Disaster Nursing Powerpoint

8/11/2019 Disaster Nursing Powerpoint

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EMERGENCY NURSING

AMB UL A NCEAMBULANCE


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NURSES AND EDUCATION

Education is the most powerful

weapon which you can use to

change the world.Nelson Mandela


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SPECIFIC OBJECTIVES:At the end of the ER lecture discussion, the students will

be able to:

1. Define and explain emergency care nursing.

2. Identify the different functional requirements of anER department.

3. States the legal aspects involved in various

emergency situation.

4. Explain the Principles of ER care.


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SPECIFIC OBJECTIVES:

5. Discuss the process of assessment in various emergencysituations.

6. Utilize the nursing process in the care of patients in

emergency situation. 7. Formulate appropriate nursing diagnosis as to priority.

8. Evaluate outcome of the nursing care goals for each

situation.


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INTRODUCTION

Emergency Nursingis a nursing specialty in which nursescare for patients in the emergency or critical phase of theirillness or injury.

While this is common to many nursing specialties, the key

difference is that an emergency nurse is skilled at dealingwith people in the phase when a diagnosis has not beenmade and the cause of the problem is not known.


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emergency managementrefers to care to patientswith urgent and critical needs.

- Its philosophy include the concept that anemergency is whatever the patient or the

family considers it to be.- Large number of people seek emergency care for

serious life-threatening conditions.


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Emergency departmentsoften the first place wherevictims of family violence, abuse, or neglect go to seek for

help. Emergency Assessment:

A systematic approach to the assessment of anemergency patient is essential.

Often the most dramatic injury is not the most serious.


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Scope and practice of

Emergency Nursing

Specialized education

Expertise in assessing and identifying patients

health care problems

Establishes priorities, monitors acutely ill, andinjured patients

Nursing interventions are accomplished

independently


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Providing Holistic care

1. Patient-focused interventions

2. Family-focused interventions

*anxiety and denial

*remorse and guilt

*anger

*griefPsychological Considerations

Body trauma is an insult to physiologic and psychologicalhomeostasis, it requires both physiologic and psychological

healing.


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Approach to the Patient:

1. Understand and accept the basic anxieties of the acutelytraumatized patient. Be aware of the patient fear of

death, mutilation, and isolation.2. Personalize the situation as much as possible. Speak, react

and respond in a warm manner.

3. Give an explanation on a level that the patient can grasp.

An informed patient can cope withpsychological/physiologic stress in a more positive manner.

4. Accept the rights of the patient and family to have anddisplay their own feelings.


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Approach to the patient cont. . .

5. Maintain a calm and reassuring manner.

6. Understand and support the pts. feeling concerning loss ofcontrol( emotional, physical and intellectual).

7. Treat the unconscious patient as if conscious. Touch, callby name, and explain every procedure that is done. Avoid

making negative comments about pts condition.8. Orient the patient to person, time and place as soon as

he/she is conscious, reinforce by repeating thisinformation.

9. Bring the patient back to reality in a calm and reassuringmanner.


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Approach to family:

1. Inform where the patient is and give as much information

as possible about the treatment he/she is receiving.2. Recognize the anxiety of the family and allow them to talkabout their feelings. Allow the expressions of remorse,anger, guilt and criticism.

3. Deal with reality as gently and quickly as possible; avoidencouraging and supporting denial.

4. Assist the family to cope with sudden and unexpecteddeath.


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5. Some helpful measures include the following:

- Take the family to a private place.- Talk to all of the family together so they can mourn

together.

- Assure the family that everything possible was done:

inform them of the treatment rendered- Avoid volunteering unnecessary information ( patient was

drinking and etc.)

- Be recognizant of cultural and religious beliefs and needs.


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QUALITIES of an Emergency nurse:

has had specialized education, training, and experienceto gain expertise in assessing and identifying patientshealth care problems in crisis situations

establishes priorities

monitors and continuously assesses acutely ill andinjured patients

supports and attends to families

supervises allied health personnel

Teaches patients and families within a time-limitedhigh-pressured care environment.


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DELEGATION

A process by which responsibility andauthority for performing tasks aretransferred from one individual to anotherwho accepts that authority andresponsibility but remains accountable forthe task

5 Rs

- Right task

- Right circumstance

- Right person

- Right communication

- Right feedback


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Scope of Practice

RN

- Decision maker/ delegator

- Unstable patients

- Newly admitted or transferred patients- Health teachings or discharge teachings

- Blood transfusion/ chemotherapy/ central

catheters


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LPN/LVN

- Technical doers

- Stable patients with predictable outcomes- Wound care, traction, casts

- NGT and colostomy care

- Oral meds and parenteral (IM, SQ) therapies,

NO IV push- Data collection

CAN

- Stable patients

- Routine of care (eg. Ambulating, turning, I

and O, feeding, measurements of ht. and wt.)


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- Indirect activities: bed making,

transporting patients, stocking supplies)

Steps:

1. Define the task

2. Determine the delegate

3. Communicate expectations and outcomes4. Reach mutual agreement about the task

5. Monitor the task and provide guidance

6. Evaluate results

7. Provide feedback


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PRIORITIZATION

- decisions in which needs or problems require

immediate attention or action and which onescould be delayed at a later time if they are not

urgent

Principles

a. Needs that are life threatening or could result toharm if left untreated are high priorities

b. Actual problems have high priority than potential

problems

c. Problems identified by client are of higherpriority

d. Principles of Maslow or ABC may guide

decisions


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ISSUES IN EMERGENCY NURSING CARE

Documentation of consent

Consent to examine and treat the patient is part of the EDrecord.

Patient must consent to invasive procedure unless he/she isunconscious or in critical condition and unable to makedecisions.

If brought unconscious w/out family or friends, it must be

documented.

Limitin xp s t h lth isks


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Limiting exposure to health risks

> All health care providers should adhere strictly tostandard precautions for minimizing exposure.


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REMEMBER!!!

UNIVERSAL PRECAUTIONS:

The routine use of appropriate barrierprecautions to prevent skin and mucousmembrane exposure when contact with blood

or other body fluids of any individual mayoccur or is anticipated.

Universal Precautions apply to blood and toall other body fluids with potential for

spreading any infections.


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PRINCIPLES OF EMERGENCY CARE

TRIAGE

>trier, French word meaning, to sort.

>used to sort patients into groups based on the severity

of their health problems and the immediacy with whichthese problems must be treated.

>an advanced skill

Most of the patients entering an emergency department are

greeted by a triage nurse.


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Triage means to sort

Looks at medical needs and urgency of eachindividual patient

Sorting based on limited data acquisition

Also must consider resource availability


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Routine hospital triage directs all available resources to

the patients who are most critically ill, regardless of thepotential outcome.

Field triage hospital triage during a disaster.

>scarce resources must be used to benefit the mostpeople possible.

***this distinction affects triage decisions***


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POINTS TO REMEMBER ABOUT

TRIAGE CONSIDERATIONS

Identification of the patient

Assessment

Facilitation of treatment Communication

Legal liability

- Personal responsibility for ones own acts

- Reasonable care under the circumstances

- Care in accordance with accepted standards


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PERSONNEL IN THE TRIAGE SYSTEM

Emergency squad personnel

Nursing personnel

Physician staff

Hospital administration


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Ethical Justification

This is one of the few places where a "utilitarian rule" governsmedicine: the greater good of the greater number rather

than the particular good of the patient at hand. This rule isjustified only because of the clear necessity of general

public welfare in a crisis.A. Jonsen and K. Edwards, Resource Allocation in Ethics in

Medicine, Univ. of Washington School of Medicine,http://eduserv.hscer.washington.edu/bioethics/topics/resal

l.html


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TRIAGE SYSTEM CATEGORIES Emergent 1 have the highest priority

> life-threatening conditions and must be seen immediately.Conditions requiring immediate medical intervention. Any delay intx is potentially life or limb threatening.Condition such as : Airway compromise, cardiac arrest, Severeshock, cardiac arrest, cervical spine injury, multiplesystem trauma

Altered level of consciousness, eclampsia

Urgent serious health problems, but not immediately life-threatening ones; must be seen within an hour.

Non-urgent episodic illnesses that can be addressed within 24hours w/out increased morbidity

Fast-track requires simple first aid or basic primary care.


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Triage Categories Of Severity/Prioritization

Class I. Red Tag: Critical-top priorityLife-threatening but treatable injuries requiring

rapid medical attention- ARD, airway obstruction, shock, massive

hemorrhageRx: ABCs of resuscitation; Prioritize for transport Class II. Yellow Tag: Severe-Urgent care priority

Potentially serious injuries, but are stable enoughto wait a short while (within 1-2 hours) formedical treatment- Penetrating or abdominal wounds, major burns,closed head injuries with decreased LOC

Rx: ABCs of resuscitation; Prioritize for transport


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Class III. Green: Non-urgent- delayed priority- Minor injuries that can wait for longer

periods of time (2-6 hours) for treatment- Moderate burns, fractures, dislocations, eyeinjuries, lacerations, facial injuries withoutairway obstruction sprains, strains, contusionsRx: ABCs of resuscitation; Prioritize for

transport Black Tag:- Dead or still with life signs but injuries are

incompatible with survival in austereconditions

- Morgue at disaster site until bodies can bemoved


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AREAS OF TRIAGE

Disaster Scene

- Simple triage is used in a scene of mass

casualty; sort those who need critical attention

and immediate transport to the hospital and

those with less serious injuries

- Triage done to prioritize patients based on

severity of condition: treat as many as possible

when resources are insufficient for all to be

treated immediately


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Hospital

1. Triage team staff stations at the entrance

2. Rapid triage evaluation is made3. Clerk applies a stat record identification band, hand

the corresponding triage slip to the triage officer,

places the stat chart with the patient, logs the stat

medical record number, stat name number and the

patients name and the emergency department are

assignment

4. Patient is stabilized and leaves the ER after a rapid

reassessment to a treatment location and team in

the ER or another designated area for a more

thorough evaluation and assessment


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PROCESS OF TRIAGE

ASSESS AND INTERVENE**Priorities for patient with an emergent or urgenthealth problem

1. stabilization2. provision of critical treatments

3. prompt transfer to the appropriate setting(ICU, OR, General Care Unit)


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Why Should Planners Plan For Good Triage?

As a system tool, it provides a way to draworganization out of chaos.

Helps to get care to those who need it andwill benefit from it the most and speedsefficient patient evacuation.


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Why Should Planners Plan For Good Triage?

Helps in resourceplanningand allocation.

Provides an objective framework for

stressful and emotional decisions, helpingrescue workers to be more efficient andeffective.


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TRIAGE MOTTO:

Daily Emergencies

Do the best for each individual.

Disaster Settings

Do the greatest good for thegreatest number. Maximize

survival.


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2 Methodological approach to help identify andprioritize patient needs:

1. Primary Assessment

2. Secondary Assessment


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Systematic Approach to effectively establishing andtreating health priorities:

1. Primary surveyfocuses on stabilizing life-

threatening conditions, FIND ALL IMMEDIATETHREATS TO LIFE; 1.5 2minutes only

A Airway

- establish a patent airway

B BreathingAirway : Does the patient have an open airway?

Breathing : Is the patient breathing?

- Provide adequate ventilation, employingresuscitation measures when necessary. (Traumapatients must have the cervical spine protected andchest injuries assessed first)

Primary Assessment:


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y

1. The initial rapid assessment of the patient is meant toidentify life threatening problems (ABC)

1ststep is to determine if the patient is conscious. Ifconscious, the primary assessment can be performed at aglance.

A patient who is alert and talking indicates that there isbreathing and circulation.

A conscious patient indicates that circulation is adequateand enough blood being circulated to the brain.

If however the patient is not fully conscious, primaryassessment should proceed.

In a seriously ill or injured patient, it is recommended toadd 2 letters to the primary survey D- disability , E expose


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CONT.

C Circulation

- Evaluate and restore cardiac output bycontrolling hemorrhage, preventing and treatingshock, and maintaining or restoring effectivecirculation.

Circulation: Is there pulse? Is there profusebleeding?

D Disability

- Determine neurologic disability by assessingneurologic function using the Glasgow Coma Scale;apply a cervical collar


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Disability assess level of consciousness and pupils

Assess level of consciousness using AVPU scale:

- A is the patient alert?

- V Does the patient responds to the voice?

- P Does the patient respond to painful stimulus?

- U Is the patient unresponsive even to painfulstimulus?

E- Exposure

Remove clothing


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2. Secondary survey approach

a. Complete health history and head-to-toe assessment

Is a systematic, brief (2 to 3 minutes) examination of thepatient from head to toe of critical patients

It is to detect and prioritize additional injuries or todetect signs of underlying medical conditions.


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History1. If possible a brief history of the patients chief

complaint, accident, or illness is taken from the patient

or companion, relative , pre-hospital provider.2. What is the mechanism of injury circumstances,

forces, location, and time of injury?3. When did the symptoms appear?

4. Was the patient unconscious after the accident?5. How did the patient reach the hospital?6. What was the health status of the patient before the

accident or illness?7. Is there any hx of illness?8. Is the patient currently taking any medications?9. Does the patient have any allergy?10. Is the patient under a health care providers care?

( name of health provider)


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NURSING ALERT:

To obtain a good descriptive history, donot ask questions that can be answered byyes or no

b. Take the vital signs to establish complete baseline

information.c. Perform a Head to toe assessment including neuro


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d. Diagnostic and laboratory testing

e. Insertion or application of monitoring devices such as ECGelectrodes, arterial lines, or urinary catheter.

f. Bandaging and splinting of suspected fractures.

g. Cleaning and dressing of wounds.h. Performance of other necessary interventions based on theindividual patients condition.

i. Continual monitoring.


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If secondary survey reveals any of the following,

transport immediately:

- Tender distended abdomen

- Pelvic instability

- Bilateral femur fractures

Brief neuro exam:a. LOC (AVPU)

b. Motor- toes can be moved

c. Sensationcan feel touch to digits

d. Pupils PERL


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Transport Decision and Critical Intervention

- Critical trauma transported. All Rx done in transport

- Intervention to be done at scene:- Removal of airway obstruction

- Stop major bleeding

- Sealing sucking wounds

- Hyperventilate- Decompression of tension pneumothorax

Critical injuries can be simplified into 3 conditions:

a. Difficulty with respiration

b. Difficulty with circulation

c. Decreased LOC


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FUNCTIONAL REQUIREMENTS OF ANEMERGENCY DEPARTMENT

HOSPITAL POLICIES institutional

ED STAFF:

1. Head of the departments2. ER Supervisors

3. Head Nurse

4. Resident Doctors

5. Staff Nurse6. Nursing attendants, orderlies, handlers.


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EQUIPMENTS

EMERGENCY CART

defibrillator


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defibrillator


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LARYNGOSCOPE


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INTUBATION SET


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OXYGEN TANKS

SUCTION APPARATUS & SUCTION


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SUCTION APPARATUS & SUCTIONCATHETERS


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URINARY CATHETERS

IV FLUIDS IV CANNULA & IV


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IV FLUIDS, IV CANNULA & IVADMINISTRATION SET


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EMERGENCY MEDS & SYRINGES

CARDIOPULMONARY


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CARDIOPULMONARY

RESUSCITATION

Is a technique of basic life support for thepurpose of oxygenating the brain and

heart until appropriate.

Definitive medical treatment can restore

normal heart and ventilatory action.

Indications:


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Indications:

1. Cardiac Arrest

a. Ventricular fibrillation

b. Ventricular tachycardia

c. Asystole

2. Respiratory Arrest

a. Drowningb. Stroke

c. Foreign body obstruction

d. Smoke inhalation

e. Drug overdosef. Electricution/injury by lightning

g. Suffocation

h. Accident/injury

i. Coma


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Assessment:

Immediate loss of consciousness

Absence of palpable carotid or

femoral pulse; pulselessness in

large arteries

NURSING ALERT:The patient who has been

resuscitated is at risk for another

episode of cardiac arrest.


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Responsiveness/airway

Determine unresponsiveness: tap orgently shake patient while shouting,are you ok?

Place patient supine on a firm, flat

surface, kneel at the level ofpatients shoulder. If the patient hasa suspected head or neck trauma,the rescuer should move the patient

only if absolutely necessary.


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C P R


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PULSE SITES

ADULT CAROTID IN NECK

RADIAL IN WRIST

CHILD

CAROTID IN NECK

BRACHIAL IN ARM

INFANT

-BRACHIAL IN ARM

FEMORAL IN GROIN


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PULSE CHECKS

BE SURE PULSE IS ABSENT AND

BEGIN CPR

ADULT-AFTER 1 MINUTE OR 4

CYCLES OF 1 OR 2 MAN CPR CHILD & INFANT-AFTER 1 MINUTE

OR 20 CYCLES

AND EVERY FEW MINUTES


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COMPRESSIONS--ADULT

COMPRESS 1 1/2 - 2 INCHES GIVE 100 COMPRESSION'S PER

MINUTE FOR 1 OR 2 MAN CPR

USE 2 HANDS ON LOWER HALF OF

STERNUM CHECK CAROTID PULSE AFTER 1

MINUTE OF CPR

CHECK CAROTID PULSE DURING 2MAN CPR


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COMPRESSIONS--CHILD

COMPRESS 1/3 TO1/2 DEPTH OFCHEST

GIVE 100 COMPRESSION'S PER

MINUTE

USE THE HEAL OF 1 HAND ON THELOWER HALF OF THE STERNUM


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COMPRESSIONS--INFANT

COMPRESS 1/3 TO 1/2 DEPTH OFCHEST

USE 2 THUMBS AROUND THE CHEST

GIVE 100 COMPRESSION'S PER

MINUTE

USE 2 FINGERS 1 FINGER BELOW THE

NIPPLE LINE


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COMPRESSION RATIOS

ADULT

15 : 2 FOR 2 RESCUERS

15 : 2 FOR 1 RESCUER

CHILD

5 : 1 RATIO

INFANT

5 : 1 RATIO


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COMPLICATIONS OF CPR

PUNCTURED LUNG

LIVER LACERATION

FRACTURED RIBS/STERNUM

GASTRIC DISTENTION

GIVE SLOW EVEN BREATHS

PROPER HAND POSITION TO MINIMIZE

RIB FRACTURES


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AHA 2005

ACLS GUIDELINESIncreased Emphasis On:

Effective CPRPush hard and push fast

Chest compressions

Trauma:


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Trauma:Initial Management Priorities

A B C

Airway:- assess

- establish

- maintain

Breathing:- assess

- support

Circulation:

- assess

- access

- stop hemorrhage

- resuscitate

Airway


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AirwayNew Old

5 cycles of CPR/ 2 min prior tophoning 911 for infants/children

No jaw thrust (lay people)

Health care providers may usehead-chin tilt in injured patientsif jaw thrust fails

1 min of CPR prior tophoning 911 forinfants/children

Jaw thrust only forinjured patients

(both health careproviders and laypeople)


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BREATHING

ALL rescue breaths over 1 s, with adequate volume toproduce visible chest rise

Lay people: check for normalbreathing in adults

Normal (not deep) breath prior to AR

Continuous cycles when intubated only

8-10 resps per min when intubated (q 6-8 s) No rescue breathing without compressions for lay people


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BREATHING - OLD

Rescue breaths over 1-2 s

Varying tidal volumes suggested

10-12 resps/min once intubated


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CIRCULATION - NEW Single compression to ventilation ratio for ALL single

rescuers for ALL victims (excluding newborns) 30:2 (100/min)

5 cycles (2 min) CPR in between rhythm checks

Health care providers (2 rescuer):

Adults 30:2

Infants/children 15:2

CIRCULATION


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CIRCULATIONNEW OLD

Limit interruptions incompressions

Rescuers may use one or twohands for child CPR

Unwitnessed arrests: mayconsider 5 cycles of CPR prior todefibrillation (or response time >4 min)

Minimizations in interruptionsnot emphasized

Adult: 15:2

Infant and child: 5:1

Rhythm and pulse checks afterdefibrillation


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LEGAL ASPECTS IN EMERGENCY NURSING

LAW the sum total of rules and regulationsby which society is governed.

- it is man-made and regulates socialconduct in a formal and binding way.

CONSENT free and rational act thatpresupposes knowledge of the thing towhich the consent is being given by aperson who is legally capable to giveconsent.

NATURE OF CONSENT

i h i i i b i


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- is an authorization given, by a patient or a personauthorized by law to give the consent in the patients behalf

- secured by the nurse upon admission- usually for diagnostic procedures and initial treatment

deemed necessary by the medical staff.

- substantiated by a written authorization as a proof

against any liability that may arise due to an alleged unlawfultouching of a patient.

INFORMED CONSENT


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- Hayt and Hayt states that It is established principleof law that every human being of adult years and sound mind

has the right to determine what shall be done with his ownbody.

- he may choose whether to be treated or not and towhat extent, no matter how necessary the medical care, or

how imminent the danger to his life or health if he fails tosubmit to treatment.

ESSENTIAL ELEMENTS OF INFORMED CONSENT:


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1. diagnosis and explanation of the condition

2. fair explanation of the procedures to be done and used

and the consequences3. a description of alternative treatments or procedures

4. description of the benefits to be expected

5. material rights if any

6. prognosis, if the recommended care, procedure, isrefused

PROOF OF CONSENT


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- a written consent should be signed to show that theprocedures the one consented to and that the person

understands the nature of the procedure, the risks involvedand the possible consequences.

Who must consent?

- the patient

- another person gives consent if patient is incompetent,minor, or mentally ill or physically unable and is not in anemergency case

CONSENT IN EMERGENCY SITUATION:


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- No consent is necessary because inaction at such timemay cause greater injury.

LEGAL LIABILITY


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LEGAL LIABILITY Nurses are governed by civil and criminal law in roles as

providers of services, employees of institutions, and privatecitizens.

A nurse has a personal and legal obligation to provide astandard of client care expected of a reasonably competent

professional nurse. Professional nurses are held responsible for harm resultingfrom their negligent acts, or their failure to act.

R ibili i f h h i


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Responsibilities of the nurse to the patient:

PRIMARY RESPONSIBILITY: To give patient the kind ofcare his/her condition needs regardless of his/her race,creed, color, nationality or status.

Patients care must be based on needs, the physicians

orders, and the ailment; and shall involve the patient andallows the family to participate. (9thed. Professional Nsg inthe Phils by Venzon).

Nurses are advised to be familiar with the patients Bill ofRi hts d bs its p isi s


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Rights and observe its provisions.

The nurse may only repeat what the doctor wishes to

disclose, if the patient insist on knowing what the diagnosisis all about.

Confidentiality whatever info gathered by the nurseduring the course of caring for the patient shall always be

treated with CONFIDENTIALITY


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Confidential information may be revealed only when:

1. The patient permits such revelations as in claim forhospitalization, insurance benefits.

2. The case is medico-legal such as attempted suicide,gunshot wounds w/c have to be reported to the localpolice or NBI

3. Patient is ill of communicable disease and public safetymay be jeopardized; and

4. Given to members of the health team if information is

relevant to his care.

L l S f d


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Legal Safeguards Systematic reporting system for incidents or unusual

occurrences. Proper documentationNurses Bill of Rights Legal defense in a negligent action is when nurses know

and attain the standard of care in giving service and thatthey have documented the care they have given in aconcise and accurate manner.

NURSINGASSESSMENTS


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N NG E MEN PURPOSES:

Surveying the clients health status and risk factors for aparticular health problems

Identifying latent or occult (undetected) disease

Screening for a specific disease, such as diabetes orhypertension.

Identifying risks for particular health problem

Determining functional impact of disease (humanresponse to actual or potential health problems)

Evaluating the effectiveness of the health care plan

Health history


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Health history

Purposes:Elicits a detailed, accurate, and chronological

health record as seen in the clients perspective.

Connect with the client and develop goodrapport, provides insight into the clientsfunctional status, and helps focus and guidesubsequent physical examinations.

Ph i l E i ti


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Physical Examination

Physical examination is the secondcomponent of a complete nursing healthassessment. History findings help focus

the physical examination. Practice and adhere to standard

precautions throughout the entirephysical assessment.

ASSESSMENT TECHNIQUES


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ASSESSMENT TECHNIQUES

Inspection

an important assessment point (but commonly forgotten)Inspection employs the senses of vision and smell to

observe the client.

Auscultation

Involves listening (usually through a stethoscope) tosounds produced in the body, particularly the heart,lungs, blood vessels, stomach, and intestines.

A doppler ultrasonic stethoscope and an acoustic

stethoscope can be used to amplify body sound.

Palpation

Different parts of the hand are used to detect


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Different parts of the hand are used to detectcharacteristics of pulsation, vibrations, texture, shape,temperature, and movement.

Confirm and amplify findings observed during inspection.

Light palpation is always done first. Using finger pads,provide superficial and delicate palpation to explore skintexture and moisture; overt, large or deep masses; andfluid, muscle guarding, and superficial tenderness.

Deep palpation, uses the hand to explore internalstructures.


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Percussion

Sharply tapping the body surface with thefingers, hands, or a rubber reflex hammerproduces sounds whose quality depends on thedensity of underlying structures (organ borders,fluid, gas)Used to elicit tenderness and to assess reflexes.

Supportive Studies


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Supportive Studies

Laboratory Studies3 categories

Urinalysis

Hematology

Blood chemistry Diagnostic Studies

Performed during routine physical examinations and

assist in diagnosing disease.

Nurses responsibility


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Nurse s responsibility The nurse is responsible for the patient during the pretest,

intratest,posttest periods. Facility policies, procedures, and protocols for collecting,

handling, and transporting specimens should be followed atall times.

The nurse must educate the client concerning preparationfor the diagnostic test

Obtain written consent if necessary

Ensure clients safety during the procedure

Assist with the procedure if necessary Monitor for complications after the diagnostic test

Standard precaution must be adhered to at all times.

COMMON TYPES OF EMERGENCIES


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COMMON TYPES OF EMERGENCIES

CARDIAC EMERGENCIES/CHEST TRAUMA

RESPIRATORY EMERGENCIES

CNS EMERGENCIES

CARDIAC EMERGENCIES


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CHEST PAIN

ACUTE CORONARY


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ACUTE CORONARYSYNDROME

UNSTABLE ANGINA

MYOCARDIAL INFARCTION


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ANGINA PECTORIS


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ANGINA PECTORIS

1. Transient paroxysmal chest pain produced by insufficient blood flow to the myocardium resultingin myocardial ischemia.

2. Risk Factors

2.1 CAD

2.2 Atherosclerosis

2.3 HPN

2.4 Diabetes Mellitus ( DM )

2.5 Severe Anemia

2.6 Severe Aortic Insufficiency

3. Precipitating Factors

3.1 Physical Exertion

3.2 Consumption of Heavy Meal

3.3 Extremely Cold Weather

3.4 Strong Emotions

3.5 Cigarette Smoking

3.6 Sexual Activity

ASSESSMENT FINDINGS FOR ANGINA
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PECTORIS

4.

Assessment Findings

4.1Pain : Substernal with possibleradiation to the neck, jaw, backand arms but relieved by rest.

4.2 Palpitations and Tachycardia4.3 Dyspnea

4.4 Diaphoresis

4.5 Increased Serum Lipid Levels

4.6 Diagnostic Tests

a. ECG : Segment depressionand I wave inversion during chestpain

b. Stress Test : Abnormal ECGduring exercise

CHEST PAIN-ANGINA PECTORIS Clinical syndrome usually characterized by episodes or


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Clinical syndrome usually characterized by episodes orparoxysms of pain or pressure in the anterior chest.

Cause is usually insufficient coronary blood flow w/c resultsin a decreased oxygen supply to meet an increasedmyocardial demand for oxygen in response to physicalexertion or emotional stress.

Pain is often felt deep in the chest behind the upper ormiddle 3rdof the sternum (retrosternal area).

Pain is poorly localized and may radiate to the neck, jaw,shoulders, and inner aspects of the upper arms, usually theleft arm.

Tightness or a heavy, choking, or strangling sensation thathas a vise-like, insistent quality.

NURSING PROCESS


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Assessments: PQRST

P Position/LocationWhere is your pain located?Can you point to it?

-ProvocationWhat are you doing when the pain began?

Q- QualityHow would you describe the pain?

Is it like the pain you had before?- Quantity

Has the pain been constant?

R Radiation


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Can you feel the pain anywhere else?

- ReliefDid anything make the pain better?

S Severity

use pain rating scale

- SymptomsDid you notice any other symptoms with

the pain?

T Timing

How long ago did the pain start?

Nu sin Di n sis


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Nursing Diagnosis

1. Ineffective myocardial tissue perfusion secondary to

CAD as evidenced by chest pain.2. Anxiety related to fear of death

3. Deficient knowledge about the underlying disease andmethods for avoiding complications.

4. Noncompliance, ineffective management of therapeuticregimen related to failure to accept necessary lifestylechanges.

Planning and goals

1 Immediate and appropriate treatment when angina


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1. Immediate and appropriate treatment when anginaoccurs

2. Prevention of angina3. Reduction of anxiety

4. Awareness of the disease process

5. Understanding of the prescribed care,adherence to the self-care program, and absence ofcomplications.

Nursing Interventions

1. Treating angina


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> Stop activities, sit or rest in a semi-fowler position.

>Assess the angina

>Measure the vital signs

>Observe for signs of respiratory

distress>Nitroglycerin-can be repeated up to 3doses if chest pain is unchanged or lessened but stillpresent.

>Oxygen therapy-Administer oxygen.>For significant pain despite treatment,transfer to ICU


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2. Reducing anxiety-Provide emotional support.3. Preventing pain

4. Promoting home and community-based care.

Allow patient to notify physician immediately if pain occurs andpersists despite rest and medication>teaching patients self-care

Myocardial Infarction


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y Refers to the process by w/c areas of the myocardial cells

in the heart are permanently destroyed.

Caused by a reduced blood flow to the coronary artery dueto occlusion of an artery.

Due to profound imbalance existing between myocardialoxygen supply and demand.

Causes:

vasospasm of a coronary artery

Decreased oxygen supply

Increased demand of oxygen



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1. Death of myocardial cells from

inadquate oxygenation often causedby a sudden complete blockage ofcoronary artery; characterized bylocalized formation of necrosis (tissue destruction ) with subsequent

healing by scar formation andfibrosis.

2.. Risk Factors

a. Atheresoclerotic CAD

b. Thrombus formationc. Hypertension

d. Diabetes Mellitus


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NURSING PROCESS Assessment:


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Assessment:

Use systematic assessment w/c includes a careful history,

particularly as it relates to symptoms.Chest pain or discomfort- Substernal pain with radiation to the neck, jaw,

or back,;severe, crushing excruciating pain unrelieved by rest or nitrates.

Difficulty of breathing (dyspnea)

Nausea and vomiting

Skin : cool, clammy and ashen

f. Initial increase in Bp and pulse with gradual drop in blood pressure

Palpitations

Unusual fatigue

Faintness (syncope)Sweating (diaphoresis)

Nursing Diagnosis:

Ineffective cardiopulmonary tissue perfusion related to


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p y preduced coronary blood flow from coronary thrombus andatherosclerotic plaque.

Potential impaired gas exchange related to fluid overloadfrom left ventricular dysfunction

Potential altered peripheral tissue perfusion related todecreased cardiac output from left ventriculardysfunction

Anxiety related to fear of death

Deficient knowledge about post-MI self-care

Planning and goals:

Relief of pain or ischemic signs and symptoms


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Prevention of further myocardial damage

Absence of respiratory dysfunctionMaitenance or attainment of adequate tissue perfusion

by decreasing the hearts workload

Reduced anxiety

Adherence to the self-care programAbsence or early recognition of complications.

NURSING INTERVENTIONS FOR PATIENTS WITH



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Establish patent IV Line. Provide Pain relief.

Administer oxygen needed.

Provide bed rest with semi-fowlers position.

Monitor ECG and hemodynamic procedures. Administer antiarrythmic drugs as ordered.

Perform cardiac and lung assessments.

Monitor urine output and report output < 30 cc/hr.

Maintain full liquid diet with gradual increase to soft; low sodium Maintain quiet environment.

Transport to CCU soonest possible

Nursing Interventions

Relieving pain and other signs and symptoms of ischemia


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Improving respiratory function

Promoting adequate tissue perfusionReducing anxiety

Monitoring and managing potential complications

Promoting home and community-based care.

CARDIAC TAMPONADE


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CARDIAC TAMPONADE


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Compression of the heart as a result of fluid within thepericardial sac (pericardial effusion)

Usually caused by blunt or penetrating trauma to the chest.

Penetrating wound to the heart is associated with high

mortality.


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INTRA-ABDOMINAL INJURIES


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PENETRATING TRAUMA-

Stabbing wound site generally indicates whichorgans are affected. Wound severity depends onsize (width, shape and length) of the knife orinstrument used.

BLUNT TRAUMA occurs from direct impact of the forceto the abdominal wall, and/or thoracic area. Organs of theabdomen most often injured are the more solid organs thekidney, liver, spleen. May sustain pneumothorax,hemothorax,flail chest, myocardial bruising with the blunttrauma to the chest.
http://www.fxunltd.com/Paramedic/Stabwound.jpg


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STAB WOUND/GUNSHOT WOUND
http://www.fxunltd.com/Paramedic/Stabwound.jpghttp://www.fxunltd.com/Paramedic/Stabwound.jpg


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Are serious and usually requires surgery

High incidence of injury to hollow organ particularly smallbowel

Liver is the most frequently injured solid organ

High velocity missile create extensive tissue damage.

All abdominal gunshot wounds that cross the peritoneumrequire surgical exploration

Stab wound may be managed non operatively.

ASSESSMENT: Assess and treat client for life threatening injuries- respiratory status

d h h


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and hemorrhage.

Attempt to determine the type of force that caused the injury.

If the weapon or object producing the penetrating wound is still inplace, do not remove it. Object may not be removed until client is insurgery where bleeding and organ damage are more accessible for

repair

Remove the client's clothing and inspect the entire body for injuries.Penetrating injuries may not be bleeding or obvious initially. Carefullylogroll the client on his side and inspect back and trunk for injury.

Check the pulses in each extremity and evaluate the blood pressure inthe upper and lower extremity.

If abdominal trauma caused damage to the aorta, there may be

decrease in the blood pressure in the lower extremities

ASSESSMENT:

Carefully assess the thorax and continue to evaluate quality


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Carefully assess the thorax and continue to evaluate qualityof respirations. Frequent assessment of the quality and

presence of breath sounds, evaluate changes of breathsounds.

Asymmetry of the chest wall movement may indicatehemothorax or pneumothorax.

The presence of puncture penetrating wounds of the thoraxand fractured ribs may precipitate pneumothorax andatelectasis.

Observe for c changes in respirations and level of

consciousness that are indicative of hypoxia. Paradoxical movement of the chest wall indicate multiple rib

fractures and flail chest.

RESPIRATORY EMERGENCIES


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ACUTE RESPIRATORY DISTRESS

ACUTE RESPIRATORY DISTRESS SYNDROME(ARDS)
http://www.meduniwien.ac.at/kinderreanimation/bilder/clone2/html/bilder0904.html


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Previously called, ADULT RESPIRATORY DISTRESS

SYNDROME Characterized by sudden and progressive pulmonary edema,

increasing bilateral infiltrates, hypoxemia, and reduced lungcompliance.

Acute phase:rapid onset of severe dyspnea that usuallyoccurs 12 to 48 hours after the initiating event.

Hypoxia is a condition characterized by an inadequateamount of oxygen.

Hypoxemia decrease oxygen saturation of the blood;generally occus when PO2 is below 50mmhg

Nursing Diagnosis:


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Hypoxia Potential Complications: respiratory failure,

inadequate cardiac output, dysrhythmia.Ineffective Airway Clearance related to ineffective cough orinability to remove airway secretions.

Ineffective breath patterns related to hyperventilation,

hypoventilation, CNS depressions of respiratory system.Impaired Gas exchange related alveolar hypoventilation orperfusion

Activity intolerance related to inadequate oxygen for ADL.

Anxiety related to breathlessness

Nursing Management


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Goal : to maintain good pulmonary hygiene and prevent

hypoxic episode general measures:Assess patency of airway (first priority)Position client to maintain patent airway.

A. unconscious client position on side with the chinextended notify physician and remain with client.B. conscious client elevate the head of the bed andposition on side as well.

Close monitoringUse of respiratory modalities (O2administration, chest physiotheraphy,endotracheal intubation, nebulizer therapy,

mechanical vent suctioning etc )

Nursing Management cont.


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Positioning to improve ventilation and perfusion in the

lungs and enhance secretion drainage.Explain procedure to reduce anxiety

Rest is essential to reduce oxygen consumption,decreasing oxygen needs.

Encourage cough and deep breathing exercise.Suction client as indicated by amount of sputum and

ability to cough

Maintain adequate fluid intake to keep secretions

liquified.

PULMONARY EMBOLISM


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PULMONARY EMBOLISM


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Refers to the obstruction of the pulmonary artery or one ofits branches by a thrombus that originates somewhere inthe venous system or in the right side of the heart.

The severity of the problem depends on the size of theemboli

The right lobe mostly frequent involved

Of the clients who die, die within 2 hours.

Clinical Manifestation


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Dyspnea Sudden, sharp, substernalchest pain

Coughing with hemoptysis

Tachycardia

Symptoms of hypoxia

Nursing Management


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Bed rest

Minimizing the risk of pulmonary embolism Preventing thrombus formation

Assessing potential for pulmonary embolism

Monitoring thrombolytic therapy

Managing pain

Managing oxygen therapy

Relieving anxiety

Monitoring for complications Providing postoperative nursing care

Promoting home and community-based care

STATUS ASTHMATICUS


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STATUS ASTHMATICUS


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Is severe and persistent asthma that does not respond toconventional therapy.

Attacks can last longer than 24 hours

The basic characteristics in asthma decrease the diameter

of the bronchi and are apparent in status asthmaticus.Constriction of the bronchiolar smooth muscle

Swelling of the bronchial mucosa

Thickened secretions

Clinical manifestations


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Clinical manifestations

Cough Shortness of breath

Expiratory wheezing

Symptoms of hypoxia

Retractions

Tachycardia

Increased anxiety, restlessness


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Nursing Management


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Position pt. on high back rest

Constant monitoring for the first 12 to 24 hours or untilstatus asthmaticus is under control.

Assessment of skin turgor to identify signs of dehydration

Fluid intake is essential to combat dehydration, to loosen

secretions, and facilitate expectoration. Conservation of patients energy

Non allergenic pillow should be used.

SMOKE INHALATION


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SMOKE INHALATION Inhalation injury is the leading cause of death in fire

victims


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victims.

Causes pulmonary damage:

Indicators:

History indicating that the burn occurred in anenclosed area

Burns of the face or neckSinged nasal hair

Hoarseness, voice change, dry cough, stridor, sootysputum

Bloody sputumLabored breathing or tachypnea and other signs of

reduced oxygen levels

Erythema and blistering of the oral or pharyngeal

mucosa

CNS EMERGENCIES


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CEREBRO-VASCULAR ACCIDENT (CVA)

CEREBRO-VASCULAR ACCIDENT (CVA) a.k.aSTROKE


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Sudden lost of brain function resulting from the disruptionof the blood supply to a part of the brain.

Most common site: middle cerebral artery

DRUG OVERDOSE


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DRUG OVERDOSE


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UNCONSCIOUS


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SHOCK


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Shockcharacterized by inadequate blood flow and tissue

perfusion


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Clinical Manifestation:

Restlessness- apprehensive

Increase pulse rate, weak and thready

Tachycardia to bradycardia

Urine output decreased - oliguria

Continued decrease blood pressure

Decrease sensory perception

Cool, moist skin

Rapid shallow respirationslabored, irregular respirations. Skin color pallor o cyanotic

Classification of shock

1.Hypovolemicredusced venous returndue to reduced blood

volume 15 to 25% reduction on vol.


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conditons such as hemorrhage, Burns, severe fluid loss,

dehydration

Treatment: Administer volume replacement, whole blood,

volume expander

2.Cardiogenicheart is unable to pump effectively and

circulate the intravascular vol.

Conditons: MI, Dysrhytmias, CHF

Treatment: Monitor EKG, medication to increase cardiac

output, digitalis and dopamine

3. Neurogenicalteration in the destribution of the blood volume. Increase

venous capacity due to a loss of peripheral vasomotor tone.

C dit S i l d i j


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Conditons: Spinal cord injury

4. Septicdilation of blood vessels by humoral or vasoactive substances

ConditionsOverwhelming infection, generally gram negative and positive

Treatment: Evaluate for origin of infection

5. Vasogenic (anaphylactic)antigen-antibody reaction with release of

histamine causing vasodilation

Conditions: Transfusion reactions, insect bites, side effectso of

medications, allergies to food

Treatment: Maintain airway problem with laryngeal edema ( chest tightnessoccur)

Oxygen as indicated,

epinephrine and benadryl IV

Nursing Interventions:

identify and correct cause of shock


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identify and correct cause of shock

maintain adequate respiratory function maintain adequate circulation

Blood volume

Cardiac output

Vascular tone Position in supine with legs elevated

Maintain patent airway

Provide supplemental Oxygen as ordered

Establish life line

Monitor blood pressure closely in individuals at increased risk.

SHOCK


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SEIZURES


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DISASTER NURSING


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DISASTER Any patient-generating incident that overloads

either existing personnel supplies and


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either existing personnel, supplies, andequipment, or is any patient-generating incident inwhich back-up supplies and personnel are notavailable in a reasonable amount of time

An occurrence, either natural or man-madecauses human suffering and creates human

needs that victims cannot alleviate withoutassistance.

Forces overwhelm a community.

Services are compromised.

Outside assistance is required. Is a result of vast ecological breakdown in the

relation between humans and their environment,as serious or sudden event on such scale that thestricken community needs extraordinary efforts to

co e with outside hel or international aid

MAJOR DISASTER

- any hurricane, tornado, storm, flood, high water, wind-

driven water tidal wave earthquake drought fire


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driven water, tidal wave, earthquake, drought, fire,

explosion, or any other catastrophe, which, in thedetermination of the President, causes damage of

sufficient severity and magnitude to warrant major disaster

assistance above and beyond local/state emergency

services by the government to supplement the effort and

available resources of local governments and private releif

organizations in alleviating the damage, loss, hardship, or

suffering caused by a disaster

State of Emergency

Any various types of catastrophes included in the


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y yp p

definition of a major disaster which requires

Federal emergency assistance to supplement

State and Local efforts to save lives and protect

property, public health and safety, or to avert or

lessen the threat of a disaster

Disaster Categories

Multiple patient incident


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- an incident that generates at least two, but fewer

than 10 patients- self-limiting and can be handled effectively withoutrequiring aid from resources outside the community

Multiple casualty incident

- generates 10 but fewer than 100 casualties andnecessitates total community and perhaps stateinvolvement eg. Airplane crashes, storms, floods

Mass casualty incident

- generates more than 100 victims; additional aidand assistance is required; occur infrequently butmust be anticipated in disaster planning

eg. Wars, major hurricanes, major earthquakes

Types of Disaster

1 E t l Di t t id th h it l


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1. External Disastersoccurs outside the hospital;

natural or man-madea. Natural- floods, earhtquakes, tornadoes, etc.

b. Man-made- war, fire, transportation accidents,

food contamination

2. Internal Disasters- occurs within an institution,such as hospital fire or bomb threat

Characteristics of Disaster Agents


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Predictability Frequency

Controllability/Mitigation

Time: speed, duration

Scope

Intensity

Community Implications
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http://en.wikipedia.org/wiki/Image:HurricaneRita21Sept05a.jpg


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Natural Disaster: Tsunami


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Nuclear Attack


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Epidemiology of a Disaster


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Agent - the physical items that actually causesthe injury or destruction

Hosthumankind (age, immunization status,

preexisting health status, degree of mobility,

emotional stability

Environmentfactors affecting outcome of a

disaster

a. Physicaltime, weather conditions, food

and water, functioning of utilities

b. Chemicalleakage of stored chemicals,

food

c. Biologicaloccur or increase as a result

of contaminated water, improper waste


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, p p

disposal, insect or rodent proliferation,improper food storage

d. Socialcontribute to the individuals

support system (loss of family members,

change in roles, questioning of religious

beliefs)

Factors that influence response to disaster


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1. Situationalwarning time before a disaster occurs,

nature and severity of a disaster, physical proximity

and closeness to the victims affected

2. Personalpsychological proximity, coping ability,

losses, role overload, previous disaster experience

Stages of a Disaster


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1. Warning stage

- Provide sufficient time for preparing to handle

the potential event

- Minimize loss of lives and mitigate damage

- Disaster plans are activated, emergencyoperations centers are established, and the

affected area is evaluated or provided with in-

place protection

- Problems: communication, doubt, adaptation

2. Impact Stagestaying alive (primary objective)

Few seconds to minutesearthquake, explosion

Few days or weeksfloods, heat waves


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Several monthsdroughts, epidemics

3. Inventory StageSurvivors assesses the effectsof the event and identify what must be done next; aperiod of isolation in which mitigative actions arerequired to prevent additional loss of life

4. Rescue StageHelp arrives to rescue survivorsand to help the injured

5. Remedy Stage - Recovery activities are beinginitiated

6. Recovery StageEncompasses total recoveryfrom the impact and resulting situation; requiresholistic recovery and development of adaptivebehavior to produce lasting changes

Four Stages of the Victims Emotional Response

Denial deny the magnitude of the problem


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Denialdeny the magnitude of the problem,

understand the problem but seem unaffectedemotionally

Strong emotional responseregards the problem as

overwhelming and unbearable; retell or relive the

experience over and over; weeping, restlessness,anger, sadness, passivity,sweating

Acceptancemakes a concetrated effort to solve the

problem; feels more hopeful and confident

Recoveryfrom crisis reaction; feel back to normaland routines become important again; sense of well-

being restored; decision ability returns; carries out

plans


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Common Problems at Mass Casualty Incidents

Failure in adequate alerting


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Failure in adequate alerting

Lack of rapid primary stabilization of patients Failure to move, collect, and organize patients

rapidly at a suitable location

Use of overly time-consuming and inappropriate

care methods Premature commencement of transportation

Improper use of personnel in the field

Lack of proper distribution of patients, which results

in improper use of medical facilities

Lack of recognizable EMS command in the field

Role of the Nurse at the Disaster Site

I f t


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Insure safety

First Aid

Emergency care

Role of the Nurse in a Shelter Objective: temporary means of caring Assessment Planing:

24/7 nursing and ancillary coverage

Supplies Implementation Evaluation

Role of the CHN in a Community Setting After a

Disaster


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Goal: Achieve the best possible level of health

for persons in a community after a disaster Primary Prevention Secondary Prevention Tertiary Prevention

NURSES ROLES IN DISASTERS

D t i it d f th t


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Determine magnitude of the event

Define health needs of the affected groups

Establish priorities and objectives

Identify actual and potential public healthproblems

Determine resources needed to respond to theneeds identified

Collaborate with other professional disciplines,governmental and non-governmental agencies

Maintain a unified chain of command Communication

ADVANTAGES OF TRIAGE


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Helps to bring order and organization to achaotic scene.

It identifies and provides care to those who

are in greatest need

Helps make the difficult decisions easier Assure that resources are used in the

most effective manner

May take some of the emotional burden

away from those doing triage

WHY IS DISASTER TRIAGE NEEDED

Inadequate resource to meet immediate needs


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Infrastructure limitations

Inadequate hazard preparation

Limited transport capabilities

Multiple agencies responding

Hospital Resources Overwhelmed


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Questions/Comments


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Thank you very


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much!

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