Copy Of Emergency Nursing

EMERGENCY – IT IS WHATEVER THE PATIENT OR THE FAMILY CONSIDERS IT TO BE. EMERGENCY NURSING • It is the nursing care given to patients with urgent and critical needs EMERGENCY NURSE • has a specialized education, training, and experience to gain expertise in assessing and identifying patients’ health care problems in crisis situations • establishes priorities, monitors and continuously assesses acutely ill and injured patients, supports and attends to families, supervises allied health personnel, and teaches patients and families within a time-limited, high-pressured care environment

DISASTER NURSING • a branch of emergency nursing, it refers to nursing care given to patients who are victims of disasters, whether it is manmade or natural phenomena. INCIDENT COMMAND SYSTEM • It is a management tool for organizing personnel, facilities, equipment, and communication for any emergency situation.

INCIDENT COMMANDER •

The head of the incident command system

• He must be continuously informed of all the activities and informed about any deviation from the established plan

EMERGENCY OPERATIONS PLAN (EOP) -It is done by a planning committee, composed of local/national administrators, safety officer, ED manager, evaluating the community to anticipate the type of disaster that might occur. COMPONENTS of EOP  Activation Response  Internal/External Communication Plans  Plan for coordinated patient care  Security Plans  Identification of external resources  A plan for people management and traffic flow  Data Management Strategy

 Anticipated Resources

 Deactivation Response

 Mass Casualty Incident Planning

 Post- Incident Response

 Educational Plan

 Plan for Practice Drills

•

from French word meaning “to sort”

• it is used to sort patients into groups based on the severity of their health problems and the immediacy with which these problems must be treated

TRIAGE NURSE – acts as a gatekeeper, sorting patients into categories, ensuring that the more seriously ill are treated first

 Conditions requiring immediate medical intervention, any delay in treatment is potentially life or limb threatening. Must be seen IMMEDIATELY! EXAMPLES: • AIRWAY COMPROMISE • CARDIAC ARREST • SEVERE SHOCK • CERVICAL SPINE INJURY • MULTISYSTEM TRAUMA

• ALTERED LEVEL OF CONSCIOUSNESS • ECLAMPSIA

 PATIENTS WHO PRESENT AS STABLE BUT WHOSE CONDITION REQUIRES MEDICAL INTERVENTION WITHIN A FEW HOURS.  THERE IS NO IMMEDIATE THREAT TO LIFE OR LIMB TO THESE PATIENTS EXAMPLES: • FEVER • MINOR BURNS • MINOR MUSCULOSKELETAL INJURIES • LACERATIONS

 PATIENTS WHO PRESENT WITH CHRONIC OR MINOR INJURIES  NO DANGER TO LIFE OR LIMB  PATIENTS ARE IN NO OBVIOUS DISTRESS EXAMPLES: • CHRONIC LOW BACK PAIN • DENTAL PROBLEMS • MISSED MENSES

PRINCIPLE OF TRIAGE IN A DISASTER: • DO THE GREATEST GOOD FOR THE GREATEST NUMBER • Decisions are based on the likelihood of survival and consumption of available resources.

TRIAGE CATEGORY

PRIORITY

COLOR

IMMEDIATE

1

RED

DELAYED

2

YELLOW

MINIMAL

3

GREEN

EXPECTANT

4

BLACK

TYPICAL CONDITIONS: • Sucking chest wound • airway obstruction secondary to mechanical cause, • shock • hemothorax, tension pneumothorax • asphyxia • unstable chest and abdominal wounds, • incomplete amputations, open fractures of long bones • 2nd / 3rd degree burns of 15-40% TBSA

TYPICAL CONDITIONS: • Stable abdominal wounds w/o evidence of significant hemorrhage • soft tissue injuries • Maxillofacial wounds w/o airway compromise • Vascular injuries w/ adequate collateral circulation • Genitourinary Tract Disruption • Fractures requiring open reduction, debridement, and external fixation

TYPICAL CONDITIONS: • Upper extremity fractures • Minor Burns • Sprains • Small Lacerations w/o significant bleeding • Behavioral disorders or Psychological disturbances

TYPICAL CONDITIONS: • Unresponsive patients w/ penetrating head wounds • High spinal cord injury • Wounds involving multiple anatomical sites and organs • 2nd /3rd degree burns in excess of 60% of BSA • Seizures or vomiting w/n 24 hours after Radiation Exposure • Profound shock with multiple injuries and agonal respirations • Patients with no Pulse, no BP, pupils fixed and dilated

PRIMARY ASSESSMENT: MEANT TO IDENTIFY LIFETHREATENING PROBLEMS

IRWAY

REATHING

IRCULATION

ISABILITY

XPOSE

SECONDARY ASSESSMENT: Systematic, brief (2-3 mins) examination from head to toe; Purpose is to detect and prioritize additional injuries and detect signs of underlying medical conditions  What is the mechanism of injury?  When did the symptoms appear?  Was the patient unconscious after the accident?  How did the pt. reach the hospital?  What was the health status of the patient prior the accident or illness?  Is there history of present illness?  Is the patient taking any medications?  Does the patient have allergies?  Was treatment attempted before arrival at the hospital?

 Understand and accept basic anxieties, be aware of patient’s fear  Accept the rights of the patient and family, to have and display their feelings  Maintain a calm and reassuring manner  Treat the unconscious patient as if CONSCIOUS. (Touch, call by name, explain every procedure)  Orient the patient as soon he becomes conscious.  Inform the family where the patient is, and give as much as information as possible about the treatment  Assist family to cope with sudden and unexpected death  take them on a private place and talk to them so they can mourn together  assure the family that everything was done  avoid giving sedation to family members

1. BASIC LIFE SUPPORT - an emergency procedure that consists of recognizing respiratory or cardiac arrest or both the proper application of CPR to maintain life until a victim recovers or advance life support is available. 2. ADVANCE CARDIAC LIFE SUPPORT - the use of special equipment to maintain breathing and circulation for the victim of a cardiac emergency. 3. PROLONGEDLIFE SUPPORT - for post resuscitative and long term resuscitation.

1.The FIRST LINK: EARLY ACCESS It is the event initiated after the patient’s collapse until the arrival of Emergency Medical Services personnel prepared to provide care. 2.The SECOND LINK: EARLY CPR If started immediately after the victim’s collapse, the probability of survival approximately doubles when it is initiated before the arrival of EMS. 3.The THIRD LINK: EARLY DEFIBRILLATION It is most likely to improve survival. It is the key intervention to increase the chances of survival of patients with out-of-hospital cardiac arrest. 4.The FOURTH LINK: EARLY ACLS If provided by highly trained personnel like paramedics, provision of advanced care outside the hospital would be

1.What to DO: •Do obtain consent when possible. •Do think the worst. It’s best to administer first aid for the gravest possibility. •Do provide comfort and emotional support. •Do respect the victim’s modesty and physical privacy. •Do be as calm and as direct as possible. •Do care for the most serious injuries first. •Do assist the victim with his/her prescription medication. •Do handle the victim to a minimum. •Do loosen tight clothing.

2.What Not to DO: •Do not let the victim see his/her own injury. •Do not leave the victim alone except to get help. •Do not assume that the victim’s obvious injuries are the only ones. •Do not make any unrealistic promises. •Do not trust the judgment of a confused victim and require them to make decision.

-is a rapid movement of patient from unsafe place to a place of safety. Indications for emergency Rescue: 1. Danger of fire or explosion. 2. Danger of toxic gases or asphyxia due to lack of oxygen. 3. Natural Disasters 4. Risk of drowning. 5. Danger of electrocution. 6. Danger of collapsing walls. Methods of Rescue: 1. For immediate rescue without any assistance, drag or pull the victim. 2. Most of the one-man drags/carries and other transfer methods can be used as methods of rescue.

-is moving a patient from one place to another after giving first aid. Factors to be considered in the selection of choosing the transfer method: 1. Nature and severity of the injury. 2. Size of the victim. 3. Physical capabilities of the first aider. 4. Number of personnel and equipment available. 5. Nature of the evacuation route. 6. Distance to be covered. 7. Gender of the victims. (last consideration)

Pointers to be observed during transfer: 1.Victim’s airway must be maintained open. 2. Hemorrhage is controlled. 3. Victim is safely maintained in the proper position. 4. Regular check of the victim’s condition is made. 5. Supporting bandages and dressings as remain effectively applied. 6. The method of transfer is safe, comfortable and as speedy as circumstances permit. 7. The patient’s body is moved as one unit. 8. First aiders/bearers must observed ergonomics in lifting and moving of patient.

1.One man assist/carries/drags 2. Two man assist/carries 3.Three man carries 4.four/six/eight-man carry 5.Blanket 6.Improvised stretcher using two poles with: • blanket • Empty sacks • Shirts or coats • Triangular bandages 7.Commercial stretchers 8.Ambulance or rescue van 9.Other vehicles.

- a technique of basic life support for the purpose of oxygenating the brain and heart until appropriate, definitive medical treatment can restore normal heart and ventilatory function. INDICATIONS: 1. Cardiac Arrest a. Ventricular Fibrillation b. Ventricular Tachycardia c. Asystole d. Pulseless electrical activity 2. Respiratory Arrest

c. Foreign-body obstruction d. Smoke inhalation e. Electrocution f. Suffocation g. Drug Overdose i.

Accident/Injury

a. Drowning

j. Coma

b. Stroke

h. Epiglottitis

ASSESSMENT: • Immediate loss of consciousness • Absence of breath sounds or air movement • Absence of palpable carotid or femoral pulse; pulselessness in large arteries

COMPLICATIONS: • Rib Fracture (most common) • Postresuscitation Distress Syndrome • Neurologic Impairment; Brain Damage

I.

RESPONSIVENESS/AIRWAY

•

Determine unresponsiveness; “ARE YOU OKAY?”

•

Activate Emergency Medical Assistance

•

Place patient supine on a firm, flat surface. Kneel at the level of the patient’s shoulders

•

Open the airway: HEADTILT/CHIN LIFT MANEUVER, JAW THRUST MANEUVER

2. BREATHING •

Look, Listen and Feel

•

Rescue breathing: 2 full breaths

3. CIRCULATION •

Check carotid pulse

WAYS TO VENTILATE THE LUNGS 1. MOUTH-TO-MOUTH = a quick, effective way to provide O2 and ventilation to the victim. 2. MOUTH-TO-NOSE = recommended when it is impossible to ventilate through the victim’s mouth. (Trismus, mouth injury) 3. MOUTH-TO-NOSE and MOUTH = if the pt. is an infant 4. MOUTH-TO-STOMA = used if the pt. has a stoma; a permanent opening that connects the trachea directly to the front of the neck. For Rescue Breathing Alone: - Rate is 10-12 breaths in ADULT - (1.5 - 2 sec/breath) ( 1 breath every 4 to 5 secs) - Rate is 20 breaths for a CHILD and INFANT - (1 – 1.5 sec/breath) ( 1 breath every 3 secs)

Table of Cardiopulmonary Resuscitation for Adult, Child & Infant

Adult Compression Area

Depth How to compress

Child

Infant

Lower half of the Lower half of the Lower half of the sternum but not hitting sternum but not hitting sternum but not hitting the xiphoid process: the xiphoid process: the xiphoid process: 1 measure up to 2 measure up to 1 finger finger width below the fingers from from substernal imaginary nipple line. substernal notch. notch. Approximately 1 ½ to Approximately 1 to 1 2 inches ½ inches

Approximately ½ to 1 inch

Heel of 1 hand, other Heel of 1 hand. hand on top.

2 fingers (middle & ring fingertips)

Compression- 30:2 (1 or 2 rescuers) 30:2 (1 or 2 rescuers) 30:2 (1 or 2 rescuers) ventilation ratio

Number of cycles per minute

5 cycles in 2 minutes 5 cycles in 2 minutes

5 cycles in 2 minutes

CRITERIA FOR NOT STARTING CPR -

All patients in cardiac arrest receive resuscitation unless:

1. The pt. has a valid DNR order 2. The pt. has signs of irreversible death: rigor mortis, livor mortis, algor mortis, decapitation 3. No physiological benefit can be expected because the vital functions have deteriorated despite maximal therapy 4. Witholding attempts to resuscitate in the DR is appropriate for newly born infants with: -

Confirmed gestation less than 23 weeks or birthweight less than 400 grams

-

Anencephaly

-PONTENEOUS signs of circulation are restored

-URN OVER to medical services or properly trained authorized personnel - PERATOR is already exhausted and cannot continue CPR - HYSICIAN assumes responsibility (declares death, take-over, etc.)

KINDS OF AIRWAY OBSTRUCTION: 1. Anatomic Airway Obstruction 2. Mechanical Airway Obstruction

TYPES OF AIRWAY OBSTRUCTION 1. Partial Airway Obstruction with Good Air Exchange 2. Partial Airway Obstruction with Poor Air Exchange 3. Complete Airway Obstruction

Clinical Manifestations: UNIVERSAL DISTRESS SIGNAL ( patient may clutch the neck between the thumb and fingers), choking, stridor, apprehensive appearance, restlessness. CYANOSIS and LOSS of CONSCIOUSNESS develop as hypoxia worsens.

For Standing or sitting conscious patient: • Stand behind the patient; wrap your arms around the patient’s waist • Make a FIST, placing thumb side of the fist against the pt’s abdomen, in the midline SLIGHTLY ABOVE the UMBILICUS and WELL BELOW the XIPHOID PROCESS • Make a quick INWARD and UPWARD thrust. Each thrust is separated. For patient lying (unconscious): • position patient at the back (supine); kneel astride the patient’s thigh • Place HEEL of one HAND against the pt’s abdomen, place the second hand directly on the top of the fist. • Make a quick UPWARD thrust

FINGER SWEEP: used only in unconscious adult client •

Make a TONGUE-JAW LIFT. Opening the pt’s mouth by grasping both tongue and lower jaw between the thumb and fingers, and lifting the mandible.

•

Insert index finger of other hand to scrape across the back of the throat

•

Use a hooking action

CHEST THRUST: used only in patients in advanced stages of pregnancy or in markedly obese clients a. Conscious Patient standing or sitting •

Stand behind the client with arms under patient’s axilla to encircle patient’s chest

•

Place thumb side of fist on the MIDDLE of STERNUM, grasp with the other hand and perform BACKWARD thrust until foreign body is expelled.

A. HEAD-TILT-CHIN-LIFT MANEUVER B. JAW-THRUST MANEUVER C. OROPAHRYNGEAL AIRWAY D. ENDOTRACHEAL INTUBATION Indications:  To establish an airway for patients cannot be adequately ventilated with an oropharyngeal airway  To bypass upper airway obstruction  To permit connection to ambubag or mechanical ventilator  To prevent aspiration  To facilitate removal of tracheobronchial secretions

E. CRICOTHYROIDOTOMY • a puncture or incision of the cricothyroid membrane to establish an emergency airway in certain emergency situations where endotracheal intubation or tracheostomy is not possible. • indicated to pts. with trauma to head and neck, and in allergic reaction causing laryngeal edema • use of gauge 11 needle or scalpel blade Nursing Actions: • Extend the neck. Place towel roll beneath the shoulders • Insert the needle at a 10 to 30 degree caudal direction in the midline jest above the upper part of the cricoid cartilage • Listen for air passing back and forth

1. OPEN HEAD INJURY – skull is fractured 2. CLOSED HEAD INJURY – skull is intact 3. CONCUSSION – temporary loss of consciousness that results in transient interruption if the brain’s normal functioning 4. CONTUSSSION – bruising of the brain tissue 5. INTRACRANIAL HEMORRHAGE – significant bleeding into a space or potential space between the skull and the brain a. Epidural hematoma b. Subdural hematoma ALERT: Assume cervical spine fracture for any patient with a c. Subarachnoid hemorrhages significant head injury, until proven otherwise.

PRIMARY ASSESSMENT: Assess for ABC SECONDARY ASSESSMENT:  Change in LOC – most sensitive indicator in the pt’s condition  CUSHING’S TRIAD ( bradypnea, bradycardia, widened pulse pressure) – indicating increased intracranial pressure  unequal or unresponsive pupils; impaired vision  Battle’s sign – bluish discoloration of the mastoid, indicating a possible BASAL SKULL FRACTURE  Rhinorrhea or otorrhea – indicative of CSF leak  Periorbital Ecchymosis – indicates anterior basilar fracture

ALERT: If basilar skull fracture or severe midface fractures are suspected, a nasogastric tube(NGT) is CONTRAINDICATED!

MANAGEMENT:  Open airway by Jaw-Thrust Manuever, suction orally if needed  Administer high flow oxygen: most common death is CEREBRAL ANOXIA  In general, hyperventilate the patient to 20-25 bpm, causing cerebral vasoconstriction and minimizing cerebral edema  Apply a bulky, loose dressing; don’t apply pressure  IV line of PNSS or Plain LR  prepare to manage seizures  maintain normothermia  Medications: a. Diazepam b. Steroids c. Mannitol  Prepare of immediate surgery if pt. shows evidence of neurologic deterioration

• SIMPLE – closed • COMPOUND – open • LINEAR Fx – common hairline break, w/o displacement of structure • COMMINUTED Fx – splinters or crushes the bone in several fragments • DEPRESSED Fx – pushes the bone toward the brain • CRANIAL VAULT Fx – top of the head • BASILAR Fx – base of the skull and frontal sinuses ALERT: • Damage to the brain is the first concern, it is considered a neurosurgical condition • In children, skull’s thinness and elasticity allows a depression w/o a break in the bone

CAUSES: Traumatic blows to the head, VA, severe beatings S/Sx: scalp wounds, agitation and irritability, loss of consciousness, labored breathing, abnormal deep tendon reflexes, altered pupillary and moor response IF CONSCIOUS: complains of persistent localized headache IF JAGGED BONE FRAGMENTS: may cause cerebral bleeding HALO SIGN – blood-tinged spot surrounded by lighter ring IF SPHENOIDAL Fx: damages the optic nerve and may cause BLINDNESS IF TEMPORAL Fx: may cause unilateral deafness or facial PRIORITY NURSING DIAGNOSIS: paralysis  ALTERED CEREBRAL TISSUE PERFUSION r/t increased ICP  INEFFECTIVE BREATHING PATTERN r/t compression of brain stem  ALTERED THOUGHT PROCESSES r/t cerebral anoxia

TREATMENT: For LINEAR FRACTURES:  supporative (mild analgesics)  cleaning and debridement of wounds If conscious: observed for 4 hours; if not, admit for evaluation  if VS stable, may go home with instruction sheet For VAULT and BASILAR FRACTURES:  Craniotomy to remove fragemnts  anti-biotics  Dexamethasone  Osmotic Diuretics (MANNITOL) if increased ICP is present

NURSING CONSIDERATIONS:  maintain patent airway; nasal airway contraindicated to basilar fx  support with O2 administration  suction pt. through mouth not nose if CSF leak is present  RHINORRHEA – wipe it, don’t let him blow it!  OTORRHEA – cover it lightly with sterile gauze, don’t pack it!  Position head on side  Maintain a supine position with bed elevated to 30 degrees  don’t give narcotics or sedative  assist in surgery, maintaining sterile technique

PRIMARY ASSESSMENT: • immediate immobilization of the spine • A B C ( Intercoastal paralysis w/ diapragmatic breathing) SUBSEQUENT ASSESSMENT: • Hypotension, bradycardia, hypothermia - suggests SPINAL SHOCK • Total sensory loss and motor paralysis below the level of injury MANAGEMENT:  Nasotracheal intubation  initaite IV access, monitor blood gas  indwelling urinary catheterization  prepare to manage seizures  Meds: High dose steroids and diazepam

PRIMARY ASSESSMENT: • Immobilization of spine while performing assessment • ABC – (tongue swelling, bleeding, broken or missed teeth) SUBSEQUENT ASSESSMENT: • Paralysis if the upward gaze – indicative of INFERIOR ORBIT FX • Crepitus on nose – indicates nasal fracture • Flattening of the cheek and loss of sensation below the orbit – indicates ZYGOMA (cheekbone) FX •Malocclussion of teeth, trismus – indicative of MAXILLA FX PRIMARY INTERVENTIONS:  Insertion of oral airway or intubation  Nasopharyngeal airway should only be used if no evidence of nasal fracture or rhinorrhea

1. CLOSED WOUND A. CONTUSION – bleeding beneath the skin into the soft tissue B. HEMATOMA – well-defined pocket of blood and fluid beneath the skin 2. OPEN WOUND A. ABRASION – superficial loss of skin from rubbing or scraping B. LACERATION – tear in the skin, can be insicional or jagged C. PUNCTURE – penetration of a pointed object, can be penetrating or perforating D. AVULSION – tearing off or loss of a flap of skin

PRIMARY MANAGEMENT: - IRECT PRESSURE - LEVATION - RESSURE POINTS - OAK, SOAP, SCRUB, SURGERY - NTI-TETANUS, ANTIBIOTICS - RRIGATE - RESS

1. FRACTURE – a break in he continuity of the bone; occurs when stress is placed on a bone is greater than the bone can absorb ALERT: fractured cervical spine, pelvis and femur may produce life threatening injuries; posterior dislocations of the hip are life- and limb-threatening emergencies due to potential blood loss. Clinical Manifestations: • Pain and tenderness over fracture site • Crepitus or grating over fracture site •

swelling and edema

• Deformity, shortening of an extremity or rotation of extremity

MANAGEMENT PROCESS OF FRACTURES -EDUCTION -setting the bone; refers to the restoration of the fracture fragments into anatomic position and alignment -MMOBILIZATION - maintains reduction until bone healing occurs - EHABILITATION - Regaining normal function of the affected part  use of cast and splint to immobilize extremity and maintain reduction  Skin Traction – force applied to the skin using foam rubber, tapes  Skeletal Traction – force applied to the bony skeleton directly, using wires, pins, tongs placed in the bone  ORIF – operative intervention to achieve reduction, alignment and stabilization  Endoprosthetic Replacement – implantation of metal

NURSING CONSIDERATIONS:  Elevate to prevent or limit swelling  Apply ice packs or cold compress; not place directly in skin  Splint and maintain in good alignment, immobilize the joint above and below the fracture  Give pain medications as ordered  Assist in casting; use the palm of your hands in holding a wet cast  Avoid resting cast on hard surfaces or sharp edges  Do neurovascular checks hourly for the first 24 hours  Assess for COMPARTMENT SYNDROME – check for 6 P’s  If Compartment syndrome is suspected, do not elevate limb above the level of the cast  Notify the physician  Bivalve the cast

2. TRAUMATIC JOINT DISLOCATION - occurs when the surfaces of the bones forming the joint no longer in anatomic position ALERT: this is a medical emergency because of associated disruption of surrounding blood and nerve supplies * Subluxation – partial disruption of the articulating surfaces Clinical Manifestations: •

Pain and deformity

•

Loss of normal movement

•

X-ray confirmation of dislocation w/o assoc. fracture

Management: Immobilize part, Secure reduction of dislocations manually (usually preferred under anesthesia) Nursing Considerations:  Assess neurovascular status before and after reduction of dislocation  Administer pain medications (NSAIDs)  Ensure proper use of immobilization device (elastic

3. SPRAIN – an injury to the ligamentous structure surrounding a joint; usually caused by a wrench or twist resulting in a decrease joint stability Clinical Manifestations: • Rapid swelling due to extravasation of blood w/n tissues • Pain on passive movement of joint • discoloration, and limited use or movement 4. STRAIN – a microscopic tearing of the muscle cause by excessive force, stretching, or overuse Clinical Manifestations: • Pain with isometric contractions • Swelling and tenderness • Hemorrhage in muscle

MANAGEMENT OF SPRAINS AND STRAINS

-OMPRESSION (Elastic Bandage) -EST -CE (for the first 24 hrs; 1 hr on, 2 hrs off during waking hours)

-EDICATIONS ( NSAIDs) -LEVATION -UPPORT (Use of crutches, splints) NURSING CONSIDERATIONS:  Apply ice compress for the first 24 hrs to produce vasoconstriction, decrease edema, and reduce discomfort  Apply warm compress after 24 hrs to promote circulation and absorption (20 to 30 minutes at a time)  Educate to rest injured part for a month to allow healing  Educate to resume activities gradually and to warm up

-

Inadequate tissue perfusion, resulting in failure of one or more of the ff:

a. pump failure of the heart

c. arterial resistance levels

b. Blood volume

d. capacity of venous beds

-

Can be classified as:

A. HYPOVOLEMIC - occurs when significant amount of fluid is lost in the intravascular space (Ex. Hemorrhage, burns, fluid shifts) B. CARDIOGENIC – occurs when the heart fails as a pump. Primary causes includes MI, dysrhythmias; Secondary causes includes mechanical restriction of cardiac function or venous obstruction like in Cardiac Tamponade, tension pneumothrorax, VCO

PRIMARY INTERVENTIONS:  Assess for ABC  Resuscitate as necessary  Administer O2 to augment O2-carrying capacity of arterial blood  Start cardiac monitoring  Control hemorrhage SUBSEQUENT ASSESSMENT: o Assess LOC, decreasing LOC indicates progression of shock o Monitor arterial blood pressure (narrowing pulse pressure, fall in systolic pressure) o Assess pulse quality and rate change (tachycardia, weak and thready) o Assess urinary output (25ml/hr may indicate shock) o Assess capillary perfusion o Assess for metabolic acidosis due to anaerobic metabolism of cells

MANAGEMENT:  Administer O2 via ET or nonrebreather face mask (if intubated, may be hyperventilated to control acidosis)  Fluid resuscitation (2 large-bore IV lines, Ringer’s Lactate, BT)  Insertion of an indwelling catheter  Maintain patient in a supine position with legs elevated  Continue to monitor VS, ECG, CVP, ABG, UO, HCT, Hgb,and electrolytes; refer changes on the following  Maintain normothermia (high fever will increase the cellular metabolism effects of shock  Medications: Inotropics, Vasopressor, and Anti-biotics

-It is a useful tool in the diagnosis of those conditions that may cause abberations in the electrical activity WAVE INTERPRETATIONS: P WAVE : Atrial Depolarization; first positive deflection Q WAVE: first negative deflection R WAVE: first positive deflection S WAVE: negative deflection, after R wave QRS COMPLEX: Ventricular Depolarization T WAVE: Ventricular Repolarization

 Check order for ECG, in cases of arrest, prepare the machine at the bedside at ER  Provide Privacy  Instruct patient to lie still and avoid movement  Remove metal objects on the patients (jewelries)  Place Chest leads as labeled: Lead 1: Red, Right Arm Lead 2: Yellow, Left Arm Lead 3: Green, Left Foot Neutralizer: Black, Right foot V1: Red, 4th ICS, Right Sternal Border V2: Yellow, 4th ICS, Left sternal border V3: Green, midway between V2 and V4 V4: Brown, 5th ICS, Left MCL V5: Black, 5th ICS, LAAL V6: Violet, 5th ICS, LMAL

- It is a trauma in the chest without an open wound - usually cause by VA, blast injuries SIGNS/SYMPTOMS: RIB FRACTURES: tenderness, slight edema, pain that worsens with deep breathing and movement, shallow and splinted respirations STERNAL FRACTURES: persistent chest pain MULTIPLE RIB FRACTURES: -FLAIL CHEST (loss of chest wall integrity) - decreased lung inflation, paradoxical chest movements - extreme pain - rapid and shallow respirations - hypotension, cyanosis

COMPLICATIONS: 1. TENSION PNEUMOTHORAX - a condition in which air enters the chest but can’t be ejected during exhalation -There is lung collapse and mediastinal shift S/Sx: tracheal deviation, cyanosis and severe dyspnea, absent breath sound on the affected side, agitation, JVD 2. HEMOTHORAX – collection of blood in the pleural cavity, usually results from ribs, lacerating lung tisssue or an intercoastal artery -It is the most common cause of shock following chest trauma 3. LACERATION or RUPTURE of AORTA – immediately fatal 4. DIAPHRAGMATIC RUPTURE – causes severe respi. Distress; if untreated abdominal viscera may herniate, compromising both circulation and vital capacity of lungs 5. CARDIAC TAMPONADE – rapid unchecked rise in intrapericardia pressure that impairs diastolic filling of the heart

ASSESSMENT AND DIAGNOSIS: • Percussion: - Hemothorax: Dullness - Tension Pnuemothorax: tymphany • Auscultation: - Tension Pnemothorax: PMI is deviated - Cardiac tamponade: muffled heart tones • X-ray • Thoracentesis – yeilds blood and serosanguinous fluid • ECG • Retrograde aortography – reveals aortic laceration • Echocardiography • Computed Tomography

TREATMENT: Simple Rib Fractures  mild analgesics, bed rest, apply heat  incentive spirometry  deep breathing, coughing and splinting Severe Rib Fractures  intercoastal nerve blocks  position for semi-fowlers, administer O2 Hemothorax  Chest tube insertion at 5th -6th ICS anterior to MAL  administer IV fuids, O2, Blood Transfusion  Thoracotomy  Thoracentesis

TREATMENT: Tension Pneumothorax  insertion of spinal, 14G or 16G needle into the 2nd ICS at MCL to release pressure  Chest Tubes  Surgical Repair Aortic Rupture/Laceration  immediate surgery - synthetic grafts - aortic anastomosis  O2, BT, IV

NURSING CONSIDEARTIONS:  monitor VS, (q 15, first hour post thoracentesis and post CTT)  After CTT insertion, encourage cough and breathing exersises  Chest tubes should have continuous FLUCTUATIONS  if BUBBLING, air leak is suspected  if FLUCTUATION STOPS, mechanical blockage or lung has already expanded  have an extra bottle with PNSS, clamps and sterile gauze at bedside  in case of dislodgment, cover the opening with sterile/petroleum gauze to prevent rapid lung collapse  Assist with proper positioning  Bed Rest

1. PENETRATING ABDOMINAL INJURY – usually the result of gunshot wound or stab wounds; may cross the diaphragm and enters the chest 2. BLUNT ABDOMINAL INJURY – caused by vehicular accidents or falls PRIMARY ASSESSMENT AND INTERVENTIONS: • ASSESS ABC • INITITATE RESUSCITATION AS NEEDED • CONTROL BLEEDING AND PREPARE TO TREAT SHOCK • IF THERE IS AN IMPALED OBJECT IN THE ABDOMEN, LEAVE IT THERE AND STABILIZE THE OBJECT WITH BULKY DRESSINGS

SUBSEQUENT ASSESSMENT: • Obtain hx of the mechanism of the injury • Evaluate signs and symptoms of hemorrhage • Note tenderness, rebound tenderness, guarding, rigidity and spasm • KEHR’S SIGN – pain radiating to the left shoulder; a sign of blood beneath the diaphragm. Pain in right shoulder can result from liver laceration • CULLEN’S SIGN – slight bluish discoloration around the navel; a sign of hemoperitonium • Rebound tenderness and boardlike rigidity are indicative of a significant intra-abdominal injury • Loss of dullness over solid organs; Dullness over regions containing gas may indicate presence of blood • Look for increasing abdominal distention, measure abdominal girth the umbilical level • Rectal and pelvic examination

GENERAL INTERVENTIONS:  Keep pt. quiet in the stretcher, any movement may dislodge a

clot  Cut the clothing, count the number of wounds, look for entrance and exit wounds  Apply compression to external bleeding wounds  double IV line and infuse Ringer’s Lactate  Insert NGT to decompress the abdomen  Cover protruding abdominal viscera w/ sterile saline dressings; don’t attempt to place back the protruding organs  Cover open wounds with dry dressings  Insert indwelling catheter; if pelvic fracture is suspected, catheter should not be placed until integrity of urethra is ensured.  Meds: Tetanus Prophylaxis, Antibiotics  Assist in peritoneal lavage  Prepare pt. for surgery if the condition persists. (Exploratory

It is the inadequacy or the collapse of peripheral circulation due to volume and electrolyte depletion ASSESSMENT: temperature may be normal or slightly elevated, hypotension, tachycardia, tachypnea, pale and moist skin, fatigue, headache, dizziness, syncope DIAGNOSTICS: hemoconcentration, hyponatremia or hypernatremia, ECG may show dysrhythmias MANAGEMENT:  

Move patient to a cool environment, remove all clothing Position the patient supine with the feet slightly elevated

 Monitor VS every 15 mins and cardiac rhythm  Educate to avoid immediate reexposure to high

- It is a combination of hyperpyrexia and neurologic symptoms. It caused by a shutdown or failure of the heatregulating mechanisms of the body CLINICAL MANIFESTATIONS: • bizarre behavior or irritability, progressing to confusion, delirium and coma • 40.6 degrees Celcius, hypotension, tachycardia, tachypnea • skin may appear flushed and hot; at start it maybe moist progressing to dryness (Anhidrosis) NURSING ALERT: • Elderly clients are high-risk to develop heat-stroke • Once diagnosis is confirmed, it is imperative to reduce patient’s temperature

MANAGEMENT:  EVAPORATIVE COOLING, most effective, by spraying tepid water on skin while fans are used to blow  Apply ice packs to necks, groin, axillae, and scalp  Soak sheets/towels in ice water and place on patient  If temp. fails to decrease, initiate core cooling: iced saline lavage, cool fluid peritoneal dialysis, cool fluid bladder irrigation  Discontinue active cooling when the temp. reaches 39 degrees Celcius  Oxygenate the pt. via ET or nonrebreather mask  Monitor VS, ECG, and neurologic status  Start IV infusion using Ringer’s Lactate  Anti-pyretics are not useful  Indwelling catheterization  WOF hypokalemia, metabolic acidosis, seizures

-It is a condition where the core temp. is less than 35 degrees Celcius as a result in the exposure to cold. - 3 compensatory mechanisms: a. shivering – produces heat thru muscular activity b. peripheral vasoconstriction – to decrease heat loss c. raising basal metabolic rate NURSING ALERT: • Elderly are greater risk for hypothermia due to altered compensatory mechanisms • Extreme caution should be used in moving or transporting hypothermic pts., because the heart is near fibrillation threshold

CLINICAL MANIFESTIONS: • slow, spontaneous respirations • heart sounds may not be audible even if its beating • BP is extremely difficult to hear • fixed dilated pupils, no pulse, no BP; initiate CPR • drowsiness progressing to coma • shivering is suppressed on temp. below 32.3 degrees • ataxia • cold diuresis • fruity or acetone odor of breath GOAL of MANAGEMENT: Rewarm without precipitating cardiac dysrhythmias.

MANAGEMENT:  Passive External Rewarming (temp above 28 degrees) -Remove all wet clothing, and replace with warm clothing - Provide insulation by wrapping the patient in several blankets - Provide warm fluids Disadvantage: slow process  Active External Rewarming (temp above 28 degrees) -Provide external heat for patient- warm hot water bottles to the armpits, neck, or groin - Warm water immersion -Disadvantages: 1. causes peripheral vasodilation, returning cool blood to the core, causing an initial lowering of the core temp. 2. Acidosis due to “washing out” of lactic acid from the peripheral tissue

3. An increased in metabolic demands before the heart is warmed to meet these needs.  Active Core Rewarming (temp below 28 degrees) -Inhalation of warm, humidified O2 by mask or ventilator - warmed IV fluids - Warm gastric lavage -Peritoneal dialysis with warmed standard dialysis solution - Cardiopulmonary bypass Disadvantage: invasiveness of the procedure

-It is a survival for atleast 24 hours after submersion, with most common consequence of hypoxemia. -Hypoxia and acidosis are common problems of the victim. -Resultant pathophysiologic changes and pulmonary injury depend on type of fluid and the volume aspirated. a. Fresh water aspiration- results in loss of surfactant, hence an inability to expand lungs b. Saltwater aspiration- leads to pulmonary edema from the osmotic effect of salt within the lungs. Clinical Manifestations: -difficulty of breathing -cyanosis -chills

-hypothermia

MANAGEMENT:  Immediate CPR  Endotracheal intubation with PEEP  VS, check degree of hypothermia  Rewarming procedures  Intravascular volume expansion and inotropic agents  ECG  Indwelling catheterization  NGT insertion

ASSESSMENT: • ABC • Identify the poison •Obtain blood and urine tests; gastric contents may be sent to laboratory • Monitor neurologic status • Monitor fluid and electrolytes GENERAL INTERVENTIONS: • Initiate large-bore IV access, monitor shock • Prevent aspiration of gastric contents by positioning head on side • Maintain seizures precaution

MINIMIZING ABSORPTION 

Administration of activated charcoal with a cathartic to hasten secretion.



Induction of emesis with syrup of ipecac; done only in patients with good gag reflex and is conscious.



Adult dose is 30 ml by mouth followed by 2 glasses of water; Pedia dose is15 ml followed by 8 – 16 oz. of water.

NURSING ALERT: Do not induce emesis after ingestion of caustic substances, hydrocarbons, iodides, silver nitrates, petroleum distillates; to a patient having seizure or to pregnant patient. 

Gastric lavage for the obtunded patient. Save gastric aspirate for toxicology screen.



Procedure to enhance the removal of ingested substance if the patient is deteriorating.

1. Forced diuresis with urine pH alteration – to enhance renal clearance.

2. Hemoperfusion (process of passing blood through an extracorporeal circuit and a cartridge containing an adsorbent, such as charcoal, after which the detoxified blood is returned to the patient) 3. Hemodialysis – to purify and accelerate the elimination of circulating toxins. 4. Repeated dose of charcoal. 5. Providing an antidote – antidote is a chemical or physiologic antagonist that will neutralize the poison. 

PURPOSES: 1. To remove unabsorbed poison after ingestion. 2. To diagnose and treat gastric hemorrhage and for the arrest of hemorrhage. 3. To cleanse stomach before endoscopic procedures. 4. To remove liquid or small particles of material from the stomach. NURSING CONSIDERATIONS    

Insertion of NGT or OGT. Place patient on left lateral position with head lower 15 degrees downward. Elevate funnel and pour approx. 150 – 200 ml. Lavage fluid is left in place for about one minute before allowed to drain

  

Save samples of first two washings. Repeat lavage procedure until the returns are relatively clear and no particular matter is seen. At the completion of the lavage:

1. Stomach may be left empty. 2. An Adsorbent may be instilled in the tube and allowed to remain in the stomach. 3. A saline cathartic may be instilled in the tube. 

Pinch off the tube during removal or maintain suction while tubing is being withdrawn.



Give the patient a cathartic if prescribed.



Warn patient that stool will turn black from the charcoal.

-It is an example of inhaled poison and results in the incomplete hydrocarbon combustion - Carbon monoxide exerts its toxic effects by binding to circulating hemoglobin to reduce the oxygen carrying capacity of the blood. - Carbon monoxide and hemoglobin is 200 – 300 times affinity compared to oxygen and hemoglobin. - Creation of carboxyhemoglobin resulting to tissue anoxia. CLINICAL MANIFESTATIONS - Respiratory depression, stridor. - Confusion progressing to coma. - Headache, muscular weakness, palpitation, and dizziness. - Skin is pink in color, cherry red, or cyanotic. - ABG: carboxyhemoglobin level is 12% (Normal), 30 – 40% severe carbon monoxide poisoning.

MANAGEMENT:  Provide 100% oxygen by tight-fitting mask (the elimination half life of carboxyhemoglobin, in serum, for a person breathing room air is 5 hours and 20 minutes. If patient breaths 100% oxygen the half life is reduced to 80 minutes  100% oxygen in hyperbaric chamber reduces halflife to 20 minutes.  Intubate if necessary to protect airway.  Continuous ECG monitoring, treat dysrhythmias.  Correct acid-base and electrolyte imbalances.  Continuous observation of psychoses, spastic paralysis, visual disturbances, and deterioration of personality may persist after resuscitation and may be symptoms of permanent CNS damage.

-These are injected poisons that can produce either local or systemic reactions. - Local reactions are characterized by pain, erythema and edema at the site of injury. - Systemic reactions usually begin within minutes. (Unconsciousness, laryngeal edema, bronchospasm, and cardiovascular collapse. MANAGEMENT:  ABC  Epinephrine is the drug of choice give SQ.  Administer bronchodilator.  Initiate IV with Ringers Lactate.  Prepare for CPR.

NURSING CONSIDERATIONS:  Apply ice packs to site to relieve pain.  Elevate extremities with large edematous local reaction.  Administer anti histamine for local reaction.  Clean wounds thoroughly with soap and water or antiseptic solution.  Educate patient. - Have epinephrine on hand - Wear emergency medical bracelet indicating hypersensitivity. - If sting occurs, remove stinger with one quick scrape of fingernail. - Do not squeeze venom sack, because this may cause additional venom to be injected. - Avoid insect feeding areas.

CLINICAL MANIFESTATIONS: -Burning pain, swelling, and numbness of the site. - Hemorrhagic blisters may occur after few hours of bite and entire extremity may become edematous. - WOF signs of systemic reactions (nausea, sweating, weakness, lightheadedness, initial euphoria followed by drowsiness, dysphagia, paralysis of various muscle groups, shock, seizures, and coma). MANAGEMENT:  Wash the site of bite, keep the patient calm and immobilize extremity.  Administer O2 and start IV line.  Administer anti-venin and be alert to allergic reaction.  Administer vasopressors in the treatment of shock.

- a.k.a Delirium Tremens or Alcoholic Hallucinosis -An acute toxic state that follows a prolonged bout of steady drinking or sudden withdrawal from prolonged intake of alcohol. - Symptoms begins as early as 4 hours after reduction of alcohol intake and peaks at 24 - 48 hours but may last up to 2 weeks. CLINICAL MANIFESTATIONS:  Shakes, seizures, and hallucinations.  History of drinking episodes.  N/V, malaise, weakness, anxiety.  Autonomic hyperreactivity (tachycardia, diaphoresis, increase temperature, dilated but reactive pupils).

ALCOHOLISM – a chronic disease or disorder characterized by excessive alcohol intake and interference in the individuals health, interpersonal realtionship and economic functioning -Considered to be present when there is .1% or 10 ml for every 1000 ml of blood - At .1 - .2%, there is low coordination - At .2 - .3%, there is ataxia, tremors, irritability, and stupor - At .3 and above, there is unconsciousness COMMON BEHAVIORAL PROBLEMS: 5 D’s D-enial D-ependency D-emanding D-estructive D-omineering

COMMON WITHDRAWAL SIGNS AND SYMPTOMS:

-ALLUCINATIONS (VISUAL AND TACTILE) -NCREASED VITAL SUGNS -REMORS -WEATING AND SIEZURE

COMMON DEFENSE MECHANISMS: -ENIAL -ATIONALIZATION -SOLATION -ROJECTION

PRIORITY NURSING DIAGNOSIS: - INEFFECTIVE INDIVIDUAL COPING DRUG OF CHOICE for aversion therapy of an alcoholic: - DISULFIRAM (antabuse) Instruct patient to avoid, when taking Disulfiram: -OUTH WASH -VER THE COUNTER COLD REMIDIES -OOD SAUCES MADE UP OF WINE -RUIT FLAVORED EXTRACTS -FTERSHAVE LOTIONS -INEGAR -KIN PRODUCTS

MANAGEMENT:  Protect patient from injury, diazepam or phenytoin for seizure control as prescribed.  Monitor VS every 30 minutes.  Use a non-alcohol skin preparation, draw blood for measurement of ethanol concentration, toxicologic screen for other drug abuse.  Maintain electrolyte balance and hydration.  Observe for hypoglycemia.  Administer thiamine followed by parenteral dextrose if liver glycogen is depleted.  Give orange juice, gatorade, or other carbohydrates to stabilize blood sugar.  Place patient in a private room with close observation.

-It is an urgent, serious disturbances of behavior, affect, or thought that makes the patient unable to cope with his life situation and interpersonal relationship

-Is usually episodic and is a means of expressing feelings of anger, fear and hopelessness about a situation. - Manage through: a. Establish control, keeping the door open, and be in clear veiw of staff b. Ask if he has a weapon, avoid touching an agitated pt. c. Adopt a calm, nonconfrontational approach d. Provide emotional support; CRISIS INTERVENTION

-Ultimate form of self-destruction; “cry for help” -Major Interventions: PREVENTION and LISTEN - RISK FACTORS -EX (female attempts, male commits suicide) -NSUCCESSFUL PREVIOUS ATTEMPT -DENTIFICATION

with family member committed

suicide

-HRONIC -LLNESS -EPRESSION/DEPENDENT PRERSONALITY -GE (18-25 AND ABOVE 40)/ALCOHOLISM -ETHALITY OF PREVIOUS ATTEMPTS

PRIORITY NURSING DIAGNOSIS: Risk for Injury, Self-directed NURSING INTERVENTIONS:  Provide one-on-one monitoring  Have frequent unscheduled rounds  Avoid use of metals and glass utensils  Remove shampoos, perfumes, medicines at the bedside  Monitor for signs of impending suicide (giving away of valued possession)

• According to RA 8353, RAPE refers to the insertion of penis into the mouth, vagina, anus of a victim • Insertion of any object into the mouth or anus • It is generally considered as an act of hostility, anger, or violence ELEMENTS OF RAPE: • Use of threat/force • lack of consent of the victim • Actual penetration of the penis into the vagina Different Kinds of Rape: • POWER – done to prove one’s masculinity • ANGER – done as a means of retaliation • SADISTIC – done to express erotic feelings

RAPE TRAUMA SYNDROME -

It refers to a group of signs and symptoms experienced by a victim in reaction to rape 4 Phases

1. ACUTE PHASE – characterized by shock, numbness and disbelief 2. DENIAL – characterized by victim’s refusal to talk about the event 3. HEIGHTENED ANXIETY – characterized by fear, tension, and nightmares 4. REORGANIZATION – victim’s life normalizes PRIORITY NURSING CARE: Preservation of evidences TREATMENT: Crisis Intervention