Emergency Nursing

Objectives

 Discuss the unique challenges of nursing

practice in an emergency care setting
 List the most common type of trauma and
interventions to prevent trauma.
 Identify the components of an initial trauma
assessment
 Describe the collaborative management of
trauma patient
Historical Perspectives

 Emergency nursing was officially recognized

as a specialty in 1970
 According to ENA, the definition of
Emergency Nursing includes
 The assessment , diagnosis and treatment of
perceived actual or potential , sudden or
urgent, physical or psychosocial problems
that are primarily episodic or acute.
 These may require minimal care or life
support measures, education of patient
and significant others, appropriate referral
and knowledge of legal implications
 Characteristics of Emergency
Nursing Practice
 Assessment , analysis , nursing diagnosis,
planning, implementation and evaluation of
human responses of individuals in all age
groups
 Care that is complicated by limited access to
medical history and the episodic nature of the
health care
 Triage and prioritization
 Emergency operations preparedness
 Stabilization and resuscitation
 Crisis intervention for unique patient
populations such as sexual assault survivors.
 Provision of care in uncontrolled or un
predictable environments
 Consistency as much as possible across the
continuum of care.
Principles of
Emergency Care
Triage

Means to sort out or sift out

Emergency Nurses Association
( guidelines for triage )
 Level I – resuscitation

 Level II – Emergent

 Level III- Urgent

 Level IV- less urgent

 Level V - Nonurgent
Four Color – Coded Disaster
Triage System
 Black – Dead

 Red- Critical or Life threatening

 Yellow- Serious

 Green - Minimal
 policies on disposition and managent
of DEM patients.doc
 Triage Category Systems

 RED- Critical...... Likely to survive with immediate

simple care
 BLUE - Catastrophic Survives with extensive
care or poor prognosis...
 YELLOW - Urgent..... Survives with care given in
few hours

 GREEN - Minor ..... Survives with care delayed

hours to days

 BLACK - Dead
As a triage nurse in a
busy emergency
department, it is your
responsibility to prioritize
patients who present for
care
Based on your
understanding of the
triage process, assign
each of the following
patients according to the
four color coded disaster
triage system
 Mr. P. Pascual is a 28 year old who fell off a
roof while working.
 He has a wrist fracture, several small
lacerations, and a swollen ankle.
 He is awake , alert and complaining of pain
Answer

SERIOUS
 S. Milby is a three year old who bit through
her lip when she fell off her bicycle
 She is frightened and crying
Answer

MINIMAL
 Mr. M is a 62 year old who suffered a heart
attack.
 Paramedics were called to Mr. M’s house
where defibrillation for ventricular fibrillation
was necessary.
 He has just arrived at the emergency
department .
 His blood pressure is 100/60
 He is diaphoretic and pale
ANSWER

CRITICAL
Assess and Intervene

ABCD method
Primary Survey

 Airway

 Breathing

 Circulation
 Disability
 Exposure
Secondary Survey

 Complete health history and head to toe

assessment
 Diagnostic and laboratory testing
 Insertion or application of monitoring devices
 Splinting of suspected fractures
 Cleansing , closure and dressing or wounds.
Issues in Emergency nursing
care
 Documentation of consent and Privacy
 Violence in the Emergency Department
 Restraints
 Mandatory Reporting
 Evidence . Collection and Preservation
 Providing Holistic Care
Ethical Issues in the Emergency
Department
 Unexpected Death

 Organ and Tissue Donation

 Airway obstruction

 Hemorrhage

 Hypovolemic shock

 Wounds
 Trauma
 Environmental Emergencies
 Poisoning
 Substance Abuse
 Violence, Abuse and Neglect
 Psychiatric Emergencies
Airway Obstruction

ADVANCED CARDIAC LIFE SUPPORT.ppt

Cardiopulmonary-Cerebral Resuscitation.ppt
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Airway Obstruction
Hemorrhage
Hemorrhage

 Results in the reduction of circulating blood

volume
 Minor bleeding
 Signs and Symptoms
 Control of External Hemorrhage

 Control of Internal Bleeding

Hypovolemic Shock
Shock

 Is a condition in which there is loss of

circulating blood volume
Management
Airway Patent AIRWAY

Breathing Maintaining Breathing

Circulation Restoration of circulating

blood volume
Wounds
Wounds

 Involving injury to soft tissue from minor tears

to severe crushing injuries
Management

 Wound Cleansing
 Primary Closure
 Delayed Primary Closure
 Tetanus prophylaxis
Trauma
Trauma

 an unintentional or intentional wound or injury

inflicted on the body from a mechanism which
the body cannot protect itself.
 Forensic Evidence
 Injury Prevention
 Multiple Trauma
Assessment and Diagnostic
Findings
 Gross evidence of trauma may be slight or
absent
Management

 To determine the extent of injuries and to

establish priorities.
Intraabdominal Injuries
 Penetrating

 Blunt trauma
Assessment and Diagnostic
Findings
 Adominal Assessment
 Peritoneal irritation
 Hypotension and symptoms of shock
 Internal Bleeding
 Intraperitoneal Injury
 Genitourinary Injury
Management

 Airway

 Breathing

 Circulation
Crush Injuries
Assessment and Diagnostic
Findings
 Hypovolemic shock
 Paralysis of the body part
 Erythema and blistering of skin
 Damaged body part
 Renal dysfunction
Fractures
Management

 Assessment of Airway, Breathing and

Circulation
Environmental
Emergencies
Heat Stroke

 Is acute medical emergency caused by

failure of the heat regulating mechanisms of
the body
Frostbite

 Is trauma from exposure to freezing

temperature and actual freezing of the
intracellular fluid and fluids in the intercellular
spacess
Hypothermia

 Is a condition in which the core ( internal )

temperature is 35 degree centigrade or less
as a result of exposure to cold.
Near Drowning

 Is defined as survival for at least 24 hours

after submersion that caused a respiratory
arrest
Decompression Sickness

 Occurs in patients who have engaged in

diving , high altitude flying, or flying in
commercial aircraft within 24 hours after
diving.
Anaphylactic Reaction

 Is acute systemic hypersensitivity reaction

that occurs within seconds or minutes after
exposure to certain foreign substances
Poisoning
 Is any substance that, when ingested,
inhaled, absorbed applied to the skin, or
produced within the body in relatively small
amounts, injures the body by its chemical
action.
Emergency Treatment

 To remove or inactivate the poison before it is

absorbed.
 To provide supportive care in maintaining
vital organ systems
 To administer a specific antidote to neutralize
a specific poison
 Ingested ( Swallowed ) Poisons
 Carbon Monoxide Poisoning
 Skin contamination Poisoning
 Food poisoning
Substance Abuse
 Is the misuse or specific substances to alter
mood or behavior
 Drug and Alcohol Abuse
 Acute Alcohol Intoxication
 Alcohol Withdrawal Syndrome/ Delirium
Tremens
Violence, Abuse and
Neglect
Assessing for Abuse,
Maltreatment and Neglect
 I noticed that you have
Sexual Assault
Psychiatric
Emergencies
 Overactive Patients
 Violent behavior
 Posttraumatic Stress Disorder
 Underactive or Depressed Patients
 Suicidal Patients
EMERGENCY NURSING
The Specialty of
Emergency Nursing
 Specific body system

 Specific disease process/problem

 Specific age group

 Specific population, such as women’s health care or

mental health
CORE
The scope of emergency
practice involves the
* ASSESSMENT
* ANALYSIS
* NURSING DIAGNOSIS
* OUTCOME
Independent and
Collaborative
DIMENSIONS
 Responsibilities
 Functions
 Roles
 Skills
BOUNDARIES
Internal and External
INTERSECTIONS
Professional and
Governmental groups
Major Trauma
Mechanisms of injury
 Knowledge of the object producing the injury ( motor
vehicle,handgun )
 Type of energy released ( kinetic, thermal, chemical
 Force of energy ( velocity of vehicle or missile )
 Use of protective devices ( seat belts, air bags ,
helmets )
Type of injury

 Blunt injury
 Penetrating injuries
Oxygen delivery and
consumption
Neuroendocrine stress
response
Systemic Inflammatory
Response syndrome
Multiple Organ
Dysfucntion Syndrome
Coagulopathy
Hypothermia
Psychologic Response
Assessment

History and Risk factors

 Mechanism of injury

 Intoxicants

 Preexisting medical conditions

 Last meal

 Initial subjective presentation

 Initial objective presentation

Diagnostic Tests
 Complete Blood Count
 Blood chemistries
 Arterial blood gas ( ABG ) analysis
 Oximetry
 Type and cross-match
 Blood alcohol, toxicology screen
 Urinalysis
 X-ray
 Computed tomography
Collaborative Management
 Airway management
 Oxygen
 Fluid management
- Crystalloids
- ColloidsColloids
 Packed red blood cells
 Gastric intubation
 Urinary drainage
 Pharmacotheraphy
- Antibiotics
- Analgesics and Anxiolytics

 Nutrition theraphy

 Surgery
Nursing Diagnoses
 Fluid volume deficit related to active loss secondary
to physical injury
 Altered protection related to clotting factor
alterations ; decreased hemoglobin level.
 Risk for infection related to inadequate primary
defenses secondary to physical trauma or surgery
 Impaired tissue integrity related to mechanical
factors
 Hypothermia related to exposure at the scene of
injury
 Altered nutrition ;less than body requirements ,
related to increased need secondary to
hypermetabolic posttrauma site
 Fear related to potentially threatening
situation
 Risk for injury
 Posttrauma syndrome
TRAUMATIC
BRAIN INJURY
PRIMARY BRAIN INJURIES

 Contusion
 Diffuse axonal injuries
 Concussion
Secondary brain injuries

 Intrinsic

 Extrinsic
Diagnostic tests
 Skull X-ray
 Cervical spine X-ray
 Computed tomography ( CT )
 MRI
 Cerebral angiography
 EEG
 Serum laboratory studies
Collaborative Mangement
 Surgical intervention
 Management of intracranial pressure of dynamics
 Reduction of ICP by CSF drainage
 Hyperventilation
 Monitoring jugular venous oxygen saturation
 Diuresis theraphy
 Maintenance of blood pressure to maintain
cerebral perfusion pressure
 Reduction of metabolic demand
 Modifying nursing care activites that raise
ICP
 Nutrition
 Rehabilitation
Nursing Diagnoses

 Impaired gas exchange

 Risk for infection
 Decreased adaptivecapacity
 Ineffective thermoregulation
 Risk for disuse syndrome
CHEST TRAUMA
Collaborative Management

 Oxygen theraphy
 Intubation
 Mechanical ventilation
 Blood replacement
 Chest tubes
 Analgesia
 Pleural decompression
 Stabilization and fixation of flail chest
 Thoracotomy
Nursing Diagnoses

 Risk for fluid volume deficit

Near Drowning
 Is a survival of more than 24 hr following
drowning
 Near drowning with aspiration ( wet )
 Near drowning without aspiration ( dry )
Collaborative Management
 Oxygen therapy
 Endotracheal intubation
 Positive end-expiratory pressure ( PEEP )
 Bronchoscopy
 Extracorporeal membrane oxygenation
 Rewarming for hypothermia
 Pharmacotheraphy
 Fluid and electrolyte management
 Neurologic support
 Management of event that precipitated the
near drowning
 Impaired gas exchange
 Hypothermia
 Risk for infection
Cardiac Trauma
Diagnostic Tests

 Chest X-ray
 Troponin
 Cardiac Enzymes
 ECG
 MUGA
 Echocardiography
 TEE
Collaborative Management

 Treatment of dysrhythnias
 Relief of acute pain
 Immediate corrective surgical repair
 Treatment of shcok
 Treatment of myocardial failure
Nursing Diagnoses

 Altered Tissue perfusion

Acute Cardiac
Tamponade
 Is a sudden accumulation of blood , fluid,
clots, pus , and /or gas in the pericardial
space, which copresses the heart and
interferes with both ventricular filling ( diastole
) and ejection ( systole ).
Etiology

 Trauma
 Iatrogenic
 Infection
 Carcinoma
 Nontraumatichemorrhage
 Left ventricular hemorrhage
Assessment

 Beck’s triad – distended

neckveins,hypotension, muffled heart tones
Collaborative

 Pericardicentesis
 Surgical Procedure
 Fluid Resuscitation
 Inotropic agents
 Oxygen,intubation,mechanical ventilation
Nursing Diagnoses

 Decreased Cardiac Output

Renal and Lower
Urinary Tract Trauma
Pelvic Fracture
Acute Spinal Cord
Injury
Abdominal Trauma