Emergency Chapter 70 PPT

Chapter 70

Emergency Nursing Care Principles and Triage

©2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.

Introduction

• Emergency– Medical condition requiring immediate or

timely intervention to prevent permanent disability or death

• Trauma– Wound or injury

• Emergency nursing– Care of clients who require emergency

intervention


Introduction (cont’d.)

• Disaster– Situation or event of greater magnitude than

emergency– Unforeseen, serious, or immediate threats to

public health– Natural: fires, earthquakes, floods, hurricanes,

or tornadoes– Man-made: war, terrorism, or contamination of

environment


Emergency/Disaster Preparedness

• Preparing for emergencies or disasters– Identify who needs to know how to do what

• CDC Core Competencies


Approaches to Emergency Care

• Triage – Classification of clients according to condition

or injury to determine priority of need and treatment

• Hospital triage– Establishes priorities and levels of care

needed by clients


Approaches to Emergency Care (cont’d.)

• Disaster triage and mass casualty incidents – System used in event of community disaster

when more victims than care providers• Provides safe and orderly management

– Triage priorities on how to save most


Shock

• Condition of profound hemodynamic and metabolic disturbance – Characterized by inadequate tissue perfusion

• Body’s inability to meet tissue demand for oxygen


Shock (cont’d.)

• Major types– Hypovolemic– Cardiogenic– Distributive

• Septic• Anaphylactic• Neurogenic


Nursing Management

• Important considerations– Focus is to identify the type of shock and

initiate interventions as soon as possible• Hypovolemic: restore volume• Cardiogenic: improve myocardial function• Septic: give IV antibiotics and fluid• Neurogenic: give medications for hypotension• Anaphylactic: identify cause


Cardiopulmonary Emergencies

• Emergencies that jeopardize function of heart and lungs– May result from trauma or illness

• Medical–surgical management– Medical goal: maintain CAB

• Intubate as needed– Pharmacological: pain control– Activity: bed rest


Nursing Management

• Important considerations– Initiate CPR if indicated– Remain with the client to reduce anxiety– Administer pain medication as ordered– Suction as necessary to keep airway patent– Monitor vital signs and lung sounds– Encourage turning and deep breathing


Neurological/Neurosurgical Emergencies

• Include:– Head injuries, spinal cord trauma, strokes or

“brain attacks,” hypoglycemia, carbon monoxide poisoning, drug overdose, and electrolyte imbalance

• Medical–surgical management– Medical: maintain CAB– Pharmacological: oxygen– Activity: semi-Fowler’s position


Nursing Management

• Important considerations– Immediately administer oxygen as ordered– Monitor vital signs– Assess GCS score– Maintain the client in a semi-Fowler’s position,

or as ordered– Orient to date and time as needed


Abdominal Emergencies

• Diverse– Simple contusion to ruptured spleen – Illnesses from gastroenteritis to GI bleeding

• Medical–surgical management– Medical: IV access, oxygen, maintenance of

CAB, blood products, NG tube, x-ray, and labs– Pharmacological: narcotics for pain– Wound care: sterile saline soaked gauze for

eviceration©2013 Delmar Cengage Learning. All Rights Reserved. May not be scanned, copied, duplicated, or posted to a publicly accessible website, in whole or in part.

Nursing Management

• Important considerations– Administer oxygen and follow agency protocol

for managing CAB– Initiate IV access– Administer analgesics as ordered– Monitor vital signs, bowel sounds, and

abdominal girth– Administer medications


Medical–Surgical Management

• Treatment– Medical: CAB, IV access, blood and urine

specimens– Surgical: depends on injury– Pharmacological: antibiotics, pain medication – Diet: NPO– Activity: return to full activity as soon as

possible


Nursing Management (cont’d.)

– Encourage the client to keep the wound and dressing dry and clean, but instruct how to remove and change the dressing when dirty or wet


Ocular Emergencies

• Include:– Foreign bodies, impaled objects, and avulsed

eyeballs• Medical–surgical management

– Medical: primary goal is to restore health of eye

– Surgical: needed for retinal detachment– Activity: initially limited


Ocular Emergencies (cont’d.)

• Nursing management– Maintain the client in semi-Fowler’s position– Instill eye medications and apply an eye patch


Musculoskeletal Emergencies

• Muscle strain– Overstretching of muscle

• Sprain– Twisting of joint and partial rupture of

ligaments• Dislocation

– Bone displacement from joint


Musculoskeletal Emergencies (cont’d.)

• Fracture– Break in continuity of bone



• Treatment– Medical: RICE (rest, ice, compression,

elevation)– Surgical: depends on injury– Pharmacological: pain control– Diet: NPO depending on injury– Activity: depends on injury


Nursing Management

• Important considerations– Immobilize the affected part– Administer analgesic as ordered– Elevate the injured area– Apply ice packs, as ordered– Assess pulse, skin color, capillary refill, ability

to move fingers or toes, and sensation in the injured area


Soft-Tissue Emergencies

• Minor abrasions, lacerations, puncture wounds, contusions, bites of all varieties, and burns– Most do not require emergency care– Some severe


Soft-Tissue Emergencies (cont’d.)

• Medical–surgical management – Medical: prompt intervention, clean, suture,

concern for infection– Pharmacological: pain medication, antibiotics,

etc.– Activity: depends on injury


Nursing Management

• Important considerations– Determine the client’s immunization status– Use aseptic technique when cleansing soft-

tissue injuries– Administer analgesic, immunization(s), and

antibiotic


Nursing Management (cont’d.)

– Encourage the client to keep the wound and dressing dry and clean, but instruct how to remove and change the dressing when dirty or wet


Poisoning and Overdoses

• May be accidental or intentional– Treated as an emergency

• Medical–surgical management– Medical: manage CAB– Pharmacological: depends on incident – Diet: NPO


Poisoning and Overdoses (cont’d.)

• Nursing management– Assess for CAB, initiate IV access, and

administer oxygen


Environmental/Temperature Emergencies

• May be life-threatening• Hypothermia and frostbite can result from

cold temperatures or submersion in cold water– Heart rate and metabolic rate fall– Cardiac arrest may follow



• Treatment– Medical: rewarming– Pharmacological: IV and oxygen– Diet: fluids


Nursing Management

• Important considerations– Initiate CPR if needed– Monitor vital signs– Establish IV access– Provide oxygen and administer fluid and

electrolytes as ordered– Warm or cool body as indicated– Monitor cardiac response


Nursing Process (cont’d.)

• Nursing diagnoses include:– Hypothermia

• Related to exposure to cold environment/long submersion in cold water

– Hyperthermia • Related to environmental exposure to heat


Multiple-System Trauma

• Injury sustained in more than one body system– Blunt injuries and penetrating trauma

• Medical–surgical management– Immediately manage cab, control bleeding,

remove clothing to visualize injuries, start IV line, administer tetanus, and obtain labs and x-rays


Nursing Management

• Important considerations– Assess and initiate CAB– Establish IV access– Remove the client’s clothing for visualization

of injuries– Obtain blood and urine specimens– Assess level of consciousness– Monitor vital signs and neurological status


Legal Issues

• Medical personnel may care for clients without obtaining informed consent in emergencies– Good Samaritan laws provide protection

against malpractice to people who stop at scene of accident and render safe and appropriate care


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Emergency Chapter 70 PPT