EMERGENCY NURSING
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KOMUNITAS BLOGGER UNIVERSITAS SRIWIJAYA
EMERGENCY NURSING Emergency Care • episodic and crisis-oriented care provided
to patients with serious or potentially life-threatening injuries or illnesses. • Philosophy :
an EMERGENCY is whatever the patient or family considers it to be. Emergency
Assessment • systematic approach • Usually, the most dramatic injury is not the
most serious. • The primary and secondary surveys provide the emergency nurse with a
methodical approach to help identify and prioritize patient needs. Primary Assessment •
A – Airway • B – Breathing • C – Circulation • D –
Disability » AVPU Scale Secondary Assessment • brief, thorough, systematic
assessment designed to identify all injuries. • The steps include : –
Expose/environmental control – Full set of vital signs – Five interventions
– Facilitate family presence, and – Give comfort measures. • Nursing
process in Emergency Situation * logical framework for problem-solving in limited time &
pressured environment ER Nurse has : • expertise in assessing & identifying
patient’s health care problem in crisis situation • establishment of priorities •
monitoring an acutely ill and injured patient • supporting and attending to family •
supervising allied health personnel & teaching patients and their families Approach to
Patients • assessment of psychological functioning includes evaluation of emotional
expression, degree of anxiety & cognitive functioning • Rapid physical assessment
Approach to Family • they are told of the patient’s location and interventions
being given Guidelines in helping the family deal with sudden death in the ER : • Take
the family to a private place & talk to the family together • Assure the family that
every possible intervention was done • Avoid using euphemism, show family of your
concern thru touch. • Allow family to talk about the deceased and what they meant to
them; this permits ventilation of feelings • Encourage family members to support each
other and freely express their emotions • Avoid giving sedation to family members as
this may mask or delay the grieving process. • Encourage the family to view the body if
they wish to do so. Cover the mutilated areas before the family sees the body. • Spend
a few minutes with the family, listening to them History • M – Mechanism of injury
• I – Injuries sustained / suspected • V – Vital Signs • T Treatment Head to Toe Assessment • Head & Face • Chest • Abdomen /
Flanks • Pelvis / Perineum • Extremities • Posterior surface PRIORITIES
& PRINCIPLES OF EMERGENCY MANAGEMENT Priorities – Major Goals
• To preserve life • To prevent deterioration before more definitive treatment can be
given. • To restore the patient to useful living ***injuries to face, neck and chest that
impairs respiration are the highest priorities PRINCIPLES • maintain patent airway
& provide adequate ventilation employing resuscitation measures when necessary
• control haemorrhage & its consequences • evaluate and restore cardiac
output • prevent and treat shock, maintain or restore effective circulation • carry out
a rapid initial and ongoing physical examination • assess whether or not the patient can
follow commands, evaluate the size & reactivity of pupils • start ECG monitoring if
appropriate • splint suspected fractures including cervical spines in patients with head
injuries • protect wounds with sterile dressings • start a flow sheet of
patient’s vital sign, neurological state, to guide in decision making TRIAGE •
comes from the French word trier • “to sort” • characteristic of a
hierarchy based on the potential for loss of life • advanced skill Emergent patients •
have the highest priority—their conditions • are life threatening, and they must be
seen immediately. Urgent Patients • patients have serious health problems, but not
immediately life-threatening ones; • they must be seen within 1 hour. Non-urgent
Patients • patients have episodic illnesses that can be addressed within 24 hours
without increased morbidity (Berner, 2001). “Fast-Track” Patients •
increasingly used class • These patients require simple first aid or basic primary care.
• They may be treated in the ED or safely referred to a clinic or physician’s office.
Cardiopulmonary Resuscitation • technique of basic life support • Purpose :
Oxygenating the brain and heart until appropriate, definitive medical treatment can restore
normal heart and ventillatory action. Indications • Cardiac arrest • Respiratory
arrest Assessment • Immediate loss of consciousness • Absence of breath sounds
or air movement through nose or mouth • Absence of palpable carotid or femoral pulse;
pulselessness in large arteries Complications • Post-resuscitation distress syndrome
(secondary derangements in multiple organs) • Neurologic impairment, brain damage
Airway Obstruction • Acute upper airway obstruction is a life-threatening medical
emergency. • Partial or Complete Pathophysiology • Upper airway obstruction
causes – Aspiration of foreign bodies – Anaphylaxis – viral or bacterial
infection – Trauma – inhalation or chemical burns – In adults, aspiration
of a bolus of meat is the most common cause of airway obstruction. – In children,
small toys, buttons, coins, and other objects are commonly aspirated in addition to food.
Clinical Manifestations • Choking • apprehensive appearance • inspiratory and
expiratory stridor • labored breathing • use of accessory muscles (suprasternal and
intercostal retraction) • flaring nostrils • increasing anxiety • Restlessness
• confusion. • Cyanosis and loss of consciousness develop as hypoxia worsens.
Assessment & diagnostic Findings • asking the person whether he or she is
choking and requires help • unconscious, inspection of the oropharynx may reveal the
offending object. • X-rays, laryngoscopy, or bronchoscopy also may be performed.
Management • Establishing an airway may be as simple as repositioning the
patient’s head to prevent the tongue from obstructing the pharynx. HEAD INJURY
• fractures to the skull and face, direct injuries to the brain (as from a bullet), and indirect
injuries to the brain (such as a concussion, contusion, or intracranial hemorrhage). •
Head injuries commonly occur from motor vehicle accidents, assaults, or falls. •
Concussion – A temporary loss of consciousness that results from a transient
interruption of the brain\'s normal functioning. • Contusion – A bruising of the
brain tissue. Actual small amounts of bleeding into the brain tissue. Intracranial hemorrhage:
• Significant bleeding into a space or a potential space between the skull and the brain.
• serious complication of a head injury with a high mortality due a rising intracranial
pressure (ICP) and the potential for brain herniation. • Classified as epidural
hematomas, subdural hematomas, or subarachnoid hemorrhages, depending on the site of
bleeding. Primary Assessment • Airway – assess for vomitus, bleeding, and
foreign objects – Ensure cervical spine immobilization • Breathing –
assess for abnormally slow or shallow respirations – An elevated carbon dioxide
partial pressure can worsen cerebral edema • Circulation – Assess pulse and
bleeding. • Disability – assess the patient\'s neurologic status. Primary
Intervention • Open the airway using the jaw-thrust technique without head tilt. Make
sure that you do not stimulate the gag reflex as this can cause increases in ICP. •
Administer high-flow O2: the most common cause of death from head injury is cerebral
anoxia. • Assist inadequate respirations with a bag-valve mask as necessary. •
Control bleeding do not apply pressure to the injury site. Apply a bulky, loose dressing. •
Initiate two I.V. lines. HEMORRHAGE • results in the reduction of circulating blood
volume is a primary cause of shock. • The goals of emergency management are
– to control the bleeding, maintain an adequately circulating blood volume for tissue
oxygenation, – prevent shock. • Patients who hemorrhage are at risk for cardiac
arrest caused by hypovolemia with secondary anoxia. Management • Fluid replacement
to maintain circulation. • Replacement fluids may include isotonic electrolyte solutions
(lactated Ringer’s, normal saline), colloid, and blood component therapy. • Blood
transfusion (“E” cases Rh- to women, Rh+ in men) HYPOVOLEMIC SHOCK
• Shock is a condition in which there is loss of effective circulating blood volume. •
Inadequate organ and tissue perfusion follow, ultimately resulting in cellular metabolic
derangements. • The underlying cause of shock (hypovolemic, cardiogenic, neurogenic,
or septic) must be determined. • Hypovolemia is the most common cause • Altered
tissue perfusion related to • failing circulation, • impaired gas exchange related to a
ventilation–perfusion imbalance, • decreased cardiac output related to decreased
circulating blood volume • The goals of treatment are to restore and maintain tissue
perfusion and to correct physiologic abnormalities. Clinical Manifestations • Decreasing
arterial pressure • Increasing pulse rate • Cold, moist skin • Delayed capillary
refill • Pallor • Thirst • Diaphoresis • Altered sensorium • Oliguria
• Metabolic acidosis • Hyperpnea Management • Ensure a patent airway and
maintain breathing • Ventillatory assistance • rapid physical examination •
rapid fluid and blood replacement • Blood component therapy • Intravenous fluids
are infused at a rapid rate • Infusion of lactated Ringer’s solution is useful initially
§ it approximates plasma electrolyte composition and osmolality, § allows time for
blood typing and screening, § Restores circulation, § Serves as an adjunct to blood
component therapy. DOWNLOAD