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Emergency Nursing Emergency Room Nursing: • Consent to examine and treat is part of the ER record.

The patient must give consent for invasive procedures, but if pt is unable due to being unconscious or in critical condition and is without friends or family, this should be documented. • Early identification and adherence to standard precautions for patients who are potentially infectious is crucial. Nurses in the ER are usually fitted with a HEPA mask. • Waiting and examine rooms are often places of violence when patients and family channel their anger and frustrations. o Safety is the first priority. Security personnel are usually on staff to provide safety for patients, families and staff. o Gang members and feuding families are kept in separate rooms • Patients from prison or those under guard need to be handcuffed to the bed and assessed to ensure the safety of the staff and patients. In addition, the following precautions are taken o Never release hand or ankle restraints o Always have a guard present in the room o Place the patient face down to avoid head-butting, spitting or biting o Medication may be necessary to control violent patients Patients in the ER frequently deal with severe, sudden injury and death. Nurses need to ease anxiety and use effective communication. Talk to them in a way that promotes a sense of security. Give honest answers on a level the family can understand. Families are often feeling guilt and the nurse should encourage them to verbalize their feelings. When dealing with sudden death, the nurse should o Take the family to a private room o Reassure them everything that was possible was done o Avoid giving sedation to family members o Encourage the family to view the body if they want. • If a patient is unconscious, talk to them, touch them and explain each procedure as if they are awake. Common age group in ER is 65+. Emergencies in this age group are difficult to treat as they may be asymptomatic and have multiple underlying issues. Remember older patients have fewer social and financial support systems and may need referrals. Principals of Emergency Care: • Triage means to sort and is used to sort patients based on the severity of the injuries/illnesses. Three categories emergent, urgent and non-urgent. **Some facilities have 5 levels; adding resuscitation before emergent and minor behind non-urgent**  Resuscitation: needs treatment immediately to prevent death o Emergent: Life threatening and must be seen immediately. o Urgent: Serious health problems and must been seen within 1 hour. o Non-urgent Have episodic illnesses that can addressed within 24 hours without increased morbidity. These patients need basic first aid or primary care and can be treated in the ER or safely referred to their PHP.  Minor likely require no resources to provide their evaluation and management. • Resources are imaging studies, medications administered by IV or IM, invasive procedures or insertion of a catheter. Airway Obstruction: If permanent airway obstruction is present, permanent brain injury can occur within 3-5 minutes secondary to hypoxia.

increased respiratory difficulty or cyanosis. • Head-tilt-Chin-Lift: Patient is placed in a supine position on a firm.** Intubation: • Oropharyngeal Airway Insertion (OAI): A semicircular tube that is inserted over the back of the tongue into the lower posterior pharynx in a patient who is spontaneously breathing but is unconscious. grasping the angles of the lower jaw are lifted. • Type O negative for women of child bearing age and children. The patient may clutch their neck between the thumb and fingers (universal distress signal) If a person has a partial obstruction. • Fluid replacement is imperative. near the chin and lifted up. Establishing an airway: • Abdominal thrusts (Heimlich maneuver): a sub diaphragmatic abdominal thrust. If the patient demonstrates a weak. This prevents the tongue from falling backwards against the pharynx and obstructing the airway. flat surface. • When in doubt. to create an artificial cough and expel an obstructing object. The chin and teeth are brought forward to support the jaw. by elevating the diaphragm. Place one hand on the victims forehead. . they should be treated as if they have a complete airway obstruction. displacing the mandible forward. firm pressure is applied over bleeding area or involved artery at a site proximal to the wound. o Two large bore IV needles are inserted for fluid replacement and blood infusion. **only use this method if cervical injury is ruled out** • Jaw-Thrust: One hand is placed on either side of the jaw. high-pitched noise while inhaling.• A person with a foreign body obstruction. • Type O positive for men and post menopausal women. they usually can cough spontaneously and breathe. A cut is made into the Cricothyroid membrane to establish an airway. The fingers of the other hand are placed under the bony part of the jaw. It is indicated for the following reasons: o For patients who cannot be adequately be ventilated with an OAI o To bypass an upper airway obstruction o To prevent aspiration o To permit connection of the patient to a resuscitation bag or mechanical ventilator o To facilitate removal of tracheobronchial secretions • Combitube: This is a tube that rapidly provides pharyngeal ventilation when a patient is not hospitalized and cannot be intubated in the field. Maintain circulating blood volume and prevent shock. Cricothyroidectomy (Cricothyroid Membrane Puncture) emergency tracheotomy. This is only used in emergency situations when endotracheal intubation is not possible or is contraindicated. Packed red blood cells are infused in massive blood loss. it is warmed first. **This can be used if a neck injury is suspected because it does not extend the neck. cannot speak. and firm backward pressure is applied with the palm to tilt the head back. Controlling external hemorrhage: • Direct. • Platelets and clotting factors are given when large amounts of blood are needed. • Endotracheal Intubation: To establish and maintain the airway in patients with respiratory insufficiency or hypoxia. ineffective cough. can force air into the lungs. cough or breathe. Then a firm pressure dressing is applied and the injured part is elevated to stop bleeding if possible. Type O negative is safe for everyone. Hemorrhage: Goals are to control bleeding. It also allows for suction secretions. o The infusion rate is determined by the severity of blood loss and when large amounts of blood are given.

Betadine or peroxide should not be allowed to get deep into wound • Apply non-adherent dressing to protect wound • Primary Closure: To suture a wound depends on the nature of the wound. tears. and degree of contamination and vascularity of the tissues. Delayed Primary Closure: May be indicated if tissue has been lost or there is a high potential for infection.• A tourniquet is applied only as a last resort. • If a patient dies. usually with a sharp instrument. etc. Control of Internal Bleeding: If no signs of external bleeding can be found but the pt shows signs of shock. swabs of tissue samples from hands and under the fingernails are taken as we as photographs of wounds. but especially trauma. It is tied tightly just proximal to the wound to control blood flow. how the injury occurred. then sutures may be indicated. In the surviving patient. usually deeper than is long • Cut: same as stab but longer than is deep • Patterned: wound representing the outline of an object Wound Cleansing: • Clip hair around wound • Clean with copious amounts normal saline to clean away dirt. Do not give clothing to family members.. the time. The pt is tagged with a skin marking or a piece of tape on the forehead with a “T” stating the location and the time the tourniquet was applied. • When cutting away clothes. Hands are covered with paper bags to protect the evidence on the hands and under the fingernails. Each piece is put in a separate paper bag. etc. . If there are no signs of suppuration (formation of pursuant drainage). clothing. in the clothing. • Packed red blood cells are given at a rapid rate • ABG’s are obtained • Patient is kept supine o Pt is taken for more definitive treatment to determine location/cause of bleeding Hypovolemic shock: • Obtain and maintain a patent airway • Infuse IV fluids at a rapid rate until systolic BP is maintained at normal rate • Insert Foley to monitor accurate hourly urinary output Wounds: • Laceration: skin tear with irregular edges and vein bridging • Avulsion: tearing away of tissues from supporting structures • Abrasion: denuded skin • Ecchymosis/contusion: blood trapped under the surface of the skin • Hematoma: tumor like mass of blood trapped under skin • Stab: incision of the skin with we defined edges. internal bleeding is suspected. the time since injury was sustained. Then the wound is splintered in a functional position to prevent motion and prevent contractures. you need to document a description of the wounds. A tetanus prophylaxis will be given if one was not given within 5 years or if pts immunization status is unknown. and collection of the evidence. do not cut through any cuts. • A verbal statement from the patient should be taken and any remarks in the patient’s own words are put in quotation marks. etc. al lines and tubes remain in place. Collection of Forensic Evidence: In emergency. A think layer of gauze (to allow drainage) and then an occlusive dressing.

) Internal Bleeding: Hemorrhage frequently accompanies abdominal injury. Any injury interfering with a vita physiological function (airway. usually require surgery • Blunt trauma may result from MVA’s. falls.Injury Prevention: Three areas of injury prevention: • Education: Provide information and written materials on preventing violence and maintain safety in the home and car. • GU injuries: Do NOT put in a Foley until a GU consult has cleared the patient of any GU/urinary injuries. Other signs are guarding. o Do NOT use the word accident because these events are preventable. spleen. o Absence of bowel sounds may be an early indication of intraperitoneal involvement. etc. but internal. head or extremities. progressive abdominal distention and muscle rigidity. These provide safety without requiring any personal intervention on the part of the patient. crashes. kidney or blood vessels can lead to massive blood loss into the peritoneal cavity. • Penetrating (stab wounds. Labs to help confirm are:  UA to detect hematuria  Hemoglobin & hematocrit  WBC counts increased levels are seen in trauma)  Amylase (increased levels can mean pancreatic injury or a perforation of the GI tract.000. • Patients with multiple traumas should be treated as if they have a spinal cord injury until this is ruled out or confirmed. An amputation may look like the bleeding has stopped. less visible bleeding may be occurring. S/S of internal/external bleeding are: • Inspect the front/back/flanks of body for: bluish discoloration. People at risk for trauma should be identified and given materials and counseling to prevent/avoid risky behaviors. An injury which looks the least lethal may be the most significant. After at least 400 M has been returned. Multiple Traumas: Caused by a single catastrophic event that causes life threatening injuries to at least two distinct organs or organ systems. • The goals of treatment are to determine the extent of the injuries and prioritize treatment. not infringe on rights. Blunt injuries to the liver. • Automatic protection: Airbags and seat belts are included in this category.) is given the highest priority. rebound tenderness. WBC more than 500 or the presence of bile. which is meant to provide universal safety measures. • Pain in the left shoulder can mean a ruptured spleen • Pain in the right shoulder can be a lacerated liver Intra-peritoneal Injury: Referred pain is usually a sign of intraperitoneal injury. circulation. a specimen is sent to the lab. feces or blood is indicative of intraperitoneal involvement. . Intra-Abdominal Injuries: Categorized as internal or blunt trauma. blows or explosions and are usually to the chest. Diagnostic tests include: • Abdominal CT or US • Peritoneal lavage: 1 L of warmed LR or NS is instilled into the abdominal cavity. • Legislation: Nurses should be kept up to date on safety legislation. gunshot wounds). especially in the liver or spleen. asymmetry. If a RBC greater than 100. abrasion or contusion.

Only move patient with a backboard. • Do not handle body part and do NOT massage. use of cooling blankets. HARE traction (a portable traction device) is used for alignment. Assess for Ecchymosis. handle the body part gently and as little as possible and cut off clothing to visualize body part. Watch for any of the following: • Hypovolemic shock • Paralysis of a body part • Erythema or blistering of skin • Damaged body part which appears to be swollen. • The primary goal is to reduce the body’s high temperature as soon as possible. Remove patients clothing. The extremity is usually placed in a circulating bath of 98. IV infusion of LR or NS will restore fluid balance and circulation. groin. iced saline lavages to the stomach and colon or immersion of the patient in a cold water bath. kidneys and heart. • Cut away constrictive clothing or jewelry • Do not allow a patient to ambulate if lower extremities are involved. It causes thermal injury at the cellular level.6-104F for 30-40 minutes.5 indicates successful resuscitation Fractures: When examining for a possible fracture. Sites most common: hands. neck. Crush injuries: Occur when a patient is caught between two opposing forces. • If a pulse less extremity is found. tenderness and crepitation. resulting in cellular and vascular damage. insensitive to touch and may be white or mottled blue/white. chest and axxilae. If the fracture is in the hip or femur. • After the initial inspection. feet. Frost Bite: Exposure of freezing temperatures or actual freezing of the intracellular fluids. Patient is kept NPO in anticipation of surgery and any stomach contents are aspirated with an NG tube. nose and ears. • Splint major tissue injuries to control bleeding and pain. a rapid total body assessment is required and then the patient is quickly transferred to surgery for an arteriograph or arterial repair. the involved fractured body Part is assessed for CPM and then splinted before moving. resulting in damage to the liver. restore circulation. cod. keep patient on a stretcher to keep spine immobilized. reposition extremity for proper alignment. All wounds must be located. Heat Stroke: acute medical emergency when the body’s heat regulating mechanism does not function properly. • A frozen extremity may appear hard. A splint is applied to the joint at a site distal and proximal to relieve pain. If a pulse cannot be found. Treatment is repeated until circulation is restored. tense or hard • Renal dysfunction When a patient has a crushing injury. • Place sterile gauze or cotton between fingers or toes • Elevate extremity to avoid swelling . After the body’s core temp is down to 102F. ice packs on the head. • Must give rapid but controlled re-warming. It usually occurs in extended heat waves. • Watch serum lactic levels (a level under 2. which can cause kidney damage. counted and documented. Use of an electric fan during these procedures will help dissipate the heat by convection and evaporation. especially from high humidity. not only are you assessing for ABC’s but also for renal insufficiency which can be caused by an injury to the back. Most heat related deaths are in the elderly.• • • With blunt trauma. stop further tissue injury and prevent a closed fracture from becoming an open one.

name. CDC (Center for Disease Control) federal agency for disease prevention Red Cross provides support and shelter as needed OEM (Office of Emergency Management) coordinates disaster relief at state and local levels ICS (Incident Command Center) is the local organization that coordinates personnel. Do not rupture NSAIDS Hypothermia: when the body’s core temperature is below 95F. military bases. age. Triage: When faced with a large number of casualties. alcoholics. Shivering may not occur at below 90F because the body’s warmer mechanisms are not effective. you must do the greatest good for the greatest number of people. Before creating this plan. facilities. Elderly. etc. Patients in . Mass Casualty and Disaster Nursing: Level I: Local emergency response personnel can contain and manage the disaster and its aftermath Level II: Regional help from surrounding communities is needed Level III: state and federal assistance is needed • • • • • DMAT’s (Disaster Medical Assistance Teams) organizes voluntary medical personnel to set up a field hospital. trauma victims are susceptible. equipment and communication in an emergency situation. and nuclear facilities that could give occasion to mass casualties • Identify Federal. infants. warmed peritoneal lavage o Cardiac monitoring and mechanical ventilation should be accessible during rewarming o Administer warmed IV fluids o Admin sodium bicarb if metabolic acidosis has occurred o Insert Foley Terrorism.• • Blebs (fluid under the skin) are common from 1 hour to a few days after exposure. Health care facilities are required by JCAHO to create a plan for emergency preparedness and to practice the plan twice a year. warm humidified O2 by vent. and medications given. The heartbeat and blood pressure are usually so low that peripheral pulses are undetectable. address. The reason for this is so you don’t spend a limited number of resources on people with a limited chance for survival. state and judicial buildings as well as schools or any other areas where large groups of people may gather • Identify the resources available to the facility Initiating the EOP (Emergency Operations Plan): Identifying and documenting Patient Information: • Disaster tags. the facility must: • Identify the likelihood of which natural and man-made disasters are likely to occur in that area • Identify proximity to chemical plants. • Rewarming methods: warm fluid administration. The patients’ name and tag number are recorded in a disaster log book and kept at the command center to track patients and relay info to families. Therefore. location. will be given the lowest triage rating. description of injuries. if a large number of patients have conditions that have high mortality rate. which are numbered and include triage priority.

respiratory or GI disturbances • Clusters of patients presenting with the same symptoms at the same time who may be from a specific geographical location or event (sporting event. entertainment event. etc. facial wounds. These patients should be moved out of main triage area. spinal cord injuries. Preparedness: Medical personnel should be aware of any of the following: • An unusual increase in the number of patients seeking care for fever. Patients should be separated from main group but not removed.) • Suspicious of a large number of deaths in a period of time which is less than 72 hours in length . airway obstruction. open fractures of long bones. **People with disabilities should have a plan in case of a disaster which should include family or friends who will check on the disabled person. • Minor burns. NATO Triage System is the most widely used in a mass casualty situation. • Stable abdominal wounds. small cuts with significant bleeding Black=Priority 4-Triage category Expectant. hemo or pneumothorax and serious burns Yellow=Priority 2 – Triage category: Delayed. Comfort measures should be provided if possible • Unresponsive patients with penetrating head wounds. CISM (Critical Incident Stress Management) is a team who will provide care to prevent or treat emotional trauma that medical personnel may experience in this type situation. soft tissue injury. Three stages: Defusing. nurses may find ethical dilemmas. tagged and either transported or given life saving intervention at the scene. profound shock. Triage category is immediate. shock. meaning life threatening but survival good if treated immediately. as well as an escape route and location of special equipment used by person in the event rescue workers would be rescuing them. It should be made clear the chain of medical command. clergy. meaning injuries are significant but can wait hours for treatment after immediate casualties are treated. GI tract interruptions Green=Priority 3. meaning injuries are extensive and chance for survival is minimal. Triage category Minimal. They should be stationed away from patient care area and give updates on a regular schedule Caring for families: a team should be on hand for families of casualties: social workers. IT is as follows: Red=Priority 1. Communication: A designated person should communicate with media and family members. meaning injuries are minor and treatment can be delayed hours to days.triage are immediately assessed. • Chest wounds. Ethical Care: In the event of a disaster. Wounds involving multiple organs and/or sites. so all knows their position and duties expected. Debriefing and Demobilization. upper extremity fractures. Nurses’ role in disaster response plan: Nurses may be asked to perform duties outside their normal range of experience. They may find it hard not to care for those who are dying or that they may be asked to withhold information to prevent spreading panic and mis-information. For instance: a critical care nurse may be required to place chest tubes if a physician is unavailable. major burns in excess of 60% of BSA. therapists and counselors.

to prevent secondary contamination. • Treatment: Antibiotics are started and the patient is isolated with transmission precautions. headache and backache and after 1-2 days.• An increase in disease process in an otherwise healthy population PPE: Four levels: • Level A: HSMAT gear. so one should stand up to limit exposure. Must include a minimum of two steps: • Step one: removal of jewelry and clothing and then rinsing the patient with water • Step two: A thorough soap and water wash and rinse Biological Terrorism: Can be delivered in food. which is severe respiratory distress. a maculopapular rash appears on face. cremation is needed to prevent the spread of the infected spores to morticians and forensic medical personnel. These chemicals sink to the ground. Chemical Weapons: Characteristics: • Volatility: Ability of chemical to become a vapor. phosgene and sulfur mustard gas) . With severe diarrhea. This chemical causes death in 50% of those exposed. The incubation period is 1-6 days. There is a large amount of virus in the saliva and pusules and smallpox is only contagious after rash appears. skin contact and GI ingestion. Phosgene and cyanide most volatile. death can be prevented and treatment should be continued for 60 days. Smallpox: Variola has an incubation period of 12 days. Laundry and biologic waste is autoclaved before being washed with hot water and bleach. water. It can incubate for up to 60 days and the first stage of symptoms are flu-like and care is not sought until the stage 2 symptoms develop. nitrogen. and pharynx. contact with linens or clothing of infected person. A hallmark sign of inhalation is a hemorrhagic mediastinitis xray. mouth. Anthrax is penicillin resistant and if given within 24 hours of exposure. diarrhea. People who have been in face-to-face or household contact should be vaccinated within 4 days to prevent infection and death. If death occurs. hypovolemia is a concern. forearms. still includes chemical resistant suit and gloves • Level C: Air purified respirator and coverall with gloves and boots • Level D: Normal work uniform Decontamination: the process of removing accumulated contaminants. Anthrax: Bacillus anthracis is infective only in spore form and can cause hemorrhage. IF death occurs. • Persistence: Chemical is less likely to vaporize and disperse. or by droplets after the fever has decreased and the rash phase develops. cremation is preferred as virus can live in scabs for up to 13 years. malaise. Sulfur mustard and pulmonary agents have the longest latency. vomiting and abdominal pain. • Inhalation causes fever. including full body protection • Level B: Highest level of respiratory protection but less of skin and eye protection. • S/S: high fever. by direct contact or inhaled. These penetrate the skin and mucous membranes. Types of chemicals: Vesicants: (lewisite. Can be delivered by inhalation. • Toxicity: This is the potential for the chemical to cause injury to the body. • Latency: The time from absorption to the appearance of symptoms. is extremely contagious and is spread by direct contact. edema and necrosis.

When the patient arrives at the facility. Effects can begin anywhere from 30 mins to 18 hours after exposure. Next amyl nitrate pearls are crushed and put in ventilator reservoir. Wounds are irrigated and covered in waterproof dressings. o Decontaminate with soap and water. . • Can be inhaled. Eye exposure requires copious irrigation. For up to 24 hrs. it cannot be removed. S/S includes bilateral miosis. S/S include pulmonary edema. a hacking cough followed by a frothy sputum production. Personnel wear PPE and dosimeter badges. large blisters form. With respiratory exposure. bronchitis. A small drop can cause sweating and twitching while a larger amount can cause systemic symptoms. When triaging patients. they should be outside to prevent further contamination. visual disturbances. and death. Pulmonary Agents: (phosgene and chlorine) • Destroy the pulmonary membrane and fills the alveoli with fluid. Respiratory effects occur after blisters form. o Rapid administration of amyl nitrate. Atropine of 2-4mg via IV followed by 2 mg Q3-8 mins. pneumonia. Also Vitamin B12 can be given via IV in large doses. hematopoietic suppression. • Contamination: When the body is exposed to radioactive gases. o Decontaminate with large amounts of soap and water or saline solution for 820 mins. bronchoconstriction and incontinence and increased secretions. Do not scrub or use hypochlorite solutions as they cause penetration. Next sodium nitrate and then thiosulfate are given via IV. Fecal and urine samples are also taken. liquids or solids either externally or internally. Radiation is measured in rads. soman) • Most toxic and least expensive and can be inhaled or absorbed percutaneously or subQ and the effects result in the continuous stimulation of nerve endings. they are scanned for internal and external radiation exposure and are then showered and checked for remaining contaminants. and if the chemical penetrates. N&V. Contamination requires immediate medical management. SOB. an IV of dimercaprol is needed. intubation and a bronchoscopy to remove necrotic tissue is needed. Maintain airway and suction secretions. conjunctivitis. the lower the exposure. Water should be blotted. Strict isolation precautions are taken and all air ducts and vents should be covered. Nuclear Radiation Exposure: The farther away and the more a person is shielded. Initially looks like a partial thickness burn and after 24 hours. 100 rads is considered a high dose. Blood Agents: (cyanide). Also can give pralidoxine 1-2 grams in 100-150 ml NS over 15-30 mins. Nerve Agents: (sarin. ingested or absorbed through skin or mucous membranes. Patient is immediately intubated and placed on ventilation. not wiped off the skin. If lewite exposure. Three types of injury can occur: • External irradiation: when all or part of the body is exposed to radiation that penetrates or passes through the body. Leads to respiratory and muscle failure. respiratory and cardiac arrest and death.• Cause blistering and result in burning. Floors are covered to prevent tracking contaminants throughout facility. Biologic samples are taken from the nose and throat and a CBC is obtained. This person is not radioactive and does not need to be isolated or decontaminated and does not constitute a medical emergency. sodium nitrate and sodium thiosulfate is essential.

with total body exposure of the penetrating type. Latent Phase: (symptom free period). An ominous sign is bloody diarrhea and a high fever. respiratory distress. Phases of Acute Radiation Syndrome: • • • • Prodromal Phase: (presenting symptoms). usually seen on day 10 after exposure. with desquamation (radiation dermatitis) with rads over 1000 and necrosis with exposure to doses over 5000. They range from Erythema after exposure of 600-1000 rads. Acute Radiation Syndrome: occurs with very high levels of exposure. • The GI system is affected with 600 rads or higher. S/S are ICP and resulting death if ICP is not resolved. Illness phase: Follows latent phase ends. which is indicative of a poor outcome. bleeding. after resolution of Prodromal phase. and organs (usually liver. S/S include: infection. CNS injury on this level is irreversible. S/S includes decreased WBC & RBC production. F&E imbalance. thyroid and bone). Each body system is affected differently. N&V. loss of appetite. HA and increased ICP. • The CNS is affected with 1000 rads or higher. and fatigue. shock and altered LOC. S/S includes N&V. and increased excitability. N&V are seen. decreased platelets after 2 weeks and decreased RBC within 3 weeks. . occurs 48-72 hours after exposure. S/S include cerebral edema. and can last up to 3 weeks. Can take weeks to months to recover.• . which include decreased lymphocyte count. tissues. With high dose exposure: Fever. leading to bleeding disorders. kidney. and those with rapid cell production are most vulnerable. diarrhea. Incorporation: Actual uptake of radioactive agents into cells. etc. Within 2 hours of exposure. (Shorter with high dose exposure). • The hematopoietic system is the first to be effected and the least amount of rads causes S/S. then decreased neutrophils within 1 week. Skin: Rashes of varying degrees occur after exposure. Recovery phase: After illness phase.