Professional Documents
Culture Documents
function
Patient and family-focused interventions
Relieve anxiety and provide a sense of security
Allow family to stay with patient, if possible, to
alleviate anxiety
Provide explanations and information
Provide additional interventions depending upon
the stage of crisis
PRINCIPLES OF TRIAGE
What is TRIAGE?
- it is sorting
- from the French word trier meaning to choose,
referred to a battlefield
- the rapid focused assessment
What is the purpose of TRIAGE?
- is to sort or classify all incoming ED patients
- the goal is to get the
Right Patient to the
Right Place at the
Right Time for the
Right Reason to receive
Right Treatment
assessment.
What should the triage history include?
Medications
Exposure to infection
Allergies Pregnancy
Immunization
LMP
Past medical history
Family history
Anticoagulant Overdose
- Secure lab results such as CBC with PC, PT, PTT
and Creatinine
- For Heparin: Give protamine sulfate at 1mg iv for
every 50-100 units of heparin infused in the
preceeding 2 hours, dilute in 25-50ml fluid over 10
minutes
- For Warfarin: perform gastric lavage and give
activated charcoal if recently ingested; give vitamin
k 5-10 mg every 8-12 hours; give FFP 2-6units for
severe bleeding
Diazepam Overdose
- Place NGT and do gastric lavage
- Protect airway
- Instill activated charcoal, followed by repeated
doses of 20-25 gm via NGT
- Secure RBS, ABG, ECG and CXR
- Watched out for hypotension, CNS and respiratory
depression and withdrawal syndrome such as
agitation, seizure, restlessness and insomnia.
Digitalis Overdose
- considered NGT insertion and gastric lavage
- secure digitalis assay, CBC, Ca, K, Mg, CXR and
ECG/ cardiac monitor
- the treatment goal would be to correct
hypokalemia. Hypomagnesemia or hypocalecemia.
- The doctor may prescribe charcoal and cathartics
- Watch out for hypotension; fluid challenge my be
instituted
- For arrythmias, lidocaine may be given
Ethanol Toxicity
- maintain adequate airway, ventilation, circulation
and administer oxygen
- Thiamine is useful to protect/ prevent liver damage
- Phynetoin my be given in cases of seizure, but
make sure to give it SIVP and hook the patient to the
cardiac monitor
Narcotic Overdose
- maintain airway, ventilation and circulation
- may start on Naloxone 2mg every 5 minutes , max
10mg IV, IM SQ
- Activated charcoal if (+) for bowel sounds and
cathartics
- Watch out for signs of pneumonia, infections and
rhabdomyolysis
- Watch out for complications such as seizure,
pulmonary edema and hypotension
Hydrocarbon/ Kerosene Ingestion
- Respiratory support
- Treatment is not required in the absence of
symptoms
- Promote gastric emptying
- Remove contaminated clothing and wash affected
skin with soap and water.
- Provide supplemental oxygen
- secure CBC, ABG abd CXR
Isoniazid Overdose
- place an NGT and do gastric lavage is clean
or fecal impaction
- To increase urine ph, consider sodium bicarbonate
- Glucose and KCl should be infused with other fluids
Treatment Plan
- if with dehydration and hypokalemia, manage with
vigorous and with electrolyte replacement
- Cerebral edema can be best avoided using
hypertonic rehydration solution
- Alkaline diuresis to maintain urinary ph at approx 8
- Monitor urine output
- Assess hydration status
- Watch closely for signs of fluid overload
- Hemodialysis is indicated for initial salicylate level
of >160ml/dl or with profound acidosis of below 7; or
when there is renal failure, severe CNS dysfunction,
pulmonary edema or deterioration despite
supportive therapy
Other Treatments
- Acidemia: NaHCO3
- Seizure: Diazepam
- Pulmo Edema: treat with high concentration of
oxygen, furosemide and PEEP
- Cerebral Edema: treat with hyperventilation and
osmotic diuresis with Mannitol
SHOCK (Multisystem Stressor)
Pathophysiology
- Shock is a multisystem stressor that involves
inadequate tissue perfusion and altered
metabolism.
- Inadequate tissue perfusion can lbe a result of nay
condition that alters heat function (cardiogenic),
blood volume(hypovolemic), blood pressure
(neurogenic) and distribution of blood volume
(septic/ anaphylactic)
- Shock is a very complex clinical syndrome in which
tissue perfusion is inadequate to meet the demands
for oxygen
- It alters cellular functions and eventually impairs
body organ functions
- Multi Organ Dysfunction Syndrome (MODS) is a
term used to describe several impairment of the
human functions
Sepsis and Septic Shock
- Sepsis is an acute systemic clinical syndrome
caused by bacteria, viruses or fungi in the blood,
most commonly gram (-) bacilli
- At an early phase, generalized inflammatory
response is triggered, causing widespread
vasodilation
- The progression to septic shock is due to the toxins
released from the organism involved
- Bacterial endotoxins activates the complement,
coagulation and fibrinolytic system; inceases
vascular permeability and trigger the vasoactive
kinins causing vasodilation and increased capillary
permeability thereby decreasing the vascular
resistance and facilitating fluid shifting from
intravascular to interstitial
- Another response would be due to the histamine
degree of hypersensitivity
- Ingestion: cramping, nausea, vomiting and may
precede systemic shock syndrome
- Inhalation: hoarseness, dyspnea and whezing
- Allergic: urticaria or itching at the site of the sting,
or drug injection
Diagnostic Test/ Procedure
-WBC, serum glucose, GS-CS, ABG, BUN, CT, BT,
Liver studies
Collaborative Management (Septic)
- antibiotic therapy specific to he organism
- Hemodynamic monitoring
- Fluid resuscitation
- Inotropic Agents
- Ventilatory Support
- Alkaline Support
- Nutritional Support
- Steroids
- Antipyretic Agent
- Naloxone
- GI solution
Collaborative Management (Anaphylaxis)
- Airway maintenance
- Epinephrine
- Supplemental Oxygen
- Fluid Resuscitation
- Vasopressors
- Angi-histamine
- Bronchodilator
- Steroids
- Mast cell stabilizer
- Glucagon
- ECG monitoring
Nursing Diagnosis and Intervention (SEPSIS)
1. Fluid volume deficit related to active loss from
vascular compartment secondary to increased
capillary permeability and shifting of intravascular
volume into interstitial spaces
Desired Outcome
Within 4 hours of initiation of therapy, the patient is
normovolemic as eveidenced by good peripheral
pulses, stable body weight, good urine output and
decreased adventitious breath sounds
Intervention
- Monitor hemodynamic pressures
- Administer crystalloid and fluid replacement as
prescribed
- VS hourly
- Maintain proper inotropic administration
- Weigh patient daily
- Monitor specific gravity
- Assess for interstitial edema
- Proper positioning
2. Decreased Cardiac Output related to negative
inotropic changes at the myocardium secondary to
effects of tissue O2 deprivation
Desired Outcome
Within 8 hours of initiation of therapy, patient has a
n adequate cardiac output as evidenced by good BP,
urine output and god peripheral pulses
Intervention
- Assess patient for signs of deceasing CO
- Administer inotropics as prescribed
- Position patient on supine to increase/ optimize
preload and enhance stroke volume
- Monitor cardiac rhythm
- Minimize cardiac oxygen demand by assisting
patient with ADL
3. Altered Cerebral, renal, gastrointestinal tissue
perfusion related to decreased to circulating blood
volume secondary to massive vasodilatation and
interruption of arterio-venous blood flow associated
to vasoconstriction and clot formation
Desired outcome
Within 24 hours after initiating therapy, the patient
has an adequate tissue perfusion as evidenced by
orientation to time, place and person, good bowel
sounds and good urine output
Intervention
- Assess LOC hourly
- Assess signs of decreasing renal perfusion
- Assess/ monitor peripheral vascular resistance
- Assess peripheral pulses
- O2 saturation monitoring
- Assess evidence of decreasing visceral circulation
including bowel sounds
* Other examples of nursing problems
4. Impaired Gas exchange, related to alveolarcapillary membrane changes secondary to
interstitial edema, alveolar destruction and
endotoxin release with activation of histamine and
kinins
5. Ineffective breathing pattern related to decreased
lung function secondary to central respiratory
depression occurring in the lat shock
6. Ineffective thermoregulation related to successful
entry bacterial endotoxins, increasing the
hypothalamic termperature regulating center
7. Altered Nutrition less than body requirements
related to increased need secondary to increased
metabolic rate
3. Chest Trauma
4. Abdominal Trauma
5. Renal and Lower Tract Trauma
Mechanisms of Injury:
- Objects Producing Injury (ex. MVA, handgun, glass,
wood, metal)
- Type of Energy (ex. Kinetic, thermal, chemical,
radiation)
- Force of Energy (ex. Velocity, tension force,
shearing force)
- Use of Protective devices (ex. Helmet, airbags, seat
belt)
Types of Injury:
Blunt Injury occurs without interruption on the skin
integrity
Penetrating are produced from the motion of the
objects that penetrate the tissue causing direct
damage.
Oxygen Delivery and Consumption
- an oxygen debt is created by a profound imbalance
between oxygen supply and demand brought about
by hypovolemia and inadequate tissue perfusion
- after initial restoration of circulating blood volume,
he body develops a hyperdynamic circulatory
state, which is associated with improved survival
and fewer complications
- the hyperdynamic state usually peaks within 48-72
hours and diminishes in 7 -10 days
- inability to achieve this state increases the
mortality
Neuroendocrine Stress Response
- shortly after the trauma, the CNS triggers a series
of reactions that promotes cmpentation including
brain, blood, and bone marrow
- cathecolamines are released
- these hormones mobilizes glycogen stores,
increases glucose availablty, suppresses pancreatic
insulin, resulting in an increase net of glucose
- centrally mediated release of ADH promotes water
absorption, increasing intravascular volume and
diminishes urine output
Systemic Inflammatory Response Syndrome
- the release of cathecolamine triggers massive
amount of WBC at the site of injury
- SIRS is used without he presence of infection;
SEPSIS is termed in the presence of a widespread
inflammation and infection
Multi Organ Dysfunction Syndrome
Coagulopathy
Hypothermia
Psychologic Response
Environmental EmergenciesHeat
Stroke
A failure of heat regulating mechanisms
Types
Exertional: occurs in healthy individuals during
exertion in extreme heat and humidity
Hyperthermia: the result of inadequate heat loss
Management
Maintain the safety of all persons and gain control
of the situation
Determine if the patient is at risk for injuring
himself or others
Maintain the persons self-esteem while providing
care
Determine if the person has a psychiatric history or
is currently under care to contact the therapist
Crisis intervention
Interventions specific to each of the conditions
death
Decontaminate with soap and water; do not scrub
or use hypochlorite solutions
Eye exposure requires copious irrigation
Treatment for lewisite exposure: dimercaprol IV or
topically
Radiation Exposure
Radiation exposure may occur due to nuclear
weapons, nuclear reactor incidents, or exposure to
radioactive samples
Exposure to radiation is affected by time, distance,
and shielding
Types of radiation exposure:
External radiation: all or part of the body is
exposed to radiation; as decontamination is not
necessary, it is not a medical emergency
Contamination: exposure to radioactive gases
liquids or solids; requires immediate medical
management to prevent incorporation
Incorporation: uptake of the radioactive material
into the body
Radiation Decontamination
Triage outside the hospital
Cover floor and use strict isolation precautions to
prevent the tracking of contaminants
Seal air ducts and vents
Waste is double bagged and put in a container
labeled radiation waste
Staff protection
Water-resistant gowns, 2 pairs of gloves, caps,
goggles, masks, and booties
Dosimetry devices
Patients are surveyed for radiation and directed to
the decontamination area
Each patient is decontaminated with a shower
outside the ED
Water, tarps, towels, soap, gowns, all the patients
belongings, etc., must be collected and contained
Patients are surveyed and showered again as
necessary
Showering should be performed so as not to
contaminate clean areas with runoff from the
showering
Biologic samples: nasal and throat swabs; blood
Internal contamination requires additional
treatment: catharsis and gastric lavage with
chelating agents
Radiation Injuries
Acute radiation syndrome (ARS): dose of radiation
determines if ARS will develop
All body systems are affected by ARS
Presenting signs and symptoms determine
predicted survival
Probable survivors have no initial symptoms or
only minimal symptoms
Possible survivors present with nausea and
vomiting that persists for 24 to 48 hours
Improbable survivors are acutely ill with nausea,
vomiting, diarrhea, and shock; neurologic symptoms
suggest lethal dose; and survival time is variable