Rizal Provincial Hospital Ok Na

Rizal Provincial Hospital Scope of Service of the Emergency Department

Introduction

Emergency nursing is a specialty area of the nursing profession like no other.

Emergency nurses must possess both general and specific knowledge about health care to

provide quality patient care for people of all ages. Emergency nurses must be ready to

treat a wide variety of illnesses or injury situations, ranging from a sore throat to a heart

attack.

The ER nurse as member of the emergency response team has been responsible

for triaging and caring for patients at the Emergency Department (ED) for care. . This

includes assessment, diagnosing, planning, therapeutic interventions, care delivery and

evaluation. Emergency nurses specialize in rapid assessment and treatment when every

second counts, particularly during the initial phase of acute illness and trauma.

Emergency nurses must tackle diverse tasks with professionalism, efficiency, and above

all-caring.

This scope of service for the Emergency Department aims to offer guide to ER

nurses so as to provide quality care to patients in the Rizal Provincial Hospital

Emergency Department.

Created 2006 Revised May 2010 Page 1 of 49


Demographics

Rizal Provincial Hospital (RPH) is under the Rizal Provincial Health Office

governed by the provincial government of Rizal. It is located at Thomas Claudio St. San

Juan Morong Rizal.

RPH is a 100 bed secondary hospital and is expected to provide the following

services: Medical-Surgical, Gyne-Obstetrics, Pediatrics, Operating Room and Emergency

care. The RPH-ED utilizes numerous nursing diagnostic and therapeutic modalities to

facilitate patient care including the following:

Emergency Nursing Process

o Primary Survey and Secondary Survey

o Initiation of life-saving measures

o Ongoing assessment of nursing care

o Review of nursing efficacy

o Patient advocacy

IV cannulation and hydration.

Management of intravenous therapy including blood transfusion

Assisting with placement of chest tubes.

Placement of nasogastric tubes

Placement of urinary catheters.

Emergency Department Bed Capacity: 12

Core Room 4

Internal Exam Room 2

Hydration Partition 5

Surgery Partition 1

Table 1.1

Hours of Operation: 24 hours a day, 7days a week.

Age range accommodated: All ages

Contact number: (02)6531054 local number 117



Goal of the Emergency Department

To provide quality emergency care, in the most effective and efficient manner, to all

patients presenting to the RPH-ER

To provide an efficient transition into the hospital for patients requiring admission.

To provide accurate triage assessment of all direct admission patients who pass

through the department.

To strive to improve the quality of emergency care provided by reviewing practice

and adopting performance improvement projects as a vehicle for change.

To reflect contemporary practice in emergency care.

The Objectives of Emergency Department

Primary objective of Emergency Department (ED) is to render immediate quality

care to emergency patient.

Contributory objectives are:

1.) To have an understanding of survival procedures and emergency life saving

measures.

2.) To provide the best clinical experience for nurses, student nurses and other allied

member of the health care team.

Priorities of Emergency Management

The major goals of emergency medical treatment are:

To preserve life.

To prevent deterioration before definitive treatment can be given.

To restore the patient for useful living.

Guidelines in Emergency Department



1. Emergency cases should only be treated at ER and consultation at OPD.

2. Interview the patient and complete the ER Pink Form (Appendix A) then

provide ER charge slip (Appendix B) and instruct payments at the

information section. If the patient established an OPD record previously,

instruct the patient or relative to retrieve their OPD White Form record at

the information section.

3. Obtain the vital signs of the patient. Patient age 0-13 should be weighted

as well as those that will be treated under Surgery Department.

4. Place the patient in comfortable position, maintain patent airway, provide

adequate ventilation, employ resuscitation measures as necessary and

assess for chest injuries which precedes airway obstruction.

5. Assess whether or not the patient can follow command, evaluate the size

and sensitivity of the pupils and motor response.

6. Assist the doctor while examining the patient and carry out orders

promptly and accurately which includes IVF, O2 therapy and medications.

7. If the patient condition needs admission, call the ward for available room

then obtain informed consent. Complete the admission documents

(Appendix C) and attach the ER pink form to the documents whereas OPD

white form should be returned back to the information section.

8. Document pertinent information regarding patient condition and the

treatment measures given.

9. Carry out all the STAT orders like medications, procedures, laboratories

(Ultrasound, UTZ, Chest X-Ray, ECG), before the patient were brought to

their designated Ward Department.

10. For critically ill patient, the nurse should accompany the patient to the

ward for proper endorsement.

11. Refer to other agencies for further management as the patient’s condition

suggests. Coordinate to the driver and arrange referrals. Ambulance

should be equipped with oxygen set, ambubag and emergency kit prior to

transfer.



Job Description of the Nurse on Duty

In Patient Care

a. Plan to meet the total nursing needs of the patient.

b. Supervise all nursing attendants related directly and indirectly to patient care.

c. Evaluate of the effectiveness of patient care.

d. Evaluate if the effectiveness of the patient care,

e. Promote the improvement of the patient care.

f. Give direct nursing care to the patient.

g. Responsible for the accurate assessments and documenting treatments and

care rendered whether it may be independent, interdependent or dependent.

h. Responsible for execution of doctor’s order.

In Unit Management

a. Plan for the environment conducive to the physical, spiritual well being of the

patient.

b. Participate in the formulation, interpreting and implementing objectives and

policies of nursing care.

c. Promote good nurse-patient relationship.

d. Promote the improvement of nursing service in the unit,

e. Teach and guide all new nursing personnel in the unit.

f. Assist in the orientation program of the new nursing personnel in the unit.

g. Demonstrate new procedures and use of the new equipment in the unit.

h. Impart health teaching in personal hygiene to the patient and member of the

family.

Duties and Responsibilities of the Emergency Nurse on Duty (ER NOD)



The continuity of nursing care is maintained throughout a 24-hour period by three

8-hour shifts. The ER-Nurse is responsible for individualized patient care, placing patient

in rooms and liaising with case management.

Staff Nurse: Shift 6-2

I. Endorsement

Receive endorsement from 10-6 shift.

Receive the unit, check supplies and instruments available for the ER

Department.

Receive and check patients in the IE Room, Surgery and Hydration Partition and

Core Room as well as the Incoming patients during shift transition.

Check the available rooms per department for admission of patient for the shift.

Check ER Logbook and verify if records from previous shift were returned to the

information section.

II. Patient Care

Give oral medication and injection as ordered.

Prepare and administer intravenous therapy as ordered.

Assist in treatment and special procedure to be done for the patient.

Prepare the patient with medicine secured from supplies if indigent.

Explain the diagnostic procedures like X-ray, ECG, UTZ that the patient will be

subject to.

III. Ward Policies

Answer telephone calls.

Make sure that only one companion comes with the patient in the ER.

Make sure that the patient or the significant other is informed about any

procedure prior to execution.

IV. Proper Documentation

Check the admission documents, referral request and prescription before patient

were discharged or transferred.

Document all medical treatment and nursing intervention given to the patient.

Document or report any untoward incident during the shift in a clean piece of

paper. Indicate the date and time of incident, people involved, actual scenario,



with the signature over printed name of the Nurse on Duty and address it to the

Supervisor or Head Nurse.

V. Housekeeping and Maintenance

Supervise and guide the nursing attendant within the shift.

Report out of order equipments and instruments to the Head Nurse.

Request supplies from Central Supply Room for ER use.


I. Endorsement





Department.






II. Patient Care

Give oral medication and injection as ordered.


Secure consent for admission of the patient.




subject to.

III. Ward Policies







were discharged of transferred.








Maintain the cleanliness of the ER Department.



Extend help in cleaning through dusting and scrubbing off the equipments used

like urinals, bedpans, surgical instruments, and station area.


VI. Supplies and Equipments

Check available instruments for procedures.

Refill containers with supplies like dried or wet cotton balls soaked with saline,

alcohol or betadine.

Clean instruments and gloves for autoclaving.

List supplies, instruments and equipments needed for the following day that

needs to be endorsed to the incoming 10-6 NOD for requisition.


I. Endorsement





Department.






II. Patient Care

Give oral medication, intravenous, and parenteral injection as ordered.


Secure consent for admission of the patient.




subject to.

III. Ward Policies







were discharged of transferred.








Maintain the cleanliness of the ER Department.



Extend help in cleaning through dusting and scrubbing off the equipments used

like urinals, bedpans, surgical instruments, and station area.


VI. Supplies and Equipments

Check available instruments for procedures.

Refill containers with supplies like dried or wet cotton balls soaked with saline,

alcohol or betadine.

Clean instruments and gloves for autoclaving.

List supplies, instruments and equipments needed for the following day that

needs to be endorsed to the incoming 6-2 NOD for requisition.

Referral of Patient to other Hospital



Patients with condition requiring tertiary care need to be transferred to tertiary hospital

for further management. Inter-referral form is given to the patient addressed to the agency they

are being endorsed to or to their hospital of choice (Appendix F). Communicable Disease Cases

and Psychiatric Cases are transferred to specialty hospitals that cater such conditions. A referral

book is kept for records for reference and inquiry of significant others of patients.

Procurement of Medicine

Prescription should be given as soon as possible to the patient or their significant others

when medications are not available at the hospitals pharmacy. Relatives are instructed to buy

outside the hospital pharmacy whenever supplies are not available. Emergency Room (ER)

supplies used in critical cases should be replaced as soon as possible. In case that patient cannot

afford to replace the ER supplies used, a charge slip must be given to the hospital pharmacy for

inclusion in the patient’s bill.

Policies Regarding Emergency Supply



1. ER cabinet must be maintained filled adequately with supplies and emergency kit for

urgent cases. It is the responsibility of the ER nurse to determine and monitor the

adequacy of equipment, instruments and supplies for the use of the ED.

Treatment Sets Available

2 Thoracostomy Set: Adult (1) and Pedia (1)

2 Cut Down Set: Adult (1) and Pedia (1)

1 Thoracostomy set with different size of tracheostomy which has individually packed:

Lumbar Sets (2)

Suturing Set (6)

Burn Dressing Set (1)

Internal Examination Set (1)

2. No instruments or articles should be brought outside the unit except if it is subject to

sterilization.

3. Borrowing of instruments or articles for personal used and for use outside the unit is

not allowed.

4. If an instrument, catheter or drainage tube is attached to the patient upon transfer to the

ward, the nurse in charge must replace those supplies ready for another emergency; some

articles shall be replaced as soon as possible for use.

5. The outgoing and incoming nurse on duty must have endorsement of all equipment and

articles.

Disposition of Broken Articles

1. If in case of breakage of anything in the unit a letter of explanation must be written and

forwarded to the proper authority.

2. There should be a replacement at once of any breakage and losses in the unit.

3. Condemning of article that cannot be use should be brought to supply for replacement.

Patient Presentation



Patient Age Range

The Emergency Department provides health care for emergency presentations for all

triage categories of patients ranging from newborn to the aged.

Presenting Conditions

A. Surgical Case

Cases which require usual and operative procedures are catered. These include burns,

cuts, fall fractures and vehicular accident which happened few minutes prior to

consultation. Hernia that requires emergency operation is accommodated, however

elective cases are referred OPD.

B. Pediatric Case

Febrile patients are asked to consult at OPD except when there is possible convulsion.

Patient having LBM and vomiting that would require hydration are treated within the

Hydration Partition of Emergency Room.

C. Medical Cases

Febrile patients are asked to consult at OPD except for patients with convulsion and

chills. Patient having LBM and vomiting that would require hydration are treated within

the Hydration Partition of Emergency Room.

D. Obstetric and Gynecologic Cases

Obstetric and Gynecologic patients presenting to the ED will be triaged, assessed and should

be given initial treatment before referred to the Resident on Duty. Patients who are in labor,

with vaginal bleeding and the likes are assessed, given immediate care then referred. For

those coming from consultation and follow up they are referred to OPD. Pre-natal check

up is asked to come on their scheduled date.

E. Medico-Legal Case



This include vehicular accident, mauling, stub wounds, gunshot wound, suicidal attempt

or injection of poison that happen few minutes or hours prior to consultation.

F. Gross Death

Patient expires less than 24 hours are advice to secure death certificate to their respective

Municipality.

G. Dead On Arrival (DOA)

Relatives are advised to send patient for autopsy and death certificate shall be issued by

the Medico-Legal Officer who performs the examination. In case that the patient has no

relatives available it should be reported to the guard for proper coordination to the police

officer.

MINOR PROCEDURES AT ER



Thoracostomy

A surgical incision is done in the mid-axillary line at the level of the nipple line or higher

with the insertion of one or more chest tube connected to a drainage bottle.

To remove air and fluid from the thoracic cavity.

To facilitate re-expansion of the lungs after surgery or trauma.

Guidelines to the Nurses role in the Management of patient undergoing Thoracostomy

1. Explain the procedure to the patient and indicate how he can be helpful.

2. Obtain an informed consent.

3. Ensure that chest x-ray is done before and after the procedure. These are used to

localize fluid and air in the pleural cavity and facilitate in determining the puncture site.

Ascertain in advance if chest roentgenograms have been ordered and completed.

4. Prepare instruments needed in the procedure:

Scalpel and blade

Needle holder

Cutting needle

Suture silk

Metz scissor

Tissue forcep

Sterile gloves

Gauze pads

Cotton balls soaked in betadine

Local anesthetic (Lidocane)

Syringe with needle

Thoracostomy tube

Saline solution

thoracostomy bottle with connecting tube

5. Place patient in an upright position, either sitting on the side of the bed or in a chair

with arms and head resting on the back of the chair. For patients unable to sit-up, they are

placed in a semi-fowler’s position with arms held above the head.



6. Paint the midaxillary line at the level of the nipple line or higher with three coats of

betadine.

7. Assist the surgeon during the procedure.

8. After insertion of chest tube, attach the drainage tube from the pleural cavity to the

tubing that leads to along tube that ends under a sterile saline in the drainage.

9. The end of the chest catheter from the patient is submerged about 2.5cm (1inch) below

the surface of sterile normal saline. This water acts as a one-way valve or seal to allow air

or fluid from the patient’s chest to flow down the tubing.

10. Secure the connecting points of the tubing with tape to make sure that the tubing

remains airtight.

11. Mark the original fluid level wit tape on the long glass tube. This marking will show

the amount of fluid and how fast it collects in the drainage.

12. Make sure there is fluctuation of fluid level in the long glass tube. The fluctuation of

fluid level shows an effective communication between the pleural cavity and the drainage

bottle.

13. Watch for leaks of air in the drainage system as indicated by constant bubbling in the

water seal bottle.

14. Observe and report immediately of rapid, shallow breathing, cyanosis, pressure in the

chest and symptoms of hemorrhage.

15. Record amount of fluid, nature, color and viscosity. If ordered prepare sample for

labory evaluation.

16. If the patient is to be transported, place drainage bottle below the chest level.

17. Chest tube may be clamped during transportation, as a safety measure with some

units. Check with surgeon as to whether or not clamping is contraindicated. Two clamps

(hemostats) should be kept at bedside at all in case water-seal bottle is accidentally

broken.

Thoracentesis

Nursing Intervention for Patient’s undergoing Thoracentesis:

1. Inform client about the procedure and indicate how he can be helpful.



3. Obtain informed consent.

4. Prepare the equipments needed in the procedure:

Aspirating needle

Large aspirating needle

Hypodermic syringe with needle

Small forcep

Sterile gauze pad

Sterile gloves

Specimen bottle

5. Then place the patient in an upright position, either sitting on the side of the bed with

arms and head over the bedside table or sitting in the chair with arms and head resting in

the back of the chair. This position with arms and shoulder raised, elevate the rib and

makes it easier for the physician to insert the needle when desired. Patients who are

unable to sit up are placed on their side with affected side uppermost.

6. Expose the entire chest. The site of aspiration is determined from chest x-ray and

percussion.

7. The skin is disinfected with betadine. The site is usually in the 7 th or 8th intercostal

space in the posterior axillary line.

8. Assist the physician during the procedure.

9. Instruct the patient not to cough during the procedure to prevent trauma to the lungs.

10. Inform the patient on his unaffected side for approximately 1 hour to permit the

pleural puncture site to seal itself and thus prevents fluid seepage from cough or from

gravitational forces.

11. After the procedure, apply pressure dressing lower punctured site.

12. Record total amount of fluid withdrawn. If ordered, prepare samples of fluid for

diagnostic evaluation.

13. Evaluate client’s response to the procedure.

Debridement

The process of cleaning an open wound by removal of foreign materials and dead tissue

(Eschar) so healing may occur without hindrance.



Purpose:

To prevent infection since devitalizec tissue acts as a culture medium for bacteria

To promote rapid healing

Nursing Interventions for Patients undergoing Debridement:

1. Explain procedure to patient

2. Obtain consent from patient.

3. Gather necessary equipments needed in debridement.

Smooth Forcep-Thumb forccep

Sterile Gauze

Gauze pads

Saline Solution

sterile scissor

4. Position patient with the affected side exposed.

5. Analgesics are usually given as ordered by the physician to alleviate pain during the

procedure.

6. Irrigate wounds with saline solution to remove some debris attached to them

7. Assist the surgeon in the procedure as needed.

8. If bleeding occurs during the procedure brought about a thorn small blood vessel,

pressure may be applied for homeostasis.

9. Medication such as sulfamylon is then applied is then applied and smoothly with the

aid of tongue depressor.

10 The type of dressing usually consists of a single layer of fine mesh gauze. The purpose

of applying some type of light covering includes prevention of infection, facilitation of

debridement, maximum contact by topical agents, and prevention of fluid evaporation

with loss of body heat.

Incision and Drainage

Surgical procedure of an inflamed and superlative are must frequently carried out because

of infection. The cavity is usually irrigated and ound packed and allowed to heal by

granulation. The causative organism is often staphylococcus.



Nursing Intervention for Patients undergoing I and D:

1. Information patient about the procedure and indicate how he can be helpful.

2. Obtain an informed consent.

3. Gather instruments needed in the operation:

scalpel with blade

curved forcep

eye sheet

drain

syringe with needle

sterile gauze

local anesthetic

sterile gloves

4. Position patient with operative site exposed.

5. Paint the site with antiseptic solution before surgeons apply the drape.

6. After procedure, pressure dressing is applied to seal the wound.

7. Evaluate patient’s response to procedure

Excision

Removal of tissure, organ or tumor from the body.

Nursing Intervention for patient undergoing Excision.

1. Informed patient about the procedure.



2. Secure consent from the patient.

Check the order of the surgeon.

Determine available equipments needed for the procedure

Scalpel with blade

Needle holder

Cutting needle

Silk Cutting Suture

Oallis Forcep

Metz Scissor

Tissure Forcep

Sterile Gloves

Gauze Pads

Cotton With Betadine

Lidocaine

Syringe with Needle

Suturing

Nursing Intervention for patients undergoing suturing:

1. Inform patient about the procedure.

2. Secure consent from the patient.



3. Prepare the instruments needed for the procedure:

cutting needle

needle holder

suture silk

sterile 4”x4” gauze pad

cotton with betadine

local anesthetic

syringe with needle

sterile gloves (Latex-free or Latex made)

4. Position the patient exposing the affected area.

5. Arrange the instruments in the mayo table.

6. After donning gloves to the surgeon, assist in obtaining local anesthetic.

7. After suturing a clean dressing is then put in place.

8. Evaluate patient’s response to the procedure.

Removal of Foreign Body

Removal of foreign body like needle, fish hook, bone, wood or glass which penetrates the

skin and underlying tissue.

Nursing Intervention for patient undergoing removal of foreign body.



1. Position patient with site exposed.

2. Instruct the patient not to remove foreign body since unskilled manipulation produces

swelling or infection which makes removal difficult.

3. The physician places marker ear the foreign body before any attempt of surgical

removal is made.

4. Request for x-ray is made as ordered to confirm the success of the surgery.

5. Ensure x-ray examination is done before the procedure.

6. During the procedure, instruct patient to prevent trauma and decrease movement that

may affect the affected surgical area.

7. Dressing is applied after removal of the foreign body.

8. Instruction in cleaning and home management is given to the patient.

SURGICAL CASES AT ER

Vehicular Accident

Nursing Considerations:



*Note if the patient is positive in Alcoholic Breath (+). For any medico-legal pattern a

form should be attached to the OPD record.

Wounds

1. Ask the patient when, where and how did the patient acquired the wound.

R! More than 3hours delay in management increases risk of infection.

2. Inspect the wound using aseptic techniques.

2.a Shave around wound if necessary.

3. Clean the wound area as well as the surrounding tissue in aseptic technique.

3.a If the wound is open, clean the wound in and around with cotton soaked in

betadine.

3.b Lacerated wound exposing internal organs can be flushed with PNSS.

3.c Remove devitalized tissue and foreign matter.

3.d Clamp and tie bleeding vessels and/or pack the wound with sterile gauze and

bandage for pressure.

4. Assist physician in suturing the wound.

5. Apply non-adhesive dressing.

6. Administer antimicrobial agents as prescribed.

7. Elevate site to limit accumulation of fluid in he affected area.

8. Administer tetanus prophylaxis as prescribed.

6. If the patient may go home, advice the patient and relative for home management.

7. If the patient condition requires hospitalization. Inform the patient and relative and

secure consent.

8. Advise the patient and relative to report any signs of complication like fever, bleeding,

rapid swelling, foul odor, profuse serosangenious drainage.

Multiple Traumas

1. Place the patient on stretcher.

2. Assess the patient ABC’s:

3. Provide open airway and ventilation.

4. Stop bleeding at open wound by packing with sterile gauze and elastic bandage.



5. Take vital signs and GCS score.

6. Refer to the ROD.

7. Interview the patient or the significant other for history of incident: NOITOIDOIPOI

Nature of Incident (NOI), Time of Incident (TOI), Date of Incident (DOI), Place of

Incident (POI)

8. Splint long fracture.

9. Catheterize the patient as ordered.

Burns

Superficial Partial Thickness (1st Degree Burn)

Involves the epidermis, reddish, painful.

Deep Partial Thickness (2nd Degree Burn)

Involves the dermis, moist surface, with vesicles, painful.



Full Thickness (3rd Degree Burn)

Involves the subcutaneous layer, pearly white, no pain.

Full Thickness (4th Degree Burn)

Involves the muscles and bones, blackish or charred, no pain.

Nursing Intervention:

1. Promote respiratory function.

Establish an open airway

Provide Oxygen therapy as prescribed.

2. Promote Fluid-Electrolyte, Acid-Base Balance

3. Assess the vital signs, urine output and note LOC.

Emergency Treatment:

1. First Aid

Burns less than 10%, immense in cold or tap water for 15 minutes.

For chemical burns, do copious water lavage.

2. Airway

Endotracheal intubation is preferred than traecheotomy if necessary to establish

airway

3. Intravenous therapy

Intravenous therapy is required for burns larger that 20% in adults.

Large bore needle, venipunture or cut should be used for IV therapy.

Sample for CBC, blood typing, blood sugar, BUN, UA, Na+, and K+

Weight the patient if not possible, ask the patient’s weight or have an estimate.

Fluid replacement:

1. Plain LR only in 1st 24 hours

2. Adult: 2ml x body weight (kg) x % of burn

3. Children: 3mil x body weight (kg) x % burn

4. Insert a Foley catheter for patient on IVF to monitor urine output.

5. Give analgesic as ordered.

6. Give tetanus prophylaxis as ordered.



7. Wound care

a. Clean the wound with soap and water.

b. Remove the rigs and bracelet of the patient.

c. Do not provide a pillow is the ear of the patient is burned.

d. Cover the wound with sterile or clean dressing.

8. Transport

a. Contact the receiving hospital.

b. Maintain correct IV infusion.

c. Ensure drainage

d. Administer oxygen.

MEDICAL CASES AT ER

Cerebrovascular Accident (CVA)

CVA or Stroke is the onset of neurological dysfunction resulting from disruption of the

blood supply to the brain.



Nursing Interventions:

1. Asses the patient’s level or responsiveness, arousal and awareness

Measure the neurological assessment of the patient using Glasgowcoma scale (GCS).

2. Place patient in a comfortable position, if unconscious, patient in lateral or semi prone.

3. Check the patient’s baseline neurovital signs.

4. Assess the patient’s airway. Remove dentures or anything that obstruct the airway.

5. Administer oxygen as needed.

6. Refer to the medical resident duty.

7. Carry out physician’s order such as:

Insertion of intravenous fluid and medications.

Preparing for possible insertion of nasogastric tube and IFC

Request for blood chemistries, Electrocardiogram (ECG), Chest X-ray (CXR)

Instruct the patient and/ or relatives for the prescribed diet of the patient.

8. Accompany patient to ward nurse

Bronchial Asthma

A disease characterizes by variable, recurrent, reversible airway obstruction clinically

manifested by intermittent episodes of wheeling and dyspea. It is associated with hyper

responsiveness of the bronchi to various stimuli that may be antigen-mediated.



Nursing Responsibilities

1. Assess the rate, depth and character of respiration.

2. Place the patient in high Fowler’s position, sitting position, or whichever position the

patient feels comfortable.

3. Administer oxygen installation at 2-3L/min as needed.

4. Teach the patient how to do deep breathing properly. Promote its use and benefits

towards his condition.

5. Take vital signs.

6. Call the physician.

7. Provide nebulization therapy as ordered.

8. Administered medications as ordered.

9. Assess effectiveness of the therapy.

10. Refer to doctor for further order.

Hypertension

A disease of vascular regulation in which the mechanisms that control arterial pressure

within the normal range are altered.




1. Identify signs and symptoms such as headache, weakness muscle cramps, tingling

palpitations and sweating visual disturbances.

2. Take the patient’s vital signs and record.

If the blood pressure is 140/90 mmhg and above, let the patient lie on bed.

3. Refer the resident on duty.

4. Administer medication as ordered (usually nifedipine 5mg SL)

5. Recheck the blood pressure after 15-30 minutes of drug administration. And document

and refer the response of the patient to the Medical Resident on Duty (MROD) for further

management.

7. Request for ECG and other blood chemistries as ordered.

8. Instruct patient on diet restrictions and the importance of follow up and health care

visits.

Myocardial Infarction (M.I.)

Dynamic process by which one or more regions of the heart muscle experience as severe

or prolonged del rense in oxygen supply because of insufficient coronary blood flow ;

subsequently , necrosis or tissue death occurs.




1. Gather information regarding the patient’s chest pain.

Nature and Intensity

Onset and Duration

Location and Radiation

Precipitating and Aggravating Factors

2. Place the patient n Fowler’s position to reduce workload of the heart.

3. Obtain Vital Signs.

4. Refer to the MROD.

5. Administer O2 therapy as ordered and encourage deep breathing exercise.

6. Request for ECG and their laboratory examination as ordered.

7. Administer medication nitroglycerine (NTG) and narcotics as ordered.

8. Obtain baseline vital signs prior to giving agents and 10-15 minutes after each dose.

9. If his condition requires hospitalization, inform patient and relatives and secure

consent.

10. Provide a quiet atmosphere.

11. Accompany the patient to the ward for proper endorsement.

Peptic Ulcer Disease (PUD)

Excavation of the mucosal lining of the esophagus, stomach, pylorus and duodenum.


1. Determine the location, character, radiation,



2. Determie if there is gastrointestinsl bleeding and refer to resident physician.


4. If there is profuse bleeding:

Administer prescribed IV fluids.

Request for stat determination of hemoglobin, hematocrit and typing.

Prepare patient for NGT insertion and do gastric lavage as orders by the

physician.

Administer prescribed medications.

5. If hospitalization is needed, inform the patient ad relatives. Secure consent for

admission.

6. Endorse to ward nurse.

Seizure

Episodes of abnormal motor, sensry autonomic or psychic activity as a consequence of

sudden excessive discharge of electrical impulse from cerebral neurons.




A.During the attack:

1. If aura proceeded, insert padded tongue depressor to patient’s mouth.

2. When jaws are already clenched because of spasms, do not try to insert the mouth

depressor.

3. Place the patient on the side to prevent aspiration. Loosen the patients clothing.

4. Safety precautions should be implemented.

5. Administer Oxygen therapy.

B. After the Attack:

1. Turn the patient’s head to his side.

2. Take and record vital signs.

3. Note for the following and record:

Description of the circumstances before the attack

The first thing the patient did during the attack

Duration and frequency of the attack.

4. Refer to the physician.

5. Administer IV fluids ad anticonvulsant drugs as ordered.

6. Suction secretions as ordered.

7. Observe patient closely.

8. If his condition requires hospitalization, inform the patient and relatives and secure

consent.

9. Endorse the patient to ward nurse.

Acute Gastroenteritis (AGE)

Increase in frequency and consistency of bowel movement ranging from formed turned to

watery.


1. Determine the characteristics, amount frequency of stool and vomittus.



2. Assess for signs of dehydration.


4. Refer to MROD

5. If the patient’s condition doses not require hospitalization, instruct on oresol intake and

observance of proper hygiene.

6. If hospitalization is required, inform the patient and/or significant others then secure

consent.

7. Administer IV fluids as ordered.

8. Endorse to ward or accompany the patient and significant other to Hydration Section.

Alcohol Intoxication


1. Assess the patient’s level of consciousness.

2. Place patient in a comfortable position.

3. Check the vital signs and papillary size and reaction to light.

4. Refer to MROD.

5. Request for random blood sugar as ordered.

6. Administer IV fluid with high concentration of glucose and vitamin B complex as

prescribed.

7. If the patient is severely agitated or violent, restraints can be applied for the safety of

the patient and the nurse.

8. If the condition needs hospitalization, inform relatives.

9. Carry out all stat orders.

10. Accompany the patient to the ward for proper endorsement.

Dyspnea

1. Assess for level of consciousness and ascertain circumstances that cause dyspnea.

2. Place the patient on high back rest while assessing the patient for accompanying signs

and symptoms such as cough, cyanosis and others.

3. Encourage doing deep breathing exercise.





6. Administer Oxygen therapy as prescribed.

Hemoptysis


1. Ascertain whether blood is coming out from nose or throat, gastrointestinal tract or

lungs.

2. Document for the quantity, color and character of the coughed out blood.

3. Place the patient on bed rest.


5. Save all coughed out blood.

6. Refer to the MROD and carry out orders.

7. Maintain a calm reassuring approach.

8. If the patient is admitted, inform the patient and secure consent.

9. Carry out all stat orders before patient is brought to ward.

10. Accompany the patient to ward for proper endorsement.

Poisoning

i. General non-corrosive


1. Assess the level of consciousness and ability to swallow.

2. Place the patient in sde lying position.



3. Administer Oxygen therapy as ordered.


5. Remove poison from the patients’s stomach immediately by inducing vomiting. Carry

out gastric lavage procedure to remove any unabsorbed poison.

6. Refer to the MROD and carry out orders.

7. Remain at the side of the paitent and provide emotional support.

8. Instruct the family to bring the unuse poison to the hospital for identification of

components.

ii. Carbon monoxide Poisoning

Occurs at industrial and household areas as an attempt to suicide. Carbon monoxide binds

to the oxygen carrying component of the blood hemoglobin and reduces oxygen transport

throughout the circulatory system.




1. Assess level of consciousness

2. Check vital signs.


4. Administer high concentration of oxygen therapy as ordered.

5. Request ECG and blood studies as ordered.

Food Poisoning

1. Determine the source and type of poison ingested.


3. Administer oxygen therapy as ordered.


5. Insert and IVF as prescribed.

6. Collect food, gastric contents, vomitus, serum and feces for diagnostics.

OB-GYNE CASES AT ER

Placenta Previa




1. Obtain baseline data. BP, PR, RR, WT, appearance, and LOC.

2. Evaluate the amount of blood loss and duration of bleeding.

3. Refer to the attending physician and carry out oders.

4. Request for stat hemoglobin, hematocrit, blood typing as ordered.

5. Administer IVF using large bore needle.

6. Position patient in left lateral decubitus to promote placental prefusion.


8. Secure consent as ordered.

9. Endorse the patient to the ward.

Abruptio Placenta


1. Obtain Vital Signs

2. Evaluate the amount of blood loss.

3. Refer to ROD and carry out orders.

4. Position the patient in left lateral with head elevated.


6. Insert an IVF using large bore needle.

7. Secure consent for admission.

Pregnancy Induced Hypertention (PIH) or Pre-Eclampsia

A disorder during pregnancy after the 20th week o gestation and involving edema,

proteinuria and hypertension.

Eclampsia



Convulsions occur in the absence of underlying neurological condition in the presence of

hypertension, edema and proteinuria.


1. Obtain baseline data.

2. Note for the intensity, duration and frequency of pain and the amount of blood loss.

3. Refer to the ROD and carry out orders.


5. Administer IVF using large bore needle. And if necessary a second line maybe inserted

as ordered.

6. Request for stat hemoglobin, hematocrit and typing.


8. Endorse to ward.

Incomplete Abortion


1. Obtain baseline vital signs.

2. Position patient on left lateral side.

3. Inform ROD and carry our orders.



4. Give all medications as ordered.


6. Administer oxygen as needed.

7. Prepare a tongue blade for eclamptic patient.

8. Explain the effects of all medications.

9. Protect eclamptic patient from injury during seizure.

10. Insert IFC and note for the color and amount of urine output

11. Accompany patient to ward with proper endorsement.

Ectopic Pregnancy

1. Obtain baseline data. Take the vital sign of the patient.

2. Note for the intensity, duration and frequency of pain and the amount of blood loss.



5. Administer IVF using a large bore needle. And if necessary a second line maybe

inserted as ordered.

6. Request for stat hemoglobin, hematocrit ad typing.

7. Bring patient to ward and endorse properly.

Septic Abortion

Error! Not a valid link.

1. Obtain baseline data. Take the vital signs.

2. Evaluate bleeding, duration of the symptoms upon manifestation.

3. Report to ROD and carry out orders.



4. Administer IV line as ordered

5. If admission, secure consent.

6. Brought patient to ward.

Postpartum Hemorrhage

Nursing Intervention :

1. Obtain baseline data.

2. Evaluate the bleeding of the patient. Note the amount and duration of bleeding.

3. Report to the ROD.

4. Administer an IV line as ordered as STAT.

5. Secure consent if the patient is for admission.

6. Request for STAT CBC, typing as ordered.

7. Endorse the patient to ward.

Uterine Atony

Caused by the following factors such as: Multiple pregnancy, Polyhyramnios, Prolong

labor with maternal exhaustion, Deep anesthesia, Fibromayomata, Retained Placental

Fragments


1. Obtain baseline data. Take and document vital signs. Assess the amount of bleeding.

2. Report to ROD and carry out orders.


4. Start IV line as ordered.

5. Emphasized the importance of complete bed rest.

6. Request for stat CBC and typing as ordered.

7. Endorse to patient to ward.

PEDIATRIC CASES AT ER

Dyspnea

Nursing Responsibility:

1. Asses the child-breathing pattern.



Respiratory Physical Assessment

1.a Note the pattern of respirations:

Rate

Regularity:

Apnea Episodes (cessation of breathing for 20seconds)

Periodic Respirations (period of rapid respiration, separated by periods of

slow breathing or short periods of no respiration which is N in young

infants)

Respiratory Efforts:

Nasal Flaring

Open Mouth Breathing

Facts in Respiratory Assessment

Infants are obligatory nose breathers and diaphragmatic breathers.

Number and size of alveoli continue to increase until age 8 years.

Until age 5, structures of the respiratory tract have a narrow lumen and children

are more susceptible to obstruction and distress from inflammation.

Normal respiratory rate in children is faster than in adults.

NORMAL RESPIRATION IN PEDIAInfants 40-601 year 20-402-4 years 20-305-10 years 20-2510-15 years 17-2215 and older 15-20

1.b Observe skin color and temperature particularly mucus membranes and peripheral

extremities.

1.c . Note behavior:

position of comfort

signs of irritability, lethargy, facial expression, if (+) anxiety

2. Take and document the vital signs: HR, RR, T, WT and assessment.

3. Refer to the ROD and carry out orders.



Interdependent Nursing Intervention:

0xygen therapy R! Verify the ordered regulation per minute to the physician.

Dependent Nursing Inervention:

Suctioning R! Assess response of patient and note if there is (+) improvement in

respiratory status. Fr

Deep Breathing Exercise R! Laughing and crying also stimulate coughing and

deep breathing.

4. If patient have diarrhea is mild and with signs of dehydration, give oresol solution as

tolerated, and hydrate the patient as ordered.

5. If the patient is severely dehydrated and needs admission, inform relatives and secure

consent.

6. Administered IVF and regulate as ordered. Document the time the IVF was started.

8. Endorsed properly to ward.

Fever

Nursing Intervention:

1. Assess physical condition and appearance of the patient. Note if the patient has a

history of convulsion.

2. Take vital signs and weight.

3. If highly febrile perform Tepid Sponge Bath (TSB) till fever subsides.

4. Administer antipyretic as ordered.

6. Continue TSB.

7. Educate patient with home medication and management.

8. Inform the patient and/or relative if admission is needed then secure consent.

9. Start IV therapy, regulate and document the start of infusion then carry out all orders.

10. Endorse patient to the ward.

Seizure - An involuntary contraction of muscle caused by abnormal electrical brain

discharges.

Febrile Seizure-Associated with high fever 38.9°C to 40ºC.




1. Assess the patient. Note the onset and duration of seizure as well as previous history.

2. Maintain a patent airway with the child lying on his side during onset of seizure.

3. Apply tongue depressor if needed.

4. Take vital signs: T, PR, RR, and WT

5. Perform TSB to patient or instruct to significant others. R! Reduce fever.

*After seizure subsides *Refrain from alcohol or cold water bath. R! Extreme

cooling causes shock! Alcohol fumes stimulates seizure!


7. Suction secretion PRN.


9. Administer IV therapy and carry out orders.

10. Inform the NOD on ward for oxygen need of the patient.

11. Endorse the patient to ward.

Tetanus (Lock Jaw)


1. Assess the patient for muscle rigidity, stiff ness of neck and jaw and opisthotonus,

2. Administer oxygen therapy per inhalation.


4. Refrain patient from movement or stimulation to avoid seizure episode or spasm.

5. Refer to ROD.

6. Administer IVF therapy and emergency drugs as ordered.

7. Inform relative and patient about the condition of the patient.


9. If the patient needs to be transferred, inform the relative and make necessary

arrangements for transfer ambulance, on call ROD and NOD.

Food Poisoning

Ingestion of food/drink with chemical or natural substance contaminated with bacterial

toxins or organisms.




1. Assess the patient. Note for the source and type of poisoning substance ingested.


3. Administer oxygen therapy per inhalation.

4. Inform ROD and carry out order/s.

5. Administer IVF therapy and emergency medications.

6. Prepare NGT and saline and assist the ROD in the procedure.

7. Perform gastric lavage until clear out put is obtained.

8. Inform the relative and/or patient the need of admission and secure consent.

9. Endorse to ward.

APPENDICES

APPENDIX A -- PINK ER FORM

RIZAL PROVINCIAL HOSPITALMorong, Rizal



EMERGENCY ROOM SECTION PATIENT’S RECORD

Name: _______________________________ OPD NO.: ___________Address: _____________________________ ERS NO.: ___________Age: ______ Status: ______ Sex: M F Date of Birth: ______/ ______/ ______Person Responsible: ________________ Tel./ Cellphone No.:_______________Philhealth Member: Yes No

Date: _____/_______/ _______ Time Seen: _______/_______ AM/ PMTime Arrived: ____/ _____AM / PM Time Disposed: ___________ AM/ PM

Department: Please Check: Medicine Surgery Pediatrics OB-Gyne Others

Admitted Transferred Sent Home Absconded Expired

HISTORY OF PRESENT ILLNESS CLINICAL HISTORY

Physcial Examination:Vital Signs: BP: HR: RR: TEMP: WT:

Physical Examination:Clinical Impression: _______________________________________________________________________________________________________________________________Management: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________ _______________________________ RESIDENT ON DUTY NURSE ON DUTY

APPENDIX B --ER CHARGE SLIP



APPENDIX CSEQUENCE OF ADMISSION DOCUMENTS

1. ADMISSION PREFACE2. INTRAVENOUS FLUID SHEET3. CLINICAL CASE RECORD4. T, P, R GRAPHING SHEET5. CONSENT6. DOCTOR’S ORDER7. NURSES REPORT

APPENDIX D – INFORMATION SHEET


EMERGENCY ROOM SECTIIONCHARGE SLIP

Date:_________________

Name:_________________________________________________________

CHARGES (Please check appropriately) AMOUNT

ER Consultation Php 20.00 Nebulization 20.00 Oxygen consumption 15.00 Hydration 20.00 Suture Removal Others _____________________________ _____________________________ _____________________________

TOTAL: Php ______________

-- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- --

ACKNOWLEDGEMENT SLIP Ibalik po sa EMERGENCY ROOM NURSE ang bahaging ito para sa maayos na pagtatala ng iyong pagpapakonsulta.

Amount Paid:___________________ Info Clerk:___________________



______________________________ ____________________________ _______________________ Family Name Given Name Middle Name Apelyido Pangalan Gitnang Apelyido

__________ _____________ __________________ __________________________ Age Sex Status Date of Birth Edad Kasarian Petsa ng Kapanganakan

__________________________ __________________________ __________________________ Sitio/ Barangay/Street Municipality Province Kumpletong Address Bayan Probinsya

______________________________ _________________________ _________________________ Person Responsible Relationship Tel./Celphone No.

APPENDIX F



INTER-HOSPITAL REFERRAL SLIP


INTER-HOSPITAL REFERRAL SLIP

To: ______________________________________ Date:___________________Patient: ____________________________ Age: _____ Sex/ Status: __________Address: _________________________________________________________Chief Complaint: __________________________________________________History of Present Illness: ___________________________________________________________________________________________________________________________________________________________________________Pertinent Physical Findings: _________________________________________________________________________________________________________________________________________________________________________Action taken/ Meds given/ Laboratory: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________Impression: ______________________________________________________________________________________________________________________Reason for referral: ________________________________________________________________________________________________________________

Thank you!

_______________________________


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