EMERGENCY NURSING

A M B U L A N C E
AMBULANCE
NURSES AND EDUCATION

Education is the most powerful
weapon which you can use to
change the world.
Nelson Mandela

SPECIFIC OBJECTIVES:
At the end of the ER lecture discussion, the students will
be able to:
1. Define and explain emergency care nursing.
2. Identify the different functional requirements of an
ER department.
3. States the legal aspects involved in various
emergency situation.
4. Explain the Principles of ER care.

SPECIFIC OBJECTIVES:
5. Discuss the process of assessment in various emergency
situations.
6. Utilize the nursing process in the care of patients in
emergency situation.
7. Formulate appropriate nursing diagnosis as to priority.
8. Evaluate outcome of the nursing care goals for each
situation.
INTRODUCTION
Emergency Nursing is a nursing specialty in which nurses
care for patients in the emergency or critical phase of their
illness or injury.
While this is common to many nursing specialties, the key
difference is that an emergency nurse is skilled at dealing
with people in the phase when a diagnosis has not been
made and the cause of the problem is not known.
emergency management refers to care to patients
with urgent and critical needs.

- Its philosophy include the concept that an
emergency is whatever the patient or the
family considers it to be.
- Large number of people seek emergency care for
serious life-threatening conditions.

Emergency departments often the first place where
victims of family violence, abuse, or neglect go to seek for
help.
Emergency Assessment:
A systematic approach to the assessment of an
emergency patient is essential.
Often the most dramatic injury is not the most serious.


Scope and practice of
Emergency Nursing
Specialized education
Expertise in assessing and identifying patients
health care problems
Establishes priorities, monitors acutely ill, and
injured patients
Nursing interventions are accomplished
independently

Providing Holistic care
1. Patient-focused interventions
2. Family-focused interventions
*anxiety and denial
*remorse and guilt
*anger
*grief
Psychological Considerations
Body trauma is an insult to physiologic and psychological
homeostasis, it requires both physiologic and psychological
healing.

Approach to the Patient:
1. Understand and accept the basic anxieties of the acutely
traumatized patient. Be aware of the patient fear of
death, mutilation, and isolation.
2. Personalize the situation as much as possible. Speak, react
and respond in a warm manner.
3. Give an explanation on a level that the patient can grasp.
An informed patient can cope with
psychological/physiologic stress in a more positive manner.
4. Accept the rights of the patient and family to have and
display their own feelings.
Approach to the patient cont. . .
5. Maintain a calm and reassuring manner.
6. Understand and support the pts. feeling concerning loss of
control( emotional, physical and intellectual).
7. Treat the unconscious patient as if conscious. Touch, call
by name, and explain every procedure that is done. Avoid
making negative comments about pts condition.
8. Orient the patient to person, time and place as soon as
he/she is conscious, reinforce by repeating this
information.
9. Bring the patient back to reality in a calm and reassuring
manner.

Approach to family:
1. Inform where the patient is and give as much information
as possible about the treatment he/she is receiving.
2. Recognize the anxiety of the family and allow them to talk
about their feelings. Allow the expressions of remorse,
anger, guilt and criticism.
3. Deal with reality as gently and quickly as possible; avoid
encouraging and supporting denial.
4. Assist the family to cope with sudden and unexpected
death.
5. Some helpful measures include the following:
- Take the family to a private place.
- Talk to all of the family together so they can mourn
together.
- Assure the family that everything possible was done:
inform them of the treatment rendered
- Avoid volunteering unnecessary information ( patient was
drinking and etc.)
- Be recognizant of cultural and religious beliefs and needs.



QUALITIES of an Emergency nurse:
has had specialized education, training, and experience
to gain expertise in assessing and identifying patients
health care problems in crisis situations
establishes priorities
monitors and continuously assesses acutely ill and
injured patients
supports and attends to families
supervises allied health personnel
Teaches patients and families within a time-limited
high-pressured care environment.



DELEGATION
A process by which responsibility and
authority for performing tasks are
transferred from one individual to another
who accepts that authority and
responsibility but remains accountable for
the task
5 Rs
- Right task
- Right circumstance
- Right person
- Right communication
- Right feedback
Scope of Practice
RN
- Decision maker/ delegator
- Unstable patients
- Newly admitted or transferred patients
- Health teachings or discharge teachings
- Blood transfusion/ chemotherapy/ central
catheters

LPN/LVN
- Technical doers
- Stable patients with predictable outcomes
- Wound care, traction, casts
- NGT and colostomy care
- Oral meds and parenteral (IM, SQ) therapies,
NO IV push
- Data collection

CAN
- Stable patients
- Routine of care (eg. Ambulating, turning, I
and O, feeding, measurements of ht. and wt.)
- Indirect activities: bed making,
transporting patients, stocking supplies)

Steps:
1. Define the task
2. Determine the delegate
3. Communicate expectations and outcomes
4. Reach mutual agreement about the task
5. Monitor the task and provide guidance
6. Evaluate results
7. Provide feedback

PRIORITIZATION
- decisions in which needs or problems require
immediate attention or action and which ones
could be delayed at a later time if they are not
urgent
Principles
a. Needs that are life threatening or could result to
harm if left untreated are high priorities
b. Actual problems have high priority than potential
problems
c. Problems identified by client are of higher
priority
d. Principles of Maslow or ABC may guide
decisions
ISSUES IN EMERGENCY NURSING CARE

Documentation of consent
Consent to examine and treat the patient is part of the ED
record.
Patient must consent to invasive procedure unless he/she is
unconscious or in critical condition and unable to make
decisions.
If brought unconscious w/out family or friends, it must be
documented.
Limiting exposure to health risks
> All health care providers should adhere strictly to
standard precautions for minimizing exposure.





REMEMBER!!!
UNIVERSAL PRECAUTIONS:
The routine use of appropriate barrier
precautions to prevent skin and mucous
membrane exposure when contact with blood
or other body fluids of any individual may
occur or is anticipated.
Universal Precautions apply to blood and to
all other body fluids with potential for
spreading any infections.

PRINCIPLES OF EMERGENCY CARE
TRIAGE
> trier, French word meaning, to sort.
>used to sort patients into groups based on the severity
of their health problems and the immediacy with which
these problems must be treated.
>an advanced skill
Most of the patients entering an emergency department are
greeted by a triage nurse.


The role of the triage nurse is to do a brief evaluation of
the patient to determine the level of acuity or priority
of care.
The triage nurse acts a gatekeeper, sorting patients into
categories, ensuring that the more seriously ill are
treated first.

Purpose: To deliver the greatest good to
the greatest number.
Triage means to sort
Looks at medical needs and urgency of each
individual patient
Sorting based on limited data acquisition
Also must consider resource availability

Routine hospital triage directs all available resources to
the patients who are most critically ill, regardless of the
potential outcome.

Field triage hospital triage during a disaster.
>scarce resources must be used to benefit the most
people possible.

***this distinction affects triage decisions***
POINTS TO REMEMBER ABOUT
TRIAGE CONSIDERATIONS
Identification of the patient
Assessment
Facilitation of treatment
Communication
Legal liability
- Personal responsibility for ones own acts
- Reasonable care under the circumstances
- Care in accordance with accepted standards
PERSONNEL IN THE TRIAGE SYSTEM
Emergency squad personnel
Nursing personnel
Physician staff
Hospital administration
Ethical Justification
This is one of the few places where a "utilitarian rule" governs
medicine: the greater good of the greater number rather
than the particular good of the patient at hand. This rule is
justified only because of the clear necessity of general
public welfare in a crisis.
A. Jonsen and K. Edwards, Resource Allocation in Ethics in
Medicine, Univ. of Washington School of Medicine,
http://eduserv.hscer.washington.edu/bioethics/topics/resal
l.html

TRIAGE SYSTEM CATEGORIES
Emergent 1 have the highest priority
> life-threatening conditions and must be seen immediately.
Conditions requiring immediate medical intervention. Any delay in
tx is potentially life or limb threatening.
Condition such as : Airway compromise, cardiac arrest, Severe
shock, cardiac arrest, cervical spine injury, multiple
system trauma
Altered level of consciousness, eclampsia

Urgent serious health problems, but not immediately life-
threatening ones; must be seen within an hour.

Non-urgent episodic illnesses that can be addressed within 24
hours w/out increased morbidity

Fast-track requires simple first aid or basic primary care.


Triage Categories Of Severity/Prioritization
Class I. Red Tag: Critical-top priority
Life-threatening but treatable injuries requiring
rapid medical attention
- ARD, airway obstruction, shock, massive
hemorrhage
Rx: ABCs of resuscitation; Prioritize for transport
Class II. Yellow Tag: Severe-Urgent care priority
Potentially serious injuries, but are stable enough
to wait a short while (within 1-2 hours) for
medical treatment
- Penetrating or abdominal wounds, major burns,
closed head injuries with decreased LOC
Rx: ABCs of resuscitation; Prioritize for transport

Class III. Green: Non-urgent- delayed priority
- Minor injuries that can wait for longer
periods of time (2-6 hours) for treatment
- Moderate burns, fractures, dislocations, eye
injuries, lacerations, facial injuries without
airway obstruction sprains, strains, contusions
Rx: ABCs of resuscitation; Prioritize for
transport
Black Tag:
- Dead or still with life signs but injuries are
incompatible with survival in austere
conditions
- Morgue at disaster site until bodies can be
moved

AREAS OF TRIAGE
Disaster Scene
- Simple triage is used in a scene of mass
casualty; sort those who need critical attention
and immediate transport to the hospital and
those with less serious injuries
- Triage done to prioritize patients based on
severity of condition: treat as many as possible
when resources are insufficient for all to be
treated immediately
Hospital
1. Triage team staff stations at the entrance
2. Rapid triage evaluation is made
3. Clerk applies a stat record identification band, hand
the corresponding triage slip to the triage officer,
places the stat chart with the patient, logs the stat
medical record number, stat name number and the
patients name and the emergency department are
assignment
4. Patient is stabilized and leaves the ER after a rapid
reassessment to a treatment location and team in
the ER or another designated area for a more
thorough evaluation and assessment
PROCESS OF TRIAGE

ASSESS AND INTERVENE
**Priorities for patient with an emergent or urgent
health problem
1. stabilization
2. provision of critical treatments
3. prompt transfer to the appropriate setting
(ICU, OR, General Care Unit)


Why Should Planners Plan For Good Triage?
As a system tool, it provides a way to draw
organization out of chaos.
Helps to get care to those who need it and
will benefit from it the most and speeds
efficient patient evacuation.

Why Should Planners Plan For Good Triage?
Helps in resource planning and allocation.
Provides an objective framework for
stressful and emotional decisions, helping
rescue workers to be more efficient and
effective.


TRIAGE MOTTO:
Daily Emergencies
Do the best for each individual.
Disaster Settings
Do the greatest good for the
greatest number. Maximize
survival.
2 Methodological approach to help identify and
prioritize patient needs:
1. Primary Assessment
2. Secondary Assessment



Systematic Approach to effectively establishing and
treating health priorities:
1. Primary survey focuses on stabilizing life-
threatening conditions, FIND ALL IMMEDIATE
THREATS TO LIFE; 1.5 2minutes only
A Airway
- establish a patent airway
B Breathing
Airway : Does the patient have an open airway?
Breathing : Is the patient breathing?
- Provide adequate ventilation, employing
resuscitation measures when necessary. (Trauma
patients must have the cervical spine protected and
chest injuries assessed first)

Primary Assessment:
1. The initial rapid assessment of the patient is meant to
identify life threatening problems (ABC)
1
st
step is to determine if the patient is conscious. If
conscious, the primary assessment can be performed at a
glance.
A patient who is alert and talking indicates that there is
breathing and circulation.
A conscious patient indicates that circulation is adequate
and enough blood being circulated to the brain.
If however the patient is not fully conscious, primary
assessment should proceed.
In a seriously ill or injured patient, it is recommended to
add 2 letters to the primary survey D- disability , E
expose
CONT.
C Circulation
- Evaluate and restore cardiac output by
controlling hemorrhage, preventing and treating
shock, and maintaining or restoring effective
circulation.
Circulation: Is there pulse? Is there profuse
bleeding?
D Disability
- Determine neurologic disability by assessing
neurologic function using the Glasgow Coma Scale;
apply a cervical collar

Disability assess level of consciousness and pupils
Assess level of consciousness using AVPU scale:
- A is the patient alert?
- V Does the patient responds to the voice?
- P Does the patient respond to painful stimulus?
- U Is the patient unresponsive even to painful
stimulus?
E- Exposure
Remove clothing


2. Secondary survey approach
a. Complete health history and head-to-toe assessment

Is a systematic, brief (2 to 3 minutes) examination of the
patient from head to toe of critical patients
It is to detect and prioritize additional injuries or to
detect signs of underlying medical conditions.



History
1. If possible a brief history of the patients chief
complaint, accident, or illness is taken from the patient
or companion, relative , pre-hospital provider.
2. What is the mechanism of injury circumstances,
forces, location, and time of injury?
3. When did the symptoms appear?
4. Was the patient unconscious after the accident?
5. How did the patient reach the hospital?
6. What was the health status of the patient before the
accident or illness?
7. Is there any hx of illness?
8. Is the patient currently taking any medications?
9. Does the patient have any allergy?
10. Is the patient under a health care providers care?
( name of health provider)

NURSING ALERT:
To obtain a good descriptive history, do
not ask questions that can be answered by
yes or no
b. Take the vital signs to establish complete baseline
information.
c. Perform a Head to toe assessment including neuro

d. Diagnostic and laboratory testing
e. Insertion or application of monitoring devices such as ECG
electrodes, arterial lines, or urinary catheter.
f. Bandaging and splinting of suspected fractures.
g. Cleaning and dressing of wounds.
h. Performance of other necessary interventions based on the
individual patients condition.
i. Continual monitoring.

If secondary survey reveals any of the following,
transport immediately:
- Tender distended abdomen
- Pelvic instability
- Bilateral femur fractures

Brief neuro exam:
a. LOC (AVPU)
b. Motor- toes can be moved
c. Sensation can feel touch to digits
d. Pupils PERL
Transport Decision and Critical Intervention
- Critical trauma transported. All Rx done in transport
- Intervention to be done at scene:
- Removal of airway obstruction
- Stop major bleeding
- Sealing sucking wounds
- Hyperventilate
- Decompression of tension pneumothorax

Critical injuries can be simplified into 3 conditions:
a. Difficulty with respiration
b. Difficulty with circulation
c. Decreased LOC
FUNCTIONAL REQUIREMENTS OF AN
EMERGENCY DEPARTMENT
HOSPITAL POLICIES institutional

ED STAFF:
1. Head of the departments
2. ER Supervisors
3. Head Nurse
4. Resident Doctors
5. Staff Nurse
6. Nursing attendants, orderlies, handlers.

EQUIPMENTS
EMERGENCY CART
defibrillator

LARYNGOSCOPE
INTUBATION SET
OXYGEN TANKS
SUCTION APPARATUS & SUCTION
CATHETERS
URINARY CATHETERS
IV FLUIDS, IV CANNULA & IV
ADMINISTRATION SET
EMERGENCY MEDS & SYRINGES
CARDIOPULMONARY
RESUSCITATION
Is a technique of basic life support for the
purpose of oxygenating the brain and
heart until appropriate.
Definitive medical treatment can restore
normal heart and ventilatory action.

Indications:
1. Cardiac Arrest
a. Ventricular fibrillation
b. Ventricular tachycardia
c. Asystole
2. Respiratory Arrest
a. Drowning
b. Stroke
c. Foreign body obstruction
d. Smoke inhalation
e. Drug overdose
f. Electricution/injury by lightning
g. Suffocation
h. Accident/injury
i. Coma



Assessment:
Immediate loss of consciousness
Absence of palpable carotid or
femoral pulse; pulselessness in
large arteries
NURSING ALERT:
The patient who has been
resuscitated is at risk for another
episode of cardiac arrest.
Responsiveness/airway
Determine unresponsiveness: tap or
gently shake patient while shouting,
are you ok?
Place patient supine on a firm, flat
surface, kneel at the level of
patients shoulder. If the patient has
a suspected head or neck trauma,
the rescuer should move the patient
only if absolutely necessary.
C P R
PULSE SITES
ADULT
CAROTID IN NECK
RADIAL IN WRIST
CHILD
CAROTID IN NECK
BRACHIAL IN ARM
INFANT
-BRACHIAL IN ARM
FEMORAL IN GROIN

PULSE CHECKS
BE SURE PULSE IS ABSENT AND
BEGIN CPR
ADULT-AFTER 1 MINUTE OR 4
CYCLES OF 1 OR 2 MAN CPR
CHILD & INFANT-AFTER 1 MINUTE
OR 20 CYCLES
AND EVERY FEW MINUTES

COMPRESSIONS--ADULT
COMPRESS 1 1/2 - 2 INCHES
GIVE 100 COMPRESSION'S PER
MINUTE FOR 1 OR 2 MAN CPR
USE 2 HANDS ON LOWER HALF OF
STERNUM
CHECK CAROTID PULSE AFTER 1
MINUTE OF CPR
CHECK CAROTID PULSE DURING 2
MAN CPR

COMPRESSIONS--CHILD
COMPRESS 1/3 TO1/2 DEPTH OF
CHEST
GIVE 100 COMPRESSION'S PER
MINUTE
USE THE HEAL OF 1 HAND ON THE
LOWER HALF OF THE STERNUM
COMPRESSIONS--INFANT
COMPRESS 1/3 TO 1/2 DEPTH OF
CHEST
USE 2 THUMBS AROUND THE CHEST
GIVE 100 COMPRESSION'S PER
MINUTE
USE 2 FINGERS 1 FINGER BELOW THE
NIPPLE LINE

COMPRESSION RATIOS
ADULT
15 : 2 FOR 2 RESCUERS
15 : 2 FOR 1 RESCUER
CHILD
5 : 1 RATIO
INFANT
5 : 1 RATIO

COMPLICATIONS OF CPR
PUNCTURED LUNG
LIVER LACERATION
FRACTURED RIBS/STERNUM
GASTRIC DISTENTION
GIVE SLOW EVEN BREATHS
PROPER HAND POSITION TO MINIMIZE
RIB FRACTURES
AHA 2005
ACLS GUIDELINES
Increased Emphasis On:

Effective CPR
Push hard and push fast
Chest compressions
Trauma:
Initial Management Priorities
A B C
Airway:
- assess
- establish
- maintain
Breathing:
- assess
- support
Circulation:
- assess
- access
- stop hemorrhage
- resuscitate

Airway
New Old
5 cycles of CPR/ 2 min prior to
phoning 911 for infants/children
No jaw thrust (lay people)
Health care providers may use
head-chin tilt in injured patients
if jaw thrust fails

1 min of CPR prior to
phoning 911 for
infants/children
Jaw thrust only for
injured patients
(both health care
providers and lay
people)


BREATHING
ALL rescue breaths over 1 s, with adequate volume to
produce visible chest rise
Lay people: check for normal breathing in adults
Normal (not deep) breath prior to AR
Continuous cycles when intubated only
8-10 resps per min when intubated (q 6-8 s)
No rescue breathing without compressions for lay people

BREATHING - OLD
Rescue breaths over 1-2 s
Varying tidal volumes suggested
10-12 resps/min once intubated
CIRCULATION - NEW
Single compression to ventilation ratio for ALL single
rescuers for ALL victims (excluding newborns)
30:2 (100/min)
5 cycles (2 min) CPR in between rhythm checks
Health care providers (2 rescuer):
Adults 30:2
Infants/children 15:2

CIRCULATION
NEW OLD

Limit interruptions in
compressions
Rescuers may use one or two
hands for child CPR
Unwitnessed arrests: may
consider 5 cycles of CPR prior to
defibrillation (or response time >
4 min)
Minimizations in interruptions
not emphasized
Adult: 15:2
Infant and child: 5:1
Rhythm and pulse checks after
defibrillation

LEGAL ASPECTS IN EMERGENCY NURSING
LAW the sum total of rules and regulations
by which society is governed.
- it is man-made and regulates social
conduct in a formal and binding way.

CONSENT free and rational act that
presupposes knowledge of the thing to
which the consent is being given by a
person who is legally capable to give
consent.
NATURE OF CONSENT
- is an authorization given, by a patient or a person
authorized by law to give the consent in the patients behalf
- secured by the nurse upon admission
- usually for diagnostic procedures and initial treatment
deemed necessary by the medical staff.
- substantiated by a written authorization as a proof
against any liability that may arise due to an alleged unlawful
touching of a patient.
INFORMED CONSENT
- Hayt and Hayt states that It is established principle
of law that every human being of adult years and sound mind
has the right to determine what shall be done with his own
body.
- he may choose whether to be treated or not and to
what extent, no matter how necessary the medical care, or
how imminent the danger to his life or health if he fails to
submit to treatment.
ESSENTIAL ELEMENTS OF INFORMED CONSENT:
1. diagnosis and explanation of the condition
2. fair explanation of the procedures to be done and used
and the consequences
3. a description of alternative treatments or procedures
4. description of the benefits to be expected
5. material rights if any
6. prognosis, if the recommended care, procedure, is
refused
PROOF OF CONSENT
- a written consent should be signed to show that the
procedures the one consented to and that the person
understands the nature of the procedure, the risks involved
and the possible consequences.
Who must consent?
- the patient
- another person gives consent if patient is incompetent,
minor, or mentally ill or physically unable and is not in an
emergency case
CONSENT IN EMERGENCY SITUATION:
- No consent is necessary because inaction at such time
may cause greater injury.
LEGAL LIABILITY
Nurses are governed by civil and criminal law in roles as
providers of services, employees of institutions, and private
citizens.
A nurse has a personal and legal obligation to provide a
standard of client care expected of a reasonably competent
professional nurse.
Professional nurses are held responsible for harm resulting
from their negligent acts, or their failure to act.
Responsibilities of the nurse to the patient:
PRIMARY RESPONSIBILITY: To give patient the kind of
care his/her condition needs regardless of his/her race,
creed, color, nationality or status.
Patients care must be based on needs, the physicians
orders, and the ailment; and shall involve the patient and
allows the family to participate. (9
th
ed. Professional Nsg in
the Phils by Venzon).
Nurses are advised to be familiar with the patients Bill of
Rights and observe its provisions.
The nurse may only repeat what the doctor wishes to
disclose, if the patient insist on knowing what the diagnosis
is all about.
Confidentiality whatever info gathered by the nurse
during the course of caring for the patient shall always be
treated with CONFIDENTIALITY
Confidential information may be revealed only when:
1. The patient permits such revelations as in claim for
hospitalization, insurance benefits.
2. The case is medico-legal such as attempted suicide,
gunshot wounds w/c have to be reported to the local
police or NBI
3. Patient is ill of communicable disease and public safety
may be jeopardized; and
4. Given to members of the health team if information is
relevant to his care.
Legal Safeguards
Systematic reporting system for incidents or unusual
occurrences.
Proper documentation
Nurses Bill of Rights
Legal defense in a negligent action is when nurses know
and attain the standard of care in giving service and that
they have documented the care they have given in a
concise and accurate manner.
NURSING ASSESSMENTS
PURPOSES:
Surveying the clients health status and risk factors for a
particular health problems
Identifying latent or occult (undetected) disease
Screening for a specific disease, such as diabetes or
hypertension.
Identifying risks for particular health problem
Determining functional impact of disease (human
response to actual or potential health problems)
Evaluating the effectiveness of the health care plan
Health history
Purposes:
Elicits a detailed, accurate, and chronological
health record as seen in the clients perspective.
Connect with the client and develop good
rapport, provides insight into the clients
functional status, and helps focus and guide
subsequent physical examinations.
Physical Examination
Physical examination is the second
component of a complete nursing health
assessment. History findings help focus
the physical examination.
Practice and adhere to standard
precautions throughout the entire
physical assessment.
ASSESSMENT TECHNIQUES
Inspection
an important assessment point (but commonly forgotten)
Inspection employs the senses of vision and smell to
observe the client.
Auscultation
Involves listening (usually through a stethoscope) to
sounds produced in the body, particularly the heart,
lungs, blood vessels, stomach, and intestines.
A doppler ultrasonic stethoscope and an acoustic
stethoscope can be used to amplify body sound.

Palpation
Different parts of the hand are used to detect
characteristics of pulsation, vibrations, texture, shape,
temperature, and movement.
Confirm and amplify findings observed during inspection.
Light palpation is always done first. Using finger pads,
provide superficial and delicate palpation to explore skin
texture and moisture; overt, large or deep masses; and
fluid, muscle guarding, and superficial tenderness.
Deep palpation, uses the hand to explore internal
structures.


Percussion
Sharply tapping the body surface with the
fingers, hands, or a rubber reflex hammer
produces sounds whose quality depends on the
density of underlying structures (organ borders,
fluid, gas)
Used to elicit tenderness and to assess reflexes.
Supportive Studies
Laboratory Studies
3 categories
Urinalysis
Hematology
Blood chemistry
Diagnostic Studies
Performed during routine physical examinations and
assist in diagnosing disease.
Nurses responsibility
The nurse is responsible for the patient during the pretest,
intratest,posttest periods.
Facility policies, procedures, and protocols for collecting,
handling, and transporting specimens should be followed at
all times.
The nurse must educate the client concerning preparation
for the diagnostic test
Obtain written consent if necessary
Ensure clients safety during the procedure
Assist with the procedure if necessary
Monitor for complications after the diagnostic test
Standard precaution must be adhered to at all times.
COMMON TYPES OF EMERGENCIES
CARDIAC EMERGENCIES/CHEST TRAUMA

RESPIRATORY EMERGENCIES

CNS EMERGENCIES
CARDIAC EMERGENCIES
CHEST PAIN

ACUTE CORONARY
SYNDROME
UNSTABLE ANGINA
MYOCARDIAL INFARCTION
ANGINA PECTORIS
1. Transient paroxysmal chest pain produced by insufficient blood flow to the myocardium resulting
in myocardial ischemia.

2. Risk Factors

2.1 CAD
2.2 Atherosclerosis
2.3 HPN
2.4 Diabetes Mellitus ( DM )
2.5 Severe Anemia
2.6 Severe Aortic Insufficiency

3. Precipitating Factors

3.1 Physical Exertion
3.2 Consumption of Heavy Meal
3.3 Extremely Cold Weather
3.4 Strong Emotions
3.5 Cigarette Smoking
3.6 Sexual Activity

ASSESSMENT FINDINGS FOR ANGINA
PECTORIS
4. Assessment Findings

4.1 Pain : Substernal with possible
radiation to the neck, jaw, back
and arms but relieved by rest.
4.2 Palpitations and Tachycardia
4.3 Dyspnea
4.4 Diaphoresis
4.5 Increased Serum Lipid Levels
4.6 Diagnostic Tests
a. ECG : Segment depression
and I wave inversion during chest
pain
b. Stress Test : Abnormal ECG
during exercise

CHEST PAIN-ANGINA PECTORIS
Clinical syndrome usually characterized by episodes or
paroxysms of pain or pressure in the anterior chest.
Cause is usually insufficient coronary blood flow w/c results
in a decreased oxygen supply to meet an increased
myocardial demand for oxygen in response to physical
exertion or emotional stress.
Pain is often felt deep in the chest behind the upper or
middle 3
rd
of the sternum (retrosternal area).
Pain is poorly localized and may radiate to the neck, jaw,
shoulders, and inner aspects of the upper arms, usually the
left arm.
Tightness or a heavy, choking, or strangling sensation that
has a vise-like, insistent quality.


NURSING PROCESS

Assessments: PQRST

P Position/Location
Where is your pain located?
Can you point to it?
- Provocation
What are you doing when the pain began?
Q- Quality
How would you describe the pain?
Is it like the pain you had before?
- Quantity
Has the pain been constant?



R Radiation
Can you feel the pain anywhere else?
- Relief
Did anything make the pain better?
S Severity
use pain rating scale
- Symptoms
Did you notice any other symptoms with
the pain?
T Timing
How long ago did the pain start?
Nursing Diagnosis
1. Ineffective myocardial tissue perfusion secondary to
CAD as evidenced by chest pain.
2. Anxiety related to fear of death
3. Deficient knowledge about the underlying disease and
methods for avoiding complications.
4. Noncompliance, ineffective management of therapeutic
regimen related to failure to accept necessary lifestyle
changes.
Planning and goals
1. Immediate and appropriate treatment when angina
occurs
2. Prevention of angina
3. Reduction of anxiety
4. Awareness of the disease process
5. Understanding of the prescribed care,
adherence to the self-care program, and absence of
complications.
Nursing Interventions
1. Treating angina
> Stop activities, sit or rest in a semi-
fowler position.
>Assess the angina
>Measure the vital signs
>Observe for signs of respiratory
distress
>Nitroglycerin-can be repeated up to 3
doses if chest pain is unchanged or lessened but still
present.
>Oxygen therapy-Administer oxygen.
>For significant pain despite treatment,
transfer to ICU

2. Reducing anxiety-Provide emotional support.
3. Preventing pain
4. Promoting home and community-based care.
Allow patient to notify physician immediately if pain occurs and
persists despite rest and medication
>teaching patients self-care



Myocardial Infarction
Refers to the process by w/c areas of the myocardial cells
in the heart are permanently destroyed.
Caused by a reduced blood flow to the coronary artery due
to occlusion of an artery.
Due to profound imbalance existing between myocardial
oxygen supply and demand.
Causes:
vasospasm of a coronary artery
Decreased oxygen supply
Increased demand of oxygen

MYOCARDIAL INFARCTION
1. Death of myocardial cells from
inadquate oxygenation often caused
by a sudden complete blockage of
coronary artery; characterized by
localized formation of necrosis (
tissue destruction ) with subsequent
healing by scar formation and
fibrosis.
2.. Risk Factors
a. Atheresoclerotic CAD
b. Thrombus formation
c. Hypertension
d. Diabetes Mellitus



NURSING PROCESS
Assessment:
Use systematic assessment w/c includes a careful history,
particularly as it relates to symptoms.
Chest pain or discomfort- Substernal pain with radiation to the neck, jaw,
or back,;severe, crushing excruciating pain unrelieved by rest or nitrates.
Difficulty of breathing (dyspnea)
Nausea and vomiting
Skin : cool, clammy and ashen
f. Initial increase in Bp and pulse with gradual drop in blood pressure
Palpitations
Unusual fatigue
Faintness (syncope)
Sweating (diaphoresis)



Nursing Diagnosis:
Ineffective cardiopulmonary tissue perfusion related to
reduced coronary blood flow from coronary thrombus and
atherosclerotic plaque.
Potential impaired gas exchange related to fluid overload
from left ventricular dysfunction
Potential altered peripheral tissue perfusion related to
decreased cardiac output from left ventricular
dysfunction
Anxiety related to fear of death
Deficient knowledge about post-MI self-care
Planning and goals:
Relief of pain or ischemic signs and symptoms
Prevention of further myocardial damage
Absence of respiratory dysfunction
Maitenance or attainment of adequate tissue perfusion
by decreasing the hearts workload
Reduced anxiety
Adherence to the self-care program
Absence or early recognition of complications.
NURSING INTERVENTIONS FOR PATIENTS WITH
MYOCARDIAL INFARCTION
Establish patent IV Line.
Provide Pain relief.
Administer oxygen needed.
Provide bed rest with semi-fowlers position.
Monitor ECG and hemodynamic procedures.
Administer antiarrythmic drugs as ordered.
Perform cardiac and lung assessments.
Monitor urine output and report output < 30 cc/hr.
Maintain full liquid diet with gradual increase to soft; low sodium
Maintain quiet environment.
Transport to CCU soonest possible
Nursing Interventions
Relieving pain and other signs and symptoms of ischemia
Improving respiratory function
Promoting adequate tissue perfusion
Reducing anxiety
Monitoring and managing potential complications
Promoting home and community-based care.
CARDIAC TAMPONADE
CARDIAC TAMPONADE
Compression of the heart as a result of fluid within the
pericardial sac (pericardial effusion)
Usually caused by blunt or penetrating trauma to the chest.
Penetrating wound to the heart is associated with high
mortality.



Signs and symptoms:
Decreased cardiac output
Faintness
Shortness of breath
Anxiety
pain
Pressure created in the trachea from swelling of the
pericardial sac
cough
Rising venous pressure
Distended neck veins
Paradoxical pulse
Muffled or distant heart sound


INTRA-ABDOMINAL INJURIES
PENETRATING TRAUMA-
Stabbing wound site generally indicates which
organs are affected. Wound severity depends on
size (width, shape and length) of the knife or
instrument used.

BLUNT TRAUMA occurs from direct impact of the force
to the abdominal wall, and/or thoracic area. Organs of the
abdomen most often injured are the more solid organs the
kidney, liver, spleen. May sustain pneumothorax,
hemothorax,flail chest, myocardial bruising with the blunt
trauma to the chest.

STAB WOUND/GUNSHOT WOUND
Are serious and usually requires surgery
High incidence of injury to hollow organ particularly small
bowel
Liver is the most frequently injured solid organ
High velocity missile create extensive tissue damage.
All abdominal gunshot wounds that cross the peritoneum
require surgical exploration
Stab wound may be managed non operatively.
ASSESSMENT:
Assess and treat client for life threatening injuries- respiratory status
and hemorrhage.

Attempt to determine the type of force that caused the injury.

If the weapon or object producing the penetrating wound is still in
place, do not remove it. Object may not be removed until client is in
surgery where bleeding and organ damage are more accessible for
repair

Remove the client's clothing and inspect the entire body for injuries.
Penetrating injuries may not be bleeding or obvious initially. Carefully
logroll the client on his side and inspect back and trunk for injury.

Check the pulses in each extremity and evaluate the blood pressure in
the upper and lower extremity.

If abdominal trauma caused damage to the aorta, there may be
decrease in the blood pressure in the lower extremities.
ASSESSMENT:
Carefully assess the thorax and continue to evaluate quality
of respirations. Frequent assessment of the quality and
presence of breath sounds, evaluate changes of breath
sounds.
Asymmetry of the chest wall movement may indicate
hemothorax or pneumothorax.
The presence of puncture penetrating wounds of the thorax
and fractured ribs may precipitate pneumothorax and
atelectasis.
Observe for c changes in respirations and level of
consciousness that are indicative of hypoxia.
Paradoxical movement of the chest wall indicate multiple rib
fractures and flail chest.
RESPIRATORY EMERGENCIES
ACUTE RESPIRATORY DISTRESS

ACUTE RESPIRATORY DISTRESS SYNDROME
(ARDS)
Previously called, ADULT RESPIRATORY DISTRESS
SYNDROME
Characterized by sudden and progressive pulmonary edema,
increasing bilateral infiltrates, hypoxemia, and reduced lung
compliance.
Acute phase:rapid onset of severe dyspnea that usually
occurs 12 to 48 hours after the initiating event.
Hypoxia is a condition characterized by an inadequate
amount of oxygen.
Hypoxemia decrease oxygen saturation of the blood;
generally occus when PO2 is below 50mmhg
Nursing Diagnosis:
Hypoxia Potential Complications: respiratory failure,
inadequate cardiac output, dysrhythmia.
Ineffective Airway Clearance related to ineffective cough or
inability to remove airway secretions.
Ineffective breath patterns related to hyperventilation,
hypoventilation, CNS depressions of respiratory system.
Impaired Gas exchange related alveolar hypoventilation or
perfusion
Activity intolerance related to inadequate oxygen for ADL.
Anxiety related to breathlessness
Nursing Management
Goal : to maintain good pulmonary hygiene and prevent
hypoxic episode
general measures:
Assess patency of airway (first priority)
Position client to maintain patent airway.
A. unconscious client position on side with the chin
extended notify physician and remain with client.
B. conscious client elevate the head of the bed and
position on side as well.
Close monitoring
Use of respiratory modalities (O2
administration, chest physiotheraphy,
endotracheal intubation, nebulizer therapy,
mechanical vent, suctioning, etc.)
Nursing Management cont.
Positioning to improve ventilation and perfusion in the
lungs and enhance secretion drainage.
Explain procedure to reduce anxiety
Rest is essential to reduce oxygen consumption,
decreasing oxygen needs.
Encourage cough and deep breathing exercise.
Suction client as indicated by amount of sputum and
ability to cough
Maintain adequate fluid intake to keep secretions
liquified.


PULMONARY EMBOLISM
PULMONARY EMBOLISM
Refers to the obstruction of the pulmonary artery or one of
its branches by a thrombus that originates somewhere in
the venous system or in the right side of the heart.
The severity of the problem depends on the size of the
emboli
The right lobe mostly frequent involved
Of the clients who die, die within 2 hours.

Clinical Manifestation
Dyspnea
Sudden, sharp, substernalchest pain
Coughing with hemoptysis
Tachycardia
Symptoms of hypoxia
Nursing Management
Bed rest
Minimizing the risk of pulmonary embolism
Preventing thrombus formation
Assessing potential for pulmonary embolism
Monitoring thrombolytic therapy
Managing pain
Managing oxygen therapy
Relieving anxiety
Monitoring for complications
Providing postoperative nursing care
Promoting home and community-based care
STATUS ASTHMATICUS
STATUS ASTHMATICUS
Is severe and persistent asthma that does not respond to
conventional therapy.
Attacks can last longer than 24 hours
The basic characteristics in asthma decrease the diameter
of the bronchi and are apparent in status asthmaticus.
Constriction of the bronchiolar smooth muscle
Swelling of the bronchial mucosa
Thickened secretions
Clinical manifestations
Cough
Shortness of breath
Expiratory wheezing
Symptoms of hypoxia
Retractions
Tachycardia
Increased anxiety, restlessness
Nursing Management
Position pt. on high back rest
Constant monitoring for the first 12 to 24 hours or until
status asthmaticus is under control.
Assessment of skin turgor to identify signs of dehydration
Fluid intake is essential to combat dehydration, to loosen
secretions, and facilitate expectoration.
Conservation of patients energy
Non allergenic pillow should be used.
SMOKE INHALATION
SMOKE INHALATION
Inhalation injury is the leading cause of death in fire
victims.
Causes pulmonary damage:
Indicators:
History indicating that the burn occurred in an
enclosed area
Burns of the face or neck
Singed nasal hair
Hoarseness, voice change, dry cough, stridor, sooty
sputum
Bloody sputum
Labored breathing or tachypnea and other signs of
reduced oxygen levels
Erythema and blistering of the oral or pharyngeal
mucosa.
CNS EMERGENCIES
CEREBRO-VASCULAR ACCIDENT (CVA)
CEREBRO-VASCULAR ACCIDENT (CVA) a.k.a
STROKE
Sudden lost of brain function resulting from the disruption
of the blood supply to a part of the brain.
Most common site: middle cerebral artery

DRUG OVERDOSE
DRUG OVERDOSE
UNCONSCIOUS
UNCONSCIOUS
SHOCK
Shock characterized by inadequate blood flow and tissue
perfusion
Clinical Manifestation:
Restlessness- apprehensive
Increase pulse rate, weak and thready
Tachycardia to bradycardia
Urine output decreased - oliguria
Continued decrease blood pressure
Decrease sensory perception
Cool, moist skin
Rapid shallow respirations labored, irregular respirations.
Skin color pallor o cyanotic


Classification of shock
1.Hypovolemic redusced venous returndue to reduced blood
volume 15 to 25% reduction on vol.
conditons such as hemorrhage, Burns, severe fluid loss,
dehydration
Treatment: Administer volume replacement, whole blood,
volume expander
2.Cardiogenic heart is unable to pump effectively and
circulate the intravascular vol.
Conditons: MI, Dysrhytmias, CHF
Treatment: Monitor EKG, medication to increase cardiac
output, digitalis and dopamine
3. Neurogenic alteration in the destribution of the blood volume. Increase
venous capacity due to a loss of peripheral vasomotor tone.
Conditons: Spinal cord injury

4. Septic dilation of blood vessels by humoral or vasoactive substances
Conditions Overwhelming infection, generally gram negative and positive
Treatment: Evaluate for origin of infection

5. Vasogenic (anaphylactic) antigen-antibody reaction with release of
histamine causing vasodilation
Conditions: Transfusion reactions, insect bites, side effectso of
medications, allergies to food
Treatment: Maintain airway problem with laryngeal edema ( chest tightness
occur)
Oxygen as indicated,
epinephrine and benadryl IV

Nursing Interventions:
identify and correct cause of shock
maintain adequate respiratory function
maintain adequate circulation
Blood volume
Cardiac output
Vascular tone
Position in supine with legs elevated
Maintain patent airway
Provide supplemental Oxygen as ordered
Establish life line
Monitor blood pressure closely in individuals at increased risk.

SHOCK
SEIZURES
DISASTER NURSING
DISASTER
Any patient-generating incident that overloads
either existing personnel, supplies, and
equipment, or is any patient-generating incident in
which back-up supplies and personnel are not
available in a reasonable amount of time
An occurrence, either natural or man-made
causes human suffering and creates human
needs that victims cannot alleviate without
assistance.
Forces overwhelm a community.
Services are compromised.
Outside assistance is required.
Is a result of vast ecological breakdown in the
relation between humans and their environment,
as serious or sudden event on such scale that the
stricken community needs extraordinary efforts to
cope with outside help or international aid.

MAJOR DISASTER
- any hurricane, tornado, storm, flood, high water, wind-
driven water, tidal wave, earthquake, drought, fire,
explosion, or any other catastrophe, which, in the
determination of the President, causes damage of
sufficient severity and magnitude to warrant major disaster
assistance above and beyond local/state emergency
services by the government to supplement the effort and
available resources of local governments and private releif
organizations in alleviating the damage, loss, hardship, or
suffering caused by a disaster
State of Emergency
Any various types of catastrophes included in the
definition of a major disaster which requires
Federal emergency assistance to supplement
State and Local efforts to save lives and protect
property, public health and safety, or to avert or
lessen the threat of a disaster

Disaster Categories
Multiple patient incident
- an incident that generates at least two, but fewer
than 10 patients
- self-limiting and can be handled effectively without
requiring aid from resources outside the community
Multiple casualty incident
- generates 10 but fewer than 100 casualties and
necessitates total community and perhaps state
involvement eg. Airplane crashes, storms, floods
Mass casualty incident
- generates more than 100 victims; additional aid
and assistance is required; occur infrequently but
must be anticipated in disaster planning
eg. Wars, major hurricanes, major earthquakes

Types of Disaster
1. External Disasters occurs outside the hospital;
natural or man-made
a. Natural- floods, earhtquakes, tornadoes, etc.
b. Man-made- war, fire, transportation accidents,
food contamination
2. Internal Disasters- occurs within an institution,
such as hospital fire or bomb threat
Characteristics of Disaster Agents
Predictability
Frequency
Controllability/Mitigation
Time: speed, duration
Scope
Intensity
Community Implications
Natural Disaster: Tsunami
Nuclear Attack
Epidemiology of a Disaster
Agent - the physical items that actually causes
the injury or destruction
Host humankind (age, immunization status,
preexisting health status, degree of mobility,
emotional stability
Environment factors affecting outcome of a
disaster
a. Physical time, weather conditions, food
and water, functioning of utilities
b. Chemical leakage of stored chemicals,
food

c. Biological occur or increase as a result
of contaminated water, improper waste
disposal, insect or rodent proliferation,
improper food storage
d. Social contribute to the individuals
support system (loss of family members,
change in roles, questioning of religious
beliefs)

Factors that influence response to disaster

1. Situational warning time before a disaster occurs,
nature and severity of a disaster, physical proximity
and closeness to the victims affected
2. Personal psychological proximity, coping ability,
losses, role overload, previous disaster experience
Stages of a Disaster
1. Warning stage
- Provide sufficient time for preparing to handle
the potential event
- Minimize loss of lives and mitigate damage
- Disaster plans are activated, emergency
operations centers are established, and the
affected area is evaluated or provided with in-
place protection
- Problems: communication, doubt, adaptation
2. Impact Stage staying alive (primary objective)
Few seconds to minutes earthquake, explosion
Few days or weeks floods, heat waves
Several months droughts, epidemics
3. Inventory Stage Survivors assesses the effects
of the event and identify what must be done next; a
period of isolation in which mitigative actions are
required to prevent additional loss of life
4. Rescue Stage Help arrives to rescue survivors
and to help the injured
5. Remedy Stage - Recovery activities are being
initiated
6. Recovery Stage Encompasses total recovery
from the impact and resulting situation; requires
holistic recovery and development of adaptive
behavior to produce lasting changes
Four Stages of the Victims Emotional Response
Denial deny the magnitude of the problem,
understand the problem but seem unaffected
emotionally
Strong emotional response regards the problem as
overwhelming and unbearable; retell or relive the
experience over and over; weeping, restlessness,
anger, sadness, passivity,sweating
Acceptance makes a concetrated effort to solve the
problem; feels more hopeful and confident
Recovery from crisis reaction; feel back to normal
and routines become important again; sense of well-
being restored; decision ability returns; carries out
plans
Principles of Disaster Management
Prevent the occurrence of the disaster whenever
possible
Minimize the number of casualties if the disaster
cannot be prevented
Prevent further casualties from occurring after the
initial impact of the disaster
Rescue the victims
Provide first aid to the injured
Evacuate the injured to medical facilities
Provide definitive medical care
Promote reconstruction of lives

Common Problems at Mass Casualty Incidents
Failure in adequate alerting
Lack of rapid primary stabilization of patients
Failure to move, collect, and organize patients
rapidly at a suitable location
Use of overly time-consuming and inappropriate
care methods
Premature commencement of transportation
Improper use of personnel in the field
Lack of proper distribution of patients, which results
in improper use of medical facilities
Lack of recognizable EMS command in the field
Role of the Nurse at the Disaster Site
Insure safety
First Aid
Emergency care

Role of the Nurse in a Shelter
Objective: temporary means of caring
Assessment
Planing:
24/7 nursing and ancillary coverage
Supplies
Implementation
Evaluation

Role of the CHN in a Community Setting After a
Disaster
Goal: Achieve the best possible level of health
for persons in a community after a disaster
Primary Prevention
Secondary Prevention
Tertiary Prevention


NURSES ROLES IN DISASTERS
Determine magnitude of the event
Define health needs of the affected groups
Establish priorities and objectives
Identify actual and potential public health
problems
Determine resources needed to respond to the
needs identified
Collaborate with other professional disciplines,
governmental and non-governmental agencies
Maintain a unified chain of command
Communication
ADVANTAGES OF TRIAGE
Helps to bring order and organization to a
chaotic scene.
It identifies and provides care to those who
are in greatest need
Helps make the difficult decisions easier
Assure that resources are used in the
most effective manner
May take some of the emotional burden
away from those doing triage

WHY IS DISASTER TRIAGE NEEDED
Inadequate resource to meet immediate needs
Infrastructure limitations
Inadequate hazard preparation
Limited transport capabilities
Multiple agencies responding
Hospital Resources Overwhelmed


WHO DECIDES IN TRIAGE
Nurses dont act for legal fears of being
blamed for deaths, and lack of clarity on
where they fit in the command structure
Nurses function to the level of their training
and experience.
If nurses they are the most trained
personnel the site, they are in charge.

Questions/Comments

Thank you very
much!