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EMERGENCY NURSING Roberto M. Salvador Jr.

RN MD Is a specialized education, training and experience to gain expertise in assessing and identifying patients health care problems in crisis situations. Emergency nurse establish priorities, monitors and continuously assesses acutely ill and injured patients, supports and attends to families, supervise allied health personnel and teaches the patient and families within a time limited, high pressured care environment. Issues in Emergency Nursing Care 1. Documentation of consent. 2. Limiting exposure to health risk. Providing holistic care a. Patient focused intervention b. Family focused intervention 1. Anxiety and denial 2. Remorse and guilt 3. Anger 4. grief Helping family members cope

Take the family members to a private place Talk to the family together Reassure the family that everything possible was done Encourage family members to support each other Encourage the family to view the body if they wish Spend time with the family members, listening to them and identifying any needs Avoid unnecessary information Care given to clients with urgent and critical needs Care must be rendered without delay Diversified situations Consent (unless unconscious and without S.O.) Common clients (elderly, stomach pain, chest pain, fever, drug related, wound) Disaster Nursing (terrorism) Principle: TRIAGE Triage

- a process use in sorting victims into categories of priority for care and transport based on severity of injuries and medical emergencies. TRIAGE French word trier to sort Sorting of clients based on the severity of health problems Hierarchy based on the potential for life loss Advanced skills Principles of tactical triage 1. Accomplish the greatest good for the greatest number of casualties 2. Employ the most efficient use of available resources 3. Return personnel to duty as soon as possible TRIAGE 3 categories of TRIAGE (Berners) 1. Emergent 2. Urgent 3. Non-urgent TRIAGE I Emergent Highest priority Life threatening conditions, limbs Must be treated immediately a. Airway compromise

b. c. d. e.

Cardiac arrest Shock Stroke Major Burns

TRIAGE II Urgent Threatening conditions Not immediate Must be seen within 1 hour a. Fever b. Minor Burns c. Lacerations TRIAGE III Non-urgent Can be addressed within 24 hours Chronic conditions a. Dental problems b. Missed Menses 4th category Fast track simple first aid TRIAGE Assess and Intervene (Primary survey) A airway B breathing C circulation D disability E expose QUICK ASSESSMENT HEAD

MOUTH , LIPS & TEETH EYES NOSE & EARS FACE SPINE & TRUNK LIMBS GLASCOW COMA SCALE Eye opening response spontaneous 4 To voice 3 To pain 2 None 1

Localized pain 5 Withdraw 4 Flexion 3 Extension 2 None 1 Secondary Survey done after the priorities has been addressed. a. Complete History and PE b. Diagnostic and laboratory testing c. ECG, Arterial lines, urinary catheters d. Splinting of suspected fractures e. Cleaning and dressing of wounds f. other necessary interventions WOUNDS Laceration skin tear with irregular edges Avulsion tearing away from supporting structure Abrasion denuded skin Ecchymosis/contusion blood trapped Hematoma tumorlike under the skin mass of blood trapped under the skin

Verbal response oriented 5 Confused 4 Inappropriate words 3 Incomprehensible 2 None 1 Motor response Obeys commands 6

Stab incision with well defined edges Stab wound with evisceration Gun shot wound Entry Exit Management: wound cleansing wound closure primary closure delayed primary closure Tetanus prophylaxis antibiotics Wound closure Primary closure Delayed primary closure Hemorrhage Stopping bleeding is essential to the care and survival Primary cause of shock Signs & Symptoms of Shock: Cool moist skin Falling blood pressure Increasing heart rate Delayed capillary refill Decreasing urine volume Management: fluid replacement control of external bleeding control of internal bleeding

Fluid replacement & Blood replacement Control of external hemorrhage: Direct pressure a. Temporal b. Facial c. Carotid d. Subclavian e. Brachial f. Radial & Ulnar g. Femoral h. Pressure dressing i. Tourniquets (last resort) Control of Internal Bleeding Signs & Symptoms: tachycardia Falling blood pressure Thirst Apprehension Cool & moist skin Delayed capillary refill Management Packed Red Blood Cell transfusion Surgery Pharmacologic therapy

SHOCK Signs and Symptoms Early stage Restless, confusion

increase pulse rate, RR cold, moist skin decreased pulse pressure pallor thirst, dry mucous membrane diaphoresis oliguria Late stage shallow respiration Dec. BP Oliguria, anuria Cool, clammy skin ( hypovolemic, cardiogenic, septic) Cool, mottled skin ( neurogenic, vasogenic) Lethargy Cyanosis Dilated pupils

whole blood and blood products colloid solutions (albumin, plasma) plasma expanders crystalloids solution Isotonic solutions plain LR 2. Assisting cardiac support modified trendelenburg position assisting with respiratory supports oxygen therapy mechanical ventilation suctioning deep breathing,coughing exercise 3. Assisting with renal support monitor urine output bun, crea 4. assisting GI support histamine blockers, antacids NGT 5. promoting safety restraints strict asepsis technique Trauma Unintentional or intentional wound or injury 4th leading cause of death in the US

Nursing problems: a. altered tissue perfusion related to failing circulation b. impaired gas exchange related to ventilationperfusion imbalance c. decreased cardiac output related to decreased circulating blood volume Management: 1. Promoting fluid balance and cardiac output

Leading cause of death in children & young adults < 44 years of age Injury prevention ( only way to reduce incidence of trauma) a. Education b. Legislation c. Automatic protection TRAUMA Stab Wound 1. Intra-abdominal injuries: Penetrating abdominal injuries Gunshot wound, Stab wounds Serious & requires surgery Liver ( most frequently injured solid organ) All abdominal gunshot wounds require surgical exploration Stab wounds may be managed nonoperatively Blunt Trauma Blunt Abdominal Injury Result from motor vehicle crashes, falls, blows or explosions Injuries may be hidden or difficult to detect Involves the liver, kidneys, spleen, blood vessel

Assessment & Diagnostic Findings History & PE Lab studies: Urinalysis serial Hct. level WBC count Serum amylase analysis Internal Bleeding Inspection ( front of the body, flanks & back) Bluish discoloration, asymmetry, abrasion, contusion Abdominal CT Scan Abdominal Ultrasound Left shoulder pain ( ruptured spleen) Right shoulder pain (liver laceration) Intraperitoneal Injury Assess for tenderness, rebound tenderness, guarding, rigidity, spasm, increasing distention & pain Referred pain ( intraperitoneal injury) Diagnosis: 1. abdominal ultrasound 2. abdominal CT scan

3. Diagnostic peritoneal lavage 1 L LRS/ NSS 400 ml return RBC > 100,000/mm3 WBC ct > 500/mm3 Bile, feces, food Sinography ( detection of peritoneal penetration) Purse string Small catheter Contrast agent X-ray Intraabdominal Injury Management: Resuscitation procedure Occlusion of chest wound Direct pressure Intravenous fluid replacement Immobilization of the spine Cervical spine immobilization Tetanus prophylaxis Broad spectrum antibiotics Multiple Casualty Incident MCI is defined as an event involving a number and/or severity of casualties,which is beyond the capabilities of available care teams and facilities.

MINIMAL (GREEN TAG) Also known as the walking wounded Examples include but are not limited to small burns, lacerations, abrasions, and small fractures. These casualties have minor injuries and can usually care for themselves with self-aid or buddy aid. These casualties should still be employed for mission requirements (e.g., scene security). DELAYED (YELLOW TAG) The delayed category includes wounded casualties who may need surgery, but whose general condition permits a delay in surgical treatment without unduly endangering life or limb. Medical treatment (splinting, pain control, etc.) will be required but it can wait. Examples include but are not limited to casualties with no evidence of shock who have large soft tissue wounds, fractures of

major bones, intraabdominal or thoracic wounds, or burns to less than 20% of total body surface area. IMMEDIATE (RED TAG) The immediate category includes casualties who require immediate LSI and/or surgery. Put simply, if medical attention is not provided, the patient will die. The key to successful triage is to locate these individuals as quickly as possible. Examples include but are not limited to hemodynamically unstable casualties with airway obstruction, chest or abdominal injuries, massive external bleeding, or shock. EXPECTANT (BLACK TAG) Casualties in this category have wounds that are so extensive that even if they were the sole casualty and had the benefit of optimal medical resources, their survival would be highly unlikely. Even so, expectant casualties should not be

neglected. They should receive comfort measures, pain medications, if possible, and they deserve retriage as appropriate. Examples include but are not limited to casualties with penetrating or blunt head wounds and those with absent radial pulses. TRIAGE TAGS Triage tags are designed to communicate the triage category, treatment rendered, and other medical information. By necessity, the information on the tag is brief. Triage tags are usually placed on the casualty by the triage officer although other members of the team may place or add information to the tags. PURPOSE To furnish the attending care provider during the evacuation of a casualty with essential information about the injury or disease and the treatment provided.

The sole or initial medical record for the troops injured in combat. Each triage tag is coded with a unique sequential seven-character serial number used for identification and tracking of the casualty. The serial number is located on the top right and left diagonal tearoffs. Management: Determine the extent of injury Establish priority of treatment Nursing management in Sprain, Strain: 1. Immobilize extremity and advise rest 2. Apply cold packs initially then heat packs 3. Compression bandage may be applied to relieve edema 4. Assist in cast application 5. Administer NSAIDS FRACTURE A fracture is a complete or incomplete break in the continuity of bone. This will be accompanied by varying degrees of injury to surrounding soft tissues.

CLASSIFICATION OF FRACTURES BROAD CLASSIFICATION 1. Complete fracture Involves a break across the entire cross-section of the bone & is frequently displaced 2. Incomplete fracture (usually in adults) The break occurs through only a part of the cross-section of the bone Break in the continuity of the bone cause: DISPLACEMENT OF FRAGMENT CAUSES: DAMAGE TO THE SOFT PART CAUSES: Clinical Features of Fractures: 1) pain and tenderness over the involved area 2) loss of function 3) deformity 4) attitude ( shortening) 5) abnormal mobility and crepitus (a grating sensation produced when bones rub each other) 6) neurovascular injury ( localized swelling & discoloration of the skin) 7) radiographic findings

EMERGENCY MANAGEMENT OF FRACTURE 1. Immobilize any suspected fracture by splinting 2. Support the extremity above and below when moving the affected part from a vehicle 3. Suggested temporary splints- hard board, stick, rolled sheets 4. Apply sling if forearm fracture is suspected or the suspected fractured arm maybe bandaged to the chest 5. Open fracture is managed by covering a clean/sterile gauze to prevent contamination 6. DO NOT attempt to reduce ( re-align) the fracture 5 Ps in Fracture: P pain P pallor P - paresthesia P - pulselessness P - Paralysis Nursing Considerations Assess A airway B breathing C circulation neurogenic D disability E expose

always IMMOBILIZE the affected bone Principles of Fracture Treatment 1. Reduction of fracture 2. Maintenance of alignment 3. Promote callus formation 4. Restoration of function 5. Prevent complications ER Management 1. Assess 2. Immobilization 3. A, B, C, D, E 4. Control bleeding 5. TT, TIG and TAT immunization 6. Wound care 7. Diagnostic and Lab Procedures 8. Fracture Reduction Compartment Syndrome - a condition in which the circulation and function of tissues within a closed space are compromised by an increased pressure within that space S/Sx: 4 Ps - Pain / Pallor / Paralysis / Pulselessness * although none is pathognomonic, pain is the most important * best indicator: tissue pressure measurement - a surgical emergency (fasciotomy)

Whitesides Technique * for measuring intracompartmental pressure * results in permanent neurovascular damage if not relieved in 4 to 6 hrs. * the normal tissue pressure within closed compartments is approximately 0 mmHg > pressures of within 10 to 30mmHg of a patients diastolic blood pressure there will be inadequate tissue perfusion and relative ischemia > if the pressure within a compartment equals or exceeds the patients diastolic blood pressure - there will be no effective tissue perfusion Compartment syndrome ASSESSMENT FINDINGS 1. Pain- Deep, throbbing and UNRELIEVED by opioids Pain is due to reduction in the size of the muscle compartment by tight cast Pain is due to increased mass in the compartment by edema, swelling or hemorrhage 2. Paresthesia- burning or tingling sensation 3. Numbness 4. Motor weakness

5. Pulselessness, impaired capillary refill time and cyanotic skin 6. Edema unrelieved by elevation

Compartment syndrome Medical and Nursing management 1. Assess frequently the neurovascular status of the casted extremity 2. Elevate the extremity above the level of the heart 3. Assist in cast removal and FASCIOTOMY Fat Embolism Occurs usually in fractures of the long bones Fat globules may move into the blood stream because the marrow pressure is greater than capillary pressure Fat globules occlude the small blood vessels of the lungs, brain kidneys and other organs Onset of s/sx of fat embolism is rapid, (within 24-72 hours) ASSESSMENT FINDINGS 1. Sudden dyspnea and respiratory distress

2. tachycardia 3. Chest pain 4. Crackles, wheezes and cough 5. Petechial rashes over the chest, axilla and hard palate Nursing Management Support the respiratory function Respiratory failure is the most common cause of death Administer O2 in high concentration Prepare for possible intubation and ventilator support Environmental Emergencies HEAT CRAMPS People at risk: Not acclimatized to heat Elderly & very young Unable to care for themselves With chronic & debilitating diseases Taking certain medications Causes thermal injury at the cellular level ( heart, liver, kidney, blood coagulation) Management: To reduce high temperature ASAP cool sheets & towels, TSB Ice pack Cooling blankets

Iced Saline Lavage Immersion in cold water bath Massage ( promote circulation) Pt monitoring ( VS, ECG, CVP) Oxygenation (100%) IV infusion therapy Monitor urine output Patient education Frostbite Trauma from exposure to freezing temperature Actual freezing of tissue fluids Results in cellular & vascular damage Feet, hand, nose, ears Assessment: History of exposure to cold Frozen extremity, hard, cold , insensitive to touch Management: Restore normal body temperature Circulating back of 37 40 C Sterile gauze or cotton in between fingers & toes Massage is contraindicated Whirlpool bath Escharotomy Fasciotomy Hypothermia The core (internal) temperature is 35 C or less Assessment and Findings:

Progressive deterioration Apathy Poor judgement Ataxia Dysarthria Drowsiness Pulmonary edema Coagulopathy Management: Monitoring VS, CVP, UO, ABG, Blood chem., ECG, Chest Xray Rewarming a. core rewarming method, CP bypass, warm fluid, warm humidified oxygen, warm peritoneal lavage b. Passive external rewarming, warm blankets over the bed heaters Supportive Care Near Drowning Survival for at least 24 hours after submersion Hypoxemia ( most common consequence) Leading cause of unintentional death in children younger than 14 years old Factors: Alcohol ingestion Inability to swim Diving injuries Hypothermia Exhaustion

Fresh water aspiration (loss of surfactant) Salt water aspiration (pulmonary edema) Management: Maintain cerebral perfusion Adequate oxygenation Immediate CPR Monitor temperature by rectal probe Rewarming procedures ECG monitoring Indwelling urinary catheter NGT . Decompression Sickness (DCS) Also called The Bends Diving, high altitude flying or flying in commercial aircraft within 24 hours after diving Results from nitrogen bubbles trapped in the body Musculoskeletal pain, numbness/hypesthesia Nitrogen bubbles become air emboli, stroke, paralysis, death

Assessment & Diagnosis: Detailed history Rapid ascent, loss of air in the tank, buddy breathing, recent alcohol intake, lack of sleep or flight within 24 hours

Management: Patent airway Adequate ventilation Oxygenation (100%) Hyperbaric chamber Anaphylactic Reaction Acute systemic hypersensitivity reaction Occurs within seconds or minutes after exposure to certain foreign substances Medications Insect stings Foods Immunoglobulin E (IgE) Diagnosis: Respiratory symptoms DOB Stridor secondary to laryngeal edema Fainting, itching, swelling of mucus membrane Sudden drop in BP Management: Patent airway & ventilation ET intubation Aqueous epinephrine Crichothyroidotomy Antihistamines Aminophylines Albuterol inhalers Isoproterenol or Dopamine IV Benzodiazepines Latex Allergy

Affects healthcare providers who uses this product Management: Latex free products . Injected Poisons: Stinging Insects Venoms of the hymenoptera (bees, hornets, yellow jackets, fire ants, wasps) Venom allergy ( IgE mediated reaction) Stinging Clinical Manifestations: Generalized urticaria Itching Malaise Anxiety Bronchospasm Shock Death Management: Stinger removal Wound care with soap & water Ice application Oral Antihistamines & analgesic Aqueous epinephrine SQ Desensitization therapy Snake Bites Affects ages 1- 9 years Pit vipers (most frequent poisonous snake in the US) Cobra ( Philippines) Upper extremity (most common site)

Envenomation (injection of a poisonous material by sting, spine, bite) Medical emergency Management: Have victim lie down Remove constrictive items Provide warmth Cleanse & cover the wound Immobilize the injured part below the level of the heart Ice & tourniquet is contraindicated Corticosteroids are contraindicated in the first 6-8 hours after bite Observe for at least 6 hours Administration of antivenin within 12 hours after the bite Children requires more antivenin than adults Skin or eye test to detect allergy to antivenin Measurement of circumference of the affected part before administration of antivenin and every 15 minutes thereafter After symptoms decrease, every 30-60 minutes for the next 48 hours Done to detect compartment syndrome (swelling, loss of pulse, increase pain, paresthesia) Diphenhydramine & Cemetidine

Too rapid infusion ( most common caused of allergic reaction) Common Household Poisons: First Aid Management Absorbed Poisons - a poison that enters the body through the skin. Injected Poisons - a poison that enters the body through a bite, stings, or syringe Ingested or Swallowed Poisons (Corrosive) Alkaline or acid agents caused tissue destruction after in contact with mucus membrane Management: Airway, ventilation, oxygenation Water or milk to drink for dilution Syrup of Ipecac, Gastric lavage, Activated charcoal and Catharsis are all Contraindicated. Antidote as early as possible Monitor VS, CVP, Fluid & Electrolytes Psychiatric consultation Inhaled Poisons : Carbon Monoxide Poisoning

Result of industrial or household incidence or attempted suicide Carbon monoxide exerts its toxic effect by binding to circulating hemoglobin thereby reducing O2 carrying capacity of the blood Carboxyhemoglobin does not transport oxygen Hgb has 200x more affinity than oxygen Signs & Symptoms : Headache Muscle weakness Palpitation Dizziness Confusion Cyanosis Coma Management Reverse cerebral and myocardial hypoxia and to hasten elimination of carbon monoxide Carry the patient to fresh air immediately and open all windows and doors Loosen all tight clothing Initiate CPR, 100% O2 Food Poisoning After ingestion of contaminated food or drinks

Botulism ( serious form of food poisoning) Management: Determine the source & type of food poisoning Food, gastric contents, vomitus, serum, feces are examined Fluid & electrolyte correction Antiemetic medication Elicit information How soon after eating did the symptom occurs What was eaten and did the food have an unusual smell Did anyone else become ill eating the same food Did vomiting or diarrhea occurs Neurologic symptoms What is the patient appearance Substance Abuse Misused of specific substances to alter mood or behavior Drug & alcohol Acute Alcohol Intoxication Affects young adults or people older than 60 years of age It is a psychotropic drugs Alcohol or ethanol is a direct multisystem toxin & CNS depressant: Drowsiness Incoordination Slurring of speech

Sudden mood changes, Aggression, belligerence, grandiosity Uninhibited behavior Management: Detoxification of the acute poisoning, recovery, rehabilitation Denial & defensiveness Approach patient in a calm or non-judgemental manner Alcohol Withdrawal Syndrome/Delirium Tremens Acute toxic state that occurs as a result as a cessation of alcohol intake Signs & symptoms: Anxiety Uncontrollable fear Tremor Irritability Agitation Insomnia Incontinence Visual, tactile, auditory, olfactory hallucination Diagnostic Testing 1. Most commonly used tests include a. Urine Drug Screen (UDS) b. Blood Alcohol Level (BAL) 1.Legal intoxication is 0.10% a. Clumsiness b. Impaired reaction time

2.0.20% brain is depressed, ataxia 3.May experience withdrawal symptoms if BAL is high 2. Length of time drugs can be found in urine and blood varies with dosage and metabolic properties of drug Management: Adequate sedation & support Allow pt to rest and recover Place pt in a calm, nonstressful environment Alcohol free environment Refer pt to self help groups such as AA Negative conditioning with Disulfiram(Antabuse) Naltrexone HCL (antidote) Drug Overdose Nursing Diagnosis Risk for Injury 1. Determine disorientation, level of agitation, risk for suicide or harm to self or others 2. Protective environment, frequent observation 3. Vital signs q 15 minutes: feedback for symptoms of withdrawal Ineffective Individual Coping 1. Limit setting; encourage expression of feelings, fears 2. Teach alternative ways of dealing with stress

Altered Nutrition: Less than Body Requirements 1. Referral to dietician; nutritional assessment including blood work 2. Client modification of diet, goal setting for weight according to need Self-Esteem Disturbance 1. Acceptance of person 2. Focus on strength and accomplishments BURNS MAJORITY OF BURN CASES ARE DUE TO NEGLIGENCE SO HAZARD PRECAUTIONS MUST BE OBSERVED. pinabayaan ng NANAY Carelessness with match Scald from hot liquid Defective electrical equipment Immersion in overheating bath water Use of chemicals Safety Dont panic Drop to the floor Look for the exit Cover face with wet cloth Immerse into cool water or running water immediately if you get burned to prevent further injury. Extinguish any remaining fire by dropping and rolling onto the floor.

ASSESSMENT AIRWAY BREATHING CIRCULATION DISABILITIES EXPOSE Expose cont A airway - check nose, face and neck (priority) singed and sooty hair of the nose B breathing rise and fall of chest C circulation - if there is no breathing and circulation start CPR D check for disability and manage accordingly E expose to determine extent of injury Types of Burns Thermal dry flames, moist and heat Mechanical friction or abrasion Chemical acid or alkali Electrical most fatal Radiation sunlight Classification of Burns Burn classification as to depth Superficial Partial thickness (1st degree) Outer layer of dermis Erythema, pain up to 48 hrs

Healing 1-2 wks [sunburn] Burn classification as to depth Deep Partial thickness (2nd degree) Epidermis & dermis involved Blisters & edema, frequently quite painful Healing 14-21 days Burn classification as to depth Full thickness (3rd degree) Epidermis, dermis, subcutaneous fat are involved Dry, pearly white or charred in appearance Not painful Eschar must be removed; may need grafting

- cover with dry non-sticking sterile dressing - treat victim for shock and keep warm Chemical Burns - remove the chemical by flushing with water - flush for 20 min or longer - cover with dry dressing Electrical Burns - unplug or turn off power - check ABC - treat for shock INHALATION INJURIES Heat InhalationHOT AIR OR FLAMES Systemic ToxinsENCLOSED FIRE-CO IS INHALED Smoke InhalationsFREQUENTLY HIDDEN BY MORE VISIBLE INJURIES (6080% FATALITIES) Indications of inhalation injury usually appears within 2-48 hours after the burn occurred. Indications may include: The patient faints Fire or smoke present in a closed area Evidence of respiratory distress or upper airway obstruction Soot around the mouth or nose

ABCDE assessment Airway and fluid resuscitation (priority) Give TIG or TAT and TT Prophylactic antibiotic Sterile dressing for wound Thermal Burns Management: 1st and 2nd degree - relieve pain by immersing in cold water or applying cold cloth - Cover the burn with dry, non-sticking sterile dressing 3rd degree

Nasal hairs (SCORCHED HAIR), eyebrows, eyelashes have been singed Burns around the face or neck Criteria for classification of extent of burns Minor Burn - 2nd degree burn <15% TBSA in adults or <10% TBSA in children - 3rd degree burns <2%TBSA (not involving eyes, ears, face, hands, feet, perineum, joints) Moderate uncomplicated Burn - 2nd degree 15-25% TBSA in adults or 10-20% in childreb - 3rd degree <10% Major Burn - 2nd degree >25% TBSA in adults or 20% in children - all burns involving the critical areas Critical areas Face Hands Feet Perineum Chest ESTIMATION of BURNS Various methods are utilized for estimating the extent of burn injury 1. The Rule of Nines in adults Head and Neck9% Anterior trunk- 18%

Posterior trunk18% Upper arms18% ( 9% each x 2) Lower ext36% ( 18% EACH X 2) Perineum1% Fluid replacement Consensus formula LRS 2-4ml x BW (kg) x %TBSA Half given in 1st 8 hrs, then half for 16 hrs Evans formula - colloid: 1ml x BW x TBSA - electrolytes 1ml x BW x TBSA - Glucose (D5W5%) 200ml for IWL

Parkland Formula (4ml x TBSA x 1st 8H 2nd 8H and for the 3rd 8H last part Burn Management

BWkg) give , give give the

1.EMERGENT PHASE Begins at the time of injury and ends with the restoration of the capillary permeability ( with 48-72 hours) The GOAL is to PREVENT hypovolemic shock and

preserve the vital body organ function Emergency and pre-hospital care 1st Phase Fluid Accumulation IV to IT and IC most critical period 36-48H post burn, FVD or hypovolemia 3rd fluid shift edema on the injured area (IV to IT) fatal form is circumferential edema from chest injury 1st Phase Cont c. edema and p. edema (IV to IC) hyponatremia (IV to outside from it) hyperkalemia (cell injury) 1st Phase Cont BV curlings ulcer or paralytic ileus (dec. BV), NPO, NGT lavage, TPN Infection may set in (isolation) Fluid Resuscitation Blood Monitoring ETT Insertiom Pulse Carbon Monoxide Oximetry Arrhythmias Monitoring Burn Management 2.RESUSCITATIVE PHASE Begins with the initiation of fluids and ENDS when capillary integrity returns to

near-normal and large fluid shifts have decreased The GOAL is to prevent shock by maintaining adequate circulating blood volume to maintain vital organ perfusion 2nd Phase Fluid Remobilization IT and IC to IV May last 48-60H FVE (CHF) Hypokalemia Diuresis phase (oliguria may signifies RF) ISC IVC Hemodilution 2nd Phase Cont Hyponatremia due to fluid loss from diuresis phase Infection may set in (isolation) Anemia may linger up to recovery period Complications from immobility may set in (Circulo-O-electric bed) Anemia may linger Burn Management 3.ACUTE PHASE Begins when the client is HEMODYNAMICALLY stable, capillary permeability is restored and DIURESIS has begun Emphasis is placed on restorative therapy and the phase continues until wound closure is achieved

The FOCUS is on infection control, wound care, wound closure, nutritional support, pain management and physical therapy 3rd Phase to Recovery Period Infection may set in (isolation, Sulfadiazine application) Healing process to scar formation and contractures Surgery (Reconstructive or Plastic) STSG auto-graft 3rd Phase Cont Debridement and Escharotomy Diet: high caloric high CHON Psychological Aspect: dec. self esteem, stigma, perceived body changes, isolation, depression, loss of identity these are all related to physical disfigurement.

- minimal penetration to eschar Silver Nitrate - bacteriostatic and fungicidal - does not penetrate eschar Mafenide acetate - Gram (-) and (+) -diffuses rapidly to eschar Nursing Management 1. Emergent phase (time of injury) Remove person from source of burn. 1) Thermal: smother burn beginning with the head. 2) Smoke inhalation: ensure patent airway. 3) Chemical: remove clothing that contains chemical; lavage area with copious amounts of water. 4) Electrical: note victim position, identify entry/exit routes, maintain airway. Nursing Management 1. Emergent phase (time of injury) Cool the burn for several minutes. DONT USE ICE!! Wrap in dry, clean sheet or blanket to prevent further contamination of wound and provide warmth and conserve body heat. Assess how and when burn occurred.

Burn Management 4.REHABILITATIVE PHASE The final phase of Burn care, restoration of functions, cosmetic surgery Goals of this phase patient independence and restoration of maximal function Infection Prevention Silver sulfadiazine - bactericidal

Nursing Management 1. Emergent phase (time of injury) Remove constricting clothes and jewelry Cover the wound with a sterile dressing or clean, dry cloth Provide IV route only if possible Transport immediately to a hospital or burn facility Nursing Management 2. Resuscitative and Shock phase (first 2448 hours) Provide appropriate fluid resuscitation based on the Parkland formula 4 mL Plain LR x %TBSA of burns x kg body weight Nursing Management 3. Fluid remobilization or diuretic phase (25 days post burn) Monitor and treat potential complications like acute renal failure, paralytic ileus, Curlings ulcer and hypokalemia Nursing Management 4. Convalescent phase a. Starts when diuresis is completed and wound healing and coverage begin. GENERAL NURSING INTERVENTIONS IN THE HOSPITAL 1. Provide relief/control of pain.

a. Administer morphine sulfate IV and monitor vital signs closely. b. Administer analgesics/narcotics 30 minutes before wound care. c. Position burned areas in proper alignment GENERAL NURSING INTERVENTIONS IN THE HOSPITAL 2. Monitor alterations in fluid and electrolyte balance. a. Assess for fluid shifts and electrolyte alterations b. Monitor Foley catheter output hourly (30 cc per hour desired). c. Weigh daily. d. Monitor circulation status regularly. e. Administer/monitor crystlloids/colloids GENERAL NURSING INTERVENTIONS IN THE HOSPITAL 3. Promote maximal nutritional status. a. Monitor tube feedings if Peripheral Nutrition is ordered. NPO immediately after injury!!! ONLY when oral intake permitted, provide high-calorie, high-protein, high- carbohydrate diet with

vitamin and mineral supplements. c. Serve small portions. d. Schedule wound care and other treatments at least 1 hour before meals. GENERAL NURSING INTERVENTIONS IN THE HOSPITAL 4. Prevent wound infection. a. Place client in controlled sterile environment. b. Use hydrotherapy for no more than 30 minutes to prevent electrolyte loss. Observe wound for separation of eschar and cellulitis. GENERAL NURSING INTERVENTIONS IN THE HOSPITAL 5. Prevent GI complications. a. Assess for signs and symptoms of paralytic ileus. b. Assist with insertion of NG tube to prevent/control Curlings/stress ulcer; monitor patency/drainage. GENERAL NURSING INTERVENTIONS IN THE HOSPITAL 5. Prevent GI complications. c. Administer prophylactic antacids through NG tube and/or IV cimetidine (Tagamet) or ranitidine (Zantac) (to prevent stress ulcer). d. Monitor bowel sounds. e. Test stools for occult blood.

Rehabilitation Methods of coping and resocialization Ensure optimum nutrition Initiate physical therapy to regain and maintain optimal range of motion and achieve wound coverage Provide psychosocial support to promote mental health Rehabilitation Provide family-centered care to promote integrity of the family as a unit Encourage post-discharge follow-up for several years Ensure appropriate referral to cosmetic surgeon, psychiatrist, occupational therapist, nutritionist and physical therapist Drugs for Burns Mafenide (Sulfamylon) 1) Administer analgesics 30 minutes before application. 2) Monitor acid-base status and renal function studies. SIDE EFFECT: LACTIC ACIDOSIS 3) Provide daily BATH for removal of previously applied cream. Drugs for Burns Silver sulfadiazine (Silvadene)

1) Administer analgesics 30 minutes before application. 2) Observe for and report hypersensitivity reactions (rash, itching) 3) Store drug away from heat 4) Disadvantage: poor eschar penetration Drugs for Burns Silver nitrate 1) Handle carefully; solution leaves a gray or black stain on skin, clothing, and utensils. 2) Administer analgesic before application. 3) Keep dressings wet with solution; dryness increases the concentration and causes precipitation of silver salts in the wound. Drugs for Burns Povidone-iodine (Betadine) Administer analgesics before application. Assess for metabolic acidosis/renal function Gentamicin Assess vestibular/auditory and renal functions at regular intervals. Cimetidine Given to prevent Curlings ulcer Wound debridement (ESCHAROTOMY)

Skin grafting Autograft Homograft - from living or recently deceased Heterografts from animals Biosynthetic biobrane Dermal substitute integra, alloderm Skin Grafting Donts in burns DO NOT apply ointment, butter, ice, medications, fluffy cotton dressing, adhesive bandages, cream, oil spray, or any household remedy to a burn. This can interfere with proper healing. DO NOT allow the burn to become contaminated. Avoid breathing or coughing on the burned area. DO NOT disturb blisters or dead skin. DO NOT apply cold compresses and DO NOT immerse a severe burn in cold water. This can cause shock. DO NOT place a pillow under the victim's head if there is an airway burn and they are lying down. This can close the airway. Violence, Abuse, Neglect Family Violence, Abuse & Neglect

Domestic violence is the leading cause of death for young African American Women Men & persons with disabilities are also victims of domestic violence Elder abuse results physical, psychological abuse, neglect, vilations of personal rights & financial abuse Clinical Manifestation: Unexplained bruises, laceration, abrasion, head injuries & fractures Malnutrition & Dehydration (most common in neglect) Assessment: Early detection & Intervention Careful history Management: Primary concern safety & welfare of the pt. Separation of the pt with the abuser Mandatory reporting laws Sexual Assault Rape is force sexual act Victims may either be male or female Crisis Intervention: Assessment & diagnostic findings rape trauma syndrome

phases of psychological reaction acute disorganization phase ( shock, disbelief, fear, guilt, humiliation, anger) Denial Phase: (anxiety, fear, flash backs, sleep disturbances, hyperalertness & psychosomatic reactions) Phase of Reorganization: (Recovery) Physical examination Informed and written consent Focus on External evidence of trauma Dried semen stains Treat potential STD Postcoital contraceptive medication Ovral _ 12-24hrs not later than 72 hrs Management: Give sympathetic support Reduce emotional trauma Gather available evidence Respect patient privacy and sensitivity Goal: have pt. regain control over her/his life . Violence in the Emergency Department Pts & families waiting for assistance at the ED are sometimes dissatisfied resulting in violence Management: Safety is the first priority

Psychiatric Emergencies Is an urgent, serious disturbance of behavior, affect, or thought that makes the pt. unable to cope with life situations & interpersonal relationships Concern: Determining whether pt is at risk for injuring self or others Aim: Maintain pt self esteem while providing care . Overactive Patients Display disturbed, uncooperative & paranoid behavior Management: Reliable history about mental illness, hospitalization, injuries, illnesses, use of alcohol or drugs Immediate goal: Gain control of the situation Restraint is used as the last resort Psychotropic agent : Chlorpromazine, (Thorazine), Haloperidol (Haldol) Violent Behavior Usually episodic Means of expressing feelings of anger, fear, or hopelessness Management: Goal : bring the violence under control

Use calm & noncritical approach Crisis intervention Sedative Restraint Post Traumatic Stress Disorder (PTSD) . Development of characteristic symptoms after a psychologically stressful event Symptoms include intrusive thoughts & dreams, phobic avoidance reaction, heightened vigilance, exaggerated startle reaction, generalized anxiety, societal withdrawal Assessment: Evaluation of the pts pretrauma history, the trauma itself & post trauma functioning Management: Crisis intervention Establish a trusting & sharing relationship Education of the pt and family Underactive or Depressed Patient Depression may be masked by anxiety & somatic complaints Clinical manifestations: Sadness Apathy Feeling of worthlessness

Self-blame Suicidal thoughts Anorexia, Weight loss Decrease interest in sex Sleeplessness Management: Ventilating personal feelings Suicidal precaution Antidepressant & antianxiety agents Psychiatric consultation Suicidal Patients . Attempted suicide is an act that stems from depression Viewed as a cry for help or intervention Weight loss Sleep disturbances Somatic complaints Suicidal preoccupation Management: Treat the consequences of suicidal attempt & prevent further self injury Crisis intervention Myxedematous coma 1. Life-threatening complication of long-standing and untreated hypothyroidism 2. Hyponatremia, hypoglycemia, acidosis 3. Precipitated by stressors, failure to take thyroid replacement meds 4. Treatment includes restoring balance throughout

systems and increasing thyroid hormone levels Diagnostic Tests a. Serum thyroid antibodies (TA): antibodies in Hashimotos Thyroiditis b. TSH test: (from pituitary) elevated with primary hypothyroidism c. T3 and T4: decreased for diagnosis of hypothyroidism d. T3 uptake test; decreased with hypothyroidism RAI uptake test 1. Oral or intravenous dose of radioactive iodine (131I or 123I) given to client 2. Thyroid scanned after 24 hours 3. Uptake decreased with hypothyroidism 4. Size and shape of gland revealed f. Serum cholesterol is elevated DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 1. Monitor VS especially HR 2. Administer hormone replacement: usually Levothyroxine( Synthroid)should be taken on an empty stomach DISORDERS OF the THYROID GLAND

NURSING INTERVENTIONS 3. Instruct patient to eat LOW calorie, LOW cholesterol and LOW fat diet 4. Manage constipation appropriately 5. Provide a WARM environment DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 6. Avoid sedatives and narcotics because of increased sensitivity to these medications 7. Instruct patient to report chest pain promptly Nursing Diagnoses a. Decreased Cardiac Output b. Constipation c. Risk for Impaired Skin Integrity: due to over all edema high risk for skin breakdown: preventative interventions DISORDERS OF the THYROID GLAND Thyroid storm An acute LIFE-threatening condition characterized by excessive thyroid hormone DISORDERS OF the THYROID GLAND Thyroid storm CAUSE: Manipulation of the thyroid during surgery causing

the release of excessive hormones in the blood DISORDERS OF the THYROID GLAND ASSESSMENT Findings for Thyroid Storm 1. HIGH fever 2. Tachycardia and Tachypnea 3. Systolic HYPERtension DISORDERS OF the THYROID GLAND ASSESSMENT Findings for Thyroid Storm 4. Delirium and coma 5. Severe vomiting and diarrhea 6. Restlessness, Agitation, confusion and Seizures DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 1. Maintain PATENT airway and adequate ventilation 2. Administer anti-thyroid medications such as Lugols solution, Propranolol, and Glucocorticoids DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 3. Monitor VS 4. Monitor Cardiac rhythms 5. Administer PARACETAMOL ( not Aspirin) for FEVER

DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 6. Manage Seizures as required. 7. Provide a quiet environment Diabetic Ketoacidosis This is cause by the absence of insulin leading to fat breakdown and production of ketone bodies Three main clinical features: 1. HYPERGLYCEMIA 2. DEHYDRATION & electrolyte loss 3. ACIDOSIS DKA PATHOPHYSIOLOGY No insulin reduced glucose breakdown and increased liver glucose production Hyperglycemia DKA PATHOPHYSIOLOGY Hyperglycemia kidney attempts to excrete glucose increased osmotic load diuresis Dehydration DKA PATHOPHYSIOLOGY No glucose in the cell fat is broken down for energy ketone bodies are produced Ketoacidosis

DKA Risk factors 1. infection or illnesscommon 2. stress 3. undiagnosed DM 4. inadequate insulin, missed dose of insulin DKA ASSESSMENT FINDINGS 1. 3 Ps 2. Headache, blurred vision and weakness 3. Orthostatic hypotension DKA ASSESSMENT FINDINGS 4. Nausea, vomiting and abdominal pain 5. Acetone (fruity) breath 6. Hyperventilation or KUSSMAULs breathing HYPERGLYCEMIA Hyperglycemia DKA LABORATORY FINDINGS 1. Blood glucose level of 300800 mg/dL 2. Urinary ketones DKA LABORATORY FINDINGS 3. ABG result of metabolic acidosis- LOW pH, LOW pCO2 as a compensation, LOW bicarbonate 4. Electrolyte imbalancespotassium levels may be HIGH due to acidosis and dehydration DKA

NURSING INTERVENTIONS 1. Assist in the correction of dehydration Up to 6 liters of fluid may be ordered for infusion, initially NSS then D5W Monitor hydration status Monitor I and O Monitor for volume overload DKA NURSING INTERVENTIONS 2. Assist in restoring Electrolytes Kidney function is FIRST determined before giving potassium supplements! DKA NURSING INTERVENTIONS 3. Reverse the Acidosis REGULAR insulin injection is ordered IV bolus 5-10 units The insulin is followed by drip infusion in units per hour BICARBONATE is not used! HHNS A serious condition in which hyperosmolarity and extreme hyperglycemia predominate Ketosis is minimal Onset is slow and takes hours to days to develop HHNS PATHOPHYSIOLOGY Lack of insulin action or Insulin resistance hyperglycemia

Hyperglycemia osmotic diuresis loss of water and electrolytes HHNS PATHOPHYSIOLOGY Insulin is too low to prevent hyperglycemia but enough to prevent fat breakdown Occurs most commonly in type 2 DM, ages 50-70 HHNS Precipitating factors 1. Infection 2. Stress 3. Surgery 4. Medication like thiazides 5. Treatment like dialysis HHNS ASSESSMENT FINDINGS 1. Profound dehydration 2. Hypotension 3. Tachycardia 4. Altered sensorium 5. Seizures and hemiparesis HHNS DIAGNOSTIC TESTS 1. Blood glucose- 600 to 1,200 mg/dL 2. Blood osmolality- 350 mOsm/L 3. Electrolyte abnormalities HHNS NURSING INTERVENTIONS Approach is similar to the DKA 1. Correction of Dehydration by IVF 2. Correction of electrolyte imbalance by replacement therapy

HHNS NURSING INTERVENTIONS 3. Administration of insulin injection and drips 4. Continuous monitoring of urine output MACROVASCULAR CX Nursing management 1. Diet modification 2. Exercise MACROVASCULAR CX Nursing management 3. Prevention and treatment of underlying conditions such as MI, CAD and stroke 4. Administration of prescribed medications for hypertension, hyperlipidemia and obesity Myocardial infarction Death of myocardial tissue in regions of the heart with abrupt interruption of coronary blood supply Myocardial infarction ETIOLOGY and Risk factors 1. CAD 2. Coronary vasospasm 3. Coronary artery occlusion by embolus and thrombus 4. Conditions that decrease perfusion- hemorrhage, shock Myocardial infarction Risk factors 1. Hypercholesterolemia 2. Smoking 3. Hypertension 4. Obesity

5. Stress 6. Sedentary lifestyle Myocardial infarction PATHOPHYSIOLOGY Interrupted coronary blood flow myocardial ischemia anaerobic myocardial metabolism for several hours myocardial death depressed cardiac function triggers autonomic nervous system response further imbalance of myocardial O2 demand and supply Myocardial infarction ASSESSMENT findings 1. CHEST PAIN Chest pain is described as severe, persistent, crushing substernal discomfort Radiates to the neck, arm, jaw and back Myocardial infarction ASSESSMENT findings 1. CHEST PAIN Occurs without cause, primarily early morning NOT relieved by rest or nitroglycerin Lasts 30 minutes or longer Myocardial infarction Assessment findings 2. Dyspnea 3. Diaphoresis 4. cold clammy skin 5. N/V

6. restlessness, sense of doom 7. tachycardia or bradycardia 8. hypotension 9. S3 and dysrhythmias Myocardial infarction Laboratory findings 1. ECG- the ST segment is ELEVATED. T wave inversion, presence of Q wave 2. Myocardial enzymeselevated CK-MB, LDH and Troponin levels 3. CBC- may show elevated WBC count 4. Test after the acute stageExercise tolerance test, thallium scans, cardiac catheterization Myocardial infarction Nursing Interventions 1. Provide Oxygen at 2 lpm, Semi-fowlers 2. Administer medications Morphine to relieve pain nitrates, thrombolytics, aspirin and anticoagulants Stool softener and hypolipidemics 3. Minimize patient anxiety Provide information as to procedures and drug therapy Myocardial infarction 4. Provide adequate rest periods 5. Minimize metabolic demands Provide soft diet

Provide a low-sodium, low cholesterol and low fat diet 6. Minimize anxiety Reassure client and provide information as needed Myocardial infarction 7. Assist in treatment modalities such as PTCA and CABG 8. Monitor for complications of MI- especially dysrhythmias, since ventricular tachycardia can happen in the first few hours after MI 9. Provide client teaching MI

Medical Management 1. ANALGESIC The choice is MORPHINE It reduces pain and anxiety Relaxes bronchioles to enhance oxygenation MI Medical Management 2. ACE Prevents formation of angiotensin II Limits the area of infarction MI Medical Management 3. Thrombolytics Streptokinase, Alteplase

Dissolve clots in the coronary artery allowing blood to flow PURPOSE Dfunctionissolve and lyze the thrombus (thrombolysis) Allowing blood to flow again (reperfusion) Minimizing the size of infarction Preserving ventricular Absolute Contraindication Active bleeding Known bleeding disorder History of hemorrhagic stroke History of intracranial vessel malformation Recent major surgery or trauma Uncontrolled hypertension Pregnancy Nursing Consideration Minimize skin puncture Avoid IM injection Draw blood for laboratory test when starting IV line Start Iv line prior to thrombolytic therapy Monitor for dysrhythmias, hypotension, and allergic reaction Monitor for reperfusion, resolution of angina or acute ST segment changes Check for signs and symptoms of bleeding, < Hgb, Hct, < BP,

>HR, oozing or bulging at the site, change in LOC Apply direct pressure Anticoagulant Heparin - prevents formation of thrombin - monitor PTT - Protamine Sulfate Warfarin - Suppresses formation of prothrombin - monitor PT - Vit K Myocardial infarction NURSING INTERVENTIONS AFTER ACUTE EPISODE 1. Maintain bed rest for the first 3 days 2. Provide passive ROM exercises 3. Progress with dangling of the feet at side of bed Myocardial infarction NURSING INTERVENTIONS AFTER ACUTE EPISODE 4. Proceed with sitting out of bed, on the chair for 30 minutes TID 5. Proceed with ambulation in the room toilet hallway TID Myocardial infarction NURSING INTERVENTIONS AFTER ACUTE EPISODE Cardiac rehabilitation

To extend and improve quality of life Physical conditioning Patients who are able to walk 3-4 mph are usually ready to resume sexual activities Treatments for coronary disease - angioplasty Coronary angioplasty involves inserting a balloon into a diseased (blocked/narrowed) coronary artery through an artery in the groin or arm. Commonly a metal support (stent) is inserted into the artery to help keep it open. A close up of a Stent. Angina Pectoris NURSING MANAGEMENT 1. Administer prescribed medications Nitrates- to dilate the coronary arteries Aspirin- to prevent thrombus formation Beta-blockers- to reduce BP and HR Calcium-channel blockers- to dilate coronary artery and reduce vasospasm Basic Life Support This is a strategy which aims to improve the outcome for victims of Cardiopulmonary arrest and is now being adopted internationally It involves a series of events which are interconnected to

each other like the links of a chain HOW DOES CPR WORK? All the living cells of our body need a steady supply of oxygen to keep us alive CPR works because you can breathe air into the victims lungs to provide oxygen into the blood. Then, when you press on the chest, you move oxygen-carrying blood through the body. WHEN WILL YOU DO CPR? CPR must be started as soon as possible when the carotid pulse is not appreciated or if breathing either stops or ineffective. In case of doubt, do CPR. Any delay in starting CPR reduces the chances of survival. In addition, the brain cells begin to die after four to six minutes without oxygen.

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