EMERGENCY NURSING
Dr. Jayesh Patidar
www.drjayeshpatidar.blogspot.com
Learning Objectives
1. Explain emergency care as a collaborative, holistic approach that includes the patient, the family, and significant others. 2. Discuss priority emergency measures instituted for any patient with an emergency condition. 3. Describe the emergency management of patients with intraabdominal injuries. 4. Identify the priorities of care for the patient with multiple injuries. 5. Compare and contrast the emergency management of patients with heat stroke, frostbite, and hypothermia.
Learning Objectives
6.Specify the similarities and differences of the emergency
management of patients with swallowed or inhaled poisons,
skin contamination, and food poisoning. 7. Discuss the emergency management of patients with drug
overdose and with acute alcohol intoxication.
8. Describe the significance of crisis intervention in the care of rape victims. 9. Differentiate between the emergency care of patients who are overactive, those who are violent, those who are depressed, and those who are suicidal.
Scope and Practice of Emergency Nursing
Emergency management traditionally refers to urgent and critical care needs; however, the ED has increasingly been used for non-urgent problems, and emergency management has broadened to include the concept that an emergency is whatever the patient or family considers it to be The emergency nurse has special training, education, experience, and expertise in assessing and identifying health care problems in crisis situations
Scope and Practice of Emergency Nursing (cont.)
Nursing interventions are accomplished interdependently in consultation with or under the direction of a physician or nurse practitioner The emergency room staff works as a team
Issues in Emergency Nursing Care
Documentation of consent Limiting exposure to health risks Holistic care
Continuum of Care
Discharge planning Community Services
Priority Emergency Measures for All Patients
Make safety the first priority Preplan to ensure security and a safe environment Closely observe patient and family members in the event that they respond to stress with physical violence Assess the patient and family for psychological function
Priority Emergency Measures for All Patients (cont.)
Patient and family-focused interventions
Relieve anxiety and provide a sense of security Allow family to stay with patient, if possible, to alleviate anxiety Provide explanations and information Provide additional interventions depending upon the stage of crisis
Principles of Emergency Care
Triage Assess and Intervene
Emergent
Urgent Non-urgent
A, B, C
Neuro Health history and head-to-toe assessment
Principles of Emergency Care (contd)
Assess and Intervene
A, B, C Neuro
Diagnostic and lab testing
Insertion of monitoring devices Splinting Wounds
Health history
Triage
Triage sorts patients by hierarchy based on the severity of health problems and the immediacy with which these problems must be treated The triage nurse collects data and classifies the illnesses and injuries to ensure that the patients most in need of care do not needlessly wait
Protocols may be initiated in the triage area
ED triage differs from disaster triage in that patients who are the most critically ill receive the most resources, regardless of potential outcome
Airway Obstruction
Head-Tilt-Chin-Lift Maneuver Jaw-Thrust Maneuver Oropharyngeal Airway Insertion Endotracheal Intubation Alternative Intubation Method
Cricothyroidotomy
Hemorrhage
Fluid Replacement Control of External Hemorrhage Control of Internal Bleeding
Hypovolemic Shock
Patent airway and ventilation Restoration of circulating fluid volume Central Venous Pressure Blood component therapy
Wounds
Restore physical integrity and function of injured tissue, with minimal scarring and without infection Wound cleansing
Primary closure
Delayed primary closure
Management of Patients With Intra-Abdominal Injuries
Blunt trauma or penetrating injuries Abdominal trauma can cause massive lifethreatening blood loss into abdominal cavity
Assessment
Obtain history Perform abdominal assessment and assess other body systems for injuries that frequently accompany abdominal injuries
Management of Patients With Intra-Abdominal Injuries (cont.)
Assessment (cont.) Assess for referred pain that may indicate spleen, liver, or intraperitoneal injury Perform laboratory studies, CT scan, abdominal ultrasound (FAST), and diagnostic peritoneal lavage Assess stab wound via sonography
Management of Patients With Intra-Abdominal Injuries (cont.)
Ensure airway, breathing, and circulation Immobilize cervical spine Continually monitor the patient
Document all wounds
If viscera are protruding, cover with a sterile, moist saline dressing Hold oral fluids
NG to aspirate stomach contents
Provide tetanus and antibiotic prophylaxis Provide rapid transport to surgery if indicated
Priorities of Care for the Patient With Multiple Trauma
Use a team approach Determine the extent of injuries and establish priorities of treatment Assume cervical spine injury Assign highest priority to injuries interfering with vital physiologic function
Priorities in the Management of the Patient With Multiple Injuries
Priorities in the Management of the Patient with Multiple Injuries (cont.)
Environmental EmergenciesHeat Stroke
A failure of heat regulating mechanisms
Types Exertional: occurs in healthy individuals during exertion in extreme heat and humidity
Hyperthermia: the result of inadequate heat loss
Elderly, very young, ill, or debilitatedand persons on some medicationsare at high risk Can cause death Manifestations: CNS dysfunction, elevated temperature, hot dry skin, anhydrosis, tachypnea, hypotension, and tachycardia
Management of Patients With Heat Stroke
Use ABCs and reduce temperature to 39 C as quickly as possible Cooling methods Cool sheets, towels, or sponging with cool water Apply ice to neck, groin, chest, and axillae Cooling blankets Iced lavage of the stomach or colon Immersion in cold water bath Monitor temperature, VS, ECG, CVP, LOC, urine output Use IVs to replace fluid losses Hyperthermia may recur in 3 to 4 hours; avoid hypothermia
Environmental EmergenciesFrostbite
Trauma from freezing temperature and actual freezing of fluid in the intracellular and intercellular spaces Manifestations: hard, cold, and insensitive to touch; may appear white or mottled; and may turn red and painful as rewarmed The extent of injury is not always initially known Controlled but rapid rewarming; 37 to 40 C circulating bath for 30- to 40-minute intervals Administer analgesics for pain Do not massage or handle; if feet are involved, do not allow patient to walk
Environmental EmergenciesHypothermia
Internal core temperate is 35 C or less
Elderly, infants, persons with concurrent illness, the homeless, and trauma victims are at risk
Alcohol ingestion increases susceptibility
Hypothermia may be seen with frostbite; treatment of hypothermia takes precedence
Physiologic changes in all organ systems
Monitor continuously
Management of Patients With Hypothermia
Use ABCs, remove wet clothing, and rewarm Rewarming Active core rewarming
Cardiopulmonary bypass, warm fluid administration, warm humidified oxygen, and warm peritoneal lavage Passive external rewarming Warm blankets and over-the-bed heaters
Cold blood returning from the extremities has high levels of lactic acid and can cause potential cardiac dysrhythmias and electrolyte disturbances
Management of Patients With Poisoning
Poison is any substance that when ingested, inhaled, absorbed, applied to the skin, or produced within the body in relativity small amounts injures the body by its chemical action Treatment goals: Remove or inactivate the poison before it is absorbed Provide supportive care in maintaining vital organ systems Administer specific antidotes Implement treatment to hasten the elimination of the poison
Assessment of Patients With Ingested Poisons
Use ABCs Monitor VS, LOC, ECG, and UO Assess laboratory specimens Determine what, when, and how much substance was ingested Assess signs and symptoms of poisoning and tissue damage Assess health history Determine age and weight
Management of Patients With Ingested Poisons
Measures to remove the toxin or decrease its absorption
Use of emetics Gastric lavage Activated charcoal Cathartic when appropriate Administration of specific antagonist as early as possible
Other measures may include diuresis, dialysis, or hemoperfusion
Management of Patients With Ingested Poisons (cont.)
Corrosive agents such as acids and alkalis cause destruction of tissues by contact; do not induce vomiting with corrosive agents
Management Patients With Carbon Monoxide Poisoning
Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin, which does not transport oxygen Manifestations: CNS symptoms predominate Skin color is not a reliable sign and pulse oximetry is not valid Treatment Get to fresh air immediately Perform CPR as necessary Administer oxygen: 100% or oxygen under hyperbaric pressure Monitor patient continuously
Management of Patients With Chemical Burns
Severity of the injury depends upon the mechanism of action of the substance, the penetrating strength and concentration, and the amount of skin exposed to the agent Immediately flush the skin with running water from a shower, hose, or faucet
Lye or white phosphorus must be brushed off the skin dry
Management of Patients With Chemical Burns (cont.)
Protect health care personnel from the substance
Determine the substance
Some substances may require prolonged flushing/irrigation Follow-up care includes reexamination of the area at 24 hours, 72 hours, and 7 days
Management of Patients With Food Poisoning
A sudden illness due to the ingestion of contaminated food or drink Food poisoning, such as botulism or fish poisoning, may result in respiratory paralysis and death ABCs and supportive measures Determination of food poisoning: see Chart 71-12 Treat fluid and electrolyte imbalances Control nausea and vomiting Provide clear liquid diet and progression of diet after nausea and vomiting subside
Management of Patients With Substance Abuse
Acute alcohol intoxication: a multisystem toxin Alcohol poisoning may result in death
Maintain airway and observe for CNS depression and hypotension
Rule out other potential causes of the behaviors before it is assumed the patient is intoxicated Use a nonjudgmental, calm manner Patient may need sedation if noisy or belligerent Examine for withdrawal delirium, injuries, and evidence of other disorders Commonly abused substances: see Table 71-1
Crisis InterventionRape Victims
How the patient is received and treated in the ED is important to his or her psychological well-being
Crisis intervention begins as soon as the patient enters the facility; the patient should be seen immediately Goals are to provide support, reduce emotional trauma, and gather evidence for possible legal proceedings Patient reaction; rape trauma syndrome
History taking and documentation
Physical examination and collection of forensic evidence Role of the sexual assault nurse examiner (SANE)
Psychiatric Emergencies
Overactive, underactive, violent, and depressed or suicidal patients Management
Maintain the safety of all persons and gain control of the situation
Determine if the patient is at risk for injuring himself or others Maintain the persons self-esteem while providing care Determine if the person has a psychiatric history or is currently under care to contact the therapist Crisis intervention Interventions specific to each of the conditions
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