emergency nursing outline

7/31/2019 Emergency Nursing Outline

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Emergency Nursing Terms 3/23/2012 6:09:00 PM

Antivenin: antitoxin manufactured from venom of poisonous snakes to

assist the patients immune system response to an envenomation.

Carboxyhemoglobin: hemoglobin that is bound to carbon monoxide and

therefore is unable to bind with oxygen, resulting in hypoxemia.

Corrosive Poison: alkaline or acidic agent; causes tissue destruction aftercontact

Cricothyroidotomy: surgical opening of the cricothyroid membrane to

obtain an airway that is maintained w/ a tracheostomy or endotracheal tube.

Diagnostic Peritoneal Lavage:instillation of lactated Ringers or normal

saline solution into the abdominal cavity to detect red blood cells, white

blood cells, bile, bacteria, amylase, or gastrointestinal contents indicative of

abdominal injury.

Emergent: triage category signifying potentially life-threatening injuries or

illnesses requiring immediate treatment.

Envenomation: injection of a poisonous material sting, spine, bite, or other

means.

Fasciotomy: surgical incision of the extremity to the level of the fascia to

relieve pressure and restore neurovascular function to the extremity.

Hare Traction: portable in-line traction applied to the lower extremity to

manage femur or hip fracture or dislocations.

Minor: triage category signifying non-life threatening injuries or illnesses

that can be routinely managed in a clinic or physicians office or that requireno medical care.

Nonurgent: triage category signifying episodic or minor injury or illness in

which treatment may be delayed several hours or longer without increased

morbidity.

Resuscitation: triage category signifying life-threatening injuries or

illnesses requiring immediate intervention.

Triage: process of assessing patients to determine management priorities.

Urgent: triage category signifying serious illness or injury that is not

immediately life-threatening.

Emergency Management: care given to patients with urgent and critical

needs.

Grief: complex emotional response to anticipated or actual loss.


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Emergency Nursing- Outline 3/23/2012 6:09:00 PM

Scope and Practice of Emergency Nursing

Issues in Emergency Nursing Careo Independent and dependent nursing interventions

Documentation of Consent and Privacyo Consent is always given except if pt. is unconsciouso What is included in documentation?

Monitoring of pts condition, Rx & time administered,response to Rx, condition at d/c or transfer w/ follow-up

care.

Privacy policy Limiting Exposure to Health Risks

o Health care providers @ higher risk for communicable dses Due to lack of comprehensive medical hx HEPA: high efficiency particulate air filter mask Potential high risk for chemicals, gases, & radiation

Violence in the Emergency Departmento Nurses must deal w/ the high emotions of fam & friendso Prisoners:

Hand/ankle restraint never released Guard in the room Pt placed face down on bed to avoid spitting, banging Meds may be administered

Providing Holistic Careo Pts and family may fear:

Anxiety, denial, remorse, guilt, anger, grief, andreconciliation. -> Ineffective Coping

Initial goal: anxiety reduction Patient-focused Interventions

Even tho the pt is unconscious, should still provide

explanations & validate name

Family-focused Interventionso Always inform the famo Ok for fam to present during resusc to answer was

everything done?

Anxiety & Denialo Honest answers given at lvl of anxiety of fam


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Remorse & Guilto Promote verbalizations

Angero Allow expression of anger

Griefo Allow expression of crying

Caring for Emergency Personnelo Nonjudgemental counseling & stress debriefing

Emergency Nursing & the Continuum of Careo Pt. is rapidly assessed, treated, referred

D/C planningo Verbal & written instructiono legibleo Should be avail. In all languageso Instructions include: prescribed meds, treatments, diet,

activity, when to contact a h.c provider

Community Serviceso Social workero Home care resources

Gerontologic Considerationso 65 years & oldero weakness, fatigue, falling, usu. Atypical presentationo nurse asses psychosocial resources, anticipate d/c,o referrals for support services

Principles of Emergency Care

Triage: RESUSCITATION, EMERGENT, URGENT, NONURGENT,MINOR

4th category- FAST TRACKo require simple first aid only

UP-TRIAGING: used if pt. has v/s that deviates Resources: imaging studies, meds via IV or IM, sedation Nurses must collect:

o v/s, pain assess., hx, past medical hx, weight, allergies,domestic violence screening, diagnostic data

o SAMPLE: signs/symptoms, allergies, past medical hx, last oralintake, events that occurred before


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o LMP, smoke or drugs?, under a physicians care?, last tetanusimmunization

Other responsibilities of the nurse:o Basic first aid: ice, bleeding control, basic wound care,

protocol based order (antipyretics, analgesics, ECG,urinalysis, in chare of waiting area, safe environment

Assess & Intervene

Prompt transfer Primary & secondary survey Follow ABCD Treat shock & hypothermia Determine neuro status Secondary survey

o Health hxo Head to toe assessmento Dx & labso Splintingo Wound dressing

Always prioritize Attend to emotional & comfort needs Attention & support

AIRWAY OBSTRUCTION Pathophysiology

o Partial or full occlusiono Hypoxia w/in 3-5 mins -> brain injury or deatho Decreased oxygen saturationo Unconsciousnesso Causes of upper airway obstruction

Foreign bodies, anaphylaxis, viral or bacterial infection,trauma, inhalation, chemical burns, medications, motor

coordination diseases

Clinical Manifestationso Universal Distress Signal: Clutching neck btwn thumb &

fingers

o Cyanosiso Loss of consciousness


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Assessment & diagnostic Findingso X-rays, laryngoscopy, bronchoscopy

Managemento Encourage pt. to cough forcefullyo Any signs of wheezing, ineffective cough, increased respi

difficulty should be treated as a complete airway obstruction

o Initiate rescue breathingo Establishing an Airway

Abdominal thrust, head-tilt-chin-lift maneuver, jaw-thrust maneuver, insertion of specialized equipment,

chest movement, air movement

Ineffective airway clearance r/t to obstruction ofthe airway by the tongue, an object, or fluids

Ineffective breathing patterno Abdominal Thrusts

Subdiagphramatic abdominal thrusts Abdominal thrusts Heimlich mauever

o Head-Tilt-Chin-Lift Manuever Turn body as one unit Fingers under bony part of lower jaw, & chin lifted up Used only for those with no cervical spine injury

o Jaw Thrust Maneuver

One hand on ea. side of jaw The angles of lower jaw are grasped and lifted Displaces the mandible forward For those w/ spinal cord injury


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o Oropharyngeal Airway Insertion

Inserted over the back of the tongue into the lowerposterior pharynx

Prevents the tongue frm falling back against theposterior pharynx

Allows suctioning secretionso Endotracheal Intubation

To establish and maintain the airway in patients w/respi insufficiency or hypoxia

For connection to a resuusciation bag or mechanicalventilator

Meds for rapid sequence intubation: Sedative, ananalgesic, and a neuromuscular blockade agent

Intubation w/ a Combitube

provides pharyngeal ventilation also fxns as an ET tube one balloon inflated to 100 mL to occlude

oropharynx

rationale: permits ventilation by forcing air thruthe larynx

other balloon filled w/ 12 mL to anchor device inesophagus


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NSG. INTERVENTIONS: auscultate breath sounds if too difficult, insert a laryngeal mask airway

Cricothyroidotomy

For emergency when ET intubation iscontraindicated

Maintaining Ventilation Nurse monitors pulse oximetry, capnography, &

ABG

Pneumothorax or sucking open chest wound ismanaged w/ a chest tube

HEMORRHAGE

Leads to the reduction of circulating blood volume -> shock Signs of Shock:

o Cool, moist skino Decrease in BPo Increasing heart rateo Delayed capillary refillo Decreasing urine volume

Goals of emergency managemento Cntrl bleedingo Maintain adequate circulating blood volume for tissue

oxygenation

o Prevent shock At risk for cardiac arrest due to hypovolemia 2ndary to anoxia Management

o Fluid Replacement


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Blood loss= fluid volume deficit & decreased cardiacoutput

2 large-gauge IV catheters for analysis, typing, & cross-matching of blood

Replacement fluids= LR, NSS, colloids, bloodcomponent therapy

Make sure blood is warmed or else it may lead tocardiac arrest & coagulopathy

o Control of External Hemorrhage Direct, firm pressure Elevate affected part Immobilize affected part Use tourniquet as last resort

o Cntrl of Internal Bleeding Sx/S: tachycardia, falling BP, thirst, apprehension, cool

& moist skin, delayed capillary refill

Mngt: RBCs administered at a rapid rate ABG OBTAINED TO EVALUATE PULMONARY FXN &

TISSUE PERFUSION

Pt. maintained in supine positionHYPOVOLEMIC SHOCK

Shock: loss of effective circulating volume Cellular metabolic derangements Underlying causes of shock

o Neurogenic, cardiogenic, anaphylactic, septic, hypovolemicWOUNDS

Vary frm minor tears to severe crushing injuries Goal of Treatment:

o Restore physical integrity and form the injured tissue whileminimizing scars

Photographs are helpful Determine when & how it occurred Use aseptic technique Evaluate sensory, motor, & vascular function Management


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o Wound Cleansing Hair may be clipped Clean wound w/ normal saline solution or polymer

agent

Betadine or hydrogen peroxide should NOT be primaryuse of disinfectant b/c they may cause further injury

May put anesthetic agent area may be infiltrated w/ a local intradermal anesthetic localized pain at site of injury cleaning & debdriding

irrigate wound w/ sterile isotonic solution devitalized tissue & foreign matter are removed small bleeding vessels are clamped, tied, or

cauterized,

apply a nonadherent dressing to serve as a splinto Primary Closure

Suture or stapled Subcutaneous fat brought together Subcuticular layer closed Epidermis is closed Sterile strips Bonding agent

o Delayed Primary Closure Indicated if tissue has been lost or there is a high

potential for infection!

Add a thin layer of gauze cover by occlusive dressing Wound is splinted If no signs of suppuration (form. Of purulent drainage),

the wound may be suture

Use antibiotics to prevent infection (depends on age ofwound & risk of contamination)

Site is immobilized & elevated Tetanus prophylaxis Tetanus booster given

Trauma


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Trauma: an unintentional or intentional wound or injury inflicted onthe body frm a mechanism against w/c the body cannot protect

itself

Collection of Forensic Evidence

Documentation: wounds, mechanism of injury, time of events,collection of evidence, transfer of custody of items include officers

name, date, and the time, pts own words w/ quotes

Mgnt in medical and forensic perspective Wet clothes should be hung Clothing put in a paper bag Clothing not given to families Valuables are inventoried & placed in the hospital safe For suicide:

o Autopsyo Cover pts hands w/ paper bags to protect evidenceo Tissue specimenso Photographs

Injury Prevention

Nurses role to provide injury prevention information 3 components of injury prevention


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3/23/2012 6:09:00 PM

emergency nursing outline

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