EMERGENCY NURSING Nursing process in Emergency Situation * Logical framework for problemsolving in limited time & pressured environment

ER NURSE HAS: expertise in assessing & identifying patients health care problem in crisis situation establishment of priorities monitoring an acutely ill and injured patient supporting and attending to family supervising allied health personnel & teaching patients and their families APPROACH TO PATIENTS: assessment of psychological functioning includes evaluation of emotional expression, degree of anxiety & cognitive functioning Rapid physical assessment APPROACH TO FAMILY: they are told of the patients location and interventions being given GUIDELINES IN HELPING THE FAMILY DEALS WITH SUDDEN DEATH IN THE ER: Take the family to a private place & talk to the family together Assure the family that every possible intervention was done Avoid using euphemism, show family of your concern thru touch. Allow family to talk about the deceased and what they meant to them; this permits ventilation of feelings Encourage family members to support each other and freely express their emotions Avoid giving sedation to family members as this may mask or delay the grieving process. Encourage the family to view the body if they wish to do so. Cover the mutilated areas before the family sees the body. Spend a few minutes with the family, listening to them PRIORITIES AND PRINCIPLES OF EMERGENCY MANAGEMENT PRIORITIES MAJOR GOALS: To preserve life To prevent deterioration before more definitive treatment can be given.

To restore the patient to useful living

* Injuries to face, neck and chest that impairs respiration are the highest priorities PRINCIPLES: maintain patent airway & provide adequate ventilation employing resuscitation measures when necessary control haemorrhage & its consequences evaluate and restore cardiac output prevent and treat shock, maintain or restore effective circulation carry out a rapid initial and ongoing physical examination assess whether or not the patient can follow commands, evaluate the size & reactivity of pupils start ECG monitoring if appropriate splint suspected fractures including cervical spines in patients with head injuries protect wounds with sterile dressings start a flow sheet of patients vital sign, neurological state, to guide in decision making HEAD INJURIES: CONCUSSION - prevents patient from reacting to stimuli for a few minutes after head injury, but has no after effects CONTUSSION - resembles concussion except that patient is unconscious for more than a few minutes - may have a petechial bleeding of his brain - Serious consequence may follow COMPRESSION - The result of spreading edema or an expanding blood clot which gradually damages the surrounding brain - A timely burr hole to remove a blood clot which is compressing a patients brain maybe life-saving

CONTUSSION (w/ definite brain damage) -prolonged every 48 hours - 13-14 GCS - ABNORMAL, PROGRESS to PARALYSIS SIGNS & SYMPTOMS: headache dizziness nausea & vomiting loss of consciousness CONCUSSION (no brain injury, jarring of brain) short 3 -15 GCS 8-48 hours 15 (NORMAL) No neurological deficit

Many patients vomit and aspirate their stomach contents upon his admission to the hospital Insert a NGT Caution: if you decide to insert an NGT, do so: After intubation, or you may drown him in his own gastric content Pass it when he was in the recovery position

GENERAL ASSESSMENT: examine body and limbs first then head and neck smell breath for alcohol check for causes of coma, epilepsy, DM, liver failure, meningitis, drugs, malaria NEUROLOGICAL EXAMINATION: if conscious, test the motor power of his 4 limbs if restless, rub his chest over his sternum with your closed fist and see how he respond press firmly with your nail above his orbits His grimace ,ay be weakened on one side than the other Lift arms and legs, release them to see how they fall away EYES: size and equality of his pupils and whether they react to light check for swelling, black eye; conjunctival hemorrhage only indicates a fracture usually at the orbital plate of the frontal bone SCALP AND SKULL: look for cuts and bruises feel for the edges of a depressed fracture place a pad or bandage to control bleeding in the scalp but if it does not, suture it temporarily bring the patient to the x-ray room EARS AND NOSE: a bleeding nose may indicate a fractured base and a bleeding ear if a patients ear is bleeding, dont examine it for fear of introducing infection

LEVEL OF CONCIOUSNESS: Conscious Alert- easily arousable Drowsy Unconscious Lethargy/ stupor- with response to pain Coma- (-) response to pain THE GENERAL METHOD: Caution: 1. Admit all patients especially children who have been unconscious with a head injury even for a moment 2. Observe them carefully for 24 hrs AIRWAY: place patient in the recovery position clear his mouth and pharynx insert an oral airway if the patients consciousness is impaired, he has no cough reflex intubate the patient before you insert an NGT as soon as his consciousness improves, he will reject the Endotracheal tube EMPTY PATIENTS STOMACH:

AIRWAY OBSTRUCTION: Incomplete Crowing sound is heard (encourage to cough) Complete Clutching of the neck Ask: Are you choking? Perform Heimlichs Complete If patient becomes unconscious: Place supine on flat surface Perform tongue-jaw lift maneuver FINGERSWEEP to remove object Open airway and attempt ventilation Perform Heimlich while supine Reattempt ventilation

ASSESSMENT: Determine the nature of the bite because this will help determine the need for a vaccine A provoked bite (children teasing or accidentally hurting the animal, bite while feeding or handling animals) with the animal appearing healthy, rabies vaccine is usually withheld Bites from animals considered wild or provoked bites indicate vaccination CLINICAL MANIFESTATIONS: PRODROMAL (1-4days) : fever, h/a, myalgia, n/v, sore throat, non-productive cough & anorexia

ENCEPHALITIC (Excitatory) : excessive

motor activity, excitation, agitation, confusion, hallucination & combativeness : opisthotonus : seizure or focal paralysis later develops & as the disease progresses, lucid period becomes shorter, coma : postural hypotension : salivation, lacrimation, perspiration & anisocoria, T=40.6

Pediatric considerations: INFANT & CHILD: never DO blind fingersweep Give five back blows in the interscapular area and turn the infant with head lower than trunk then deliver chest thrust below the nipple line Obstetric considerations: Hand is placed over the middle part of sternum: backward chest thrust If unconscious: place pillow below the RIGHT abdomen to displace uterus DOG BITES: MOT: bite through the skin via saliva containing large number of virus, exposure of mucous membrane to infected tissue or secretion or through skin breaks or wound. EXTENT & LOCATION of the Bite: 1. Severe multiple or dep punctured wounds, or any bites on the head, face, neck, hands or fingers. 2. Mild scratches, lacerations, open wounds like abrasions suspected of being contaminated with saliva.

PARALYTIC : diplopia, facial palsy &

dysphagia, hydrophobia characterized by painful, violent, involuntary movement of the diaphragm, accessory respiratory muscles, pharyngeal & laryngeal muscles initiated by swallowing liquids; involvement of the respiratory muscle causes apneic death IMMEDIATE LOCAL CARE: Free bleeding from the wound is encouraged Thorough irrigation with copious amounts of saline solution Cleaning with soap & water Debridement Administration of antibiotic Administration of tetanus post exposure prophylaxis Primary suturing of wound is generally not advised, but severe laceration may be sutured if exposure to rabies is unlikely IMMUNIZATION

SNAKE BITES: Poisonous snakes can control the position of their fangs accounting for the variability Large snakes are considered more venomous Venom consists of enzymatic complex proteins which affects all soft tissues; it is neurotoxic, hemorrhagic, thrombogenic, hemolytic, cytotoxic & anticoagulant POISONOUS: Called pit vipers named after the characteristic pit, a heat sensitive organ located between the eye & nostril on each side of the head Contains elliptical pupils Well developed fangs that protrudes from the maxilla Presence of a single row of subcaudal plates in their belly NON-POISONOUS: Do not have a facial pit Has a round pupil Have rows of teeth No caudal plates CLINICAL MANIFESTATIONS: Excruciating pain at the bite site 1 or 2 fang marks Swelling, tenderness may appear in few minutes after the bite Swelling increases in 24 hrs., vesicles, and eventual sloughing of tissue occur Systemic symptoms : paresthesia & muscle fasciculations hypotension, weakness, sweating, chills, nausea & vomiting LOCAL TREATMENT: Varies considerably in relation to the length of time from the bite IMMOBILIZATION : prevents excessive movements will inhibit the local diffusion of venom (30% maybe absorbed in 30 mins ff rigorous movement) TOURNIQUET : to obstruct the venous & lymphatic flow 1. Applied loosely, index finger should be inserted beneath 2. Should not be released once applied & left in place during the 1st 30 mins-2 hrs while suction is done

3. May be removed: as soon as IV infusion is started, Antivenin is ready for administration, if the patient is not in shock Remove as much venom as soon as possible but within 30 mins after the snake bite Incision & mechanical suction can be done 50% can be removed if the suction is started within 3 mins Neutralization of venom by giving antivenin is the most important treatment for snakebites Anticonvulsants & assisting or ventilation during seizure episodes Aspiration precaution if there is excessive salivation

BSN IV HENDERSON DRA. CIC RAGASA