Emergency and critical care management

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

Issues in Emergency Nursing Care

legal issues occupational health and safety risk for ED staff challenge of providing holistic care in the context of a fast-paced technology driven environment

Patient focused interventions:

act confidently and competently Explanations that the patient can understand Human contact and reassuring words unconsious patient be treated consciously reorientation as patient regains consciousness

Family focused interventions:

encouraged the fam members to talk about feelings Encourage asking Encourage verbalization of feelings Allow anger to be ventilated

Principles of Emergency Care

Rapid assessment, treatment and referral to appropriate setting for ongoing career

Triage
to sort used to sort patients into groups based on the severity of their health problems and the immediacy with which these problems must be treated

Assesss and intervene

Primary survey focus on stabilizing life threatening conditions Secondary survey done after primary survey are addressed
health history head to toe assessment diagnostic findings application of monitoring devices splinting of fractures wound dressing

Airway adequate ventilation and resuscitation Evaluate and restore cardiac output neurologic disability

Roles and responsibilities

Emergency nurse
expert in assessing and identifying patients health care problems Specialized education training and expertise establishes priorities monitors patient continuously support and attends to families collect crucial initial data maintain privacy and confidentiality good communication use all resources health teaching crowd control

Qualifications 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

have firm convictions possess good communication skills be 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

Critical Care Nursing

- is the field of nursing with a focus on the utmost care of the critically ill or unstable patients. Critical care nurses can be found working in a wide variety of environments and specialties, such as emergency departments and the intensive care units.

Roles of the critical care nurse

1. Care provider 2. Educator 3. Manager 4. Advocate

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 patient s rights

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

Qualifications of a Critical Care Nurse

A diploma in nursing, an associate s degree in nursing (ADN) or a bachelor s 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.

Emergency Conditions

Wound
Types: 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 defined edges,usually longed and deep patterned-wound representing the outline of object

assessment
when and how the wound occurred extent of damage sensory motor and vascular function changes

management
hair 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

primary closure
wound suturing depends on: .nature of wound .time since the injury sustained .degree of contamination .vascularity of tissue

Sutures: - placed near the wound edges with the skin edges elevated carefully to promote optimal healing Sterile strips: - for close and clean superficial wounds

Delayed primary closure

Indication: high potential for infection loss of tissues

Poisoning
- any substance that when ingested, inhaled or injected can injure the body Accidental poisoning are common in children Intentional poisoning are common in adolescent and adult

Ingested poisons
-maybe an alkaline or acidic substance Assessment: 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

Management:
Control airway, ventilation, oxygenation Stabilize cardiovascular and other functions Remove toxins or decrease absorption Corrosive poison- give water or milk for dilution Dilution is not attempted if there s: Acute airway edema or obstruction Clinical evidence of esophageal or gastric damage

Gastric emptying procedures - syrup of Ipecac -gastric lavage -activated charcoal -cathartic Antidote - specific chemical or physiologic antagonist administered as early as possible

Inhaled poisons: Carbon Monoxide poisoning

- industrial, household incidence CO binds to hemoglobin reducing its O 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 O)

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% O

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

Food poisoning
- sudden illness after ingestion of contaminated food or drinks - botulism Assessment: How soon S/Sx occur? How does food smell? Diarrhea? Neurologic symptoms? Fever?

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.

Environmental emergencies

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.

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

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

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

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 potential outcome 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

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

Types of triage
1. Simple - used in mass casualty incidents -sorts those who need critical attention and immediate transportation to hospital and those with less serious injuries START model (Simple Triage And Rapid Treatment) -performed by lightly trained individual and emergency personnel but not intended to supersede or instruct medical personnel or techniques -developed at Hoag Hospital in Newport Beach, California

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)

2.Advanced
-has ethical implications -to divert scarce resources to patient who don t have the chance to live -Western Europe Triage Revised Trauma Score -medical validated scoring system incorporated some triage conditions Injury Severity Score -assign score from 0-75 based on severity of injury

Emergent: highest priority; lifethreatening; 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 morbidity Fast-track: require simple first aid or primary care

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

Delayed (Yellow): injuries are significant and require medical care but can wait for hours without threat to life or limb stable abdominal wounds without significant hemorrhage; soft tissue injuries; maxillafascia wounds without airway compromise; vascular injuries with adequate collateral circulation; genitourinary tract injuries

Minor (Green): minor; treatment delayed by hours to days upper extremity fracture; minor burns; sprains; small lacerations without significant bleeding; behavioral disorders/ psychologic disturbances Expectant (Black): chances of survival are unlikely; person is separated but not abandoned; comfort measures provided unresponsive; spinal cord injury; MODS

Regional Variation
1. United States of America
NATO 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 duty Class 2: injuries require immediate threat to life Class 3: injuries are serious but not a threat to life Class 4: expectant

2. Canada (Primary Care Level Paramedics)

Canadian Triage and Acuity Scale: injury and physiologic 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 score 0-2; beyond help Immediate: 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

3. Finland
(Red) cannot wait (Yellow) has to wait (Green) can wait (Black) lost

4. France by doctors -performed

4 level scale: DCD: deceased; beyond urgency UA: absolute urgency; treatment on site UR: relative urgency; waiting for evacuation UMP:medical psychological emergency; lightly wounded but psychologically shocked

5. Germany
-preliminary assessment done at the ambulance -no CPR done so if person cannot breathe, consider deceased T1 (Red) immediate transportation ASAP T2 (Yellow) constant observation and rapid treatment, transportation as soon as practical T3 (Green) treatment when practical, diagnose when possible T4 (Brown) observation and administration of analgesia T5 (Black) collection of bodies; identify if possible

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

6. Japan
I II III O life threatening non- life threatening but urgent treatment required minor injuries dead; survival unlikely

Evacuation Field triage

Deceased left where they fell, covered if necessary Immediate (Priority 1) Delayed (Priority 2) Minor (Priority 3)

In hospital triage
(Black) - expectant (Red) immediate;likely to survive; crippling injuries (Yellow) observation (Green) walking wounded (White) Dismiss; first aid