EMERGENCY NURSING

PRICIPLES OF EMERGENCY CARE

Emergency Care- is a kind of care that must be rendered without delay. In a hospital ED, several patients with diverse health problemssome life-threatening, some notmay present to the ED simultaneously.

TRIAGE

The word triage comes from French word trier, meaning to sort. Hospital EDs use various triage systems with differing terminology, but all share this characteristics of a hierarchy based on the potential loss of life. A basic and widely used system uses three categories: emergent, urgent, and non-urgent.

3 Categories of Triage 1. Emergent- are patients which have the highest priority. Their conditions are lifethreatening, and they must be seen immediately. 2. Urgent- are patients which have serious health problems, but not immediately lifethreatening ones; they must be seen within 1 hour.

3. Non-urgent- are patients which have episodic illnesses that can be addresses within 24 hours without increased morbidity.

Fourth- the increasingly used class is fast track, where patients require simple first aid or basic primary care. They may be treated in the ED or safely referred to a clinic or physicians office.

Priorities of Care and Triage Categories Triage Level I Resuscitation Conditions requiring immediate nursing and physician assessment. Any delay in treatment is potentially life- or limb-threatening. Includes conditions such as: Airway compromise. Cardiac arrest. Severe shock. Cervical spine injury. Multisystem trauma. Altered level of consciousness (LOC) (unconsciousness). Eclampsia.

Triage Level II - Emergent Conditions requiring nursing assessment and physician assessment within 15 minutes of arrival. Conditions include: Head injuries, Severe trauma, Lethargy or agitation, Conscious overdose, Severe allergic reaction, Chemical exposure to the eyes. Chest pain, Back pain, GI bleeding with unstable vital signs. Stroke with deficit, Severe asthma. Abdominal pain in patients older than age 50. Vomiting and diarrhea with dehydration. Fever in infants younger than 3 months. Acute psychotic episode,Severe headache. Any pain greater than 7 on a scale of 10. Any sexual assault, Any neonate age 7 days or younger.

Triage Level III Urgent

Conditions requiring nursing and physician assessment within 30 minutes of arrival. Conditions include: Alert head injury with vomiting. Mild to moderate asthma. Moderate trauma. Abuse or neglect. GI bleed with stable vital signs. History of seizure, alert on arrival.

Triage Level IV Less Urgent Conditions requiring nursing and physician assessment within one hour. Conditions include:

Alert head injury without vomiting. Minor trauma. Vomiting and diarrhea in patient older than age 2 without evidence of dehydration. Earache. Minor allergic reaction. Corneal foreign body. Chronic back pain.

Triage Level V Non-urgent Conditions requiring nursing and physician assessment within two hours. Conditions include:

Minor trauma, not acute. Sore throat. Minor symptoms. Chronic abdominal pain.

Basic Life Support

Basic Life Support

Life Support is a series of emergency life saving procedures that are carried out to prolong the life of a victim suffering a life threatening condition.

Kinds of LIFE SUPPORT

BASIC Life Support an emergency procedure that consist of recognition of respiratory or cardiac arrest and the proper application of CPR and RB to maintain the life of the patient until advanced care is available.

ADVANCED CARDIAC Life Support the use of special equipment to maintain breathing and circulation of a patient with cardiac emergency.
PROLONGED Life Support for post resuscitative and long term resuscitation.

Air that enters the lungs contains about 21% of Oxygen and only a trace of Carbon Dioxide. Air that is exhaled from the lungs contains about 16% Oxygen and 4% Carbon Dioxide. Only 5% of Oxygen is being utilized by the body. CLINICAL DEATH a condition in which breathing and circulation stops. BIOLOGICAL DEATH a condition in which brain is deprived of oxygen long enough to cause irreversible damage.

Brain Damage not Likely-0-4 min. Brain Damage Possible-4-6min. Brain Damage Probable -6-10 min. Brain Damage is Certain- Over 10 min.

Respiratory Arrest is a condition in which breathing stops or is inadequate.

RESCUE BREATHING is a technique of breathing air into a persons lungs to supply him with enough oxygen needed to survive. Ways to Ventilate the Lungs Mouth to mouth Mouth to nose Mouth to mouth and nose Mouth to stoma Mouth to face shield Mouth to mask BAG Mask Device

Foreign Body Airway Obstruction Management Types of Obstruction Anatomical when tongue drops back and obstructs the throat Mechanical when foreign body lodges in the airway Classification of Obstruction MILD SEVERE

Heimlich Maneuver a technique that is carried out to relieve airway obstruction. It is utilized to elevate the diaphragm thus pushing the air from the lungs up to push the object out of the airway. It also initiates coughing. It is also called Abdominal Thrust.

Heimlich Maneuver

Conscious Adult and Child (MILD) Ask Are you choking? Stand beside the patient. Your midline of your body should be perpendicular to the patients shoulders. Hold the patients shoulder that is far from you. Give 5 back blows. Location between the shoulder blades. Use the heel of your hand. Stand behind the patient. Give 5 abdominal thrust. Location 1 finger above the navel.

Conscious Infant (MILD) Shout for help. Sandwich the infant face down. Head lower than the body. Give 5 back blows in between the shoulder blades. Sandwich the infant face up. Give 5 chest thrust. Location 1finger below the imaginary nipple line.

Unconscious Adult and Child (SEVERE) Finger sweeping if theres an object seen. Check breathing for 5 seconds. If breathless, give two ventilations. If air bounces back on first attempt, reposition the head. On second attempt perform abdominal thrusts. Repeat the cycle until obstruction is relieved and further assess the patient.

Unconscious Infant (SEVERE)

Shout for help. Finger sweeping if theres an object seen. Check breathing for 5 seconds. If breathless, give two ventilations. If air bounces back on first attempt, reposition the head. On second attempt perform abdominal thrusts. Repeat the cycle until obstruction is relieved and further assess the patient.

Cardiac Arrest is a condition in which circulation ceases and vital organs are deprived of oxygen. Conditions of Cardiac Arrest Cardio vascular collapse heart is still beating but its action is so weak that blood is not circulated properly. Ventricular Fibrillation occurs when the individual fascicles of the heart beat independently rather than the synchronized manner. Cardiac Standstill the heart has stopped beating.

Criteria for not starting CPR Patient has a valid DNR order
Cardio Pulmonary Resuscitation a combination of chest compressions and rescue breathing to effectively revive the patient. Compression Only CPR if a person is not willing to give mouth to mouth ventilation, chest compression should be provided rather than no attempt to CPR being made.

Signs of Irreversible Death Rigor mortis Decapitation Dependent Lividity No Physiologic benefit Delivery room cases Premature less 23wks or very low birth weight less 400 grams Anencephaly Confirmed trisomy 13 (patau) and 18 (Edwards)

Cardiopulmonary resuscitation (CPR): First aid

Remember to spell C-A-B Circulation: Restore blood circulation with chest compressions

1. Put the person on his or her back on a firm surface. 2. Kneel next to the person's neck and shoulders. 3. Place the heel of one hand over the center of the person's chest, between the nipples. Place your other hand on top of the first hand. Keep your elbows straight and position your shoulders directly above your hands. 4. Use your upper body weight (not just your arms) as you push straight down on (compress) the chest at least 2 inches (approximately 5 centimeters). Push hard at a rate of about 100 compressions a minute. 5. If you haven't been trained in CPR, continue chest compressions until there are signs of movement or until emergency medical personnel take over. If you have been trained in CPR, go on to checking the airway and rescue breathing.

Airway: Clear the airway

1.

If you're trained in CPR and you've performed 30 chest compressions, open the person's airway using the head-tilt, chin-lift maneuver. Put your palm on the person's forehead and gently tilt the head back. Then with the other hand, gently lift the chin forward to open the airway.

2. Check for normal breathing, taking no more than five or 10 seconds. Look for chest motion, listen for normal breath sounds, and feel for the person's breath on your cheek and ear. Gasping is not considered to be normal breathing. If the person isn't breathing normally and you are trained in CPR, begin mouth-to-mouth breathing.

Breathing: Breathe for the person

1.

With the airway open (using the head-tilt, chin-lift maneuver), pinch the nostrils shut for mouth-tomouth breathing and cover the person's mouth with yours, making a seal.

2. Prepare to give two rescue breaths. Give the first rescue breath lasting one second and watch to see if the chest rises. If it does rise, give the second breath. If the chest doesn't rise, repeat the head-tilt, chin-lift maneuver and then give the second breath. Thirty chest compressions followed by two rescue breaths is considered one cycle. 3. Resume chest compressions to restore circulation.

Breathing
4. If the person has not begun moving after five cycles (about two minutes) and an automatic external defibrillator (AED) is available, apply it and follow the prompts. Administer one shock, then resume CPR starting with chest compressions for two more minutes before administering a second shock. If you're not trained to use an AED, a 911 operator may be able to guide you in its use. Use pediatric pads, if available, for children ages 1 through 8. Do not use an AED for babies younger than age 1. If an AED isn't available, go to step 5 below. 5. Continue CPR until there are signs of movement or emergency medical personnel take over.

To perform CPR on a baby Circulation: Restore blood circulation 1. Place the baby on his or her back on a firm, flat surface, such as a table. The floor or ground also will do. 2. Imagine a horizontal line drawn between the baby's nipples. Place two fingers of one hand just below this line, in the center of the chest. 3. Gently compress the chest about 1.5 inches (about 4 cm). 4. Count aloud as you pump in a fairly rapid rhythm. You should pump at a rate of 100 compressions a minute.

Airway: Clear the airway

1.

After 30 compressions, gently tip the head back by lifting the chin with one hand and pushing down on the forehead with the other hand. In no more than 10 seconds, put your ear near the baby's mouth and check for breathing: Look for chest motion, listen for breath sounds, and feel for breath on your cheek and ear.

2.

Breathing: Breathe for the infant

1.

Cover the baby's mouth and nose with your mouth.

2.

Prepare to give two rescue breaths. Use the strength of your cheeks to deliver gentle puffs of air (instead of deep breaths from your lungs) to slowly breathe into the baby's mouth one time, taking one second for the breath. Watch to see if the baby's chest rises. If it does, give a second rescue breath. If the chest does not rise, repeat the head-tilt, chin-lift maneuver and then give the second breath.

Breathing: Breathe for the infant

3. If the baby's chest still doesn't rise, examine the mouth to make sure no foreign material is inside. If the object is seen, sweep it out with your finger. If the airway seems blocked, perform first aid for a choking baby. 4. Give two breaths after every 30 chest compressions. 5. Perform CPR for about two minutes before calling for help unless someone else can make the call while you attend to the baby. 6. Continue CPR until you see signs of life or until medical personnel arrive.

When to STOP CPR

S Spontaneous signs of circulation are restored T Turned over to medical services or properly trained personnel O Operator is already exhausted P Physician assumes responsibility

OPENING THE Maximum head tilt Neutral plus AIRWAY ADULT LOCATION OF PULSE METHOD BREATHS Carotid CHILD Carotid

Neutral INFANT Brachial

Mouth to mouth
Full slow

Mouth to mouth Mouth to mouth and nose

Full slow regulated 20 per min BREATHE, 1,1001 BREATHE 1,1002BREATHE 1,1020BREATHE Gentle slow

RATE COUNTING

12 per min BREATHE, 1,1002,1003,1001 BREATHE 1,1002,1003,1002 BREATHE 1,1002,1003,1012 BREATHE

20 per min BREATHE, 1,1001 BREATHE 1,1002BREATHE 1,1020BREATHE

CARDIOPULMONARY RESUSCITATION

Adult COMPRESSION AREA- Simplified approach center of the chest DEPTH-1 -2 inch
HOW TO COMPRESS-heel of one hand other hand on top COMPRESION VENTILATION RATIO-30:2 NUMBER OF CYCLES-5

CARDIOPULMONARY RESUSCITATION

Child COMPRESSION AREA- Simplified approach center of the chest DEPTH-1 inch HOW TO COMPRESS-heel of one hand COMPRESION VENTILATION RATIO-30:2 NUMBER OF CYCLES-5

CARDIOPULMONARY RESUSCITATION Infant

COMPRESSION AREA- One finger below the imaginary nipple line DEPTH- -1 inch HOW TO COMPRESS-Two fingers COMPRESION VENTILATION RATIO-30:2 NUMBER OF CYCLES-5

Guidelines in Giving Emergency Care

I. Survey the Scene Scene Safety for the victim, bystander and healthcare provider Scene Assessment Mechanism of injury / Nature of illness Number of patients and additional resources II. Activating Medical Assistance CALL FIRST CARE FIRST

Guidelines in Giving Emergency Care

III. Do a Primary Survey Consciousness Airway Open and check Maximum head tilt / Jaw Thrust Breathing Look, Listen and Feel Circulation - Pulse Hemorrhage Check bleeding Spinal Cord Injury always assume a trauma. (BABINSKI REFLEX)

Guidelines in Giving Emergency Care

IV. Do a Secondary Survey

Patient History Vital Signs Head to Toe Exam

Head-to-Toe Assessment Begins with assessment of the patient's general appearance, including body position or any guarding or posturing. Work from the head down, systematically assessing the patient one body area at a time.

Head and face Inspect for any lacerations, abrasions, contusions, avulsions, puncture wounds, impaled objects, ecchymosis, or edema. Palpate for crackling, or bony deformities.

Chest Inspect for breathing effectiveness, paradoxical chest wall movement, disruptions in chest wall integrity. Auscultate for bilateral breath sounds and adventitious breath sounds. Palpate for bony crepitus or deformities. Abdomen/flanks Inspect for lacerations, abrasions, contusions, avulsions, puncture wounds, impaled objects, ecchymosis, edema, scars, eviscerations, or distention. Auscultate for the presence of bowel sounds. Palpate for rigidity, guarding, masses, or areas of tenderness.

Pelvis/perineum

Inspect for lacerations, abrasions, contusions, avulsions, puncture wounds, impaled objects, ecchymosis, edema, or scars. Look for blood at the urinary meatus. Look for priapism (which could indicate spinal cord injury). Palpate for pelvic instability and anal sphincter tone.

Extremities

Inspect skin color and temperature. Look for signs of injury and bleeding. Does the patient have movement and sensation of all extremities? Palpate peripheral pulses, any bony crepitus, or areas of tenderness.

Posterior surfaces utilizing help, logroll the patient in order to: Inspect for possible injuries. Palpate the vertebral column and all areas for tenderness.

END OF PRESENTATION ----THANK YOU--GOD BLESS YOU ALL!