Emergency Nursing
Content
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EMERGENCY NURSING
Emergency Care
• • episodic and crisis-oriented care provided to patients with serious or potentially life-threatening injuries or illnesses. Philosophy : an EMERGENCY is whatever the patient or family considers it to be.
Emergency Assessment
• • • systematic approach Usually, the most dramatic injury is not the most serious. The primary and secondary surveys provide the emergency nurse with a methodical approach to help identify and prioritize patient needs. Primary Assessment • A – Airway • B – Breathing • C – Circulation • D – Disability » AVPU Scale Secondary Assessment • brief, thorough, systematic assessment designed to identify all injuries. • The steps include : – Expose/environmental control – Full set of vital signs – Five interventions – Facilitate family presence, and – Give comfort measures. • History • • • • Nursing process in Emergency Situation * logical framework for problem-solving in limited time & pressured environment M – Mechanism of injury I – Injuries sustained / suspected V – Vital Signs T - Treatment
Head to Toe Assessment • Head & Face • Chest • Abdomen / Flanks • Pelvis / Perineum • Extremities • Posterior surface
ER Nurse has:
• • • • • expertise in assessing & identifying patient’s health care problem in crisis situation establishment of priorities monitoring an acutely ill and injured patient supporting and attending to family supervising allied health personnel & teaching patients and their families Approach to Patients • assessment of psychological functioning includes evaluation of emotional expression, degree of anxiety & cognitive functioning • Rapid physical assessment Approach to Family • they are told of the patient’s location and interventions being given
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Guidelines in helping the family deal with sudden death in the ER :
• • • • • • • • Take the family to a private place & talk to the family together Assure the family that every possible intervention was done Avoid using euphemism, show family of your concern thru touch. Allow family to talk about the deceased and what they meant to them; this permits ventilation of feelings Encourage family members to support each other and freely express their emotions Avoid giving sedation to family members as this may mask or delay the grieving process. Encourage the family to view the body if they wish to do so. Cover the mutilated areas before the family sees the body. Spend a few minutes with the family, listening to them
PRIORITIES & PRINCIPLES OF EMERGENCY MANAGEMENT
Priorities – Major Goals • To preserve life • To prevent deterioration before more definitive treatment can be given. • To restore the patient to useful living ***injuries to face, neck and chest that impairs respiration are the highest priorities PRINCIPLES • maintain patent airway & provide adequate ventilation employing resuscitation measures when necessary • control haemorrhage & its consequences • evaluate and restore cardiac output • prevent and treat shock, maintain or restore effective circulation • carry out a rapid initial and ongoing physical examination • assess whether or not the patient can follow commands, evaluate the size & reactivity of pupils • start ECG monitoring if appropriate • splint suspected fractures including cervical spines in patients with head injuries • protect wounds with sterile dressings • start a flow sheet of patient’s vital sign, neurological state, to guide in decision making TRIAGE • comes from the French word trier • “to sort” • characteristic of a hierarchy based on the potential for loss of life • advanced skill Emergent patients • have the highest priority—their conditions • are life threatening, and they must be seen immediately. Urgent Patients • patients have serious health problems, but not immediately life-threatening ones; • they must be seen within 1 hour. Non-urgent Patients • patients have episodic illnesses that can be addressed within 24 hours without increased morbidity (Berner, 2001). “Fast-Track” Patients • increasingly used class • These patients require simple first aid or basic primary care. • They may be treated in the ED or safely referred to a clinic or physician’s office.
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CARDIOPULMONARY RESUSCITATION • technique of basic life support • Purpose : Oxygenating the brain and heart until appropriate, definitive medical treatment can restore normal heart and ventilatory action. Indications • Cardiac arrest • Respiratory arrest Assessment • Immediate loss of consciousness • Absence of breath sounds or air movement through nose or mouth • Absence of palpable carotid or femoral pulse; pulselessness in large arteries Complications • Post-resuscitation distress syndrome (secondary derangements in multiple organs) • Neurologic impairment, brain damage AIRWAY OBSTRUCTION • Acute upper airway obstruction is a life-threatening medical emergency. • Partial or Complete Pathophysiology • Upper airway obstruction causes – Aspiration of foreign bodies – Anaphylaxis – viral or bacterial infection – Trauma – inhalation or chemical burns – In adults, aspiration of a bolus of meat is the most common cause of airway obstruction. – In children, small toys, buttons, coins, and other objects are commonly aspirated in addition to food. Clinical Manifestations • Choking • apprehensive appearance • inspiratory and expiratory stridor • labored breathing • use of accessory muscles (suprasternal and intercostal retraction) • flaring nostrils • increasing anxiety • Restlessness • confusion. • Cyanosis and loss of consciousness develop as hypoxia worsens. Assessment & diagnostic Findings • asking the person whether he or she is choking and requires help • unconscious, inspection of the oropharynx may reveal the offending object. • X-rays, laryngoscopy, or bronchoscopy also may be performed. Management • Establishing an airway may be as simple as repositioning the patient’s head to prevent the tongue from obstructing the pharynx. HEAD INJURY • • • fractures to the skull and face, direct injuries to the brain (as from a bullet), and indirect injuries to the brain (such as a concussion, contusion, or intracranial hemorrhage). Head injuries commonly occur from motor vehicle accidents, assaults, or falls. Concussion – A temporary loss of consciousness that results from a transient interruption of the brain's normal functioning.
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• Contusion – A bruising of the brain tissue. Actual small amounts of bleeding into the brain tissue.
INTRACRANIAL HEMORRHAGE • Significant bleeding into a space or a potential space between the skull and the brain. • serious complication of a head injury with a high mortality due a rising intracranial pressure (ICP) and the potential for brain herniation. • Classified as epidural hematomas, subdural hematomas, or subarachnoid hemorrhages, depending on the site of bleeding. Primary Assessment • Airway – assess for vomitus, bleeding, and foreign objects – Ensure cervical spine immobilization • Breathing – assess for abnormally slow or shallow respirations – An elevated carbon dioxide partial pressure can worsen cerebral edema • Circulation – Assess pulse and bleeding. • Disability – assess the patient's neurologic status. Primary Intervention • Open the airway using the jaw-thrust technique without head tilt. Make sure that you do not stimulate the gag reflex as this can cause increases in ICP. • Administer high-flow O2: the most common cause of death from head injury is cerebral anoxia. • Assist inadequate respirations with a bag-valve mask as necessary. • Control bleeding do not apply pressure to the injury site. Apply a bulky, loose dressing. • Initiate two I.V. lines. HEMORRHAGE • results in the reduction of circulating blood volume is a primary cause of shock. • The goals of emergency management are – to control the bleeding, maintain an adequately circulating blood volume for tissue oxygenation, – prevent shock. • Patients who hemorrhage are at risk for cardiac arrest caused by hypovolemia with secondary anoxia. Management • Fluid replacement to maintain circulation. • Replacement fluids may include isotonic electrolyte solutions (lactated Ringer’s, normal saline), colloid, and blood component therapy. • Blood transfusion (“E” cases Rh- to women, Rh+ in men) HYPOVOLEMIC SHOCK • Shock is a condition in which there is loss of effective circulating blood volume. • Inadequate organ and tissue perfusion follow, ultimately resulting in cellular metabolic derangements. • The underlying cause of shock (hypovolemic, cardiogenic, neurogenic, or septic) must be determined. • Hypovolemia is the most common cause • Altered tissue perfusion related to • failing circulation, • impaired gas exchange related to a ventilation–perfusion imbalance, • decreased cardiac output related to decreased circulating blood volume • The goals of treatment are to restore and maintain tissue perfusion and to correct physiologic abnormalities. Clinical Manifestations • Decreasing arterial pressure • Increasing pulse rate • Cold, moist skin • Delayed capillary refill • Pallor • Thirst • Diaphoresis
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• • • • Altered sensorium Oliguria Metabolic acidosis Hyperpnea
Management • Ensure a patent airway and maintain breathing • Ventilatory assistance • rapid physical examination • rapid fluid and blood replacement • Blood component therapy • Intravenous fluids are infused at a rapid rate • Infusion of lactated Ringer’s solution is useful initially it approximates plasma electrolyte composition and osmolality, allows time for blood typing and screening, Restores circulation, Serves as an adjunct to blood component therapy.
EMERGENCY NURSING
Emergency Care
• • episodic and crisis-oriented care provided to patients with serious or potentially life-threatening injuries or illnesses. Philosophy : an EMERGENCY is whatever the patient or family considers it to be.
Emergency Assessment
• • • systematic approach Usually, the most dramatic injury is not the most serious. The primary and secondary surveys provide the emergency nurse with a methodical approach to help identify and prioritize patient needs. Primary Assessment • A – Airway • B – Breathing • C – Circulation • D – Disability » AVPU Scale Secondary Assessment • brief, thorough, systematic assessment designed to identify all injuries. • The steps include : – Expose/environmental control – Full set of vital signs – Five interventions – Facilitate family presence, and – Give comfort measures. • History • • • • Nursing process in Emergency Situation * logical framework for problem-solving in limited time & pressured environment M – Mechanism of injury I – Injuries sustained / suspected V – Vital Signs T - Treatment
Head to Toe Assessment • Head & Face • Chest • Abdomen / Flanks • Pelvis / Perineum • Extremities • Posterior surface
ER Nurse has:
• • • • • expertise in assessing & identifying patient’s health care problem in crisis situation establishment of priorities monitoring an acutely ill and injured patient supporting and attending to family supervising allied health personnel & teaching patients and their families Approach to Patients • assessment of psychological functioning includes evaluation of emotional expression, degree of anxiety & cognitive functioning • Rapid physical assessment Approach to Family • they are told of the patient’s location and interventions being given
2
Guidelines in helping the family deal with sudden death in the ER :
• • • • • • • • Take the family to a private place & talk to the family together Assure the family that every possible intervention was done Avoid using euphemism, show family of your concern thru touch. Allow family to talk about the deceased and what they meant to them; this permits ventilation of feelings Encourage family members to support each other and freely express their emotions Avoid giving sedation to family members as this may mask or delay the grieving process. Encourage the family to view the body if they wish to do so. Cover the mutilated areas before the family sees the body. Spend a few minutes with the family, listening to them
PRIORITIES & PRINCIPLES OF EMERGENCY MANAGEMENT
Priorities – Major Goals • To preserve life • To prevent deterioration before more definitive treatment can be given. • To restore the patient to useful living ***injuries to face, neck and chest that impairs respiration are the highest priorities PRINCIPLES • maintain patent airway & provide adequate ventilation employing resuscitation measures when necessary • control haemorrhage & its consequences • evaluate and restore cardiac output • prevent and treat shock, maintain or restore effective circulation • carry out a rapid initial and ongoing physical examination • assess whether or not the patient can follow commands, evaluate the size & reactivity of pupils • start ECG monitoring if appropriate • splint suspected fractures including cervical spines in patients with head injuries • protect wounds with sterile dressings • start a flow sheet of patient’s vital sign, neurological state, to guide in decision making TRIAGE • comes from the French word trier • “to sort” • characteristic of a hierarchy based on the potential for loss of life • advanced skill Emergent patients • have the highest priority—their conditions • are life threatening, and they must be seen immediately. Urgent Patients • patients have serious health problems, but not immediately life-threatening ones; • they must be seen within 1 hour. Non-urgent Patients • patients have episodic illnesses that can be addressed within 24 hours without increased morbidity (Berner, 2001). “Fast-Track” Patients • increasingly used class • These patients require simple first aid or basic primary care. • They may be treated in the ED or safely referred to a clinic or physician’s office.
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CARDIOPULMONARY RESUSCITATION • technique of basic life support • Purpose : Oxygenating the brain and heart until appropriate, definitive medical treatment can restore normal heart and ventilatory action. Indications • Cardiac arrest • Respiratory arrest Assessment • Immediate loss of consciousness • Absence of breath sounds or air movement through nose or mouth • Absence of palpable carotid or femoral pulse; pulselessness in large arteries Complications • Post-resuscitation distress syndrome (secondary derangements in multiple organs) • Neurologic impairment, brain damage AIRWAY OBSTRUCTION • Acute upper airway obstruction is a life-threatening medical emergency. • Partial or Complete Pathophysiology • Upper airway obstruction causes – Aspiration of foreign bodies – Anaphylaxis – viral or bacterial infection – Trauma – inhalation or chemical burns – In adults, aspiration of a bolus of meat is the most common cause of airway obstruction. – In children, small toys, buttons, coins, and other objects are commonly aspirated in addition to food. Clinical Manifestations • Choking • apprehensive appearance • inspiratory and expiratory stridor • labored breathing • use of accessory muscles (suprasternal and intercostal retraction) • flaring nostrils • increasing anxiety • Restlessness • confusion. • Cyanosis and loss of consciousness develop as hypoxia worsens. Assessment & diagnostic Findings • asking the person whether he or she is choking and requires help • unconscious, inspection of the oropharynx may reveal the offending object. • X-rays, laryngoscopy, or bronchoscopy also may be performed. Management • Establishing an airway may be as simple as repositioning the patient’s head to prevent the tongue from obstructing the pharynx. HEAD INJURY • • • fractures to the skull and face, direct injuries to the brain (as from a bullet), and indirect injuries to the brain (such as a concussion, contusion, or intracranial hemorrhage). Head injuries commonly occur from motor vehicle accidents, assaults, or falls. Concussion – A temporary loss of consciousness that results from a transient interruption of the brain's normal functioning.
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• Contusion – A bruising of the brain tissue. Actual small amounts of bleeding into the brain tissue.
INTRACRANIAL HEMORRHAGE • Significant bleeding into a space or a potential space between the skull and the brain. • serious complication of a head injury with a high mortality due a rising intracranial pressure (ICP) and the potential for brain herniation. • Classified as epidural hematomas, subdural hematomas, or subarachnoid hemorrhages, depending on the site of bleeding. Primary Assessment • Airway – assess for vomitus, bleeding, and foreign objects – Ensure cervical spine immobilization • Breathing – assess for abnormally slow or shallow respirations – An elevated carbon dioxide partial pressure can worsen cerebral edema • Circulation – Assess pulse and bleeding. • Disability – assess the patient's neurologic status. Primary Intervention • Open the airway using the jaw-thrust technique without head tilt. Make sure that you do not stimulate the gag reflex as this can cause increases in ICP. • Administer high-flow O2: the most common cause of death from head injury is cerebral anoxia. • Assist inadequate respirations with a bag-valve mask as necessary. • Control bleeding do not apply pressure to the injury site. Apply a bulky, loose dressing. • Initiate two I.V. lines. HEMORRHAGE • results in the reduction of circulating blood volume is a primary cause of shock. • The goals of emergency management are – to control the bleeding, maintain an adequately circulating blood volume for tissue oxygenation, – prevent shock. • Patients who hemorrhage are at risk for cardiac arrest caused by hypovolemia with secondary anoxia. Management • Fluid replacement to maintain circulation. • Replacement fluids may include isotonic electrolyte solutions (lactated Ringer’s, normal saline), colloid, and blood component therapy. • Blood transfusion (“E” cases Rh- to women, Rh+ in men) HYPOVOLEMIC SHOCK • Shock is a condition in which there is loss of effective circulating blood volume. • Inadequate organ and tissue perfusion follow, ultimately resulting in cellular metabolic derangements. • The underlying cause of shock (hypovolemic, cardiogenic, neurogenic, or septic) must be determined. • Hypovolemia is the most common cause • Altered tissue perfusion related to • failing circulation, • impaired gas exchange related to a ventilation–perfusion imbalance, • decreased cardiac output related to decreased circulating blood volume • The goals of treatment are to restore and maintain tissue perfusion and to correct physiologic abnormalities. Clinical Manifestations • Decreasing arterial pressure • Increasing pulse rate • Cold, moist skin • Delayed capillary refill • Pallor • Thirst • Diaphoresis
5
• • • • Altered sensorium Oliguria Metabolic acidosis Hyperpnea
Management • Ensure a patent airway and maintain breathing • Ventilatory assistance • rapid physical examination • rapid fluid and blood replacement • Blood component therapy • Intravenous fluids are infused at a rapid rate • Infusion of lactated Ringer’s solution is useful initially it approximates plasma electrolyte composition and osmolality, allows time for blood typing and screening, Restores circulation, Serves as an adjunct to blood component therapy.
