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Emergency and critical care
management
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Emergency Nursing Management
care to patient with urgent and critical needs
emergency is whatever the patient and family
considers it to be
care without delay
the strength of nursing and medicine are
complementary in an emergency situation
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Issues in Emergency Nursing
Carelegal issues
occupational health and safety risk for EDstaff
challenge of providing holistic care in the
context of a fast-paced technology driven
environment
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Patient focused
interventions:act confidently and
competently
Explanations that the
patient can understand
Human contact and
reassuring words
unconsious patient betreated consciously
reorientation as patient
regains consciousness
Family focused
interventions:
encouraged the fam
members to talk about
feelings
Encourage asking
Encourage verbalization
of feelingsAllow anger to be
ventilated
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Principles of Emergency Care
Rapid assessment, treatment and
referral to appropriate setting for
ongoing career
Triageto sort
used to sort patients into groups based on theseverity of their health problems and the
immediacy with which these problems must be
treated
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Assesss and intervene
Airway
adequate ventilation
and resuscitation
Evaluate and restore
cardiac output
neurologic disability
Primary survey
focus on stabilizing lifethreatening conditions
Secondary survey
done after primary survey areaddressed
health history
head to toe assessment
diagnostic findings
application of monitoring
devices
splinting of fractures
wound dressing
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Roles and responsibilities
expert in assessing and identifying patients health care problems
Specialized education training and expertise
establishes priorities
monitors patient continuouslysupport and attends to families
collect crucial initial data
maintain privacy and confidentiality
good communication
use all resources
health teaching
crowd control
Emergency nurse
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Q ualifications to become an ER nurse
possess valid RN license
certified Basic Life support
minimum of 2 years critical care nursing
experience with at least 6 months of this being in
emergency department
have at least 3 evaluation shifts in role of triage
be able to function well under stressful situation
able to make accurate assessment regarding
patient care
have working knowledge on internal operations
of emergency department
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have firm convictions
possess good communication skillsbe able to offer emotional support
able to think ahead
a spot teacher
control traffic flow
possess good crisis intervention skills
assist in discharge planning
able to deal with patient communication
problems
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Critical Care Nursing
- is the field of nursing with a focus on
the utmost care of the critically ill or
unstable patients. Critical care nursescan be found working in a wide variety
of environments and specialties, such
as emergency departments andthe intensive care units.
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Functions of the critical care nurse
1. Assesses and implements treatment for patient
2. Provides direct measures to resuscitate
3. Uses independent, dependent, and
interdependent interventions
4. Provides health education
5. Supervises patient care and personnel
6. Supports patient adaptation, restores health, and
preserves the patients rights
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Legal issues affecting the
provision of critical care nursing
1. Negligence
2. MALPRACTICE
3. INFORMED CONSENT
4. Implied consent
5. Advanced directives, including
DURABLE POWER OF ATTORNEY and living wills
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Q ualifications of a Critical Care Nurse
A diploma in nursing, an associates degree in nursing (ADN)
or a bachelors degree in nursing (BSN) and pass a national
licensing exam.
Certification is not mandatory
A required number of clinical hours
Certified critical care nurses (CCRN) must have been in
critical care practice for a minimum of two years to be eligible
for the examination.
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Emergency Conditions
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WoundTypes:
Laceration-skin tear with irregular edges
Avulsion-tearing away from supporting structures
Abrasion-denuded skin
Ecchymosis/contusion-blood trapped under the skin
Hematoma-tumor-like mass of blood trapped under skin
Stab wound-incision of skin with well-defined edges
cut/incision-incision of skin with well definededges,usually longed and deep
patterned-wound representing the outline of object
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assessment
when and how the wound occurred
extent of damage
sensory motor and vascular function changes
managementhair around the wound is clipped or shaved
normal saline solution or polymer agent
antibacterial agent (betadine) not allowed
to get deep into wound without rinsing
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primary closure
wound suturing depends on:
.nature of wound
.time since the injury sustained
.degree of contamination
.vascularity of tissue
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Sutures:
- placed near the wound edges with
the skin edges elevated carefully to
promote optimal healing
Sterile strips:
- for close and clean superficial
wounds
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Delayed primary closure
Indication:
high potential for infection
loss of tissues
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Poisoning
- any substance that when ingested,
inhaled or injected can injure the body
Accidental poisoning are common in
children
Intentional poisoning are common inadolescent and adult
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Ingested poisons
-maybe an alkaline or acidic substanceAssessment:
Substance taken
Amount
time of ingestion
signs and symptoms ( pain or burning sensation)
any evidence of redness or burning in the throat,pain on swallowing
inability to swallow, vomiting or drooling, age and
weight of patient, pertinent history
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Management:
Control airway, ventilation, oxygenation
Stabilize cardiovascular and other functions
Remove toxins or decrease absorption
Corrosive poison- give water or milk fordilution
Dilution is not attempted if theres:
Acute airway edema or obstruction
Clinical evidence of esophageal or gastric
damage
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Gastric emptying procedures
- syrup of Ipecac
-gastric lavage
-activated charcoal-cathartic
Antidote
- specific chemical or physiologic
antagonist administered as early as
possible
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Inhaled poisons: Carbon Monoxide
poisoning- industrial, household incidence CO binds to
hemoglobin reducing its O² carrying capacity
Assessment:
Skin color ( pink or cherry red to cyanotic)- not a
reliable sign
Pulse oximetry not valid (blood may appear
saturated based on reading but not with O²)
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Management:
Immediate treatment
Carry patient to open space with fresh air
immediately
Open all doors and windows
Keep patient as quiet as possible
Admin. 100% O²
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Skin contamination poisoning
Management:
Drenche immediately with running water
Water should not be applied to burns from
lye- potential for explosion or deepening of
wound
Skin of health care provider should be
protected as well
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Food poisoning
- sudden illness after ingestion of contaminatedfood or drinks
- botulism
Assessment:
How soon S/Sx occur?
How does food smell?
Diarrhea? Neurologic symptoms?
Fever?
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Management:
Determine source and type of food poisoning
Bring suspected food to medical facility
Support respiratory system
Admin. Fluid and Electrolytes
Control nausea to prevent vomiting
- mild nausea ( give sips of weak tea, carbonated drinks,
tap water)
After nausea subsides give clear liquids for 12 hrs.
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Environmental emergencies
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Heat stroke
- Heat stroke is a form of hyperthermia
- Heat stroke is a medical emergency and
can be fatal if not promptly and
properly treated.
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Management:
Reduce high temp as quickly as possible
Apply ice to neck, chest , axilla, groin while
spraying with tepid water
Cooling blankets, ice saline lavage
Massage patient
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Frost bites
trauma from exposure to freezing temp
cellular and vascular damage
commonly affected: feet, nose, hands, ears
First degree ( redness and erythema) to fourth
degree ( full depth tissue destruction)
Frozen extremities are hard, cold and insensitive to
touch
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Management:Remove constrictive clothing and accessories
Early ,controlled,and rapid rewarming
Do not massage
Once rewarmed, affected part is elevated
Gauze placed between fingers to avoid maceration
Do not rupture bleb
Whirlpool bath
Tetanus prophylaxis
Movement of affected extremities
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Triage system: hierarchy based on
potential loss of life
1. Routine Emergency Triage Protocols(civilian type): directs all available
resources to patients who are most
critically ill, regardless of potentialoutcome
2. Field Triage/ Hospital triage during a
disaster (military type): scarce resources
must be used to benefit the most people
possible or to those with and increased
risk of survival
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French doctors during World War I:
Likely to live, regardless of what care to
receive
Likely to die, regardless of what care to
receive
Whom immediate care might make a
positive difference in the outcome
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Types of triage1. Simple
- used in mass casualty incidents
-sorts those who need critical attention and
immediate transportation to hospital and those with
less serious injuriesSTART model (Simple Triage And Rapid Treatment)
-performed by lightly trained individual and
emergency personnel but not intended to supersedeor instruct medical personnel or techniques
-developed at Hoag Hospital in Newport Beach,
California
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4 groups:
-Expectant who are beyond help (Black)
-Injured who can be helped by immediate
transportation (Red)
-Injured whose transportation can be delayed
(Yellow)
-With minor injuries who need help less
urgently (Green)
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2.Advanced
-has ethical implications-to divert scarce resources to patient who dont
have the chance to live
-Western EuropeTriage Revised Trauma Score
-medical validated scoring system
incorporated some triage conditionsInjury Severity Score
-assign score from 0-75 based on severity
of injury
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Emergent: highest priority; life-
threatening; immediate
Urgent: Severe Health Problems but not
immediately life threatening but must be
seen within 1 hour
Non-urgent: episodic illness can be
addressed within 24 hours without
increasing morbidityFast-track: require simple first aid or
primary care
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North Atlantic Treaty Organization
(NATO)
-widely used-according to the severity of injury
Immediate (Red):injuries are life-threatening;
survivable with minimum intervention
sucking chest wound; airway obstruction; shock;
hemothorax; asphyxia; abdominal wounds;
incomplete amputations; open fractures; 2 or 3
degree burns; pneumothorax
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Delayed (Yellow): injuries are significant and
require medical care but can wait for hours
without threat to life or limb
stable abdominal wounds without significanthemorrhage; soft tissue injuries; maxilla-
fascia wounds without airway compromise;
vascular injuries with adequate collateral
circulation; genitourinary tract injuries
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Minor (Green): minor; treatment delayed byhours to days
upper extremity fracture; minor burns;sprains; small lacerations withoutsignificant bleeding; behavioral disorders/
psychologic disturbances
Expectant (Black): chances of survival are
unlikely; person is separated but notabandoned; comfort measures provided
unresponsive; spinal cord injury; MODS
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Regional Variation
1. United States of AmericaNATO evacuation priority:
>Urgent: within 2 hours to save
>Priority: within 4 hours or will casually
deteriorate to urgent>Routine: within 24 hours to complete treatment
Methods of Field assessment
Secondary survey categories:
Class 1: minor treatment can return to dutyClass 2: injuries require immediate threat to life
Class 3: injuries are serious but not a threat to life
Class 4: expectant
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2. Canada (Primary Care Level Paramedics)
Canadian Triage and Acuity Scale: injury andphysiologic findings are ranked by severity from 1 5
3. United Kingdom (Smart Incident Command System)
Major Incident Medical Management and Support: armed forces;
prioritized 1 4
Categories:
Dead: trauma score0
-2; beyond helpImmediate: trauma score 3-10;need immediate attention
Urgent: trauma score 10-11; medical care can be delayed
Delayed: trauma score 12; does not need immediate care
i l d
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3. Finland(Red) cannot wait
(Yellow) has to wait(Green) can wait
(Black) lost
4. France-performed by doctors4 level scale:
DCD: deceased; beyond urgencyUA: absolute urgency; treatment on
siteUR: relative urgency; waiting forevacuationUMP:medical psychological emergency;
lightly wounded but psychologically
shocked
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5. Germany
-preliminary assessment done at the ambulance
-no CPR done so if person cannot breathe, considerdeceased
T1 (Red) immediate transportation ASAP
T2 (Yellow) constant observation and rapidtreatment, transportation as soon aspractical
T3 (Green) treatment when practical, diagnosewhen possible
T4 (Brown) observation and administration of analgesia
T5 (Black) collection of bodies; identify if possible
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6. Israel
-simplified description of START
Immediate: injure who are lying on
ground silently
Delayed: injured lying on ground
but screaming
Walking wounded: help less urgent
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6. JapanI life threatening
II non- life threatening but urgent treatment requiredIII minor injuries
O dead; survival unlikely
Evacuation Field triageDeceased left where they fell, covered if
necessary
Immediate (Priority 1)
Delayed (Priority 2)
Minor (Priority 3)