TOPIC: EMERGENCY NURSING  If the patient is unconscious and brought

to the ER without family or friends, this

 Care given to patients with urgent and fact should be documented
critical needs  After treatment, a notation is made on the
 Also for non-urgent cases or whatever the record about the patient’s condition on
patient or family considers an emergency discharge or transfer and about
 Serious life-threatening cardiac conditions instructions given to the patient and
(Myocardial infarction, Acute heart failure, family for follow-up care.
Pulmonary edema Cardiac dysrhythmias)
Exposure to Health Risks
The Emergency Nurse  All emergency health care providers
 Applies the ADPIE on the human should adhere strictly to standard
responses of individuals in all age groups precautions for minimizing exposure.
whose care is made difficult by the limited  Early identification and adherence to
access to past medical history and the transmission-based precautions for
episodic nature of their health care patients who are potentially infectious is
 Triage and prioritization. crucial.
 Emergency operations preparedness.  ER nurses are usually fitted with a
 Stabilization and resuscitation. personal high-efficiency particulate air
 Crisis intervention for unique patient (HEPA)-filter mask apparatus to use when
populations, such as sexual assault treating patients with airborne diseases.
survivors.
 Provision of care in uncontrolled and
unpredictable environments. Providing Holistic Care
 Consistency as much as possible across  Sudden illness or trauma is a stress to
the continuum of care physiologic and psychosocial homeostasis
that requires physiologic & psychological
The Nursing Process healing.
 Provides logical framework for problem  When confronted with trauma, severe
solving in this environment disfigurement, severe illness, or sudden
 Nursing assessment must be continuous, death, the family experiences several
and nursing diagnoses change with the stages of crisis beginning with anxiety,
patient’s condition and progress through denial, remorse &
 Although a patient may have several guilt, anger, grief & reconciliation.
diagnoses at a given time, the focus is on  The initial goal for the patient and family
the most life-threatening ones is anxiety reduction, a prerequisite to
 Both independent and interdependent recovering the ability to cope.
nursing interventions are required  Assessment of the patient and family’s
psychological function includes evaluating
Emergency Nursing in Disasters emotional expression, degree of anxiety,
 The emergency nurse must expand his or and cognitive functioning.
her knowledge base to encompass
recognizing & treating patients exposed to Nursing Diagnoses
biologic and other terror weapons  Possible nursing diagnoses include:
 The emergency nurse must anticipate Anxiety related to uncertain potential
nursing care in the event of a mass outcomes of the illness or trauma and
casualty incident. ineffective individual coping related to
acute situational crises
Documentation of Consent  Possible diagnoses for the family include:
 Consent to examine and treat the patient Anticipatory grieving and alterations in
is part of the ER record. family processes related to acute
 The patient must consent to invasive situational crises
procedures unless he or she is
unconscious or in critical condition and Patient-Focused Interventions
unable to make decisions.  Those caring for the patient should act
confidently and competently to relieve
anxiety.
 Reacting and responding to the patient in  Avoid volunteering unnecessary
a warm manner promotes a sense of information.
security.
 Explanations should be given on a level Discharge Planning
that the patient can understand, because  Instructions for continuing care are given
an informed patient is better able to cope to the patient and the family or significant
positively with stress. others.
 Human contact & reassuring words reduce  All instructions should be given not only
the panic of the severely injured person verbally but also in writing, so that the
and aid in dispelling the fear of the patient can refer to them later.
unknown.  Instructions should include information
 The unconscious patient should be treated about prescribed medications, treatments,
as if conscious (i.e. touching, calling by diet, activity, and contact info as well as
name, explaining procedures) follow-up appointments
 As the patient regains consciousness, the
nurse should orient the patient by stating TOPIC: PRINCIPLES OF EMERGENCY ROOM
is or her name, the date, and the location CARE

Family-Focused Interventions Triage

 The family is kept informed about where  comes from the French word trier, which
the patient is, how he or she is doing, and means "to sort;” A method to quickly
the care that is being given. evaluate and categorize the patients
 Allowing the family to stay with the requiring the most emergent medical
patient, when possible, also helps allay attention.
their anxieties. Determination of Priority in ER Triage
 Additional interventions are based on the  classified based on principle to benefit the
assessment of the stage of crisis that the largest number of people
family is experiencing.
 Helping Them Cope with Sudden Death ER Triage
 Take the family to a private place. Emergent
 Talk to the family together, so they can  (immediate): patients have the highest
mourn together. priority; must be seen immediately
 Reassure the family that everything Urgent
possible was done; inform them of the  (delayed or minor): patients have serious
treatment rendered. health problems, but not immediately life-
 Show the family that you care by touching, threatening ones; seen w/in 1 hour
offering coffee, and offering the services Non-urgent (minor or support): patients
of the chaplain.  have episodic illnesses addressed within
24 hours
Helping them Cope with Sudden Death
 Encourage family members to support Determination of Priority in Field Triage
each other & to express emotions freely.  critical clients are given lowest priority
 Avoid giving sedation to family members;  victims who require minimal care and can
this may mask or delay the grieving be of help to others are treated first:
process, which is necessary to achieve o Red  emergent (immediate)
emotional equilibrium and to prevent o Yellow  immediate (delayed)
prolonged depression. o Green  Urgent (minor)
 Encourage the family to view the body if o Blue  Fast tract or psychological
they wish; this action helps integrate the support needed
loss. o Black  patient is dead or
 Spend time with the family, listening to
progressing rapidly towards death
them and identifying any needs that they
may have.
NOTE:
 Allow family members to talk about the
 Triage Tags should be used on all calls
deceased and what he or she meant to
involving 3 or more patients.
them; this permits ventilation of feelings
 The general placement location should be
of loss.
on one of the patient’s arms.
  When a triage tag has been utilized,  A complete health history & head-to-toe
remember to document the tag number in assessment
the history portion of your run report  Diagnostic & laboratory testing
 Application of monitoring devices
 Splinting of suspected fractures
“E” Cart  Cleaning & dressing of wounds
 Located in designated areas where  Performance of other necessary
medical emergencies and resuscitation is interventions based on the patient’s
needed condition.
 Purpose: to maximize the efficiency in
locating medications/supplies needed for TOPIC: AIRWAY OBSTRUCTION
emergency situations.
Drawer 5  An acute upper airway obstruction is a
 Contains respiratory supplies such as blockage of the upper airway, which can
oxygen tubing, a flow meter, a face shield, be in the trachea, laryngeal (voice box), or
and a bag-valve-mask device for bronchi areas
delivering artificial respirations  Causes: Viral and bacterial infections, fire
Drawer 4 or inhalation burns, chemical burns and
 Contains suction supplies & gloves reactions, allergic reactions, foreign
Drawer 3 bodies, and trauma.
 Contains intravenous fluids o In adults, aspiration of a bolus of
Drawer 2 meat is the most common cause.
 Contains equipment for establishing IV o In children, small toys, buttons,
access, tubes for laboratory tests, and coins, and other objects are
syringes to flush medication lines. commonly aspired in addition to
Drawer 1 food
 Contains medications needed during a
code such as epinephrine, atropine, Clinical Manifestations
lidocaine, CaCl2 and NaHCO3  Choking
NOTE:  Apprehensive appearance
 The back of the cart usually houses the  Inspiratory & expiratory stridor
cardiac board  Labored breathing
 Flaring of nostrils
Assessment and Intervention in the ER: Primary  Use of accessory muscles (suprasternal &
Survey
intercostal retractions)
The primary Survey
 increase anxiety, restlessness, confusion
 Focuses on stabilizing lifethreatening
 Cyanosis & loss of consciousness develops
conditions; employs the ABCD Method
as hypoxia worsens.
The ABCD Method
Assessment and Diagnostics
 Airway -
 Involves simply asking whether the patient
Establish the
is choking & requires help
airway
 If unconscious, inspection of the
 Breathing -
oropharynx may reveal the object.
Provide
 X-rays, laryngoscopy, or bronchoscopy
adequate
may also be performed.
ventilation
 For elderly patients, sedatives & hypnotic
 Circulation - Evaluate & restore cardiac
medications,
output by controlling hemorrhage,
diseases
preventing & treating shock, and
affecting motor
maintaining or restoring effective
coordination, &
circulation
mental
 Disability - Determine neurologic disability
dysfunction are risk factors for
by assessing neuro function using the
asphyxiation of food.
Glasgow Coma Scale
 Victims cannot speak, breath or cough.

Assess and Intervene: The Secondary Survey

  If victim can breathe spontaneously,  Ineffective airway clearance due to
partial obstruction should be suspected; obstruction of the tongue, object, or fluids
the victim is encouraged to cough it out. (blood, saliva)
 If the patient has a weak cough, stridor,  Ineffective breathing pattern due to
DOB & cyanosis, do the Heimlich. obstruction or injury
 After the obstruction is removed, rescue
breathing is initiated; if the patient has no TOPIC: HEMORRHAGE
pulse, start cardiac compressions.
 Bleeding that may be external, internal or
Head-Tilt-Chin-Lift-Maneuver both
1. Place the patient on a firm, flat surface.  External: Laceration, avulsion, GSW, stab
2. Open the airway by placing one hand on wound
the victim’s forehead, and apply firm  Internal: Bleeding in body cavities and
backward pressure with the palm to tilt internal organs
the head back.
3. Place the fingers of the other hand under Assessment
the bony part of the lower jaw near the  Results in reduction of circulating blood
chin and lift up. vol., w/c is the principal cause of shock
4. Bring the chin and teeth forward to  Signs and symptoms of shock:
support the jaw. o Cool, moist skin
o Hypotension
Jaw-Thrust Maneuver o Tachycardia
1. Place the patient on a firm, flat surface. o Delated capillary refill
2. Open the airway by placing one hand on o Oliguria
each side of the victim’s jaw, followed by
grasping and lifting the angles, thus Management
displacing the mandible forward.  Fluid Replacement
 Two large-bore intravenous cannulae are
Oropharyngeal Airway Insertion inserted to provide a means for fluid and
 A semicircular tube or tube-like plastic blood replacement, and blood samples are
device inserted over the back of the obtained for analysis, typing, & cross-
tongue into the lower pharynx matching.
 Used in a patient who is breathing  Replacement fluids may include isotonic
spontaneously but unconscious solutions (LRS, NSS), colloid, and blood
component therapy.
ET Intubation: Indications  Packed RBCs are infused when there is
1. To establish an airway for patients who massive hemorrhage
cannot be adequately intubated with an  In emergencies, O (-) blood is used for
oropharyngeal airway. women of child-bearing age.
2. To bypass an upper airway obstruction  O (+) blood is used for men and
3. To prevent aspiration postmenopausal women.
4. To permit connection of the patient to a  Additional platelets and clotting factors
resuscitation bag or mech. ventilator are give when large amounts of blood is
5. To facilitate removal of tracheobronchial needed.
secretions
Control of External Hemorrhage
Cricithyroidotomy  Physical assessment is done to identify
 Used in the following emergencies in w/c area of the hemorrhage.
ET intubation is contraindicated:  Direct, firm pressure is applied over the
o Extensive maxillofacial trauma bleeding area or the involved artery.
o Cervical spine injuries  A firm pressure dressing is applied, and
o Laryngospasm the injured part is elevated to stop venous
o Laryngeal edema & capillary bleeding if possible.
o Hemorrhage into neck tissue  If the injured area is an extremity, it is
o Laryngeal obstruction immobilized to control blood loss.

Nursing Diagnoses for Airway Obstruction Control of Bleeding: Tourniquets

  Applied only as a last resort just proximal  Large-bore intravenous needles or
to the wound and tied tightly enough to catheters are inserted into peripheral vv.
control arterial blood flow; tag the client  A central venous pressure catheter may
with a “T” stating the location and the also be inserted in or near the RA.
time applied  LRS approximates plasma electrolyte
 Loosened periodically to prevent composition and osmolarity
irreparable vascular on neuro damage  A Foley catheter is inserted to record
 If still with arterial bleeding, remove urinary output every hour; urine volume
tourniquet and apply pressure dressing indicates adequacy of kidney perfusion
 If traumatically amputated, the tourniquet  Ongoing nursing surveillance of the total
remains in place until the OR. patient is maintained to assess the
patient’s response to treatment; a flow
Control of Internal Bleeding sheet is used to document parameters
 Watch out for tachycardia, hypotension,  Lactic acidosis is a common side effect &
thirst, apprehension, cool and moist skin, causes poor cardiac performance
or delayed capillary refill.
 Packed RBC are administered at a rapid TOPIC: WOUND
rate, and the patient is prepped for OR.
 Arterial blood is obtained to evaluate  A type of physical trauma wherein the skin
pulmonary perfusion & to establish is torn, cut or punctured (open wound), or
baseline hemodynamic parameters where blunt force trauma causes a
 Patient is maintained in a supine position contusion (closed wound).
and closely monitored.  Specifically refers to a sharp injury which
damages the dermis of the skin.
TOPIC: HYPOVOLEMIC SHOCK
Type of Wounds
 A condition where there is loss of effective  Open (Incised wound, Laceration,
circulating blood volume due to rapid fluid Abrasion, Puncture wound, Gunshot
loss that can result to multi-organ failure wound)
Causes  Closed (Contusion, Hematoma, Crushing
 Massive external or internal bleeding injury)
 Traumatic, vascular, GI and pregnancy
related Incised Wound
 Burns  A clean cut by a sharp edged object such
as glass or metal.
Nursing Diagnoses for Hypovolemic Shock  As the blood vessels at the wound edges
1. Altered tissue perfusion related to failing are cut straight across, there may be
circulation profuse bleeding
2. Impaired gas exchange related to a V-P
imbalance Laceration
3. Decreased cardiac output related to  Ripping forces or rough brushing against a
decreased circulating blood volume surface which can cause rough tears in the
skin or lacerations.
Clinical Manifestations  Laceration wounds are usually bigger and
 Weakness, lightheadedness, and confusion can cause more tissue damage due to the
 Tachycardia size of the wound.
 Tachypnea
 Decrease in pulse pressure Abrasion
 Cool clammy skin  Superficial wounds that occur at the
 Delayed capillary refill surface of the skin.
 Friction burns and slides can cause
Management abrasion
 Rapid blood and fluid replacement; blood  Characteristic in the way that only the top
component therapy optimizes cardiac most layer of the skin is scrapped off.
preload, correct hypotension, & maintain  Bleeding is not profuse though wounds
tissue perfusion
Puncture Wound
  Small entry site
 Though not large in surface area, wounds
are deep and can cause great internal
damage

Gunshot Wound (GSW)

 Caused by firing bullets or any other small
arms.
 Have a clean entry site but a large and
ragged exit site.

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

Management