EMERGENCY AND DISASTER NURSING TERMS USE:

Post Traumatic Stress Syndrome - characteristic of

symptoms after a psychologically stressful event was out of range of an normal human experience.

Trauma - Intentional or unintentional wounds/injuries on the

human body from particular mechanical mechanism that exceeds the bodys ability to protect itself from injury

EMERGENCY IT IS WHATEVER THE PATIENT OR THE

FAMILY CONSIDERS IT TO BE.

SCOPE AND PRACTICE OF EMERGENCY NURSING

The emergency nurse has had specialized education, training, and experience. The emergency nurse establishes priorities, monitors and continuously assesses acutely ill and injured patients, supports and attends to families, supervises allied health personnel, and teaches patients and families within a time-limited, highpressured care environment. Nursing interventions are accomplished interdependently, in consultation with or under the direction of a licensed physician. Appropriate nursing and medical interventions are anticipated based on assessment data. The emergency health care staff members work as a team in performing the highly technical, hands-on skills required to care for patients in an emergency situation. Patients in the ED have a wide variety of actual or potential problems, and their condition may change constantly. Although a patient may have several diagnosis at a given time, the focus is on the most life-threatening ones ISSUES IN EMERGENCY NURSING CARE

Emergency Management - traditionally refers to care given

to patients with urgent and critical needs.

EMERGENCY NURSING - It is the nursing care given to

patients with urgent and critical needs

Triage - process of assessing patients to determine

management priorities.

EMERGENCY NURSE - has a specialized education, training,

and experience to gain expertise in assessing and identifying patients health care problems in crisis situations establishes priorities, monitors and continuously assesses acutely ill and injured patients, supports and attends to families, supervises allied health personnel, and teaches patients and families within a time-limited, high-pressured care environment

First Aid - an immediate or emergency treatment given to a

person who has been injured before complete medical and surgical treatment can be secured.

BLS - level of medical care which is used for patient with

illness or injury until full medical care can be given.

ACLS ADVANCE CARDIAC LIFE SUPPORT- Set of clinical

interventions for the urgent treatment of cardiac arrest and often life threatening medical emergencies as well as the knowledge and skills to deploy those interventions.

DISASTER NURSING - a branch of emergency nursing, it

refers to nursing care given to patients who are victims of disasters, whether it is manmade or natural phenomena.

Defibrillation - Restoration of normal rhythm to the heart in

ventricular or atrial fibrillation

INCIDENT COMMAND SYSTEM - It is a management tool

for organizing personnel, facilities, equipment, and communication for any emergency situation.

Disaster - Any catastrophic situation in which the normal

patterns of life (or ecosystems) have been disrupted and extraordinary, emergency interventions are required to save and preserve human lives and/or the environment.

INCIDENT COMMANDER - The head of the incident

command system He must be continuously informed of all the activities and informed about any deviation from the established plan

Mass Casualty Incident - situation in which the number of

casualties exceeds the number of resources.

 Emergency nursing is demanding because of the diversity of conditions and situations which are unique in the ER. Issues include legal issues, occupational health and safety risks for ED staff, and the challenge of providing holistic care in the context of a fastpaced, technology-driven environment in which serious illness and death are confronted on a daily basis. The emergency nurse must expand his or her knowledge base to encompass recognizing and treating patients and anticipate nursing care in the event of a mass casualty incident. Legal Issues Includes: Actual Consent Implied Consent Parental Consent Good Samaritan Law Gives legal protection to the rescuer who act in good faith and are not guilty of gross negligence or willful misconduct. Focus of Emergency Care Preserve or Prolong Life Alleviate Suffering Do No Further Harm Restore to Optimal Function

Dos Donts let the patient see his own injury Make any unrealistic promises Obtain Consent Think of the Worst Respect Victims Modesty & Privacy

Check for ABCs of life

A Airway B Breathing C - Circulation

Team Members Rescuer Emergency Medical Technician Paramedics Emergency Medicine Physicians Incident Commander Inpatient Unit Staff

Guidelines in Giving Emergency Care

A Ask for help I Intervene D Do no Further Harm

Stages of Crisis 1. Anxiety and Denial encouraged to recognize and talk about their feelings. asking questions is encouraged. honest answers given

Support Staff

Emergency Action Principle I. Survey the Scene Is the Scene Safe? What Happened? Are there any bystanders who can help?

identify as a trained first aider!

prolonged denial is not encouraged or supported 2. Remorse and Guilt

verbalize their feelings 3. Anger way of handling anxiety and fear allow the anger to be ventilated 4. Grief help family members work through their grief letting them know that it is normal and acceptable Core Competencies in Emergency Nursing Assessment Priority Setting/Critical Thinking Skills Knowledge of Emergency Care Technical Skills Communication

II. Do a Primary Survey - organization of approach so that immediate threats to life are rapidly identified and effectively manage.

Primary Survey A - Airway/Cervical Spine - Establish Patent Airway - Maintain Alignment - GCS 8 = Prepare Intubation B Breathing

Golden Rules of Emergency Care

Assess and Intervene

- Assess Breath Sounds - Observe for Chest Wall Trauma - Prepare for chest decompression C Circulation - Monitor VS - Maintain Vascular Access - Direct Pressure D Disability - Evaluate LOC - Re-evaluate clients LOC - Use AVPU mnemonics Estimated Blood Pressure SITE SBP 80 Radial Femoral 70 E Exposure - Remove clothing - Maintain Privacy - Prevent Hypothermia III. Activate Medical Assistance Information to be Relayed: What Happened? Number of Persons Injured Extent of Injury and First Aid given Telephone number from where youre calling

L Last Meal Taken E Events Prior to Accident Check Vital Signs

V. Triage

comes from the French word trier, meaning to sort process of assessing patients to determine
management priorities Categories:

1. Emergent - highest priority, conditions are life

threatening and need immediate attention Airway obstruction, sucking chest wound, shock, unstable chest and abdominal wounds, open fractures of long bones

2. Urgent have serious health problems but not

immediately life threatening ones. Must be seen within 1 hour Maxillofacial wounds without airway compromise, eye injuries, stable abdominal wounds without evidence of significant hemorrhage, fractures

3. Non-urgent patients have episodic illness than can

IV. Do Secondary Survey 60 Carotid Interview the Patient S Symptoms A Allergies Control of Hemorrhage M Medication P Previous/Present Illness be addressed within 24 hours without increased morbidity Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding, behavioral disorders or psychological disturbances.

3. Non-urgent patients have episodic illness than can

be addressed within 24 hours without increased morbidity Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding, behavioral disorders or psychological disturbances. TRIAGE CATEGOR Y PRIORIT Y COLOR FIRST AID Role of First Aid Bridge the Gap Between the Victim and the Physician Immediately start giving interventions in prehospital setting Value of First Aid Training Self-help Health for Others Preparation for Disaster

1.

MOUTH-TO-MOUTH = a quick, effective way to provide O2 and ventilation to the victim.

2. MOUTH-TO-NOSE = recommended when it is impossible to ventilate through the victims mouth. (Trismus, mouth injury) 3. MOUTH-TO-NOSE and MOUTH = if the pt. is an infant 4. MOUTH-TO-STOMA = used if the pt. has a stoma; a permanent opening that connects the trachea directly to the front of the neck. For Rescue Breathing Alone:

IMMEDIA TE DELAYED MINIMAL EXPECTA

Field TRIAGE 1. Immediate:

1 2 3 4

RED YELLOW GREEN BLACK

Safety Awareness
Rate is 10-12 breaths in ADULT (1.5 - 2 sec/breath) ( 1 breath every 4 to 5 secs) Rate is 20 breaths for a CHILD and INFANT (1 1.5 sec/breath) ( 1 breath every 3 secs)

BASIC LIFE SUPPORT - an emergency procedure that consists of recognizing respiratory or cardiac arrest or both the proper application of CPR to maintain life until a victim recovers or advance life support is available. Artificial Respiration a way of breathing air to persons lungs when breathing ceased or stopped function.

Injuries are life-threatening but survivable with

minimal intervention. Individuals in this group can progress rapidly to expectant if treatment is delayed. 2. Delayed: Injuries are significant and require medical care, but can wait hours without threat to life or limb. Individuals in this group receive treatment only after immediate casualties are treated. 3. Minimal: Injuries are minor and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area. 4. Expectant: Injuries are extensive and chances of survival are unlikely even with definitive care. 5. Fast-Track: Psychological support needed

Table of Cardiopulmonary Resuscitation for Adult, Child & Infant

Adult Lower half of the sternum but not hitting the xiphoid process: measure up to 2 fingers from substernal notch. Approximatel y 1 to 2 Child Lower half of the sternum but not hitting the xiphoid process: measure up to 1 finger from substernal notch. Approximat ely 1 to 1 Infant Lower half of the sternum but not hitting the xiphoid process: 1 finger width below the imaginary nipple line.

Respiratory Arrest a condition when the respiration or breathing pattern of an individual stops to function, while the pulse and circulation may continue. Causes: Choking, Electrocution, strangulation, drowning and suffocation.

Compressi on Area

WAYS TO VENTILATE THE LUNGS

Depth

Approximat ely to 1

How to compress

inches Heel of 1 hand, other hand on top. 30:2 (1 or 2 rescuers)

inches Heel of 1 hand.

Compressi onventilatio n ratio Number of cycles per minute

30:2 (1 or 2 rescuers)

inch 2 fingers (middle & ring fingertips) 30:2 (1 or 2 rescuers)

Go for Help

5 cycles in 2 minutes

5 cycles in 2 minutes

5 cycles in 2 minutes

Give Rescue Breaths

Procedure

Infant(0-1yr)

Child(1-8 yrs)

Adult

Safe Approach Assess for Response

Approach and assess situation Shout and gently pinch Gently shouting are you ok? then shake the victim Placed Supine on a firm and flat surface

if someone responds to your shout for help send that person to phone for ambulance if youre on your own, leave the casualty and make the phone call for yourself * never leave if the patient has collapsed as a result of trauma or drowning or if the casualty is a child 5 rescue breaths 2 rescue breaths Place mouth pinch nose seal lips over the and around the nose and ventilate mouth and mouth of via mouth blow steadily the infant for 1.5 2 look for seconds look for chest look for chest rising rising chest rising

The Casualty is Breathing: Place in recovery position Before moving casualty remove any objects safely from her pockets Kneel beside casualty, place arm nearest at right angles, and then bend elbow keeping the palm uppermost. Bring far arm across the casualtys chest and hold back of the casualtys hand against the nearest cheek With your other hand grasp the far thigh just above the knee, then pull the casualty towards you and on to his or her side

Positioning Open the Airway

CRITERIA FOR NOT STARTING CPR All patients in cardiac arrest receive resuscitation unless: 1. The pt. has a valid DNR order livor mortis, algor mortis, decapitation 3. No physiological benefit can be expected because the vital functions have deteriorated despite maximal therapy 4. Witholding attempts to resuscitate in the DR is appropriate for newly born infants with: 2. The pt. has signs of irreversible death: rigor mortis,

Assess for Breathing

The Casualty is

Check for foreign bodies then remove using finger sweep Head-tilt-chin-lift maneuver Jaw-thrust Maneuver Bring cheek over the mouth and nose of the casualty Look for chest movement Listen for breath sounds Feel for breathing on your cheek NOT Breathing:

When to Stop

Confirmed gestation less than 23 weeks or birthweight less than 400 grams Anencephaly

EARLY DEFIBRILLATION - 7-10% decrease per

minute without defibrillation patient

EARLY ACLS technique that attempts to stabilize

when the patient has spontaneous breathing when the first aider is too exhausted to continue when another first aider takes over when EMS arrives and takes over AIRWAY OBSTRUCTION KINDS OF AIRWAY OBSTRUCTION: 1. Anatomic Airway Obstruction 2. Mechanical Airway Obstruction TYPES 1. 2. 3. When to STOP CPR: S SPONTANEOUS BREATH RESTORED T TURNED OVER THE MEDICAL SERVICES O OPERATOR IS EXHAUSTED TO CONTINUE P PHYSICIAN ASSUMES RESPONSIBILITY OF AIRWAY OBSTRUCTION Partial Airway Obstruction with Good Air Exchange Partial Airway Obstruction with Poor Air Exchange Complete Airway Obstruction

For patient lying (unconscious): position patient at the back (supine); kneel astride the patients thigh Place HEEL of one HAND against the pts abdomen, place the second hand directly on the top of the fist. Make a quick UPWARD thrust FINGER SWEEP: used only in unconscious adult client Make a TONGUE-JAW LIFT. Opening the pts mouth by grasping both tongue and lower jaw between the thumb and fingers, and lifting the mandible. Insert index finger of other hand to scrape across the back of the throat Use a hooking action CHEST THRUST: used only in patients in advanced stages of pregnancy or in markedly obese clients a. Conscious Patient standing or sitting Stand behind the client with arms under patients axilla to encircle patients chest Place thumb side of fist on the MIDDLE of STERNUM, grasp with the other hand and perform BACKWARD thrust until foreign body is expelled.

Clinical Manifestations: UNIVERSAL DISTRESS SIGNAL (patient may clutch the neck between the thumb and fingers), choking, stridor, apprehensive appearance, restlessness. CYANOSIS and LOSS of CONSCIOUSNESS develop as hypoxia worsens.

MANAGEMENT FOR AIRWAY OBSTRUCTION HEIMLICH MANEUVER (Subdiaphragmatic Abdominal Thrusts) For Standing or sitting conscious patient: Stand behind the patient; wrap your arms around the patients waist Make a FIST, placing thumb side of the fist against the pts abdomen, in the midline SLIGHTLY ABOVE the UMBILICUS and WELL BELOW the XIPHOID PROCESS Make a quick INWARD and UPWARD thrust. Each thrust is separated.

COMPLICATIONS OF CPR: RIB FRACTURE STERNUM FRACTURE LACERATION OF THE LIVER OR SPLEEN

MEASURES TO ESTABLISH AIRWAY A. HEAD-TILT-CHIN-LIFT MANEUVER B. JAW-THRUST MANEUVER C. OROPAHRYNGEAL AIRWAY

PNEUMOTHORAX, HEMOTHORAX
CHAIN OF SURVIVAL EARLY ACCESS early recognition of cardiac arrest, prompt activation of emergency services EARLY BLS prevent brain damage, buy time for the arrival of defibrillator

D. ENDOTRACHEAL INTUBATION Indications: To establish an airway for patients cannot be adequately ventilated with an oropharyngeal airway To bypass upper airway obstruction

To permit connection to ambubag or mechanical ventilator To prevent aspiration To facilitate removal of tracheobronchial secretions

5. INTRACRANIAL HEMORRHAGE significant

bleeding into a space or potential space between the skull and the brain a. Epidural hematoma the most serious type of hematoma; forms rapidly and results from arterial bleeding forms between the dura and the skull from a tear int the meningeal area b. Subdural hematoma forms slowly and results from a venous bleed

E. CRICOTHYROIDOTOMY a puncture or incision of the cricothyroid membrane to establish an emergency airway in certain emergency situations where endotracheal intubation or tracheostomy is not possible. indicated to pts. with trauma to head and neck, and in allergic reaction causing laryngeal edema use of gauge 11 needle or scalpel blade Nursing Actions: Extend the neck. Place towel roll beneath the shoulders Insert the needle at a 10 to 30 degree caudal direction in the midline jest above the upper part of the cricoid cartilage Listen for air passing back and forth Direct the needle downward and posteriorly, and tape it.

a surgical emergency
c. Intracerebral hemorrhage bleeding directly into the brain matter
ALERT: Assume cervical spine fracture for any patient with a significant head injury, until proven otherwise. PRIMARY ASSESSMENT: Assess for ABC SECONDARY ASSESSMENT: Change in LOC most sensitive indicator in the pts condition CUSHINGS TRIAD ( bradypnea, bradycardia, widened pulse pressure) indicating increased intracranial pressure unequal or unresponsive pupils; impaired vision Battles sign bluish discoloration of the mastoid, indicating a possible BASAL SKULL FRACTURE Rhinorrhea or otorrhea indicative of CSF leak Periorbital Ecchymosis indicates anterior basilar fracture ALERT: If basilar skull fracture or severe midface fractures are suspected, a nasogastric tube(NGT) is CONTRAINDICATED! MANAGEMENT:

Open airway by Jaw-Thrust Manuever, suction orally if needed Administer high flow oxygen: most common death is CEREBRAL ANOXIA In general, hyperventilate the patient to 20-25 bpm, causing cerebral vasoconstriction and minimizing cerebral edema Apply a bulky, loose dressing; dont apply pressure IV line of PNSS or Plain LR prepare to manage seizures maintain normothermia Medications: a. Diazepam b. Steroids c. Mannitol Prepare of immediate surgery if pt. shows evidence of neurologic deterioration

INJURIES TO HEAD, SPINE, AND FACE A. HEAD INJURIES 1. OPEN HEAD INJURY skull is fractured 2. CLOSED HEAD INJURY skull is intact 3. CONCUSSION temporary loss of consciousness that results in transient interruption if the brains normal functioning 4. CONTUSSSION bruising of the brain tissue

B. SKULL FRACTURES SIMPLE closed COMPOUND open LINEAR Fx common hairline break, w/o displacement of structure COMMINUTED Fx splinters or crushes the bone in several fragments DEPRESSED Fx pushes the bone toward the brain CRANIAL VAULT Fx top of the head BASILAR Fx base of the skull and frontal sinuses ALERT: Damage to the brain is the first concern, it is considered a neurosurgical condition In children, skulls thinness and elasticity allows a depression w/o a break in the bone CAUSES: Traumatic blows to the head, VA, severe beatings

S/Sx: scalp wounds, agitation and irritability, loss of consciousness, labored breathing, abnormal deep tendon reflexes, altered pupillary and moor response IF CONSCIOUS: complains of persistent localized headache IF JAGGED BONE FRAGMENTS: may cause cerebral bleeding HALO SIGN blood-tinged spot surrounded by lighter ring IF SPHENOIDAL Fx: damages the optic nerve and may cause BLINDNESS IF TEMPORAL Fx: may cause unilateral deafness or facial paralysis TREATMENT: For LINEAR FRACTURES: supporative (mild analgesics) cleaning and debridement of wounds If conscious: observed for 4 hours; if not, admit for evaluation if VS stable, may go home with instruction sheet For VAULT and BASILAR FRACTURES: Craniotomy to remove fragemnts anti-biotics Dexamethasone Osmotic Diuretics (MANNITOL) if increased ICP is present NURSING CONSIDERATIONS: maintain patent airway; nasal airway contraindicated to basilar fx support with O2 administration suction pt. through mouth not nose if CSF leak is present RHINORRHEA wipe it, dont let him blow it! OTORRHEA cover it lightly with sterile gauze, dont pack it! Position head on side Maintain a supine position with bed elevated to 30 degrees dont give narcotics or sedative

assist in surgery, maintaining sterile technique

C. CERVICAL SPINE INJURIES PRIMARY ASSESSMENT: immediate immobilization of the spine A B C ( Intercoastal paralysis w/ diapragmatic breathing) SUBSEQUENT ASSESSMENT: Hypotension, bradycardia, hypothermia - suggests SPINAL SHOCK Total sensory loss and motor paralysis below the level of injury MANAGEMENT: Nasotracheal intubation initaite IV access, monitor blood gas indwelling urinary catheterization prepare to manage seizures Meds: High dose steroids and diazepam

Immobilization of spine while performing assessment ABC (tongue swelling, bleeding, broken or missed teeth) SUBSEQUENT ASSESSMENT: Paralysis if the upward gaze indicative of INFERIOR ORBIT FX Crepitus on nose indicates nasal fracture Flattening of the cheek and loss of sensation below the orbit indicates ZYGOMA (cheekbone) FX Malocclussion of teeth, trismus indicative of MAXILLA FX PRIMARY INTERVENTIONS: Insertion of oral airway or intubation Nasopharyngeal airway should only be used if no evidence of nasal fracture or rhinorrhea Apply bulky, loose dressing; apply ice to areas of swelling

D. MAXILLOFACIAL TRAUMA PRIMARY ASSESSMENT: