Emergnecy Nursing part I

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foxyt14
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288281
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Emergnecy Nursing part I
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2014-11-05 17:28:43
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emergency
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Emergency Nursing part I N176
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  1. Goals of emergency care
    • rapid stabilization....plan within 1 hr
    • prevention of complications
    • early recovery
  2. Skills required for emergency care
    • rapid assessment
    • management of emergencies
    • broad knowledge base...acls/pals etc...
    • crisis intervention
    • good communication skills
    • triage abilities....decide if emergent/non emergent
    • good at patient teaching....filling in Dr. gaps
  3. If a person is unconscious and needs blood what happens ethically?
    implied consent is used....and transfusion occurs
  4. TIPS
    • trauma intervention program services
    • 24/7 volunteer group that helps with crisis intervention
  5. When does a case become a coroners case?
    • no dr. visit in last 20 days of life
    • dr. cant figure out reasonable cause of death
    • possible/known homicide/suicide
    • possible criminal action
    • when aspiration, starvation, drugs, alcohol, poisoning are suspected as cause of death
    • when contagious disease is known or suspected cause
    • death while in custody/prison
    • all deaths of state hospital patients
    • SIDS
    • death from surgery
  6. Define the triage process
    it is a sorting of patients

    process of deciding the priorities for intervention of a given person or groups of people based on their acuity/needs
  7. Advantages of triage
    • allows for early assessment of the seriously compromised patient
    • allows for immediate intervention in life threatening situations
    • decreases anxiety/fear
    • expedition of non critical patients
  8. 3 categories of triage
    • emergent
    • urgent
    • non-emergent
  9. emergent
    need immediate medical attention, time and delay could be life threatening

    • stroke
    • MI
    • anaphylaxis
    • severed limb
    • airway compromise
    • SCI
    • seizures
    • Diabetic complications
    • severe shock
    • obvious multiple trauma
    • excessively high temp-over 105
    • emergency childbirth, complication of prego,
    • hemorrhage
    • eclampsia
  10. urgent
    person needing medical attention within the next few hours

    • dehydration
    • concussion
    • burns
    • fx
    • chest pain from URI
    • severe pain
    • temp 102-105
    • drug overuse
    • poisoning
  11. non-emergent
    a condition that does not require the resources of an ED or emergency service, non acute or minor in severity

    • dead already
    • laceration
    • fx/sprains/strains
    • frequent flyers
    • chronic backache/headache
  12. Unwritten rule of triage.....
    anyone who according to my instinct looks sick, seems sick or acts sick should be triaged at my discretion, regardless of the "rules"
  13. Patients who need to be watched closely....red flags
    • MV over 35 mph (possible ruptured aorta)
    • forces of decal as in falls or explosions
    • loss of consciousness after an accident
    • chest/abdominal pain after injury
    • fx of 1st or second ribs...high mortality
    • fx of 9,10,11th ribs or more than 3 ribs
    • possible aspiration
    • possible lung tissue contusions
    • possible cervical spine trauma in pt. w/head injury
    • pulse rate >120 at rest
  14. Fx of these ribs is associated with death
    1st or 2nd
  15. Primary Survey of a patient in triage
    • Airway
    • Breathing
    • Circulation
    • Disability
    • Exposure/Environmental control

    *this assessment is mandatory for all patients no matter their chief complaint*
  16. Airway assessment
    • clear and open
    • assess for obstruction....tongue
    • assess for respiratory distress
    • check for loose teeth or foreign objects
    • assess for bleeding, vomit or edema
  17. Airway Interventions
    • suction
    • jaw thrust maneuver
    • ET tube
    • rigid cervical collar, backboard, towel rolls, forehead secure to backboard
  18. Breathing assessment
    • paradoxical movement
    • accessory/abdominal muscle involvement
    • listen/feel for air being expired
    • RR?
    • note nail beds, mucous membrane and skin for cyanosis
    • assess for JVD
    • assess position of trachea
  19. Intervention for breathing
    • supplemental O2
    • AMBU with 100% O2 if resp inadequate
    • prepare for intubation
    • suction
    • prepare for chest tube insertion
  20. Circulation assessment
    • carotid/femoral pulse
    • palpate pulse for quality and rate
    • assess color, temp and moisture of skin
    • check cap refill
    • blood pressure
  21. Intervention for circulation
    • CPR if pulse absent
    • shock=2 lg bore IV, NS or LR
    • blood products admin
    • auto transfusion if isolated chest trauma
    • blood samples for type and cross....control bleeding
  22. Disability assessment
    brief neuro assessment-LOC/pupils

    Identify deformities-inspect extremities for any obvious deformities and determine ROM and strength

    pain assessment
  23. Disability intervention
    • periodically reassess LOC and mental status
    • immobilize any obvious deformity
    • periodically reassess pain
  24. Secondary survey
    • Full set of VS/family present
    • Give comfort measures
    • History and Head to toe assessment
    • Inspect posterior surfaces
  25. What are you asking for details about with History?
    • Allergies
    • Medications
    • PMH
    • Last meal
    • Events preceding event
  26. In order to give BP meds SBP must be....
    >90....preferably 100+
  27. Ear assessment
    • looking for CSF or blood
    • otoscope look at tympanic membrane, should reflect light...NOT blue (blood behind membrane)
    • Battle sign
  28. Eye assessment
    • look for orbital ecchymosis
    • conjunctival redness
    • rhinorrhea
    • PERRLA
    • Cardinal gaze
    • push bone for orbital fx
  29. Mouth assessment
    • check for missing teeth
    • bleeding points
    • bleeding/edematous tongue
    • abscess?
  30. Neck vein assessment
    increased volume w/distention is seen with patient in supine or semi fowlers position

    • from....
    • tension pneumothorax
    • lateral displacement of heart
    • myocardial tamponade
    • myocardial contusion
    • JVD
  31. Chest assessment
    check for stability of the chest and rib cage with BOTH a sternal press and barrel push against sides of the ribs toward the center
  32. Sign of pneumothorax and ruptured bronchus
    subcutaneous emphysema felt in the neck and subclavicular areas
  33. Lung assessment
    check for quality, rate, equality and adventitious or diminished breath sounds
  34. Abdomen assessment
    • check for discoloration, marks, wounds, swelling
    • carefully logroll to examine the back looking for retroperitoneal bleeding, and exit wounds

    **ausculatate 1st, then palpate looking for guarding and distention
  35. Gallstones are felt....
    RUQ
  36. Appendicitis....
    RLQ with rebound
  37. Pelvis assessment
    press downward on both hips and the symphisis, even a semiconscious patient will groan if they have a broken pubis
  38. Pelvic fx can cause....
    a lot of occult bleeding
  39. Prego comes in with vaginal bleeding....what do I do?
    • confirm prego with HCG
    • do type and cross
    • find out Rh factor
    • US to see if fetus if viable
    • ask for hx of previous prego
  40. Extremity assessment
    • check for pain
    • deformity
    • ROM
    • look for cellulitis
    • abscesses
  41. How do you inspect posterior surfaces?
    strip em and flip em

    • check for bleeding
    • c spine...in line
    • bruising
    • lacerations
    • place paper clips at site of GSW
  42. In order to fully and appropriately assess your patient you must
    remove all of their clothes
  43. Cardinal characteristics of an unconscious patient with unknown etiology
    • altered state of mentation
    • abnormal respiratory pattern
    • abnormal eye signs
    • abnormal body movements, reflexes, posture
    • inappropriate response to painful stimulation
  44. Rule of seizures
    we are all entitled to have 1 seizure....but with the 2nd you will go on meds
  45. AEIOU
    assessment for unconscious patient

    • Alcohol
    • Epilepsy/encephalopathy
    • Insulin
    • Overdose
    • Uremia
  46. TIPS
    assessment for unconscious patient

    • Trauma/Tumor
    • Infection-sepsis
    • Psychiatric-schizo/bipolar
    • Stroke/Syncope/Shock
  47. Interventions for the unconscious patient with unknown etiology
    • Secure the airway and establish IV access
    • Glasgow coma scale with brief neuro exam
    • Obtain blood samples BEFORE any meds are given
    • O2
    • ABG
    • Monitor ICP
    • Foley
    • Control body temp
  48. Person with DKA
    IV of NS to get the glucose back in to the cell 1st....and then give insulin plus Dextrose
  49. Fluids and kids/elderly
    their bodies work differently....so always limit fluids you give
  50. Age at which your likelihood of dying during a trauma increases
    45+ yo
  51. What is the golden hour?
    • want the patient to be stable within the first hour
    • controlled airway
    • aggressive management of shock
    • appropriate definitive care
  52. Management philosophy for a trauma
    • think worst first
    • don't panic
    • use a systematic approach to evaluate and treat
    • look beyond the obvious
    • be aggressive with your management
  53. Patterns of injury....
    • get info from anyone...pt, paramedics, family
    • stripe em and flip em
    • mech of injury
    • who did it and how
    • any known drugs on board
    • any allergies
    • any medical problems
    • alcoholic withdrawl or dts possible
    • time and amount of food/fluids
    • date of last tetanus/booster
    • bleeder? on anticoagulants?
  54. If a child is in a trauma....what is crucial?
    get an accurate weight
  55. What do I need to know if a person is in a MVA?
    • type of vehicle and speed at impact
    • circumstances on impact-stationary, moving
    • thrown from vehicle?
    • direction of forces...head on, read end?
    • wearing aseatbelt
  56. When does blunt injury occur with a MVA?
    with the impact and the shearing forces of deceleration
  57. Person in a MVA...suspect
    possible tissue trauma on lower abdomen or retroperitoneal injury

    steering wheel trauma with possible facial bone damage and airway compromise, damage to sternal area, fx ribs, possible cardiac contusion or tamponade
  58. MVA...right front seat passenger will be....
    thrown into or through the windshield.

    evaluate for facial trauma and airway compromise
  59. Lacerated knees =
    fractured femur
  60. High velocity impact=
    fracture to the head of the femur
  61. Motorcycle injuries....find out
    • were they wearing a helmet?
    • speed at impact
    • were they thrown?
  62. Motorcycle injury....always suspect....
    • head injuries with facial lacerations
    • neck and c spine injuries
    • fracture femurs
  63. Penetrating injuries
    • impalements
    • GSW
    • knives
    • icepicks
  64. Person with GSW
    always look for entrance and exit wounds....can do this unless you remove all of their clothes
  65. Knife wounds
    • men thrust upwards
    • women use overhand movement and thrust downward
  66. Rules for penetrating objects
    leave the object in place and stabilized until surgical removal is accomplished...could be tamponading a slashed artery

    • type and cross
    • ancef for infection
    • pain meds
  67. What do I want to know about a fall?
    • cause...slipped/syncope/jump
    • distance of fall
    • surface of landing
    • position of landing...on feet, head, supine
  68. If a person fell, always suspect....
    • compression fx of the spine from forward flexion
    • fx of heels, knees, hips
    • deceleration injury to the liver, spleen and laceration of aorta distal to the left subclavian artery
  69. Cardiac tamponade presentation and management
    • muffled, distant heart sounds
    • hypotensive
    • neck vein distention
    • increased CVP

    medical emergency-pericardiocentsis with surgical repair
  70. Pneumothorax presentation and management
    • dyspnea
    • decreased chest wall movement
    • diminished/absent breath sounds
    • hyperresonance to percussion

    chest tube insertion with drainage at 3/4 mid intercostal or 5/6 .....????
  71. Hemothorax presentation and management
    • dyspnea
    • diminished or absent breath sounds
    • dullness to percussion

    chest tube insertion with drainage plus autotransfusion of collected blood and treatment for hypovolemia as needed
  72. Tension pneumothorax presentation and management
    • cyanosis
    • air hunger
    • violent agitation
    • tracheal deviation AWAY from affected side
    • subcutaneous emphysema
    • neck vein distention

    needle decompression and chest tube insertion
  73. What is a flail chest?
    fracture of 3 or more adjacent ribs causing loss of chest wall stability
  74. Flail chest presentation and management
    • paradoxic movement of chest wall
    • respiratory distress
    • associated hemothorax, pneumothorax or pulmonary contusion

    • stabilize flail segment with intubation or taping
    • oxygen
    • analgesia
  75. Rib fracture presentation and management
    pain

    pain management...splint is NOT acceptable
  76. Clinical manifestations of abdominal trauma
    • guarding/splinting of abdominal wall
    • hard, distended abdomen
    • decreased/absent bowel sounds
    • contusions, abrasions, bruising over the abdomen
    • pain, rebound tenderness
    • hematemisis
    • avoiding of abdominal breathing
  77. Interventions for abdominal trauma
    • control external bleeding with direct pressure
    • IV access
    • blood type and cross/CBC
    • stabilize impaled object with bulky dressing
    • cover protruding organs or tissue with sterile saline dressing
    • insert catheter
    • obtain urine for UA
    • Insert NG if no facial trauma
    • anticipate diagnostic peritoneal lavage
  78. Ongoing monitoring for a patient with abdominal trauma
    • VS, LOC, O2 saturation and UO
    • keep warm with blankets, warm IV fluids or warm humidified O2
    • Look for Grey Turner/Cullens
    • Kehrs sign....left shoulder pain
    • Lap belt injuries
    • signs of shock
  79. Labs to watch for a patient that has abdominal trauma
    • increased WBC >15,000
    • Increased amylase and liver enzymes
    • hematuria
    • blood in stool or NG aspirate
    • **falling H/H
  80. Complications of trauma and fractures
    • infection
    • compartment syndrome
    • venous thrombosis
    • fat embolism
    • Disseminated intravascular coagulation (DIC)
  81. S/S of compartment syndrome
    • 5 P's
    • pain
    • pressure
    • paresthesia....late
    • pallor....late
    • pulseless....late
  82. Care for compartment syndrome
    • prevention is the key
    • avoid elevation of the extremity above the heart
    • avoid cold compress
    • loosen the badage or bivalve the cast
    • fasciotomy
    • monitor for signs of infection
  83. S/S of venous thrombosis
    • unilateral leg edema/swelling
    • extremity pain
    • warm skin
    • erythema
    • systemic temp >100.4
  84. Care for venous thrombosis
    • prevent
    • antiembolism hose
    • sequentials
    • hourly dorsiflex/plantarflex toes
    • warfarin/heparin
  85. When do you get a fat embolism?
    long bone fx
  86. S/S of fat embolism
    • chest pain
    • tachypnea
    • cyanosis
    • dyspnea
    • apprehension
    • brady
    • decreased O2 sat
    • petechiae around the neck, anterior chest wall, axilla, buccal membrane and conjunctiva of the eye
  87. Care for a fat embolism
    • prevention is key
    • immobilize long bone fx
    • limit repositioning until fx is stabilized
  88. What's DIC
    clotting and bleeding at the same time
  89. S/S of DIC
    • follows severe trauma
    • unexplained drop in BP
    • petechiae and ecchymosis
    • bleeding from at least 3 points at once
  90. Care for a person with DIC
    • early intervention is key with anticipation of
    • rapid shock
    • ADMIN HEPARIN
    • O2
    • Maintenance of BP
    • vigorous treatment of infection or bleeding
  91. Ongoing labs during a trauma
    • single lead rhythm strip
    • H/H
    • type and cross
    • CBC
    • Chem 7
    • Drug screen if necessary
    • ABG's
    • Cardiac enzymes
    • EKG
    • Serum lypase
    • Liver enzymes
    • IVP, cystogram, CXR, C spine, CT
    • UA for presence of heme
    • Culture and sensitivity
  92. What is always a sign of hypoxia?
    HYPOTENSION
  93. Cyanosis can mean
    airway issue...check it again to ensure the patient is ventilating adequately with enough O2
  94. Anxiety and tachy should make me think....
    possible blood loss and incipient shock

    can also mean they are in pain or have a fever
  95. Delirium means.....
    decreased cerebral blood flow and incipient shock

    can also mean the person may have an infection or alcohol/drugs on board
  96. Why would I see skin changes like cool, clammy, mottled, cyanotic skin?
    release of epi when the person is in shock
  97. What does it mean if a patients HOB is at 45 and they have distended neck veins?
    • severe chest damage
    • tension pneumothorax
    • cardiac tamponade
    • CHF
  98. Flat neck veins=
    hypovolemia
  99. What is the biggest indicator that a person needs fluid....
    decreased UO...cuz it is the major monitor of visceral blood flow
  100. Before I transfer a patient from the ED make sure.....
    • they are stable
    • not hypoxic
    • no cervical spine fx
    • no aortic tear
    • no pneumothorax/hemothorax
    • no esophageal or bronchial trauma
  101. If a person is experiencing anxiety....what do I do first?
    calming techniques and figure out the problem....don't just give them ativan

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