ER Lecture

NURSING CARE MANAGEMENT 104

Q AND ACritical Thinking

1. The following clients present to a walk-in clinic at the same time. Which should the nurse schedule to be seen first?A. 25 year old with high fever, vomiting and diarrhea b. 38 year old with sore throat, fever, and swollen lymph glands c. 40 year old with severe headache, vomiting and stiff neck d. 44 year old limping on a very swollen bruised ankle

Q AND ACritical Thinking2. The nurse just received report on the following clients. Who should the nurse see first?a. 35 year old with suspected acute tubular necrosis, urine output totaled 25ccs for the last two hours. b. 49 year old with cancer of the breast, 2 days post mastectomy, reported to be having difficulty coping with the diagnosis. c. 54 year old with TB in respiratory isolation, requesting pain medication d. 36 year old with chest tube insertion after a spontaneous pneumothorax, respirations 16

Q AND ACritical Thinking3. As a nurse working the ER, which client needs the most immediate attention?a. a 3 yr old with a barking cough, oxygen sat of 93 in room air, and occasional inspiratory stridor b. a 10 month old with a tympanic temperature of 102, green nasal drainage, and pulling at the ears c. an 8 month old with a harsh paroxysmal cough, audible expiratory wheeze and mild retractions d. a 3 year old with complaints of a sore throat, tongue slightly protruding out his mouth, and drooling.

Q AND ACritical Thinking4. The charge nurse is apporached by a new graduate nurse who has been assigned four clients: a diabetic with a 4:00 pm blood sugar of 99, a cardiac client with a potassium of 3.3,; a client with pyelonephritis with a temperature of 100.8, and an adult client with a 20% second degree burn of the legs. Which client should the charge nurse suggest to assess first?a. the diabetic b. the cardiac client c. plelonephritis client d. burn client

1.

The emergency nurse has had specialized education, training, and experience.

2.

The emergency nurse establishes priorities, monitors and continuously assesses acutely ill and injured patients, supports and attends to families, supervises allied health personnel, and teaches patients and families within a timelimited, high-pressured care environment.

3. Nursing interventions are accomplished interdependently, in consultation with or under the direction of a licensed physician. 4. Appropriate nursing and medical interventions are anticipated based on assessment data. 5. The emergency health care staff members work as a team in performing the highly technical, hands-on skills required to care for patients in an emergency situation.

6. Patients in the ED have a wide variety of actual or potential problems, and their condition may change constantly.

7. Although a patient may have several diagnosis at a given time, the focus is on the most life-threatening ones


1. A nurse on the cardiac unit is caring for four clients in the emergency room. Which client should the nurse assess first? a) a client scheduled for cardiac ultrasound this morning b) a client with syncope being discharged today c) a client with chronic bronchitis on nasal oxygen d) a client with a diabetic foot ulcer that needs a dressing change


2. A nurse enters a room and finds lying face down on the floor, bleeding from a gash in the head. Which action should the nurse perform first? a) determine level of consciousness b) push the call button for help c) turn the client face up to assess d) go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician


2. A nurse enters a room and finds lying face down on the floor, bleeding from a gash in the head. Which action should the nurse perform first? a) determine level of consciousness b) push the call button for help c) turn the client face up to assess d) go out in the hall to get the nursing assistant to stay with the client while the nurse calls the physician


You are on duty in the ED when a code is called overhead. As the code nurse, you grab the crash cart and run to the code, which is in the employees lounge of the operating room. On the couch you find a nurse unconscious, cyanotic and barely breathing. His scrub shirt has been cut off, and you attach ECG leads to his chest. His pulse is 45; respirations are 8 and shallow.

Q AND ACritical ThinkingYou are on duty in the ED when a code is called overhead. As the code nurse, you grab the crash cart and run to the code, which is in the employees lounge of the operating room. On the couch you find a nurse unconscious, cyanotic and barely breathing. Her scrub shirt has been cut off, and you attach ECG leads to her chest. Her pulse is 45; respirations are 8 and shallow.

A. B. C. D. E.

INTUBATION IV LINE INSERTION DEFIBRILLATION CHEST TUBE INSERTION SURGICAL PREPARATION


A. B. C. D. E. F. G. H.

MORPHINE NALOXONE ATROPINE DEXAMETHASONE D5 LR 0.9% NaCl D5W LASIX


A. B. C. D. E. F. G. H.

MORPHINE NALOXONE ATROPINE DEXAMETHASONE D5 LR 0.9% NaCl D5W LASIX

Preserve or prolong life Alleviate suffering Do no further harm Restore to optimal function

A I D

-

ASK FOR HELP INTERVENE DO NO FURTHER HARM

Assessment Priority setting/critical thinking skills Knowledge of Emergency Care Technical skills Communication skills

CHAIN OF SURVIVAL

EARLY ACCESS early recognition of cardiac arrest, prompt activation of emergency services EARLY BLS prevent brain damage, buy time for the arrival of defibrillator

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CHAIN OF SURVIVAL EARLY DEFIBRILLATION EARLY ACLS technique that attempts to stabilize patient

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I. Survey the Scene A. Is the scene is safe? B. What happened? C. Are there any bystanders who can help? D. Identify as a trained first aiders. II. Do a Primary Survey A - Airway/Cervical Spine Establish Patent Airway Maintain alignment

B - Breathing Assess breath sounds Observe for chest wall trauma Prepare for chest decompression C - Circulation Monitor VS Maintain vascular access Direct pressure

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D - Disability Evaluate LOC Re-evaluate clients LOC E - Exposure Remove clothing Maintain privacy Prevent hypothermia

III. Activate Medical Assistance A. Information to be relayed: - What happened? - Number of persons injured - Extent of injury and first aid given - Telephone number from where you are calling

IV. Do Secondary Survey A. Interview the Patient S Symptoms A Allergies M Medication P Previous/Present Illness L Last Meal Taken E Events Prior to Accident B. Check the vital signs V. Triage - Comes from the French word trier, meaning to sort

1. Emergent-highest priority, conditions are life threatening and need immediate attention

2. Urgent have serious health problems but not immediately life threatening ones. Must be seen within 1 hour

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3. Non-urgent patients have episodic illness than can be addressed within 24 hours without increased morbidity

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1. Immediate:Injuries are life-threatening but survivable with minimal intervention. Individuals in this group can progress rapidly to expectant if treatment is delayed.

2. Delayed:Injuries are significant and require medical care, but can wait hours without threat to life or limb..

3. Minimal: Injuries are minor and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area.

4. Expectant:Injuries are extensive and chances of survival are unlikely even with definitive care.

5. Fast-Track: Fast-Track: Psychological support needed

Result of an external force applied to the head and brain causing disruption of physiologic stability locally, at the point of injury Trauma to the skull resulting in mild to extensive damage to the brain.

1. Open- Scalp lacerations - Fractures in the skull - Interruption of the dura mater

2. ClosedConcussions Contusions

3. Hemorrhage causes hematoma or clot formation

1.

Epidural Hematoma

2.

Subdural Hematoma

3.

Intracerebral Hemorrhage

Altered level consciousness Confusion Papillary abnormalities

of

Altered or absent gag reflex or vomiting Absent corneal reflex Sudden onset of neurologic deficits

Vision impairment

and

hearing

CSF drainage from ears or nose Sensory dysfunction Spasticity Headache and vertigo Movement disorders reflex activity changes Seizure activity or

GOAL: Maintain oxygen and nutrient rich cerebral blood flow 1.Monitor respiratory status and airway 2.Neurologic status and VS 3.Monitor inc. ICP 4.Head elevation 20-30 degrees 5.Restrict fluids and monitor I and O 6.Immobilization of neck 7.Initiate normothermia measures

GOAL: Maintain oxygen and nutrient rich cerebral blood flow 8. Assess cranial nerve fxn, reflexes, and motor and sensory fxns. 9. Initiate SZ precautions. 10. Monitor for pain and restlessness 11. Avoid administration of morphine sulfate 12. Monitor for drainage from the nose or ears.

GOAL: Maintain oxygen and nutrient rich cerebral blood flow 13. If there are leaks, monitor for nuchal rigidity. 14. Do not attempt to clean the nose, suction or allow the client to blow the nose if drainage occurs 15. do not clean te ear of drainage when noted but apply a loose, dry sterile dressing

1.Osmotic diuretics 2.Loop diuretics 3.Opioids 4.Sedatives 5.Antiepileptic drugs

Approximately a quarter of deaths due to trauma are attributed to thoracic injury. Reasons of immediate deaths Reasons of early deaths

1. BLUNT TRAUMA Example: Example: Rib fractures 2. PENETRATING TRAUMA

Management: Management: 1. Rest 2. Ice Compress then Local Heat 3. Analgesia 4. Splint the chest during coughing or deep breathing

FLAIL CHEST The unstable segment moves separately and in an opposite direction from the rest of the thoracic cage during the respiration cycle. Assessment: - Paradoxical respirations - Severe chest pain - Dyspnea/ Tachypnea - Cyanosis - Tachycardia

Management: 1. 2. 3. 4. 5. High Fowlers position Humidified O2 Analgesia Coughing & deep breathing Prepare for intubation with mechanical ventilation

B. Penetrating Chest Trauma - occurs when a foreign object penetrates the chest wall 1.Pneumothorax - Accumulation of atmospheric air in the pleural space may lead to lung collapse Types: 1.Spontaneous Pneumothorax 2.Tension Pneumothorax

Assessment: o Dyspnea o Tachypnea o Absent breathe sounds o Sucking sound o Cyanosis o Sharp chest pain o Tachycardia

Management: 1. Apply dressing over an open chest wound 2. O2 as Rx 3. High Fowlers 4. Chest tube placement - Monitor for chest tube system - Monitor for subcutaneous emphysema Chest Tube Drainage System - returns (-) pressure to the intra-pleural space - remove abnormal accumulation of air & fluids serves as lungs while healing is going on

Pulmonary Embolism- Dislodgement of thrombus to the pulmonary artery - Caused by thrombus & pulmonary emboli - Other risk factors: deep vein thrombosis, immobilization, surgery, obesity, pregnancy, CHF, advanced age, prior History of thromboembolism

Assessment Dyspnea Chest pain Tachypnea & tachycardia Hypotension Shallow respirations Rales on auscultation Cough Blood-tinged sputum Distended neck veins Cyanosis

Management 1. O2 as Rx 2. High Fowlers 3. Maintain bed rest 4. Incentive spirometry as Rx 5. Pulse oximetry 6. Prepare for intubation & mechanical ventilation 7. IV heparin (bolus) 8. Warfarin (Coumadin) 9. Monitor PT & PTT closely 10. Prepare the client for embolectomy, vein ligation, or insertion of an umbrella filter as Rx

ABDOMINAL TRAUMAA. Penetrating Abdominal Trauma Causes: - Gunshot wound - Stab wound - Embedded object from explosion Assessment: - Absence of bowel sound shock - Orthostatic hypotension tenderness

- Hypovolemic - Pain and

Management: 1. Maintain hemodynamic status IVF & blood transfusion 2. Surgery- EXLAP 3. Peritoneal Lavage

B. Blunt Abdominal Trauma Assessment: - Left upper quadrant pain (Spleen) - Right upper quadrant pain (liver) - Signs of hypovolemic shock Management: 1. Maintain hemodynamic status 2. Monitor VS and oxygen supplements 3. Assess signs and symptoms of shock

FOREIGN BODY AND AIRWAY OBSTRUCTION

CAUSES:

improper chewing of large pieces of food aspiraton of vomitus, or a foreign body position of head, the tongue resulting to difficulty of breathing or respiratory arrest

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Types of ObstructionI. Anatomical tongue and epiglottis

I.

Mechanical coins, food, toy etc

Assessment and Clinical Manifestations 1. Mild airway obstruction

- can talk, breath and cough with high pitch breath sound - cough mechanism not effective to dislodge foreign body 2. Severe airway obstruction

- cant talk, breath or cough3. Nasal flaring, cyanosis, excessive salivation

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Intervention:CONCIOUS PATIENT: -

1. Ask the victim, are you choking? 2. If the victims airway is obstructed partially, a crowing sound is audible; encourage the victim to cough. 3. Relieve the obstruction by heimlick maneuver A. Heimlich maneuver:stand behind the victim place arms around the victims waist make a fist place the thumb side of the fist just above the and well below the xyphoid process. Perform 5 quick in and up thrusts. Continue abdominal thrusts until the object is dislodged or the victim becomes unconscious.

umbilicus

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UNCONSCIOUS PATIENT

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.

Assess LOC Check for ABCs Open airway using jaw thrust technique Finger sweep to remove object Attempt ventilation Reposition the head if unsuccessful; reattempt ventilation Relieve the obstruction by the Heimlich maneuver with five thrust; then finger sweep the mouth Reattempt ventilation Repeat the sequence of jaw thrust, finger sweep, breaths and Heimlich maneuver until successful Be sure to assess the victims pulse and respirations Perform CPR if required

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Choking Child or Infant Choking is suspected in infants and children experiencing acute respiratory distress associated with coughing, gagging, or stridor. Allow the victim to continue to cough if the cough is forceful If cough is ineffective or if increase respiratory difficulty is still noted, perform CPR

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Foreign Objects in the Ear Dont probe the ear with a tool Remove the object if clearly visible Try using gravity and shake the head gently Try using oil for an insect Dont use oil to remove any other object than an insect

Foreign Objects in the Eye

Flush eye clear with use of water

Foreign Objects in the Nose Dont probe at the object with cotton ball or other tool Breathe thru your mouth until the object is removed Blow your nose gently to try to free the object

POISONING69 DaRRaN

Poison Any substance that impairs health or destroys life when ingested, inhaled or otherwise absorbed by the body.

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Suspect poisoning if:1. 2. 3. Someone suddenly becomes ill for no apparent reason and begins to act unusually Is depressed and suddenly becomes ill Is found near a toxic substance and is breathing any unusual fumes, or has stains, liquid or powder in his or her clothing, skin or lips

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Ingestion Poisoning Botulism Clostridium botulinum. From canned foods Staphylococcus Aureus from unrefrigerated pack filled foods, fish Petroleum Poisoning includes poisoning with a substance such as kerosene, fuel, insecticides and cleaning fluids

Acetaminophen Poisoning most common drug accidentally ingested by children Corrosive Chemical Poisoning strong detergents and dry cleaners results in drooling of saliva, painful burning sensation and pain and redness in the mouth

Diagnostics:1. Baseline ABG should be obtained periodically 2. Baseline blood samples 3. ECG

Assessment:1. 2. 3. 4. 5. 6. Headache 2. Double vision Difficulty in swallowing, talking and breathing Dry sore throat Muscle incoordination Nausea and vomiting74 DaRRaN

Management 1. Check victims ABCs. 2. If victim starts having seizures, protect him from injury 3. If victim vomits, clear the airway 4. Calm and reassure the victim while calling for medical help

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P O IS ON-

Prevention. Child Proofing Oral fluids in large amount Ipecac Support respiration and circulation Oral Activated Charcoal Never induce vomiting if substance ingested is corrosive76 DaRRaN

Inhalation Poisoning Carbon Monoxide Poisoning

- Carbon monoxide is a colorless, odorless & tasteless gasAssessment: - appears intoxicated - Muscle weakness - Headache & dizziness

Management1. 2. 3. 4. 5. Check ABCs Remove victim from exposure Loosen tight clothing Administer O2 (100% delivery) Initiate CPR if required

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BURN TRAUMAIs the damage caused to skin and deeper body structures by heat (flames, scald, contact with heat), electrical, chemical or radiation.

FACTORS DETERMINING SEVERITY OF BURN1. Age 2. Patients medical condition 3. Location 4. Depth

4. DepthAffected Part Classification Description of Wound What to Expect

1st degree superficial

Epidermis

Pin, painful sunburn Blisters form after 24 hours

Discomfort last after 48 hrs; heals in 3-7 days 3-

2nd degree partial thickness

Pediermis and part of the dermis

Red, wet blisters, bullae very painful

Heals in 2-3 weeks, in no complication 2-

2nd degree deep partial thickness

Only the skin appendages in the hair follicle remain

Waxy white, difficult to distinguish from 3rd degree except hair growth becomes apparent in 7-10 days, 7little or no pain

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

3rd degree Full thickness

Epidermis, dermis and subcutaneous tissue . no skin appendages

-Dry, leathery, may be red or black -May have thrombosed veins -Marked edema -Distal circulation may be decreased -Painless

Requires excision and grafting. 1010- 14 days for graft to revascularize

4th degree deep full thickness

Skin, muscle, tendon, bonde

Dry, charred, bone may 81 be visible

Requires excision, grafting and sometimes amputation

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5. Size: Rule of nine Child < 3 years old 18% 9% 18% 18% 14% 1%82

Adult

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

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

6. Temperature

determines the extent of injury

7. Exposure to the Source

A. Thermal Burns caused by exposure to flames, hot liquids, steam or hot objects B. Chemical Burns caused by tissue contact with strong acids, alkalis or organic compounds C. Electrical Burns result in internal tissue damaging, alternating current is more dangerous than direct current for it is associated with cardiopulmonary arrest, ventricular fibrillation D. Radiation Burns are caused by exposure to ultraviolet light, x-rays or a radioactive source.

Types of Burns and their Treatment Scald 1. Burn caused by hot liquid 2. Immediately flush the burn area with water (under a tap or hose for up to 20 min) 3. If no water is readily available, remove clothing immediately as clothing soaked with hot liquid retains heat Flame 1. Smother the flames with a coat or blanket, get the victim on the floor or ground (stop, drop, and Roll) 2. Prevent victim from running 3. If water is available, immediately cool the burn area with water 4. If water is not available, remove clothing; avoid pulling clothing across the burnt face Airway 1. If face or front of the trunk is burnt, there could be burns to the airway 2. There is a risk of swelling or air passage, leading to difficulty in breathing

Smoke inhalation1. 2. 3. 4. 5. Urgent treatment is required with care of the airway, breathing and circulation When 02 in the air is used up by fire, or replaced by other gases, the oxygen level in the air will be dangerously low Spasm in the air passages as a result of irritation by smoke or gases Severe burns to the air passages causing swelling and obstruction Victim will show signs and symptoms of lack of O2. He may also be confused or unconscious

Electrical1. 2. 3. 4. 5. Check for Danger Turn of the electricity supply if possible Avoid any direct contact with the skin of the victim or any conducting material touching the victim until he is disconnected Once the area is safe, check the ABCs If necessary, perform rescue breathing or CPR85 DaRRaN

Chemical1. Flood affected area with water for 20-30 min 2. Remove contaminated clothing 3. If possible, identify the chemical for possible subsequent neutralization 4. Avoid contact with the chemical

Sunburn1. Exposure to ultraviolet rays in natural sunlight is the main cause of sunburn 2. General skin damage and eventually skin cancer develops 3. The signs and symptoms of sunburn are pain, redness and fever86 DaRRaN

FACT

When we treat man as he is, we make him worse than he is; when we treat him as if he already were what he potentially could be, we make him what he should be

ER Lecture

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