Emergency Nursing Part 1

EMERGENCY Nursing

An EMERGENCY is an unforeseen happening requiring prompt action, and will exist when an individual’s physiologic or psychologic integrity is suddenly impaired.

OR

It is any sudden illness or injury that is perceived by the client or significant other as requiring immediate intervention – the emergency continues until the condition is stable or no longer threatens the client’s integrity or well being.

EMERGENCY NURSING – the nursing care of individuals and their families/ significant others with sudden or unexpected, actual or potential life/limb threatening conditions in an uncontrollable environment. It involves the nursing diagnoses and management of responses of clients/ significant others to sudden change in the health status. Accidents are the leading killer of people between the ages 1 to 44. Injuries requiring the emergency treatment plunge patients and their families into crisis.

Nurses are frequently called on to provide emergency care in the community or in settings where medical help is not immediately available, therefore all nurses need to know the basics of emergency care; beginning at the accident scene and continues until patient’s condition has stabilized or until patient is transferred to a care facility.

Developing first aid common sense is an important part of providing first aid care. When first aid is properly given the effects of injuries and medical emergencies can reduce, it can keep an ill or injured person alive, and can mean a difference between a short and a long hospital stay. Proper first aid must be given quickly and effectively or the victim’s condition can become more serious by the time further help arrive on the scene of the incident through rehabilitation and discharge planning.

EMERGENCY CARE

Objectives Of The Emergency Management:

 To preserve life

 To prevent deterioration before definitive treatment can be given

 To restore the patient to useful living

Goal Of Emergency Care – prompt, effective resuscitation and stabilization of critically ill or injured clients.

Triage – “sorting” “prioritizing”

 Used in establishing emergency care priorities.

 A process of distinguishing between patients with minor or major injury at the scene of the injury and in the emergency room.

 It is separating persons who require immediate care from those who can wait for aid and selecting the best hospital for all. In the best circumstances, the triage personnel rapidly identify those persons with the most severe injuries, provide them with the appropriate level of resuscitation, and dispatch them to the nearest hospital most equipped to help them.

Triage Category :

• Emergent – life threatening emergency; usually involves the ABCs; the client may die without intervention done immediately

• Urgent – emergencies that require intervention within a few hours

• Non-urgent – not life-threatening; interventions may be delayed beyond a few hours

FOUR-COLOR CODED TRIAGE SYSTEM

( Civilian Triage System)

• 0 - Black – DEAD

• 1 - Red – CRITICAL OR LIFE THREATENING

 These victims have a reasonable chance of survival only if they receive immediate treatment. Emergency treatment is initiated immediately and continued during transportation.

 This category includes victims with respiratory insufficiency, head injury with decreasing LOC, hemorrhage and severe abdominal injury.

2 - Yellow – SERIOUS

 These victims can wait for transportation after they receive initial emergency treatment.

 They include victims with immobilized closed fractures, soft-tissue injuries without hemorrhage, and burns on less than 40% of the body.

3 - Green – MINIMAL

 Victims in this category are ambulatory, have minor injuries and may be dazed. They can be treated by nonprofessionals and held for observation if necessary.

FOUR EMERGENCY ACTION PRINCIPLES:

In the excitement of an emergency, it is important to stop for a moment to clear your head and think before you act. When responding to an emergency situation, remain calm and apply the following four emergency action principles.

1. Survey The Scene – when you respond in an emergency, make a quick decision-making survey of the entire scene. Do not look only at the victim;

look at the area around the victim (should take a few seconds only). Decide what needs to be done immediately and the order in which you will take steps.

Consider the following as you survey:

IS THE SCENE SAFE?

Do not try to help the victim by becoming a victim yourself. If you cannot get to the victim because of extreme hazards, such as fire, toxic fumes, electrical wires, deep or swift-moving waters, open electrical wires, etc. – call for help (EMS)

If you can get safely to the patient, decide whether it is safe to remain at the scene while you continue the steps of the emergency action principles and care for the victim.

If it is not safe, you may need to make an immediate emergency rescue. As a general rule, do not move an injured person if you do not have to.

WHAT HAPPENED?

• If the victim is conscious, ask specific questions to determine what happened and the extent of the victim’s illness or injury

• If the victim is unconscious, look around for clues – the scene itself often gives the answer

• Quickly look for a medical alert tag if the patient is not responsive which may provide information about what might be wrong and how you could care for the victim.

HOW MANY PEOPLE ARE INJURED?

Look beyond the victim you see at first glance – there may be other victims

ARE THERE BYSTANDERS WHO CAN HELP?

Use the bystanders to help you find out what happened

Bystanders may not be trained in first aid but can help you in other ways, such as calling for help, offering emotional support to the victims, and keeping onlookers from getting too close to the scene

Identify yourself as a person trained in first aid

 Tell the victim and bystander who you are and that you are trained in first aid – this might help reassure the victim

 You can take charge of the situation, letting others know that a trained person is at hand

 Before giving first aid to a conscious patient, obtain his/her consent

2. Do A Primary Survey (Primary Assessment) Of The Victim – the purpose of the primary survey is to check for life-threatening conditions and to give

urgent first aid

Check for life-threatening conditions – check the ABC’s

 Airway - does the victim have an open airway? open an unconscious victim’s airway using the HEAD-TILT/CHIN-LIFT

 METHOD (if cervical spinal injury is ruled out) and the JAW-THRUST METHOD (if with neck injury)

 BREATHING - check for breathlessness (LOOK-LISTEN AND FEEL)

 CIRCULATION - is there a pulse (CHECK CAROTID PULSE)

- Is the person bleeding severely?

- then control any severe bleeding

3. Shout/ Call For Help Or Phone Emergency Medical Services System For Help, If Applicable

= First step in the adult BLS protocol is to access EMS

= However for the pediatric BLS protocol, 1 minute of CPR is recommended before breaking to call EMS

Make call accurately to include information such as location, caller’s name,tel. no. used, what has happened, no. of victims, victim’s condition, the help being given.

4. DO A SECONDARY SURVEY (SECONDARY ASSESSMENT OF THE VICTIM

– the purpose of secondary survey is to check the victim carefully and in orderly way for injuries or other problems that are not life-threatening but which could cause problem if not corrected.

Interview the patient and bystanders

Check vs. –pulse, RR, skin appearance

Do a Head-to-Toe exam.

NURSING PROCESS IN EMERGENCY

CARE SETTINGS

1) Components of the nursing process is similar to those used in other settings.

2) Several factors influence nursing process in emergency care settings and include the following:

 Limited time frames

 Urgency of the person’s condition

 Possible need for definitive care in another clinical setting

 Limited historic information

 Role and resources of the emergency
3) Often intervention occurs before complete assessment is done, OR sometimes done simultaneously with the assessment.

4) Nursing diagnoses is limited to those that can be managed in an emergency setting.

5) A detailed, written, personalized care plans are not routinely employed in an emergency care setting – rather a standardized care plan is used

EMERGENCY ASSESSMENT

 When an emergency occurs or on arriving at the emergency scene, it is important to assess the situation, the patient, and the environment before initiating action.

 Obtain as much information as quickly as possible by getting a brief history of the situation because this can provide clues to the priority assessments and interventions, using the mnemonic

A – llergies

M – edication currently prescribed or using

P – ast medical and surgical history

L – ast meal

E – vents preceding the emergency and any care rendered

 As with most critical illness, assessment followed by appropriate intervention will influence the ultimate outcome for the traumatized patient

 Primary Assessment – initially made to maintain the patient’s airway, breathing and circulation (ABCs) as well as perform any necessary hemorrhage control

 Assess for any life-threatening problems involving the patient’s ABCs – if you detect any problems immediately begin Basic Life Support (BLS) or Advanced Cardiac Life Support (ACLS)

 With BLS, establish the patient’s unresponsiveness, and whether the patient has respiratory or cardiac arrest; then use CPR to restore patent airway, breathing and adequate circulation.

 In the hospitals, ACLS technic is used employing airways, ventilatory and circulatory adjuncts, monitors, occasionally drugs, and defibrillation or cardioversion equipments.

 Secondary Assessment – identify the patient’s most serious problems by evaluating subjective and objective factors and is usually done when the patient’s ABCs has stabilized. A complete head-to-toe assessment is carried out in order to identify subjective and objective factors.

PRIORITY ASSESSMENT GUIDE

AIRWAY

 presence of respirations

 presence of foreign body,

 vomitus, loose dentures in mouth

BREATHING

» respiration rate, depth,

» character

» use of accessory muscles for breathing

» Tracheal deviation

CIRCULATION

» presence of carotid pulse

» pulse rate, strength, rhythm

» presence of hemorrhage

» skin color, temperature, moisture

LEVEL OF CONSCIOUSNESS

» response to voice and touch or painful stimulus

» Pupillary response

» in unconscious patients – presence of Medic-Alert tag

GENERAL INTERVENTIONS - Some Principles Of Management when accidental injuries or sudden illness occur serve as guidelines when giving first aid care:

• Remain calm and think before acting

• Identify oneself as a nurse to the victim and bystander

• Do a rapid assessment for priorities (such as cessation of breathing or heartbeat)

• Carry out lifesaving measures as indicated by the priority assessment

• Do a head-to-toe assessment before initiating general first aid measures

• Keep the patient lying down or in the position in which he or she is found (unless orthopnea is present), protected from dampness or cold

• If victim is conscious, explain what is occurring – assure him or her that help will be given

• Avoid unnecessary handling or moving of the victim; move the victim only if danger is present

• Do not give fluids if there is possibility of abdominal injury or if anesthesia will be necessary within a short time

• Do not transport victim until all first aid measure have been carried out and appropriate transportation is available

– Lifesaving measures are carried out first when the initial assessment indicates the presence of breathing or circulatory difficulties.

– After breathing has been reestablished and excessive bleeding controlled, other interventions are carried out when the head-to-toe assessment is completed.

PRIORITY NURSING INTERVENTIONS

• Airway patency

• Supplemental oxygenation – initiated at 6-10 L/min

• Spinal precautions and immobilization

• CPR

• Brief Neurologic examination

• Psychological support of the needs of the victims and significant others

• Discharge planning

CARDINAL RULE OF INTERVENTION – “DO NOT FURTHER HARM”

Interventions may not be personalized – it is often based on a standard protocol as a result of research findings and experience.

DOCUMENTATION – should be accurate and organized

AIRWAY OBSTRUCTION AND BREATHING DIFFICULTIES-ASPHYXIA

Severe hypoxia leading to unconsciousness and possible death if the condition is not corrected.

Assessment Findings :

a) constricted pupils

b) dyspnea

c) prominent neck muscles

d) intercostals rib retractions

e) noisy respirations or laryngeal stridor

f) cyanosis

g) bradycardia and shallow respirations or cessation of breathing

Treatment :

• Open airway through proper head

positioning or Heimlich maneuver

b) CPR

c) supplemental oxygenation

d) Supportive care (Vital signs, support nutrition, fluid and electrolytes, elimination and psychological support)

ACUTE MYOCARDIAL INFARCTION

Sudden onset of severe chest pain without precipitating factors

Assessment Findings :

a) severe substernal chest pain which may radiate to the arms, jaw and neck;

b) anxiety and apprehension

c) diaphoresis

d) nausea and vomiting

e) lightheadedness and dyspnea

Treatment :

a) If no respirations and heartbeat - perform CPR

b) Oxygen and proper positioning (semi-Fowler’s)

c) maintain a calm atmosphere

d) pain medications

e) vital signs

f) Supportive care

Near Drowning and Drowning

Drowning is the fourth leading cause of accidental death in the US – many of these drowning occur in home swimming pool.

Most deaths due to drowning is caused by the respiratory obstruction as a result of bronchospasm or laryngeal spasm resulting from the effort to breathe under water.

Near Drowning – refers to surviving, temporarily at least, the physiologic effects of hypoxemia and acidosis that result from submersion in fluid; it also refers to asphyxiation from a fluid medium, with the person either recovering spontaneously or resuscitated at least, temporarily

Three Forms of Near Drowning

• Wet Drowning – the most common type and refers to asphyxiation from the aspiration of fluid into the lungs, inhaled as the person panics and hasps for breath.

• Dry Drowning – refers to asphyxiation from laryngospasm that prevents both air and water from entering the lungs

• Secondary Drowning – the recurrence of respiratory distress after recovery from the initial incident – occurs from a few minutes to several days later.

Immersion Syndrome – death after submersion in very cold water, thought to be caused from dysrhythmias resulting from vagal stimulation.

Effects of water aspirated into the lungs:

Salt water – because of its hypertonicity, pulls fluid into the alveoli, causing persistent hypovolemia with hemoconcentration and pulmonary edema.

Freshwater – rapidly absorbed into the circulation, causing temporary hypervolemia, hemodilution and intravasculasr hemolysis.

Both saltwater and freshwater wash out alveolar surfactant leading to alveolar collapse.

Hypoxemia and Metabolic Acidosis – the most serious consequences of near drowning.

Assessment Findings :

a) history of submersion

• cardiopulmonary arrest – asystole, apnea

• cyanosis, lethargy, confusion, unconsciousness

• fluid and electrolyte abnormalities – vomiting, abdominal distension, restlessness, irritability

• cough produces a frothy, pink sputum (pulmonary edema)

• hypothermia

Interventions :

 Vigorous, prolonged CPR – possibly for several hours

 Do not waste time trying to remove water from the lungs – ventilate immediately with 100% oxygen and 5 – 10 cm of PEEP

 ABGs, CBC, Electrolytes and STAT Portable Chest film

 CVP lines

 Diuretics and other appropriate therapies if pulmonary edema is present

 Insert foley catheter, measure urine frequently

 NGT insertion to remove swallowed water

 Evaluate for other injuries – suspect C-spine injury if the person is unconscious

 Treat the cause of near drowning – such as MI

 Perform appropriate toxicologic studies for suspected drug or alcohol ingestion

 Steroids may be used, although still controversial

 Antibiotics

 Admit the patient and observe for 24 to 48 hours – Repeat Chest film after 24 hours

 Give psychological support

HEMORRHAGE / BLEEDING

An escape of blood from the blood vessels, resulting in either external or internal loss of blood, and fluid shifts; resulting from cell membrane dysfunction, and leading to intravascular volume depletion.

Assessment Findings :

a) frank bleeding for external hemorrhage

b) changes in pulse rate

c) signs and symptoms of circulatory collapse (shock)

d) low urine output

Interventions :

a) Direct pressure (for external bleeding)

b) Use of tourniquet

c) Surgical intervention for internal bleeding

d) Fluid replacement

SHOCK

Circulatory shock is a profound alteration in tissue perfusion; occurring from either a decreased cellular perfusion or an inability to use an adequate perfusion.

Assessment Findings in Shock :

• Mild

- skin is pale, cool and clammy

- possible postural changes in pulse and blood pressure

- the patient states feeling cool

• Moderate

- increased diaphoresis and pallor

- pulse may be rapid, and blood pressure may decrease

- thirst

• Severe

- pulse rapid, weak, sometimes irregular

- blood pressure low

- respiration deep and rapid

- agitation, disorientation

General Intervention :

 Ensure adequate airway and ventilation

 Initiate oxygen therapy at 6-10 L/min (unless the patient has history of COPD)

 Start at least one peripheral IV line at least with a large gauge needle – G-14 to –16 catheter

 Initiate cardiac monitoring

 Preposition anti-shock suit on a stretcher, if possible

 Insert foley catheter – monitor urine output q 15 min to 30 min

 Initiate continuous vital signs monitoring, document on the flow sheet

 Provide continuous psychological support to the person and significant others.

Hypovelemic Shock

Assessment Findings:

 cool, clammy skin

 hypotension

 diaphoresis

 flat neck veins

 history of volume loss ( bleeding, hemorrhage)

Interventions :

 Positioning – Modified Trendelenburg – to increase the circulating blood volume to the vital organs

 Start a second IV line – infuse LR or NSS, blood products

 Draw appropriate laboratory studies specimen

 Prepare for insertion of central lines, or arterial lines, if possible

 Initiate measure to stop bleeding if appropriate – pressure dressings, direct pressure

Cardiogenic Shock

Assessment Findings:

 alterations in LOC

 tachycardia

 tachypnea

 hypertension

 distended neck veins

Interventions :

 Hang an IV of D5W cc with a microdripper

 Pressor agents – Dobutamine, Dopamine

 Other medications depending on the etiology of the cardiogenic shock – MI, CHF – such as diuretics, anitarrhythmics and digitalis

 Surgical Management – as in temporary cardiac pacing

 Insertion of CVP or Swan Ganz catherers

 Other management will depend on the etiology

Assessment Findings :

 history of exposure to allergens such as bee stings, etc

 hypertension

 urticaria (hives)

 generalized swelling

 bronchospasm and wheezing

 hoarseness

 nausea, vomiting

 generalized itching or burning

 a sense of impending doom

Interventions :

 Prepare for surgical management of the airways.

 Decrease further absorption of the antigen – stop IV fluids; place tourniquet between injection/ sting site and heart if feasible; elevate injection/ sting site above the site.

 Epinephrine 1:1000 0.3 – 0.5 ml IM, SC or sublingually, or by inhalation.

 Epinephrine 1:1000 0.5 to 10 ml IV slowly over 5 – 10 minutes

 IV fluid resuscitation with isotonic solution

 Give medications such as Diphenhydramine HCL (Benadryl) 50 – 100 mg IM; Aminophylline IV drip for bronchospasms; Steroids; Vesopressors such as neropinephrine, dopamine.

 Ice pack to injection/ sting site

 Meat tenderizer paste to sting site

Septic Shock

– often associated with gram-negative septicemia

Assessment Findings :

 warm, flushed skin with fever

 subtle change in the LOC such as confusion, agitation

 Hypotension

Interventions :

 Identify origin of sepsis

 Apply MAST suit/ positioning

 Vigorous IV resuscitation

 Antibiotic therapy

 Dopamine or Dobutamine, Aramine, Norepinephrine, Isoproterenol, Digitalis, Calcium

 Temperature control

 Medications such as – Naloxone; Diphenhydramine HCL; Steroids; and Herapin if DIC develops

Neurogenic Shock

– results from adequate vasomotor tone of the blood vessels which causes them to unable to constrict appropriately.

Assessment Findings :

 Bradycardia

 Hypotension

 Warm, dry skin

Interventions :

 Treat bradycardia with atropine

 Vasopressors such as neropinephrine, aramine, dopamine

MULTIPLE TRAUMA

Refers to injury to two or more body systems and occurs with such severe injuries such as –

 Crushing and penetrating chest injuries

 Crushing pelvic injuries

 Spinal cord injuries

 Multiple bone of soft tissue injuries

 Injuries causing hemorrhage with shock

 Head injuries with decreasing LOC

Mechanism of Injury

 Motor vehicular accidents

 GSW

 Stabwounds

 Falls or jumps from high places

 In motor vehicular accidents the head is injured 80% most of the time, legs 40%, chest 25% and abdomen 15%.

 Falls from great heights often cause multiple fractures, for example, legs, hips, spine, pelvis, base of skull.

 Penetrating chest wounds may also involve abdominal organs.

Victims of multiple trauma require rapid stabilization at the accident site followed by immediate transfer to an emergency room.

The care of accident victims with multiple trauma is complex and requires high quality medical and nursing care by specialized practitioners in both emergency rooms and ICUs – the treatment of one system may add to the problems of another injured system. For example, large amounts of fluid given to alter or prevent renal problems may compromise an inadequate ventilatory system

Intervention – General Interventions :

 Ensure as adequate airway with spinal immobilization

 Ventilate and initiate oxygen therapy at 6 – 10 L/ min

 Insert one or two peripheral IV lines using G-14 to 16 catheter

 Initiate cardiac monitoring

 Insert an NGT

 Insert a urinary catheter, if no blood is present in urinary meatus

 Monitor urine output every 15 to 30 minutes

 Monitor vital signs continuously and document

 Provide continuous psychological support

Snake Bites

Assessment Findings

a) Local reactions such as –

 Intense burning pain immediately after the bite

 Swelling and copious bleeding

 Two puncture wounds above and two bites below

 Blisters and bleeding develop with in 1 hour and becomes large and hemorrhagic

 Significant swelling

b) Generalized reactions

 Muscle twitching and fasciculation, especially around the mouth

 Metallic taste in the mouth

 Nausea and vomiting

 GI bleeding

 Diaphoresis

 Tachycardia

 Hypotension

 Syncope and coma

 Shallow respiration progressing to respiratory arrest

Interventions

a) Maintain and support the ABCs

• Act calmly and reassure the person –

position the patient at rest, placing the

involved part at heart level as possible

b) Apply a constricting band above the site – to minimize lymphatic and venous

return, if necessary, move the band up the limb ahead of the swelling

c) Provide cardiac stabilization

d) Wash skin, incise and suction wounds to remove venom

e) Bitten area can be cooled

• Start one or two large bore IVs

• Draw blood for laboratory studies

• Steroids may be used for anaphylactic reactions – however, it is contraindicated in routine treatment of snake bite as they may enhance absorption of venom or block antivenin action

• Administer antivenin IV

• Measure girth of the extremity proximal to bite every 15 – 30 minutes

• Administer tetanus prophylaxis and antibiotics as ordered

• Cardiac monitoring and intensive nursing care

• Pain relief

• Limit initial wound care to cleansing and dressing with large, absorbent, bulky dressing

Assessment Findings

 stingers may be seen

 local erythema

 edema and pain

Interventions

 Remove stinger by scrapping it

 Clean the area – apply meat tenderizer paste

 Learning/ teaching – such as prevention of bee stings

ANIMAL BITES – may result in puncture wounds, lacerated wounds and avulsions as the individual pulls away from a biting animal.

 Cat bites produce a higher percentage of infections, mostly by Pasteurella multocida (an organism commonly found in animal mouths).

 Dog bites become infected only in about 5% of cases. Be sure to assess the possibility of rabies from the biting animals, especially after dog or wild animal bites.

Assessment Findings

 history of a bite

 puncture wounds, lacerated wounds or skin loss

Interventions

 Carefully wound cleansing – irrigate and debride wound

 Apply bulky, fluffy and absorbent dressings

 X-Ray of hand or head to assess possible fractures

 Rabies prophylaxis if indicated, especially if the animal cannot be kept for observation

 Tetanus prophylaxis

 Antibiotics may be given – Penicillin

 Provide psychological support