EMERGENCY NURSING

According to the Emergency Nursing Association (ENA), emergency nursing involves the assessment, diagnosis and treatment of perceived , actual or potential, sudden or urgent, physical or psychosocial problems that are primarily episodic or acute. Emergency Nursing is a nursing specialty in which nurses care for patients in the emergency or critical phase of their illness or injury. the key difference is that an emergency nurse is skilled at dealing with people in the phase when a diagnosis has not yet been made and the cause of the problem is not known. 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, high-pressured care environment.

ISSUES IN EMERGENCY NURSING CARE 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 fast-paced, technology-driven environment in which serious illness and death are confronted on a daily basis. 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 Golden Rules of Emergency Care Dos - Obtain Consent - Think of the Worst - Respect Victims Modesty & Privacy Donts - let the patient see his own injury - Make any unrealistic promises Stages of Crisis 1. Anxiety and Denial encouraged to recognize and talk about their feelings. asking questions is encouraged. honest answers given 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 Role of the Emergency Nurse Establishes priorities Monitors and continuously assesses acutely ill and injured patients. Supports and attends to families

Supervises allied health personnel Teaches patients and families within a limited, high pressure care environment Components of Emergency Nursing 1. Triage 2. Nursing Assessment 3. Complete Health History and Head-to-toe Assessment 4. Nursing Documentation 5. Patient Transport. 1. Triage Definition: A process of assessing patients to determine management priorities. Purpose: The triage is used to sort patients into groups based on the severity of their health problems and the immediacy with which these problems must be treated. The severity of the clients problems are rated according to the predetermined categories which are emergent; urgent; and non-urgent. Three Category Triage Rating: Emergent triage category - signifying life threatening or potentially life threatening injuries or illness requiring immediate treatment. Urgent triage category - signifying serious illness or injury that is not immediately life-threatening. Non-urgent triage category - signifying episodic or minor injury or illness in which treatment may be delayed several hours or longer without increased morbidity. 2. Nursing Assessment For the patient with an emergent or urgent health problems, the priorities of emergency care are: Stabilization Provision of critical treatment Prompt transfer to the appropriate setting The nursing assessment process for any client entering the Emergency Room is divided into: Primary assessment Secondary assessment Primary Assessment Focuses on establishing life-threatening conditions. The purpose is to immediately identify any client problem that poses a threat, immediate or potential to life, limb or vision. Information is gathered primarily through objective data. If any abnormalities are found during primary assessment, immediate interventions such as CPR and advanced life support (ALS) must be instituted to aid in preserving the clients life, limb or vision. ABC mnemonic plus disability: A Airway patency. Establish a patent airway. B Breathing effectiveness. Provide adequate ventilation, employing resuscitation measures when necessary , (trauma patients must have the cervical spine protected and chest injuries assessed first). C Circulation (both peripheral and organ specific). Evaluate and restore cardiac output by controlling hemorrhage, preventing and treating shock and maintaining or restoring effective circulation. D Determine neurologic disability by assessing neurologic function using the Glasgow Coma Scale. Once it is determined that a clients ABCs status is satisfactory, the second assessment is performed. Secondary Assessment - Identify any other non-life threatening problems the client may be experiencing. Both subjective information and objective data are obtained. Assessment: Neurologic Assessment Level of Consciousness Orientation to person, place, time, and event Glasgow Coma Scale Score (GCS) Secondary Assessment In children, a brief neurologic assessment can be determined using the AVPU mnemonic: A Alert (the child is awake and alert and needs no stimulus to respond to the environment) V Verbal (the child requires a verbal stimulus to elicit a response) P Pain (the child require a painful stimulus to evoke response) U Unresponsive (the child is unresponsive to any applied stimulus)

2. Complete Health History and Head-to-toe Assessment a. History. Nature of the clients chief complaint Duration of the problem Mechanism of injury from blunt or penetrating forces Associated manifestations related to primary problem Past pertinent medical history Current medications and compliance Use of over-the-counter (OTC) medications or herbs Routine use of alcohol or illicit drugs Known medication allergies Immunization history Women of childbearing age need to be asked about normal last menstrual period (LMP), number of pregnancies and outcomes, and age at onset or at end of menstruation. b. Pain The most frequent complaint for which clients seek emergency care is related to both acute and chronic pain. Asking questions according to the PQRST mnemonic provides useful information: P Provokes. Are there any specific factors that cause the pain to increase or decrease? Q Quality. What descriptive terminology identifies the type of pain: dull, sharp, colicky pressure? R Region/radiation where the pain is located? Does it move to other areas? S Severity. Use a rating scale of 1 to 10, visual analogs, or word descriptors to describe pain severity. T Timing. How long has the pain been present? Are there cycles related to when the pain is present or absent? c. Head-to-toe Assessment Note the clients: - Overall health condition - Skin color, gait, posture - Unusual markings or body odors - Mood and affect In doing the assessment, remove the clients clothing and examine the areas where the chief complaint and any other associated complaints are focused. Monitor vital signs and pulse oximetry values. d. Diagnostic and Laboratory Testing. e. Insertion or application of monitoring devices such as ECG electrodes, arterial lines and/or urinary catheters. f. Splinting of suspected fractures. g. Cleaning and dressing of wounds. h. Performance of other necessary interventions based on the individual patients condition. 4. Nursing Documentation Documentation must include recording of all: Assessment findings Diagnostic tests Intervention and management Responses to treatment Achieved outcomes Clients education Documentation needs to be complete but concise, providing an ongoing records of the clients condition and responses. 5. Patient Transport. Equipments used at the Emergency Room 1. Defibrillator - a device that delivers an electric shock at a preset voltage to the myocardium through the chest wall. It is used for restoring the normal cardiac rhythm and rate when the heart has stopped beating or its fibrillating. 2. Cardiac Monitor - a device for the continuous observation of cardiac function. It may include electrocardiograph and oscilloscope readings, recording devices, and a visual or audible record of heart function and rhythm. An alarm system may be set to alert staff of variation from a certain rate. Purpose: To observe continuously the hearts electrical activity in patients with symptomatic arrhythmia or any cardiac abnormality that might lead to life threatening arrhythmias. To evaluate effects of therapy. 3. Mechanical Ventilator - is a device that functions as a substitute for the action of the thoracic cage and diaphragm. It can maintain ventilation automatically for prolonged periods.

a. Purpose: - for patient who is unable to maintain safe levels of oxygen or carbon dioxide by spontaneous breathing even with the assistance of other oxygen delivery devices. b. Modes of Mechanical Ventilation Mechanical ventilators can be programmed to assist, control, or assist-control: Control Mode - ventilator delivers a set tidal volume at a prescribed rate, using predetermined inspiratory and expiratory times. It cycles automatically at a rate that is selected by the operator. This mode can fully regulate ventilation in a patient with paralysis or respiratory arrest. Assist / Control - inspiratory cycle of ventilator is activated by the patients voluntary inspiratory effort. The patient initiates inspiration and receives a preset tidal volume from the machine , which augments his ventilatory effort while letting him determine his own rate. The patient initiates breathing and a backup control delivers a preset number of breaths at a set of volume. Intermittent Mandatory Ventilation - allows patient to breathe spontaneously through ventilator circuitry. Periodically, at preselected rate and volume, cycles to give a man ventilator breath. A minimum level of ventilation is provided. It is indicated to patients who are breathing spontaneously, but a tidal volume, at a rate less than adequate for their needs. 4. Emergency Cart a. Emergency Drugs b. Oral airways - is semicircular in shape, minimally flexible, curved piece of hard plastic. When inserted, it extends from just outside the lips, over the tongue and to the pharynx. - enables the nurse to suction through the central core or along the side of the airway, facilitate resuscitation, and maintain airway patency in the unconscious client. c. Endotracheal tube - is an artificial airway inserted through the mouth into the trachea. d. Ambu-bag - portable resuscitation device that provides manual inflation of the lungs. Ambu-bag is usually used with supplemental oxygen. - Ambu stands for Air Mask Bag Unit. - the bags are available in infant, child, and adult models to deliver inhaled volumes of 240 ml per breath depending on the manufacturer. e. Laryngoscope - an endoscope for examining the larynx. 5. Pulse Oximeter - it is a device that tells you the percentage of oxygen circulating in the blood, by measuring the oxygen saturation (SaO2) of the hemoglobin. - it consists of a small and portable monitor and a sensing unit that clips onto the patients finger. Along with the SaO2, the meter also gives you a pulse rate. Several things to keep in mind when using the pulse oximeter. The measurement becomes inaccurate in hypothermic patients, and in patients in decompensated shock. The device will give false high readings in patients with carbon monoxide poisoning. Chronic smokers have residual carbon monoxide in their blood, so their readings may give false highs. Extremely bright lights might interfere with the sensors function. Inadequate perfusion due to poor arterial circulation, or the use of blood pressure cuff on the same extremity as the sensor, may prevent proper operation of the device. Patient movement, dysfunctional hemoglobin, and certain intravascular dyes, can also affect the reading. Very dense fingernail polish or acrylic nails may interfere with sensor function. Anything that compromises venous return, may alter the reading. Keep the sensor at heart level whenever possible. 6. Electrocardiogram (ECG) Machine - is a device that records the electrical impulses generated by the heart during cardiac cycle. The electrical impulses are conducted to the bodys surfaces, where they are detected by electrodes placed on the limbs and chest. The electrodes carry the electrical impulses to a continuously running graph that plots the ECG wave pattern. 7. Nebulizer - a device that uses the aerosol principle to suspend a maximum number of water drops or particles of the desired size in inspired air. Adding moisture to the respiratory system through nebulization may improve clearance of pulmonary secretions. Types: Jet aerosol nebulizer uses gas under pressure. Ultrasonic nebulizer uses high-frequency vibrations to break up the water or medication into fine drops or particles.

8. Suction Machine - a device use to provide an efficient means of removing a body fluid (e.g., blood, mucus, vomitus) from respiratory tract, body cavity or wound. - to remove excessive or thick secretions. - to ensure that the airway is patent for the child with an endotracheal (ET) or tracheostomy tube. 9. Pick-up forceps with Solutions: 10. Different sets: I & D: Blade handle # 3 with Blade # 11 tissue forcep with teeth 2 artery forceps (hemostat) penrose drain scissors (mayo), may be used to cut suture lap sheet pieces of gauze. Suture Set. Suture scissors Needle holder Needles (soft tissue round; hard tissue cutting) Silk 3-0 or sutures Small clamps or curve or mosquito forceps OS and lap sheet. Cut-down Set (No veins visible): Suture set BH # 3 with B # 15 Small scissors (metz or iris) Small rakes or cat paws Tubing (polyethylene / abbocath) For pedia: Silk 4-0 Aneurysm needle or groove director. Tracheostomy set Suture set Tracheostomy tube Metz Tracheal hooks Tracheal retractors Small rakes Small / big army or navy Sufratulle 6-12 clamps

Emergency Meds
Adrenalin (epinephrine) - used for any form of allergies mild or severe (cause anaphylactic shock) Atropine Sulfate - used to lessen secretions. - Used in cases where there is poisoning, excessive secretions, cardiac failure. Anti-Convulsant drugs - MgSO4 / Ca Gluconate for preeclamsia - NaHC03 To correct metabolic acidosis - Steroids Solu-Cortef / DAFA - Nitroglycerin Treatment for angina - Nifidepine Anti-hypertension (by increasing peripheral resistance and coronary blood flow Levophed / Isuprel - Aminophylline Bronchodilator Give in casesof skin asthma

Fluids: - Shock, Dengue Fever, Vomiting D5LR - LBM D5.3NaCl D5 IMB D5 NM - if patient has no IVF, give LR available I.V. gauge 19 B.T. gauge 18

Airway Obstruction
The airway is partially or completely occluded Permanent brain damage or death will occur within 3-5 minutes

Clinical Manifestations Labored Breathing Use of Accessory Muscles Cyanosis Confusion Flaring Nostrils Hypoxia Loss of Consciousness Management 1. Head-tilt/chin-lift maneuver Check Breathing. Opening the airway. Place patient in a supine position. Place one hand in a patients forehead. Apply pressure to tilt the head back. Place the other hand under the bony part of lower jaw near the chin and lifted Top: Airway obstruction produced by the tongue and the epiglottis. Bottom: Relief by head-tilt/chin-lift. Note: Do not use this maneuver if you suspect cervical spine injury. 2.Jaw-Thrust Maneuver One hand is placed on each side of patient jaw. Displace our mandible forward. 3.Oropharyngeal Airway Insertion An oropharyngeal airway (also known as an oral airway,OPA or Guedel pattern airway) is a medical device called an airway adjunct used to maintain a patent (open) airway. It does this by preventing the tongue from (either partially or completely) covering the epiglottis, which could prevent the patient from breathing. designed by Arthur E. Guedel Oropharyngeal airways come in a variety of sizes, from infant to adult, and are used mostly in pre-hospital emergency care 4. Endotracheal Intubation refers to the placement of a tube into an external or internal orifice of the body. Tracheal intubation is the placement of a flexible plastic tube into the trachea to protect the patient's airway and provide a means of mechanical ventilation. The most common intubation is orotracheal intubation where, with the assistance of a laryngoscope, an endotracheal tube is passed through the mouth, larynx, and vocal cords, into the trachea. A bulb is then inflated near the distal tip of the tube to help secure it in place and protect the airway from blood, vomit, and secretions Indications Comatose or intoxicated patients who are unable to protect their airways. In such patients, the throat muscles may lose their tone so that the upper airways obstruct or collapse and air can not easily enter into the lungs. General anesthesia. In anesthetized patients spontaneous respiration may be decreased or absent due to the effect of anesthetics, opioids, or muscle relaxants. To enable mechanical ventilation, an endotracheal tube is often used, although there are alternative devices such as face masks or laryngeal mask airways. Cardiopulmonary Resuscitation.

up.

5. Heimlich Maneuver Abdominal thrusts, also known as the Heimlich Maneuver (after Henry Heimlich) Performing abdominal thrusts involves a rescuer standing behind a patient and using their hands to exert pressure on the bottom of the diaphragm. This compresses the lungs and exerts pressure on any object lodged in the trachea, hopefully expelling it. This amounts to an artificial cough . Alternatives to Intubation Tracheostomy - a surgical technique, typically for patients who require long-term respiratory support

Hypoxia
Hypoxia literally means "a deficiency in oxygen." Hypoxia (medical), a shortage of oxygen in the body. Hypoxemia is the reduction of oxygen specifically in the blood; Anoxia is when there is no oxygen available at all.

Types of Hypoxia Hypoxemic Hypoxia is a generalized hypoxia, an inadequate supply of oxygen to the body as a whole. Anemic Hypoxia - total oxygen content of the blood is reduced. Hypemic Hypoxia - the blood fails to deliver oxygen to target tissues. Histotoxic Hypoxia the quantity of oxygen reaching the cells is normal, but the cells are unable to effectively use the oxygen . Ischemic Hypoxia - there is a local restriction in the flow of otherwise well-oxygenated blood Symptoms Headache Fatigue Nausea Cyanosis Seizure Coma Death Management Remove Obstruction/Cause Oxygen Inhalation Bypass Airway Rest

Hanging and Strangulation

Hanging is the lethal suspension of a person by a ligature. A method of suicide in which a person applies a ligature to the neck and brings about unconsciousness and then death. Strangling involves one or several mechanisms that interfere with the normal flow of oxygen into the brain. Strangulation - is a compression of the neck that leads to unconsciousness or death by causing an increasingly hypoxic state in the brain. Fatal strangling typically occurs in cases of violence, accidents, and as the mechanism of suicide. Ligature strangulation Strangulation without suspension using some form of cord-like object . Manual strangulation Strangulation using the fingers or other extremity Aims of Care Restore adequate breathing To arrange urgent transport in the hospital Recognition A constricting article around the neck. Marks around the casualty neck. Cyanosis or impaired consciousness. Prominent veins on the face. Special Precautions Observe proper transport Do not destroy materials used in constricting the neck, police may need it as evidence.

Drowning
Drowning is death as caused by suffocation when a liquid causes interruption of the body's absorption of oxygen from the air leading to asphyxia. The primary cause of death is hypoxia and acidosis leading to cardiac arrest . Near drowning is the survival of a drowning event involving unconsciousness or water inhalation and can lead to serious secondary complications, including death, after the event

Aims of Care To restore adequate breathing To keep casualty warm To arrange urgent transport in the hospital. Risks factors In no particular order: Lack of supervision of young children (less than 5 years old). Water conditions exceed the swimmer's ability - turbulent or fast water, water out of depth, falling through ice, Entrapment - physically unable to get out of the situation because of a lack of an escape route, snagging or by being hampered by clothing or equipment. Impaired judgment and physical incapacitation arising from the use of drugs, principally alcohol. Incapacitation arising from acute illness while swimming - heart attack, seizure or stroke. Forcible submersion by another person - murder or misguided children's play. Drowning following a car crash or submersion. Incidence Victims are more likely to be male, young or adolescent. Surveys indicate that 10% of children under 5 have experienced a situation with a high risk of drowning. The causes of drowning cases as follows: 44% are related to swimming 17% are related to boating 14% are un attributed 10% related to scuba diving 7% related to car accidents Prevention Learn to swim Keep a watch out for others. Swim in areas where adequate supervision is present ie a trained and certified Lifeguard. Ensure that boats are reliable, properly loaded and that functional emergency equipment is onboard. Wear a properly fitting lifejacket while enjoying water sports such as sailing, surfing. Pay attention to the weather, tides and water conditions. Keep children under a watchful eye . Do not dive into an unknown depth and or bottom contour area. Avoid swimming alone Avoid swimming at night Avoid swimming under the influence of drugs and or alcohol . Be aware of your personal limits Drowning Rescue Do not endanger yourself during this process. Throw a rope. Use a long stick. The focus of the first aid for a near-drowning victim in the water is to get oxygen into the lungs without aggravating any suspected neck injury.

Inhalation of Fumes
Smoke inhalation is the primary cause of death in victims of indoor fires. Smoke inhalation injury refers to injury due to inhalation or exposure to hot gaseous products of combustion. This can cause serious respiratory complications This refers to the inhalation of smoke or gases such as carbon monoxide. The casualty is most likely to have low levels of oxygen in his body tissues. A person who is confined in a space during fire is assumed to have inhaled smoke. A smoke from burning plastics, foams and synthetic wall covering is likely to contain poisonous fumes. Inhalation of Carbon Monoxide Carbon Monoxide is a poisonous gas that is produced by burning. It acts directly on the red blood cells preventing them from carrying oxygen to the body tissues. Carbon Monoxide has no taste or smell. Signs and Symptoms Coughing Vomiting Nausea, Sleepiness Confusion Difficulty Breathing Treatment Treatment consists of humidified oxygen, bronchodilators, suction, endotracheal tube and chest physiotherapy. Other measures include adequate fluids and control of infection by daily sputum stains and appropriate antibiotics.

Penetrating Chest Wound

Depending on its size, a penetrating chest wound may cause varying degrees of damage to bones, soft tissue, blood vessels, and nerves. The risk of death and disease from a chest wound depends on the size and severity of the wound. Gunshot wounds are usually more serious than stab wounds because they cause more severe lacerations and rapid blood loss. With prompt, aggressive treatment, up to 90% of patients with penetrating chest wounds recover.

Causes Stab wounds from a knife or an ice pick and gunshot wounds are the most common penetrating chest wounds. Explosions or firearms fired at close range are the usual source of large wounds. Aims of Care To seal the wound and maintain breathig To minimize shock Arrange immediate transport to the hospital Diagnostic tests X-rays Physical Assessment Treatment In a penetrating chest wound, treatment involves maintaining a patent airway and providing ventilatory support as needed. Chest tube insertion allows the reestablishment of intrathoracic pressure and drainage of blood from a hemothorax. The patient's wound needs surgical repair. The patient also may need analgesics and antibiotics. Tetanus prophylaxis, and infusion of blood products and I.V. fluids.

Hyperventilation
Hyperventilation (or overbreathing) is the state of breathing faster and/or deeper than necessary, thereby reducing the carbon dioxide concentration of the blood below normal. Causes Stress or anxiety commonly are causes of hyperventilation; this is known as hyperventilation syndrome . Hyperventilation can also be brought about voluntarily, by taking many deep breaths. Hyperventilation can also occur as a consequence of various lung diseases. Signs and Symptoms Unnaturally fast deep breathing. Cramps in the hands. Dizziness Faintness Management Ask casualty to regain control of her breathing. Rebreath her own exhaled air in a paper bag. Encourage to seek medical attention

Asthma
Asthma is a chronic condition involving the respiratory system in which the airways occasionally constrict, become inflamed, and are lined with excessive amounts of mucus, often in response to one or more triggers. These episodes may be triggered by such things as exposure to an environmental stimulant such as an allergen, environmental tobacco smoke, cold or warm air, perfume, pet dander, moist air, exercise or exertion, or emotional stress Signs and symptoms Wheezing Shortness of breath Chest tightness Coughing Inability for physical exertion Tachycardia Use of accessory muscles Causes Hereditary Poor air quality Environmental tobacco smoke Viral respiratory infections Antibiotic use Psychological stress Management Identify allergens Remove source of stress Bronchodilators

Nebulization Steroids Antibiotics Rest

WOUNDS and BLEEDINGS

A. Hemorrhage Bleeding, technically known as hemorrhage is the loss of blood from the circulatory system. Bleeding can occur internally, where blood leaks from blood vessels inside the body or externally, either through a natural opening such as the vagina, mouth or anus, or through a break in the skin. Loss of 10-15% of total blood volume can be endured with clinical problem in a healthy person. Causes Hemophilia low platelet count (thrombocytopenia) Anticoagulant medications, such as warfarin Trauma and Injuries Four Classes of Hemorrhage Class I Hemorrhage involves up to 15% of blood volume. There is typically no change in vital signs and fluid resuscitation is not usually necessary. Class II Hemorrhage involves 15-30% of total blood volume. A patient is often tachycardic (rapid heart beat) with a narrowing of the difference between the systolic and diastolic blood pressures. The body attempts to compensate with peripheral vasoconstriction. Skin may start to look pale and be cool to the touch. The patient might start acting differently. Volume resuscitation with crystaloids (Saline solution or Lactated Ringer's solution) is all that is typically required. Blood transfusion is not typically required. Class III Hemorrhage involves loss of 30-40% of circulating blood volume. The patient's blood pressure drops, the heart rate increases, peripheral perfusion, such as capillary refill worsens, and the mental status worsens. Fluid resuscitation with crystalloid and blood transfusion are usually necessary. Class IV Hemorrhage involves loss of >40% of circulating blood volume. The limit of the body's compensation is reached and aggressive resuscitation is required to prevent death. B. Wounds Wound is a type of injury in which in the skin is torn, cut or punctured (an open wound), or where blunt force trauma causes a contusion (a closed wound). In pathology, it specifically refers to a sharp injury which damages the dermis of the skin. Types of Wounds a. Incisions or incised wounds, caused by a clean, sharp-edged object such as a knife, a razor or a glass splinter. b. Lacerations, irregular wounds caused by a blunt impact to soft tissue that lies over hard tissue (e.g. laceration of the skin covering the skull) or tearing of skin and other tissues such as caused by childbirth. c. Abrasions (grazes), superficial wounds in which the topmost layer of the skin (the epidermis) is scraped off. Abrasions are often caused by a sliding fall onto a rough surface. d.Puncture wounds, caused by an object puncturing the skin, such as a nail or needle. f. Gunshot wounds, caused by a bullet or similar projectile driving into or through the body. There may be two wounds, one at the site of entry and one at the site of exit . g. Contusions, more commonly known as bruises, caused by blunt force trauma that damages tissue under the skin. h. Hematomas, also called blood tumors, caused by damage to a blood vessel that in turn causes blood to collect under the skin. i. Crushing Injuries , caused by a great or extreme amount of force applied over a long period of time. Management Wound Care Antibiotics Pain Reliever Tetanus Toxoid and HTIG Control Bleeding The pattern of injury, evaluation and treatment will vary with the mechanism of the injury C. Infected Wounds Diabetes is a known factor in the host response, especially if the patients blood sugar is not well controlled. Signs and Symptoms: A wound becomes red, hot, swollen and painful. It has Pus Lymph nodes becomes swollen and tender. Danger of tetanus is very great to people who have not been vaccinated.

Management Proper Wound Care Use of Antibiotics Pain Relievers Health Teachings D. Nosebleeding Nose bleeding occurs frequently in patients with a deviated septum. Septal perforations, or holes in the septum, frequently bleed. Foreign bodies placed in the nose by children or disturbed people may result in bleeding. Causes Direct trauma to the nose, accidental or self-inflicted is probably the most common cause of nose bleeds. Extreme Heat High Blood Pressure Aims of Care Control Blood Loss Maintain an Open Airway Management Ask the casualty to sit down and tilt her head move forward. Ask the casualty to breath through her mouth. See for any foreign object on the nose Advise not to spit, cough or exert effort Advise to rest. E. Varicose Veins Varicose veins are veins that have become enlarged and twisted. Aims of Care To bring blood loss under control. To minimize shock. To arrange immediate transfer to Hospital Management Put on Gloves Raise and Support the injured leg as high as possible Apply firm and direct pressure. Remove garments such as stockings and garters.

POISONING
Poison - Any substance that impairs health or destroys life when ingested, inhaled or otherwise absorbed by the body Suspect poisoning if: 1. Someone suddenly becomes ill for no apparent reason and begins to act unusually 2. Is depressed and suddenly becomes ill 3. Is found near a toxic substance and is breathing any unusual fumes, or has stains, liquid or powder in his or her clothing, skin or lips Ingestion Poisoning Botulism Clostridium botulinum. From canned foods Note: Save the Vomitus Staphylococcus Aureus from unrefrigerated cram filled foods, fish Note: Save the Vomitus Petroleum Poisoning includes poisoning with a substance such as kerosene, fuel, insecticides and cleaning fluids Note: Never induce vomiting! May result in Chemical Pneumonia Acetaminophen Poisoning most common drug accidentally ingested by children Antidote: Acetylcysteine Corrosive Chemical Poisoning strong detergents and dry cleaners results in drooling of saliva, painful burning sensation and pain and redness in the mouth Note: Never induce vomiting, may cause further injury Activated Charcoal, Milk of Magnesia Diagnostics: Baseline ABG should be obtained periodically Baseline blood samples (CBC, BUN, electrolytes) ECG (since many toxic agents affect cardiac rhythm) Assessment: Headache Double vision Difficulty in swallowing, talking and breathing

 Dry sore throat Muscle incoordination Nausea and vomiting Management: Check victims ABCs. Begin rescue breathing if necessary If ABCs are present but the victim is unconscious, place him in recovery position If victim starts having seizures, protect him from injury If victim vomits, clear the airway Calm and reassure the victim while calling for medical help P Prevention. Child Proofing O Oral fluids in large amount IIpecac S Support respiration and circulation OOral Activated Charcoal NNever induce vomiting if substance ingested is corrosive LAVAGE Inhalation Poisoning Carbon Monoxide Poisoning Carbon monoxide is a colorless, odorless & tasteless gas Assessment: - appears intoxicated - Muscle weakness - Heaadache & dizziness - Pink or cherry red skin (not a reliable sign) - Confusion which may eventually lead to coma Management: 1. Check ABCs 2. Remove victim from exposure 3. Loosen tight clothing 4. Administer O2 (100% delivery) 5. Initiate CPR if required

BURN TRAUMA
Is the damage caused to skin and deeper body structures by heat (flames, scald, contact with heat) , electrical, chemical or radiation FACTORS DETERMINING SEVERITY OF BURN: 1. age mortality rates are higher for children < 4 yrs of age and for clients > 65 yrs of age 2. Patients medical condition debilitating disorders such as cardiac, respiratory, endocrine and renal disorders negatively influence the clients response to injury and treatment. - mortality rate is higher when the client has a pre-existing disorder at the time of the burn injury 3. location burns on the head, neck and chest are associated with pulmonary complications; burns on the face are associated with corneal abrasion; burns on the ear are associated with auricular chondritis; hands and joints require intensive therapy; the perineal area is prone to autocontamination by urine and feces; circumferential burns of the extremities can produce a tourniquet-like effect and lead to vascular compromise (compartment syndrome). 4. Depth Classification 1st degree superficial 2nd degree partial thickness 2nd degree deep partial thickness Affected Part Epidermis Description of Wound Pin, painful sunburn Blisters form after 24 hours Red, wet blisters, bullae very painful Waxy white, difficult to distinguish from 3rd degree except hair growth becomes apparent in 710 days, little or no pain What to Expect Discomfort last after 48 hrs; heals in 3-7 days Heals in 2-3 weeks, in no complication Slow to heal 94-8 weeks) surgical incision and grafting unless has complication

Pediermis and part of the dermis Only the skin appendages in the hair follicle remain

3rd degree Full thickness

Epidermis, dermis and subcutaneous tissue . no skin appendages

Dry, leathery, may be red or black May have thrombosed veins Marked edema Distal circulation may be decreased Painless Dry, charred, bone may be visible

Requires excision and grafting. 10- 14 days for graft to revascularize

4th degree deep full thickness

Skin, muscle, tendon, bonde

Requires excision, grafting and sometimes amputation

5. Size: Rule of nine Assessment Head and neck 1 arm Posterior trunk Anterior trunk 1 leg Perineum Child < 3 years old 18% 9% 18% 18% 14% 1% Adult 9% 9% 18% 18% 18% 1%

6. Temperature - determines the extent of injury 7. Exposure to the Source Thermal Burns caused by exposure to flames, hot liquids, steam or hot objects Chemical Burns caused by tissue contact with strong acids, alkalis or organic compounds Electrical Burns result in internal tissue damaging, alternating current is more dangerous than direct current for it is associated with cardiopulmonary arrest, ventricular fibrillation, titanic muscle contractions, and long bone and vertebral fractures. Radiation Burns are caused by exposure to ultraviolet light, x-rays or a radioactive source. Types of Burns and their Treatment: Scald burn caused by hot liquid immediately flush the burn area with water (under a tap or hose for up to 20 min) if no water is readily available, remove clothing immediately as clothing soaked with hot liquid retains heat If water is available, immediately cool the burn area with water If water is not available, remove clothing; avoid pulling clothing across the burnt face Cover the burn area with a loose, clean, dry cloth to prevent contamination Do not break blisters or apply lotions, ointments, creams or powder Flame Smother the flames with a coat or blanket, get the victim on the floor or ground (stop, drop, and Roll) Airway if face or front of the trunk is burnt, there could be burns to the airway there is a risk of swelling or air passage, leading to difficulty in breathing Smoke inhalation Urgent treatment is required with care of the airway, breathing and circulation When 02 in the air is used up by fire, or replaced by other gases, the oxygen level in the air will be dangerously low Spasm in the air passages as a result of irritation by smoke or gases Severe burns to the air passages causing swelling and obstruction Victim will show signs and symptoms of lack of O2. He may also be confused or unconscious Electrical check for Danger turn of the electricity supply if possible avoid any direct contact with the skin of the victim or any conducting material touching the victim until he is disconnected once the area is safe, check the ABCs if necessary, perform rescue breathing or CPR

Chemical Flood affected area with water for 20-30 min Remove contaminated clothing If possible, identify the chemical for possible subsequent neutralization Avoid contact with the chemical Sunburn Exposure to ultraviolet rays in natural sunlight is the main cause of sunburn General skin damage and eventually skin cancer develops The signs and symptoms of sunburn are pain, redness and fever

Orthopedic Emergencies
A. Bone Fractures - A bone fracture (sometimes abbreviated as Fx) is a medical condition in which a bone is cracked or broken. It is a break in the continuity of the bone - Although fractures are commonly referred to as bone breaks, the word break is not part of formal orthopedic terminology. Categories of Fracture Closed fractures are those in which the skin is intact, while open (compound) fractures involve wounds that communicate with the fracture and may expose bone to contamination. Open Fractures the broken bone end pierce the skin surface. This carries high risk for infection. Types of Fracture: Compacted Fracture- A fracture caused when bone fragments are driven into each other. Comminuted Fracture- A fracture which results in several fragments. Spiral Fracture- A fracture where at least one part of the bone has been twisted. Compression Fracture- A fracture that usually occurs in the vertebrae. Oblique Fracture- A fracture that is diagonal to a bone's long axis. Transverse Fracture- A fracture that is at a right angle to the bone's long axis. Linear Fracture- A fracture that is parallel to the bone's long axis. Incomplete Fracture- A fracture in which the bone fragments are still partially joined. Complete Fracture- A fracture in which bone fragments separate completely. Management Immobilization Splinting Pain Relief Antibiotic I and D Realignment Surgery B. Joint dislocation Joint dislocation (Latin: luxatio) occurs when bones in a joint become displaced or misaligned. It is often caused by a sudden impact to the joint. The ligaments always become damaged as a result of a dislocation . Treatment Anyone experiencing a joint should seek medical assistance as soon as possible. A dislocated joint can only be successfully 'reduced' into its normal position by a trained medical professional. Trying to reduce a joint without any training could result in making the injury substantially worse. X-rays are usually taken to confirm a diagnosis and detect any fractures which may also have occurred at the time of dislocation. Once a diagnosis is confirmed, the joint is usually manipulated back into position. This can be a very painful process, therefore this is typically done under local or in an Operating Room under a General Anaesthetic. Management: After a dislocation, injured joints are usually held in place through a splint (for straight joints like fingers and toes) or a bandage (for complex joints like shoulders). Additional to this, the joint muscles, tendons and ligaments must also be strengthened. This is usually done through a course of Physiotherapy, which will also help reduce the chances of repeated dislocations of the same joint. C. Sprain and Strain A sprain is a stretch and/or tear of a ligament, the fibrous band of connective tissue that joins the end of one bone with another. Ligaments stabilize and support the body's joints. For example, ligaments in the knee connect the upper leg with the lower leg, enabling people to walk and run. A strain is an injury of a muscle and/or tendon. Tendons are fibrous cords of tissue that attach muscles to bone.

A sprain is caused by direct or indirect trauma (a fall, a blow to the body, etc.) that knocks a joint out of position, and overstretches, and, in severe cases, ruptures the supporting ligaments . Chronic strains are the result of overuse (prolonged, repetitive movement) of muscles and tendons. Inadequate rest breaks during intensive training precipitates a strain. Acute strains are caused by a direct blow to the body, overstretching, or excessive muscle contraction. Professional and amateur athletes and the general public, as well, can sustain this injury. People at risk for the injury have a history of sprains and strains, are overweight, and are in poor physical condition. While the intensity varies, pain, bruising, swelling, and inflammation are common to all three categories of sprains: mild, moderate, severe. The individual will usually feel a tear or pop in the joint. A severe sprain produces excruciating pain at the moment of injury, as ligaments tear completely, or separate from the bone. Typical indications include pain, muscle spasm, muscle weakness, swelling, inflammation, and cramping. In severe strains, the muscle and/or tendon is partially or completely ruptured, often incapacitating the individual.

Management: Rest Ice Compression Elevation Splinting Rest: Stop all activities which cause pain to avoid the strain becoming more serious. Ice: Helps reduce swelling. Never ice for more than 10-15 minutes at a time. Use a layer of fabric or paper in between the ice and the injury to avoid burning the skin. Compression: Wrap the strained area to reduce swelling. Elevation: Keep the strained area as close to the level of the heart as is conveniently possible to keep blood from pooling in the injured area Prevention Tips No one is immune to sprains and strains Participate in a conditioning program to build muscle strength. Do stretching exercises daily. Always wear properly fitting shoes . Nourish your muscles by eating a well-balanced diet. Warm up before any sports activity, including practice Use or wear protective equipment appropriate for that sport . D. Spinal Cord Injury Spinal cord injury causes myelopathy or damage to white matter or myelinated fiber tracts that carry sensation and motor signals to and from the brain. Trauma such as automobile accidents, falls, gunshots, diving accidents, war injuries, etc. Cervical injuries C4 : May have some use of biceps and shoulders, but weaker C5 : May retain the use of shoulders and biceps, but not of the wrists or hands. C6 : Generally retain some wrist control, but no hand function. C7 and T1 : Can usually straighten their arms but still may have dexterity problems with the hand and fingers. C7 is generally the level for functional independence. Thoracic Injuries T1 to T8 : Most often have control of the hands, but lack control of the abdominal muscles so control of the trunk is difficult or impossible. Effects are less severe the lower the injury. T9 to T12 : Allows good trunk and abdominal muscle control, and sitting balance is very good . The effect of injuries to the lumbar or sacral region of the spinal canal are decreased control of the legs and hips, urinary system, and anus. Management: Mobilize Patient as one unit Provide a C-Collar ABC Resuscitate if necessary Arrange urgent transfer to the hospital E. Ribcage Injury There are 12 ribs on each side of the chest that protect the heart, lungs, and the upper abdominal contents. All of the ribs are attached to the vertebrae (backbone) in the rear. In the front, 10 of them are attached to the sternum (breastbone) by pieces of cartilage. Direct blows to the ribs may bruise or break the ribs or injure to the rib cartilage. The ribs may tear away from the cartilage that attaches them to the breastbone. This tearing away from the cartilage is called a costochondral separation. Rib injuries usually result from a direct blow to the chest wall. Breaks usually occur in the curved portion of the outer part of the rib cage. A costochondral separation may occur when you land hard on your feet or even when you cough or sneeze violently.

What are the symptoms? A rib injury causes pain and tenderness over the place of injury. You may have pain when you breathe, move, laugh, or cough. Diagnosis? The doctor will review the symptoms presented, examines the rib cage, and listens to the lungs. Chest x-ray may be ordered to look for any rib damage, lung damage, or bleeding around the lungs. Treatment Rest Putting an ice pack over the injured rib for 20 to 30 minutes every 3 to 4 hours for 2 to 3 days, or until the pain goes away. Taking an anti-inflammatory or other pain medication If you broke a rib it may take 4 to 6 weeks to heal. Your doctor may take an x-ray to see that the bone has healed before he or she allows you to return to your activity, especially if it is a contact sport. You may participate in non-contact activities sooner if you can do so without pain in your ribs and without pain when you breathe. If you have bruised your ribs or separated the cartilage from the ribs, you may return to your activity when you can do so without pain.

Nervous System Emergencies

A. Concussion Concussion, from the Latin concutere ("to shake violently"). The terms mild brain injury, mild traumatic brain injury (MTBI), mild head injury (MHI), and minor head trauma and concussion may be used interchangeably. concussion can cause a variety of physical, cognitive, and emotional symptoms. Causes: The leading causes of MTBI in adults are falls and vehicle accidents. sports injuries assaults, industrial and work-related injuries, and injuries that occur in the home and school. Among children aged 5 to 14, sports and bicycle accidents cause the greatest number of concussions. Signs and Symptoms Headache and difficulty concentrating dizziness, vomiting, nausea, lack of motor coordination, difficulty balancing,. light sensitivity seeing bright lights, blurred vision double vision. Tinnitus, or a ringing in the ears, is also commonly reported Convulsions Diagnosis: Diagnosis of MTBI is based on physical and neurological exams, duration of unconsciousness (usually less than 30 minutes) and post-traumatic amnesia (PTA; usually less than 24 hours), and the Glasgow Coma Scale (MTBI sufferers have scores of 13 to 15 ) CT Scan B. Contusion Cerebral contusion, Latin contusio cerebri, a form of traumatic brain injury, is a bruise of the brain tissue. Like bruises in other tissues, cerebral contusion can be caused by multiple microhemorrhages, small blood vessel leaks into brain tissue. Treatment aims to prevent dangerous rises in intracranial pressure, the pressure within the skull. Contusions are likely to heal on their own without medical intervention Signs and Symptoms: Contusion can present with weakness, lack of motor coordination, numbness, aphasia, and memory and cognitive problems. Signs depend on the contusion's location in the brain. Causes: The interior of the skull has sharp ridges by which a moving brain can be injured. Often caused by a blow to the head. Treatment: Since cerebral swelling presents a danger to the patient, treatment of cerebral contusion aims to prevent swelling. Measures to avoid swelling include prevention of hypotension (low blood pressure). Due to the danger of increased intracranial pressure, surgery may be necessary to reduce it. People with cerebral contusion may require intensive care and close monitoring.

C. Skull Fracture Linear skull fractures - the most common type of skull fracture, occur in 69% of patients with severe head injury. Usually caused by widely distributed forces, linear fractures often occur when the impact causes the area of the skull that was struck to bend inward, making the area around it buckle outward. Diastatic fractures are linear fractures that cause the bones of the skull to separate at the skull sutures in young children whose skull bones have not yet fused. Comminuted skull fractures- those in which a bone is shattered into many pieces, can result in bits of bone being driven into the brain, lacerating it.Depressed skull fractures, a very serious type of trauma occurring in 11% of severe head injuries, are comminuted fractures in which broken bones are displaced inward. This type of fracture carries a high risk of increasing pressure on the brain, crushing the delicate tissue. Basilar skull fractures-breaks in bones at the base of the skull, require more force to cause than cranial vault fractures. Thus they are rare, occurring as the only fracture in only 4% of severe head injury patients. Basilar fractures have characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes (bruising of the orbits of the eyes that result from blood collecting there as it leaks from the fracture site); and Battle's sign (caused when blood collects behind the ears and causes bruising). In medical terminology, Battle's sign, also mastoid ecchymosis, is an indication of fracture of the base of the posterior portion of the skull, and may suggest underlying brain trauma. Battle's sign consists of bruising over the mastoid process, as a result of extravasation of blood along the path of the posterior auricular artery. The sign is named after William Henry Battle. Diagnostic and Laboratory Tests 1. History and Physical exam. 2. Arterial Blood Gases. 3. Complete Blood Count. 4. Serum Glucose. 5. Serum Electrolytes 6. CT Scan 7. MRI 8. EEG 9. Glasgow Coma Scale Therapeutic Nursing Management: 1. Assess / Monitor: Respiratory Status (breathing pattern, CO2 levels) Neurological Status every 15 minutes until client is stable (vital signs, PERRLA, LOC) For signs of ICP. For posturing (decorticate, decerebrate, flaccid). For pain and restlessness. For indication of infection. 2. Nursing activities: a. Maintain patent airway. b. Elevate head to reduce intracranial pressure. c. Implement seizure precautions. d. Instruct client to avoid coughing. e. Report presence of CSF from nose or ears to clients doctor. f. Administer pain medications as ordered in the absence of ICP (avoid morphine sulfate because it produces respiratory depression). g. Maintain client safety. (side rails up, padded side rails). h. Provide emotional support. i. Implement measures to prevent complication of immobility (turn every two hours, footboard and splints). j. Prepare client for surgery if indicated. Pharmacology: Osmotic diuretics (Mannitol) Corticosteroids (Decadron) Anti-hypertensives. Antipyretics Muscle relaxants. Anticonvulsants. Analgesics. (no morphine sulfate). Complication: Brain hypoxia Cerebral edema CSF flow obstruction Shock

Infection Motor and/or sensory disability Coma Death

Age-related Changes Gerontological Conditions. the presence of dementia or confusion in the older adult may mask signs and symptoms associated with head injury. D. Stroke Stroke is the rapidly developing loss of brain functions due to a disturbance in the blood vessels supplying blood to the brain. This can be due to ischemia (lack of blood supply) caused by thrombosis or embolism, or due to a hemorrhage. In the past, stroke was referred to as cerebrovascular accident or CVA, but the term "stroke" is now preferred. Stroke is a medical emergency and can cause permanent neurological damage, complications and death if not promptly diagnosed and treated. Risk factors: Advanced age Hypertension (high blood pressure), Previous stroke or transient ischemic attack (TIA) Diabetes High cholesterol Cigarette smoking Atrial fibrillation, the contraceptive pill, migraine with aura, and thrombophilia (a tendency to thrombosis). High blood pressure is the most important modifiable risk factor of stroke. Classification: Ischemic Stroke- blood supply to part of the brain is decreased, leading to dysfunction and necrosis of the brain tissue in that area. There are four reasons why this might happen: thrombosis (obstruction of a blood vessel by a blood clot forming locally), embolism (is due to a embolus from elsewhere in the body), systemic hypoperfusion (general decrease in blood supply, e.g. in shock) and venous thrombosis. Stroke without an obvious explanation is termed "cryptogenic" (of unknown origin). Thrombotic stroke -In thrombotic stroke, a thrombus (blood clot) usually forms around atherosclerotic plaques. Embolic stroke refers to the blockage of an artery by an embolus, a traveling particle or debris in the arterial bloodstream originating from elsewhere. An embolus is most frequently a thrombus, but it can also be a number of other substances including fat (e.g. from bone marrow in a broken bone), air, cancer cells or clumps of bacteria (usually from infectious endocarditis . Diagnosis: CT scans (most often without contrast enhancements) or MRI scans, Doppler ultrasound, and arteriography. For detecting chronic hemorrhages, MRI scan is more sensitive A systematic review found that acute facial paresis, arm drift, or abnormal speech are the best findings. Prevention: Given the disease burden of stroke, prevention is an important public health concern. The most important modifiable risk factors for stroke are high blood pressure and atrial fibrillation Other modifiable risk factors include high blood cholesterol levels, diabetes, cigarette smoking (active and passive), heavy alcohol consumption and drug use,lack of physical activity, obesity and unhealthy diet . Hypertension accounts for 35-50% of stroke risk. High cholesterol levels have been consistently associated with (ischemic) stroke. Patients with diabetes mellitus are 2 to 3 times more likely to develop stroke . E. Seizure A seizure, also known as a convulsion or fit, is a sudden loss of consciousness, a change in one's state of consciousness, or loss of control over one's body. Seizure Types: Epileptic Seizure Absence seizure Atonic seizure Focal seizures Simple partial seizure Jacksonian seizure Tonic-clonic seizure Non-epileptic seizure Febrile seizure Post-traumatic seizure Psychogenic non-epileptic seizures

Causes: Seizures are caused by abnormal electrical discharges in the brain. Symptoms may vary depending on the part of the brain that is involved, but seizures often cause unusual sensations, uncontrollable muscle spasms, and loss of consciousness. Some seizures may be the result of a medical problem. Low blood sugar, infection, a head injury, accidental poisoning, or drug overdose can cause a seizure. A seizure may also be due to a brain tumor or other health problem affecting the brain. In addition, anything that results in a sudden lack of oxygen to the brain can cause a seizure. In some cases, the cause of the seizure is never discovered. Management: ABC Safety Arrange for immediate transfer to hospital

SHOCK
is a complex clinical syndrome that may occur at anytime and in any place. It is the failure of the circulatory system to maintain adequate perfusion of vital organs Disorders leading to inadequate tissue perfusion result in decreased oxygenation at the cellular level. Inadequate oxygenation results in anaerobic cellular metabolism and accumulated waste products in cells.

Three Major Classifications Hypovolemic Shock is due to inadequate circulating blood volume resulting from hemorrhage with actual blood loss, burns with a loss of plasma proteins and fluid shifts, or dehydration with a loss of fluid volume. Reduction of blood volume from 15% to 25% (1000 1500 cc of blood) Cardiogenic Shock is due to inadequate pumping action of the heart because of primary cardiac muscle dysfunction or mechanical obstruction of blood flow caused by M.I., valvular insufficiency caused by disease or trauma, cardiac dysrhythmias, or an obstructive condition, such as pericardial tanponade or pulmonary embolus. Distributive Shock - also called vasogenic shock. - Due to changes in blood vessel tone that increase the size of the vascular space without increase in the circulating blood volume. - Result is a relative hypovolemia. - Divided into three types: Anaphylactic shock Neurogenic Shock Septic Shock Treatment Modalities for Shock 1. Shock position 2. Determine the kind of shock: - hemorrhagic & hypovolemic : infuse IVF and whole blood (BT) - CVP (normal: 6 10 ml) decreased increase IVF rate increased regulate flow rate, check for pulmonary edema. Get reading every 15 mins. 3. Fluid replacement: - isotonic solution (D5LR) plasma expanders (plasmalyte, albumin, etc.) 4. Medications - vasoconstrictors (adrenalin)