BULACAN STATE UNIVERSITY COLLEGE OF NURSING S.

Y 2009-2010

GROUP REPORT

TRIAGE NURSING

SUBMITTED BY: GROUP 3, IV -SECTION C BAUTISTA, IEZEL MONICA LAXAMANA, VANESSA ENRIQUEZ, SHERYL IBARLIN, PRINCESS MANALOTO, ALLAN

SUBMITTED TO: MR. AARON VILLANUEVA

INTRODUCTION
The term EMERGENCY MANAGEMENT traditionally refers to care given to patients with urgent and critical needs. However, because many people lack access to healthcare, the emergency department (ED) is increasingly used for non-urgent problems. Therefore, the philosophy of emergency management has broadened to include the concept that an emergency is whatever the patient or the family considers it to be. The Emergency Nurse has had specialized education, training, experience, and expertise in assessing and identifying patients health care problems in crisis situations. In addition, 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 time-limited, high-pressured care environment. By definition, Emergency care is care given that must be rendered without delay. In an ED, several patients with diverse health problems-some life-threatening, some not- may present to the ED simultaneously. One of the first principles of Emergency care is TRIAGE. TRIAGE The word triage comes from the French word trier meaning to sort. In the daily routine of the ED, triage is used to sort patients into groups based on the severity of their health problems, and the immediacy with which these problems must be treated. ED use various triage systems with differing terminology, but all share this characteristic of a hierarchy based on the potential for loss of life. A basic and widely used triage system that has been in use for many years has categories: EMERGENT, URGENT, AND NON-URGENT (berner,2005) A more refined comprehensive triage system has been implemented to incorporate the changes in the use of the ED for both emergency and routine health care. This system has five levels: RESUSCITATION, EMERGENT, URGENT, NON-URGENT, AND MINOR. (tanabe, gimbel, yarnold, et al.,2004).

Vehicular Accident
I. Definition

Vehicular accident is unintended and unforeseen event, usually resulting in personal injury or property damage. In popular usage, however, the term accident designates an unexpected event, especially if it causes injury or damage without reference to the negligence or fault of an individual. The single greatest cause of accidents in the United States is the automobile. In 1913 the American industrialist Henry Ford introduced assembly-line techniques in the manufacture of motor vehicles. The subsequent increase in the number of automobiles in use was huge and led to a great rise in the motor-vehicle accident rate. Accidental deaths reached a high of 110,000 in 1936, with a death rate of 85.9 per 100,000. In 1991 the total was estimated at 88,000, with a death rate of 34.9 per 100,000; this was the lowest accidental death toll since 1924 (85,600).

II.

Nursing diagnosis
Since vehicular accident may result in several injuries like: head and brain trauma, spinal injury, fractured/ dislocated bones, severe bleeding, and other injuries related to several body organs, nursing diagnoses may include the following; **acute pain may be r/t trauma of cerebral tissues **impaired physical mobility r/t skeletal impairment **risk for trauma (additional injury)

Fracture
A fracture, a break or crack in a bone, is caused by sudden, violent pressure against the bone. Great pain and swelling characterize both a sprain and a fracture, but inability to move the affected part, a deformed appearance, and pain or tenderness at a specific point usually indicate a fracture. Simple, or closed, fractures are not visible on the surface. Compound, or open, fractures involve a rupturing of the skin, often exposing the bone. Single and multiple fractures refer to the number of breaks in the same bone. Fractures are complete if the break is total Incomplete (greenstick) if the fracture occurs only part of the distance across a bone shaft, with bending or crushing of the bone. Incomplete fractures are found mostly in young children, whose bones are resilient.

 Signs and symptoms include: Soft tissue edema, Warmth over injured area, Ecchymosis of skin, Loss of sensation or paralysis distal to injury, Signs of shock related to severe tissue injury, blood loss, and intense pain, Evidence of fracture on x-ray film Medical management Splinting- immobilization of the affected part to prevent soft tissue from being damaged by bony parts Casting- provides rigid immobilization of affected body part for support and stability Internal fixation- use of metal screws, plates, nails and pins to stabilize reduced fractures Traction Reduction- restoration of the fracture fragments into anatomic alignment and rotation. Nursing care plan/implementation for clients with Fracture assess for complications of fracture Assess for complications of immobility assess casted extremity for presence of infection and neurovascular damage Provide emergency treatment Immobilize without altering the position of the deformity. Cover a protruding bone with a sterile dressing or clean cloth. Control bleeding if present

Administer pain medications as ordered. Prepare client for realignment of fragments through casting, splinting, traction or surgery. Provide care for a client in cast Encourage diet high in protein and Vit. C. Encourage isometric exercises to promote muscle tone and strength. Teach appropriate crutch walking technique as needed. Arrange for client to go to physical therapy as needed.

Infection in compound fractures is treated with antiseptics and antibiotics. If the broken segments lie adjacent to each other, stretching or traction to overcome the pull of powerful muscles may be used to achieve realignment, although external manipulation may sometimes bind the segments. This is called reduction. If proper alignment cannot be achieved in this way, an operation is usually performed, and the fragments are joined with screws, nuts, nails, wires or metal plates. This is open reduction. Once aligned, segments are secured externally with a plaster cast or splint to immobilize the fracture and to speed healing. When ribs are fractured, the chest is often strapped or taped to reduce pain from the motion of breathing. While healing, the body creates new tissue to join the broken segments. Minerals in the tissue harden to form solid new bone structure.

BULACAN STATE UNIVERSITY COLLEGE OF NURSING S.Y 2009-2010

DUTY REPORT

SUBMITTED BY: GROUP 3, IV -SECTION C MANALOTO, ALLAN M.

SUBMITTED TO: MR. AARON VILLANUEVA CLINICAL INSTRUCTOR