of a specific mass

casualty incident (MCI)- One person is designated as incident

commander


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Incident Command Education

- The Incident commander must be

continuously informed of all activities and

about any deviation from the establishedplan


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Hospital Operations Plan

Components of the emergency operations plan

a. An activation response

b. Internal/external communication plan

c. Plan for coordinated patient care

d. Security plans

e. Identification of external resources

f. Plan for people management and trafficflow

g. Data management strategy


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- Deactivation response

- Post incident response

- Plan for practice drills- Anticipated resources

- Mass casualty incident

- Educational plan for all of the above


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Initiating the Emergency Operations Plan:

a. Identifying patients and documenting

patient informationb. Triage

c. Managing internal problems


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Triage categories during an

MCIcategory priority color Typical conditions

Immediate- injuries arelife threatening but

survivable with minimalintervention.

Individuals in this groupcan progress rapidly to

expectant if treatmentis delayed

1 red Sucking chest wound, airwayobstruction, secondary to

mechanical cause, shock,hemothorax, tension

pneumothorax, asphyxia,unstable chest and abdominal

wounds, incompleteamputations, open fractures of

long bones, 2nd & 3rd degreeburns

Delayed: injuries aresignificant and require

medical care, but canwait hours without

threat to life or limb,

2 yellow Stable abdominal woundwithout evidence of significant

hemorrhage; soft tissue injuries.Maxillofacial wounds without

airway compromise; vascular


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Triage category color priority Typical conditions

Minimal: injuries are monir

and treatment can bedelayed hours to days.Individuals in this groupshould be moved away fromthe main triage area

green 3 Upper extremity fractures,

minor burns, sprains, smalllacerations withoutsignificant bleeding,behavioral disorders orpsychological disturbances

Expectant: injuries are

extensive and chances ofsurvival are unlikely evenwith definitive care. Persons

in this group should beseparated from other

casualties, but not

abandoned.Comfortmeasures should be providedwhen possible.

black 4 Unresponsive patients with

penetrating head wounds,high spinal cord injuries,wounds involving multiple

anatomical sites and organs,2nd and 3rd degree burns in

excess of 60% of body

surface area, seizures orvomiting within 24 hoursafter radiation exposure,

profound shock with multipleinjuries, agonal respirations,

no pulse, no BP, pupils fixed

and dilated


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