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EMERGENCY NURSING

Objectives: After 7 hours of varied learning discussion, the level IV students will be able to:

1. define emergency nursing

2. identify roles and responsibilities of an ER nurse 3. discuss the different emergency drugs 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 amiodarone atropine benadryl bretylium tosylate dubutamine epinephrine furosemide (lasix) hydrocortisone levophed

3.10 lidocaine 3.11 magnesium sulfate 3.12 naloxone 3.13 procainamide 3.14 sodium bicarbonate

3.15 valium

Emergency Nursing

is a special area of the nursing profession deals with human responses to any trauma or sudden illness that requires immediate intervention to prevent severe damage or death care is provided in any setting to persons of all ages with actual or perceived alterations in physical or emotional health

Emergency Nurses specialize in rapid assessment and treatment when every second counts, particularly during the initial phase of acute

illness and trauma. Emergency nurses must tackle diverse tasks with professionalism, efficiency, and above allcaring Roles of the Emergency Nurse 1. Care provider provides comprehensive direct care to the patient and family

2. Educator provides patient and family with education based on their learning needs and the severity of the situation and allows the patient to assume more responsibility for meeting health care needs

3. Manager coordinates activities of others in the multidisciplinary team to achieve the specific goal of providing emergency care

4. Advocate ensures protection of the patients rights

Responsibilities of the Emergency Nurse 1. Uses triage to determine priorities based on assessment and anticipation of the patients needs 2. Provides direct measures to resuscitate, if necessary 3. Provides preliminary care before the patient is transferred to the primary care area 4. Provides health education to the patient and family 5. Supervises patient care and ancillary personnel 6. Provides support and protection for the patient and family

DRUG & CLASSIFICATIO N AMIODARONE Antiarrhythmic

MECHANISM OF ACTION -slows sinus rate, increases

INDICATION, CONTRINDICATI ON, SIDE EFFECTS I: lifethreatening recurrent

PRINCIPLE OF CARE -avoid exposure to sunlight or

TREATMENT

- get emergency medical

{class III}

pulse rate and QT invtervals, decreases peripheral vascular resistance, increases refractory period of the AV node -causes blood vessels to dilate (enlarge). This effect can result in a drop in blood pressure.

ventricular arrhythmias, recurrent ventricular fibrillation CI: sinus node dysfunction, heart block, severe bradycardia, hypokalemia SE: irregular heartbeat pattern -wheezing, cough, chest pain, trouble breathing, coughing up blood -blurred vision, vision loss, headache or pain behind your eyes, sometimes with vomiting I: administration prior to anesthesia to reduce or prevent secretions of respiratory tract, to control rhinorrhea, treatment of parkinsonism, restoration of cardiac rate and arterial pressure in some

artificial UV rays -use a sunscreen (minimum SPF 15) and wear protective clothing if you must be out in the sun

help if you have any of these signs of an allergic reaction: hives; difficulty breathing; swelling of your face, lips, tongue, or throat.

ATROPINE parenteral anticholinergic agent and muscarinic antagonist.

-inhibits action of acetylcholine or other cholinergic stimuli at postganglioni c cholinergic receptors, including smooth muscles, secretory glands, and CNS sites.

- take prescribed dose 30 to 60 min before meals and at bedtime -ensure adequate hydration; provide environment al control (temperature ) to prevent hyperpyrexia

-carefully check concentratio n before administerin g medication to ensure that proper strength is being used.

situations, treatment of peptic ulcers, management of hypersecretion, irritation, or inflammation of stomach, intestines, or pancreas CI: Hypersensitivit y to anticholinergics , narrow-angle glaucoma, primary glaucoma or tendency toward glaucoma (ophthalmic), adhesions between iris and lens, prostatic hypertrophy SE: abnormal movements; agitation; amnesia; anxiety; ataxia dizziness; dysarthria; dysmetria; fatigue; hallucinations; headache -cold skin; cyanosed skin; dermatitis; dry mucous membranes; dry warm skin - abdominal

BENADRYL antihistamine

Diphenhydra mine blocks the effects of the naturally occurring chemical histamine in the body.

pain; constipation I: Allergic rhinitis due to inhalant allergens & foods; mild, uncomplicated allergic skin manifestations of urticaria & angioedema; amelioration of allergic reactions to blood; dermatographis m; anaphylactic reactions adjunctive to epinephrine, motion sickness, symptomatic relief of cough as may occur w/ allergies, common colds or flu. CI: Lower respiratory tract symptoms including asthma, hypersensitivity , lactation. SE: Urticaria, drug rash, anaphylactic shock, photosensitivity , excessive perspiration, chills, dry mouth, nose &

-do not take Benadryl if you have taken a monoamine oxidase inhibitor (MAOI) such as isocarboxazi d (Marplan), phenelzine (Nardil), or tranylcyprom ine (Parnate) in the last 14 days. A very dangerous drug interaction could occur, leading to serious side effects.

-use caution when driving, operating machinery, or performing other hazardous activities. Benadryl may cause dizziness or drowsiness. If you experience dizziness or drowsiness, avoid these activities. Use alcohol cautiously. Alcohol may increase drowsiness and dizziness while taking Benadryl

throat. Hypotension, palpitations, sedation, sleepiness, disturbed coordination. Hallucination BRETYLIUM TOSYLATE Antidysrhythmi c (Class III) -causes a chemical sympathecto my-like state by inhibiting norepinephri ne release and depressing adrenergic nerve terminal excitability; produces a positive inotropic effect on the myocardium. I: VF and VT, currently the second drug of choice in the treatment of refractory or recurrent VF -tosylate injection should be diluted with a minimum of 50 mL of Dextrose Injection 5%, CI: digitalisUSP, or induced Sodium dysrhythmias, not effective in Chloride abolishing atrial Injection, USP, prior to dysrhythmias intravenous SE: Vertigo, use vomiting, dizziness, syncope, hypotension, bradycardia, increased PVCs, angina, transient hypertension and tachycardia lasting approximately 20 minutes -instruct patient to make position changes slowly and to request assistance with ambulation -advise men to sit on toilet while urinating -monitor patient's vital signs frequently, including cardiac rhythm. Transient increase in arrhythmias and hypertensio n may occur within 1 hr after initial administrati on -especially note slow or irregular pulse or significant hypotension

. If BP is less than 75 mm Hg, notify health care provider. DOBUTAMINE -it increases myocardial Sympathomime contractility tic and increases CO without significant change in BP. It increases coronary blood flow and myocardial oxygen consumption I: heart failure -dobutamine and cardiogenic injection shock must be further CI: idiopathic diluted at the hypertrophic time of stenosis administratio n to at least 50 mL prior to administratio n in an i.v. container with one of the following i.v. solutions: 5% Dextrose Injection, 0.9% Sodium Chloride Injection, or Sodium Lactate Injection. I.V. solutions should be used within 24 hours of preparation -protect the patient's airway and support ventilation and perfusion. If needed, meticulously monitor and maintain, within acceptable limits, the patient's vital signs, blood gases, serum electrolytes, etc.

EPINEPHRINE Bronchodilator, vasopressor, cardiac stimulant

-epinephrine, an active principle of the adrenal medulla, is a direct-acting sympathomi metic. It stimulates and -

-observe for adverse effects: tachycardia, hypertensio n, chest pain, and cardiac dysrhythmia s I: cardiac -therapy with -monitoring arrest, any the patient hypersensitivity adrenergic carefully, reactions, bronchodilat especially anaphylaxis, or should be for and acute stopped. cardiovascul asthma attacks ar status. CI: acute narrow-angle -report the drugs

adrenergic receptors resulting in relaxation of smooth muscle of the bronchial tree, cardiac stimulation and dilation of skeletal muscle vasculature.

glaucoma and coronary insufficiency SE: upset stomach, vomiting, sweating, dizziness, nervousness, weakness, pale skin, headache, shaking hands that you cannot control

inability to maintain a desired effect despite increased doses

FUROSEMIDE (LASIX) DIURETIC

-it promotes the excretion of fluid and electrolytes and reduces plasma volume

I: edematous states: congestive heart failure, pulmonary edema, hepatic and renal disease, and hypertension CI: sensitivity to the drug and anuria SE: blurred vision, confusion, constipation; difficulty breathing or swallowing, dizziness, fever, headache, loss of hearing, muscle cramps, rapid, excessive weight loss, restlessness

-Ttherapy should be individualize d according to patient response to gain maximal therapeutic response and to determine the minimal dose needed to maintain that response.

-patients receiving Lasix (furosemide ) should be advised that they may experience symptoms from excessive fluid and/or electrolyte losses.

-patients with -the usual initial dose of diabetes mellitus Lasix (furosemide) should be told that is 20 to 80 furosemide mg given as may a single increase dose. blood Ordinarily a glucose prompt levels and diuresis thereby ensues. If affect urine needed, the glucose same dose tests. The can be administered skin of some patients 6 to 8 hours may be later or the dose may be more sensitive to increased. the effects The dose of sunlight may be raised by 20 while taking or 40 mg and furosemide. given not sooner than 6 to 8 hours after the previous dose until

HYDROCORTI SONE Short-acting corticosteroids

-it decreases inflammation, suppresses the immune response, stimulates n=bone marrow and influences protein, fat, and carbohydrate metabolism

I: inflammatory diseases, adrenal insufficiency, and shock states

hydrocortiso ne comes as ointment, cream, lotion, liquid, gel, CI: systemic medicated fungal cloth infections and towelette, septic shock and spray for use on the SE: muscle skin; foam, cramps, suppositories weakness, , cream, dizziness, ointment, confusion, and enema thirst, upset for rectal stomach, use; and vomiting, lurred paste for use vision, in the mouth. headache, restlessness, hydrocortiso constipation ne is usually used one to four times a day for skin problems. -for mouth sores, it usually is applied two or three times a day after meals and at bedtime. If mouth sores do not begin to heal within 7 days, call your doctor.

-do not share this medication with others -lifestyle changes that may help this medication work better include exercising, stopping smoking, reducing stress, and changing your diet.

LEVOPHED

-vasopressor

I: restoration of

-monitor BP

Norepinephrine bitartrate

LIDOCAINE antidysrhythmi c

and cardiac stimulant; effects are mediated by alpha1- or beta1adrenergic receptors in target organs; potent vasoconstrict or (alpha effect) acting in arterial and venous beds; potent positive inotropic agent (beta1 effect), increasing the force of myocardial contraction and increasing coronary blood flow. -decreases diastolic depolarizatio n, decreasing automaticity of ventricular cells; increases ventricular fibrillation threshold

BP controlling certain acute hypotensive states, adjunct in the treatment of cardiac arrest and profound hypotension CI: hypovolemia, profound hypoxia or hypercarbia, mesenteric or peripheral vascular thrombosis SE: headache, bradycardia, hypertension

every 2min. from the start of infusion until desired BP is achieved, then monitor every 5min. if infusion is continued -administer IV infusions into a large vein, preferably the antecubital fossa, to prevent extravasatio n

norepinephr ine is used onlu in acute emergency situations, patient teaching will depend on patients awareness and will relate mainly to patients status and to monitoring being done

I: acute ventricular arrhythmias during cardiac surgery and MI CI: CHF, cardiogenic shock SE: dizziness, fatigue, drowsiness, nausea, vomiting, rash I: seizures associated with

-titrate dose to minimum needed for cardiac stability -reduce dosage when treating arrhythmias in CHF

-oral lidocaine can cause numbness of tongue -dosage is changed frequently in response to cardiac rhythm

MAGNESIUM SULFATE

-it replaces and

-do not give oral

-use only temporary

Electrolyte replenisher

maintains magnesium levels in body fluids. It depresses the CNS, prodcing anticonvulsa nt effects

eclampsia and preeclampsia, hypomagnese mia, and torsades de pointes CI: heart block, myocardial damage, and renal failure

magnesium sulfate with abdominal pain -monitor bowel function Maintain urine output at a level of 100ml

measure to relieve constipation -report sweating, flushing, muscle tremors or twitching

NALOXONE Narcotic antagonist

SE: weakness, dizziness, fainting, sweating, palpitations, excessive bowel activity -it competes I: narcoticwith induced narcotics for respiratory receptor sites depression in the CNS. CI: allergy to opioid antagonist SE: nausea, vomiting, sweating, hypotension, hypertension I: premature ventricular complexes, ventricular tachycardia, and atrial dysrhythmias CI: second- or third-degree heart block, hypersensitivity to procaine,

-monitor patient continuously after use of naloxone; repeat doses may be needed, depending on duration of opioid and time of last dose -monitor patient response carefully, especially when beginning therapy -reduce dosage in patients <120lb

-monitor respiratory depth and rate -provide oxygen and artificial ventilation

PROCAINAMI DE antidysrhythmi c

-it depresses cardiac automaticity, excitability, and conductivity

-take drug at evenly spaced intervals, around-theclock -monitor cardiac rhythm

and myasthenia gravis SE: mental depression, seizures, confusion, hypotension, rash, nausea

SODIUM BICARBONAT E Alkalizer Antacid Electrolyte replenisher

-it increases the plasma bicarbonate, buffers excess hydrogen ion concentration , and increases blood pH

I: metabolic acidosis and need to alkalinize the urine CI: metabolic or repiratory acidosis, hypocalcemia SE: gastric rupture following ingestion, systemic alkalosis, hypokalemia, hhypernatremi a I: anxiety disorders, acute alcohol withdrawal, adjunct for the relief of skeletal muscle spasm, convulsive disorders CI: myasthenia gravis (a muscle

-check to see that patients with supraventric ular tachyarrhyth mias have been digitalized before giving procainamid e -have patient chew oral tablets thoroughly before swallowing, and follow them with a full glass water -do not give oral sodium bicarbonate within 2hr of other oral drugs to reduce risk of drug interaction -carefully monitor pulse, BP, respiration during IV administratio n -reduced dose of opioid analgesics with IV

-have periodic blood tests and medical evaluations -report irritability, headache, tremors, confusion, swelling extremities

VALIUM

Group of benzodiazepi Benzodiazepine ne s tranquilizers which exert anxiolytic, sedative, musclerelaxant, anticonvulsa nt and amnesic effects. This

-take drug exactly as prescribed -do not stop taking this drug without consulting your healthcare provider

is known to be the result of facilitating the action of aminobutyric acid (GABA), the most important inhibitory neurotransmi tter in the brain.

diazepam weakness disorder); severe liver disease; narrow-angle glaucoma; a severe breathing problem; or sleep apnea (breathing stops during sleep). SE: confusion, depression, dysarthria, headache, constipation, nausea

RESCUE, TRANSFER AND AMBULATION


Objectives: After 7 hours of varied learning discussion, the level IV students will be able to:

1. define the following terms: 1.1 rescue 1.2 transfer 1.3 ambulation

2. identify factors that affect transfer and ambulation

3. enumerate guidelines before, during and after rescue, transfer and ambulation

4. cite the different commands used in rescue and transfer

5. discuss the materials/equipment used

6. perform the different methods of rescue, transfer and ambulation 6.1 one-man carry - assist to walk - cloth drag - blanket drag - carry in arms - feet drag - arm drag - piggyback carry - incline drag - firemans carry - pack strap carry 6.2 two-man carry - assist to walk - hand as a liter - 4-hand-seat 6.3 three-man carry - bearers alongside

- carry by extremities - firemans carry w/ assistance

- hammock carry

6.4 four-man carry 6.5 six-man carry - blanket carry - improvised stretcher - blanket and poles stretcher - commercial stretcher - ambulance or rescue van 1. Definition of terms: 1. Rescue- A procedure that moves a victim of a disaster or accident from a dangerous location to a place of safety. -refers to operations that usually involve the saving of life, or prevention of injury.

- implies feeling from imminent danger by prompt or vigorous action.

2. Transfer- An act to convey or cause to pass from one place, person, or thing to another. 3. Ambulation- To walk from place to place independently with or without assistive device. FACTORS THAT AFFECT TRANSFER AND AMBULATION Patient safety -falls are the most common hazard to a patient being transferred. The patient may become dizzy or have less strength than expected or the nurse may not be strong enough to accomplish the task. - this should be the first concern of nurses who would assist. Never leave the patient on his own during the activity Body Mechanics

- to provide a convenient and safe manner of doing the procedure - using correct techniques in performing certain functions in a manner that does not add undue strain to the body Ability -one may need more than one person to transfer a heavy or severely disabled patient. Assistance from an appropriate staff should be taken into consideration. Psychology

-the patient should be properly dressed. It is important for patient to be covered for both warmth and modesty. Sociology

-Explain the procedure to the patient and encourage questions so that patient can participate fully in transfer and ambulation - you should communicate with patient while guiding and assisting them Neuromuscular and skeletal impediments disease and injuries that affect the neuromuscular or skeletal systems can hinder movement. Nutrition - adequate nutrition supplies vitamins and minerals essential for body functioning General Health the clients general health status is reflected on how the individual moves - illness, disability, inactivity and chronic fatigue have unfavorable effects in musculoskeletal function.

GUIDELINES IN RESCUE: Before: Recognize the hazard Survey the scene o Is there a fire involved? (Appendix A) o Is there a smell of raw or leaking fuel?

o Is the bus likely to be hit by other vehicles? o Does the possibility exist that interventions will cause further threat to safety?

Assess if moving the victim would cause further injury

During: Monitor conditions and adjust procedures to meet unexpected circumstances Move evacuated students to the nearest safe location at least 100 feet. Be prepared to give information to emergency medical personnel regarding victims medical or physical requirements. After: Relay everything you have done to emergency medical personnel Give all the information needed by the emergency medical personnel

GUIDELINES IN TRANSFER Before: Know patients diagnosis and any restrictions to be observed. Assess patients capabilities. Find out what equipment is available or suited for the patient as well as who is available to assist you. With the data in hand, devise a plan to transfer the patient in the safest and most convenient manner Wash hands for asepsis During:

Identify the patient Lower the bed itself as well as the headboard Foot coverings are essential for patients security and to prevent slipping As simply as possible, explain to patient what you intend to do or how you intend to help, as well as how he is expected to participate Evaluate patients body alignment and comfort After: Document activity to keep a record for other members of the health care team

GUIDELINES IN AMBULATION Before: Identify patients capabilities and the activity ordered. Check on patients previous level of activity. Find out whether assistive devices were used. Take vital signs as a baseline Set a tentative goal for how far you expect the patient to ambulate Explain procedure Obtain patients robe and shoes.

During: Position the bed and help patient to stand using techniques in transferring. Using the direction for the type of ambulation, ambulate the patient Watch the patient carefully for signs of fatigue or adverse responses.

After: Return patient to bed and position for comfort.

Recheck vital signs and compare and note excessive changes. Document the activity.

ONE-MAN CARRY Assist to walk Procedure: The patients arm is placed across the back of waist of the first aider. If the casualty has an injured leg, position yourself with the injured leg next to you. Indications: used only with a conscious casualty who can walk or at least hop on one leg can be used to move a casualty a long distance or until the casualty tires Carry in arms Procedure: Slide one of your arms under the casualty's arm, behind his back, and under his other arm. Move to the casualty's side, bend down, and place your other arm behind the casualty's knees. Indications: to move a conscious or unconscious casualty who cannot walk only used for short distances Piggyback Carry Procedure: Assist the patient to stand. Place his/her arms over your shoulder so they cross your chest. Bend over and lift patient. While patient holds on with his/her arms, crouch and grasp each thigh. Use a lifting motion to move patient unto your back. Pass your forearms under patients knees and grasps his/her wrists. Indications:

used only for a conscious casualty who can put his/her arm around your neck can be used to move a casualty a moderate or long distance Firemans Carry Procedure: The carrier would grasp the subjects wrist and put the casualtys arm across one of his/her shoulders. Then, the carrier would reach between the casualtys legs, passing carriers arm between the casualtys legs and then grasping behind the casualtys thigh. Indications: a common way for firefighters to carry injured or unconscious people away from danger can be used to move a casualty a moderate distance Blanket carry Procedure: The casualty is placed in the middle of the blanket lying on his back. Three or more people kneel on each side and roll the edges of the blanket toward the casualty. When the rolled edges are tight and large enough to grasp securely, the casualty should be lifted and carried. Indications: used whenever possible to transport casualties only used in cases where there are no fractures nor extensive wounds of the body TWO-MAN CARRY Two-man support carry - can be used in transporting both conscious or unconscious casualties. If the casualty is taller than the bearers it may be necessary for the bearers to lift the casualty's legs and let them rest on their forearms. Two-man arms carry - The two-man arms carry is useful in carrying a casualty for a moderate distance. It is also useful for placing him on a litter. To lessen fatigue, the bearers should carry him high and as close to their chests as

possible. In extreme emergencies when there is no time to obtain a board, this manual carry is the safest one for transporting a casualty with a back/neck injury. Use two additional bearers to keep his head and legs in alignment with his body. Carry by extremities - is a most useful two-man carry for transporting a casualty for a long distance. The taller of the two bearers should position himself at the casualty's head. By altering this carry so that both bearers face the casualty, it is also useful for placing him on a litter. Hand as a litter - is used in carrying a casualty for a short distance and in placing him on a litter. 4-Hand seat - Only a conscious casualty can be transported with the four-hand seat carry because he must help support himself by placing his arms around the bearers' shoulders. This carry is especially useful in transporting the casualty with a head or foot injury and is used when the distance to be traveled is moderate. THREE-MAN CARRY Bearers along side STEPS: First aiders position their arms and hands in preparation for lift The first aider kneel at one side of the victim and place their arms beneath the victims back (shoulder), waist, hips and knees. First aider lift victim to their knees After rolling victim to their chests, all first-aiders stand. The commander will then command to face front and walk Then the procedure is reversed to lower the victim

INDICATION: For narrow alley With no spinal cord injury

CONTRAINDICATION:

With spinal cord injury

Hammock Carry -Three to six people stand on alternate sides of the injured person and linked hands beneath the victim. The person at the victim's head gives the command, and all three lift the victim to their knees simultaneously. STEPS: First-aiders A and C are on one side of the victim and B is on the other side. All carriers kneel on the knee towards the victims feet First aider A cradles the victims head and shoulders with the top arm. The other arm is placed under the lower back. First aider B slides his top arm under the victims back above first aider As bottom arm and his other arm just below the buttocks. First aider C slides his top arm under the victims thighs above first aider Bs bottom arm. His other arm is placed under the victims legs below the knees. At a signal, the victim is lifted to the carriers knees and rested there while the hands are slide far enough under the victim to allow rotation of the hands inward to secure an interlocking grip. At the next signal READY TO CARRY, all carriers stand erect with the victim. To lower the victim to the ground, merely reverse the procedure.

INDICATION: For wide spaces Spinal cord injury is not suspected

CONTRAINDICATION: FOUR MAN CARRY COMMAND USED FOR TWO OR MORE RESCUERS Narrow spaces

Preparatory

Executory

Ready to kneel . Kneel Hands over the patient.. Move Ready to insert.. Insert Patient on your knees, ready to lift ... Lift Patients body press to the chest.. Press Ready to stand. Stand Face the Leg/Head.. Move Ready to walk, inner foot first Walk Ready to stop Stop Face center Move On your knees and rest. Kneel Ready to unloadUnload Reminders : All team members must answer ready after the leader gives preparatory command. Likewise, leader shall only give the executory command for all members who answered ready. The four-man carry is the carry normally used to transport a casualty when the terrain is generally smooth and level. 1. The bearers position themselves as described below prior to performing the carry. The leader of the litter squad (bearer one) positions himself at the litter handle nearest the casualty's right shoulder, normally at the back of the litter. This position allows him to observe the casualty and to direct the three other members of the squad. In figure 3-28, bearer one is the leader of the litter squad. 2 . The other three-squad members position themselves at the remaining litter handles. 3. All bearers face the direction of travel and kneel on one knee (the knee near the litter). On the preparatory command "Prepare to Lift," each bearer grasps his litter handle with the hand closest to the litter and places his other hand on his raised knee. On the command of execution "LIFT," all bearers rise together, lifting the litter and keeping it level.

4. Each bearer uses the hand on his knee to help support and balance himself as he rises. Leg muscles, not back muscles, are used when lifting a litter. This helps to prevent back injury. 5. After the bearers are standing, they are in position for the four-man carry. The command to proceed is "Four-Man Carry, MOVE." This command is also used to change to the four-man carry from another carry without lowering the litter. SIX-MAN CARRY IMPROVISED STRETCHERS If a commercially prepared stretcher is not available, you can improvise one by using a tabletop, door, two rigid poles and a blanket or clothing. Don't use non-rigid stretchers for casualties with suspected head or spinal injuries. Knowing how to improvise stretchers will ensure the comfort and well being of casualties when transporting the casualty without the availability of an actual stretcher. Types of improvised Stretchers: a. b. c. d. e. Rolled Blanket stretcher Blanket and 2 poles stretcher Belt or shirt and 2 poles stretcher Hammock stretcher Chair Stretcher

Rolled Blanket stretcher The casualty is placed in the middle of the blanket in the supine position. Three or four people kneel on each side and roll the edges of the blanket toward the casualty, as shown in the figure. When the rolled edges are tight and large enough to grasp securely, the casualty should be lifted and carried. Blanket and poles stretcher

1. Place the blanket flat on the ground and place a pole one-third of the way from the end. Fold the one-third length of the blanket over the pole. 2. Place the second pole parallel to the first so that it is on the doubled part of the blanket, about 15 cm (6 in) from the doubled edge. 3. Fold the remaining blanket over the two poles. The casualty's weight on the blanket holds the folds in place. Blanket Carry -A variety of materials, such as blankets, can be used as improvised stretchers. The blanket carry can be used to remove victims who cannot be removed by other means. Six rescuers are recommended for this carry to ensure the victim's stability during the move. One rescuer must be designated to lead to ensure teamwork when performing the lift. -Don't use this lift if head/spinal injuries are suspected Roll the blanket or rug lengthwise for half its width. Position bearers at the head and feet to keep the head, neck and body in line. Kneel at the casualty's shoulder and position a bearer at the waist to help logroll the casualty onto the uninjured side. Turn the casualty as a unit so that his/her body is not twisted during the logroll. Roll the casualty back over the blanket roll to lay face up on the blanket. Unroll the blanket and then roll the edges of the blanket to each side of the casualty. Get ready to lift the casualty have bearers grip the rolls at the head and shoulders, and at the hips and legs. Keep the blanket tight as the casualty is lifted and placed on the stretcher.

ADVANCED LIFE SUPPORT

Objectives: After 7 hours of varied learning discussion, the level IV students will be able to:

1. define the following terms: 1.1. 1.2. 1.3. 1.4. 1.5. advanced cardiac life support defibrillation defibrillator endotracheal tube endotracheal tube intubation

2. discuss the chain of survival 2.1. 2.2. 2.3. 2.4. easy access easy CPR easy defibrillation easy advanced cardiac life support

3. explain endotracheal tube intubation 4. enumerate the types of : 4.1. 4.2. defibrillators defibrillations

5. cite specific nursing responsibilities before during and after automated external defibrillator and endotracheal tube intubation 6. demonstrate beginning skills in operating automated external defibrillator

Definition of Terms: 1. Advanced Cardiac Life Support Includes the knowledge and skills necessary to provide the appropriate early treatment for cardiac arrest, as well as the management of situations likely to lead to it and the stabilization following successful cardiopulmonary resuscitation

2. Defibrillation
-

consists of delivering a therapeutic dose of electrical energy to the affected heart with a device called defibrillator

3. Defibrillator Depolarizes a critical mass of the heart muscle, terminates the arrhythmia and allows normal sinus rhythm to be reestablished by the bodys natural pacemaker in the sinoatrial node of the heart

4. Endotracheal Tube is a breathing tube and is used temporarily for breathing because it keeps airway open

5. Endotracheal tube intubation is a procedure by which a tube is inserted through the mouth down into the trachea

Basic Life Support is the level of medical care which is used for patients with lifethreatening illnesses or injuries until the patient can be given full medical care at a hospital. It can be provided by trained medical personnel, including emergency medical technicians, paramedics and by laypersons who have received BLS training. BLS is generally used in the pre-hospital setting, and can be provided without medical equipment.

Advanced Life Support

is a set of life-saving protocols and skills that extend Basic Life Support to further support the circulation and provide an open airway and adequate ventilation (breathing).

CHAIN OF SURVIVAL

The chain of survival is a protocol that helps first responders, emergency medical providers and certified civilian responders provide essential care to a victim of choking or cardiac or respiratory arrest. The goal of the chain of survival is to increase the victim's chance for recovery through early action. Early Access
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To accomplish early access means first ensuring that the scene of the incident is safe. Then it is necessary to assess the victim's consciousness by asking "Are you okay?" Next, activate EMS by calling 1-6-1, or other local emergency number, and obtain an automatic electronic defibrillator, or AED, if available.

The 1-6-1 dispatcher will want to keep the caller on the phone to obtain continuous information about the scene and victim. Be sure to tell the dispatcher if you are alone or need to leave the phone to get an AED. Do not hang up. Three cycles of CPR should be done before calling 1-6-1 if the rescuer is alone. If other people are available, the rescuer should designate a specific individual to make the emergency call and another to retrieve the AED. Early CPR
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If the victim is non-responsive, start cardiopulmonary resuscitation, or CPR. First, assess the patient's breathing and pulse. The victim's airway should be opened using a head tilt and chin lift only if no neck or spine injury is

suspected. If it is possible that spinal injury has occurred, the airway can be opened using the jaw thrust technique. Next, visually check for foreign objects that may be obstructing the airway. Remove any objects with a finger sweep. Do not do a blind finger sweep. Begin chest compressions and rescue breathing. Complete five cycles of CPR before continuing on to the next step: early defibrillation. Early Defibrillation
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Electrical signals become disorganized when the heart is in cardiac arrest. The impulses cannot effectively contract the heart muscle to pump blood into circulation. This is called ventricular fibrillation. The AED sends a counter shock through the heart muscle to defibrillate or reorganize the cardiac current. AEDs come with easy-to-understand directions; many have digitalized voice instructions. This helps them to be used efficiently by lay rescuers. Most public buildings and transportation centers are equipped with AEDs. When EMS personnel arrive at the scene, they will stabilize and then transport the patient to the hospital. Activating EMS early in the chain of survival helps ensure early access to advanced care. Advanced care can be started in the pre-hospital setting by certified paramedics. Paramedics are trained in advanced life support techniques. Advanced care will also be provided by nurses and physicians in the hospital where they have access to more diagnostic and life-preserving machines.

Early Advanced Care


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ENDOTRACHEAL TUBE INTUBATION Endotracheal intubation (EI) is indicated in several clinical situations including respiratory failure, cardiorespiratory arrest, upper airway obstruction, in patients at risk for aspiration, and for certain elective procedures. It is mandatory that a clinician responsible for airway management be familiar with airway anatomy and how it pertains to intubation. Ideally, prior to attempting EI, all necessary equipment, medications, emergency supplies, and support staff should be in place. INDICATIONS of Endotracheal Tube Intubation

Endotracheal intubation is indicated in several clinical situations including acute hypoxemic or hypercapnic respiratory failure, or impending respiratory failure. This procedure is also used to protect the airway in conditions of upper airway obstruction, either mechanical or from airway pathology. Patients at risk for aspiration, most commonly from central nervous system derangements may benefit from elective intubation.

In addition, elective EI is performed for many operative procedures; at times to facilitate certain diagnostic procedures (ex. computed tomographic scan); Aid in respiratory hygiene. Another potential indication for EI includes the need to hyperventilate by mechanical ventilation, attempting to reduce intracranial pressure in patients with acute intracranial hypertension.

PROCEDURE The doctor often inserts the tube with the help of a laryngoscope, an instrument that permits the doctor to see the upper portion of the trachea, just below the vocal cords. During the procedure the laryngoscope is used to hold the tongue aside while inserting the tube into the trachea. It is important that the head be positioned in the appropriate manner to allow for proper visualization. Pressure is often applied to the thyroid cartilage (Adam's apple) to help with visualization and prevent possible aspiration of stomach contents. Types of Defibrillators Defibrillators are classified as either being manual or automated. The steps that must be performed by the operator vary greatly with each type of defibrillator Manual Defibrillators In operating a manual defibrillator, the electrical counterchange is administered by placing the paddles correctly on the patients body and holding them there for defibrillation. Features: Manual control of ECG size or display Variable energy level choices Cardioversion option quick look paddle capabilities

Automated External Defibrillator These devices are easier to operate than the manual defibrillator because they are based on computer technology which is designed to

analyze the heart rhythm itself and then advise the user whether a shock is required.

Nursing Responsibilities Automated External Defibrillator BEFORE:


1. Check area for dangers: Water, Metal & Gas. If need be move patient to

safer place. 2. Remove casualtys clothing (including bra appropriately) to expose chest area where the pads need to be placed
3. Check & remove obstacles to AED pads (HJMPS) Hair, Jewelry, Medical

patch, Pace maker & Skin (wet). Do it systematically from neck, collar area, chest and stomach areas. 4. Check indicator to confirm AED is functional. Check wires are properly connected. Switch on AED & follow AED Voice Prompt Step-by-Step Instructions. DURING: 1. Firmly attach the pads on the chest area. 2. Ask everyone to stand clear and press the analyze button when prompted by the machine. Be careful not to touch or move the patient while the AED is in analysis mode. 3. Follow AED voice prompt. 4. Make sure that no one is touching the patient or his bed and call out Stand Clear. AFTER: 1. Maintain open airway. 2. Assess patients condition, level of consciousness and respiratory rate.

3. Document the procedure, including the voltage delivered with each attempt and rhythm strips before and after the procedure. Endotrachael Tube Intubation
Before: o o o o o

Gather all the materials needed Check the light of the laryngoscope the patient's position flat with their face at the level of the xiphoid cartilage of the standing person performing the procedure compresses the cricoid cartilage against the cervical vertebrae, preventing gastric reflux and aspiration do open gloving or wear personal protective equipment

During: o o o o o

nurse should calmly describe the vital-signs status of the patient regularly Be prepared to pass the ET tube and other equipment to the person intubating or physician If necessary, suction patients pharynx observed for equal expansion and auscultation performed at the mid-axillary line Administer sedatives, per doctors order

After: o o o o o

The tube should be secured patient attached to an appropriate ventilator and a check X-ray ordered arterial blood gases should be taken auscultate both sides of the chest suction secretions via the Endotracheal Tube

BANDAGING and SPLINTING


Objectives: After 7 hours of varied learning discussion, the level IV students will be able to: 1. Define the following terms: 1.1 bandage 1.2 bandaging 1.3 splinting

1.4 cravat 2. determine the purpose in bandaging and splinting 3. identify the principles in bandaging and splinting 4. enumerate the types of bandages and splints 5. demonstrate beginning skills in bandaging and splinting 5.1 bandaging open phase - scalp bandage - arm sling - underarm sling - chest bandage - burned hand & foot semi-cravat - genital bandage cravat - forehead/eyes/neck - cheek/jaw/ear - shoulders/hip - cuff sling - forearm/foreleg - elbow/knee straight/bent - open/close palm 5.2 splinting - arm sling - leg sling

DEFINITION OF TERMS: 1. Bandage - is a piece of material used either to support a medical device such as a dressing or splint, or on its own to provide support to the body, they can also be used to restrict a part of the body. 2. Bandaging - the act of applying a bandage which is used to hold a dressing in place over a bleeding wound for control of hemorrhage and to provide support to the injured part.

3. Splinting - . is the technique to secure the part of the body that is injured to decrease further damage or injury to that part of the body, and to make the individual more comfortable until treatment can be initiated. 4. Cravat - a triangular bandage, folded lengthwise. It may be used as a circular, figure-eight, or spiral bandage to control bleeding or to tie splints in place. - Phases of triangular bandage: Broad Semi-broad Narrow Cravat BANDAGING PURPOSE: Asepsis - to prevent infection Pressure - to prevent bleeding Fixation of dressing - to protect the injured part Increase the temperature of the injured part - to promote vasodilation

PRINCIPLES Wash hands - to prevent cross contamination Assist victim in a comfortable position - to ensure safety Neatness of the bandage - to easily determine the injured part Apply dressing to open wound - to control bleeding Use few turns as possible

- to reasonably tighten the bandage Tips of the fingers and toes should be left exposed - to easily check the capillary refill time

TYPES OF BANDAGES: Triangular - could be used on many parts of the body to support and immobilize.

Crape bandage - type of woven gauze which has the quality of stretching.

Gauze/cotton bandage - lightly woven, cotton material. Frequently used to retain dressings on wounds of fingers, hands, toes, feet, head.

Adhesive bandage -use to retain dressing and also used where application of pressure to an area is needed.

SPLINTING

MAJOR TYPES OF SPLINTS

Anatomic splints - involve splinting an injured to the uninjured leg or splinting fingers together. used in broken bones and strained, sprained or dislocated joints. Ex:

Mechanical splint

Rigid splints may be made from a board , a piece of plastic or metal, a rolled newspaper or magazine , or thick cardboard. used for extremity injuries. Ex:

Soft splints

may be made from a pillow, folded blanket or towel, or triangular bandage folded into a sling. used in hand or wrist injuries

PURPOSE: Decrease muscular spasm Relief of pain Prevention of additional damage to muscles and other soft tissue To immobilize the injured area

PRINCIPLES: Always consider life before limb Expose the injury Control bleeding Check for pulses, movement and sensation distal to the injury Never allow patient to bear weight on the injured limb Elevate the injury above the level of the heart Avoid placing straps directly over the injured area

Steps in Bandaging:

Head 1. Place the bandage on a fat surface and fold the longest portion over about an inch, once or twice, deending upon the size of the bandage and the victim. 2. Place the bandage on the head so that theh folded base rests on the forehead. If the flat rotion of the forehead is not used, the bandage will slip and not hold securely. 3. Extend the angle (right angle) back over the head and down the back of the head and neck. 4. Bring the 2 folded ends completely around the head, just above the ears. 5. Secure in front with a square knot and tuck under the ends if they are long. 6. Tuck the part behind the head into and under the 2 circular turns about the head.

Ear and Chin 1. Fold the bandage into a cravat, some 3-4 inches wide. 2. Place a compress over the injury; then start with the cravat over the compress, the beneath the chin, across the flat portion of the head to prevent slipping. 3. Cross the 2 ends of the cravat just above and in front of the ear.

4. Extend the 2 ends of the cravat around the back of the head and across the forehead and tie on the opposite side of the head with a square knot.

Torso-Chest and Back 1. Place the point (right angle) over the shoulder for either chest or back inquiries. 2. Extend the 2 long ends around the body and tie with a square knot; this knot should be tied directly below the point (right angle). 3. With the 12 or 15 inches of bandage remaining, tie with the angle end above the shoulder and with the square knot. If this remaining portion is not long enough to reach the shoulder and tie, then a strip of gauze or muslin will be needed to make this connection and to tie.

Arm Sling 1. Place the bandage in position on the side away from the injury, 1 poit over the shoulder with the base in a vertical position, the angle pointed toward the injury. 2. Move the injured arm across in a horizontal position, slightly elevated.

3. Bring the downward long point of the bandage up and over the injured shoulder, the around the neck. 4. Tie the 2 ends of the bandage with a square knot, on the side of the neck. 5. Leave the fingers on the injured hand expose for observation. 6. Tie and tuck the point of the bandage, or pin with a safety pin.
7. Use the 2nd bandage, which has been folded as a cravat, to secure the

injured arm on the body. Extend this bandage around the body, over the midpoint of the upper arm, and tie with a square knot on the opposite side of the body. Eye Injury 1. Place a sterile eye pad over the injured eye. 2. Fold the bandage as a cravat. 3. Place the cravat on n angle with the midportion covering the injured eye, continue around the head with the two ends of the cravat in opposite directions, tie with a square knot. 4. With 2 bandages, place one across the head with one extending downward and over the good eye.
5. With the 2nd bandage, on an angle, tie around the head completely

covering the injured eye with the cravat the dressing will be over the eye and beneath the cravat. 6. Pull up with both ends of the first bandage to uncover the uninjured eye so that the victim can see. Tie the 2 ends of the cravat on top of the head with a square knot.

Forearm 1. Place one end of the bandage up the arm in a diagonal position.

2. Hold the bandage in this position, then with the longer end of the bandage, wrap it firmly around the forearm overlapping each time and going up the arm as fast as possible. 3. Tie the 2 ends with a square knot to secure the bandage. Hips and Shoulder 1. Place one bandage flat on a table. 2. Fold the second bandage into a cravat, some 3-4 inches wide. 3. Role the angle (right angle) of the first bandage around the cravat 2 or 3 times to fasten them together. 4. Place the bandages on the injured shoulder or hip. 5. Extend the cravat around the neck and under the opposite arm pit and tie with a square knot. The bandage being applied to the hip should be extended the body and tied. 6. Extend the end of the second bandage around the arm, just above the elbow, the bring to the front and tie with a square knot. If it is the hip, the bandage should be extended around the leg, above the knee, and secure with a square knot.

Ankle 1. Fold the triangular bandage into a 3 inch cravat. 2. Take the shoe off, especially if a sprain is suspected.

3. Place the middle part of the cravat in the instep portion of the foot. 4. Cross the 2 ends of the cravat behind the heel. 5. Pull the ends in opposite direction and down, around and under the cravat. 6. Pull up on the cravat from each side to tighten and until the wrap is reasonably secure. 7. Tie on top or in front of the foot with a square knot. 8. Test to make certain that the bandage will not pull off over the foot. It must be secure.

Source:

Richard W.O. Beebe and Deborah L. Funk: Fundamentals of Emergency Care: Delmar Thomson learning, 2001; pg. 672

Warren H. Cole and Charles B. Puestow: Emengency Care: Meredith Corporation, 1972; pg. 51

National Safety Council: Standard First Aid, CPR, and AED: McGraw Hill, 2006; pg. 55- 87

James E. Aaron: First aid and Emergency care: Macmillan, 19790; pg.319

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