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It is the nursing care

given to patients with

urgent and critical

needs

EMERGENCY IT IS WHATEVER THEPATIENT OR THE FAMILY CONSIDERS IT TO BE.

EMERGENCYNURSING

has a specialized education, training,

and experience to gain expertise inassessing and identifying patients

health care problems in crisis

situations

establishes priorities, monitors

and continuously assesses acutely illand injured patients, supports and

attends to families, supervises allied

health personnel, and teaches

patients and families within a time-

limited, high-pressured care

environment

EMERGENCYNURSE

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DISASTER NURSING - a branch of emergencynursing, it refers to nursing care given to patients who are

victims of disasters, whether it is manmade or natural

phenomena.

INCIDENT COMMAND

SYSTEM It is a management tool

for organizing personnel,

facilities, equipment, and

communication for any

emergency situation.

INCIDENT

COMMANDER

The head of the incident

command system

He must be continuously

informed of all the

activities and informedabout any deviation from

the established plan

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EMERGENCY OPERATIONS PLAN (EOP)

It is done by a planning committee, composed of local/national

administrators, safety officer, ED manager, evaluating the

community to anticipate the type of disaster that might occur.

Activation Response

Internal/External Communication

Plans

Plan for coordinated patient care

Security Plans

COMPONENTS of EOP

Identification of external resources

A plan for people management and traffic

flow

Data Management Strategy

Deactivation Response

Post- Incident Response

Plan for Practice Drills

Anticipated Resources

Mass Casualty Incident Planning

Educational Plan

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from French word trier

meaning to sort

it is used to sort patients

into groups based on theseverity of their health

problems and the

immediacy with which

these problems must be

treated

TRIAGENURSE acts as

a gatekeeper, sortingpatients into

categories, ensuring

that the more

seriously ill aretreated first

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Conditions requiring immediate

medical intervention, any delay in treatment is potentially life

or limb threatening. Must be seen IMMEDIATELY!

AIRWAY COMPROMISE , CARDIAC ARREST

SEVERE SHOCK, CERVICAL SPINE INJURY

MULTISYSTEM TRAUMA, ALTERED LEVEL OF

CONSCIOUSNESS, ECLAMPSIA

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Patients who present with Chronic or

minor injuries, no danger to life or limb, patient is in no

obvious cardiopulmunary distress

FEVER

MINOR BURNS

MINOR MUSCULOSKELETAL INJURIES

LACERATIONS

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Patients who presents

as stable but whose condition requires medical

intervention w/in a few hours. No immediate treat to life

or limb to these patients.

CHRONIC LOW BACK PAIN

DENTAL PROBLEMS

MISSED MENSES

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DO THE GREATEST GOOD FOR THE GREATEST

NUMBER -

TRIAGETRIAGE

CATEGORYCATEGORY

PRIORITYPRIORITY COLORCOLOR

IMMEDIATEIMMEDIATE 11 REDRED

DELAYEDDELAYED 22 YELLOWYELLOW

MINIMALMINIMAL 33 GREENGREEN

EXPECTANTEXPECTANT 44 BLACKBLACK

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TRIAGE CATEGORYTRIAGE CATEGORY

Sucking chest wound

airway obstruction secondary to

mechanical cause,

shock

hemothorax, tension pneumothorax

asphyxia

unstable chest and abdominal

wounds,

incomplete amputations, openfractures of long bones

2nd / 3rd degree burns of 15-40%

TBSA

Stable abdominal wounds

w/o evidence of significant

hemorrhage

soft tissue injuries

Maxillofacial wounds w/o

airway compromise

Vascular injuries w/

adequate collateral

circulation

Genitourinary Tract

Disruption

Fractures requiring open

reduction, debridement, and

external fixation

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TRIAGE CATEGORYTRIAGE CATEGORY

Upper extremity fractures

Minor Burns

Sprains

Small Lacerations w/o

significant bleeding

Behavioral disorders or

Psychological disturbances

Unresponsive patients w/

penetrating head wounds

High spinal cord injury

Wounds involving multiple

anatomical sites and organs

2nd/3rd degree burns in excess

of 60% of BSA

Seizures or vomiting w/n 24

hours after Radiation Exposure

Profound shock with multiple

injuries and agonal respirations

Patients with no Pulse, no BP,

pupils fixed and dilated

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1. PRIMARY ASSESSMENTMEANT TO IDENTIFY LIFE-THREATENING PROBLEMS

IRWAY

REATHING

IRCULATION

ISABILITY

XPOSE

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2. SECONDARY ASSESSMENTSystematic, brief (2-3 mins) examination from head to toe

Purpose is to detect and prioritize additional injuries

and detect signs of underlying medical conditions

What is the mechanism of injury?

When did the symptoms appear?

Was the patient unconscious after the accident?

How did the pt. reach the hospital?

What was the health status of the patient prior the accident

or illness?

Is there history of present illness?

Is the patient taking any medications?

Does the patient have allergies?

Was treatment attempted before arrival at the hospital?

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Understand and accept basic anxieties, be aware of patients fear

Accept the rights of the patient and family, to have and display theirfeelings

Maintain a calm and reassuring manner

Treat the unconscious patient as if CONSCIOUS. (Touch, call by name,

explain every procedure) Orient the patient as soon he becomes conscious.

Inform the family where the patient is, and give as much as information

as possible about the treatment

Assist family to cope with sudden and unexpected death

take them on a private place and talk to them so they can

mourn together

assure the family that everything was done

avoid giving sedation to family members

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an emergency procedure

that consists of recognizing

respiratory or cardiac arrest

or both the properapplication of CPR to

maintain life until a victim

recovers or advance life

support is available.

the use of special

e uipment to maintain

breathing and circulation

for the victim of a cardiac

emergency.

for post resuscitative and long

term resuscitation.

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FIRST LINK - EARLY ACCESS

It is the event initiated after

the patients collapse until

the arrival of EmergencyMedical Services personnel

prepared to provide care.

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SECOND LINK - EARLY CPR

If started immediately after

the victims collapse, the

probability of survivalapproximately doubles

when it is initiated before

the arrival of EMS.

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THIRD LINK - EARLY DEFIBRILLATION

It is most likely to improve

survival. It is the key

intervention to increase thechances of survival of

patients with out-of-hospital

cardiac arrest.

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SECOND LINK - EARLY ACLS

If provided by highly trained

personnel like paramedics,

provision of advanced careoutside the hospital would

be possible.

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Do obtain consent when possible.

Do think the worst. Its best to administer first aid for the

gravest possibility.

Do provide comfort and emotional support.

Do respect the victims modesty and physical privacy.

Do be as calm and as direct as possible.

Do care for the most serious injuries first.

Do assist the victim with his/her prescription medication.

Do handle the victim to a minimum.

Do loosen tight clothing.

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Do not let the victim see his/her own injury.

Do not leave the victim alone except to get

help.

Do not assume that the victims obvious

injuries are the only ones.

Do not make any unrealistic promises.

Do not trust the judgment of a confused

victim and require them to make decision.

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is a rapid movement of

patient from unsafe place

to a place of safety.

1. Danger of fire or explosion.

2. Danger of toxic gases or asphyxia due to lack

of oxygen.

3. Natural Disasters

4. Risk of drowning.

5. Danger of electrocution.

6. Danger of collapsing walls.

1. For immediate rescue without

any assistance, drag or pullthe victim.

2. Most of the one-man

drags/carries and other

transfer methods can be used

as methods of rescue.

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is moving a patient from

one place to another

after giving first aid.

1. Nature and severity of the injury.

2. Size of the victim.

3. Physical capabilities of the first aider.

4. Number of personnel and equipment

available.

5. Nature of the evacuation route.

6. Distance to be covered.

7. Gender of the victims. (last consideration)

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Pointers to be

observed during

transfer1.Victims airway must be maintained open.

2. Hemorrhage is controlled.

3. Victim is safely maintained in the proper position.4. Regular check of the victims condition is made.

5. Supporting bandages and dressings as remain

effectively applied.

6. The method of transfer is safe, comfortable and asspeedy as circumstances permit.

7. The patients body is moved as one unit.

8. First aiders/bearers must observed ergonomics in

lifting and moving of patient.

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1.One man

assist/carries/drags

2. Two man assist/carries

3.Three man carries

4.four/six/eight-man carry

5.Blanket

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6.Improvised stretcher using

two poles with:

blanket

Empty sacks

Shirts or coats

Triangular bandages

7.Commercial stretchers

8.Ambulance or rescue van

9.Other vehicles.

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RESPONSIVENESS/AIRWAY

Determine unresponsiveness; ARE YOU OKAY?

Activate Emergency Medical Assistance

Place patient supine on a firm, flat surface. Kneel at

the level of the patients shoulders

Open the airway: HEADTILT/CHIN LIFT

MANEUVER, JAW THRUST MANEUVER

BREATHING

Look, Listen and Feel

Rescue breathing: 2 full breaths

CIRCULATION

Check carotid pulse

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mouth to mouth

mouth to nose

mouth to stoma

mouth to mouth and nose

mouth to barrier device

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AdultAdult ChildChild InfantInfant

CompressionCompression

AreaArea

Lower half of theLower half of the

sternum but notsternum but not

hitting thehitting the xiphoidxiphoid

process: measureprocess: measure

up to 2 fingers fromup to 2 fingers from

substernalsubsternal notch.notch.


sternum but notsternum but not

hitting thehitting the xiphoidxiphoid

process: measureprocess: measure

up to 1 finger fromup to 1 finger from

substernalsubsternal notch.notch.


sternum but not hittingsternum but not hitting

the xiphoid process: 1the xiphoid process: 1

finger width below thefinger width below the

imaginary nipple line.imaginary nipple line.

DepthDepth Approximately 1 Approximately 1 to 2 inchesto 2 inches

Approximately 1 to 1Approximately 1 to 1

inches inches

Approximately to 1Approximately to 1

inchinch

How toHow to

compresscompress

Heel of1 hand,Heel of1 hand,

other hand on top.other hand on top.

Heel of1 hand.Heel of1 hand. 2 fingers (middle &2 fingers (middle &

ring fingertips)ring fingertips)

CompressionCompression--

ventilation ratioventilation ratio

30:2 (1 or 230:2 (1 or 2

rescuers)rescuers)

30:2 (1 or 230:2 (1 or 2

rescuers)rescuers)

30:2 (1 or 2 rescuers)30:2 (1 or 2 rescuers)

Number ofNumber of

cycles percycles per

minuteminute

5 cycles in 25 cycles in 2

minutesminutes

5 cycles in 25 cycles in 2

minutesminutes

5 cycles in 2 minutes5 cycles in 2 minutes

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-PONTENEOUS signs of circulation are

restored

-URN OVER to medical services or properly

trained authorized personnel

- PERATOR is already exhausted and cannot

continue CPR

- HYSICIAN assumes responsibility (declares

death, take-over, etc.)

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KINDS OF AIRWAY OBSTRUCTION

Anatomic Airway Obstruction

Mechanical Airway Obstruction

Clinical Manifestations:

, choking,

stridor, apprehensive appearance, restlessness.

CYANOSIS and LOSS of CONSCIOUSNESS

develop as hypoxia worsens.

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HEIMLICH MANEUVER

(Subdiagphramatic AbdominalThrust)

FINGER SWEEP

CHEST THRUST

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1. OPEN HEAD INJURY

2. CLOSED HEAD INJURY

3. CONCUSSION temporary loss of

4. consciousness that results in transient

5. interruption if the brains normal functioning

6. CONTUSSSION bruising of the brain tissue

7. INTRACRANIAL HEMORRHAGE significant bleeding into a space or

potential space between the skull and the brain

a. Epidural hematoma

b. Subdural hematoma

c. Subarachnoid hemorrhages

ALERT: Assume cervical spine fracture for

any patient with a significant head injury,

until proven otherwise.

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PRIMARY ASSESSMENT: Assess for ABC

SECONDARY ASSESSMENT:

Change in LOC, CUSHINGS TRIAD ( bradypnea,

bradycardia, widened pulse pressure) indicating

increased intracranial pressure

Pupils, Battles Sign

Rhinorrhea or otorrhea indicative of CSF leak

Periorbital Ecchymosis indicates anterior basilar

fracture

ALERT: If basilar skull

fracture or severemidface fractures are

suspected, a

nasogastric tube(NGT)

is CONTRAINDICATED!

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MANAGEMENT:

Open airway by Jaw-Thrust Manuever, suction orally if needed

Administer high flow oxygen: most common death is CEREBRAL ANOXIA

In general, hyperventilate the patient to 20-25 bpm, causing cerebral

vasoconstriction and minimizing cerebral edema

Apply a bulky, loose dressing; dont apply pressure

IV line of PNSS or Plain LR

prepare to manage seizures

maintain normothermia

Medications:

a. Diazepam

b. Steroids

c. Mannitol

Prepare of immediate surgery if pt. shows evidence of neurologic deterioration

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SIMPLE

COMPOUND

LINEAR Fx

COMMINUTED Fx

DEPRESSED Fx

CRANIAL VAULT Fx

BASILAR Fx

ALERT:

Damage to the brain is the first concern, it

is considered a neurosurgical condition

In children, skulls thinness and elasticity

allows a depression w/o a break in the bone

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For LINEAR FRACTURES:

supporative (mild analgesics)

cleaning and debridement of wounds

If conscious: observed for 4 hours; if not, admit for

evaluation

if VS stable, may go home with instruction sheet

For VAULT and BASILAR FRACTURES:

Craniotomy to remove fragments antibiotics

Dexamethasone

Osmotic Diuretics (MANNITOL) if increased ICP is

present

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maintain patent airway; nasal airway contraindicated to basilar fx

support with O2 administration

suction pt. through mouth not nose if CSF leak is present

RHINORRHEA wipe it, dont let him blow it!

OTORRHEA cover it lightly with sterile gauze, dont pack it!

Position head on side

Maintain a supine position with bed elevated to 30 degrees

dont give narcotics or sedative

assist in surgery, maintaining sterile technique

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PRIMARY ASSESSMENT:

immediate immobilization of the spine

A B C ( Intercoastal paralysis w/ diapragmatic breathing)

SUBSEQUENT ASSESSMENT:

Hypotension, bradycardia, hypothermia - suggestsSPINAL SHOCK

Total sensory loss and motor paralysis below the level of

injury

MANAGEMENT:

Nasotracheal intubation

initaite IV access, monitor blood gas

indwelling urinary catheterization

prepare to manage seizures

Meds: High dose steroids and diazepam

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PRIMARY ASSESSMENT

Immobilization of spine while performing assessment

ABC (tongue swelling, bleeding, broken or missed

teeth)

SUBSEQUENT ASSESSMENT

Paralysis if the upward gaze indicative of INFERIORORBIT FX

Crepitus on nose indicates nasal fracture

Flattening of the cheek and loss of sensation below the orbit

indicates ZYGOMA (cheekbone) FX

Malocclussion of teeth, trismus indicative of MAXILLA FX

PRIMARY INTERVENTIONS:

Insertion of oral airway or intubation

Nasopharyngeal airway should only be used if no evidence

of nasal fracture or rhinorrhea

Apply bulky, loose dressing; apply ice to areas of swelling

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1. FRACTURE a break in he continuity of the bone; occurs when stress is

placed on a bone is greater than the bone can absorb

ALERT: fractured cervical spine, pelvis and femur may produce life

threatening injuries; posterior dislocations of the hip are life- and limb-

threatening emergencies due to potential blood loss.


Pain and tenderness over fracture site

Crepitus or grating over fracture site

swelling and edema

Deformity, shortening of an extremity or rotation of extremity

EMERGENCY Management: IMMOBILIZE, INITIATE IV

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MANAGEMENT PROCESS OF FRACTURES

-EDUCTION

-setting the bone; refers to the restoration of the fracturefragments into anatomic position and alignment

-MMOBILIZATION

- maintains reduction until bone healing occurs

- EHABILITATION

- Regaining normal function of the affected part

use of cast and splint to immobilize extremity and maintain reduction

Skin Traction force applied to the skin using foam rubber, tapes

Skeletal Traction force applied to the bony skeleton directly, using wires,pins, tongs placed in the bone

ORIF operative intervention to achieve reduction, alignment and

stabilization

Endoprosthetic Replacement implantation of metal device

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Elevate to prevent or limit swelling

Apply ice packs or cold compress; not place directly in skin

Splint and maintain in good alignment, immobilize the joint above and below the

fracture

Give pain medications as ordered

Assist in casting; use the palm of your hands in holding a wet castAvoid resting cast on hard surfaces or sharp edges

Do neurovascular checks hourly for the first 24 hours

Assess forCOMPARTMENT SYNDROME check for6 Ps

If Compartment syndrome is suspected, do not elevate limb above the levelof the cast

Notify the physician

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SPRAIN an injury to the ligamentous structure surrounding a joint;usually caused by a wrench or twist resulting in a decrease joint stability

Clinical Manifestations: Rapid swelling due to extravasation of blood w/n tissues

Pain on passive movement of joint

discoloration, and limited use or movement

STRAIN a microscopic tearing of the muscle cause by excessiveforce, stretching, or overuse


Pain with isometric contractions

Swelling and tenderness

Hemorrhage in muscle

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MANAGEMENT OF SPRAINS AND STRAINS

-OMPRESSION (Elastic Bandage)

-EST

-CE (for the first 24 hrs; 1 hr on, 2 hrs off during waking hours)

-EDICATIONS ( NSAIDs)

-LEVATION

-UPPORT (Use of crutches, splints)

NURSING CONSIDERATIONS:

Apply ice compress for the first 24 hrs to produce vasoconstriction,

decrease edema, and reduce discomfort

Apply warm compress after 24 hrs to promote circulation and absorption

(20 to 30 minutes at a time)

Educate to rest injured part for a month to allow healing

Educate to resume activities gradually and to warm up

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- It is a trauma in the chest without an open wound

- usually cause by VA, blast injuries

RIB FRACTURES: tenderness, slight edema, pain that worsens with deep

breathing and movement, shallow and splinted respirations

STERNAL FRACTURES: persistent chest pain

MULTIPLE RIB FRACTURES:-FLAIL CHEST (loss of chest wall integrity)

- decreased lung inflation, paradoxical chest movements

- extreme pain

- rapid and shallow respirations- hypotension, cyanosis

- respiratory acidosis

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TENSION PNEUMOTHORAX

HEMOTHORAX

LACERATION or RUPTURE ofAORTA

DIAPHRAGMATIC RUPTURE

CARDIAC TAMPONADE

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Simple Rib Fractures

mild analgesics, bed rest, apply heat

incentive spirometry

deep breathing, coughing and splinting

Severe Rib Fractures intercoastal nerve blocks

position for semi-fowlers, administer O2

Hemothorax Chest tube insertion at 5th-6th ICS anterior to MAL administer IV fuids, O2, Blood Transfusion

Thoracotomy

Thoracentesis

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NURSING CONSIDEARTIONS:

monitor VS, (q 15, first hour post thoracentesis and post CTT)

After CTT insertion, encourage cough and breathing exersises

Chest tubes should have continuous FLUCTUATIONS

if BUBBLING, air leak is suspected

if FLUCTUATION STOPS, mechanical blockage or lung has already

expanded

have an extra bottle with PNSS, clamps and sterile gauze at bedside

in case of dislodgment, cover the opening with sterile/petroleum gauze to

prevent rapid lung collapse

Assist with proper positioning

Bed Rest

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1. PENETRATING ABDOMINAL INJURY

2. BLUNT ABDOMINAL INJURY

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temperature may be normal or

slightly elevated, hypotension,

tachycardia, tachypnea, paleand moist skin, fatigue,

headache, dizziness, syncope

It is the inadequacy or the

collapse of peripheral

circulation due to

volume and electrolyte

depletion

Move patient to a cool environment,

remove all clothing

Position the patient supine with the feet

slightly elevated

Monitor VS every 15 mins and cardiacrhythm

Educate to avoid immediate reexposure

to high temperatures

1. Hemoconcentration

2. hyponatremia or hypernatremia

3. ECG may show dysrhythmias

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- It is a combination of hyperpyrexia

and neurologic symptoms. It caused

by a shutdown or failure of the heat-

regulating mechanisms of the body

CLINICAL MANIFESTATIONS:

bizarre behavior or irritability, progressing to confusion,

delirium and coma

40.6 degrees Celcius, hypotension, tachycardia, tachypnea

skin may appear flushed and hot; at start it maybe moist

progressing to dryness (Anhidrosis)

NURSING ALERT:

Elderly clients are high-risk to develop heat-stroke

Once diagnosis is confirmed, it is imperative to reduce

patients temperature

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3 compensatory mechanisms:

a. shivering produces heat thru muscular activity

b. peripheral vasoconstriction to decrease heat loss

c. raising basal metabolic rate

NURSING ALERT:

Elderly are greater risk for hypothermia due to

altered compensatory mechanisms

Extreme caution should be used in moving or

transporting hypothermic pts., because the heart is

near fibrillation threshold

-It is a condition where the core

temp. is less than 35 degrees

Celcius as a result in the exposure

to cold.

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slow, spontaneous respirations

heart sounds may not be audible even if its beating

BP is extremely difficult to hear

fixed dilated pupils, no pulse, no BP; initiate CPR

drowsiness progressing to coma

shivering is suppressed on temp. below 32.3 degrees

ataxia

cold diuresis

fruity or acetone odor of breath

GOAL of MANAGEMENT: Rewarm without precipitatingcardiac dysrhythmias.

CLINICAL MANIFESTIONS:

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Passive External Rewarming (temp above 28 degrees)-Remove all wet clothing, and replace with warm clothing

- Provide insulation by wrapping the patient in several blankets

- Provide warm fluids

Disadvantage: slow process

Active External Rewarming (temp above 28 degrees)

-Provide external heat for patient- warm hot water bottles to the armpits, neck,

or groin

- Warm water immersionDisadvantages

1. causes peripheral vasodilation, returning cool blood to the core, causing an

initial lowering of the core temp.

2. Acidosis due to washing out of lactic acid from the peripheral tissue

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Immediate CPR

Endotracheal intubation with PEEP

VS, check degree of hypothermia

Rewarming procedures

Intravascular volume expansion and inotropic agents

ECG

Indwelling catheterization

NGT insertion

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ABC

Identify the poison

Obtain blood and urine tests;

gastric contents may be sentto laboratory

Monitor neurologic status

Monitor fluid and electrolytes

Initiate large-bore IV

access, monitor shock

Prevent aspiration of

gastric contents bypositioning head on side

, Maintain

seizures precaution

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MINIMIZING ABSORPTION

Administration of activated charcoal with a

cathartic to hasten secretion.

Induction of emesis with syrup of ipecac; done

only in patients with good gag reflex and is

conscious.

Gastric lavage for the obtunded patient. Save

gastric aspirate for toxicology screen.

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Procedure to enhance the removal of ingested

substance if the patient is deteriorating.

toenhance renal clearance.

2. Hemoperfusion (process of passing blood throughan extracorporeal circuit and a cartridge containing

an adsorbent, such as charcoal, after which thedetoxified blood is returned to the patient)

to purify and accelerate the

elimination of circulating toxins.

antidote is a chemical or

physiologic antagonist that will neutralize the poison

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Th i j t d i

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-These are injected poisons

from insects which produces

either local or systemic

reactions.

Apply ice packs to site to relieve

pain.

Elevate extremities with large

edematous local reaction.

Administer anti histamine for local

reaction.

Clean wounds thoroughly withsoap and water or antiseptic solution.

remove stinger with one quick

scrape of fingernail.

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Shakes, seizures, and hallucinations.

History of drinking episodes.

N/V, malaise, weakness, anxiety.

Autonomic hyper reactivity

(tachycardia, diaphoresis, increase

temperature, dilated but reactive pupils).

COMMON BEHAVIORAL

PROBLEMS:5 Ds

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-ALLUCINATIONS (VISUAL AND TACTILE)

-NCREASED VITAL SUGNS

-REMORS

-WEATING AND SIEZURE

-ENIAL

-ATIONALIZATION

-SOLATION

-ROJECTION

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DRUG OF CHOICE:for aversion therapy of an alcoholic:

-OUTH WASH

-VER THE COUNTER COLD REMIDIES

-OOD SAUCES MADE UP OF WINE

-RUIT FLAVORED EXTRACTS

-FTERSHAVE LOTIONS

-INEGAR

-KIN PRODUCTS

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