EMERGENCY NURSING

THE CLIENT IN EMERGENCY/ DISASTER SITUATION

Establishing Emergency Care priorities

1. Ensuring Personal Safety - survey the scene - seek assistance from the police to clear the scene - seek help if someone is violent - use safety devices, protective garb, equipment

- be careful when checking clothing - report exposures & get medical evaluation ASAP 2. Establishing Control and Rapport - establish eye contact with the client - state your name, role, outline steps you will make - state your expectations from the client - ask the clients name

3. Triage and Priority Setting - number system 1 critical, 3 least critical - terms emergent, urgent, non-urgent/immediate, delayed, minimal - colors red, yellow or green, red-critical, green-least critical

4. Performing the Primary Survey - consciousness

- Airway

- Breathing

- Circulation

5. Performing the Secondary Survey - obtain vital signs - perform head-to-toe examination looking for
D Deformity C Contusion A Abrasion P Puncture B Burn T Tenderness L Laceration S - Swelling

- check & compare pupils of both eyes - check for fluid or blood in ears, nose, mouth - gently feel the sides of the neck or signs of injury - check both collar bones & shoulders - check the chest & rib cage - check the clients abdomen - check the hipbone by pressing slowly downward & inward - check one leg at a time - check one arm at a time - check the spinal column - record all assessments including time - keep the client lying down - keep client warm & guard against chilling

6. Provision of Care a. 4 categories of interventions - medical/nursing interventions - diagnostic studies - interventions according to guidelines - ongoing monitoring b. for multi-system injured person, bleeding or injury is managed in the order of: - chest problems - abdomen: bleeding - head - spine - non-life threatening vascular injuries

- splinting or treatment of fractures - cleansing & repair of surface trauma - administration of medications 7. Psychosocial Assessment - affect/behavior - understanding of what is happening - degree of coping with this situation - extent of threat the client posses to himself - presence or absence of a developmental delay - orientation -presence or use of mind altering substances -normal coping strategies

- self-concept - support resources-human & financial 8. Communicating with Family Members - timely notification of family - provide time for family & client to see/speak - the family may provide critical information - availability of the family promotes decision making 9. Assisting with Diagnostic Tests - obtain complete & accurate VS - pulse oximetry is used for clients with respi problems & poor perfusion

- ECG is used for client with s/sx of cardiac problems - Doppler is used to measure BP - Laboratory tests - CBC - Glucose, electrolytes, BUN, creatinine - Coagulation studies - Pregnancy tests - Type and crossmatch - Liver function test - Urinalysis, culture & sensitivity - Special procedures - lumbar punture

NANDA Approved Nursing Diagnosis

1. Ineffective airway clearance - maintains a patent airway 2. Impaired physical mobility - demonstrates optimum level of mobility 3. Altered cardiac output - exhibits adequate cardiac output 4. Fluid volume excess - exhibits a normovolemic status 5. Risk for infection - absence of infection 6. Hypothermia - demonstrates normothermia

7. Risk for injury - absence of injury 8. Post-trauma response - demonstrates appropriate coping measures 9. Anticipatory grieving - exhibits an adaptive grieving process 10. Interrupted family processes - family functions adaptively in managing the crisis 11. Anxiety - relief from anxiety 12. Deficient knowledge - increases knowledge in the condition & its management

1. ANATOMICAL OBSTRUCTION
It happens when the tongue drops back and obstructs the throat. Other causes are acute asthma, croup, diphtheria, swelling, and cough (whooping).

2.MECHANICAL OBSTRUCTION When foreign objects lodge in the pharynx or airways; fluids accumulate in the back of the throat.

1. Mild Obstruction.
The victim is responsive and can cough forcefully, although frequently there is wheezing between coughs. The victim has a weak, ineffective cough, high-pitched noise while inhaling, increased respiratory difficulty, and possibly cyanosis.

2. Severe obstruction
The victim is unable to speak, breathe, or cough and may clutch the neck with the thumb and fingers. Movement of air is absent.

DEFINITION
Heimlich maneuver or abdominal thrusts is recommended for relieving foreign body airway obstruction.

Is the condition in which breathing stops or inadequate.

1. Obstruction Anatomical Mechanical 2. Diseases Bronchitis Pneumonia COPD

3.

Other causes Electrocution Circulatory Collapse Strangulation Chest Compression ( by other physical force ) Drowning Poisoning Suffocation

Is a technique of breathing air into a person lungs to supply him or her with the oxygen needed to survive.

1. Mouth-toMouth

2. Mouthto-Nose

3. Mouth-to-Mouth and Nose

4. Mouth-toStoma

TR 1-2 3-3

5. Mouth-toFace Shield

6. Mouth-toMask

7. Bag Mask Device

Adult
Opening of airway (Head-Tilt_ Maximum tilt of Chin-Lift the head Maneuver)

Child Neutral plus position Carotid pulse Mouth-to-mouth & mouth-to-nose

Full, slow regulated breath (1 to 1.5 seconds per breath)

Infant

Neutral position Brachial pulse (upper arm) Mouth-to-mouth and nose

Gentle, slow breath (1 to 1.5 seconds per breath)

Checking of Pulse Method Breaths Rate

Carotid pulse (side of neck) Mouth-to-mouth & mouth-to-nose

Full, slow breath (1.5 to 2 seconds per breath) 24 breaths per minute (1 breath every 4 to 5 seconds) Breathe 1, 1002, 1003, 1001, breath, 1, 1002, 1003, 1002, breathe 1, 1002, 1003, 1003 breath..1, 1002, 1003 1010 or up to 1024breaths

40 breaths per minute (1 breath every 3 seconds)

Counting for Standardizati on Purposes

Breathe 1, 1001, breathe 1, 1002, breathe, 2, 1003, breathe1 1040, breathe

SEQUENCE IN PERFORMING CPR & RB

Survey the Scene.

The Scene is Safe. Activate Medical Assistance & Transfer Facility.

Check Responsiveness,
Hey Mam/Sir are you OK? Victim Unresponsive. Open Airway (Head-Tilt-Chin Lift) Check Airway Check Breathing (Look, Listen & Feel) for 5 seconds.

Victim is Breathless.
Give 2 Initial Ventilatory Maneuver (2 breaths). Check for Signs of Circulation for at least 10 seconds. Victim has no signs of Circulation Ill perform CPR. Victim has inadequate/no breathing but with Signs of Circulation Ill perform Rescue Breathing.

CARDIOPULMONARY RESUSCITATION (CPR)

This is a combination of chest compression and rescue breathing. This must be combined for effective resuscitation of the victim of cardiac arrest.

Table of Comparison on Cardiopulmonary Resuscitation for Adult, Child and Infant

ADULT CHILD Center of the chest along imaginary nipple line INFANT Center of the chest 1 finger width below the imaginary nipple line Approximately 1/3 to
the depth of the chest

Compression Area

Depth How to Compress Rate Compression/ Ventilation Ratio Number of cycles per 2 minutes Counting for standardizatio n purposes

Approximately 1 to 2 inches Heel of 1 hand, other hand on top

Approximately 1/3 to the depth of the chest

Heel of 1 hand only .

2 fingers (middle & ring fingertips) At least 100/min

Approximately 100/min 30 : :2 ( 1 rescuer );15:2 ( 2 rescuers)

5 cycles 1, & 2,& 3,& 4,& 5,& 6,& 7, & 8,& 9,&10, 11, 12, 13, 14,15, 16, 17,18, 19, 20, & 1,& 2,& 3,& 4,& 5,& 6, & 7,& 8,& 9, and 1 (cycle) breathe; breathe (up to 5 cycles)

1. The patient has a valid : DO NOT RESUSCITATE order 2. The patient has signs of irreversible death a. Rigor mortis- rigid stiffening of heart and skeletal muscles after death. Decapitation

b. Dependent rigidity c. d. Decomposition

3. No physiological benefit can be expected

4. Withholding attempts to resuscitate in the delivery room is appropriate for newly born infants

a.

Confirmed gestation < 23 weeks or birth weight

< 400gms.

b. Anencephaly c. Confirmed Trisomy 13 or 18

1. S - SPONTANEOUS signs of circulation are restored. 2. T -TURNED over to medical services or properly trained and authorized personnel.

3. O - OPERATOR is already exhausted and cannot continue CPR.

4. P - PHYSICIAN assumes responsibility (declares death, takes over, etc.). 5. S SCENE becomes unsafe. 6. S SIGNED waiver to stop CPR.

(cruda)

HEAD TRAUMA (ABRAU, LLIDO) Types, mechanism of head injury, s/sx, dx exams, medical interventions, nursing management (nursing diagnosis with interventions) ABDOMINAL TRAUMA (ABREA, LOGARTA) Mechanism of injury, s/sx, dx exams, medical intervention, nursing management DENTAL TRAUMA (AGCITO, NAGAC) Types, s/sx, medical management, nursing diagnosis with interventions ALVEOLAR OSEITIS (DRY SOCKET) (AGTARAP, SALON) Assessment, nursing dx, management FRACTURED MANDIBLE (ALVAREZ, TORIO) Assessment, nursing diagnosis, management ABSCESSED TOOTH (AMORA, VILLANUEVA) Assessment, nsg dx, management

NEAR DROWNING (BALMORES, LUBO) Mechanism of injury, s/sx, factors increasing survival, dx exam, med intervention, nsg man POISONING, OVERDOSE, AND INTOXICATION Drugs, symptoms of overdose, treatment, dx exam, management, antidote Anticholinergics (BONGOCAN), acetaminophen(BORJA) , salicylates(BRAGAT), cns stimulants(CABBAB), cns depressants(CADAVEZ), barbiturates(CALAPIZ), narcotics and opioids(CASINO), hallucinogens(CO), alcohol (CRUDA) FOREIGN BODY OBSTRUCTION/ AIRWAY OBSTRUCTION (DAMILES, MABAYLAN) Mechanism of injury, s/sx, dx,exam, med inter,nsg man HEAT STROKE (DIZON, MADELO) Assessment, management HYPOTHERMIA (DULTRA, SALVADOR) Assessment, management

DECOMPRESSION SICKNESS (EGLOPAS, SARIPADA) Assessment, management HUMAN BITES (ESTRELLANES, SARSUELO) Mechanism of injury, assessment, ngs dx, management ANIMAL BITES (GACUTAN, SENDAD) Mech of injury, assessment, ngs dx, management INSECT BITES (GAMALI, SIRUNO) Mech of injury, assessment, ngs dx, management BURN TRAUMA (GEMINA, HURANO, LAGAZO, LANTONG, ) Types, classification, phases of major burn injury, patho, s/sx, dx exam, emergency key med int, medical intervention, nsg man