Emergency Nursing

Objectives

Discuss the unique challenges of nursing practice in an emergency care setting List the most common type of trauma and interventions to prevent trauma. Identify the components of an initial trauma assessment Describe the collaborative management of trauma patient

Historical Perspectives

Emergency nursing was officially recognized as a specialty in 1970 According to ENA, the definition of Emergency Nursing includes The assessment , diagnosis and treatment of perceived actual or potential , sudden or urgent, physical or psychosocial problems that are primarily episodic or acute.

These may require minimal care or life support measures, education of patient and significant others, appropriate referral and knowledge of legal implications

Characteristics of Emergency Nursing Practice

Assessment , analysis , nursing diagnosis, planning, implementation and evaluation of human responses of individuals in all age groups Care that is complicated by limited access to medical history and the episodic nature of the health care Triage and prioritization

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Emergency operations preparedness Stabilization and resuscitation Crisis intervention for unique patient populations such as sexual assault survivors. Provision of care in uncontrolled or un predictable environments Consistency as much as possible across the continuum of care.

Principles of Emergency Care

Triage

Means to sort out or sift out

Emergency Nurses Association ( guidelines for triage )

Level I – resuscitation Level II – Emergent Level III- Urgent Level IV- less urgent Level V - Nonurgent

Four Color – Coded Disaster Triage System

Black – Dead Red- Critical or Life threatening Yellow- Serious Green - Minimal policies on disposition and managent of DEM patients.doc

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Triage Category Systems

RED- Critical...... Likely to survive with immediate simple care BLUE Catastrophic Survives with extensive care or poor prognosis... YELLOW - Urgent..... Survives with care given in few hours GREEN Minor ..... Survives with care delayed hours to days BLACK Dead

As a triage nurse in a busy emergency department, it is your responsibility to prioritize patients who present for care

Based on your understanding of the triage process, assign each of the following patients according to the four color coded disaster triage system

Mr. P. Pascual is a 28 year old who fell off a roof while working. He has a wrist fracture, several small lacerations, and a swollen ankle. He is awake , alert and complaining of pain

Answer

SERIOUS

S. Milby is a three year old who bit through her lip when she fell off her bicycle She is frightened and crying

Answer

MINIMAL

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Mr. M is a 62 year old who suffered a heart attack. Paramedics were called to Mr. M’s house where defibrillation for ventricular fibrillation was necessary. He has just arrived at the emergency department . His blood pressure is 100/60 He is diaphoretic and pale

ANSWER

CRITICAL

Assess and Intervene

ABCD method

Primary Survey

Airway Breathing Circulation Disability Exposure

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Secondary Survey

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Complete health history and head to toe assessment Diagnostic and laboratory testing Insertion or application of monitoring devices Splinting of suspected fractures Cleansing , closure and dressing or wounds.

Issues in Emergency nursing care
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Documentation of consent and Privacy Violence in the Emergency Department Restraints Mandatory Reporting Evidence . Collection and Preservation Providing Holistic Care

Ethical Issues in the Emergency Department

Unexpected Death Organ and Tissue Donation

Airway obstruction Hemorrhage Hypovolemic shock Wounds Trauma

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Environmental Emergencies Poisoning Substance Abuse Violence, Abuse and Neglect Psychiatric Emergencies

Airway Obstruction

ADVANCED CARDIAC LIFE SUPPORT.ppt Cardiopulmonary-Cerebral Resuscitation.ppt ..\articles adult_choking_small.wmv adult_cpr_small.wmv

Airway Obstruction

Hemorrhage

Hemorrhage

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Results in the reduction of circulating blood volume Minor bleeding Signs and Symptoms

Control of External Hemorrhage Control of Internal Bleeding

Hypovolemic Shock

Shock

Is a condition in which there is loss of circulating blood volume

Management
Airway Patent AIRWAY

Breathing

Maintaining Breathing

Circulation

Restoration of circulating blood volume

Wounds

Wounds

Involving injury to soft tissue from minor tears to severe crushing injuries

Management
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Wound Cleansing Primary Closure Delayed Primary Closure Tetanus prophylaxis

Trauma

Trauma

an unintentional or intentional wound or injury inflicted on the body from a mechanism which the body cannot protect itself.

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Forensic Evidence Injury Prevention Multiple Trauma

Assessment and Diagnostic Findings

Gross evidence of trauma may be slight or absent

Management

To determine the extent of injuries and to establish priorities.

Intraabdominal Injuries

Penetrating Blunt trauma

Assessment and Diagnostic Findings
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Adominal Assessment Peritoneal irritation Hypotension and symptoms of shock

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Internal Bleeding Intraperitoneal Injury Genitourinary Injury

Management

Airway Breathing Circulation

Crush Injuries

Assessment and Diagnostic Findings
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Hypovolemic shock Paralysis of the body part Erythema and blistering of skin Damaged body part Renal dysfunction

Fractures

Management

Assessment of Airway, Breathing and Circulation

Environmental Emergencies

Heat Stroke

Is acute medical emergency caused by failure of the heat regulating mechanisms of the body

Frostbite

Is trauma from exposure to freezing temperature and actual freezing of the intracellular fluid and fluids in the intercellular spacess

Hypothermia

Is a condition in which the core ( internal ) temperature is 35 degree centigrade or less as a result of exposure to cold.

Near Drowning

Is defined as survival for at least 24 hours after submersion that caused a respiratory arrest

Decompression Sickness

Occurs in patients who have engaged in diving , high altitude flying, or flying in commercial aircraft within 24 hours after diving.

Anaphylactic Reaction

Is acute systemic hypersensitivity reaction that occurs within seconds or minutes after exposure to certain foreign substances

Poisoning

Is any substance that, when ingested, inhaled, absorbed applied to the skin, or produced within the body in relatively small amounts, injures the body by its chemical action.

Emergency Treatment

To remove or inactivate the poison before it is absorbed. To provide supportive care in maintaining vital organ systems To administer a specific antidote to neutralize a specific poison

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Ingested ( Swallowed ) Poisons Carbon Monoxide Poisoning Skin contamination Poisoning Food poisoning

Substance Abuse

Is the misuse or specific substances to alter mood or behavior Drug and Alcohol Abuse

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Acute Alcohol Intoxication Alcohol Withdrawal Syndrome/ Delirium Tremens

Violence, Abuse and Neglect

Assessing for Abuse, Maltreatment and Neglect

I noticed that you have

Sexual Assault

Psychiatric Emergencies

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Overactive Patients Violent behavior Posttraumatic Stress Disorder Underactive or Depressed Patients Suicidal Patients

EMERGENCY NURSING

The Specialty of Emergency Nursing

Specific body system Specific disease process/problem Specific age group Specific population, such as women’s health care or mental health

CORE

The scope of emergency practice involves the * ASSESSMENT * ANALYSIS * NURSING DIAGNOSIS * OUTCOME

Independent and Collaborative

DIMENSIONS

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Responsibilities Functions Roles Skills

BOUNDARIES

Internal and External

INTERSECTIONS

Professional and Governmental groups

Major Trauma

Mechanisms of injury

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Knowledge of the object producing the injury ( motor vehicle,handgun ) Type of energy released ( kinetic, thermal, chemical Force of energy ( velocity of vehicle or missile ) Use of protective devices ( seat belts, air bags , helmets )

Type of injury
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Blunt injury Penetrating injuries

Oxygen delivery and consumption

Neuroendocrine stress response

Systemic Inflammatory Response syndrome

Multiple Organ Dysfucntion Syndrome

Coagulopathy

Hypothermia

Psychologic Response

Assessment
History and Risk factors  Mechanism of injury  Intoxicants  Preexisting medical conditions  Last meal  Initial subjective presentation  Initial objective presentation

Diagnostic Tests
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Complete Blood Count Blood chemistries Arterial blood gas ( ABG ) analysis Oximetry Type and cross-match Blood alcohol, toxicology screen Urinalysis X-ray Computed tomography

Collaborative Management
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Airway management Oxygen Fluid management Crystalloids ColloidsColloids Packed red blood cells Gastric intubation Urinary drainage

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Pharmacotheraphy Antibiotics Analgesics and Anxiolytics Nutrition theraphy Surgery

Nursing Diagnoses

Fluid volume deficit related to active loss secondary to physical injury Altered protection related to clotting factor alterations ; decreased hemoglobin level. Risk for infection related to inadequate primary defenses secondary to physical trauma or surgery

Impaired tissue integrity related to mechanical factors Hypothermia related to exposure at the scene of injury Altered nutrition ;less than body requirements , related to increased need secondary to hypermetabolic posttrauma site

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Fear related to potentially threatening situation Risk for injury Posttrauma syndrome

TRAUMATIC BRAIN INJURY

PRIMARY BRAIN INJURIES
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Contusion Diffuse axonal injuries Concussion

Secondary brain injuries

Intrinsic Extrinsic

Diagnostic tests
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Skull X-ray Cervical spine X-ray Computed tomography ( CT ) MRI Cerebral angiography EEG Serum laboratory studies

Collaborative Mangement
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Surgical intervention Management of intracranial pressure of dynamics Reduction of ICP by CSF drainage Hyperventilation Monitoring jugular venous oxygen saturation Diuresis theraphy

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Maintenance of blood pressure to maintain cerebral perfusion pressure Reduction of metabolic demand Modifying nursing care activites that raise ICP Nutrition Rehabilitation

Nursing Diagnoses
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Impaired gas exchange Risk for infection Decreased adaptivecapacity Ineffective thermoregulation Risk for disuse syndrome

CHEST TRAUMA

Collaborative Management
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Oxygen theraphy Intubation Mechanical ventilation Blood replacement Chest tubes

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Analgesia Pleural decompression Stabilization and fixation of flail chest Thoracotomy

Nursing Diagnoses

Risk for fluid volume deficit

Near Drowning

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Is a survival of more than 24 hr following drowning Near drowning with aspiration ( wet ) Near drowning without aspiration ( dry )

Collaborative Management
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Oxygen therapy Endotracheal intubation Positive end-expiratory pressure ( PEEP ) Bronchoscopy Extracorporeal membrane oxygenation Rewarming for hypothermia Pharmacotheraphy

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Fluid and electrolyte management Neurologic support Management of event that precipitated the near drowning

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Impaired gas exchange Hypothermia Risk for infection

Cardiac Trauma

Diagnostic Tests
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Chest X-ray Troponin Cardiac Enzymes ECG MUGA

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Echocardiography TEE

Collaborative Management
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Treatment of dysrhythnias Relief of acute pain Immediate corrective surgical repair Treatment of shcok Treatment of myocardial failure

Nursing Diagnoses

Altered Tissue perfusion

Acute Cardiac Tamponade

Is a sudden accumulation of blood , fluid, clots, pus , and /or gas in the pericardial space, which copresses the heart and interferes with both ventricular filling ( diastole ) and ejection ( systole ).

Etiology
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Trauma Iatrogenic Infection Carcinoma Nontraumatichemorrhage Left ventricular hemorrhage

Assessment

Beck’s triad – distended neckveins,hypotension, muffled heart tones

Collaborative
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Pericardicentesis Surgical Procedure Fluid Resuscitation Inotropic agents Oxygen,intubation,mechanical ventilation

Nursing Diagnoses

Decreased Cardiac Output

Renal and Lower Urinary Tract Trauma

Pelvic Fracture

Acute Spinal Cord Injury

Abdominal Trauma

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