About Emergency Nursing Notes
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EMERGENCY NURSING •
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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)
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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 initial goal for the patient and family 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. •
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 and prioritization 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 •
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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 emergenc emergency y nurse nurse must must expan expand d his or her knowledge base to encompass recognizing & treating patients exposed to biologic and other terror weapons The emergenc emergency y nurse nurse must must antic anticipate ipate nursing care in the event of a mass •
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casualty incident. Documentation of Consent Consent to examine and treat the patient is part of the ER record. The patient patient must must consent consent to invasi invasive ve 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. •
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Exposure to Health Risks All emergency health care providers should adhere strictly to standard precautions for minimizing exposure. •
Compiled Notes of Bernie C. Butac
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Nursing Diagnoses Possible nursing diagnoses include: Anxiety •
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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 caring for for the patient patient should should act 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 unconsci unconscious ous pat patient ient should should be 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. •
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Family-Focused Interventions The family family is kept informed informed about where 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. Additional interventions are based on the assessment of the stage of crisis that the family is experiencing. •
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Helping Them Cope With Sudden Death Take the the family family to a private private place. place. Talk to the the family family together, together, so 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 •
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Encourage family members support each other & to express emotionsto 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.
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Triage: comes from the French word trier , which
The gen general eral placemen placement t location location should should be 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.
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Principles of Emergency Room Care
Triage Tags Tags should should b be e used on all calls calls involving 3 or more patients.
“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 & •
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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 needed 5. Black – Patient is dead or progressing rapidly towards death
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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 back of the the cart usually usually houses houses the cardiac cardiac board.
Assessment and Intervention in the ER The Primary Survey: Focuses on stabilizing stabilizing lifethreatening conditions; employs the ABCD Method The ABCD Method •
means "to sort;” A method to quickly evaluate and categorize the patients requiring the most emergent medical attention. ER Triage Emergent (imme • (immediate): diate): 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 Compiled Notes of Bernie C. Butac
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A irway - Establish airway ventilation Breathing - Providethe adequate Circulation - Evaluate & restore cardiac output by controlling hemorrhage, preventing & treating shock, and maintaining or restoring effective circulation Disability - Determine neurologic disability by assessing neuro function using the Glasgow Coma Scale
Eye opening opening Spontaneous response response T To o voice voice T To o pain None None
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Verbal Verbal response response
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Oriented Confused Inappropriate words Incomprehensible sounds None None
Motor Motor response response
Obeys command Localizes pain Withdraws Flexion Extension None None
1. Place Place the the patien patientt on a firm, firm, flat surface surface.. 2. Open Open the airway airway by by placin placing g one hand hand on the victim’s forehead, and apply firm backward pressure with the palm to tilt the head back. 3. Place Place the fin fingers gers of the the other other hand hand under 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.
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Assess and Intervene: The Secondary Survey includes: A complete health history & head-to-toe assessment Diagnostic & laboratory testing Application of monitoring devices •
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Splinting of suspected fractures Cleaning & dressing of wounds Performance of other necessary interventions based on the patient’s condition. Airway Obstruction
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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 Manifestations 1. Choking 2. Appre Apprehe hens nsiv ive e appea appearan rance ce 3. Insp Inspirat iratory ory & expi expirato ratory ry stridor stridor 4. La Labo bore red d bre breat athi hing ng 5. Fl Flar arin ing g of no nost stri rils ls 6. Use of ac acces cessory sory mus muscle cles s (supras (suprastern ternal al & intercostal retractions) 7. ñ anxiety, restlessness, confusion 8. Cyan Cyanosi osis s & loss of consci conscious ousnes ness s develop develops s 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.
Jaw-Thrust Maneuver Jaw-Thrust Maneuver 1. Place Place the the patien patientt on a firm, firm, flat surface 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 Insertion A 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: Indications 1. To estab establis lish h an airwa airway y for for patient patients s who who cannot be adequately intubated with an oropharyngeal airway. 2. To bypas bypass s an uppe upperr airway airway obstruc obstructio tion n 3. To preve prevent nt aspi aspirat ratio ion n 4. To permit permit connect connection ion of of the patient patient to to a resuscitation bag or mech. ventilator 5. To facilitate facilitate removal removal of tracheobronch tracheobronchial ial secretions
Cricothyroidotomy Used in the following emergencies in w/c ET intubation is contraindicated: 1. Extens Extensive ive maxill maxillofac ofacial ial trauma trauma 2. Cervi Cervical cal spine spine in injur jurie ies s 3. La Lary ryng ngos osp pas asm m 4. La Lary ryng ngea eall ed edem ema a 5. Hemo Hemorrh rrhag age e into into neck neck tiss tissue ue •
6. Laryn Larynge geal al obstru obstruct ctio ion n
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Nursing Diagnoses For Airway Obstruction 1. Ineffe Ineffective ctive airway clearance clearance due to obstruct obstruction ion of the tongue, object, or fluids (blood, saliva) 2. Ineffe Ineffecti ctive ve breat breathin hing g pattern pattern due to to obstruction or injury
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Hemorrhage •
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Bleeding that may be external, internal or both External: Laceration, avulsion, GSW, stab wound Internal: Bleeding in body cavities and internal organs
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Head-Tilt-Chin-Lift Maneuver Compiled Notes of Bernie C. Butac
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Assessment Results in reduction of circulating blood vol., w/c is the principal cause of shock Signs and symptoms of shock: 1. Cool Cool,, mois moistt skin skin •
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Hy Hypo pote tens nsio ion n Ta Tac chycardi rdia De Delay layed ed ca capi pilla llary ry rref efil illl Oliguria
Management Fluid Replacement Two large-bore large-bore intravenou intravenous s cannulae 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. •
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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 proximal to 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.
Nursing Diagnoses for Hypovolemic Shock 1. Altered Altered tiss tissue ue pe perfus rfusion ion relate related d to failing failing circulation 2. Impaire Impaired d gas exchan exchange ge relat related ed to to a V-P V-P imbalance 3. Decreased cardiac output related to decreased circulating blood volume Clinical Manifestations 1. Weaknes Weakness, s, lighthe lightheade adedne dness, ss, and and confusio confusion n 2. Ta Tac chycardi rdia 3. Tachypnea 4. Decre Decreas ase e in puls pulse e press pressure ure 5. Cool Cool cl clam ammy my sk skin in 6. Delay Delayed ed cap capill illary ary ref refil illl Hypovolemic Shock: Management 1. Rapid Rapid blood blood and fluid fluid replace replacemen ment; t; blood blood component therapy optimizes cardiac preload, correct hypotension, & maintain tissue perfusion 2. LargeLarge-bore bore intrav intraveno enous us needle needles s or catheters catheters are inserted into peripheral vv. 3. A central central veno venous us pressu pressure re cat cathet heter er may also also be inserted in or near the RA. 4. LRS approximates plasma electrolyte composition and osmolarity 5. A Foley Foley cathet catheter er is insert inserted ed to recor record d urinary urinary output every hour; urine volume indicates adequacy of kidney perfusion 6. Ongoin Ongoing g nursing nursing surve surveill illanc ance e of the total 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 •
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Control of Internal Bleeding •
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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 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 •
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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 •
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. Mas e extern ex al lar, or or interna int bl bleedi eeding ng 2. Massiv Traumati Trausive matic, c, ternal vascu vascular, GI GIernal and andl pre pregna gnancy ncy related 3. Burns
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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 surface area, wounds are deep and can cause great internal damage.
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Gunshot Wound (GSW) Caused by firing bullets or any other small arms. Have a clean entry site but a large and ragged exit site. •
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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 time Patterned Wound: Wound representing the outline of the object (e.g. steering wheel) causing the wound •
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The unintent unintentional ional or or intentional intentional wound 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. Desc Descrip ripti tion ons s of all all woun wounds ds 2. Mech Mechan anis ism m of inj injur ury y 3. Ti Time me of even events ts 4. Colle Collect ctio ion n of of e evi vide denc nce e 5. Stateme Statements nts made by the patient 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.
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Management: Wound Cleansing 1. Hair around around wound wound may may be be shave shaved. d. 2. NSS is used used to irrig irrigate ate the wou wound. nd. 3. Bet Betadin adine e & hydroge hydrogen n peroxid peroxide e are on only ly used used for initial cleaning & aren’t allowed to get deep into the wound without thorough rinsing. 4. Use lloca ocall or region regional al bl block ock a anes nesthe thetic tics s if indicated. Wound Management 1. Use of an antibi tibioti otics cs depen depends ds on how how the inju injury ry occurred, the age of the wound, & the risk for contamination 2. Site is immob immobili ilized zed & elevate elevated d to limit limit accumulation of fluid 3. Tetanus prophylaxis prophylaxis is administere administered d based on the condition of the wound and the immunization status Wound Healing: By First Intention Occurs when tissue is cleanly incised and reapproximated and healing occurs without complications. The incision incisional al defect defect re-epitheli re-epithelizes zes rapi rapidly dly and and matrix deposition seals the defect. •
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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 •
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for a few days and then closed as if primarily. Such wounds are left open initially because of gross contamination.
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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, extremity Incidence of delayed & trauma-related complications is higher Leads to massive blood loss into the peritoneal cavity Trauma: Assessment 1. Inspection of abdomen for signs of injury (bruises, abrasions) 2. Auscultation of bowel sounds 3. Watch out for signs of peritoneal irritation like distention, involuntary guarding, tenderness, pain, muscular rigidity, or rebound tenderness together with absent BS. Trauma: Diagnostic Findings 1. 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
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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 decompress the bladder bladder & monitor monitor urine urine output, a Foley catheter is inserted AFTER DRE. A high-riding prostate gland indicates a potential urethral injury. •
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Trauma: Management of Intra-abdominal Injuries
1. A p paten atentt airway airway is mai maintai ntained ned.. 2. Ble Bleedi eding ng is contr controll olled ed by apply applying ing d direc irectt pressure to any external bleeding wounds & by occlusion of any chest wounds. 3. Circ Circula ulatin ting g blood blood vol. is maint maintain ained ed wit with h intravenous fluid replacement including blood component therapy. 4. In blunt blunt trauma, cervical cervical spine spine immobi immobilizati lization on is maintained until cervical x-rays have been obtained & injury is ruled out. 5. All wounds wounds are are locat located, ed, counted counted & documented. 6. If abd abdomi ominal nal visc viscera era p protru rotrude, de, the the area area is covered with sterile, moist saline dressing to prevent drying. 7. Oral fl fluids uids are are withhe withheld ld and stomac stomach h content contents s are aspirated with an NGT in anticipation of surgery. Tetanus and broad-spe broad-spectrum ctrum antibiotics antibiotics are given as prescribed. 8. If still still with with evidenc evidence e 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, •
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erythema blistering of skin, damaged part appearing & swollen, tense & hard. Renal dysfunction is secondary to prolonged hypotension.
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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. •
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Multiple Injuries: Nursing Responsibilities 1. Assess Assessing ing & monit monitorin oring g the the patien patientt 2. En Ensu surin ring gv ven enou ous s acc acces ess s 3. Admini Administe sterin ring g prescrib prescribed ed meds 4. Collec Collectin ting g llabor aboratory atory specim specimens ens 5. Documenting activities and the patient’s response 6. Gross Gross eviden evidence ce may may be sligh slightt or absent; absent; the 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. Establ Establish ish airway airway & vent ventilat ilation ion.. 9. Cont Contro roll hemor hemorrh rhag age. e. 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. fractures. 14. Carry out a more thorough and ongoing
examination & assessment. FRACTURES •
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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
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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.
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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 •
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Observe lacerations, swelling & deformities includingfor 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 •
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Procedure: 1. One hand hand is is placed placed distal distal to th the e fracture fracture & some traction is applied while the other hand is placed beneath the fracture for support. 2. The spli splint nt should should exten extend d beyond beyond the the join joints ts adjacent to the fracture. 3. Upper Upper extre extremit mities ies m must ust be be splint splinted ed in a functional position. 4. If a fracture is open, moist, sterile dressing is applied. 5. Check Check th the e vascul vascular ar status status by by assess assessing ing color, temperature, pulse, and blanching of the nail bed. 6. If there there is neurov neurovasc ascula ularr com comprom promise ise,, 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 •
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tachycardia. Management The primary primary goal is to reduce reduce the 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 applied to neck, neck, groin, groin, ches chest, t, & axillae while spraying with tepid water; cooling blankets 3. Iced sali saline ne lavage lavage of stoma stomach ch or colon if temperature does not decrease 4. Immers Immersio ion n in col cold d water water bath bath •
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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 •
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Pathophysiology Hyperthermia results because of inadequate heat loss, which can also cause death. Most heat-related deaths occur in the elderly, •
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because their circulatory systems are unable to compensate for the stress imposed by heat
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Nurse Teachings Advise client to avoid immediate exposure to high temperature (10am-2pm). •
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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 from exposure exposure to freezing 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 (fulldepth tissue destruction) •
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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 •
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Management The goal is to restore restore normal normal body 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. •
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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 victims are at risk resultin resulting g from treatment with cold fluids, unwarmed oxygen, and exposure during examination. Hypothermia takes precedence in treatment over frostbite. •
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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. •
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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. •
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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
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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. •
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Management: Passive External Rewarming Includes the use of warm blankets or over-thebed heaters Increases blood flow to the acidotic, anaerobic extremities Cold blood returning to the core can cause cardiac dysrhythmias & electrolyte imbalances •
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Supportive Care External cardiac compression •
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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 •
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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. •
Risk Factors 1. Al Alco coho holl inge ingest stio ion n 2. In Inab abil ilit ity y to to swi swim m 3. Di Divi ving ng in inju juri ries es 4. Hy Hypo poth ther ermi mia a 5. Exha Exhaus usti tion on 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. •
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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 Treatme nt Goals Maintaining cerebral perfusion and adequate oxygenation to prevent further damage to vital organs •
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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 O 2, 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 •
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hypothermic; use a rectal probe such to assess Prescribed warming procedures as corporeal rewarming, warmed PD, inhalation of warmed aerosolized O2, and torso warming
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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. Joi Joint nt/e /ext xtrem remit ity y pa pain in 2. nu numb mbne ness ss,, hype hypest sthe hesi sia a 3. loss of of RO ROM 4. ne neuro uro Sx mi mimi mick ckin ing g CVA CVA 5. CP arre arrest st in sev severe ere cases cases Management A patient airway and adequate ventilation are established & 100% O2 is given throughout treatment & transport
A CXR1is to identify aspiration, least IVobtained line is started with LRS or NSS.and at If a head injury is suspected, the head of the bed is lowered. Wet clothing is removed and the patient is kept warm. Transferr to the closest Transfe closest hyperbaric hyperbaric chamber 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 1. Respi Respirat rator ory y Sig Signs ns: : Symptoms 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. Cardi Cardiov ovasc ascul ular: ar: Tachyca Tachycardia rdia or bradycard bradycardia ia 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 an occurs, a crico-thyroidotomy is used to provide 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 Compiled Notes of Bernie C. Butac
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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 agents, askearlier caregiver whether agentantigenic was received at an 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, amount, time time since since ingestion 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 following procedures procedures may be done: 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 center should should be called 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 Guidelines 1. Remove Remove dent denture ures s and inspect inspect for for loose loose teeth. 2. Measur Measure e the dista distance nce between between the bridg bridge e of the nose and the xiphoid process and mark tube with indelible pencil or tape. 3. Lubrica Lubricate te tube tube with KY-J KY-Jell elly. y. 4. If comato comatose, se, patient patient is in intub tubate ated d with with cuffed nasotracheal or endotracheal tube before placement of NGT. 5. Place Place patien patientt in a left left lateral lateral positio position n with with head lowered 15°. 6. Pass Pass the tube tube orally orally wh while ile keep keeping ing the the head head in neutral position. position. Pass tube to marking (50 cm). 7. Aspirat Aspirate e gastric gastric cont content ents s with tthe he sy syring ringe e attached to the tube before instilling water/antidote & save specimen.
8. Remove Remove syrin syringe ge and and attach attach funn funnel el to the the end of the tube or use a 50mL syringe to instill solution into tube. 9. Elevate Elevate funnel funnel above above patie patient’s nt’s hea head d and 150-200mL of solution into it. 10. Lower funnel funnel and siphon the gastric gastric contents, or connect to suction. 11. Save the samples samples of the first two washings. 12. Repeat the the lavage until the returns returns are clear and no particulate matter is seen. 13. The stomach may may be left empty, and an absorbent or saline cathartic is instilled and allowed to remain inside. 14. Pinch out the tube tube during removal removal or suction while withdrawing and keep head lower than the body. 15. Warn patient patient that stools will turn black from the charcoal. Management The specific specific chemical chemical is given as early as possible to reverse effects. Procedures include administration of charcoal, diuresis, dialysis, and hemoperfusion.
If poisoningevaluation is due to ais suicide attempt, psychiatric 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 oxygencarrying 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, rapidly leadsdizziness, to coma.and confusion, which Skin color ranges from cherry-red to pale and is not a reliable sign.
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Pulse oximetry will record false (+)’s.
CO Poisoning Management Goal: to reverse cerebral and myocardial hypoxia and hasten elimination of CO by: 1. Carrying Carrying the patient patient to fresh fresh air immediately and opening doors and windows 2. Looseni Loosening ng all tight tight clothi clothing ng 3. Initiate CPR if required; give O2. 4. Prevent Prevent chillin chilling; g; wrap wrap in blank blankets ets.. 5. Keep Keep patie patient nt as quiet quiet as possib possible. le. 6. Do NOT NOT give give al alcoh cohol ol in any any form. form. 7. Upon arrival at the ER, analyze carboxyhemoglobin levels and give 100% O2 until level is <5%. 8. Watch Watch out for for psychos psychoses, es, spast spastic ic paralys paralysis, is, 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 Transmi tted through through ingestion ingestion of contamin contaminated ated food, water, or unpasteurized milk, or through contact with infected infants, pets or wild animals. Salmonella Transmitted Transmi tted by by drinking drinking unpasteu unpasteurized rized 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 Transmi tted through through feces. It causes 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)
Assessment 1. How soon after after eating eating did tthe he symp symptom toms s occur? 2. What was eaten eaten in the the previou previous s mea meal? l? Did Did the food have an unusual odor or taste? 3. Did anyo anyone ne else else becom become e ill from from e eatin ating g the same food? 4. Did vomitin vomiting g occur? occur? What What was was tthe he appearance of the vomit? 5. Di Did d diar diarrh rhea ea oc occu cur? r? 6. Any other other n neuro eurologi logic c sympto symptoms? ms? 7. Does Does tthe he patient patient have a fever? fever? 8. What is the the client’ client’s s ap appea pearanc rance? e? 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 much exposure exposure to to sun and and UV Direct contact with heat and burning object Hot water and liquids Compiled Notes of Bernie C. Butac
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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
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, mushrooms, shellfish, shellfish, inc includin luding g the puffer fish
Chemicals
Lund & for Browder Method: Assigns percentage of BSA 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 epidermal layer is is damaged 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 injured skin skin is red red or mottled, mottled, possibl possibly y weepy with vesicles or blisters and considerable swelling. When healing is complete, the skin is usually somewhat discolored Tightening Tighte ning and and contracture contracture may develop. 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 surface is is dry and edema is present. 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 Management Maintenance of Airway Patency A. As Asse sess ss the air airway way.. B. Aus Auscul cultate tate the trach trachea, ea, and and mon monito itorr for adventitious breath sounds or decreased breath sounds. C. If client client is is dyspne dyspneic ic or if if there there is c carbo arbon n monoxide poisoning, a high liter flow of 8 to 10 liters of oxygen is recommended. D. If com compromis promise e is is sus suspected pected,, the victim may be intubated and ventilated. Indications for intubation are airway obstruction and a PaO2 of less than 60 mm Hg. The continuou continuous s monitoring monitoring by means of a pulse oximeter assists in assuring adequate oxygenation. E. The clien client's t's level level of consci conscious ousnes ness s should should be carefully monitored. Burn victims are most often alert, oriented and cooperative even with extensive injuries. Fluid Resuscitation The maximum maximum loss of fluid occurs occurs within within 12 to
18 hours the burn. The total after quantity quanti ty of fluid fluid required required to correct this volume deficit is replaced in the first 24 hours following the burn injury. The amount amount of fluid fluid required required tto o 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 Consen sensus sus Form Formula: ula: 2-4 mL x body weight 1. Con
(kg.) x % body surface area burned. Half to be given in first 8 hours, remaining half to be given over next 16 hours.
2. Evan Evans s Form Formul ula a 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. Park Parkla land nd Form Formul ula a 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)
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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: Emergent 1. Airway 2. Breathing 3. Circu rculat atiion 4. Disabi ability 5. Exposure 6. Fl Fluid uid Resus Resusci citat tatio ion n
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 severity of a chemical chemical burn is determi determined ned 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 skin should should be continuously continuously drenched drenched immediately with running water from a shower, hose or faucet as the patient’s clothing is removed. The skin skin of the the health health care professional 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 standard burn burn treatment treatment for for the siz size e& location of the wound (antimicrobials, debridement, tetanus toxoid) is instituted. The patient patient may require plastic surgery for further wound management The patient patient is instructed instructed to have the the affected affected
area at risk 24 &of72 hours and in 7 days re-examined because of the under-estimating the extent & depth of these types of injuries.
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