Revised ER NSG

University of the Assumption College of Nursing
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LESSON I EMERGENCY and DISASTER NURSING

Nurses are always faced with challenges and rewards for the care they provide for other people. Their task is not only confined in the four walls of the hospital but in the outside world as well. Every nurse must tackle diverse tasks with professionalism, competency, and above all concern. And in every emergency situation, nurses must focus in rapid assessment and management and must be geared up to provide client care for almost any situation they may encounter and must always learn by heart that every second counts.
Learning Objectives: After an interactive lecture/ discussion, students will be able to: Define the meaning of emergency and emergency nursing Identify the different emergency situations Discuss how to assess and manage patients in emergency situations Make and report quickly accurate assessments of people in emergency situations Act quickly, safely and appropriately in emergency situations Perform appropriate nursing intervention in any given situation
Prepared by: Leah Marie S. Navarro, RN, MAN
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EMERGENCY:
A suddenly occurring threat to life or health that calls for immediate attention to seriously ill or injured victims (Blackwell, 2005) It encompasses an unforeseen combination of circumstances calling for immediate action for a range of victims from one to many. (LeMone and Burke, 2007) Any natural or man-made situation that results in severe injury, harm, or loss of humans or property. (Veenema, 2007)
EMERGENCY NURSING:
Is the delivery of specialized care to a variety of ill or injured patients (Lippincott Williams and Wilkins, 2007)
The following are TYPES OF EMERGENCY, their clinical manifestations, assessment, and management: (Smeltzer, et al., 2010)
AIRWAY OBSTRUCTION Upper airway obstruction is a medical emergency, which maybe partial or complete occlusion caused by aspiration of foreign bodies, anaphylaxis, viral or bacterial infection, trauma, and inhalation or chemical burns. ***Partial obstruction of the airway can lead to progressive hypoxia, hypercarbia, and respiratory and cardiac arrest ***Complete obstruction can cause brain injury or death will occur within 3 to 5 minutes secondary to hypoxia Clinical Manifestations of a patient with airway obstruction: Patient cannot speak, breathe or cough Clutch the neck between the thumb and fingers Choking Apprehension Refusing to lie flat Inspiratory and expiratory stridor Labored breathing Use of accessory muscles Flaring nostrils Increasing anxiety Restlessness Confusion Cyanosis and loss of consciousness are late signs Assessment and Diagnostic Findings: Ask the person if he or she is choking If patient is unconscious, inspection of the oropharynx X-ray, laryngoscopy and bronchoscopy may also be performed
Prepared by: Leah Marie S. Navarro, RN, MAN Page 2
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Management: Abdominal thrust (Heimlich maneuver)
Adapted from hubpages.com
How to perform abdominal thrust: o Stand behind the person who choking o Place both arms around the persons waist o Make a fist with one hand with the thumb outside the fist o Place thumb side of the fist against the persons abdomen above the navel and below the xiphoid process o Grasp fist with one hand o Quickly and forcefully exert pressure against the persons diaphragm, pressing upward with quick, firm thrusts o Apply thrusts 6 to 10 times until the obstruction is cleared o The pressure from the thrusts should lift the diaphragm, force air into the lungs, and create an artificial cough powerful enough to expel the aspirated object Note: Hands crossed at the neck is the universal sign for choking. Head-tilt-chin- lift maneuver How to perform the head-tilt-chin- lift maneuver: o Place one hand on the victims forehead, and firm backward pressure is applied with the palm to tilt the head back o The fingers of the other hand are placed under the bony part of the lower jaw near the chin and lifted up o The chin and the teeth are brought forward almost to occlusion to support the jaw
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Nursing alert: The head-tilt-chin-lift maneuver, which helps tilt the head back, should be used only if it is determined that the patients cervical spine is not injured. (Smeltzer, et. al., 2010)
Adapted from pmrcrc.blogspot.com Jaw-thrust maneuver *** This is done by placing one hand on each side of the patients jaw, the angles of the patients lower jaw are grasped and lifted, displacing the mandible forward. ***This is a safe approach to opening the airway of a patient with suspected spinal cord injury because it can be accomplished without extending the head.
Adapted from www.tags-search.com

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Oropharyngeal airway insertion
Adapted from viaaereadificil.com.br ***For a patient who is breathing spontaneously but who is unconscious, a semicircular tube or tubelike plastic device called an oropharyngeal airway is inserted over the back of the tongue into the lower posterior pharynx. *** This type of device prevents the tongue from falling back against the posterior pharynx and obstructing the airway. It can also allow health care providers to suction secretions. Endotracheal intubation ***To establish and maintain the airway in patients with respiratory insufficiency or hypoxia is the purpose of endotracheal intubation. ***This is performed by physicians, nurse anesthetist, respiratory therapist, flight nurses, and nurse practitioners, because the procedure requires skill, only these people who have had extensive training can perform the procedure. Cricothyroidotomy
Adapted from www.surgeryencyclopedia.com

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***It is the opening of the cricothyroid membrane to establish airway. This procedure is used in emergency situation in which endotracheal intubation is either not possible or contraindicated.
HEMORRHAGE
The following are the management of hemorrhage: Fluid replacement - it is imperative to maintain circulation. Replacement fluids may include isotonic electrolyte solutions, colloids and blood components therapy. The table below will show you the Volume Resuscitation Therapies according to LeMone and Burke, 2007 COMPONENT Normal Saline INDICATIONS ADVANTAGES DIADVANTAGES Hyperchloremic acidosis associated with prolonged use of sodium solutions
Restoration of Good availability circulating volume Low cost Vehicle compatible Safe to use with administration of blood
Whole Blood
Replaces blood volume and oxygencarrying capacity in hemorrhage and shock
Contains RBCs, plasma proteins, clotting factors, and plasma
Contains few platelets or granulocytes; deficient in clotting factors V and VII Greatest risks are for incompatibility or circulatory overload
Packed RBCs
Restoration of intravascular volume Replacement of oxygen-carrying capacity
One unit of RBCs should increase the hemoglobin of a 70kg adult by approximately 1g/dl in the absence of volume overload or continuing blood loss
Red cells require compatibility testing Risk for transmitting blood borne pathogens Should be warmed to avoid hypothermia
Platelets
Continued hemorrhage
Compatibility testing is not required Typical platelet transfusion should
Postexposure prophylaxis with anti Rh immune globulin should be considered

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raise the platelets of following Rh+ platelet a 70-kg adult transfusion to an Rhapproximately woman 30,000-50,000/UL Good availability Nursing Alert: The infusion rate is determined by the severity of the blood loss and the clinical evidence of hypovolemia. If massive blood replacement is necessary, the blood must be warmed in a commercial blood warmer, because administration of large amounts of blood that has been refrigerated has a core effect that may lead to cardiac arrest and coagulopathy. (Smeltzer, et. al., 2010)
Control of external hemorrhage a Direct Pressure According to LeMone and Burke, 2007, the following are the major pressure points used for the control of bleeding: Temporal to control scalp bleeding Carotid to control head and neck bleeding Subclavian to control bleeding in axilla, shoulder, and upper chest Brachial to control arm bleeding Radial to control bleeding in hand and wrist Femoral to control upper leg bleeding Popliteal to control lower leg bleeding
Adapted from wildernessmanuals.com Adapted from www.wildernessmanuals.com

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Application of Tourniquet
Adapted from www.tpub.com Control of internal hemorrhage ***According to LeMone and Burke, 2007, discovering the cause and location of injury, as well as the extent of related blood loss, are the most important concerns. Once the source of internal hemorrhage has been recognized, interventions are initiated, including operative control of bleeding and continual assessment of the client.
HYPOVOLEMIC SHOCK
- Shock is a condition in which there is loss of effective circulating blood volume. Inadequate organ and tissue perfusion follows, ultimately resulting in cellular metabolic derangements. (Smeltzer, et. al., 2010) - According to LeMone and Burke, hypovolemic shock is caused by a decrease in intravascular volume of 15% or more. In hypovolemic shock, the venous blood returning to the heart decreases, and ventricular filling drops. The following are the causes of loss of plasma or blood: Hemorrhage (>500 ml blood loss) traumatic injuries, major surgeries Fluid shifting conditions - Burns (large partial-thickness or full-thickness burns) - Nephrotic syndrome - Liver cirrhosis - Pancreatitis
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- Bowel obstruction Dehydration - Excessive sweating (vigorous exercise) - Excessive vomiting or diarrhea - Insensible fluid losses (respiratory tract, hot environment) - Polyuria (DM, diabetes insipidus) - Diuretic medications - Inadequate oral fluid intake - Impaired recognition of thirst (older people)
Manifestations of Hypovolemic Shock: (LeMone and Burke, 2007) Initial Stage: o Blood pressure : normal to slightly decreased o Pulse: slightly increased from baseline o Respirations: normal (baseline) o Skin: cool, pale (in periphery), moist o Mental Status: alert and oriented o Urine output: slight decrease o Others: thirst, decreased capillary refill time Compensatory and Progressive Stage: o Blood pressure: hypotension o Pulse: rapid and thread o Respirations: increased o Skin: cool, pale (includes trunk), poor turgor with fluid loss, edematous with fluid shift o Mental status: restless, anxious, confused, or agitated o Urine output: oliguria (less than 30 ml/hr) o Others: marked thirst, acidosis, hyperkalemia, decreased capillary refill time, decreased or absent peripheral pulse Irreversible Stage: o Blood pressure: severe hypotension (often systolic pressure is below 80mmHg) o Pulse: very rapid, weak o Respirations: rapid, shallow, crackles and wheezes o Skin: cool, pale, mottled with cyanosis o Mental status: disoriented, lethargic, comatose o Urine output: anuria o Others: loss of reflexes, decreased or absent peripheral pulses
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Basic Pathophysiology (Smeltzer, et. al., 2010) Decreased blood volume
Decreased venous return
Decreased stroke volume
Decreased cardiac output
Decreased tissue perfusion Venous return is decreased because of the lack of fluid in the vascular space, causing decreased ventricular filling. The ventricles do not have as much blood as normal to pump out, so the stroke volume is decreased. The heart rate will increase to compensate for the diminished stroke volume and resulting poor cardiac output and blood pressure. Eventually, if the fluid or blood loss continues, the heart rate will not be able to compensate for the decreased stroke volume. The end result of hypovolemic shock is inadequate tissue perfusion.
Management of hypovolemic shock: A. Medical: Treatment of the underlying cause Fluid and blood replacement *** Deliver a minimum of 20 ml/kg of crystalloid (or colloid equivalent)
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Fluids Crystalloids
Indications
Advantages
Disadvantages
0.9% sodium -Restoration of circulating Widely available, chloride (normal volume inexpensive, safe saline solution) -Vehicle compatible with to use administration of blood
Require large volume of infusion; can cause hypernatremia, pulmonary edema, abdominal compartment syndrome Requires large volume of infusion; can cause metabolic acidosis, pulmonary edema, abdominal compartment syndrome Danger of hypernatremia and cardiovascular compromise from rapid fluid shifts
Lactated Ringers
Restoration of circulating Lactate ion helps volume buffer metabolic Replacement of electrolyte acidosis, good deficit availability, safe to use, low cost
Hypertonic saline (3%)
Small volume needed to restore intravascular volume
Colloids Albumin 25%) (5%, Expands blood volume in Rapidly expands Expensive; requires shock and trauma plasma volume, human donors, limited good availability supply; can cause heart failure, not substitute for whole blood, hypersensitivity reaction can occur Synthetic plasma Interferes with platelet expander aggregation; not recommended for hemorrhagic shock Synthetic plasma Prolongs bleeding expander and clotting time
Dextran
Hetastarch
(Adapted from Smeltzer, et al.,2010 and LeMone and Burke, 2007)
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Redistribution of fluid
Adapted from Smeltzer, et al., 2010
Proper positioning (modified Trendelenburg) for the patient who shows signs of shock. The lower extremities are elevated to an angle of about 20 degrees; the knees are straight, the trunk is horizontal, and the head is slightly elevated. (Smeltzer, et. al., 2010)
B. Nursing: Administering blood and fluids safely Implementing other measures - Oxygen administration
WOUNDS
***According to Langan and James, 2005, wounds are categorized according to which skin or tissue is broken. The six types of wounds are as follows: Abrasions occur when the skin is rubbed or scraped off. It can become infected when dirt and germs become embedded. Incisions are made with sharp cutting instruments. Incisions tend to bleed freely because the blood vessels are cut cleanly with little surrounding tissue damage. Lacerations are torn wounds with torn tissue underneath. They are made with blunt objects. Bomb fragments can cause lacerations. Punctures occur when objects penetrate into the tissues, leaving a small surface opening. They do not bleed freely, but larger wounds may cause internal bleeding. Avulsions are the tearing away of tissue from a body part. Bleeding typically is heavy. The torn tissue may be reattached, so place the tissue in a sterile dressing in a cool container. Take care not to freeze the tissue or submerge in water or saline.
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Amputations are traumatic or nontraumatic removal of limbs from the body. Shock will develop, and a tourniquet is often necessary.
The following are the management of wounds: Wound cleansing Primary closure Delayed primary closure The primary goal of treatment is to restore the physical integrity and function of the injured tissue while minimizing scarring and preventing infection. (Smeltzer, et. al., 2010)
TRAUMA
***According to LeMone and Burke, 2007, it is an injury to human tissues and organs resulting from the transfer of energy from the environment. Multiple trauma ***is caused by a single catastrophic event that causes life-threatening injuries to at least two distinct organs or organ systems. Priority management: Establish airway and ventilation Control hemorrhage Prevent and treat hypovolemic shock Assess for head and neck injuries Evaluate for other injuries reassess head and neck, chest, assess abdomen, back and extremities Splint fractures Perform a more thorough and ongoing examination and assessment Intra-abdominal injuries Categories: Penetrating abdominal trauma results in high incidence of injury to hollow organs, particularly the small bowels. The liver is the most frequently injured solid organ. Blunt trauma to the abdomen results from motor vehicle crushes, falls, blows and explosions. Assessment: Internal bleeding o Front of the body, flanks and back are inspected for bluish discoloration, asymmetry, abrasion and contusion
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Pain in the left shoulder is common in a patient with bleeding from a ruptured spleen, whereas pain in the right shoulder can result from laceration of the liver. (Smeltzer, et al., 2010) Intraperitoneal injury o Abdomen is assessed for tenderness, rebound tenderness, guarding, rigidity, spasm, increasing distention, and pain Referred pain is a significant finding because it suggests intraperitoneal injury. (Smeltzer, et al., 2010) Genito- urinary injury o Typically includes a rectal and/or vaginal examination, is performed to determine any injury to the pelvis, bladder, urethra, or intestinal wall.
Laboratory studies that aid in assessment include the following: Urinalysis to detect hematuria (indicative of a urinary tract injury) Serial hematocrit and hemoglobin levels to evaluate trends reflecting the presence or absence of bleeding White blood cell (WBC) count to detect elevation (generally associated with trauma) Serum amylase analysis to detect increasing levels, which suggest pancreatic injury or perforation of the gastrointestinal tract
Management: Resuscitation procedures (restoration of airway, breathing and circulation) Immobilization Know the mechanism of injury Withheld oral fluids Tetanus prophylaxis and broad spectrum antibiotics are administered as prescribed Continuously monitor condition of patient for changes
Crush Injuries
*** It occurs when a person is caught between opposing forces. The patient is observed for the following: Hypovolemic shock resulting from extravasation of blood and plasma into injured tissues after compression has been released Paralysis of a body part Erythema and blistering of skin Damaged body part (usually an extremity) appearing swollen, tense and hard Renal dysfunction
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Management: Observe patient for acute renal insufficiency Elevate an injured extremity to relieve swelling and pressure Medications for pain and anxiety as prescribed Fracture ***According to Ignatavicius and Workman, 2010, it is a break or disruption in the continuity of a bone that often affects the human needs for mobility and sensation. A fracture is classified by the extent of the break: (Ignatavicius and Workman, 2010) Complete fracture the break is across the entire width of the bone in such a way that the bone is divided into two distinct sections Incomplete fracture the fracture does not divide the bone onto two portions because the break is through only part of the bone A fracture is also described by the extent of associated soft-tissue damage according to Ignatavicius and Workman, 2010: Closed or simple fracture is one that does not extend through the skin and therefore has no visible wound. Open or compound fracture the skin surface over the broken bone is disrupted, which causes an external wound. ***These fractures are often graded to define the extent of tissue damage: o Grade I is the least severe injury, and skin damage is minimal o Grade II - an open fracture is accompanied by skin and muscle contusions o Grade III there is damage to skin, muscle, nerve tissue, and blood vessels Specific Types of Fractures: Comminuted fracture is one that produces several bone fragments. Avulsion a fracture in which a fragment of bone has been pulled away by a tendon and its attachment Compression a fracture in which bone has been compressed (seen in vertebral fractures) Depressed a fracture in which fragments are driven inward ( seen frequently in fractures of skull and facial bones) Epiphyseal a fracture through the epiphysis Greenstick a fracture in which one side of the bone is broken and the other side is bent Impacted a fracture in which a bone fragment is driven into another bone fragment Oblique a fracture occurring at an angle across the bone (less stable than a transverse fracture) Pathologic a fracture that occurs through an area of diseased bone, can occur without trauma or fall Spiral a fracture that twist around the shaft of the bone Stress a fracture that results from repeated loading of bone and muscle Transverse a fracture that is straight across the bone shaft
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Adapted from nursingcrib.com Clinical Manifestations of fracture according to Smeltzer,et al., 2010: Pain Loss of function Deformity Shortening Crepitus Nursing Alert: Testing for crepitus can produce further tissue damage and should be minimized as much as possible. (Smeltzer, et al., 2010)
The following are the management for fracture: Reduction *Fracture Reduction refers to restoration of the fracture fragments to anatomic alignment and positioning. Closed Reduction is accomplished by bringing the bone fragments into anatomic alignment through manipulation and manual traction. The extremity is held in the aligned position while the physician applies a cast, splint, or other device. Open Reduction through a surgical approach, the fracture fragments are anatomically aligned. Internal fixation devices (metallic pins, wires, screws, plates, nails, and rods) may be used to hold the bone fragments in position until solid bone healing occurs. Immobilization Maintaining and restoring function Controlling by elevating the injured extremity and applying ice as prescribed Routine monitoring of neurovascular status Restlessness, anxiety, and discomforts are controlled with reassurance, position changes and pain relief strategies
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Isometric and muscle-setting exercises are encouraged to minimize atrophy and to promote circulation Participation in activities of daily living is encouraged to promote independent functioning and self-esteem Factors that enhance fracture healing: Immobilization of fracture fragments Maximum bone fragment contact Sufficient blood supply Proper nutrition Exercise: weight bearing for long bones Hormones: growth hormone, thyroid, calcitonin, vitamin D, anabolic steroids Electric potential across fracture Factors that inhibit fracture healing: Extensive local trauma Bone loss Weight bearing prior to approval Malalignment of the fracture fragments Inadequate immobilization Space or tissue between bone fragments Infection Local malignancy Metabolic bone disease (eg. Pagets disease of the bone) Irradiated bone (radiation necrosis) Avascular necrosis Intra-articular fracture Age (elderly persons heal more slowly) Corticosteroids (inhibit the repair rate) According to Ignatavicius and Workman, the following are the complications of fracture: Acute compartment syndrome Crush syndrome Hypovolemic shock Fat embolism syndrome Venous thromboembolism Infection Chronic complications, such as ischemic necrosis and delayed union ENVIRONMENTAL EMERGENCIES Heat stroke is an acute medical emergency caused by failure of the heatregulating mechanisms of the body. The most common cause of heat stroke is prolonged exposure to an environmental temperature of greater than 39.2 C (102.5 F).
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Most heat-related deaths occur in the elderly because their circulatory systems are unable to compensate for stress imposed by heat. (Smeltzer, et al., 2010) Management: Primary goal reduce the high body temperature as quickly as possible is the primary goal IV infusion therapy of normal saline and lactated Ringers solution Frequent measurement of urine output Dialysis for renal failure, antiseizure medications to control seizures, potassium for hypokalemia, and sodium bicarbonate to correct metabolic acidosis are additional supportive care Frostbite is trauma from exposure to freezing temperatures and freezing of the intracellular fluid and fluids in the intercellular spaces. Frostbite can result in venous stasis and thrombosis. Management: Restore normal body temperature is the goal of management Remove constrictive clothing and jewelry that could impair circulation Wet clothing is removed as rapidly as possible Controlled yet rapid rewarming is instituted *hemorrhagic blebs which may develop 1 hour to a few days after rewarming are left intact and not ruptured. Nonhemorrhagic blisters are debrided to decrease the inflammatory mediators found in the blister fluid. Dry heat should never be applied, nor should the frostbitten areas be rubbed or massaged as part of the warming process. These actions produce further tissue injury. (Ignatavicius and Workman, 2010) Hypothermia is a condition in which the core (internal) temperature is 35 C (95 F) or less as a result of exposure to cold or an inability to maintain body temperature in the absence of low ambient temperatures. Management: Monitoring The ABCs of basic life support are a priority Patients vital signs, CVP, urine output, arterial blood gas levels, blood chemistry determinations and chest x-rays are evaluated frequently Continuous ECG monitoring is performed An arterial line is inserted and maintained to record blood pressure and to facilitate blood sampling Rewarming Active internal (core) rewarming methods are used for moderate to severe hypothermia (less than 28 C to 32.2 C)
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and include cardiopulmonary bypass, warm fluid administration, warm humidified oxygen by ventilator, and warmed peritoneal lavage. Passive or active external rewarming is used for mild hypothermia (32.2 C to 35 C). Passive active rewarming uses over-the-bed heaters to the extremities and increases blood flow to the acidotic, anaerobic extremities. Active external rewarming uses forced air warm blankets. Care must be taken to prevent extremity burn from these devices, because the patient may not have effective sensation to feel the burn. Supportive care Supportive care during rewarming includes the following as directed: External cardiac compression Defibrillation of ventricular fibrillation Mechanical ventilation with positive end-expiratory pressure (PEEP) and heated humidified oxygen to maintain tissue oxygenation Administration of warmed IV fluids to correct hypotension and to maintain urine output and core rewarming Administration of sodium bicarbonate to correct metabolic acidosis if necessary Administration of antiarrhythmic medications Insertion of an indwelling urinary catheter to monitor urinary output and renal function
Near drowning is defined as survival for at least 24 hours after submersion that caused respiratory arrest. The most common consequence is hypoxemia. Factors associated with drowning and near drowning include alcohol ingestion, inability to swim, diving injuries, hypothermia, and exhaustion. Management: Therapeutic goals include maintaining cerebral perfusion and adequate oxygenation to prevent further damage to vital organs Immediate cardiopulmonary resuscitation is the factor with the greatest influence on survival Arterial blood gases are monitored to evaluate oxygen, carbon dioxide, bicarbonate levels, and pH. Use of endotreacheal intubation with PEEP improves oxygenation, prevents aspiration, and corrects intrapulmonary shunting and ventilation-perfusion abnormalities caused by aspiration of water. If patient is breathing spontaneously, supplemental oxygen amy be administered by mask Prescribed rewarming procedures are started during resuscitation Intravascular volume expansion and inotropic agents are used to treat hypotension and impaired tissue perfusion ECG monitoring is initiated, because dysrrhythmias frequently occur An indwelling urinary catheter is inserted to measure urine output
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Nasogastric intubation is used to decompress the stomach and to prevent the patient from aspirating gastric contents
Decompression sickness also called the bends, occurs in patients who have engaged in diving (lake, as well as ocean, diving), high- altitude flying, or flying in commercial aircraft within 24 hours after diving. Decompression sickness results from formation of nitrogen bubbles that occur with rapid changes in atmospheric pressure. They may occur in joint or muscle spaces, resulting in musculoskeletal pain, numbness, or hypesthesia. *Signs and symptoms include joint and extremity pain, numbness, hypesthesia, and loss of range of motion. Neurologic symptoms mimicking those of a stroke or spinal cord injury can indicate an air embolus. Nitrogen bubbles can become air emboli in the bloodstream and thereby produce stroke, paralysis or death. (Smeltzer, et al., 2010) Management: Patent airway and adequate ventilation are established 100% oxygen is administered throughout treatment and transport Chest x-ray is obtained to identify aspiration At least one IV line is started with lactated Ringers or normal saline solution If an air embolus is suspected, the head of the bed should be lowered Patients wet clothing is removed, and the patient is kept warm If air transport is necessary, low-altitude flight (below 1000 feet) is required Anaphylactic reaction is an acute systemic hypersensitivity reaction that occurs within seconds or minutes after exposure to certain foreign substances, such as medications and other agents, or foods. *Be alert for the following signs and symptoms: Respiratory Signs: o Nasal congestion o Itching o Sneezing and coughing o Possible respiratory distress that progresses rapidly o Chest tightness o Other respiratory difficulties, such as wheezing, dyspnea, and cyanosis Skin Manifestations: o Flushing with a sense of warmth and diffuse erythema o Generalized itching over the entire body o Urticaria (hives) o Massive facial angioedema possible with accompanying upper respiratory edema
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Cardiovascular Manifestations: o Tachycardia or bradycardia o Peripheral vascular collapse as indicated by: Pallor Imperceptible pulse Decreasing blood pressure Circulatory failure, leading to coma and death Gastrointestinal Problems: o Nausea o Vomiting o Colicky abdominal pains o Diarrhea
Management: If patient is in cardiac arrest, cardiopulmonary resuscitation is instituted Oxygen is provided in high concentrations during cardiopulmonary resuscitation or if the patient is cyanotic, dyspneic, or wheezing Epinephrine, in a 1:1000 dilution, is administered subcutaneously in the upper extremity or thigh and may be followed by a continuous IV infusion Antihistamines and corticosteroids may also be administered to prevent recurrence of the reaction and to treat urticaria and angioedema IV fluids, volume expanders, and vasopressor agents are administered to maintain blood pressure and normal hemodynamic status In patients with episodes of bronchospasm or a history of bronchial asthma or chronic obstructive pulmonary disease, aminophylline and corticosteroids may also be administered to improve airway patency and function If hypotension is unresponsive to vasopressors, glucagon may be administered intravenously for its acute inotropic and chronotropic effects POISONING ***Poison is any substance that, when ingested, inhaled, absorbed, applied to the skin, or produced within the body in relatively small amounts, injures the body by its chemical action. Ingested (Swallowed) Poisons swallowed poisons may be corrosive. Corrosive poisons include alkaline and acid agents that can cause tissue destruction after coming in contact with mucous membranes. Management: Control of the airway, ventilation, and oxygenation are essential ECG, vital signs, and neurologic status are monitored closely for changes An indwelling urinary catheter is inserted to monitor renal function
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Blood specimens are obtained to determine the concentration of drug or poison Efforts are made to determine what substance was ingested; the amount; the time since ingestion; signs and symptoms; age and weight of the patient The patient who has ingested a corrosive poison, which can be a strong acid or alkaline substance, is given water or milk to drink for dilution
Dilution is not attempted if the patient has acute airway edema or obstruction or if there is clinical evidence of esophageal, gastric, or intestinal burn or perforation. (Smeltzer, et al., 2010)
The following gastric emptying procedures may be used as prescribed: o Syrup of ipecac to induce vomiting in the alert patient (never use with corrosive poisons) o Gastric lavage for the obtunded patient; gastric aspirate is saved and sent to the laboratory for testing o Activated charcoal administration if the poison is one that is absorbed by charcoal o Cathartic, when appropriate
Vomiting is never induced after ingestion of caustic substances (acid or alkaline) or petroleum distillates. (Smeltzer, et al., 2010) If there is a specific chemical or physiologic antagonist (antidote), it is administered as early as possible to reverse or diminish the effects of the toxin
Carbon monoxide poisoning *** Carbon monoxide poisoning may occur as a result of industrial or household incidents or attempted suicide. Clinical Manifestations: Person may appear intoxicated Headache Muscular weakness Palpitation Dizziness Confusion, which can progress rapidly to coma Management: Carry the patient to fresh air immediately; open all doors and windows Loosen all tight clothing Initiate cardiopulmonary resuscitation if required; administer 100% oxygen
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Prevent chilling; wrap the patient in blankets Keep the patient as quiet as possible Do not give alcohol in any form or permit the patient to smoke Carboxyhemoglobin levels are analyzed on arrival at the emergency department and before treatment with oxygen if possible
Skin Contamination Poisoning (Chemical Burns) The skin should be drenched immediately with running water from a shower, hose, or faucet, except in the case of lye and white phosphorus, which should be brushed off the skin dry. Food Poisoning ***Food poisoning is a sudden illness that occurs after ingestion of contaminated food or drink. Management: The key treatment is determining the source and type of food poisoning Patients respirations, blood pressure, level of consciousness, central venous pressure, and muscular activity are monitored closely Fluid and electrolyte status should be assessed Patient is assessed for signs and symptoms of fluid and electrolyte imbalances Weight and serum electrolyte levels are obtained for future comparisons Measures to control nausea are also important to prevent vomiting For mild nausea, the patient is encouraged to take sips of weak tea, carbonated drinks, or tap water After nausea and vomiting subside, clear liquids are usually prescribed for 12-24 hours, and the diet is gradually progressed to a low-residue, bland diet SUBSTANCE ABUSE ***It is the misuse of specific substances, such as drugs or alcohol, to alter mood or behavior. Acute Alcohol Intoxication **Alcohol is a psychotropic drug that affects mood, judgment, behavior, concentration, and consciousness. Also known as ethanol, alcohol is a multi system toxin and CNS depressant. Management: Assessed patient for head injury, hypoglycemia (mimics intoxication), and other health problems Nurse should approach the patient in a non judgmental manner, using a firm, consistent, accepting, and reasonable attitude If drowsy, the patient should be allowed to sleep off the state of alcoholic intoxication
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Patient should be undressed and kept warm with blankets If patient is noisy and belligerent, sedation may be necessary
Alcohol Withdrawal Syndrome / Delirium Tremens **It is an acute toxic state that occurs as a result of sudden cessation of alcohol intake after a bout of heavy drinking or, more typically, after prolonged intake of alcohol. Signs of patient with Delirium Tremens: Anxiety Uncontrollable fear Tremor Irritability Agitation Insomnia Incontinence Talkative and preoccupied Experience visual, tactile, olfactory and auditory hallucinations that are often terrifying Tachycardia Dilated pupils Profuse perspiration Elevated vital signs in toxic state Delirium tremens is a life threatening condition and carries a high mortality rate. (Smeltzer, et al., 2010) Management: adequate sedation and support to allow the patient to rest and recover without danger of injury or peripheral vascular collapse physical examination is performed to identify preexisting or contributing illnesses or injuries drug history is obtained to elicit information baseline blood pressure is determined patient is sedated as directed with sufficient dosage of benzodiazepines patient is placed in a non stressful environment nad observed closely room remains lighted to minimize the potential for illusions and hallucinations closet and bathroom doors are closed to eliminate shadows someone is designated to stay with the patient PSYCHIATRIC EMERGENCIES *** Psychiatric emergency is an urgent, serious disturbance of behavior , affect, or thought that makes the patient unable to cope with life situations and interpersonal relationships.
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Overactive Patients ***Patients who display disturbed, uncooperative, and paranoid behavior and those who feel anxious and panicky may be prone to assaultive and destructive impulses and abnormal social behavior Management: To gain control of the situation is the immediate goal Restraints are used as last resort and only as prescribed. (Smeltzer, et al., 2010) Approach the patient with a calm, confident, and firm manner Helpful interventions include the following: o Introduce yourself by name o Tell the patient, I am here to help you. o Repeat the patients name from time to time o Speak in one thought sentences and be consistent o Give the patient space and time to slow down o Show interest in, listen to, and encourage the patient to talk about personal thoughts and feelings o Offer appropriate and honest explanations A psychotropic agent may be prescribed for emergency management of functional psychosis
Psychotropic agents should not be used if the patients behavior results from the use of hallucinogens. (Smeltzer, et al.,2010) Violent behavior ***Violent and aggressive behavior, usually episodic, is a means of expressing feelings of anger, fear, or hopelessness about a situation. Management: Goal of treatment is to bring the violence under control A specially designated room with at least two exits should be used for the interview No objects that could be used as weapons should be in sight, in the room, or carried in with health care personnel Patient should not be left alone Sudden movements should be avoided Patient is allowed the opportunity to express anger verbally Medication may be prescribed to reduce tension, anxiety, and hyperactivity Posttraumatic Stress Disorder ***It is the development of characteristic symptoms after a psychologically stressful event that is considered outside the range of normal human experience.
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Symptoms: Intrusive thoughts and dreams Phobic avoidance reaction Heightened vigilance Exaggerated startle reaction Generalized anxiety Societal withdrawal Management: Establish a trusting relationship Address and work through the trauma experience Teach the coping skills needed for recovery and self-care Underactive or Depressed Patients ***Depression is a common response to health problems and is an underdiagnosed problem, particularly in hospitalized patients. A person experiences at least five out of nine characteristics, with one of the first two symptoms present most of the time: 1. Depressed mood 2. Loss of pleasure or interest 3. Weight gain or loss 4. Sleeping difficulties 5. Psychomotor agitation or retardation 6. Fatigue 7. Feeling worthless 8. Inability to concentrate 9. Thoughts of suicide or death Management: Talk with the patient about his or her fears, frustrations, anger, and despair Help the patient learn to cope effectively with conflict, interpersonal problems and grief Encourage the patient to discuss actual and potential losses Help the patient identify and decrease negative self-talk and unrealistic expectations Monitor the patient for the onset of new problems Psychoeducational programs, establishment of support systems, and counseling can reduce anxiety- and depression-related distress Suicidal Patients ***Attempted suicide is an act that stems from depression and can be viewed as cry fro help and intervention. Males are at greater risk than females. Risk Factors for suicide: Age younger than 20 or older than 45 years, especially older than 65 years Gender women make more attempts, men are more successful
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Dysfunctional family Family history of suicide Severe depression Severe, intractable pain Chronic, debilitating medical problems Substance abuse Severe anxiety Overwhelming problems Severe alteration in self-esteem or body image Lethal suicide plan
Emergency management focuses on treating the consequences of the suicide attempt and preventing further self-injury. (Smeltzer, et al., 2010)
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REFERENCES: BOOKS:
1. Ignatavicius and Workman (2010). Medical Surgical Nursing (6th edition). 2. Smeltzer, Suzanne, et al., (2010). Textbook of Medical Surgical Nursing (21th edition) 3. LeMone, Priscilla and Burke, Karen (2007). Principles of Medical Surgical Nursing (4th edition) 4. Lippincott Williams and Wilkins (2007). Emergency Nursing made Incredibly Easy 5. Veenema, Tener Goodwin (2007). Disaster Nursing and Emergency Preparedness 6. Langan, Joanne and James, Dotti (2005). Preparing Nurses for Disaster Management
URL:
1. http//nursingcrib.com 2. http//www.hubpages.com 3. http//pmrcrc.blogspot.com 4. http//viaaereadificil.com.br 5. http//www.surgeryencyclopedia.com 6. http//www.wildernessmanuals.com 7. http//www.tpub.com 8. http.www.tags-search.com
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UNIVERSITY OF THE ASSUMPTION College of Nursing City of San Fernando (P) Tel. No. 045-9611482 loc.125 SCIENTIA VIRTUS COMMUNITAS Emergency Nursing Lesson 1 Pre-test Name: ________________________________________ Section: _______________ Date: ____________ Score: ___________
You learn more quickly under the guidance of experienced teachers. You waste a lot of time going down blind alleys if you have no one to lead you. - W. Somerset Maugham, 1874-1965
Direction: Choose the correct answer from the given choices in the box. Write the letter of the correct answer on the space provided for. Use capital letters only. Any form of erasure or superimposition will be considered wrong. A. B. C. D. E. F. Lacerations Emergency Impacted fracture Hypovolemic shock Hemorrhage Avulsion G. Emergency Nursing H. Modified Trendelenburg I. Simple Fracture J. Crush injury K. Abrasion L. Multiple Trauma
_____ 1. It encompasses an unforeseen combination of circumstances calling for immediate action for a range of victims from one to many. _____ 2. It is the delivery of specialized care to a variety of ill or injured patients. _____ 3. It is caused by a decrease in intravascular volume of 15% or more. _____ 4. The lower extremities are elevated to an angle of about 20 degrees; the knees
are straight, the trunk is horizontal, and the head is slightly elevated.
_____ 5. These are torn wounds with torn tissue underneath. _____ 6. It occurs when the skin is rubbed or scraped off. _____ 7. It is caused by a single catastrophic event that causes life-threatening injuries to at least two distinct organs or organ systems. _____ 8. It occurs when a person is caught between opposing forces. _____ 9. A type of fracture that does not extend through the skin and therefore has no visible wound. _____ 10. A fracture in which a bone fragment is driven into another bone fragment.
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Answer Key: (Lesson 1 Pretest)

1. Emergency 2. Emergency nursing 3. Hypovolemic shock 4. Modified trendelenburg 5. Lacerations 6. Abrasion 7. Multiple trauma 8. Crush injury 9. Simple fracture 10. Impacted fracture
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UNIVERSITY OF THE ASSUMPTION College of Nursing City of San Fernando (P) Tel. No. 045-9611482 loc.125 SCIENTIA VIRTUS COMMUNITAS Emergency Nursing Lesson 1 Post Test
Name: ________________________________________ Section: _______________
Date: ____________ Score: ___________
Most of the important things in the world have been accomplished by people who have kept on trying when there seemed to be no hope at all. - Dale Carnegie Identification: Read carefully the sentences below, then identify and write the correct answer on the space provided for. Any form of erasure or superimposition will be considered wrong. ______________________ 1. This maneuver should be used only if it is determined that the patients cervical spine is not injured. ______________________ 2. Any natural or man-made situation that results in severe injury, harm, or loss of humans or property. ______________________ 3. It restores the circulating volume and is compatible with administration of blood. ______________________ 4. It is the tearing away of tissue from a body part and bleeding typically is heavy. ______________________ 5. This intra abdominal trauma results in high incidence of injury to hollow organs, particularly the small bowels. ______________________ 6. It is a break or disruption in the continuity of a bone that often affects the human needs for mobility and sensation. ______________________ 7. Testing this can produce further tissue damage and should be minimized as much as possible. ______________________ 8. This is accomplished by bringing the bone fragments into anatomic alignment through manipulation and manual traction. ______________________ 9. It is a condition in which the core (internal) temperature is (95 F) or less as a result of exposure to cold or an inability to maintain body temperature in the absence of low ambient temperatures. ______________________ 10. This is never induced after ingestion of caustic substances (acid or alkaline) or petroleum distillates. Prepared by: Leah Marie S. Navarro, RN, MAN Page 31
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Matching Type: Match column A with Column B. Write the correct answer on the space provided for. Use capital letters only. Any form of erasure or superimposition will be considered wrong.
A
____ 1. Last resort for over active patients ____ 2. delivery of specialized care to a variety of ill or injured patients. ____ 3. occurs when the skin is rubbed or scraped off. ____ 4. a common response to health problems and is an under diagnosed problem ____ 5. torn wounds with torn tissue underneath. ____ 6. occurs when a person is caught between opposing forces ____ 7. A pressure point to control arm bleeding ____ 8. should not be used if the patients behavior results from the use of hallucinogens. ____ 9. one that produces several bone fragments ____ 10. trauma from exposure to freezing temperatures
B
A. ER nursing B. frostbite C. crush injury D. brachial E. avulsion F. laceration G. restraints H. complete fracture I. psychotropic agents J. depression K. abrasion L. comminuted fracture
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ANSWER KEY: LESSON I (POST TEST) Identification:

1. Head-tilt-chin-lift maneuver 2. Emergency 3. Sodium chloride 4. Avulsion 5. Penetrating abdominal trauma 6. Fracture 7. Crepitus 8. Closed reduction 9. Hypothermia 10. Vomiting
Matching Type:
1. G 2. A 3. K 4. J 5. F 6. C 7. D 8. I 9. L 10. B
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LESSON 2 TRIAGE NURSING

Disaster is any destructive event that disrupts the normal functioning of a community. (Veenema, 2007) What is happening in our world today is an eye opener not only to people in the medical field, but to ordinary people in the community as well. Destruction in the community and the economy, flooding all over the world, tornados, tsunamis, terrorists attacks, are clear signs of global warming and works of inhumanity which needs preparedness by trained people for the good and salvage of not only of the environment but especially of mankind.
Learning Objectives:
After the interactive lecture/discussion, students will be able to: 1. Define triage, decontamination, and disaster 2. Discuss the different levels of triage 3. Identify the typical elements gathered at the point of triage 4. Differentiate the different command system 5. Identify the different PPE and their levels of protection 6. Discuss the different hazardous materials and biological agents, their clinical manifestations and their management 7. List the different natural disasters and their risk for morbidity and mortality 8. Discuss the different stages/phases of disaster 9. Discuss PTSD, stress management, and debriefing 10. Identify the different roles of nurses in disasters
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TRIAGE
- comes from the French word tier meaning to sort. It is the continuous process in which priorities are reassigned as needed treatments, time, and condition of the victims change. (Langan and James, 2005) - it is a method of prioritizing patient care according to the type of illness or injury and the urgency of the patients condition. It is used to ensure that each patient receives care appropriate to his need and in a timely manner. (Lippincott, 2007) - is the sorting of patients to determine the priority of their health care needs and the proper site for treatment. (Smeltzer, et al., 2010) - is the sorting or classifying of patients into priority levels depending on illness or injury severity. (Ignatavicius and Workman, 2010)
START ( Simple Triage and Rapid Treatment) ***refers to a specific triage method to evaluate patient respiratory, circulatory, and neurological function and categorize each of them into one of four care categories. (Langan and James, 2005)
*** According to Veenema, 2007, START was developed by the Newport Beach, California, Fire and Marine Department and Hoag Hospital. It is easy to learn and simple to use. It is based on the persons ability to respond verbally and ambulate and their respirations, perfusion, and mental status (RPM). The system works as follows: (1) All patients who can walk (walking wounded) are categorized as Delayed (GREEN) and are asked to move away from the incident area to a specific location. (2) The next group of patients is assessed quickly (30-60 seconds per patient) by evaluating RPM: o Respiration (position upper airway or determine respiratory rate) o Perfusion/blood circulation (check capillary refill time) o Mental status (determine patients ability to obey commands)
The table below shows the color-coding for Simple Triage and Rapid Transport (START) System (Adapted from LeMone and Burke, 2007) COLOR Red (Immediate) DESCRIPTOR AND ORDER OF TRANSPORT Critically injured, with problems that will require immediate intervention to correct. (Clients with a respiratory rate of above 30 are tagged red. If their respirations are below 30, assess their circulatory status. If capillary refill takes more than 2 seconds, tag them red. If it is below 2 seconds, assess mental status. Injured, and will require some medical attention, but they will not die if care is delayed while you care for other clients; not ambulatory and will require a stretcher for transportation. ( Clients who can follow simple commands such as hand grips are tagged as yellow. Clients who cannot follow simple commands are tagged as red.
Yellow (Delayed)
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Green (Ambulatory)
Not critically injured, and can walk and care for themselves. (Have them walk to a safe place, but do not lose track of them; every client triaged at an incident is tracked to the best of the responders ability). Deceased, or have such catastrophic injuries that they are not expected to survive to be transported. (If the client is not breathing, open the airway manually. If they remain apneic, tag them black; if they begin breathing, they are tagged red)
Black (Expectant)
According to Lippincott Williams and Wilkins, 2007, the Emergency Nurses Association (ENA) has established guidelines for triage based on a five-tier system: LEVEL I: RESUSCITATION This level includes patients who need immediate nursing and medical attention. Case examples include: o Cardiopulmonary arrest o major trauma with hypotension o severe respiratory distress and seizures LEVEL II: EMERGENT These patients need immediate nursing assessment and rapid treatment. Case examples include: o Head injuries o Chest pain o Stroke o Asthma o Sexual assault injuries LEVEL III: URGENT These patients need quick attention, but can wait as long as 30 minutes for assessment and treatment. Case examples include: o Signs of infection o Mild respiratory distress o Moderate pain LEVEL IV: LESS URGENT Patients in this triage category can wait up to 1 hour for assessment and treatment. Case examples include: o Earache o Chronic back pain o Upper respiratory symptoms o Mild headache Prepared by: Leah Marie S. Navarro, RN, MAN Page 36
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LEVEL V: NONURGENT These patients can wait up to 2 hours (possibly longer) for assessment and treatment. Case examples include: o Sore throat o Menstrual cramps According to Veenema, 2007, the following are the Typical Information Elements Gathered at the Point of Triage: Name Age Gender Chief complaint History of present illness Mechanism of injury Past medical and surgical history Allergies to food and medication Current medications Date of last tetanus immunization Last menstrual period (for women between ages 11-60y/o) Vital signs: temperature, pulse, blood pressure and respiratory rate Skin vital sings: temperature, color and moisture Level of consciousness Visual inspection for deformities, lacerations, bruising, rashes, etc. Height and weight Mode of arrival Private medical provider
Military Triage: ***It is based on medical need, medical utility, and an additional category, social utility. ***Social utility is the notion of allocating resources to those who may be the most useful or most valued in a society. ***In the military, there is a social utility to treating those with minor injuries quickly because to do so serves a larger social purpose of returning soldiers to the battlefield to help win the battle.
Common Problems Experienced in Triage Nursing 1. 2. 3. 4. 5. Failure to determine and attend to a patient who complaints of severe pain Failure to recognize or acknowledge high-risk chief complaints Failure to take adequate vital signs Failure to adequately document the triage Failure to re-triage Page 37
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Key Triage Points to Remember, according to LeMone and Burke, 2007: Use a triage system that is easy to learn, easy to implement in stressful conditions, and does not require advanced diagnostic skills yet allows for basic client interventions. Use the incident Management System on every incident and wear personnel identification vests. Get accurate preliminary and final client counts and relay this information to the incident commander. Use some type of visual color-coded identification system to indicate client priority. Do not fall into trap of using your time providing one-to-one client care. Retriage clients frequently, at the incident, on arrival at the treatment area, and periodically thereafter. Make certain the walking-wounded are gathered and treated. Preplan for potential incidents that may occur. Be aware that emergency responders may be potential targets. Practice, practice, practice
HOSPITAL EMERGENCY INCIDENT COMMAND SYSTEM (HEICS) (Langan and James, 2005)
***A hospital-based incident command system used as a framework for reporting and communication, which entails assignment of specific roles to individuals in an effort to create a distinct chain of command that is temporarily enacted in response to a disaster situation. ***Under HEICS, there is an incident commander with four chiefs reporting: logistics, operations, planning, and finance. These chiefs can contact their counterpart in other agencies and communicate effectively due to the common language. ***HEICS provides an organizational chart with positions that have specific missions to address during the emergency situation. Each position has a job action sheet describing responsibilities assigned to the person holding the position. ***HEICS continues to change its systems and positions in response to new information or when gaps are identified during exercises.
INCIDENT COMMAND SYSTEM

***A framework for reporting and communication, which entails assignment specific roles to individuals in an effort to create a distinct chain of command that is temporarily enacted in response to a disaster situation. It is also the model for command, control, and coordination of the response. (Langan and James, 2005) ***It is a federally mandated command structure that coordinates personnel, facilities, equipment, and communication in any emergency situation. ***It is the center of operations for organization, planning, and transport of patients in the event of a specific local mass casualty incident (MCI). ***It ensures that any hazardous substances used during MCI are identified promptly and that appropriate personal protective equipment is distributed. Prepared by: Leah Marie S. Navarro, RN, MAN Page 38
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***The priorities of ICS are life safety, incident stability, and property conservation. ***The incident commander is the first responder on the scene, although once a higherranking responder arrives, this person will likely assume command of the situation. ***According to Langan and James, 2005 , the responsibilities of the incident commander include: Assume command Assess situation or event Implement emergency management plan Determine response strategies Activate resources Order an evacuation Averse activities Determine the end of the incident
HOSPITAL OPERATIONS PLAN (Smeltzer, et al., 2010)

***These plans are developed by the facilitys safety committee and are overseen by an administrative liaison. The emergency preparedness planning committee must have a realistic understanding of its resources. Components of the Emergency Operation Plan: An activation response: The EOP activation response of a health care facility defines where, how, and when the response is initiated. An internal/external communication plan: Communication is critical for all parties involved, including communication to and from the prehospital arena. A plan for coordinated patient care: A response is planned for coordinated patient care into and out of the facility, including transfers to other facilities. The site of the disaster can determine where the greater number of patients may self-refer. Security plans: A coordinated security plan involving facility and community agencies is key to the control of an otherwise chaotic situation. Identification of external resources: External resources are identified, including local, state, and federal resources and information about how to activate these resources. A plan for people management and traffic flow: People management includes strategies to manage the patients, the public, the media, and personnel. Specific areas are assigned, and a designated person is delegated to manage each of these groups. A data management strategy: A data management plan for every aspect of the disaster will save time at every step. A back up system for charting, tracking, and staffing is developed if the facility has a computer system.
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Demobilization response: Deactivation of the response is as important as activation; resources should not be unnecessarily exhausted. The person who decides when the facility resumes daily activities is clearly identified. Any possible residual effects of a disaster must be considered before this decision is made. An after-action report or corrective plan: Facilities often see increased volumes of patients 3 months or more after an incident. Post incident response must include a critique and a debriefing for all parties involved, immediately and again at a later date. A plan for practice drills: Practice drills that include community participation allow for troubleshooting any issues before a real-life incident occurs. Anticipated resources: Food and water must be available for staff, families, and others who may be at the facility for an extended period. MCI planning: MCI planning includes such issues as planning for mass fatalities and morgue readiness. An education plan for all of the above: A strong education plan for all personnel regarding each step of the plan allows for improved readiness and additional input for fine-tuning of the EOP.
Initiating the Emergency Operations Plan: Identifying patients and documenting patient information ***Patient tracking is a critical component of casualty management. Disaster tags, which are numbered and include tag priority are used to communicate patient information. Triage ***It is the sorting of patients to determine the priority of their health care needs and the proper site for treatment. In nondisaster situations, health care workers assign a high priority and allocate the most resources to those who are the most critically ill. Managing internal problems ***Each facility must determine its supply lists based on its own needs assessment. Communicating with the media and family ***Communication is key component of disaster management. Communication within the vast team of disaster responders is paramount; however, effective, informative communication with the media and worried family members is also crucial.
PERSONAL PROTECTIVE EQUIPMENT (Smeltzer, et al., 2010) ***The purpose of PPE is to shield health care workers from the chemical, physical, biologic, and radiologic hazards that may exist when caring for contaminated patients. Personal Protective Equipment: (LeMone and Burke, 2007) Gas mask: Used in broad range of military, industrial, and emergency situations to protect the user from hazardous dust, gas, or other aerosols. Prepared by: Leah Marie S. Navarro, RN, MAN Page 40
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Hood, helmet or headgear: Generally worn to protect the skin, eyes, airways, and respiratory system. Protective clothing: Made to guard against mild irritants and even serious lethal materials. Gloves Goggles Footwear Some protective suits are disposable, intended for one use only. Others are durable, multilayered fabrics that are completely impermeable and are reusable. ***The U.S. Environmental Protection Agency (EPA) has divided protective clothing and respiratory protection into the following four categories: Level A protection is worn when the highest level of respiratory, skin, eye, and mucous membrane protection is required. This include self-contained breathing apparatus (SCBA) and a fully encapsulating, vapor-tight, chemical-resistant suit with chemical-resistant gloves and boots. Level B protection requires the highest level of respiratory protection but a lesser level of skin and eye protection than with level A situation. This level of protection includes the SCBA and a chemical-resistant suit, but the suit is not vapor tight. Level C protection requires the air-purified respirator, which uses filters or absorbent materials to remove harmful substances from the air. A chemical-resistant coverall with splash hood, chemical-resistant gloves, and boots are included in level C protection. Level D protection is the typical work uniform No single PPE is capable of protecting against all hazards. (Smeltzer, et. al., 2010)
Adapted from www.princeton.edu.com Prepared by: Leah Marie S. Navarro, RN, MAN Page 41
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DECONTAMINATION ***It is the process of removing accumulated contaminants, is critical to the health and safety of health care providers by preventing secondary contamination. (Smeltzer, et. al., 2010) ***It is the physical process of removing harmful substances from personnel, equipment, and supplies whenever there is a risk of secondary exposure from the hazardous substance. (Langan and James, 2005) ***It is primarily for chemical warfare. It is not needed for covert bioterrorism events. The only possible exception is an overt anthrax attack in which the toxins may mimic chemical exposures and warrant decontamination until the agent is known. Decontamination Triage Procedure: ***According to Langan and James, 2005, events involving massive numbers of victims require changing triage priorities to ensure the survival of the maximum number of patients. The command center will change triage modes based on the following: Number of victims Available decontamination equipment Number of decontamination technicians Availability of medications
***The command center will contact the decontamination area and direct them to change triage priorities to what is called a support mode. (Langan and James, 2005) First priority will be victims exposed but not symptomatic Second priority will be victims exposed but minimal medical care required Third priority will be victims exposed requiring maximum medical care Final priority will be the deceased The support mode of triage requires establishing a temporary care area outside the hospital. Those awaiting decontamination will wait in the support area. (Langan and James, 2005)
***According to Smeltzer,et al., 2010, although many principles and theories surround decontamination of a patient, authorities agree that, to be effective, decontamination must include a minimum of two steps. The first step is removal of the patients clothing and jewelry and then rinsing the patient with water. The second step consists of a thorough soap-and-water wash and rinse.
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DISASTER: (Veenema, 2007) *** An ecologic disruption, or emergency of a severity and magnitude that result in deaths, injuries, illness, and property damage that cannot be effectively managed using routine procedures or resources and that require outside assistance. Classifications: Natural those caused by natural or environmental forces - result of an ecological disruption or threat that exceeds the adjustment capacity of the affected community (WHO) Man-made human generated, in which the principal direct causes are identifiable human actions, deliberate or otherwise. Three categories of man-made disasters: 1. Complex Emergencies ***Involve situations where populations suffer significant casualties as a result of war, civil strife, or other political conflict. 2. Technological disasters ***Large numbers of people, property, community infrastructure, and economic welfare are directly and adversely affected by major industrial accidents, unplanned release of nuclear energy ; and fires or explosions from hazardous substances such as fuel, chemicals, or nuclear materials. 3. Disasters that are not caused by natural hazards but occur in human settlements
Stages and Phases of a Disaster: Nondisaster Stage (Interdisaster Phase) ***Is the time for planning and preparation as the threat of a disaster is still in the future. It is a time for prevention, preparedness, and mitigation activites. Predisaster Stage (Preimpact Phase) ***Occurs when there is knowledge about an impending disaster that has not yet occurred. Activities during this stage include warning, preimpact mobilization, and evacuation if appropriate. Impact Stage (Impact Phase) ***Is a time when the disaster event has occurred and the community experiences the immediate effect. Emergency Stage (Postimpact Phase) ***Involves the immediate response to the effects of the disaster. The community relies on local assistance or aid because outside sources of aid have not yet arrived.
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Reconstruction Stage (Recovery Phase) ***Restoration, reconstruction, and mitigation take place. This stage involves rebuilding and returning to some semblance of normalcy but also includes mitigation activities or planning to prevent subsequent disasters or to minimize the effects of future disasters. The key to effective disaster management is predisaster planning and preparation.
HAZARDOUS MATERIALS (Veenema, 2007) *** It is any substance that is potentially toxic to the environment or to living cells. Classifications of hazardous materials: Nerve agents are among the most potent and deadly of the chemical weapons. They are rapidly lethal, and hazardous by any route of exposure. They are also liquid at room temperatures with the capability of producing a vapor that may be well absorbed through the skin as well as the lungs and GI tracts.
Clinical presentation of exposed patients: o Gasping o Miosis o Copious secretions o Sweating o Generalized twitching Clinical Diagnostic Test: o Red blood cell and serum cholinesterase Management: o Thorough decontamination o Immediate endotracheal intubation for patients with respiratory failure and compromised airways o Suctioning for bronchial secretions o Prophylactic anticonvulsants to prevent seizures o Oximes to reactivate the inhibited acetylcholinesterase and reverse paralysis o Antocholinergics to antagonize the muscarinic effects Vesicating/Blister Agents are chemicals the severely blister the eyes, respiratory tract, and skin on contact. Possible substances included in this class are mustard agents, Lewisites/chloroarsine agents, and phosgene oxime. Clinical Presentations: o Redness and blurring of the eyes with lacrimation o Blepharospasm o Lid edema o Nasal irritation and discharge o Sinus burning o Nose bleeds Prepared by: Leah Marie S. Navarro, RN, MAN Page 44
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o o o o o o o
Sore throat Cough Laryngitis Dyspnea Chemical [neumonitis Pulmonary edema ARDS, respiratory failure
Treatment: o Washing of exposed skin with water and soap o Flushing the eyes with copious amount of water o Typical burn therapy is accomplished with antibiotic ointment, sterile dressing, and other supportive therapy o Intubation and airway management may be required for patients with airway damage o Prevention of infection with careful cleaning and topical antibiotics and pain relief for symptomatic and supportive care
Clinical Diagnostic Tests: o CBC o Glucose o Serum electrolytes o Renal function (BUN and creatinine) o Chest X-ray o Pulse oximetry or ABG measurements Blood/ Tissue Agents are chemicals that affect the body by being absorbed into and distributed by the blood to the tissues. Substances include arsine, carbon monoxide, cyanide agents, and sodium monofluoroacetate. Clinical Presentations: Cyanide poisoning - 10-15 minutes of gasping, tachypnea, tachycardia, flushing, sweating, headache, giddiness, dizziness, followed by nausea, agitation, and confusion. For higher concentration : bradycardia, apnea, seizures, shock, coma, and death Arsine/ Phosphine poisoning burning sensation in the chest followed by chest pain upon inhalation. Initial symptoms include nausea, vomiting, headache, malaise, weakness, dizziness, abdominal pain, dyspnea, and occasionally red stained conjunctiva. Symptoms progresses to hematuria, jaundice, and possibly renal failure. Clinical Diagnostic Tests: o CBC o Blood glucose o Electrolyte determinations o Urine for hemoglobinuria Prepared by: Leah Marie S. Navarro, RN, MAN Page 45
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Management: o Closely monitor serum electrolytes, calcium, BUN, creatinine, hemoglobin, and hematocrit o For victims of arsine poisoning, avoid high levels of fluid replacement to avoid the onset of congestive heart failure symptoms. There is no antidote for arsine or phosphine poisoning. Do not administer arsenic chelating drugs. Patient may need blood transfusion. (Veeneman, 2007) Pulmonary/ Choking Agents are chemicals that causes severe irritation or swelling of the respiratory tract causing pulmonary damage and untimely impairing oxygen delivery. Substances include ammonia, bromine, chlorine, hydrogen chloride, methyl bromide, phosgene, phosphorus and sulfuryl fluoride. Clinical Presentations: o Eye pain o Redness o Lacrimation o Sore throat o Runny nose o Coughing o Headache o Nausea o Hemoptysis o Choking o Dyspnea o Rales o Hemoconcentration o Hypotension o Possible cyanosis Treatment: o Evaluation of respiratory function and oxygenation is critical o Pulse oximetry should be performed o Endotracheal intubation for patients with ventilator failure and severe hypoxemia Riot Control Agents are chemical compounds that temporarily inhibit a persons ability to function by causing irritation to the eyes, mouth, throat, lungs, and skin. Three major agents are considered to be control agents: chloroacetophenone (CN), also known as mace, chlorobenzylidenemalononitrile (CS)n and diphenyllaminearsine (DM). Clinical Presentations: o Temporary blindness due to lacrimation and blepharospasm o Conjunctival redness o Cough o Chest tightness o Sneezing o Mouth, nose, and throat irritation Prepared by: Leah Marie S. Navarro, RN, MAN Page 46
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No specific treatment is required. Situation improves within 30 minutes after exposure ends. (Veenema, 2007)
BIOLOGICAL WARFARE AND BIOLOGICAL AGENTS (Smeltzer, et. al., 2010) *** Biologic Warfare is a covert method of effecting terrorist objectives. Types of Biologic Agents: Anthrax is recognized as the most likely weaponized biologic agent available and has been recognized as a highly debilitating agent for centuries. Bacillus anthracis is a naturally occurring gram-positive, encapsulated rod that lives in the soil in the spore state throughout the world. Clinical manifestations: o Hemorrhage, edema and necrosis o Fever, nausea and vomiting o Cough, headache, chills, weakness o Mild chest discomfort, dyspnea, syncope Treatment: o Recommended treatment includes penicillin, erythromycin, gentamicin, doxycycline o In a mass casualty situation, treatment with ciprofloxacin or doxycycline is recommended. ***Treatment is continued for 60 days. Small Pox (variola) is classified as a DNA virus. It has an incubation period of approximately 12 days, extremely contagious, and is spread by direct contact. Clinical Manifestations: o High fever, malaise, headache, backache, prostration o Maculopapular rash beginning on the face, mouth, pharynx and forearms o Progresses to the trunk and also become vesicular to pustular Treatment: o Supportive care with antibiotic o Isolation with the use of transmission precautions o Standard decontamination of the room o Household or face-to-face contact with the patient after the fever begins should be vaccinated within 4 days to prevent infection and death o Cremation is preferred for all deaths because the virus can survive in scabs for up to 13 years BLAST INJURIES (Langan and James, 2005) *** Injuries from blasts are grouped under four types based on the mechanism of the blast. Primary blast mechanisms occur only with high-order explosives. Gas filled structures within the body are affected most frequently, such as the lungs, GI tract, and middle ear.
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Secondary category, injuries result from flying debris and bomb fragments. Any part of the body can be affected, and injuries range from penetrating callistic (fragmentation) to blunt injuries. Tertiary injuries result from individuals being thrown by the blast wind. Fractures, traumatic amputations, and open and closed brain injuries can occur. Quaternary category, all injuries not fitting into the previous three categories is grouped. It may include exacerbation or complications of existing conditions affecting any part of the body. Injury types include burns, crash injuries, asthma, COPD, respiratory problems, angina, hyperglycemia, and hypertension.
*** Some of the visible indicators internal soft tissue injury are: Hematemesis: vomiting bright red blood Hemoptysis: coughing up bright red blood Melena: excretion of tarry black stools Hematochezia: excretion of bright red blood from the rectum Nonmenstrual vaginal bleeding Hematuria: passing of blood in the urine Epixtaxis: nosebleed Pooling of blood near the skin surface
*** Frequently, there are no visible signs of injury and more subtle clues will have to be used, such as: Pale, clammy skin Lowered body temperature Rapid, thready pulse Decreasing blood pressure Dilated pupils that are slow to react Ringing in the ears or tinnitus Syncope Thirst Yawning, air hunger Anxiety, restlessness with feelings of impending doom NATURAL DISASTERS ***According to Veeneman, 2007, these are natural causes often result in significant losses, physical destruction of dwellings, social and economic disruption, human pain and suffering, injury, and loss of life. Earthquake generally considered to be the most destructive and frightening of all forces of nature, is a sudden, rapid shaking of the Earth caused by the breaking and shifting of rock beneath the Earths surface. It can result in a secondary disaster, catastrophic tsunami.
Risk of Morbidity and Mortality: Deaths and injuries vary according to the type of housing available, time of day of occurrence, and population density Prepared by: Leah Marie S. Navarro, RN, MAN Page 48
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Common injuries include cuts, broken bones, crush injuries, and dehydration from being trapped in rubble Stress reactions are also common Prevention/Mitigation: Incorporate principles of seismic safety into public and private decisions regarding the setting, design, and construction of structures Epidemics outbreak or occurrence of one specific disease from a single source in a group, population, community, or geographic area, in excess of the usual or expected level. ***Quick response is essential because epidemics, resulting in human and economic losses and political difficulties, develop rapidly. Flood Risk for Morbidity and Mortality: Flash-flooding, such as from excessive rainfall or sudden release of water from a dam, is the cause of most flood-related deaths Health impacts of flooding include infectious disease morbidity exacerbated by crowded living conditions Waterborne diseases become a significant hazard, as do other vector-borne disease and skin disorders Food shortages that are due to water-damaged stocks may occur The stress and exertion required for clean-up following a flood also cause significant morbidity and mortality Fires, explosions from gas leaks, downed live wires, and debris can all cause significant injury Thunderstorms formed from a combination of moisture, rapidly rising warm air, and a force capable of lifting air such as a warm or cold front, a sea breeze, or a mountain. All thunderstorms contain lightning, which is a major threat during a thunderstorm. Tsunami a series of waves usually generated by large earthquakes under or near the ocean occur when a body of water is rapidly displaced on a massive scale. According to Veeneman,2007, any of the following events may signal an approaching tsunami: A recent submarine earthquake The sea appears to be boiling, as large quantities of gas rise to the surface of the water The water is hot, smells of rotten eggs, or stings the skin There is an audible thunder or booming sound followed by a roaring or whistling sound The water may recede a great distance from the coast Red light might be visible near the horizon and, as the wave approaches, the top of the wave may glow red Prepared by: Leah Marie S. Navarro, RN, MAN Page 49
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Risk of Morbidity and Mortality First health interventions are to rescue survivors and provide medical care for any injuries Floods that accompany a tsunami result in potential health risks from contaminated water and food supplies Loss of shelter leaves people vulnerable to exposure to insects, heat, and environmental hazards Lack of medical care may result in exacerbations of chronic disease longlasting effects and recovery necessitates long-term surveillance Mental health concerns are another consequence of tsunami events
Post Traumatic Stress Disorder: (Langan and James, 2005)

***It is characterized by the development of a persistent anxiety response following a traumatic event, with a later onset and less emphasis on dissociation. ***To meet the stressor criteria of PTSD, the individuals subjective response to the traumatic experience must involve helplessness, intense fear, or horror. Symptom duration must be at least 1 month following the trauma and symptoms must be severe enough to impair functioning. Symptoms are grouped into three categories: Reexperiencing of the traumatic event as indicated by intrusive thoughts, nightmares, or flashbacks Avoidance, as indicated by marked effort to stay away from activities, places, or things related to the trauma Hyperarousal, as indicated by difficulty concentrating, insomnia, and exaggerated startle reactions.
Stress Management: (Smeltzer, et al., 2010)

***Stress or the potential for stress is ubiquitous; that is, it is both everywhere and anywhere. It is directed toward reducing and controlling stress and improving coping. Promoting a healthy lifestyle provides internal resources that aid in coping, and it buffers or cushions the impact of stressors. Enhancing coping strategies assisting a patient to adapt to perceived stressors, changes, or threats that interfere with meeting life demands and roles. Teaching relaxation techniques these are major method used to relieve stress. Educating about stress management two commonly prescribed nursing educational interventions --- providing sensory information and providing procedural information -- have the goal of reducing stress and improving the patients coping ability. Enhancing social support it has been demonstrated to be an effective moderator of life stress. Social support has been found to provide people with several different types of emotional information. o The first type of information leads people to believe that they are cared for and loved
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o o
The second type of information leads people to believe that they are esteemed and valued. The third type of information leads people to feel that they belong to a network of communication and mutual obligation.
Recommending support and therapy groups support groups exist especially for people in similar stressful situation.
Debriefing: (Langan and James, 2005)

o Psychological Debriefing developed as an in-the-field, early intervention to help soldiers and rescue workers to cope with stressful events and assist them to return to their duties as quickly as possible. Natural Debriefing refers to the spontaneous formation of groups in which individuals share their experiences with others. When survivors and rescue workers have opportunities to tell their stories, empathy, normalization, and validation are experienced, which promotes healing and recovery.
According to LeMone and Burke, 2007, the following are the Roles of Nurses in Disasters:
Prepare selves, families, friends, and communities for disasters in conjunction with the local disaster preparedness plan. Continue educating self on various types of disasters and appropriate response. Provide emergency services with consideration of victims abilities, deficits, culture, language, or special needs. Assist in the mobilization of healthcare personnel, food, water, shelter, medication, clothing, and other assistive devices. Collaborate with agencies in authority including local, state, and federal representatives to deploy resources based on the greatest good for the greatest number. Consider needs of victims including shelter both temporary and permanent, as well as psychologic, economic, legal, and spiritual factors Become involved with local, state, and national disaster planning agencies to schedule regular meetings to continually review and modify disaster plans.
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REFERENCES: BOOKS:
1. Smeltzer, Suzanne, et al., (2010). Textbook of Medical Surgical Nursing (21th edition) 2. LeMone, Priscilla and Burke, Karen (2007). Principles of Medical Surgical Nursing (4th edition) 3. Veenema, Tener Goodwin (2007). Disaster Nursing and Emergency Preparedness 4. Langan, Joanne and James, Dotti (2005). Preparing Nurses for Disaster Management
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UNIVERSITY OF THE ASSUMPTION College of Nursing City of San Fernando (P) Tel. No. 045-9611482 loc.125 SCIENTIA VIRTUS COMMUNITAS Emergency Nursing Lesson 2 Pre-test Name: ________________________________________ Section: _______________ Date: ____________ Score: ___________
Live your life each day as you would climb a mountain. An occasional glance towards the summit keeps the goal in mind, but many beautiful scenes are to be observed from each new vintage point. - Harold B Melchart Matching type: Match column A with column B. Write the correct answer on the space provided for. Any form of erasure or superimposition will be considered wrong.
A
___ 1. sorting or classifying of patients into priority Levels ____ 2. specific triage method to evaluate patient A. HEICS
B. epidemic
respiratory, circulatory, and neurological function ____ 3. notion of allocating resources to those who may be the most useful or most valued in a society. ____ 4. used as a framework for reporting and communication
C. decontamination D. flood E. START

F. disaster
____ 5. first responder on the scene G. ICS ____ 6. physical process of removing harmful substances from personnel, equipment, and supplies ____ 7. ecologic disruption, or emergency of a severity H. triage
I. earthquake J. social utility
and magnitude that result in deaths, injuries, illness ____ 8. any substance that is potentially toxic to the
environment or to living cells. ____ 9. generally considered to be the most destructive and frightening of all forces of nature ____ 10. outbreak or occurrence of one specific disease Prepared by: Leah Marie S. Navarro, RN, MAN Page 53 K. hazardous materials L. incident commander
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ANSWER KEY: (Lesson 2 Pretest)

1. H 2. E 3. J 4. A 5. L 6. C 7. F 8. K 9. I 10. B
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UNIVERSITY OF THE ASSUMPTION College of Nursing City of San Fernando (P) Tel. No. 045-9611482 loc.125 SCIENTIA VIRTUS COMMUNITAS Emergency Nursing Lesson 2 Post Test Name: ________________________________________ Section: _______________ Date: ____________ Score: ___________
Challenges are what make life interesting; overcoming them is what makes life meaningful. -Joshua J. Marine Essay and Enumeration: Answer the following in at least 2 or 3 sentences. Write clearly and legibly. You can use your own words. 1. Differentiate emergency from disaster (5 points)
2. What are the five common problems experienced in triage nursing (5 points)
3. What are the two classifications of disaster and differentiate each (5 points)
4. Identify at least four roles of nurses in disasters (5 points)
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LESSON 3
INTRAVENOUS THERAPY
Learning Objectives: At the of end of the interactive lecture - discussion, students will be able to: 1. 2. 3. 4. 5. 6. 7. Define intravenous therapy Learn the commonly used sites for venipuncture Identify the different fluids and electrolytes Discuss the importance of fluids and electrolytes in an individual Enumerate the complications of IV therapy and their interventions Discuss the procedure of IV insertion Learn the importance of blood transfusion and total parenteral nutrition
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Brief History: According to the ANSAP manual on Nursing Standards and Intravenous Practice,The Nursing Standards on Intravenous Practice was established in 1993 as a guide for those who are and will be practicing intravenous Purposes of IV therapy: To give medications that are too irritating to be given by another route In life threatening situations, it provides access for administration of medication and fluids directly in to the bloodstream, ensuring prompt onset of action and the most complete absorption When the client is unable to take fluids by mouth, it provides fluid and electrolyte replacement therapy for clients unable to take oral nourishment When the medications would be destroyed by the GI tract When the client is unable to digest or absorb a diet or when the GI tract is nonfunctional because of an interruption in its continuity or impaired absorptive capacity Special considerations: Always use aseptic technique when preparing IV solutions You can use vented tubing with a vented bottle Change IV tubing every 48 to 72 hours, according to facility policy, or more frequently if you suspect contamination Change filter according to the manufacturers recommendations or sooner if it becomes clogged
Commonly used venipuncture sites for IV therapy:
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Veins of the Upper Limbs: (Seeley, 2007) Brachial veins are the only noteworthy deep veins, which accompany the brachial artery and empty into the axillary vein. Cephalic vein which is towards the head empties into the axillary vein, and the basilica vein which is toward the base of the arm, becomes the axillary vein. These are the major superficial veins. Median cubital vein usually connects the cephalic vein or its attributes with the basilica vein. Although this vein varies in size among people, it is usually quite prominent on the anterior surface of the upper limb at the level of the elbow. It is also often used as a site for drawing blood.
The table below will show you the different types of hydrating solutions, their uses, and nursing implications: (Smeltzer, et al., 2010, LeMone and Burke, 2007, Lippincott, 2006, and Kozier, 2004) Solution Uses Nursing Implication Isotonic 0.9% Sodium Expands intravascular Assess clients carefully for Chloride volume signs of hypervolemia such as bounding pulse Replaces water lost and shortness of breath from extracellular fluid D5W is avoided in clients Used with blood at risk for increased transfusion intracranial pressure Replaces large sodium losses Lactated Ringers Replaces fluid losses from burns and the lower gastrointestinal tract Fluid of choice for acute blood loss
5% Dextrose in Water
Replaces water losses Provides free water necessary for cellular rehydration Lowers serum sodium in hypernatremia
Hypotonic 0.45% Sodium Chloride ( half normal saline)
Used to provide free water to replace hypotonic fluid losses Maintains levels of plasma sodium and chloride
Do not administer to clients at risk for IICP or third space fluid shift Administer cautiously
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0.33% Sodium Chloride (onethird normal saline)
Corrects serious sodium depletion
Hypertonic 5% Dextrose in 0.45% Sodium Chloride
Provides free water Provides sodium chloride Maintenance fluid of choice if there are no electrolyte imbalances Provides free water Provides nutrition
10% Dextrose in Water
Administer by IV pump and monitor patient closely for circulatory overload Dont give to patients with a condition that causes cellular dehydration Dont give to patients with impaired heart or kidney function
The table below will show you the different electrolytes , their principal functions, and the signs and symptoms of their imbalances: (Smeltzer, et al., 2010, Lemone and Burke, 2007, Lippincott Williams and Wilkins, 2006) Electrolyte Sodium (Na+) Major cation in extracellular fluid (ECF) Normal serum level: 135 to 145 mEq/L Principal Functions Signs and symptoms of Imbalances Hyponatremia: anorexia, nausea, vomiting, altered mental status, muscle cramps, weakness, and tremors, decreased skin turgor, headache, seizures, coma Hypernatremia: thirst, fever, flushed skin, oliguria, disorientation, dry, sticky membrane, restlessness, muscle twitching, decreasing level of consciousness
- maintains appropriate ECF osmolality -maintains neuromuscular activity -affects concentration, excretion, and absorption of potassium and chloride -helps regulate acid-base balance
Potassium (K+) Prepared by: Leah Marie S. Navarro, RN, MAN Page 59
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Major cation in intracellular fluid (ICF) Normal serum level: 3.5 to 5.0 mEq/L
-maintains cell osmolarity -assists in conduction of nerve impulses -directly affects cardiac muscle contraction -plays a major role in acidbase balance
Hypokalemia: ECG changes, decreased GI, skeletal muscle and cardiac muscle function; decreased reflexes; rapid, weak, irregular pulse; muscle weakness or irritability; leg cramps, fatigue; decreased blood pressure; decreased bowel motility; paralytic ileus, nausea and vomiting Hyperkalemia: tall, peaked T waves, muscle weakness, nausea, diarrhea, oliguria, paresthesia (altered sensation) of the face, tongue, hands, and feet, flaccid paralysis
Calcium (Ca++) Major cation found in ECF of teeth and bones Normal serum level: 8.9 to 10.1 mg/dl
-enhances bone strength and durability (along with phosphorus) -helps maintain cellmembrane structure, function, and permeability -affects activation, excitation, and contraction of cardiac and skeletal muscles
Hypocalcemia: muscle tremor, muscle spasms, tetany, tonicclonic seizures, paresthesia, bleeding, dysrhythmias, hypotension, numbness, or tingling in fingers, toes, and area surrounding the mouth Hypercalcemia: lethargy, headache, muscle flaccidity, nausea, vomiting, anorexia, constipation, hypertension, polyuria, thirst, abdominal pain
Chloride (Cl) Major anion found in ECF Normal serum level: 96 to 106 mEq/L
-maintains serum osmolarity (along with Na+) -combines with major cations to create important compounds, such as sodium chloride (NaCl) , potassium chloride (KCl)
Hypochloremia: increased muscle excitability, tetany, decreased respirations Hyperchloremia: stupor, rapid, deep breathing; muscle weakness
Phosphorus (P) Major anion found in ICF Normal serum phosphate level: 2.5 to 4.5 mg/dl
-helps maintain bones and teeth -helps maintain cell integrity -essential to intracellular processes such as the production of ATP
Hypophosphaemia: paresthesia (circumoral and peripheral), muscle weakness, speech defects (such as stuttering or stammering), muscle pain and tenderness, confusion, decreased bowel sounds Page 60
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- vital for RBC function and oxygen delivery to Hyperphosphatemia: circumoral tissues and peripheral paresthesia, muscle spasms, tetany, soft tissue calcification
Magnesium (Mg++) Major cation found in ICF (closely related to Ca++ and P) Normal serum level: 1.5 to 2.5 mg/dl with 33% bound protein and remainder as free cations
-activates intracellular enzymes; active in carbohydrate and protein metabolism -decreases acetylcholine release -facilitates Na+ and K+ movement across all membranes -influences Ca++ levels -essential for neuromuscular transmission and cardiovascular function
Hypomagnesemia: dizziness, confusion, seizures, tremor, leg and foot cramps, hyperirritability, arrhythmias, vasomotor changes, anorexia, nausea, diarrhea, dysphagia, Hypermagnesemia: drowsiness, lethargy, coma, arrhythmias, hypotension, bradycardia, peripheral vasodilation, (such as tremor), vague GI symptoms (such as nausea), facial flushing, sense of warmth, slow weak pulse, depressed deep tendon reflex
Starting an Intravenous infusion: (Kozier, 2004) ASSESSMENT: 1. Assess for vital signs 2. Assess skin turgor and allergy to tape PLANNING: 1. Consider how long the patient is likely to have the IV and what kind of fluid is to be infused 2. Verify written order for IV therapy 3. Gather needed equipment IMPLEMENTATION: 1. Explain the procedure to the client 2. Wash your hands 3. Open and prepare the infusion set 4. Spike the solution container 5. Apply an IV tag on the solution container 6. Hang the solution container on the IV pole 7. Partially fill the drip chamber with solution 8. Prime the tubing 9. If indicated, wash your hands again just prior to patient contact 10. Select the venipuncture site (if not contraindicated use clients non dominant hand) 11. Place the extremity in a dependent position 13. Apply a tourniquet firmly Prepared by: Leah Marie S. Navarro, RN, MAN Page 61
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14. 15. 16. 17. 18. 19. 20.
Put on clean gloves and clean the venipuncture site Insert the catheter and initiate the infusion Tape the catheter Dress and label the venipuncture site and tubing according to agency policy Ensure appropriate infusion flow Remove gloves and discard all used materials Wash your hands
EVALUATION: 1. Document relevant data, including assessments You will see on the table below the different complications of IV therapy, their possible causes and nursing interventions. (Adapted from Lippincott Williams and Wilkins, 2006) Signs and symptoms Possible causes Nursing interventions Phlebitis - tenderness at tip of - poor blood flow around - remove the device device and above device - apply a warm pack - redness at tip of catheter - friction from catheter - notify the doctor and along vein movement in vein - document the patients condition - puffy area over vein - device left in vein too and your intervention - vein hard on palpation long - elevated temperature - clotting at catheter tip Prevention: (thrombophlebitis) - restart the infusion using a large - solution with high or low vein for irritating infusate, or pH or high osmolarity restart with a smaller-gauge device to ensure adequate blood flow - tape device securely to prevent motion Infiltration - swelling at and around - device dislodge from I.V. site (may extend along vein or perforated vein entire limb) - discomfort, burning, or pain at site - feeling of tightness at site -decreased skin temperature around site - blanching at site - continuing fluid infusion even when vein is occluded, although rate may decrease - absent backflow of blood - slower flow rate - remove the device - apply warm soaks to aid absorption - elevate the limb - notify the doctor if severe - periodically assess circulation by checking for pulse, capillary refill, and numbness or tingling - restart the infusion, preferably in another limb or above the infiltration site - document the patients condition and your interventions Prevention: - check the I.V. site frequently, specially when using an I.V. pump Page 62
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- dont obscure area above site with tape - teach the patient to report discomfort, pain, or swelling Catheter dislodgment - catheter partly backed - loosened tape or tubing - if no infiltration occurs, retape out of vein snagged in bedclothes, without pushing catheter back - infusate infiltrating resulting in partial into vein. retraction of catheter Prevention: - tape the device securely on insertion.
Occlusion - no increase in flow rate when I.V. container is raised - blood backup in line - discomfort at insertion site
- I.V. flow interrupted - intermittent device not flushed - blood backup in line when patient walks - hypercoagulable patient - line clamped too long
- use a low flush pressure syringe during the injection. Dont use force. If resistance is met, stop immediately. If unsuccessful, reinsert the I.V. device Prevention: - maintain the I.V. flow rate - flush promptly after intermittent piggyback administration - have the patient walk with his arm below heart level to reduce the risk of blood backup.
Vein irritation or pain at I.V. site -pain during infusion -possible blanching or vasospasm occurs -red skin over vein during infusion -rapidly developing signs of phlebitis
- solution with high or low pH or high osmolarity, such potassium chloride, phenytoin, and some antibiotics (vancomycin and nafcillin)
- slow the flow rate - try using an electronic flow device to achieve a steady regulated flow Prevention: dilute solutions before administration For example, give antibiotics in 250-ml rather than 100-ml solution. If the drug has a low pH, ask the pharmacist if drug can be buffered with sodium bicarbonate. (Refer to facility policy.) - if long-term therapy is planned, ask the doctor to use the central I.V. line
Hematoma Prepared by: Leah Marie S. Navarro, RN, MAN Page 63
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tenderness at - vein punctured through venipuncture site ventral wall at time of - bruising around site venipuncture - inability to advance or - leakage of blood from flush I.V. line needle displacement
- remove the venous access device - apply pressure and warm soaks to the affected area - recheck for bleeding - document the patients condition and your interventions Prevention: Choose a vein that can accommodate the size of the intended device -release the tourniquet as soon as successful insertion is achieved
Venous spasm - pain along vein - sluggish flow rate when clamp is completely open - blanched skin over vein
- severe vein irritation from irritating drugs or fluids - administration of cold fluids or blood - very rapid flow rate (with fluids at room temperature)
- apply warm soaks over the vein and the surrounding area - slow the flow rate Prevention: Use blood warmer for blood or packed red blood cells when appropriate
Thrombosis - painful, reddened, and - injury to endothelial cells swollen vein of vein wall, allowing - sluggish or stopped I.V. platelets to adhere and flow thrombus to form
- remove the device; restart the infusion in the opposite limb if possible - apply warm soaks - watch for I.V. therapy-related infection. (thrombi provide an excellent environment for bacterial growth) Prevention: - use proper venipuncture techniques to reduce injury to vein
Thrombophlebitis - severe discomfort thrombosis - reddened, swollen, and inflammation hardened vein
and - remove the device; restart the infusion in the opposite limb if possible - apply warm soaks - notify the doctor - watch for I.V. therapy-related infection (thrombi provide an excellent environment for bacterial growth) Page 64
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Prevention: -check the site frequently. Remove device at the first sign of redness and tenderness. Circulatory overload - discomfort -neck vein engorgement - respiratory distress - increased blood pressure - crackles - large positive fluid balance (intake is greater than output)
- roller clamp loosened to allow run-on infusion - flow rate too rapid - miscalculation of fluid requirements
- raise the head of the bed - slow the infusion rate (but dont remove the venous access device) - administer oxygen as needed - notify the doctor administer medications (probably furosemide) as ordered Prevention: - Use a pump, volume-control set, controller, or rate minder for eldery or compromised patients - recheck calculations of fluid requirements -monitor the infusion frequently
Systemic infection (septicemia or bacteremia) - fever, chills, and malaise for no apparent reason - contaminated I.V. site, usually with no visible signs of infection at site
- failure to maintain aseptic technique during insertion or site care - severe phlebitis, which can set up ideal conditions for organism growth - poor taping that permit venous access device to move, which can introduce organisms into bloodstream - prolonged indwelling time of device Immunocompromised patient
- notify the doctor - administer medications as prescribed - culture the site and the device - monitor the patients vital signs Prevention: use scrupulous aseptic technique when handling solutions and tubings, inserting the venous access device, and discontinuing the infusion - secure all connections - change I.V. solutions, tubing, and venous access device at recommended times - use I.V. filters
Air embolism - respiratory distress - unequal breath sounds - weak pulse - increased central venous pressure decreased blood pressure
- empty solution container solution container empties; next container pushes air down line - tubing disconnected from venous access device or I.V. bag
- discontinue the infusion place the patient in trendelenburgs position on his left side to allow air to enter the right atrium and disperse through the pulmonary artery - administer oxygen Page 65
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- confusion, disorientation, loss of consciousness
- notify the doctor - document the patients condition and your interventions Prevention: -purge the tubing of air completely before the infusion -use an air-detection device on the pump or an air-eliminating filter proximal to the I.V. site -secure all connections
Allergic reactions - itching - allergens - tearing eyes and runny medications nose - bronchospasm - wheezing - urticarial rash - edema at I.V. site anaphylactic reaction (within minutes or up to 1 hour after exposure), including flushing, chills, anxiety, agitation, generalized itching, palpitations, paresthesia, throbbing in ears, wheezing, coughing, seizures, and cardiac arrest
such
as - if a reaction occurs, stop the infusion immediately and infuse normal saline solution - maintain a patient airway - notify the doctor - administer an antihistaminic steroid, an anti-inflammatory, and antipyretic drugs, as ordered - give 0.2 to 0.5 ml of 1:1,000 aqueous epinephrine subcutaneously. Repeat at 3minute intervals and as needed, as ordered. Prevention: - obtain the patients allergy history. Be aware of crossallergies - assist with test dosing - monitor the patient carefully during the first 15 minutes of administration of a new drug
Blood Transfusion:
It is the introduction of whole blood or blood components directly into the blood stream; mainly to (1) restore and maintain blood volume, (2) improve the oxygen-carrying capacity of blood, and (3) replace deficient blood components and improve coagulation. (Lippincott Williams and Wilkins, 2006) Two basic components of blood: 1. Cellular Elements or formed elements make up about 45% of the blood volume. a. Erythrocytes or RBC used to increase the oxygen-carrying capacity of blood in anemias, surgery, disorders with slow bleeding. One unit raises hematocrit by approximately 4%. (Kozier, 2004) Prepared by: Leah Marie S. Navarro, RN, MAN Page 66
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b. Leukocytes or white blood cells protect thee body against microorganisms and remove dead cells and debris. (Seeley, 2007) c. Thrombocytes or platelets responsible for blood clotting and involved with preventing blood loss. (Seeley, 2007) 2. Plasma maintains osmotic pressure, is involved in immunity, prevents blood loss, and transports molecules. (Seeley, 2007) a. Water or serum b. Protein (albumin, globulin, and fibrinogen) c. Lipids d. Electrolytes e. Vitamins f. Carbohydrates g. Nonprotein nitrogen compounds h. Bilirubin i. Gases Terms to remember: (Seeley, 2007) o o Antigen / agglutinogen any substance that induces a state of sensitivity or resistance to microorganisms or toxic substances after a latent period Antibody / agglutinin protein found in the plasma that is responsible for antibody mediated immunity; binds especially to an antigen
Blood Products for Transfusion: (Lemone and Burke, 2007, Lippincott, 2006 and Kozier, 2004) Component / Product Use Whole Blood Replaces blood volume and oxygen carrying capacity in Volume: 500ml hemorrhage and shock; it contains all blood products: RBC. Plasma, plasma proteins, fresh platelets, and other clotting factors Packed RBC Volume: 250ml Restores the intravascular volume and oxygen-carrying capacity of blood in anemias, surgery, disorders with slow bleeding Used to treat patient with life-threatening granulocytopenia who isnt responding to antibiotics Replaces platelets in clients with bleeding disorders or platelet deficiency. Compatibility testing is not required. Blood volume expander in shock from burns, trauma, surgery or infections. Provides plasma proteins. Cross typing isnt necessary Expands blood volume and provides clotting factors. Used to treat post-surgical hemorrhage or shock. Does not need to Page 67
White Blood Cells Volume: 150ml Platelets Volume: 35-50ml/unit Albumin
Fresh Frozen Plasma Volume: 200-250ml
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be typed and cross-matched Cryoprecipitate Restores fibrinogen, deficiencies used for clients with clotting factor
Transfusion Reactions: Adapted from Kozier, 2004 Reaction: Cause Clinical Signs Nursing Intervention Hemolytic reaction: Chills, fever, headache, 1. Discontinue the transfusion incompatibility between backache, dyspnea, immediately. clients blood and donors cyanosis, chest pain, Note: When the transfusion is blood tachycardia, hypotension discontinued , the blood tubing must be removed as well. Use new tubing for the normal saline infusion. 2. Keep the vein open with normal saline, or according to agency protocol. 3. Send the remaining blood, a sample of the clients blood, and a urine sample to the laboratory. 4. Notify the physician immediately. 5. Monitor vital signs. 6. Monitor fluid intake and output Febrile Reaction: Fever, chills,warm, flushed 1. Discontinue the transfusion sensitivity of the clients skin; headache; anxiety, immediately. blood to white blood cells, muscle pain 2. Give antipyretics as platelets, or plasma ordered. proteins 3. Notify the physician. 4. Keep the vein open with a normal saline infusion Allergic Reaction (mild): Flushing, itching, urticaria, 1. Stop or slow the sensitivity to infused bronchial wheezing transfusion , depending on plasma proteins agency protocol. 2. Notify the physician. 3. Administer medication (antihistamines) as ordered. Allergic Reaction (severe): Dyspnea, chest pain, 1. Stop the infusion antibody-antigen reaction circulatory collapse, 2. Keep the vein open with cardiac arrest normal saline. 3. Notify the physician immediately. 4. Monitor vital signs. Prepared by: Leah Marie S. Navarro, RN, MAN Page 68
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5. Circulatory Overload: blood administered faster than the circulation can accommodate Cough, dyspnea, crackles (rales), distended neck veins, tachycardia, hypertension 1. 2. 3. 4. Sepsis: contaminated High fever, chills, vomiting, blood administered diarrhea, hypotension 1. 2. 3. 4. 5. 6.
Administer cardiopulmonary resuscitation if needed. Administer medication and/or oxygen as ordered. Place the client upright, with feet dependent. Administer diuretics and oxygen as ordered. Notify the physician. Stop or slow the transfusion. Stop the transfusion Send the remaining blood to the laboratory. Notify the physician. Obtain a blood specimen from the client for culture. Adminster IV fluids, antibiotics. Keep the vein open with a normal saline infusion.
Initiating, Maintaining, and Terminating a Blood Transfusion Using a Yinjection port: (Lippincott, 2006 and ANSAP manual, 5th edition)
ASSESSMENT: 1. Assess for manifestations of hypovolemia PLANNING: 1. Verify physician order for transfusion 2. Verify that a signed consent form was obtained 3. Assess vital signs for baseline data 4. Determine any known allergies or previous adverse reactions to blood 5. Note specific signs related to the clients pathology and the reason for the transfusion IMPLEMENTATION: 1. Explain the procedure and its purpose to the client 2. If the client has an IV infusion, check whether the needle and solution are appropriate to administer blood 3. Check the physicians order with the requisition 4. Check the requisition form and the blood bag label with a laboratory technician or according to agency policy 5. With another nurse, compare the laboratory blood record with the (a) clients name and identification number, (b) number on the blood bag label and (c) ABO group and Rh type on the blood bag label Prepared by: Leah Marie S. Navarro, RN, MAN Page 69
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6. Prepare equipment needed 7. Wash hands 8. Open compatible blood set aseptically and spike blood bag carefully; prime tubing and remove air bubbles if any 9. Disinfect the Y-injection port of IV tubing and insert the needle from BT administration set 10. Transfuse the blood via the injection port at 10 15 drops per minute for the first 15 minutes and then regulate at the desired rate 11. Observe the client closely for the first 5 10 minutes and not for adverse reactions 12. Close line of PNSS or regulate to KVO as ordered while transfusion is going on 13. Document relevant data 14. Monitor the client 15 minutes after initiating the transfusion, and every 30 minutes thereafter, or more often, depending on the health status 15. Don clean gloves in terminating the transfusion 16. If no transfusion is to follow, close the blood tubing and remove the needle from the Y-injection port. 17. Flush the maintenance line and regulate the PNSS as ordered 18. Discard blood bag and BT set according to agency policy 19. Document relevant data EVALUATION: 1. Continue to observe client after termination of transfusion for delayed reactions, Changes in vital signs and health status
Total Parenteral Nutrition:

It is also known as hyperalimentation. It is the intravenous administration of carbohydrates (high concentrations of dextrose), proteins (amino acids), electrolytes, vitamins, minerals, and fat emulsions. (LeMone and Burke, 2007) It is the administration of predigested nutrients directly into the bloodstream through an IV line. Used for patients who cant receive nutrients through the GI tract, perenteral nutrition enables body cells to function despite the patients inability to eat or metabolize food. (Lippincott, 2007) It is provided when the gastrointestinal tract is nonfunctional because of an interruption in its continuity or because its absorptive capacity is impaired. It is also a means of achieving an anabolic state in clients who are unable to maintain a normal nitrogen balance. (Kozier, 2004) Indications for Total Parenteral Nutrition: (Perry and Potter, 2007) Non-functional GI Tract o Massive small bowel resection/GI surgery o Paralytic ileus o Intestinal obstruction o Trauma to abdomen, head, or neck o Severe malabsorption o Intolerance to enteral feeding Prepared by: Leah Marie S. Navarro, RN, MAN Page 70
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o Chemotherapy, radiation therapy, bone marrow transplantation Extended Bowel Rest o Enterocutaneous fistula o Inflammatory bowel disease exacerbation o Sewvere diarrhea o Moderate to severe pancreatitis Preoperative TPN o Preoperative bowel rest o Treatment of comorbid severe malnutrition in clients with nonfunctional GI tracts o Severely catabolic clients when GI tract nonusable for more than 4 to 5 days
Understanding Common Additives of TPN: (Lippincott, 2006) Acetate prevents metabolic acidosis Amino Acids provide protein necessary for tissue repair Calcium promotes development of bones and teeth and aids in blood clotting Chloride regulates the acid-base equilibrium and maintains osmotic pressure D50W provides calories for metabolism Folic Acid is needed for deoxyribonucleic acid formation and promotes growth and development Magnesium aids carbohydrate and protein absorption Micronutrients help in wound healing and red blood cell synthesis Phosphate minimizes the potential for developing peripheral paresthesia (numbness and tingling of the extremities) Potassium is needed for cellular activity an tissue synthesis Sodium helps regulate water distribution and maintain normal fluid balance Vitamin B complex aids the final absorption of carbohydrates and protein Vitamin C helps in wound healing Vitamin D is essential for bone metabolism and maintenance of serum calcium levels Vitamin K helps prevent bleeding disorders
Complications of Central Parenteral Nutrition: Problem Air embolism Immediate Prevention Action IV tubing Sudden Clamp Make sure all disconnected: respiratory catheter; catheter part of distress; position client connections catheter decreased in left are system open SpO2 levels, trendelenbur secure; clamp or removed shortness of g position; catheter when without being breath, call not in use. clamped coughing, physician; Never use a chest pain, administer stopcock with Page 71 Cause Symptoms
NCM 106 June 2011
decreased oxygen as a blood needed CVC. pressure Localized Poor aseptic Exit site: Call Use proper infection (exit technique in erythema, physician. aseptic site or tunnel) removal of tenderness, Exit: warm technique. skin flora induration or compress, Change during site purulence daily site transparent preparation within 2cm of care, oral dressings and dressing skin at exit antibiotics. every care site 7 days, gauze Tunnel: dressings Tunnel: same remove every as above but catheter 48 hours. extends Change beyond 2cm dressing from the exit if damp, site loosened, or soiled. Cleanse the site during any dressing change with chlorhexidine or povidoneiodine a minimum of 3 to 5 minutes. Routine use of antibiotic ointment not recommended Systemic Catheter hub Systemic: Systemic: infection contamination; isolation of antibiotics (catheter sepsis contamination same intravenously, or bacteremia) of infusate; microorganism remove spread of from blood catheter bacteria culture and through bloodcatheter stream from segment, with distant site client showing fever, chills, malaise, elevated white blood cell count Client receiving CPN too Excessive thirst, Call physician; Use full sterilebarrier precautions during catheter insertion and dressing change. Use antibioticimpregnated catheters. Do not disconnect tubing unnecessarily . Review medical history for Page 72
Hyperglycemia
NCM 106 June 2011
quickly; too little insulin in solution; infection
urination, blood glucose >160 mg/100ml, confusion
may need to slow infusion rate (physicain order)
glucose intolerance or diabetes; keep rate as ordered, never increase CPN to catch upuse aseptic technique and routine blood glucose monitoring.
Hypoglycemia
CPN abruptly Client is Call physician; Decrease CPN, discontinued; shaky, dizzy, if CPN tapering too much nervous, discontinued gradually insulin senses abruptly, may until hunger, blood need to restart discontinued; glucose level D10NS at blood <80 mg/100ml previous CPN glucose rate. If client monitoring is has oral used to intake, give ensure cup fruit juice. adequate Perform blood insulin. glucose monitoring; retest in 15 to 30 minutes. Adapted from Perry and Potter, 2006
Caring for the Client Receiving Central Venous Placement for Central Parenteral Nutrition (Perry and Potter, 2006) ASSESSMENT 1. Assess need for CPN, and determine clients current nutritional status and energy needs. Consult with physician and dietician. 2. Check physicians order for initiation of CPN and insertion of central vein catheter for size and type of catheter. 3. Assess clients hydration status; skin turgor, texture, and fluid intake and output. 4. Assess client for any surgical procedures of the upper chest or anatomical irregularities. 5. Consider catheter material to be used and determine if client has allergy to material. 6. Inspect condition of skin overlying supraclavicular and infraclavicular area. 7. Assess client for allergy to iodine, lidocaine, or latex. Prepared by: Leah Marie S. Navarro, RN, MAN Page 73
NCM 106 June 2011
8. Assess clients knowledge of purpose of procedure PLANNING 1. Explain to client steps for central line placement 2. Verify that consent was signed IMPLEMENTATION 1. Position the client 2. Physician wears cap, mask, and eyewear, and performs surgical scrub. Dons surgical gown and sterile gloves. 3. Nurse puts on cap, mask, and eyewear, and performs hand hygiene. 4. Physician opens central vein kit and adds any sterile equipment to kit for use during Insertion 5. Nurse saturates 4x4 gauze pads with alcohol, and physician scrubs the area. 6. Physician cleans same area for 1 minute using antimicrobial swabs 7. Allow antimicrobial solution to air-dry completely. 8. Physician removes gloves and applies new pair of sterile gloves. 9. Physician drapes the patient appropriately 10. Physician arranges equipment in kit in preparation for catheter insertion 11. Nurse sets up IV bag, fills tubing, and covers end of tubing with a sterile cap 12. Nurse places client in Trendelenburgs position and turn clients head away from insertion site 13. Physician anesthesizes venipuncture site 14. Physician inserts IV catheter into subclavian vein 15. Physician determines patency of line by widrawing blood with 5ml syringe and connects IV tubing to intravenous catheter 16. Nurse initially runs the IV fluid in at a rapid rate for 5 to 10 minutes 17. Nurse adjusts IV infusion to 30 to 40 ml/hr and connects to electronic infusion pump Until chest x-ray study is obtained 18. Physician sutures central venous catheter in place 19. Physician orders chest film 20. Cleanse insertion site with antiseptic swab 21. Remove and dispose off gloves, loop and tape tubing securely to clients shoulder 22. Assist with chest x-ray examination 23. When position of central vein catheter is confirmed, prepare parenteral nutrition solution obtained from pharmacy for infusion 24. Dispose off used supplies and perform hand hygiene EVALUATION 1. Observe client for shortness of breath, pain in the chest or shoulder after CVC Insertion 2. Observe client for bleeding or swelling at the insertion site and occlusiveness of the Dressing 3. Observe insertion site over time for erythema, warmth, tenderness, edema, or Drainage 4. Measure clients body temperature every 4 hours for 24 hours and then as ordered 5. After discontinuation of CVC observe for possible complications of air embolism, pneumothorax, hematoma at puncture site
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Performance Scale for IV Therapy: (Adapted from Elkin, et al and Roes clinical skills checklist) Able to Perform Able to Perform with assistance Unable to Perform
Skill Assessment 1. Check the written order for the type of IV therapy planned 2. Review information regarding the insertion of the IV. 3. Determine the level of emotional support and instruction needed 4. Assess the clients veins 5. Check the clients fluid, electrolyte, and nutritional status 6. Assess the type and duration of IV therapy ordered 7. Assess the clients understanding of the procedure 8. Assess the client for possible contraindications to specific interventions Planning 1. Identify goals and expected outcomes 2. Explain the procedure and rationale 3. Gather appropriate equipment Implementation 1. Check the physicians order for an IV 2. Wash your hands 3. Organize all equipment at the bedside 4. To minimize client anxiety, explain the steps of the procedure 5. Apply the tourniquet appropriately 6. Select a vein 7. Temporarily remove the tourniquet 8. Ask the patient to rest arm in a dependent position 9. Reapply the tourniquet 10. Cleanse the insertion site and allow it dry 11. Put on gloves and insert the catheter, note for backflow 12. Release the tourniquet 13. Remove the stylet and connect to IV tubing 14. Secure insertion site 15. Remove gloves and dispose all used materials 16. Wash your hands 17. Instruct the client about daily activities without dislodging the IV Prepared by: Leah Marie S. Navarro, RN, MAN
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NCM 106 June 2011
Evaluation 1. Document the clients response
Remarks: ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________
______________________________ Students Signature over printed name
______________________________________ Clinical Instructors signature over printed name
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NCM 106 June 2011
REFERENCES: BOOKS:
1. Smeltzer, Suzanne, et al., (2010). Textbook of Medical Surgical Nursing (21th edition)
2. LeMone, Priscilla and Burke, Karen, (2007). Principles of Medical Surgical Nursing (4th edition) 3. Lippincott Williams and Wilkins, (2007). Nutrition made Incredibly Easy (2nd edition) 4. Perry and Potter, (2006). Clinical Nursing Skills and Technique (6th edition) 5. Lippincott Williams and Wilkins, (2006). I.V. Therapy made Incredibly Easy (3rd edition) 6. Seeley, et al., (2007). Essentials of Anatomy and Physiology (6th edition) 7. ANSAP, Nursing Standards on intravenous Practice (5th edition)
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UNIVERSITY OF THE ASSUMPTION College of Nursing City of San Fernando (P) Tel. No. 045-9611482 loc.125 SCIENTIA VIRTUS COMMUNITAS IV Therapy Lesson 3 Pre-test Name: ________________________________________ Section: _______________ Date: ____________ Score: ___________
The secret to success is to start from scratch and keep on scratching. - Dennis Green Matching Type: Match column A with column B. Choose the correct answer and use capital letters only on the space provided.
A
____ 1. Isotonic solution ____ 2. Hypotonic solution ____ 3. Hypertonic solution ____ 4. Sodium ____ 5. Platelets ____ 6. Vitamin C ____ 7. RBC ____ 8. Calcium ____ 9. Vitamin D ____ 10. Potassium
B
A. responsible for blood coagulation B. Major cation in extracellular fluid C. Major cation found in ECF D. erythrocytes E. Major cation in intracellular fluid F. PNSS G. essential for bone metabolism H. D10W I. Major anion found in ECF J. aids in wound healing K. 0.45% Sodium Chloride
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NCM 106 June 2011
ANSWER KEY: (Lesson 3)

1. 2. 3. 4. 5. 6. 7. 8. 9. F K H B A J D C G
10. E
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NCM 106 June 2011
UNIVERSITY OF THE ASSUMPTION College of Nursing City of San Fernando (P) Tel. No. 045-9611482 loc.125 SCIENTIA VIRTUS COMMUNITAS IV Therapy Lesson 3 Post-test Name: ________________________________________ Section: _______________ Date: ____________ Score: ___________
Many of lifes failures are people who had not realized how close they were to success when they gave up. - Thomas A Edison
Enumeration: Recall topics that were discussed. Answer what are being asked. Write clearly and legibly. 1. Identify three complications of IV therapy, one of its possible cause and two nursing interventions for each. (10 pts.) 2. Identify three electrolytes and their principal function (5 pts.) 3. Enumerate three purposes of IV therapy (3 pts.) 4. Give two transfusion reactions (2 pts.)
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University of the Assumption College of Nursing

NCM 106 June 2011

LESSON I EMERGENCY and DISASTER NURSING

Prepared by: Leah Marie S. Navarro, RN, MAN

University of the Assumption College of Nursing

NCM 106 June 2011

University of the Assumption College of Nursing

NCM 106 June 2011

Management: Abdominal thrust (Heimlich maneuver)

Adapted from hubpages.com

Prepared by: Leah Marie S. Navarro, RN, MAN

University of the Assumption College of Nursing

NCM 106 June 2011

Adapted from www.tags-search.com

University of the Assumption College of Nursing

NCM 106 June 2011

Oropharyngeal airway insertion

Adapted from www.surgeryencyclopedia.com

University of the Assumption College of Nursing

NCM 106 June 2011

Replaces blood volume and oxygencarrying capacity in hemorrhage and shock

Contains RBCs, plasma proteins, clotting factors, and plasma

Restoration of intravascular volume Replacement of oxygen-carrying capacity

Compatibility testing is not required Typical platelet transfusion should

Postexposure prophylaxis with anti Rh immune globulin should be considered

Prepared by: Leah Marie S. Navarro, RN, MAN

University of the Assumption College of Nursing

NCM 106 June 2011

Adapted from wildernessmanuals.com Adapted from www.wildernessmanuals.com

University of the Assumption College of Nursing

NCM 106 June 2011

University of the Assumption College of Nursing

NCM 106 June 2011

Prepared by: Leah Marie S. Navarro, RN, MAN

University of the Assumption College of Nursing

NCM 106 June 2011

Basic Pathophysiology (Smeltzer, et. al., 2010) Decreased blood volume

Decreased venous return

Decreased stroke volume

Decreased cardiac output

Prepared by: Leah Marie S. Navarro, RN, MAN

University of the Assumption College of Nursing

NCM 106 June 2011

Hypertonic saline (3%)

Small volume needed to restore intravascular volume

(Adapted from Smeltzer, et al.,2010 and LeMone and Burke, 2007)

Prepared by: Leah Marie S. Navarro, RN, MAN

University of the Assumption College of Nursing

NCM 106 June 2011

Adapted from Smeltzer, et al., 2010

Prepared by: Leah Marie S. Navarro, RN, MAN

University of the Assumption College of Nursing

NCM 106 June 2011

Prepared by: Leah Marie S. Navarro, RN, MAN

University of the Assumption College of Nursing

NCM 106 June 2011

Prepared by: Leah Marie S. Navarro, RN, MAN

University of the Assumption College of Nursing

NCM 106 June 2011

University of the Assumption College of Nursing

NCM 106 June 2011

University of the Assumption College of Nursing

Name: __________________________ Section: _

Date: __ Score: _