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Emergency and disaster nursing Prepared by: Michael Magpantay EMERGENCY NURSING - practice of episodic, primary, critical and acute nursing care of all ages who experience physical,emotional or psychological alterations in health. Care of the Client presenting to an Emergency Department : 1. Triage classification of all clients presenting to the emergency department. Purpose: to prioritize treatment. Triage Rating Systems: 3 Categories a. Emergent conditions requiring IMMEDIATE CARE and intervention because of increased risk of mortality or threat to life, limb or vision. B-burns C-chest pain-cardiac arrest R-respiratory distress Hhemorrhage sec. to ectopic pregnancy M-major blunt or penetrating trauma b. Urgent conditions that require care ASAP and generally within 1 hour because the condition has the potential for causing the deterioration of health state if not treated ASAP. These clients will have stable V/S but have acute illness and must be treated to prevent morbidity. F-fever A-abd.pain S-stable fracture H-HA L-lacerations with controlled bleeding D-DHN c. Non-urgent- require routine care that can be delayed for more than 2 hours without the possibility of deterioration; clients presenting with non-urgent conditions frequently utilize the emergency dept. because they do not have a primary care physician. C-colds S-sore throat T-tooth ache A-abrasions R-rashes 2. Disaster Management Plan a community wide, hospital wide or emergency department plan to handle mass casualty incidents that may occur at any time. Assessment: Primary Assessment rapid initial assessment of the symptoms to determine life threatening conditions while simultaneously intervening. Airway- with C spine immobilization, patent airway, ability to speak, foreign body, chest expansion. Tx: chin-lift / jaw thrust, suctioning, intubation, cricothyroidectomy, tracheostomy, cervical spine neutral position. Breathing- effectiveness of breathing and ventilation ability. Abnormal : apnea, weak, shallow/labored respiration diminished /absent breath sounds unequal chest expansion retractions/ paroxysmal chest wall movement tracheal deviation NVE Open chest wound Sx of chest trauma Subcutaneous emphysema Tx: 1. Oxygen therapy 2. Chest tube insertion, intubation 3. Pressure dressing on a flail segment of the ribs Circulation- adequate circulation to maintain cellular tissue perfusion. Abnormal : bradycardia or tachycardia cool, pale and diaphoresis obvious uncontrolled external bleeding decrease LOC Sx of hypovolemia, pericardial tamponade, cardiac arrest

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Tx: 1. direct pressure to control external bleeding 2.IV access 3. CPR 4. Slide 10 : Pericardiocentesis-aspiration of blood from pericardial sac 5. Autotransfusion BT of one s own blood. Disability complete a brief neurological assessment to determine baseline functioning, potential life threatening complications, LOC. Abnormal: Unresponsive Slide 11 : altered pupils : fixed pupils, papillary response abnormalities. Expose- remove all clothing from the client to facilitate a thorough complete secondary assessment examination.

Secondary Assessment- a brief, systematic head to toe assessment that identifies all injuries. Tx: cervical immobilization is maintained at all times as well as continual Slide 12 : assessment of hemodynamic and oxygen status. Fahrenheit-provide measures to prevent body heat loss at this time through the use of warmed IVF, warmed blankets or healing lamps. Get V/S other assessment aids : cardiac monitor, pulse oxi,urinary catheter, NGT, lab. studies: CBC, electrolytes, Fibrin degradation products (coagulation), amylase, Slide 13 : lactate; renal studies ; blood type and crossmatch; toxicology studies. History- head to toe assessment : HPI / PMH / FH /Meds Common Problems Seen in Emergency Settings : Airway obstruction- partial or complete obstruction of the airway. 2. Tension pneumothorax- occurs when air enters the pleural space through a tear during inspiration and accumulates because it cannot Slide 14 : escape during expiration. 3. Flail chest the force of impact to the chest wall during injury causes the fracture of 3 or more continguous ribs\ in 2 or more places resulting in a floating segment. 4. Uncontrolled hemorrhage- uncontrolled bleeding. 5. Motor Vehicle Accidents *MVA- blunt and multiple trauma. Acceleration/deceleration forces increased velocity of a moving object followed by a reduction in velocity e.g. speed of a Slide 15 : vehicle. Compression forces- body parts are pressed against immobile objects due to explosive injury to air filled organs *liver and spleen Shearing forces- a rotational force exerted around a fixed site. Blunt trauma- fractures, lacerations, contusions, rupture or tearing of solid and hollow organs and major blood vessels. 6. Penetrating injuries - stab wounds/GSW : knives, pencils, forks; high velocity /high energy missiles: guns,rifles,high pressure injection devices. 7. Hypothermia a Slide 16 : condition where the core body temp. is 36 C ( 96.8 F ) or less. Tx : ABC, faster rewarming, Cordarone, D50-50 IV 8. Frostbite injury caused by exposure to cold environment and conditions. Tx : Remove from the cold envt. before thawing. Area not be rubbed mechanical friction Slide 17 : can cause tissue damage; Aloe vera topical inhibits platelet aggregation : thromboxane inhibiting effect. Tetanus prophylaxis Topical and parenteral antibiotics Oral and parenteral analgesics Slide 18 : 9. Heat exhaustion- vasomotor collapse sustained from prolonged exposure to heat. Tx : Rest in cool, shaded area TSB, direct fans toward patient F/E replacement

10.Heat stroke an extremely elevated core body temperature caused by a failure of the hypothalamus-perspiration regulating mechanism; carries 70% mortality rate. Tx : Aggressive cooling measures to institute Full body exposure and cooling by Slide 19 : evaporation Prevent shivering Cardiac monitor Ice water gastric and peritoneal lavage Prevent over correction , hypothermia and cerebral edema IV NSS, do not use LR because liver is unable to metabolize lactate. U.O. / ABCs Meds: Thorazine 10-25mg prevent shivering Mannitol Solu-Medrol 11. Drowning and Near drowning drowning is death caused by asphyxia and aspiration after submersion in water; near drowning is risk of death occurring within Slide 20 : 24 hours. Tx : ABC CBC, ABG Fresh water drowning electrolytes decreased Salt water drowning electrolytes increased XRay bilateral infiltrate Cardiac monitor

ET intubation Correct hypoxia and cyanosis, I and O Antibiotics,Epinephrine,Lidocaine,At SO4, Bronchodilators,NaHCO3,Steroids 12. Bites dog,cat, rodent, human, insect/bee, spider, tick, snake; a break in the continuity of the skin caused by a bite from an animal, insect or human. Tx : Meticulous wound care Devitalized tissue should be debrided and topical antibiotic ointment. IV antibiotics severe human and animal bite Rabies prophylaxis-animal Slide 21 : bite Carnivores-rabies positive : raccoons, bats, wild animals Herbivorous rabies negative : mice, rodents Venomous bites black widow spiders, poisonous snakes Anti venom tx: constricting band/ice to slow the circulation and spread of venom to circulation. *Wound should be left open and a bulky dressing is applied-dry sterile dressing. *ABC,V/S,LOC Muscle relaxants Animal control 13. Poisonings substances that are harmful : inhaled, ingested *food, drug, overdose or acquired by contact *insecticides Carbon monoxide inhalation Food poisoning Drug overdose: ASA overstimulation of resp. center and metabolic acidosisSlide 22 : hyperventilation, hyperthermia,hyperglycemias Insecticide surface absorption Tx : ABC,IV access Narcan-Naloxone antagonist for resp. depression due to narcotic overdose Flumazanil-for Benzodiazepine ingestion Gastric lavage-NGT Vomiting is C/I Antidotes: Ipecac, activated charcoal 14. Electrocution injury sustained by electric current Tx : ABC, Spine Slide 23 : immobility,Local wound care Meds : NaHCO 3 , Mannitol, Tetanus, Lidocaine, Amiodarone and Epinephrine End of Emergency Nursing A. General information 1. Emergency nursing deals with human responses to any trauma or sudden illness that requires immediate intervention to prevent imminent severe damage or death 2. Care is provided in any setting to persons of all ages with actual or perceived alterations in physical or emotional health. 3. Initially, patients may not have a medical diagnosis. 4. Care is episodic when patients return frequently, primary when it is the initial option for health or preventive care, or acute when patients need immediate and additional interventions. 5. Emergency nursing is a specialty area of the nursing profession like no other. 6. Emergency nurses must be ready to treat a wide variety of illnesses or injury situations, ranging from a sore throat to a heart attack. B. Historical Development of Emergency Nursing 1. Florence Nightingale was the first emergency nurse, providing care to the wounded in the Crimean War in 1854 2. The Emergency Department Nurses Association (EDNA) was organized in 1970 3. A competency-based examination, first administered in 1980, provides Certification in Emergency Nursing; certification is valid for 4 years

4. EDNA developed Standards of Emergency Nursing Practice, published in 1983, to be used as a guideline for excellence and outcome criteria against which performance is measured and evaluated 5. In 1985, the Association name was changed to Emergency Nurses Association (ENA), recognizing the practice of emergency nursing as role-specific rather than site-specific. 6. Originally ENA aimed at teaching and networking, the organization has evolved into an authority, advocate, lobbyist, and voice for emergency nursing. It has 30,000+ members and continues to grow, with members representing over 32 countries around the world. C. Emergency Care Environment 1. Prehospital care by emergency medical services (EMS), emergency medical technicians, and paramedics provides initial stabilizations and transport of patients; personnel communicate with the emergency department during patient transport 2. The national emergency telephone number 911 is the result of an effort to improve access to EMS 3. The concept of the emergency room has expanded to that of the emergency department, which provides various levels of care 4. Specialized electronic technology and techniques are used to monitor patient status continuously; these may pose safety hazards to patients, such as possible exposure to electric shock D. Triage 1. Triage classifies emergency patients for assessment and treatment priorities 2. Triage decisions require gathering objective and subjective data rapidly and effectively to determine the type of priority situation present 3. Emergent situations are potentially life-threatening; they include such conditions as respiratory distress or arrest, cardiac arrest, severe chest pain, seizures, hemorrhage, severe trauma resulting in open chest or abdominal wounds, shock, poisonings, drug overdoses, temperatures over 105F (40.5C), emergency childbirth, or delivery complications 4. Urgent situations are serious but not life-threatening if treatment is delayed briefly; they include such conditions as chest pain without respiratory distress, major fractures, burns, decreased level of consciousness, back injuries, nausea or vomiting, severe abdominal pain, temperature between 102 and 105F (38.9 and 40.5 C), bleeding from any orifice, acute panic, or anxiety 5. Nonemergency situations are not acute and are considered minor to moderately severe; they include such conditions as chronic backache or other symptoms, moderate headache, minor burns, fractures, sprains, upper respiratory or urinary infections, or instances in which a patient is dead on arrival E. Roles of the Emergency Nurse 1. Care provider: provides comprehensive direct care to the patient and family.

2. Educator: provides patient and family with education based on their learning needs and the severity of the situation and allows the patient to assume more responsibility for meeting health care needs 3. Manager: coordinates activities of others in the multidisciplinary team to achieve the specific goal of providing emergency care 4. Advocate: ensures protection of the patients rights F. Functions of the Emergency Nurse 1. Uses triage to determine priorities based on assessment and anticipation of the patients needs 2. Provides direct measures to resuscitate, if necessary 3. Provides preliminary care before the patient is transferred to the primary care area 4. Provides health education to the patient and family 5. Supervises patient care and ancillary personnel 6. Provides support and protection for the patient and family G. Legal issues affecting the provision of emergency nursing 1. Negligence 2. Malpractice 3. Good Samaritan Laws (these statutes may protect private citizens but usually do not apply to emergency personnel on duty or in normal emergency situations) 4. Informed consent 5. Implied consent 6. Duty to report suspected crimes to the police 7. Duty to gather evidence in criminal investigations; be aware of hospital policy and state laws for evidence collection 8. Advanced directives, including durable power of attorney and living wills H. Qualifications of an Emergency Nurse 1. An emergency nurse is a registered nurse with specialized education and experience in caring for emergency patients. 2. Emergency nurses continually update their education to stay informed of the latest trends, issues, and procedures in medicine today. 3. Many take a special examination that proves their level of knowledge. After successful completion of this exam they are certified in emergency nursing. 4. Some emergency nurses also acquire additional certifications in the areas of trauma nursing, pediatric nursing, nurse practitioner, and various areas of injury prevention 5. Many emergency nurses acquire additional certifications in the areas of trauma nursing, pediatric nursing, nurse practitioner, and various areas of injury prevention