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Emergency - Outline
Generalist Nursing Practice IV: Tertiary Care Across the Lifespan (NURS 4889)
Temple University
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Emergency, Terrorism, and Disaster Nursing:
Emergency Nursing: - Patients with life-threatening or potentially life-threatening problems enter the hospital through the emergency department (ED) - Triage o Process of rapidly determining patient acuity o Represents a critical assessment skill o Categorizes patients so most critical are treated first - Primary survey o Focuses on airway, breathing, circulation, and disability, exposure (ABCDE) o Identifies life-threatening conditions - If life-threatening conditions related to ABCD are identified during primary survey, interventions are started immediately and before proceeding to the next step of the survey
Primary Survey: - Airway with cervical spine stabilization and/or immobilization o Signs/symptoms in patient with compromised airway Dyspnea Inability to vocalize Presence of foreign body in airway Trauma to face or neck - Nearly all immediate trauma deaths occur because of airway obstruction. - Saliva, bloody secretions, vomitus, laryngeal trauma, dentures, facial trauma, fractures, and the tongue can obstruct the airway. - Patients at risk for airway compromise include those who have seizures, near-drowning, anaphylaxis, foreign body obstruction, or cardiopulmonary arrest. - Maintain airway: least to most invasive method o Open airway using the jaw-thrust maneuver Jaw-thrust maneuver is the recommended procedure for opening the airway of an unconscious patient with a possible neck or spinal injury. The patient should be lying supine with the rescuer kneeling at the top of the head. The rescuer places one hand on each side of the patient’s head, resting his or her elbows on the surface. The rescuer grasps the angles of the patient’s lower jaw and lifts the jaw forward with both hands without tilting the head. o Suction and/or remove foreign body o Insert nasopharyngeal/oropharyngeal airway o Endotracheal intubation - Rapid-sequence intubation o Preferred procedure for unprotected airway o Involves sedation or anesthesia and paralysis - Stabilize/immobilize cervical spine o Face, head, or neck trauma and/or significant upper torso injuries o At the scene of the injury, the cervical spine is immobilized with a rigid cervical collar or a cervical immobilization device (CID) (also known as “head blocks”). - Breathing o Assess for dyspnea, cyanosis paradoxic/asymmetric chest wall movement, decreased/absent breath sounds, tachycardia, hypotension o Many conditions cause breathing alterations including fractured ribs, pneumothorax, penetrating injury, allergic reactions, pulmonary emboli, and asthma attacks. o Administer high-flow O 2 via a nonrebreather mask o Bag-valve-mask (BVM) ventilation with 100% O 2 and intubation for life-threatening conditions
o Monitor patient response o Life-threatening conditions, such as tension pneumothorax and flail chest, can severely and quickly compromise ventilation.
- Circulation o Check central pulse (peripheral pulses may be absent because of injury or vasoconstriction) o If a pulse is felt, assess the quality and rate. Assess the skin for color, temperature, and moisture. Altered mental status and delayed capillary refill (longer than 3 seconds) are the most significant signs of shock. Take care when evaluating capillary refill in cold environments because cold delays refill. o Insert two large-bore IV catheters o Initiate aggressive fluid resuscitation using normal saline or lactated Ringer’s solution o Insert IV lines into veins in the upper extremities unless contraindicated, such as in a massive fracture or an injury that affects limb circulation. o Apply direct pressure with a sterile dressing to any obvious bleeding sites. o Obtain blood samples for typing to determine ABO and Rh group.
- Disability o Measured by patient’s level of consciousness o AVPU A = alert V = responsive to voice
P = responsive to pain U = unresponsive o Glasgow Coma Scale o Pupils
- Exposure/environmental control o Remove clothing to perform physical assessment o Prevent heat loss Once the patient is exposed, it is important to limit heat loss, prevent hypothermia, and maintain privacy by using warming blankets, overhead warmers, and *warmed IV fluids.
Secondary Survey: - Brief, systematic process to identify all injuries - Full set of vital signs/five interventions/facilitate family presence o Complete set of vital signs Blood pressure (bilateral) Heart rate Respiratory rate
Oxygen saturation Temperature
o Initiate ECG monitoring o Initiate pulse oximetry o Insert indwelling catheter o Insert orogastric/nasogastric tube o Collect blood for laboratory studies -> Cultures before abx o Family presence: family members who wish to be present during invasive procedures/resuscitation view themselves as participants in care o Their presence should be supported
Give comfort measures o Pain management strategies o Combination of: Pharmacologic measures Nonpharmacologic measures
History and head-to-toe assessment o Obtain history of event, illness, injury from patient, family, and emergency personnel o Perform head-to-toe assessment to obtain information about all other body systems
Inspect the posterior surfaces o Logroll patient (while maintaining cervical spine immobilization) to inspect the posterior surfaces
National Disaster Medical System: organizes and trains volunteer disaster medical assistance teams (DMATs) o DMATs: categorized according to ability to respond to an MCI Terrorism:
Involves overt actions for the expressed purpose of causing harm o Disease pathogens (e., bioterrorism) o Chemical agents o Radiologic/nuclear, explosive devices
Bioterrorism: - Anthrax, plague, and tularemia: treated with antibiotics assuming sufficient supplies and nonresistant organisms - Smallpox can be prevented or ameliorated by vaccination even when first given after exposure - The agents most likely to be used in a terrorist attack are anthrax, smallpox, botulism, plague, tularemia, and hemorrhagic fever. - Botulism is treated with antitoxin. - There is no established treatment for most viruses that cause hemorrhagic fever.
Chemical Agents of Terrorism: - Categorized by target organ or effect o Sarin: toxic nerve gas that can cause death within minutes of exposure Enters body through eyes and skin Acts by paralyzing respiratory muscles o Antidotes for nerve agents: atropine, pralidoxime chloride o Phosgene: colorless gas normally used in chemical manufacturing If inhaled at high concentrations for long enough period, causes severe respiratory distress, pulmonary edema, and death o Mustard gas: yellow to brown in color with garlic-like odor Irritates eyes and causes skin burns/blisters
Radiologic/Nuclear Agents of Terrorism: - Radiologic dispersal devices (RRDs) (“dirty bombs”): mix of explosives and radioactive material o When detonated, blast scatters radioactive dust, smoke, and other material into environment, resulting in radioactive contamination o Main danger from RRDs: explosion o The radioactive materials used in an RRD (e., uranium, iodine-131) do not usually generate enough radiation to cause immediate serious illness, except to those victims who are in close proximity to the explosion. - Ionizing radiation (e., nuclear bomb, damage to a nuclear reactor) - Serious threat to safety of casualties and environment - Exposure may or may not include skin contamination with radioactive material - Initiate decontamination procedures immediately if external radioactive contaminants are present. - Acute radiation syndrome develops after a substantial exposure to ionizing radiation and follows a predictable pattern.
Explosive Devices as Agents of Terrorism: - Result in one or more of following types of injuries: blast, crush, or penetrating o Blast injuries from supersonic overpressurization shock wave that results from explosion Damage to the lungs, middle ear, gastrointestinal tract - Crush injuries (i., blunt trauma) often result from explosions that occur in confined spaces and result from structural collapse (e., falling debris).
- Some explosive devices contain materials that are projected during the explosion (e., shrapnel), leading to penetrating injuries.
Emergency - Outline
Course: Generalist Nursing Practice IV: Tertiary Care Across the Lifespan (NURS 4889)
University: Temple University
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