Nursing in emergencies Presentation Transcript 1. PRESENTED BY KARTHIKA.R.T. B.Sc(N) RNRM 2.

. Definition Concept of emergency nursing Principles of emergency nursing Scope of emergency nursing Required classifications for nurses in ED Medical emergencies 3. Emergency Nursing is a nursing specialty in which nurses care for patients in the emergency or critical phase of their illness or injury. While this is common to many nursing specialties, the key difference is that an emergency nurse is skilled at dealing with people in the phase when a diagnosis has not yet been made and the cause of the problem is not known. Emergency nurses also deal with non-emergent populations that present with non-life threatening issues as well. Patients that present to the Emergency Department may range from birth to geriatric. 4. The term emergency is used for those patients who require immediate action to prevent further detoriations or stabilizing the condition till the availability of the services close to the patients. The nurse as a team member plays significant role in the early assessment,intervention either in the form of care or transferring the patient safely to the health services. 5. Establish a patent airway and provide adequate ventilation Evaluate and restore cardiac output by controlling hemorrhage and its consequences,preventing and treating shock and maintaining or restoring effecting circulation Determine the patients ability to follow commands and evaluate motor skills and papillary size and reactivity Carry out a rapid initial and ongoing physical examination 6. Start cardiac monitoring Protect and clean wounds- apply sterile dressing Identify allergies and medical history that is significant Document on the medical record the patients vital signs,blood pressure,neurologic status and intake and output to guide decision making 7. Emergency department overcrowding is a growing and severe problem_ Require crisis intervention National wide The patient population presenting Emergency Department spans the age continuum from neonates to geriatrics 8. Emergency nurses must be ready to treat a wide variety of illnesses or injury situations, ranging from a sore throat to a heart attack Is a specialty area of the nursing profession like no other. To provide quality patient care for people of all ages, emergency nurses must possess both general and specific knowledge about health care to provide quality patient care for people of all ages 9. 1 Emergency Nurses Association (ENA) 2 Certified Emergency Nurse (CEN, USA) 3 Emergency Nurse Practitioner (ENP) (UK) 4 Emergency Nurse Practitioner (ENP) (USA) 5 Emergency Care Practitioner (UK) 10. ATNC - Advanced Trauma Nursing Course ACLS - Advanced Cardiac Life Support ATLS - Advanced Trauma Life Support ENPC - Emergency Nursing Pediatric Course MICN - Mobile Intensive Care Nurse PALS - Pediatric Advanced Life Support PHEC - PreHospital Emergency Care TNCC - Trauma Nursing Core Course 11. Patient care Education Leadership and Research 12. A medical emergency is an injury or illness that is acute and poses an immediate risk to a persons life 13. TRIAGE Is to sort in the daily routine of the emergency department.It is used to sort the patient in to following categories: EMERGENT : Highest priority of care URGENT : Higher priority of care NON-URGENT: Priority of care 2. ASSESS AND INTERVENS Primary survey Secondary survey 14. PRIMARY SURVEY SECONDARY SURVEY A= Airway B=Breathing C= Circulation D= Disability E=Exposure to environment F=Full set of vitalsigns G=Give comfort H=History collection I=Inspect the post.surface 15. A= Allergy M=Medication history P=Past health history L=Last meal E=Events/Environmental preceding illness or injuries 16. Early detection Early Reporting Early Response Good On Scene Care Care in Transit Transfer to Definitive Care 17. Cardiogenic shock Congestive Heart Failure Pericarditis Cardiac Tamponade Cardiac Arrest 18.

19. It refers to a body wound or shock produced by sudden physical injury, as from violence or accident It can also described as a physical wound or injury, such as a fracture or blow 20. Poly trauma Head trauma Chest trauma Surface trauma Abdominal trauma Facial trauma Spinal cord injury Orthopaedic trauma Genitourinary trauma, Psychological trauma Blunt trauma Penetrating trauma 21. Motor vechicle accidents Falls DIAGNOSTIC EVALUATIONS: Physical examinations X-Rays 22. Definition Penetrating Abdominal trauma- causes an open wound, such as from the gunshot or stabbing.The solid organs can bleed profusely when injured.The hollow organs generally dont bleed significantly but are likely to cause peritonitis if damaged. Blunt abdominal trauma- a force to the abdomen that doesnt leave an open wound, commonly occurs with motor vehicle crashes or falls. Compression and shearing are examples. 23. 24. 25. 26. Primary assessment (ABCD): : Primary assessment (ABCD): Immediately lifethreatening problems are identified during the primary assessment. Airway, breathing, and circulation are evaluated while maintaining stability of the cervical spine. D is for neurological deficit, including level of consciousness and pupillary reaction. Secondary assessment (EFGHI): : Secondary assessment (EFGHI): The secondary assessment is a brief (two to three minute) examination of the patient intended to detect and prioritize injuries. E is for exposure: Remove clothing to check for signs of injury. F is for full set of vital signs and five interventions (monitors, pulse oximetry, indwelling urinary catheter, nasogastric tube, and labs). G: Give comfort measures. H is for headto-toe examination. I: Inspect the back turn the patient over to look for unseen injury 27. At this point, a more detailed examination of injuries identified in the secondary assessment is performed, with concentration on problems with the pulmonary, cardiovascular, or neurological system, if any. In the case of abdominal trauma, the abdomen is inspected for open wounds, external hemorrhage, foreign objects, or unusual patterns of bruising that might indicate internal bleeding. Auscultation will identify the absence or presence of bowel sounds or bruits 28. Goals are to control bleeding, maintain blood volume and prevent infection. Keep the patient quiet and on the stretcher, because movement may fragment or dislodge a clot in a large vessel and produce massive hemorrhage. Cut the clothing away from the wound. Look for entrance and exit of wound Count the number of wounds If the patient is comatose, immobilize the cervical spine until after cervical films are taken and cleared. Apply compression to external bleeding Insert two large-bore IV lines and infuse Ringers. Insert a nasogastric tube to decompress the abdomen Cover protruding abdominal vicera; do not attempt to replace the protruding organs into the abdomen. Use sterile saline dressings to protect the vicera from drying. Cover open wounds with dry dressing. Withhold oral fluids to prevent vomiting and increased peristalsis. Insert an indwelling catheter to ascertain the presence of hematuria and to monitor urinary output. 29. Tetanus prophylaxis, Broad-spectrum antibiotics. Prepare for surgery of the patient shows evidence of unexplained shock, unstable vital signs, peritoneal irritation,bowel protrusion and evisceration, significant penetrating injury, significant gastrointestinal bleeding, or peritoneal air. 30. Catheterization and urinalysis, Serial Hemoglobin and hematocrit. CBC Serum amylase, CT scan, Abdominal and chest xrays FAST for blunt abdominal trauma 31. 32. The emergency management of poisoning starts from the scene of the event, where early induction of vomiting can remove a significant portion of the ingested poison. It is not clear, however, whether early or late induction of vomiting influences the outcome. In countries where poisons information centres are accessible to the

public, people are advised to keep some ipecacuanha (Ipecac Syrup USP or Paediatric Ipecacuanha Emetic Mixture BP) at home 33. to irrigate external chemical burns with plenty of water; if corrosiveshave been ingested, to drink a cup of water or milk,which may dilute the corrosive and reduce tissue damage, provided the patient can protect his or her own airway 34. Gastric lavage Should not be considered unless a patient has ingested a potentially life-threatening amount of a poison and the procedure can be undertaken within 60 minutes of ingestion Activated charcoal May be considered if a patient has ingested a potentially toxic amount of a poison (known to be adsorbed by charcoal) up to 1 hour previously; there are insufficient data to support or exclude its use after 1 hour of ingestion Ipecacuanha Its routine administration in the emergency department should be abandoned; there are insufficient data to support or exclude its administration soon after ingestion of poison Whole-bowel irrigation May be considered for potentially toxic ingestion of sustained-release or enteric-coated drugs; there are insufficient data to support or exclude the use of whole-bowel irrigation for potentially toxic ingestion of iron, lead, zinc, or packets of illicit drugs Cathartics The administration of a cathartic alone has no role in the treatment of a poisoned patient and is not recommended as a method of gut decontamination 35. Anticholinesterase (insecticide)- Atropine; pralidoxime mesylate Arsenic, mercury, lead, gold- Dimercaprol Benzodiazepines- Flumazenil - Blockers -Glucagon Calciumchannel blockers -Calcium chloride Carbon monoxide- 100% oxygen Coumarins Vitamin K1- fresh frozen plasma Cyanide -Hydroxocobalamin Digoxin- Digitalis-specific antibodies 36. Insulin, oral hypoglycaemic agents Glucose 50%; octreotide Iron- Deferoxamine mesilate (desferrioxamine mesylate) Opioids- Naloxone hydrochloride Oxidising agents- Methylene blue Paracetamol- Acetylcysteine Paraquat Fullers earth; activated charcoal Snake venom Antevenene for bamboo snake, Russells viper, Chinese cobra, king cobra, and banded krait Stonefish venom -Stonefish antevenene Sympathomimetics Propranolol hydrochloride; esmolol hydrochloride Tricyclic antidepressants- Sodium bicarbonate 37. 1. Stabilize the child. Assess ABCs (airway, breathing, and circulation). Provide ventilatory and oxygen support. 2. Perform a rapid physical examination, start an IV infusion, draw blood for toxicology screen, and apply a cardiac monitor. 3. Obtain a history of the ingestion, including substance ingested, where child was found, by whom, position, when, how long unsupervised, history of depression or suicide, allergies, and any other medical problems. 38. 4. Reverse or eliminate the toxic substance using the appropriate method: a. Antidotes and agonists Mucomyst (for acetaminophen poisoning) Narcan (for opioid overdose) Romaxicon (for benzodiazepine overdose) b. Gastric lavage A gastric tube is inserted through the mouth. Normal saline solution is instilled and aspirated until the return is clear. Considered a less effective method of removing ingested substances from the stomach than vomiting. Reserved for children with central nervous system depression, diminished or absent gag reflex, or unwillingness to cooperate with other measures. Contraindicated in children who have ingested alkaline corrosive substances, as insertion of the tube may cause esophageal perforation. 39. Used in children who have ingested acids to decrease continued damage and potential perforation of stomach and intestines. Activated charcoal Given to absorb and remove any remaining particles of toxic substances. Usual dosage administration is 1 g/kg of body weight. A commercial preparation of activated charcoal is administered orally or through a gastric tube. Available as a ready-todrink solution in an opaque container. May be mixed with apple juice or soda if protocol allows to encourage consumption. 40. A covered cup and straw is used for oral ingestion to prevent the child from seeing the black liquid and to minimize spillage. Activated charcoal is administered only after the child has stopped vomiting, because aspiration of charcoal is damaging

to lung tissue. Should not be administered for ingestion of caustic substances or hydrocarbons. c. Cathartics Hasten excretion of a toxic substance and minimize absorption. The most commonly used cathartic is magnesium sulfate. Note: Syrup of ipecac The use of ipecac is no longer recommended because it may not remove all poison and can be harmful in some situations. Encourage parents to remove it from their homes. 41. 5. Other measures will depend on the childs condition, the nature of the ingested substance, and the time since ingestion. May include diuresis, fluid loading, cooling or warming measures, anticonvulsive measures, antiarrhythmic therapy, hemodialysis, or exchange transfusions. 6. The childs total condition is constantly evaluated to maintain airway, breathing, and circulation. Therapeutic management is adjusted as needed to treat evolving condition. 7. Consider the emotional status of the family. Provide information about the child, involve the child in care when possible, and arrange for support persons and services to be available to the child. 42. INCREASED AMOUNT OF THYROID HORMONES POST OP AFTER RADIOACTIVE IODINE ADMINISTRATION TOO SHORT PERIOD OF PRE OP TX CAUSES : EMOTIONAL STRESS PHYSICAL STRESS 43. S/SX : HYPERTHERMIA > 41C TACHYCARDIA APPREHENSION RESTLESSNESS IRRITABILITY DELIRIUM COMA 44. DECREASE TEMP ANTITHYROID DRUGS GLUCOSE DIGITALIS STEROIDS TO DECREASE ACTH 45. INCAPABILITY OF THE ADRENAL CORTEX TO PRODUCE GLUCOCORTICOIDS IN RESPONSE TO STRESS 46. ACUTE EPISODES FROM STRESS THAT TAXES THE ADRENAL CORTICAL FUNCTION BEYOND ITS CAPABILITIES POSSIBLE COMPLICATION OF ADDISONS DISEASE PRECIPITATING CAUSES : ABDOMINAL DISCOMFORT INFECTION TRAUMA HIGH TEMP EMOTIONAL UPSET ANTICOAGULANT DRUGS 47. S/SX: HYPOTENSION FLUID LOSS HYPONATREMIA LAB: SERUM ELEC: DECREASED Na INCREASED K S. BUN : S. GLUCOSE: ADRENAL HORMONE ASSAY : HYDROXYCORTICOID & 17 KETOSTEROID IN 24-HR URINE DET . 48. TO REVERSE SHOCK RESTORE BLOOD CIRCULATION REPLENISH NEEDED STEROID 49. D5NSS ADRENAL CORTICAL HORMONE REPLACEMENT: INJECTABLE NEOSYNEPHRINE - SHOCK HIGH SALT DIET ANTIBIOTICS 50. Hypertensive crisis is an umbrella term for hypertensive urgency and hypertensive emergency. These two conditions occur when blood pressure becomes very high, possibly causing organ damage. 51. Hypertensive Urgency Hypertensive urgency occurs when blood pressure spikes but there is no damage to the body's organs. Blood pressure can be brought down safely within a few hours with blood pressure medication 52. Hypertensive emergency means blood pressure is so high that organ damage can occur. Blood pressure must be reduced immediately to prevent imminent organ damage. This is done in an intensive care unit of a hospital. 53. Changes in mental status such as confusion Bleeding into the brain (stroke) Heart failure Chest pain (unstable angina) Fluid in the lungs (pulmonary edema) Heart attack Aneurysm (aortic dissection ) Eclampsia (occurs during pregnancy) Hypertensive emergency is rare. When it does occur, it is often when hypertension goes untreated, if the patient does not take his or her blood pressure medication, or he or she has taken an over-the-counter medication that exacerbates high blood pressure. 54. Headache or blurred vision Increasing confusion or level of consciousness Seizure Increasing chest pain Increasing shortness of breath Swelling or edema (fluid buildup in the tissues) 55. To diagnose a hypertensive emergency, the health care provider will ask you several questions to get a better understanding of your medical history. He or she will also need to know all medications you are taking including nonprescription and recreational drugs. Also, be sure to tell them if you are taking any herbal or dietary supplements. Certain tests will be given to monitor blood pressure and assess organ

damage, including: Regular monitoring of blood pressure Eye exam to look for swelling and bleeding Blood and urine testing 56. In a hypertensive emergency, the first goal is to bring down the blood pressure as quickly as possible with intravenous (IV) blood pressure medications to prevent further organ damage. Whatever organ damage that has occurred is treated with therapies specific to the organ that is damaged Parenteral vasodilators like sodium nitroprusside,nitroglycerin,nicardipine,hydralazine. And parenteral adrenergic inhibitors like labetalol,esmolol,phentolamine.