Ateneo de Davao University Ateneo de Davao University College of Nursing, Emergency Nursing College of Nursing, Emergency Nursing
Emergency Nursing: Emergency Nursing:
1.
1. Care given to patients with urgent and critical needs.Care given to patients with urgent and critical needs. 2.
2. Care that must be given without delay.Care that must be given without delay.
3.
3. Care whiCare which involch involves consves constant asstant assessmeessment and monint and monitorintoring of the acutelg of the acutely ill and injy ill and injured patiured patientsents Emergency Nursing:
Emergency Nursing: A specialty, because it is care given in a phase when A specialty, because it is care given in a phase when a diagnosis has not been made anda diagnosis has not been made and the cause of the problem is not yet known.
the cause of the problem is not yet known. According to
According to Emergency Nursing AssociationEmergency Nursing Association (ENA) it involves:(ENA) it involves:
•
• Assessment, Diagnosis & Treatment of perceived, actual or Assessment, Diagnosis & Treatment of perceived, actual or potential, sudden or urgent, physical or potential, sudden or urgent, physical or
psychosocial problems that is primarily episodic or
psychosocial problems that is primarily episodic or acute.acute. Qualificatio
Qualifications of an ns of an ER nurse:ER nurse:
•
• A BSN graduate and holder of a current license to practice nursing in the A BSN graduate and holder of a current license to practice nursing in the Philippines.Philippines.
•
• Has had specialized education, training, and Has had specialized education, training, and experience to gain expertise in experience to gain expertise in assessing and identifyingassessing and identifying patient’s health care problems in crisis
patient’s health care problems in crisis situations.situations. Basic
Basic Nursing ResponsibilitiNursing Responsibilities:es: 1.
1. EsEstatablblisish h prprioiorirititieses 2.
2. PrProvovidide he hololisistitic cc cararee 3.
3. MonitMonitors and cors and continontinuousluously assesy assesses acses acutely iutely ill and ill and injurenjured patid patientsents 4.
4. DoDocucumement alnt all prl prococededurures mes madeade 5.
5. SupSupervervise oise othether allr allied hied healealth peth persorsonnennell 6.
6. SupSupporport at and nd attattend end to to famfamililiesies 7.
7. Give healGive health teachith teachings to patientngs to patients and their famis and their families in a time-lies in a time-limlimited and high-ited and high-presspressured care enviured care environmeronmentnt 8.
8. ReqRequesuest ft for aor and rnd refiefill ll supsuppliplieses 9.
9. PrPrototecect st selelf af and ond oththerers:s: •
• Use universal precaution on body fluidsUse universal precaution on body fluids •
• Use masks and glovesUse masks and gloves Nursing in Disaster Condition:
Nursing in Disaster Condition: Disaster
Disaster – is a catastrophe which may be natural in origin or – is a catastrophe which may be natural in origin or manmade, whether produced accidentally or manmade, whether produced accidentally or by design.
by design.
Stages of Disaster: Stages of Disaster:
1.
1. ThreThreat Stage – wheat Stage – when situatn situation has a poteion has a potential ontial of creatif creating crising crisis but does not show acs but does not show actual contual conditidition of perilon of peril 2.
2. WarniWarning Stage – it is mong Stage – it is more specire specific than thfic than the stage of three stage of threat and almosat and almost assuret assures the reals the reality of disaity of disaster ster 3.
3. ImpacImpact – wt – when then the dihe disastesaster is r is manimanifestefested fuld full-bll-blownown 4.
4. RecovRecovery – when the assessmery – when the assessment of the disastent of the disaster effecter effects is made, the injurs is made, the injured are rescueded are rescued, and rehabil, and rehabilitatiitationon of people and their lives is begun.
of people and their lives is begun. Disaster Management Plan
Disaster Management Plan is a community-wide, hospital-wide, or emergency department plan to handleis a community-wide, hospital-wide, or emergency department plan to handle mass casualty incidents that may occur
mass casualty incidents that may occur anytime.anytime. Types of Disaster: Types of Disaster: A. NATURAL A. NATURAL • • FLOODSFLOODS • • EARTHQUAKESEARTHQUAKES • • STORMSSTORMS •
• TORNADOES / HURICANETORNADOES / HURICANE •
• EXTREME EXTREME HEAT HEAT OR OR COLDNESSCOLDNESS •
• BUSH FIRESBUSH FIRES •
B. MANMADE • STRIKES • RIOTS • MASS SHOOTINGS • HOSTAGE TAKING • TERRORISM • DEMONSTRATIONS C. TECHNICAL • VEHICULAR ACCIDENTS
• MAJOR INDUSTRIAL ACCIDENT • BUILDING COLLAPSE
• HAZARDOUS CHEMICAL INCIDENTS • FIRE INCIDENTS
Disaster Nursing Management:
1. Critical thinking is Important.
• Nurse should remain calm • Rapidly Assesses Situations
• Consider Options
• Enact Emergency Response Plan • Ability to TRIAGE
2. Collaboration with other Agencies
• Communication • Delegation • Coordination • Negotiation
Components of Emergency Nursing:
• Establish priorities (Triage and Nursing Assessment)
• Health History and Complete Head-to-toe assessment
• Formulate Nursing Diagnoses • Planning/Implementation • Nursing Documentation • Patient Transport
Triage:
• Comes from French word “trier” meaning “to sort” • Used to sort patients into groups based on:
– severity of their health problems
– immediacy with which these problems must be treated
• Classification of clients presenting to the ER for the purpose of prioritizing treatment • Looks at medical needs and urgency of each individual patient
• Sorting based on limited data acquisition • Also must consider resource availability
Categories of Triage:
1. Emergent – those conditions that require immediate care and intervention, increased risk of mortality (death) or
threat to life, limb, or vision.
2. Urgent – those conditions that require care ASAP, generally within 1 hour and have the potential for causing
3. Non-urgent – those conditions that require routine care that can be delayed for greater than 2 hours without the possibility of deterioration
Critical Qualities of a Triage Nurse • Expert Assessment Skills
• Non-judgmental Communication • Excellent interviewing techniques Coding of Triage
1. Emergent: Red, Priority I: life, limb, eye threatening that needs immediate attention, monitoring is continuous. • Chest pain
• Cardiac arrest
• Severe respiratory distress
• Chemicals in eye • Limb amputation • Trauma
• Acute neurologic deficits
2. Urgent: Yellow, Priority II: needs treatment in 20 minutes to 2 hours, monitoring is every 30-60 minutes.
• Fever more than 40C (104F) • diastolic BP more than 130mmHg • kidney stones
• simple fracture • abdominal pain
• asthma without respiratory distress
3. Non-urgent: Green, Priority III: can wait hours or days, monitoring is every 1-2 hours. • Sprain
• Minor laceration • Cold symptoms • Rash
• Simple headache
4. Dead: Black (sometimes still with life signs but injuries are incompatible with survival) Priorities of Treatment:
1. First Priority – individuals needing immediate attention to save life
• Any wound interfering with airway or causing airway obstruction.
• Sucking chest wounds, tension pneumothorax and maxillo-facial wounds in which asphyxia is present
or an impending threat.
• Any wound requiring immediate pressure for bleeding
• Shock due to major hemorrhage, to wounds of any organ systems, fractures, etc. 2. Second Priority – individual needing early surgery
• Visceral injuries including perforation of GI tract • Wounds of the biliary and pancreatic system
• Wounds of the GU tract and thoracic wounds without asphyxia
• Vascular injuries requiring repair and/or in which the use of a tourniquet is necessary • Closed cerebral injuries with increasing loss of consciousness
3. Third Priority – patients who require surgery but can tolerate a delay • Spinal injuries in which decompression is required
• Lesser fracture & dislocations • Minor injuries of the eye
• Soft tissue wounds in which debridement is necessary, but in which muscle damage is less than major • Maxillo-facial injuries without asphyxia
Priorities for patient with an emergent or urgent health problem: 1. Stabilization
3. Prompt transfer to the appropriate setting (ICU, OR, General Care Unit)
Why Should Planners Plan For Good Triage?
1. Helps in resource planning and allocation.
2. Provides an objective framework for stressful and emotional decisions, helping rescue workers to be more
efficient and effective. TRIAGE MOTTO:
1. Daily Emergencies: “Do the Best for Each Individual”
2. Disaster Settings: “Do the greatest good for the greatest number. Maximize survival” Components of ER Nursing:
1. Establish Priorities: by using triage and accurate assessment.
2. Formulate Nursing Diagnoses 3. Plan/Implement
4. Documentation
1. Establish Priorities: by using triage and accurate assessment.
I. Primary Survey - The rapid initial assessment of the client’s presenting symptoms. A - Airway
B - Breathing C - Circulation D - Disability
• It determines the presence of life-threatening conditions while simultaneously intervening.
• Purpose – to immediately identify any problem that poses a threat, immediate or potential to life, limb or vision.
• Procedure - information is gathered primarily through objective data.
• If abnormalities are found, immediate interventions such as CPR and ACLS must be instituted to aid in preserving the client’s life, limb or vision.
A – AIRWAY: Maintain patent airway
a. e.g. head tilt/chin lift, jaw thrust, suctioning, oropharyngeal or nasotracheal intubation or tracheostomy
b. Cervical spine immobilization should be maintained B – BREATHING
a. Provide adequate ventilation, employing resuscitation measures when necessary b. Application of oxygen via mask or bag-valve mask device
c. Assisting in chest tube insertion or endotracheal intubation d. –Covering of open chest wound with occlusive dressing C – CIRCULATION
a. CPR
b. Evaluate and restore cardiac output by:
• controlling hemorrhage
• preventing and treating shock
• maintaining and restoring effective circulation
c. Control hemorrhage and blood/fluid loss by:
applying direct pressure (external bleeding)
insertion of IVF, fluid volume replacement with NSS, Blood Transfusion, etc.
D – DISABILITY
a. Deformity-Open Wound-Tenderness-Swelling (DOTS)
b. Determine neurologic disability by completing a brief neurological assessment c. Determine baseline functioning, potential life threatening complications.
d. Check LOC using GCS or RLS II. Secondary Survey –
