1st Lecture (NCM106 ABC I) Care of Clients in Cellular Aberrations, ABC, Emergency and Disaster...

7/29/2019 1st Lecture (NCM106 ABC I) Care of Clients in Cellular Aberrations, ABC, Emergency and Disaster Nursing

1/14

jcmendiola_Achievers2013

Care of Clients in Cellular Aberrations,

Acute Biologic Crisis (ABC), Emergency and Disaster Nursing

(NCM106)

Acute Biologic Crisis I

Acute Biologic CrisisHistorical Background

Early development of Emergency Medical Service (EMS) was initiated on July 21, 1861 after the medicalcare and evacuation disaster experienced by the Union Army of Potomac at Bull Run (North Virginia,

USA)

EMS Advancement Recognition of:

o Army Surgeonso Medical Corpso Ambulanceso Hospitals

Refinement and Improvement of:o Administrationo Professional Personnel

o Transportationo Hospital Sanitationo Medical Records

These resulted to advances in:o Army Surgeonso Field Resuscitationso Efficiency of transportationo Energetic treatment of casualty

Historical Impact Decreases in the rates of casualty:

o 8% During World War Io 4.5% During World War IIo 2.5% During the Korean War

o Less than 2% During the VietnamWar

Prevalent Emergency Cases

Trauma Burns Spinal Cord Injury (SCI) Acute MI

NB with congenital abnormality Poisoning Alcohol-induced cases Psychiatric cases

Technologies and Upgrades Reporting and access Responses system Field stabilization Optimal resuscitation Initial care facilities Well extended; progressive and intensive critical care

o Interhospital Phaseo Advanced Phaseo Critical Phaseo Rehabilitation Phase

Trained technical and Professional EMS Personnel working as a teamo Nurseo Physiciano Emergency Techniciano Systems Coordinatoro Directors

Upgrade of above operations (Prehospital personnel)o Emergency Medical Technician Ambulanceo Emergency Medical Technician Paramedicso CPR Team (Non-EMS Personnel) Firefighters, Police Officers, Life Guards


2/14


Nursing Focus in Emergency SituationsPrehospital Intrahospital

Assume position of responsibility Supervision of both EMS and non-EMS

personnel during acute care provision

Assists in life support care

Legal Issues in the Emergency Room (ER)1. Consent

o Conscious = Get consento Unconscious

If 24 y/o revive even if without consent If pediatric client Get consent from guardian / parent

(EXCEPT IF: Communicable Disease, Emancipated Disease, Alcohol induced /

Pregnancy Cases)

2. Restrainto Physical / Chemical Restraint

Physical: Hard Leather, Body Straps Continuous patient monitoringo If patient is doing self directed injury / injury to others Put in ISOLATION for 72 HRS ONLY

3. Legislation: Give care even if patient has no moneyo COBRA 1986o OBRA 1990o EMTALA 1988

4. Reporting: Government stats any disease and mortality5. Collection and Presentation of Evidences: Collect the clothes, specimens, bullets, etc6. Violence

Ethical Issues- Unexpected deaths- Organ and Tissue Donor- Child abandonment

Competencies for RNsResponsibility to Emergency and Mass Casualty IncidentsBasic ApproachStandards of Care Guidelines

Whenever a patient is with a potentially life threatening condition, proceed with the following:o Remove the patient from potential source of danger Live electrical current, water, fireo Go through the primary emergency assessmento Call for help as soon as possibleo Assist with transport and further assess and care as indicated

Note: This information should serve as a general guide only. Each patient situation presents a unique set ofclinical factors and requires nursing judgment to guide care, which may include additional or alternate

measures.

Emergency Assessment (Chief Complaint, Primary Ax, Secondary Ax, Focused Ax)1. Chief Complaint

What brings the patient to the ER? Based on the patients own words Dont change the CC to a medical diagnosis without adequate cues

2. Primary Assessment The first step in the primary assessment is to determine if the patient is conscious Identify life-threatening problems (Airway, Breathing, Circulation) [CAB (2010)] Appropriate interventions are required before proceeding to secondary assessment


3/14


A Airway = Does the patient have an open airway? B Breathing = Is the patient breathing?Excessive use of accessory muscles (Breathlessness) C Circulation =

o Is circulation in immediate jeopardy?o Is there a pulse?o Is there profuse bleeding?

In seriously injured / ill patients, it is recommended to add two more letters to the Primary Survey D Disability

o Assess level of consciousness and pupilso A more complete neurologic survey will be completed in the secondary survey

A Is the patient ALERT?

V Does the patient respond to VOICE?

P Does the patient respond to PAINFUL STIMULI?

U The patient is UNRESPONSIVE even to painful stimuli

E Exposureo Undress the patient to look for clues to injury / illness, such as wounds / skin

lesions

3. Secondary Assessment Systematic Brief (2 3 Minutes) Head-to-Toe To detect and prioritize additional injuries / to detect signs of underlying medical conditions Continuation

i. HistoryBrief history of the CC, accident, illness

Taken from the patient or an accompanied person

- Relative- Prehospital provider

What is the mechanism of injury the circumstance, force, location and time

When did the symptom appear?

Was the patient unconscious after the accident?

How did the patient reach the hospital?What was the health status of the patient before the accident or illness?

Is there a history of illness?

Is the patient currently taking medications?

Does the patient have any allergies?

Under what health care provider was the patient in? (Name of Provider)

Was the treatment attempted before arrival at the hospital (Home Remedies,

OTC Drugs etc.)

ii. Vital SignsRoutinely includes: Temperature, Pulse Rate, Respiratory Rate, Blood Pressure

and Pain Scale

When obtained early in assessment, they help to complete baseline data

iii. Head-To-Toe Assessment General Appearance- Position / Posture / Gait- LOC Restlessness is a

DANGER SIGN

- Behavior and degree of distance- Cooperation- Skin condition and color

Head / Scalp- Bleeding

- Deformity and Depressions- Facial Symmetry

Ears- Blood- Clear Fluid (CSF)- Battles Sign (Bluish

discoloration of the mastoid area)

Eyes- Pupil size and reaction to light


4/14


- Extraocular Motions (CardinalGazes)

- Orbital Ecchymosis (RaccoonsEye)

- Gross Vision- Conjunctivae Examine for

pallor / cyanosis

Nose- Blood- CSF

Mouth- Missing teeth- Cyanosis of the lips- Foreign materials / vomitus

Neck- Tracheal deviations

Hemothorax

- Jugular distention- Tenderness

Chest- Symmetry- Tenderness / Pain- Ecchymosis- Subcutaneous Emphysema- Soft tissue injury- Breath sounds- Heart sounds

Abdomen- Distended / Rigidity- Tenderness / Pain- Guarding- Bowel Sounds- Soft tissue injury

Pelvis- Stability- Tenderness

Genitalia- Bleeding- Priaprism- Pain- Wound / Trauma- Rectal Tone

Extremities- Pain- Deformities and Bruises- Pulses-

Sensation and Strength- Soft tissue injury- Edema

Posterior (Observe Cervical spineprecautions in trauma patients)

- Soft tissue injury- Spinal tenderness Pain during

movement

- Pin and tenderness

4. Focused Assessment A more detailed assessment of

deviation from normal / problems

identified in the secondary survey

If more than one focusedassessment is necessary, any

problems identified with the

PULMONARY,

CARDIOVASCULAR, or

NEUROLOGIC System should be

ASSESSED FIRST!

Triage Definition: Is a French verb, meaning

to sort

Most patients entering an emergencydepartment are greeted by a Triage Nurse

The role of the Triage Nurse is to do briefevaluation of the patient to determine a level

of acuity / priorities of care Thus, the Triage Nurse acts as a gatekeeper,

sorting patients into categories, ensuring that

the more seriously ill are treated first

Triage in Clinical Setting Standardized Triage categories are usually

developed within each emergency

department

Most common Triage systems consist of 3Levels of acuity

Emergent / I Urgent / II Nonemergent / III

EMERGENT / I Immediate medical intervention!! Delay in treatment is potentially life or limb-

threatening

Includes conditions such as: (SAC-MACE) Severe shock Airway compromise Cardiac arrest Multisystem trauma Altered level of consciousness Cervical spine injuries Eclampsia

URGENT / II Stable but whose condition requires medium

intervention within a few hours

No immediate threat to life or limb for thesepatients

Conditions includes: (FMM-DL)o Fevero Minor Burns


5/14


o Minor Musculoskeletal Injuryo Dizzinesso Lacerations

NONEMERGENT / III Chronic / Minor Injuries There is no danger to life or limb by having these patients wait No obvious distress Conditions includes: (MR-CD)

Missed Menses Routine Chronic low back pain Dental Problems

COMMUNICATION SKILLSCommunication with a Person as a Psychological Being

- A total person is much more than the sum of his / her parts- Psychic functions: Sensing, Thinking, Feeling, and Intuition

Sensing Process through which one gathers objective data I smell alcohol I see an unconscious person who is dressed in dirty worn clothes

Thinking Cognitive process through which one recognizes the meaning of the data Alcohol is a CNS depressant This person needs to be evaluated

Feeling The affective process of all mental life I hate alcoholics

Intuition The quick perception of truth without conscious attention or reasoning This person has no social support system and probably lives on a squatters area

- NURSING ALERT!! Nurses frequently make the error of stating that what they sense is sensed by another How? Once the nurse begins to think, feel, or use intuition, the sensory function is altered

Example: Nurse may think: Ang toxic naman ng relatives na to! with a failure to sense that thisrelatives state is brought only by anxiety which needs attention. The nurses reactions and future actions may be affected in a way the nurse will be less

caring than expected Therefore, to understand anothers psyche, the nurse must rely upon reports from the

patient (Including relatives)

PEOPLE ARE SOCIAL BEINGS

- From the moment of birth until death, a person is either dependent on, independent from or interdependentwith others

- The way people make decisions is affected by their culture, which is affected by formed attitudes, values- And beliefs and these norms (i.e. culture, belief and values) are brought about by relationships they had- Understanding the WHY behavior is more often than not a prerequisite to decide how to help, this can be

understood only through the process called COMMUNICATION

Silent and Audible Language According to Sigmund Freud, No mortal can keep a secret. If his lips are silent, he chatters with his

fingertips; betrayal oozes out of him at every pore

All behavior has some meaning and is a form of communication


6/14


SILENT LANGUAGE (Space, Clothing, Color, Time, Gestures)1. Language of Space

Placement of equipment Arrangement of furniture in the waiting area Distribution of nurse stations to cubicles Where the nurse sits***

2. Language of Clothing Theres a difference between the nurse who comes to work in jeans and changes into a scrubgown and who arrives in a neat well fitting uniform

3. Language of Color Warm Colors Red, Orange, Yellow Cool Colors Green, Blue, Gray

4. Language of Time For a tardy and punctual nurse, what is communicated to the rest of the staff For a patient, what do these words mean?

- In a few minutes- In a while- A short time ago

5. Language of Gestures Gestures expressive notions or actions Subtle type Use of eyes, placement of hands, body movement when talking Dramatic type Suicide Leans forward Glancing NURSING ALERT!

To interpret anothers gestures without validating that interpretations may cause a mistake

AUDIBLE LANGUAGEo Therefore, the nurse must not only hear, but also listen to what people sayo When someone is speaking of facts, one is describing those

How to Improve Communication Skills? Identify yourself and your goal when interacting with a patient Assist patient to identify what he / she thinks / feels Seek validity for the assumptions made about patients and their behaviors

Stress and Anxiety in the ED (Emergency Department)- Common words associated with ED are:

Excitement Danger High emotions and activity

- Definition of Anxiety A primitive emotional response with somatic components elicited by external and internal cues Frequently associated with sense of:

- Hopelessness-

Isolation- Alienation- Insecurity

Reponses to Anxiety

Physical Because of Sympathetic Nervoussystem

Cold sweats Butterflies in the stomach , Pounding HR

Flushed face Dilated Pupils RR


7/14


LEVELS of ANXIETY (Mild, Moderate, Severe, Panic) Degree or level of anxiety has definite effect on a person

Mild Anxiety Motivates Ex: It is rare for an average student to consistently study for an examination weeks ahead Alertness, concentration and retention of necessary information

Moderate Anxiety Patient who routinely get sick, anxiety to moderate level Such level leads to increased concern for self, thus ability to see periphery

Do not hear and see everything Annoyed / Angry Unable to pick up cues

Nursing Responsibilities Constant reassurance Inability to recognize that the patient is in moderate anxiety will cause care

provider to get angry and defensive

Interventions:1. Lessen anxiety2. Use simple words3.

Provide quiet environment Severe Anxiety

Ability to focus, comprehend and integrate environmental stimulus Inability to move toward any goal Use one word only

Come Sit

Panic Anxiety Prevention of Anxiety

Simple explanations Clear directions Interpretation Fear of isolation

o Tell the patient that his/her family is in the waiting room and knows their generalcondition

Dont give false reassurance

Psychological Considerations in Emergency NursingPsychological Considerations:

Body Trauma is an insult to physiologic and psychological homeostasis It requires both physiologic and psychological healing

Approach to the patient Approach to the family

Understand and accept the anxieties of the patient Be aware of the patients fear of death, mutilation and isolation

Personalize situation Speak, react and respond in a warm manner Give explanations on a level that the patient can grasp Accept the rights of the patient and family to have and display their own feelings Maintain a calm and reassuring manner

Understand and support loss of control (Emotional, Physical and Intellectual) Treat the UNCONSCIOUS patient as if CONSCIOUS

Touch Call by name Explain every procedure


8/14


Avoid making negative comments Orient the patient Reinforce by repeating this information Orient to reality in a clam and reassuring way Encourage the family to do the same

Be prepared to handle all aspects of acute trauma; know what to expect and what to do Alleviate the nurses anxiety and patient confidence

Approach to Family

- Inform the family all about the patient (Location and Treatment)- Recognize and allow verbalization of anxiety, remorse, anger, guilt, and criticism- Allow the family to relieve the events, actions and feelings preceding admission to the Emergency

Department

- Deal with reality as gently and quickly as possible; avoid encouraging and supporting denial- Assist the family to cope with sudden unexpected death. Some helpful measures include the following:

Take the family to a private place Take the family together so they can mourn

- Assure the family that all possible treatment was done- Avoid using euphemisms (the substitution of an agreeable or inoffensive expression for one that may

offend / suggest something unpleasant) such as Passed on

- Show the family that you care by touching, offering coffee and so forth- Allow the family to talk about the deceased permits ventilation of feeling of loss- Encourage family to support each other and to express emotions freely, grief, loss, anger, helplessness,

fears, disbelief

- Avoid volunteering unnecessary information (Patient was drinking and so forth)- Avoid giving sedation to family members- Be cognizant of cultural and religious belief and needs- Encourage family members to view the body if they wish

Go with family to see the body Show acceptance of the body by touching to give family permission to touch and talk to the body Spend a few minutes with the family, listening to them

- Encourage the ED Staff to discuss among themselves their reaction to the event to share intense feelings forreview and for group support

Death and Dying and the Grieving Process1. Shock and Denial2. Anger3. Bargaining4. Depression5. Acceptance

Agencies

First AID! R.E.D. PointsFundamentals- It is better to know first aid and not need it, than to need it than not know itFirst Aid

Immediate care given to an injured / suddenly ill person Does not take the place of proper medical treatment

Legal Issues


9/14


Consent Expressed Implied

Abandonment Negligence

Duty to act Breach of duty Injury and damages inflicted

ACTIONS IN AN EMERGENCY Recognize the EMERGENCY Decide to help Contact EMS if needed Assess the victim Provide first aid

Scene Surveyo Ensure safety of rescuer and victimo Look for 3 THINGS

1)

Hazards that could be dangerous to you, the victims and bystanders2) The mechanism / cause of the injury / injuries3) The number of victims

Call EMSo Give the following information:

1. Phone number2. Your location3. What happened4. Number of people needing help5. The victims condition6. What had been done to the victims

Disease Precautiono Personal Protective Equipment (PPE)

- Gloves- Protective Eyewear- Mouth-to-Barrier Device

o Universal Precautions / Body Substance Isolationo Vaccines

Multiple Casually Incidents Large number of casualties Obvious disorder Overwhelming demand of care from rescuers Early notification of the Emergency services Role of the first aiders

TRIAGE (BALIKAN NLNG UNG KNINA) Occasionally move the patient first before assessment The safest way possible with the least chance of injury Factors:

Mental status of the patient Environment Available resources

General Rules


10/14


Let your equipment do the work Get as much help as you can Never risk falling / injuring yourself Follow the rule of body mechanics

Body Mechanics The safest and most efficient method of using your body to gain a mechanical advantage Keep the weight of the object as close to the body as possible

Victim Assessment Initial assessment Recognize threats Physical Examination and SAMPLE History

INITIAL ASSESSMENT

The AVPU Scale A Is the patient ALERT? V Does the patient respond to VOICE? P Does the patient respond to PAINFUL STIMULI? U The patient is UNRESPONSIVE even to painful stimuli

SAMPLE History S Symptoms = What is wrong? A Allergies = Are you allergic to anything? M Medications = Are you taking any medications? What are they for? P Past Medical History = Have you had this problem before? L Last Oral = When did you last eat/drink? What was it? E Events = How did you get hurt? What led to this problem?

PEARL and DOTS Pupils are Equal And Reactive to Light DOTS

D Deformity O T S


11/14


CHOKINGForeign Body Airway Obstruction (FBAO) About 3,800 deaths are reported to be caused by FBAO (Choking) every yearCauses:

Choking usually occurs during eating Meat is the most common cause of obstruction in adults A variety of foods and foreign bodies have been the cause of obstruction in children

Risk Factors:

- Large, poorly chewed pieces of food- Elevated blood alcohol levels- Dentures- Playing, crying, laughing / talking while food / foreign bodies are in the mouth

Prevention:

- Cut food into small pieces- Chew slowly and thoroughly- Avoid excessive intake of alcohol- Avoid laughing and talking while chewing and swallowing

Recognition:

1. Determine if the victim is choking Determine if the victim is able to speak or cough Victim may be using the Universal distress signal of choking (Clutching the neck between

thumb and index finger)

Rescuer can ask Are you choking?2. Position the patient

Stand behind victim Wrap your arms around the victims body Grab the victims hand and put them down

3. Perform abdominal thrusts Press fist into abdomen with quick inward and upward thrusts

4. Victim becomes unconscious: position the patient5. Check for foreign body

Sweep deeply into mouth with hooked fingers to remove foreign body6. Open the airway

Tap / gently shake the victim Rescuer shouts Are you okay?

7. Give rescue breaths Attempt rescue breathing Try to give 2 breaths If needed, reposition the head Try again

Observe Airway, Infant of less than 1 Year Old

1. Check for responsiveness Tap / gently shake shoulder

2. Call for help If the victim is unconscious, rescuer shouts HELP! If a second rescuer is available, have him activate the EMS

3. Position the infant Turn on back, if necessary on a firm, hard surface while supporting the head and neck


12/14


4. Open the airway Head-tilt, chin-lift method

5. Determine breathlessness Look at chest for movement Listen for breathing Feel for breathing on your ear for 3 5 seconds

6. Patient is not breathing: GIVE RESCUE BREATHS Maintain an open airway Try to give rescue breaths Use a mouth-over-mouth and nose seal Reposition the head Try to give rescue breaths

7. Delivery back blows Deliver up to 5 back blows forcefully between the shoulder blades with the heel of one hand

8. Deliver chest thrusts Deliver up to 5 thrusts in the mid-sternal region, using the same landmark as those for chest

compression

9. Perform tongue-jaw lift Do not perform a blind finger sweep Remove foreign body only if you can see it!

10. Give rescue breaths Maintain an open airway Try to give rescue breaths Observe chest rise and fall; listen and feel for escape Reposition the head and try to give rescue breaths

11. Repeat sequence until successful12. Unsuccessful resuscitation: Activate EMS!

If you are alone and your efforts are unsuccessful, activate EMS after about 1 minute of effortto clear the airway

13. Observe removal: Check for breathing and pulseTRANSPORTING PATIENTSBody Mechanics Use teamwork, equipment and imagination Use the power-lift and power-grip Lift an object as close to you as possible Use legs, hips and gluteal muscles plus abdominal muscles Proper posture Ears, shoulders and hips in vertical alignment Improve personal physical fitness

Communication and Teamwork

Size u the scene Consider the weight of the patient and recognize the need for additional help Be aware of the physical abilities and limitations of each member Select the most appropriate equipment for the job

Emergency Move

- Immediate environmental danger to the patient / rescuer, such as: Fire / danger of fire Exposure to explosives or other hazardous materials Inability to protect the patient from other hazards at the scene Inability to gain access to other patients who need life-saving care Inability to provide life-saving care because of patient location / position


13/14


Moving PatientsONE-HANDED MOVE

1. Human Crutch- If one leg is injured, help the victim walk on the GOOD leg while you support the injured side

2. Cradle Carry- Used for children and light weight adults who cannot walk

3. Firemans Carry- If the victims injuries permit, longer distances can be traveled if the victim is carried over

your shoulder

4. Pack Strap Carry- Good for longer distances

5. Piggy-back Carry- Use this method when the victim cannot walk but can use the arms to hand onto the rescuer

TWO-THREE PERSON MOVE1. Two-Person Assist

- Similar to human crutch2.

Two-Handed Seat Carry3. Four-Handed Seat Carry

4. Extremity Carry (Fore and Aft)5. Chair Carry

- Useful for a narrow passage or up / down stairs- Use sturdy chair that can take the victims weight

6. Hammock Carry- 3 6 people stand on alternate sides of the injured person and link hands beneath the victim

7. Clothes Lift- Improvised Stretchers

Door Coat Blanket

8. Blanket Lift9. Four-Bearer Lift

Bandages Broad-Fold Bandage Open Triangular Bandage Narrow-Fold Bandage Square KnotReasons for SPLINTING

1. Minimizes / Prevents further neural, vascular and other soft tissue injury2. Prevents a closed fracture from becoming an open fracture3.

Minimizes pain and discomfort4. Facilitates transport of patient

5. Prevents paralysis in the case of spinal patientsGeneral Rules of Splinting

1. Remove / cut away all clothing surrounding the injury2. Remove all jewelry3. Assess pulse, motor function and sensation distal to the injury4. Cover all wounds with sterile dressing prior to splinting5. Never intentionally replace protruding bond back into the skin!


14/14


6. Pad the splint7. Apply splint before moving the patient8. Immobilize the joint above and below the fracture9. When in doubt, splint the injury!

Hazards of Improper Splinting Compression of neurovascular structures Delay of transport Reduced circulation Aggravate the bone and joint injury

FIRST AID FOR BROKEN BONESGoals:

Prevent further injury To keep the injured limb steady To get the victim to the hospital

Symptoms:

Pain and tenderness

Inability to use the injured arm

Deformity, swelling

Bruises

Numbness

Pale, bluish skin

Splinting: Upper

Extremities1. Arm Sling and Swathe2. Upper Arm (Humerus)3. Forearm (Radium / Ulna)

4. Fingers and Hands (Position offunction)

Splinting: Elbows and

Knees1. Knee in Bent Position2. Knee in Straight Position3. Elbow in Bend Position4. Elbow in Straight Position

Splinting: Lower

Extremities1. Ankle / Foot2. Lower leg (Tibia / Fibula)3. Thigh (Femur)4. Self Splint (leg)

External Bleedingo Arterial Blood spurts from the wound, most serious type of bleeding, less likely to cloto Venous Blood flows steadily or gushes easier to controlo Capillary Blood oozes, most common type of bleeding; can be controlled easily Regardless of the type of bleeding, the first aid is the SAME First and most importantly, you must CONTROL the BLEEDING! Protect yourself against disease by wearing medical examination gloves, if not available, the following can

be used as an alternative: Several layers of gauze pads Plastic wrappers Plastic bags Water proof materials

Direct pressure stops most bleeding A pressure bandage can free you to attend toother injuries or victims

Do not remove a blood soaked dressing Elevation of the injured extremity help reduce blood flow If bleeding still continues, apply pressure at a

pressure point to slow blood flow

CAUTION: When controlling

bleeding DO NOT Touch a wound with your bare hands Use direct pressure on an eye injury, a

wound with an embedded object or a skull

fracture Remove a blood soaked dressing Remove an impaled object Apply a pressure bandage so tightly that it

cuts off circulation

Use a tourniquet

1st Lecture (NCM106 ABC I) Care of Clients in Cellular Aberrations, ABC, Emergency and Disaster...

Documents

Transcript of 1st Lecture (NCM106 ABC I) Care of Clients in Cellular Aberrations, ABC, Emergency and Disaster...