CPR Steps Check or survey the scene. Rationale: There are environmental factors that could put you in danger, such as traffic, fire, or falling masonry. Check the personivictim. Rationale: The victim should be assessed to check level of consciousness and the extent of injury. Call 911 or EMS or the local emergency number. Rationale: If the victim is not responding, call 911 or ask a bystander to call 911 before performing CPR. If possible, ask a bystander to go and search for an AED machine. People can find these in offices and many other public buildings Place the person on his/her back and open the airway. Place the person carefully on his/her back and kneel beside the chest Tilt his ner head back slightly by lifting the chin Rationale: This is to prevent the tongue trom obstructing the upper airways, Jaw thrust is recommended for clients with suspected neck injury. Open the mouth Rationale: To check for any obstruction, such as food or vomit. Remove any obstruction if itis loose. If itis not loose, trying to grasp it may push it farther into the airway. Check for breathing. Place your ear next to the person's mouth and listen for no more than 10 seconds. If you do nat hear breathing, or you only hear accasional gasps, begin CPR. Rationale: If someone is unconscious but stil breathing, do not perform CPR. Instead, if they do not seem to have a spinal injury, place them in the recovery position. Keep monitoring their breathing and perform CPR if they stop breathing CPR STEPS Perform 30 chest compressions. Place one of your hands on top of the other and clasp them together. With the heel of the hands and straight elbows, push hard and fast in the center of the chest, slightly below the nipples. Push at least 2 Inches deep. Compress their chest at a rate of least 100 times per minute. Let the chest rise fully between compressions. Rationale: External chest compressions squeeze the heart between the breastbone and the spine, moving blood from the heart to the lungs to pick up‘oxygen. When pressure is released between each compression, the heart refills with blood. The oxygenated blood is delivered to the body tissues through repeated chest compressions. Good quality chest compressions are the most important part of CPR Perform two rescue breaths Making sure their mouth is clear, ttt his/her head back slightly and lift the chin. Pinch their nose shut, place your mouth fully aver his/hers, and blow to make the chest rise. if the chest does not rise with the first breath, re-tit the head. If the chest stil does not rise with a second breath, the person might be choking Rationale: Rescue breathing provides oxygen to the victim's lungs. Repeat the cycle of 30 chest compressions and ‘two rescue breaths until the person starts breathing or help arrives. If an AD arrives, carry on performing CPR until the machine is set up and ready to use Rationale: If the unresponsive victim is breathing normally, CPR is not required Place the victim in the recovery position if you must leave to get help, or if fluids or vomit may block the airway. Rationale: If the victim is breathing normally, CPR is not required. But if breathing stops, immediately roll the victim onto his back and begin chest compressions. TRIAGE STEPS Greeting Utilize proper opening script (identifies seif and patient). This will depend on your initial assessment if the patient is conscious or not. Introduce seif to patient. Identity patient using two patient-identifiers (If possible using the International Patient Safety Goal #1) Rationale: To ensure patient safety, consciousness, and determine reliability of the patient's identification process Greeting patient courteously help start the conversation and will gain his trust. Good morning Ma‘am/Sir, | am Nurse Iwill be in-charge to assess you, Please state your complete name and where you at now, Ma'am/Sir Gather appropriate demographic data | am going to ask you some questions aboutRationale: Patient demographics can help improve the quality of care to better understand background and determine differences of care yourself such as: your name, your age, your address, your gender, your race, and your ethnicity. ‘We'll keep this information confidential and will update it in your medical record, (This will depend upon the patient's consciousness) Assessment a. Identity emergency signs and symptoms b. Do rapid assessment and determine if patient requires immediate care c. Assess several signs at the same time (check for signs respiratory distress, shock or coma) . Observe the body areas affected, observe the chest for breathing and other priority signs. Listen for abnormal signs such as stridor or grunting, €. Follow the ABCD Steps in assessment Rationale: Assessment during disaster and emergency must be quick assessment that helps the triage nurse identify those patients requiring immediate care from those who can safely wait Conversing with the patient and making him/her comfortable all throughout the assessment can help develop trust and cooperation Mam/Sir, | will now look Into different areas of your body to determine some pain or any abnormality. Measure vital signs (per facility guidelines) Rationale: Taking and monitoring the vital signs give a baseline of the patient's condition. An abnormal result may give a clue of a trauma, fracture, shock or any illness that can be hurting the organs or systems in his/her bady. This is essential in identitying clinical deterioration Now, | am going to take your Vital signs in order to, determine some baseline of the care we will about to give you Gather appropriate patient history such as history of present iliness (HPI), past medical history, chiet complaint Rationale: The purpose of obtaining a health history is to gather subjective data from the patient and/or the patient's family, in order to create a plan ‘hat will promote health, address acute health problems, and minimize chronic health conditions Make assignment for care and acuity within appropriate time frame Rationale: Patient acuity is very Important to patient safety. in emergency and critical care medicine, this is the severity of a hospitalized patient's iliness and the level of attention or service he or she will need fram professional staff Offer and document interim care measures i not an emergency (splint, ice pack, emesis basin, etc) Rationale: This is performed only it permitted in in order to alleviate discomforts. Providing nursingcare using symptom management to control symptoms and promote comfort Documents appropriately. Rationale: This is essential for good clinical communication. Appropriate documentation provides an accurate reflection of nursing assessments, changes in clinical state, care provided and pertinent patient information to ‘support the multidisciplinary team to deliver great care Closing Ends interview efficiently. Informs patient of next step and expected wait If patient has to wait, instructs patienttamily member ta inform triage nurse of any changes or worsening of the problem while waiting Thank you Mam/Sir for your cooperation and for answering all-my questions. Kindly wait for your number to be called in. Should you have any difficulty of breathing, with restlessness or feels any untoward signs or symptoms while waiting please inform me or any triage Nurse right away, thank you![Ac INTRAVENOUS INSERTION routes for administration of fluids. @ Iniravenous therapy provides venous routes for ad vm Imedications, blood and other nutrients ‘To correct and prevent fluid and electrolyte imbalance. Heserves a5 route for medication administration, blood, and nutrients, Proper catheter for venipuncture (gauge will vary with body size and Br icevone gnc ee (Administration set (depends on ype of solution and rate of administration) Bin crionay Seer. eect Becta wits atrnovtcit su Fre pux NACE Physician's oder is a must before initiation of peripheral acess and administration ofan IV solution. 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Bi Regulate IV Now infsion device BE Write onthe 1V abel the date and time of IV insertion and its reglaon. P25-Revew on te limitation in movement ith lent to nity eare provider Fran problem or discomfort Position the cient for comfort with cll iit reac TI Dispose off sed nes Sharp's container nanually orset regulation, in appropriate BR Remove gloves and wash hands, — [S0.Oheek the ellen and site of TV every ‘Helps prevent the weight of the tubing from pulling the needle out of place. | Right amount of IV fluid willbe maintained based on physician's order, ' These are pertinent data in monitoin clients intravenous therapy. * Enlist clients assistance in maintenance ofthe eatheter/cannula. | * Promioies safety and comfor. + Reduces transmission of microorganism and protect sta from '* Decreases the incidence of cross- _ infection ‘* Documentation contributes to red data collection necessary for |__ the client's eare plan. ‘+ To determine if intravenous infusing correctly