EMERGENCY AND DISASTER NURSING CARE

Emergency Nursing
- involves the provision of nursing care for px w/ acute injuries or life-threatening illnesses
Core competencies
- applied skills & knowledge that enable people to do their work

 ASSSESSMENT (foundation of the emergency nurses’ skill base)

 PRIORITY SETTING/ CRITICAL THINKING (depends on the accurate assessment as well as the
critical thinking skills)
 KNOWLEDGE OF EMERGENCY CARE
 TECHNICAL SKILLS
 COMMUNICATION (there must be effective communication)

Scope and Practice of Emergency Nursing

1. The emergency nurse has had specialized education, training, experience, and expertise in
assessing and identifying patient’s health care problems in crisis situations
2. 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-reassured care environment

Principles of Emergency Care

- Care that must be rendered without delay

Definition:

The term Triage derived from the French verb “trier” meaning to “Sort or to choose”

 It’s the process by which patients classified according to the types and urgency of their
conditions to get the
 Right patient to the
 Right place at the
 Right time with the
 Right care provider

 Triage – a process of prioritizing w/c patients are to be treated first

 Baron Dominique Jean Larrey – organized the first triage system

Triage Systems

1. Emergent – patients have the highest priority – their conditions are life-threatening, and they
must be seen immediately (ie., cardiac arrest, obstruction)
2. Urgent – patients have serious health problems but not immediate life-threatening ones; they
must be seen within 1 hour (px w/ bleeding)
3. Nonurgent – patients have episodic illnesses that can be addressed within 24 hours without
increased morbidity (simple fracture, minor lacerations)
 4. Fast Track – patients require with simple first aid or basic primary care and may be treated in
the ER or safety referred to a clinic or physician’s office (fever, colds)

Five Level Triage System (more refined and comprehensive)

1. Resuscitation – need tx immediately to prevent death

2. Emergent – may deteriorate rapidly & develop a major life-threatening situation/require times
sensitive tx
3. Urgent – non-life-threatening conditions but require two or more resources to provide their
care
4. Non-urgent – non life-threatening conditions, need only one resource to prove for their needs
5. Minor – no-life threatening conditions & likely require no resources

Primary Survey

- systematic approach to effectively establish and treat health priorities

A – Airway: maintain patent airway with cervical spine control

 Positioning
 Suctioning
 if GCS is < 8 or deep coma, prepare for endotracheal tubulation and mechanical ventilator

B – Breathing: assess breathing and ventilation. Apply high oxygen.

 assess respiratory effort

 oxygen as needed
 observe for chest wall trauma
 prepare for chest decompression if needed

C – Circulation: assess circulation with hemorrhage control

 Adequacy of HR and BP
 CPR, IV access for fluid and BT

D – Disability: check neurological status

 Evaluate the client’s LOC

 Glassgow coma scale

Four possible recordable outcomes:

 Alert/awake: check if px is fully awake -> spontaneous eye opening

 Voice:
 Pain: pain stimulus
 Unresponsive

Alert = 15 CGS

Voice Responsive = 12 GCS

Pain Responsive = 8 GCS

Unconscious = 3 GCS

E – Exposure/Environment: complete assessment of the patient but prevent hypothermia

 Clothing is removed to allow for thorough assessment

 Example: rape, child abuse, homicide, suicide, drug overdose, and assault

LOOK

 Cyanosis
 Use of accessory muscles
 Flail chest

LISTEN

FEEL

Secondary Survey

 History
 PE (head to toe)
 Complete neurologic exam
 Special Dx tests
 Reevaluation

History “AMPLE”

A: Allergies

M: Medication currently being taken by the px

P: Past illness and operations, pregnancy

L: Last meal

E: Event/ Environment related to the injury

TRAUMA – an unintentional or intentional wound or injury inflected on the body from a mechanism
against which the body protect itself

Forensic skills required by all nurses

A. Evidence of collection
B. Chain of custody
C. Documentation

Rules/Principles

 Rule 1 Have proper documentation

 Rule 2 Gather physical evidence
 Rule 3 Preserve the evidence
  Rule 4 Protect the chain of custody
 Rule 5 Testify in court

Any object (or part of an object) showing that the crime has been occurred or establishing a link
between victim and perpetrator is physical evidence.

Examples:

 Vaginal swab
 Recovered slug
 Blood stained shirt
 Injuries in the body
 Footprints
 Shoeprints

Collection of Forensic Evidence

Included in documentation are:

 Description of all wounds

 Mechanism of injury
 Time of events
 Collection of evidence

STAFF AND CLIENT SAFETY CONSIDERATIONS

 Client Identification
 Client Safety
 Risk for Errors & Adverse Events

TYPES OF EMERGENCY:

1. Medical
- Airway obstruction, hemorrhage, trauma, fractures
2. Environmental
- Heatstroke, snake bite, frostbites

What is airway obstruction?

- Any obstacle from mouth to lungs

- May be partial or complete
- Limitation of air entry into lungs
- Causing lack of oxygen

Clinical Manifestations:

- Can’t speak, breath, or cough

- Clutch neck between thumb & fingers

Other common signs/symptoms:

Management

Partial Obstruction:

 Encourage px to cough forcefully, persist w/ spontaneous coughing & breathing effort if good air
exchange exists

HEIMLICH MANEUVER

1. Have a person stand and support from behind

2. Clench a fist and put it right under the breast bone
3. Grasp the fist firmly with your other hand
4. Give inward and slightly upward thrust

GIVE FIVE BACK SLAPS

HEAD TILT AND CHIN LEFT

LATERAL LYING POSITION FOR UNCONSCIOUS PX

Fractures

 A complete or incomplete disruption of bone

Clinical Manifestation

 Acute pain
 Loss of function
 Deformity
 Shortening
 Crepitus
 Swelling and discoloration (ecchymosis)

Emergency Mgt

 Assessment of ABC
 Immobilize the body part by splinting
 Assess neurovascular status distal to the injury before and after splinting

Why do we splint?

 To stabilize the extremity

 To decrease pain
 Actually treat the injury

Guidelines for Splinting

1. Support the injured area

2. Splint injury in the position that you find it
HEMORRHAGE

- Abnormal internal or external loss of blood

Goals of Emergency Mgt

1. To control the bleeding

2. To maintain adequate circulating blood volume for tissue oxygenation
3. Prevent shock

Sources:

ARTERIAL

- Bright red
- Emitted as spurting jet
- Can lead to severe blood loss
- Often hard to control

VENOUS

- Dark red
- Steady and copious flow
- Color becomes further with oxygen desaturation
- Usually easy to control

CAPILLARY

- Bright red
- Rapid and oozing
- Blood loss becomes serious if continues for hours
- Generally minor and easy to control

INTERNAL HEMORRHAGE

Can result from:

EXTERNAL HEMORRHAGE

Mgt:

- Fluid replacement: isotonic electrolyte solution

- Blood component therapy: PRBCs

Control of external hemorrhage:

- Direct, firm pressure is applied over the bleeding area of the involved artery at a site that is
proximal to the wound

Evidence of improvement

- BP 90, p < 120

- O2 Saturation >92%
 - Warm, moist skin, <2 sec capillary refill
- Consciousness, no agitation
- Urine output .55cc/kg/hr

BEE AND WASPS

Assessment

- Immediate pain
- Wheal and flare reaction
- Swelling (Extensive), involve an entire limb or body area

Systemic effect:

- Generalized edema
- Nausea, vomiting, & diarrhea
- Urticaria
- Pruritus
- Swelling of the lips and tongue

Anaphylactic Reaction:

- Respiratory distress w/ bronchospasm

First aid:

- Quick removal of the stinger (gentry scraping or brushing it off with the edge of a knife
blade/credit card/needle)
- Application of an ice pack

Hospital care:

- Epinephrine (standard for adults: 0.3-0.5mg of 1 is to 1000 solution, IM)

- Antihistamine
- O2
- Continuous cardiac & BP monitoring
- IV infusion
- Bronchodilating agent
- Corticosteroids

HEATSTROKE

SNAKEBITE

PROGONISIS:

1. The kind and amount of venom injected

2. The site on the body the bite occurred
3.