EMERGENCY AND DISASTER NURSING TERMS USE: Trauma - Intentional or unintentional wounds/injuries on the human body from particular

mechanical mechanism that exceeds the bodys ability to protect itself from injury Emergency Management - traditionally refers to care given to patients with urgent and critical needs. Triage - process of assessing patients to determine management priorities. First Aid - an immediate or emergency treatment given to a person who has been injured before complete medical and surgical treatment can be secured. BLS - level of medical care which is used for patient with illness or injury until full medical care can be given. ACLS ADVANCE CARDIAC LIFE SUPPORT- Set of clinical interventions for the urgent treatment of cardiac arrest and often life threatening medical emergencies as well as the knowledge and skills to deploy those interventions. Defibrillation - Restoration of normal rhythm to the heart in ventricular or atrial fibrillation Disaster - Any catastrophic situation in which the normal patterns of life (or ecosystems) have been disrupted and extraordinary, emergency interventions are required to save and preserve human lives and/or the environment.

Mass Casualty Incident - situation in which the number of casualties exceeds the number of resources. Post Traumatic Stress Syndrome - characteristic of symptoms after a psychologically stressful event was out of range of an normal human experience. EMERGENCY IT IS WHATEVER THE PATIENT OR THE FAMILY CONSIDERS IT TO BE. EMERGENCY NURSING - It is the nursing care given to patients with urgent and critical needs EMERGENCY NURSE - has a specialized education, training, and experience to gain expertise in assessing and identifying patients health care problems in crisis situations establishes priorities, monitors and continuously assesses acutely ill and injured patients, supports and attends to families, supervises allied health personnel, and teaches patients and families within a time-limited, high-pressured care environment DISASTER NURSING - a branch of emergency nursing, it refers to nursing care given to patients who are victims of disasters, whether it is manmade or natural phenomena. INCIDENT COMMAND SYSTEM - It is a management tool for organizing personnel, facilities, equipment, and communication for any emergency situation.

INCIDENT COMMANDER - The head of the incident command system He must be continuously informed of all the activities and informed about any deviation from the established plan

SCOPE AND PRACTICE OF EMERGENCY NURSING The emergency nurse has had specialized education, training, and experience. The emergency nurse establishes priorities, monitors and continuously assesses acutely ill and injured patients, supports and attends to families, supervises allied health personnel, and teaches patients and families within a time-limited, highpressured care environment. Nursing interventions are accomplished interdependently, in consultation with or under the direction of a licensed physician. Appropriate nursing and medical interventions are anticipated based on assessment data. The emergency health care staff members work as a team in performing the highly technical, handson skills required to care for patients in an emergency situation.

 Patients in the ED have a wide variety of actual or potential problems, and their condition may change constantly. Although a patient may have several diagnosis at a given time, the focus is on the most lifethreatening ones ISSUES IN EMERGENCY NURSING CARE Emergency nursing is demanding because of the diversity of conditions and situations which are unique in the ER. Issues include legal issues, occupational health and safety risks for ED staff, and the challenge of providing holistic care in the context of a fastpaced, technology-driven environment in which serious illness and death are confronted on a daily basis. The emergency nurse must expand his or her knowledge base to encompass recognizing and treating patients and anticipate nursing care in the event of a mass casualty incident. Legal Issues Includes: Actual Consent Implied Consent Parental Consent

Good Samaritan Law Gives legal protection to the rescuer who act in good faith and are not guilty of gross negligence or willful misconduct. Focus of Emergency Care Preserve or Prolong Life Alleviate Suffering Do No Further Harm Restore to Optimal Function

Golden Rules of Emergency Care Dos Donts -

Obtain Consent Think of the Worst Respect Victims Modesty & Privacy let the patient see his own injury Make any unrealistic promises

Stages of Crisis 1. Anxiety and Denial encouraged to recognize and talk about their feelings. asking questions is encouraged. honest answers given prolonged denial is not encouraged or supported 2. Remorse and Guilt verbalize their feelings 3. Anger way of handling anxiety and fear allow the anger to be ventilated 4. Grief help family members work through their grief letting them know that it is normal and acceptable Core Competencies in Emergency Nursing Assessment Priority Setting/Critical Thinking Skills Knowledge of Emergency Care Technical Skills Communication Assess and Intervene Check for ABCs of life A Airway B Breathing C - Circulation Team Members Rescuer Emergency Medical Technician

Guidelines in Giving Emergency Care A Ask for help I Intervene D Do no Further Harm

Paramedics Emergency Medicine Physicians Incident Commander Support Staff Inpatient Unit Staff

Estimated Blood Pressure SITE Radial SBP 80 D Disability - Evaluate LOC - Re-evaluate clients LOC - Use AVPU mnemonics E Exposure - Remove clothing - Maintain Privacy - Prevent Hypothermia III. Activate Medical Assistance Information to be Relayed: What Happened? Number of Persons Injured Extent of Injury and First Aid given Telephone number from where youre calling IV. Do Secondary Survey Interview the Patient S Symptoms A Allergies M Medication P Previous/Present Illness L Last Meal Taken E Events Prior to Accident Check Vital Signs

Emergency Action Principle I. Survey the Scene Is the Scene Safe? What Happened? Are there any bystanders who can help? identify as a trained first aider! II. Do a Primary Survey - organization of approach so that immediate threats to life are rapidly identified and effectively manage.

Femoral

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Carotid Primary Survey A - Airway/Cervical Spine - Establish Patent Airway - Maintain Alignment - GCS 8 = Prepare Intubation B Breathing - Assess Breath Sounds - Observe for Chest Wall Trauma - Prepare for chest decompression C Circulation - Monitor VS - Maintain Vascular Access - Direct Pressure

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Control of Hemorrhage

V. Triage comes from the French word trier, meaning to sort process of assessing patients to determine management priorities Categories: 1. Emergent - highest priority, conditions are life threatening and need immediate attention Airway obstruction, sucking chest wound, shock, unstable chest and abdominal wounds, open fractures of long bones 2. Urgent have serious health problems but not immediately life threatening ones. Must be seen within 1 hour Maxillofacial wounds without airway compromise, eye injuries, stable abdominal wounds without evidence of significant hemorrhage, fractures 3. Non-urgent patients have episodic illness than can be addressed within 24 hours without increased morbidity Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding, behavioral disorders or psychological disturbances.

3. Non-urgent patients have episodic illness than can be addressed within 24 hours without increased morbidity Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding, behavioral disorders or psychological disturbances.
TRIAGE CATEGORY PRIORITY COLOR

4. Expectant: Injuries are extensive and chances of survival are unlikely even with definitive care. 5. Fast-Track: Psychological support needed FIRST AID Role of First Aid Bridge the Gap Between the Victim and the Physician Immediately start giving interventions in prehospital setting Value of First Aid Training Self-help Health for Others Preparation for Disaster Safety Awareness

IMMEDIATE 1 DELAYED MINIMAL EXPECTANT 2 3 4

RED YELLOW GREEN BLACK

Field TRIAGE 1. Immediate: Injuries are life-threatening but survivable with minimal intervention. Individuals in this group can progress rapidly to expectant if treatment is delayed. 2. Delayed: Injuries are significant and require medical care, but can wait hours without threat to life or limb. Individuals in this group receive treatment only after immediate casualties are treated. 3. Minimal: Injuries are minor and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area.

BASIC LIFE SUPPORT - an emergency procedure that consists of recognizing respiratory or cardiac arrest or both the proper application of CPR to maintain life until a victim recovers or advance life support is available. Artificial Respiration a way of breathing air to persons lungs when breathing ceased or stopped function.

Respiratory Arrest a condition when the respiration or breathing pattern of an individual stops to function, while the pulse and circulation may continue. Causes: Choking, Electrocution, strangulation, drowning and suffocation. Table of Cardiopulmonary Resuscitation for Adult, Child & Infant
Compression Area Adult Lower half of the sternum but not hitting the xiphoid process: measure up to 2 fingers from substernal notch. Child Lower half of the sternum but not hitting the xiphoid process: measure up to 1 finger from substernal notch. Approximately 1 to 1 inches Heel of 1 hand. Infant Lower half of the sternum but not hitting the xiphoid process: 1 finger width below the imaginary nipple line. Approximately to 1 inch 2 fingers (middle & ring fingertips) 30:2 (1 or 2 rescuers) 5 cycles in 2 minutes

Positioning Open the Airway

Placed Supine on a firm and flat surface Check for foreign bodies then remove using finger sweep Head-tilt-chin-lift maneuver Jaw-thrust Maneuver

Assess for Breathing

WAYS TO VENTILATE THE LUNGS 1. MOUTH-TO-MOUTH = a quick, effective way to provide O2 and ventilation to the victim. 2. MOUTH-TO-NOSE = recommended when it is impossible to ventilate through the victims mouth. (Trismus, mouth injury) 3. MOUTH-TO-NOSE and MOUTH = if the pt. is an infant 4. MOUTH-TO-STOMA = used if the pt. has a stoma; a permanent opening that connects the trachea directly to the front of the neck. For Rescue Breathing Alone: Rate is 10-12 breaths in ADULT (1.5 - 2 sec/breath) ( 1 breath every 4 to 5 secs) Rate is 20 breaths for a CHILD and INFANT (1 1.5 sec/breath) ( 1 breath every 3 secs)

Bring cheek over the mouth and nose of the casualty Look for chest movement Listen for breath sounds Feel for breathing on your cheek The Casualty is NOT Breathing: if someone responds to your shout for help send that person to phone for ambulance if youre on your own, leave the casualty and make the phone call for yourself * never leave if the patient has collapsed as a result of trauma or drowning or if the casualty is a child 5 rescue breaths 2 rescue breaths Place mouth over the nose and mouth of the infant look for chest rising pinch nose and ventilate via mouth look for chest rising seal lips around the mouth and blow steadily for 1.5 2 seconds look for chest rising

Depth How to compress Compression -ventilation ratio Number of cycles per minute

Approximately 1 to 2 inches Heel of 1 hand, other hand on top. 30:2 (1 or 2 rescuers) 5 cycles in 2 minutes

Go for Help

30:2 (1 or 2 rescuers) 5 cycles in 2 minutes

Give Rescue Breaths

Procedure

Infant(0-1yr)

Child(1-8 yrs)

Adult

Safe Approach Assess for Response

Approach and assess situation Shout and gently pinch Gently shouting are you ok? then shake the victim

With your other hand grasp the far thigh just above the knee, then pull the casualty towards you and on to his or her side

When to STOP CPR: S SPONTANEOUS BREATH RESTORED T TURNED OVER THE MEDICAL SERVICES O OPERATOR IS EXHAUSTED TO CONTINUE P PHYSICIAN ASSUMES RESPONSIBILITY

The Casualty is Breathing: Place in recovery position Before moving casualty remove any objects safely from her pockets Kneel beside casualty, place arm nearest at right angles, and then bend elbow keeping the palm uppermost. Bring far arm across the casualtys chest and hold back of the casualtys hand against the nearest cheek

CRITERIA FOR NOT STARTING CPR - All patients in cardiac arrest receive resuscitation unless: 1. The pt. has a valid DNR order 2. The pt. has signs of irreversible death: rigor mortis, livor mortis, algor mortis, decapitation 3. No physiological benefit can be expected because the vital functions have deteriorated despite maximal therapy 4. Witholding attempts to resuscitate in the DR is appropriate for newly born infants with: - Confirmed gestation less than 23 weeks or birthweight less than 400 grams - Anencephaly When to Stop when the patient has spontaneous breathing when the first aider is too exhausted to continue when another first aider takes over when EMS arrives and takes over

COMPLICATIONS OF CPR: RIB FRACTURE STERNUM FRACTURE LACERATION OF THE LIVER OR SPLEEN PNEUMOTHORAX, HEMOTHORAX

CHAIN OF SURVIVAL EARLY ACCESS early recognition of cardiac arrest, prompt activation of emergency services EARLY BLS prevent brain damage, buy time for the arrival of defibrillator EARLY DEFIBRILLATION - 7-10% decrease per minute without defibrillation EARLY ACLS technique that attempts to stabilize patient

AIRWAY OBSTRUCTION KINDS OF AIRWAY OBSTRUCTION: 1. Anatomic Airway Obstruction 2. Mechanical Airway Obstruction TYPES OF AIRWAY OBSTRUCTION 1. Partial Airway Obstruction with Good Air Exchange 2. Partial Airway Obstruction with Poor Air Exchange 3. Complete Airway Obstruction Clinical Manifestations: UNIVERSAL DISTRESS SIGNAL (patient may clutch the neck between the thumb and fingers), choking, stridor, apprehensive appearance, restlessness. CYANOSIS and LOSS of CONSCIOUSNESS develop as hypoxia worsens.

For patient lying (unconscious): position patient at the back (supine); kneel astride the patients thigh Place HEEL of one HAND against the pts abdomen, place the second hand directly on the top of the fist. Make a quick UPWARD thrust FINGER SWEEP: used only in unconscious adult client Make a TONGUE-JAW LIFT. Opening the pts mouth by grasping both tongue and lower jaw between the thumb and fingers, and lifting the mandible. Insert index finger of other hand to scrape across the back of the throat Use a hooking action CHEST THRUST: used only in patients in advanced stages of pregnancy or in markedly obese clients a. Conscious Patient standing or sitting Stand behind the client with arms under patients axilla to encircle patients chest Place thumb side of fist on the MIDDLE of STERNUM, grasp with the other hand and perform BACKWARD thrust until foreign body is expelled.

D. ENDOTRACHEAL INTUBATION Indications: To establish an airway for patients cannot be adequately ventilated with an oropharyngeal airway To bypass upper airway obstruction To permit connection to ambubag or mechanical ventilator To prevent aspiration To facilitate removal of tracheobronchial secretions E. CRICOTHYROIDOTOMY a puncture or incision of the cricothyroid membrane to establish an emergency airway in certain emergency situations where endotracheal intubation or tracheostomy is not possible. indicated to pts. with trauma to head and neck, and in allergic reaction causing laryngeal edema use of gauge 11 needle or scalpel blade Nursing Actions: Extend the neck. Place towel roll beneath the shoulders Insert the needle at a 10 to 30 degree caudal direction in the midline jest above the upper part of the cricoid cartilage Listen for air passing back and forth Direct the needle downward and posteriorly, and tape it.

MANAGEMENT FOR AIRWAY OBSTRUCTION HEIMLICH MANEUVER (Subdiaphragmatic Abdominal Thrusts) For Standing or sitting conscious patient: Stand behind the patient; wrap your arms around the patients waist Make a FIST, placing thumb side of the fist against the pts abdomen, in the midline SLIGHTLY ABOVE the UMBILICUS and WELL BELOW the XIPHOID PROCESS Make a quick INWARD and UPWARD thrust. Each thrust is separated.

MEASURES TO ESTABLISH AIRWAY A. HEAD-TILT-CHIN-LIFT MANEUVER B. JAW-THRUST MANEUVER C. OROPAHRYNGEAL AIRWAY

INJURIES TO HEAD, SPINE, AND FACE A. HEAD INJURIES 1. OPEN HEAD INJURY skull is fractured 2. CLOSED HEAD INJURY skull is intact 3. CONCUSSION temporary loss of consciousness that results in transient interruption if the brains normal functioning 4. CONTUSSSION bruising of the brain tissue 5. INTRACRANIAL HEMORRHAGE significant bleeding into a space or potential space between the skull and the brain a. Epidural hematoma the most serious type of hematoma; forms rapidly and results from arterial bleeding forms between the dura and the skull from a tear int the meningeal area b. Subdural hematoma forms slowly and results from a venous bleed a surgical emergency c. Intracerebral hemorrhage bleeding directly into the brain matter ALERT: Assume cervical spine fracture for any patient with a significant head injury, until proven otherwise. PRIMARY ASSESSMENT: Assess for ABC SECONDARY ASSESSMENT: Change in LOC most sensitive indicator in the pts condition

CUSHINGS TRIAD ( bradypnea, bradycardia, widened pulse pressure) indicating increased intracranial pressure unequal or unresponsive pupils; impaired vision Battles sign bluish discoloration of the mastoid, indicating a possible BASAL SKULL FRACTURE Rhinorrhea or otorrhea indicative of CSF leak Periorbital Ecchymosis indicates anterior basilar fracture

ALERT: If basilar skull fracture or severe midface fractures are suspected, a nasogastric tube(NGT) is CONTRAINDICATED!

MANAGEMENT: Open airway by Jaw-Thrust Manuever, suction orally if needed Administer high flow oxygen: most common death is CEREBRAL ANOXIA In general, hyperventilate the patient to 20-25 bpm, causing cerebral vasoconstriction and minimizing cerebral edema Apply a bulky, loose dressing; dont apply pressure IV line of PNSS or Plain LR prepare to manage seizures maintain normothermia Medications: a. Diazepam b. Steroids c. Mannitol Prepare of immediate surgery if pt. shows evidence of neurologic deterioration

B. SKULL FRACTURES SIMPLE closed COMPOUND open LINEAR Fx common hairline break, w/o displacement of structure COMMINUTED Fx splinters or crushes the bone in several fragments DEPRESSED Fx pushes the bone toward the brain CRANIAL VAULT Fx top of the head BASILAR Fx base of the skull and frontal sinuses ALERT: Damage to the brain is the first concern, it is considered a neurosurgical condition In children, skulls thinness and elasticity allows a depression w/o a break in the bone CAUSES: Traumatic blows to the head, VA, severe beatings S/Sx: scalp wounds, agitation and irritability, loss of consciousness, labored breathing, abnormal deep tendon reflexes, altered pupillary and moor response IF CONSCIOUS: complains of persistent localized headache IF JAGGED BONE FRAGMENTS: may cause cerebral bleeding HALO SIGN blood-tinged spot surrounded by lighter ring IF SPHENOIDAL Fx: damages the optic nerve and may cause BLINDNESS IF TEMPORAL Fx: may cause unilateral deafness or facial paralysis

TREATMENT: For LINEAR FRACTURES: supporative (mild analgesics) cleaning and debridement of wounds If conscious: observed for 4 hours; if not, admit for evaluation if VS stable, may go home with instruction sheet For VAULT and BASILAR FRACTURES: Craniotomy to remove fragemnts anti-biotics Dexamethasone Osmotic Diuretics (MANNITOL) if increased ICP is present NURSING CONSIDERATIONS: maintain patent airway; nasal airway contraindicated to basilar fx support with O2 administration suction pt. through mouth not nose if CSF leak is present RHINORRHEA wipe it, dont let him blow it! OTORRHEA cover it lightly with sterile gauze, dont pack it! Position head on side Maintain a supine position with bed elevated to 30 degrees dont give narcotics or sedative assist in surgery, maintaining sterile technique C. CERVICAL SPINE INJURIES PRIMARY ASSESSMENT: immediate immobilization of the spine A B C ( Intercoastal paralysis w/ diapragmatic breathing)

SUBSEQUENT ASSESSMENT: Hypotension, bradycardia, hypothermia suggests SPINAL SHOCK Total sensory loss and motor paralysis below the level of injury MANAGEMENT: Nasotracheal intubation initaite IV access, monitor blood gas indwelling urinary catheterization prepare to manage seizures Meds: High dose steroids and diazepam D. MAXILLOFACIAL TRAUMA PRIMARY ASSESSMENT: Immobilization of spine while performing assessment ABC (tongue swelling, bleeding, broken or missed teeth) SUBSEQUENT ASSESSMENT: Paralysis if the upward gaze indicative of INFERIOR ORBIT FX Crepitus on nose indicates nasal fracture Flattening of the cheek and loss of sensation below the orbit indicates ZYGOMA (cheekbone) FX Malocclussion of teeth, trismus indicative of MAXILLA FX PRIMARY INTERVENTIONS: Insertion of oral airway or intubation Nasopharyngeal airway should only be used if no evidence of nasal fracture or rhinorrhea Apply bulky, loose dressing; apply ice to areas of swelling

INJURIES TO SOFT TISSUES, BONES AND JOINTS A. SOFT TISSUE INJURIES 1. CLOSED WOUND A. CONTUSION bleeding beneath the skin into the soft tissue B. HEMATOMA well-defined pocket of blood and fluid beneath the skin 2. OPEN WOUND A. ABRASION superficial loss of skin from rubbing or scraping B. LACERATION tear in the skin, can be insicional or jagged C. PUNCTURE penetration of a pointed object, can be penetrating or perforating D. AVULSION tearing off or loss of a flap of skin E. AMPUTATION traumatic cutting or tearing off of a finger, toe, arm or leg PRIMARY MANAGEMENT D- IRECT PRESSURE E- LEVATION P- RESSURE POINTS S- OAK, SOAP, SCRUB, SURGERY A- NTI-TETANUS, ANTIBIOTICS I- RRIGATE D- RESS B. INJURIES TO BONES AND JOINTS 1. FRACTURE a break in he continuity of the bone; occurs when stress is placed on a bone is greater than the bone can absorb

ALERT: fractured cervical spine, pelvis and femur may produce life threatening injuries; posterior dislocations of the hip are life- and limb-threatening emergencies due to potential blood loss. Clinical Manifestations: Pain and tenderness over fracture site Crepitus or grating over fracture site swelling and edema Deformity, shortening of an extremity or rotation of extremity EMERGENCY Management: IMMOBILIZE, INITIATE IV MANAGEMENT PROCESS OF FRACTURES REDUCTION setting the bone; refers to the restoration of the fracture fragments into anatomic position and alignment IMMOBILIZATION maintains reduction until bone healing occurs REHABILITATION Regaining normal function of the affected part use of cast and splint to immobilize extremity and maintain reduction Skin Traction force applied to the skin using foam rubber, tapes Skeletal Traction force applied to the bony skeleton directly, using wires, pins, tongs placed in the bone ORIF operative intervention to achieve reduction, alignment and stabilization

Endoprosthetic Replacement implantation of metal device NURSING CONSIDERATIONS: Elevate to prevent or limit swelling Apply ice packs or cold compress; not place directly in skin Splint and maintain in good alignment, immobilize the joint above and below the fracture Give pain medications as ordered Assist in casting; use the palm of your hands in holding a wet cast Avoid resting cast on hard surfaces or sharp edges Do neurovascular checks hourly for the first 24 hours Assess for COMPARTMENT SYNDROME check for 6 Ps If Compartment syndrome is suspected, do not elevate limb above the level of the cast Notify the physician Bivalve the cast 2. TRAUMATIC JOINT DISLOCATION - occurs when the surfaces of the bones forming the joint no longer in anatomic position ALERT: this is a medical emergency because of associated disruption of surrounding blood and nerve supplies * Subluxation partial disruption of the articulating surfaces Clinical Manifestations: Pain and deformity Loss of normal movement X-ray confirmation of dislocation w/o assoc. fracture

Management: Immobilize part, Secure reduction of dislocations manually (usually preferred under anesthesia) Nursing Considerations: Assess neurovascular status before and after reduction of dislocation Administer pain medications (NSAIDs) Ensure proper use of immobilization device (elastic bandage, splints) 3. SPRAIN an injury to the ligamentous structure surrounding a joint; usually caused by a wrench or twist resulting in a decrease joint stability Clinical Manifestations: Rapid swelling due to extravasation of blood w/n tissues Pain on passive movement of joint discoloration, and limited use or movement 4. STRAIN a microscopic tearing of the muscle cause by excessive force, stretching, or overuse Clinical Manifestations: Pain with isometric contractions Swelling and tenderness Hemorrhage in muscle

MANAGEMENT OF SPRAINS AND STRAINS

COMPRESSION (Elastic Bandage) REST ICE (for the first 24 hrs; 1 hr on, 2 hrs off during waking
hours) MEDICATIONS ( NSAIDs)

ELEVATION SUPPORT (Use of crutches, splints)

NURSING CONSIDERATIONS: Apply ice compress for the first 24 hrs to produce vasoconstriction, decrease edema, and reduce discomfort Apply warm compress after 24 hrs to promote circulation and absorption (20 to 30 minutes at a time) Educate to rest injured part for a month to allow healing Educate to resume activities gradually and to warm up SHOCK AND INTERNAL INJURIES A. SHOCK - Inadequate tissue perfusion, resulting in failure of one or more of the ff: a. pump failure of the heart b. Blood volume c. arterial resistance levels d. capacity of venous beds

- Can be classified as: A. HYPOVOLEMIC - occurs when significant amount of fluid is lost in the intravascular space (Ex. Hemorrhage, burns, fluid shifts) B. CARDIOGENIC occurs when the heart fails as a pump. Primary causes includes MI, dysrhythmias; Secondary causes includes mechanical restriction of cardiac function or venous obstruction like in Cardiac Tamponade, tension pneumothrorax, VCO C. SEPTIC SHOCK from bacteria and their products circulating in the blood PRIMARY INTERVENTIONS: Assess for ABC Resuscitate as necessary Administer O2 to augment O2-carrying capacity of arterial blood Start cardiac monitoring Control hemorrhage SUBSEQUENT ASSESSMENT: o Assess LOC, decreasing LOC indicates progression of shock o Monitor arterial blood pressure (narrowing pulse pressure, fall in systolic pressure) o Assess pulse quality and rate change (tachycardia, weak and thready) o Assess urinary output (25ml/hr may indicate shock) o Assess capillary perfusion o Assess for metabolic acidosis due to anaerobic metabolism of cells o Assess for excessive thirst, hyperthermia on septic shock

MANAGEMENT: Administer O2 via ET or nonrebreather face mask (if intubated, may be hyperventilated to control acidosis) Fluid resuscitation (2 large-bore IV lines, Ringers Lactate, BT) Insertion of an indwelling catheter Maintain patient in a supine position with legs elevated Continue to monitor VS, ECG, CVP, ABG, UO, HCT, Hgb,and electrolytes; refer changes on the following Maintain normothermia (high fever will increase the cellular metabolism effects of shock Medications: Inotropics, Vasopressor, and Antibiotics ELECTROCARDIOGRAM - It is a useful tool in the diagnosis of those conditions that may cause abberations in the electrical activity WAVE INTERPRETATIONS: P WAVE : Atrial Depolarization; first positive deflection Q WAVE: first negative deflection R WAVE: first positive deflection S WAVE: negative deflection, after R wave QRS COMPLEX: Ventricular Depolarization T WAVE: Ventricular Repolarization

Nursing Responsibilities during ECG Check order for ECG, in cases of arrest, prepare the machine at the bedside at ER Provide Privacy Instruct patient to lie still and avoid movement Remove metal objects on the patients (jewelries) Place Chest leads as labeled: Lead 1: Red, Right Arm Lead 2: Yellow, Left Arm Lead 3: Green, Left Foot Neutralizer: Black, Right foot V1: Red, 4th ICS, Right Sternal Border V2: Yellow, 4th ICS, Left sternal border V3: Green, midway between V2 and V4 V4: Brown, 5th ICS, Left MCL V5: Black, 5th ICS, LAAL V6: Violet, 5th ICS, LMAL B. BLUNT CHEST INJURIES - It is a trauma in the chest without an open wound usually cause by VA, blast injuries SIGNS/SYMPTOMS: RIB FRACTURES: tenderness, slight edema, pain that worsens with deep breathing and movement, shallow and splinted respirations STERNAL FRACTURES: persistent chest pain MULTIPLE RIB FRACTURES: - FLAIL CHEST (loss of chest wall integrity) decreased lung inflation, paradoxical chest movements extreme pain rapid and shallow respirations hypotension, cyanosis respiratory acidosis

COMPLICATIONS: 1. TENSION PNEUMOTHORAX a condition in which air enters the chest but cant be ejected during exhalation There is lung collapse and mediastinal shift S/Sx: tracheal deviation, cyanosis and severe dyspnea, absent breath sound on the affected side, agitation, JVD 2. HEMOTHORAX collection of blood in the pleural cavity, usually results from ribs, lacerating lung tisssue or an intercoastal artery It is the most common cause of shock following chest trauma 2. LACERATION or RUPTURE of AORTA immediately fatal 3. DIAPHRAGMATIC RUPTURE causes severe respi. Distress; if untreated abdominal viscera may herniate, compromising both circulation and vital capacity of lungs 4. CARDIAC TAMPONADE rapid unchecked rise in intrapericardia pressure that impairs diastolic filling of the heart results from blood or fluid accumulation in the pericardial sac ASSESSMENT AND DIAGNOSIS: Percussion: - Hemothorax: Dullness - Tension Pnuemothorax: tymphany Auscultation: - Tension Pnemothorax: PMI is deviated - Cardiac tamponade: muffled heart tones X-ray

Thoracentesis yeilds blood and serosanguinous fluid ECG Retrograde aortography reveals aortic laceration Echocardiography Computed Tomography

TREATMENT: Simple Rib Fractures mild analgesics, bed rest, apply heat incentive spirometry deep breathing, coughing and splinting Severe Rib Fractures intercoastal nerve blocks position for semi-fowlers, administer O2 Hemothorax Chest tube insertion at 5th-6th ICS anterior to MAL administer IV fuids, O2, Blood Transfusion Thoracotomy Thoracentesis TREATMENT: Tension Pneumothorax insertion of spinal, 14G or 16G needle into the 2nd ICS at MCL to release pressure Chest Tubes Surgical Repair Aortic Rupture/Laceration immediate surgery - synthetic grafts - aortic anastomosis O2, BT, IV

NURSING CONSIDEARTIONS: monitor VS, (q 15, first hour post thoracentesis and post CTT) After CTT insertion, encourage cough and breathing exersises Chest tubes should have continuous FLUCTUATIONS if BUBBLING, air leak is suspected if FLUCTUATION STOPS, mechanical blockage or lung has already expanded have an extra bottle with PNSS, clamps and sterile gauze at bedside in case of dislodgment, cover the opening with sterile/petroleum gauze to prevent rapid lung collapse Assist with proper positioning Bed Rest C. ABDOMINAL INJURIES 1. PENETRATING ABDOMINAL INJURY usually the result of gunshot wound or stab wounds; may cross the diaphragm and enters the chest 2. BLUNT ABDOMINAL INJURY caused by vehicular accidents or falls PRIMARY ASSESSMENT AND INTERVENTIONS: ASSESS ABC INITITATE RESUSCITATION AS NEEDED CONTROL BLEEDING AND PREPARE TO TREAT SHOCK IF THERE IS AN IMPALED OBJECT IN THE ABDOMEN, LEAVE IT THERE AND STABILIZE THE OBJECT WITH BULKY DRESSINGS

GENERAL INTERVENTIONS: Keep pt. quiet in the stretcher, any movement may dislodge a clot Cut the clothing, count the number of wounds, look for entrance and exit wounds Apply compression to external bleeding wounds double IV line and infuse Ringers Lactate Insert NGT to decompress the abdomen Cover protruding abdominal viscera w/ sterile saline dressings; dont attempt to place back the protruding organs Cover open wounds with dry dressings Insert indwelling catheter; if pelvic fracture is suspected, catheter should not be placed until integrity of urethra is ensured. Meds: Tetanus Prophylaxis, Antibiotics Assist in peritoneal lavage Prepare pt. for surgery if the condition persists. (Exploratory Laparotomy) ENVIROMENTAL EMERGENCIES 1. HEAT EXHAUSTION - It is the inadequacy or the collapse of peripheral circulation due to volume and electrolyte depletion ASSESSMENT: temperature may be normal or slightly elevated, hypotension, tachycardia, tachypnea, pale and moist skin, fatigue, headache, dizziness, syncope DIAGNOSTICS: hemoconcentration, hyponatremia or hypernatremia, ECG may show dysrhythmias MANAGEMENT: Move patient to a cool environment, remove all clothing Position the patient supine with the feet slightly elevated

Monitor VS every 15 mins and cardiac rhythm Educate to avoid immediate reexposure to high temperatures 2. HEATSTROKE - It is a combination of hyperpyrexia and neurologic symptoms. It caused by a shutdown or failure of the heat-regulating mechanisms of the body. CLINICAL MANIFESTATIONS: bizarre behavior or irritability, progressing to confusion, delirium and coma 40.6 degrees Celcius, hypotension, tachycardia, tachypnea skin may appear flushed and hot; at start it maybe moist progressing to dryness (Anhidrosis) NURSING ALERT: Elderly clients are high-risk to develop heat-stroke Once diagnosis is confirmed, it is imperative to reduce patients temperature MANAGEMENT: EVAPORATIVE COOLING, most effective, by spraying tepid water on skin while fans are used to blow Apply ice packs to necks, groin, axillae, and scalp Soak sheets/towels in ice water and place on patient If temp. fails to decrease, initiate core cooling: iced saline lavage, cool fluid peritoneal dialysis, cool fluid bladder irrigation Discontinue active cooling when the temp. reaches 39 degrees Celcius Oxygenate the pt. via ET or nonrebreather mask Monitor VS, ECG, and neurologic status

Start IV infusion using Ringers Lactate Anti-pyretics are not useful Indwelling catheterization WOF hypokalemia, metabolic acidosis, seizures

GOAL of MANAGEMENT: Rewarm without precipitating cardiac dysrhythmias. MANAGEMENT: Passive External Rewarming (temp above 28 degrees) - Remove all wet clothing, and replace with warm clothing Provide insulation by wrapping the patient in several blankets Provide warm fluids Disadvantage: slow process Active External Rewarming (temp above 28 degrees) - Provide external heat for patient- warm hot water bottles to the armpits, neck, or groin Warm water immersion - Disadvantages: 1. causes peripheral vasodilation, returning cool blood to the core, causing an initial lowering of the core temp. 2. Acidosis due to washing out of lactic acid from the peripheral tissue 3. An increased in metabolic demands before the heart is warmed to meet these needs. Active Core Rewarming (temp below 28 degrees) - Inhalation of warm, humidified O2 by mask or ventilator warmed IV fluids Warm gastric lavage - Peritoneal dialysis with warmed standard dialysis solution Cardiopulmonary bypass Disadvantage: invasiveness of the procedure

3. HYPOTHERMIA - It is a condition where the core temp. is less than 35 degrees Celcius as a result in the exposure to cold. 3 compensatory mechanisms: a. shivering produces heat thru muscular activity b. peripheral vasoconstriction to decrease heat loss c. raising basal metabolic rate NURSING ALERT: Elderly are greater risk for hypothermia due to altered compensatory mechanisms Extreme caution should be used in moving or transporting hypothermic pts., because the heart is near fibrillation threshold CLINICAL MANIFESTIONS: slow, spontaneous respirations heart sounds may not be audible even if its beating BP is extremely difficult to hear fixed dilated pupils, no pulse, no BP; initiate CPR drowsiness progressing to coma shivering is suppressed on temp. below 32.3 degrees ataxia cold diuresis fruity or acetone odor of breath

4. NEAR-DROWNING - It is a survival for atleast 24 hours after submersion, with most common consequence of hypoxemia. - Hypoxia and acidosis are common problems of the victim. - Resultant pathophysiologic changes and pulmonary injury depend on type of fluid and the volume aspirated. a. Fresh water aspiration- results in loss of surfactant, hence an inability to expand lungs b. Saltwater aspiration- leads to pulmonary edema from the osmotic effect of salt within the lungs. Clinical Manifestations: -difficulty of breathing -hypothermia -cyanosis -chills MANAGEMENT: Immediate CPR Endotracheal intubation with PEEP VS, check degree of hypothermia Rewarming procedures Intravascular volume expansion and inotropic agents ECG Indwelling catheterization NGT insertion

TOXICOLOGIC EMERGENCIES ASSESSMENT: ABC Identify the poison Obtain blood and urine tests; gastric contents may be sent to laboratory Monitor neurologic status Monitor fluid and electrolytes GENERAL INTERVENTIONS: Initiate large-bore IV access, monitor shock Prevent aspiration of gastric contents by positioning head on side Maintain seizures precaution MINIMIZING ABSORPTION Administration of activated charcoal with a cathartic to hasten secretion. Induction of emesis with syrup of ipecac; done only in patients with good gag reflex and is conscious. Adult dose is 30 ml by mouth followed by 2 glasses of water; Pedia dose is15 ml followed by 8 16 oz. of water. NURSING ALERT: Do not induce emesis after ingestion of caustic substances, hydrocarbons, iodides, silver nitrates, petroleum distillates; to a patient having seizure or to pregnant patient. Gastric lavage for the obtunded patient. Save gastric aspirate for toxicology screen. Procedure to enhance the removal of ingested substance if the patient is deteriorating.

1. Forced diuresis with urine pH alteration to enhance renal clearance. 2. Hemoperfusion (process of passing blood through an extracorporeal circuit and a cartridge containing an adsorbent, such as charcoal, after which the detoxified blood is returned to the patient) 3. Hemodialysis to purify and accelerate the elimination of circulating toxins. 4. Repeated dose of charcoal. 5. Providing an antidote antidote is a chemical or physiologic antagonist that will neutralize the poison. GASTRIC LAVAGE PURPOSES: 1. To remove unabsorbed poison after ingestion. 2. To diagnose and treat gastric hemorrhage and for the arrest of hemorrhage. 3. To cleanse stomach before endoscopic procedures. 4. To remove liquid or small particles of material from the stomach. NURSING CONSIDERATIONS Insertion of NGT or OGT. Place patient on left lateral position with head lower 15 degrees downward. Elevate funnel and pour approx. 150 200 ml. Lavage fluid is left in place for about one minute before allowed to drain Save samples of first two washings. Repeat lavage procedure until the returns are relatively clear and no particular matter is seen. At the completion of the lavage:

1. Stomach may be left empty. 2. An Adsorbent may be instilled in the tube and allowed to remain in the stomach. 3. A saline cathartic may be instilled in the tube. Pinch off the tube during removal or maintain suction while tubing is being withdrawn. Give the patient a cathartic if prescribed. Warn patient that stool will turn black from the charcoal. 2. CARBON MONOXIDE POISONING - It is an example of inhaled poison and results in the incomplete hydrocarbon combustion Carbon monoxide exerts its toxic effects by binding to circulating hemoglobin to reduce the oxygen carrying capacity of the blood. Carbon monoxide and hemoglobin is 200 300 times affinity compared to oxygen and hemoglobin. Creation of carboxyhemoglobin resulting to tissue anoxia. CLINICAL MANIFESTATIONS Respiratory depression, stridor. Confusion progressing to coma. Headache, muscular weakness, palpitation, and dizziness. Skin is pink in color, cherry red, or cyanotic. ABG: carboxyhemoglobin level is 12% (Normal), 30 40% severe carbon monoxide poisoning. MANAGEMENT: Provide 100% oxygen by tight-fitting mask (the elimination half life of carboxyhemoglobin, in serum, for a person breathing room air is 5 hours

and 20 minutes. If patient breaths 100% oxygen the half life is reduced to 80 minutes 100% oxygen in hyperbaric chamber reduces halflife to 20 minutes. Intubate if necessary to protect airway. Continuous ECG monitoring, treat dysrhythmias. Correct acid-base and electrolyte imbalances. Continuous observation of psychoses, spastic paralysis, visual disturbances, and deterioration of personality may persist after resuscitation and may be symptoms of permanent CNS damage.

- Have epinephrine on hand - Wear emergency medical bracelet indicating hypersensitivity. - If sting occurs, remove stinger with one quick scrape of fingernail. - Do not squeeze venom sack, because this may cause additional venom to be injected. - Avoid insect feeding areas. 4. SNAKE BITES CLINICAL MANIFESTATIONS: - Burning pain, swelling, and numbness of the site. Hemorrhagic blisters may occur after few hours of bite and entire extremity may become edematous. WOF signs of systemic reactions (nausea, sweating, weakness, lightheadedness, initial euphoria followed by drowsiness, dysphagia, paralysis of various muscle groups, shock, seizures, and coma). MANAGEMENT: Wash the site of bite, keep the patient calm and immobilize extremity. Administer O2 and start IV line. Administer anti-venin and be alert to allergic reaction. Administer vasopressors in the treatment of shock. 5. ALCOHOL WITHDRAWAL DELIRIUM a.k.a Delirium Tremens or Alcoholic Hallucinosis An acute toxic state that follows a prolonged bout of steady drinking or sudden withdrawal from prolonged intake of alcohol.

Symptoms begins as early as 4 hours after reduction of alcohol intake and peaks at 24 - 48 hours but may last up to 2 weeks.

ALCOHOLISM a chronic disease or disorder characterized by excessive alcohol intake and interference in the individuals health, interpersonal realtionship and economic functioning Considered to be present when there is .1% or 10 ml for every 1000 ml of blood At .1 - .2%, there is low coordination At .2 - .3%, there is ataxia, tremors, irritability, and stupor

3. INSECT STINGS - These are injected poisons that can produce either local or systemic reactions. Local reactions are characterized by pain, erythema and edema at the site of injury. Systemic reactions usually begin within minutes. (Unconsciousness, laryngeal edema, bronchospasm, and cardiovascular collapse. MANAGEMENT: ABC Epinephrine is the drug of choice give SQ. Administer bronchodilator. Initiate IV with Ringers Lactate. Prepare for CPR. NURSING CONSIDERATIONS: Apply ice packs to site to relieve pain. Elevate extremities with large edematous local reaction. Administer anti histamine for local reaction. Clean wounds thoroughly with soap and water or antiseptic solution. Educate patient.

At .3 and above, there is unconsciousness COMMON BEHAVIORAL PROBLEMS: 5 Ds D-enial D-ependency D-emanding D-estructive D-omineering COMMON WITHDRAWAL SIGNS AND SYMPTOMS: HALLUCINATIONS (VISUAL AND TACTILE)

INCREASED VITAL SiGNS TREMORS SWEATING AND SIEZURE

COMMON DEFENSE MECHANISMS: DENIAL

RATIONALIZATION ISOLATION PROJECTION

PRIORITY NURSING DIAGNOSIS: - INEFFECTIVE INDIVIDUAL COPING DRUG OF CHOICE for aversion therapy of an alcoholic: - DISULFIRAM (antabuse) Instruct patient to avoid, when taking Disulfiram: MOUTH WASH

OVER THE COUNTER COLD REMIDIES FOOD SAUCES MADE UP OF WINE FRUIT FLAVORED EXTRACTS AFTERSHAVE LOTIONS VINEGAR SKIN PRODUCTS
MANAGEMENT: Protect patient from injury, diazepam or phenytoin for seizure control as prescribed. Monitor VS every 30 minutes. Use a non-alcohol skin preparation, draw blood for measurement of ethanol concentration, toxicologic screen for other drug abuse. Maintain electrolyte balance and hydration. Observe for hypoglycemia. Administer thiamine followed by parenteral dextrose if liver glycogen is depleted. Give orange juice, gatorade, or other carbohydrates to stabilize blood sugar. Place patient in a private room with close observation. BEHAVIORAL EMERGENCIES - It is an urgent, serious disturbances of behavior, affect, or thought that makes the patient unable to cope with his life situation and interpersonal relationship

1. VIOLENT PATIENTS - Is usually episodic and is a means of expressing feelings of anger, fear and hopelessness about a situation. Manage through: a. Establish control, keeping the door open, and be in clear veiw of staff b. Ask if he has a weapon, avoid touching an agitated pt. c. Adopt a calm, nonconfrontational approach d. Provide emotional support; CRISIS INTERVENTION 2. SUICIDE - Ultimate form of self-destruction; cry for help - Major Interventions: PREVENTION and LISTEN RISK FACTORS

PRIORITY NURSING DIAGNOSIS: Risk for Injury, Self-directed NURSING INTERVENTIONS: Provide one-on-one monitoring Have frequent unscheduled rounds Avoid use of metals and glass utensils Remove shampoos, perfumes, medicines at the bedside Monitor for signs of impending suicide (giving away of valued possession) 3. RAPE TRAUMA SYNDROME According to RA 8353, RAPE refers to the insertion of penis into the mouth, vagina, anus of a victim Insertion of any object into the mouth or anus It is generally considered as an act of hostility, anger, or violence ELEMENTS OF RAPE: Use of threat/force lack of consent of the victim Actual penetration of the penis into the vagina Different Kinds of Rape: POWER done to prove ones masculinity ANGER done as a means of retaliation SADISTIC done to express erotic feelings RAPE TRAUMA SYNDROME It refers to a group of signs and symptoms experienced by a victim in reaction to rape

SEX (female attempts, male commits suicide) UNSUCCESSFUL PREVIOUS ATTEMPT IDENTIFICATION with family member committed suicide CHRONIC ILLNESS DEPRESSION/DEPENDENT PRERSONALITY AGE (18-25 AND ABOVE 40)/ALCOHOLISM LETHALITY OF PREVIOUS ATTEMPTS

4 Phases 1. ACUTE PHASE characterized by shock, numbness and disbelief 2. DENIAL characterized by victims refusal to talk about the event 3. HEIGHTENED ANXIETY characterized by fear, tension, and nightmares 4. REORGANIZATION victims life normalizes PRIORITY NURSING CARE: Preservation of evidences TREATMENT: Crisis Intervention BURN TRAUMA - Is the damage caused to skin and deeper body structures by heat (flames, scald, contact with heat) , electrical, chemical or radiation FACTORS DETERMINING SEVERITY OF BURN: 1. age mortality rates are higher for children < 4 yrs of age and for clients > 65 yrs of age 2. Patients medical condition debilitating disorders such as cardiac, respiratory, endocrine and renal disorders negatively influence the clients response to injury and treatment. mortality rate is higher when the client has a pre-existing disorder at the time of the burn injury 3. location burns on the head, neck and chest are associated with pulmonary complications; burns on the face are associated with corneal abrasion; burns on the ear are associated with auricular chondritis; hands and joints require intensive therapy;

the perineal area is prone to autocontamination by urine and feces; circumferential burns of the extremities can produce a tourniquet-like effect and lead to vascular compromise (compartment syndrome). 4. Depth Classification 1st degree superficial Affected Part Epidermis Description of Wound Pin, painful sunburn Blisters form after 24 hours What to Expect Discomfort last after 48 hrs; heals in 3-7 days

2nd degree partial thickness

Pediermis and part of the dermis

Red, wet blisters, bullae very painful

Heals in 2-3 weeks, in no complication

2nd degree deep partial thickness

Only the skin appendages in the hair follicle remain

Waxy white, difficult to distinguish from 3rd degree except hair growth becomes apparent in 7-10 days, little or no pain Dry, leathery, may be red or black May have thrombosed veins Marked edema Distal circulation may be decreased Painless

Slow to heal 94-8 weeks) surgical incision and grafting unless has complication

3rd degree Full thickness

Epidermis, dermis and subcutaneous tissue . no skin appendages

Requires excision and grafting. 10- 14 days for graft to revascularize

4th degree deep full thickness

Skin, muscle, tendon, bonde

Dry, charred, bone may be visible

Requires excision, grafting and sometimes amputation

5. Size: Rule of nine Assessment Child < 3 years old 18% 9% 18% 18% 14% 1% Adult

Head and neck 1 arm Posterior trunk Anterior trunk 1 leg Perineum

9% 9% 18% 18% 18% 1%

6. Temperature determines the extent of injury 7. Exposure to the Source Thermal Burns caused by exposure to flames, hot liquids, steam or hot objects Chemical Burns caused by tissue contact with strong acids, alkalis or organic compounds Electrical Burns result in internal tissue damaging, alternating current is more dangerous than direct current for it is associated with cardiopulmonary arrest, ventricular fibrillation, titanic muscle contractions, and long bone and vertebral fractures. Radiation Burns are caused by exposure to ultraviolet light, x-rays or a radioactive source.

Types of Burns and their Treatment: Scald burn caused by hot liquid immediately flush the burn area with water (under a tap or hose for up to 20 min) if no water is readily available, remove clothing immediately as clothing soaked with hot liquid retains heat Flame Smother the flames with a coat or blanket, get the victim on the floor or ground (stop, drop, and Roll) Prevent victim from running If water is available, immediately cool the burn area with water If water is not available, remove clothing; avoid pulling clothing across the burnt face Cover the burn area with a loose, clean, dry cloth to prevent contamination Do not break blisters or apply lotions, ointments, creams or powder Airway if face or front of the trunk is burnt, there could be burns to the airway there is a risk of swelling or air passage, leading to difficulty in breathing Smoke inhalation Urgent treatment is required with care of the airway, breathing and circulation When 02 in the air is used up by fire, or replaced by other gases, the oxygen level in the air will be dangerously low

Spasm in the air passages as a result of irritation by smoke or gases Severe burns to the air passages causing swelling and obstruction Victim will show signs and symptoms of lack of O2. He may also be confused or unconscious Electrical check for Danger turn of the electricity supply if possible avoid any direct contact with the skin of the victim or any conducting material touching the victim until he is disconnected once the area is safe, check the ABCs if necessary, perform rescue breathing or CPR Chemical Flood affected area with water for 20-30 min Remove contaminated clothing If possible, identify the chemical for possible subsequent neutralization Avoid contact with the chemical Sunburn Exposure to ultraviolet rays in natural sunlight is the main cause of sunburn General skin damage and eventually skin cancer develops The signs and symptoms of sunburn are pain, redness and fever