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Emergency Nursing (Med Surg 3)

Terms in this set (39)

EMTALA
Emergency Medical Treatment and Labor Act (EMTALA) is a federal law that requires anyone coming to an emergency department to be stabilized and treated, regardless of their insurance status or ability to pay,
Main objectives when dealing with an agitated individual
Ensure the safety of the client, staff, and others in the area
Try to deescalate
Use open ended questions
Alert others about an agitated client
Don't be alone with agitated client; stay next to the door or exit
Verbal de-escalation tactics
Respect personal space
Do not challenge agitated
person
Begin verbal communication
Identify wants and feelings
Be short and to the point
Listen to the patient
Set clear limits
Offer choices
Warning signs of increasing violence
-pacing or restlessness
-clenched fist, loud speech
-excessive demands
-threats
-swearing
ABCDE
Airway
Breathing
Circulation
Disability
Exposure
Airway
The first stage of the primary survey is to assess the airway. If
the patient is able to talk, the airway is likely to be clear. If the
patient is unconscious, he/she may not be able to maintain
his/her own airway. The airway can be opened using a chin lift
or jaw thrust.
Airway adjuncts may be required. If the airway is blocked
(e.g., by blood or vomit), the fluid must be cleaned out of the
patient's mouth by the help of suctioning instruments. Artificial
airway if airway is not blocked
Primary Survey Breathing: the 6 life threatening thoracic conditions
The chest must be examined by inspection, palpation, percussion and auscultation. Subcutaneous emphysema and tracheal deviation must be identified if present. The aim is to identify and manage six life-threatening thoracic conditions:

Airway Obstruction
Tension Pneumothorax
Massive Hemothorax
Open Pneumothorax
Flail chest segment with Pulmonary Contusion
Cardiac Tamponade
Primary Survey Circulation Hemorrhage control management
-Hemorrhage is the predominant cause of preventable
post-injury deaths. Hypovolemic shock is caused by
significant blood loss
-Two large-bore intravenous lines are established and
crystalloid solution may be given. If the person does not
respond to this, type-specific blood, or O-negative if this is
not available, should be given
-External bleeding is controlled by direct pressure
-Occult blood loss may be into the chest, abdomen, pelvis or
from the long bones
Primary Survey Disabilty/Neurologic
-Start with AVPU (alert, verbal stimuli response, painful stimuli response, or unresponsive), and then go to more detailed assessment
-An altered level of consciousness indicates the need for immediate
reevaluation of the patient's oxygenation, ventilation, and perfusion
status
-Hypoglycemia and drugs, including alcohol, may influence the level
of consciousness
-If these are excluded, changes in the level of consciousness should
be considered to be due to traumatic brain injury until proven
otherwise
Primary survey: Exposure and environmental control
The patient should be completely undressed, usually by cutting
off the garments. It is imperative to cover the patient with warm
blankets to prevent hypothermia in the emergency department
Intravenous fluids should be warmed and a warm environment
maintained. Patient privacy should be maintained
Multiple Trauma
-Requires a team approach
-determine extent of injuries and establish priorities of treatment
-assume cervical spine injury
-injuries interfering with vital physiologic function have highest priority.
Management of the Patient With
Intra-Abdominal Injuries
-Abdominal trauma can cause massive life-threatening blood
loss into abdominal cavity
-Ensure airway, breathing, and circulation
-Immobilize cervical spine
-Continually monitor the patient
-Document all wounds
-If viscera are protruding, cover with sterile, moist
saline dressing
-Do not remove protrusion
-Hold oral fluids
-NG to aspirate stomach contents
-Tetanus and antibiotic prophylaxis
-Rapid transport to surgery if indicated
Complications of crush injuries
Hypovolemic shock
Paralysis of body part
Erythema and blistering
Damage to body part
Renal dysfunction
Heat stroke Types
Exertional: occurs in healthy individuals during exertion in extreme
heat and humidity
Hyperthermia: the result of inadequate heat loss
Heat stroke manifestations
Manifestations: CNS dysfunction, elevated temperature, hot
dry skin, anhydrosis, tachypnea, hypotension, and tachycardia
Can cause DEATH
Heat Stroke risk factors
very young people, ill or debilitated people, and
persons taking some medications are at high risk
Heat Stroke/Hyperthermia Management
Use ABCs and reduce temperature to 39°C as quickly as possible
Cooling methods
Cool sheets, towels, or sponging with cool water
Ice to neck, groin, chest, and axillae
Cooling blankets
Iced lavage of the stomach or colon
Immersion in cold water bath
Monitor temperature, VS, ECG, CVP, LOC, urine output
IVs to replace fluid losses
Note: hyperthermia may recur in 3 to 4 hours; avoid hypothermia
What is the highest temperature the human body can sustain before dying?
Usually a sustained temperature of 40 ° C ( 104 ° F) starts to shut down at the cellular level and becomes fatal
Frostbite treatment
Controlled but rapid rewarming; 37° to 40°C circulating bath
for 30- to 40-minute intervals
Analgesics for pain
Do not massage or handle; if feet are involved, do not walk
Hypothermia
-Internal core temperature is 35°C (95° F) or less
-Older adults, infants, persons with concurrent illness,
homeless people, and trauma victims are at risk
-Alcohol ingestion increases susceptibility
-Hypothermia may be seen with frostbite, and treatment of
hypothermia takes precedence
-Physiologic changes in all organ systems
-Monitor continuously
Hypothermia Management
-Use ABC's, remove wet clothing, and rewarm
Rewarming
-Active core rewarming
(Cardiopulmonary bypass, warm fluid administration, warm humidified oxygen, warm peritoneal lavage)
-Passive external rewarming
(Warm blankets and over the bed heaters)
Note: Cold blood returning from the extremities has high
levels of lactic acid and can cause potential cardiac
dysrhythmias and electrolyte disturbances
Patient with Poisoning Treatment goals
-Remove or inactivate the poison before it is absorbed
-Provide supportive care in maintaining vital organs systems
-Administer specific antidotes
-Implement treatment to hasten the elimination of the poison
Ingested poison possible types
-Swallowed poisons may be corrosive
-Corrosive poisons include alkaline and acid agents that can cause tissue destruction after coming in contact with mucuous membranes
-Alkaline products include lye, drain cleaners, toilet bowl cleaners, bleach, non-phosphate detergents, oven cleaners, and button batteries.
-Acid products include toilet bowl cleaners, pool cleaners, metal cleaners, rust removers, and battery acid.
Ingested poison s/s
Pain or burning sensations, any evidence of redness or burn
in the mouth or throat, pain on swallowing or an inability to
swallow, vomiting, drooling
Ingested poison management priorities
-Control of the airway, ventilation, and oxygenation are essential
-In the absence of cerebral or renal damage, the patient's prognosis
depends largely on successful management of respiration and
circulation
-Measures are instituted to stabilize cardiovascular and other body
functions
-ECG, vital signs, and neurologic status are monitored closely for
changes
-An indwelling urinary catheter is inserted to monitor renal function
-Measures are instituted to remove the toxin or decrease its absorption
Corrosive poison management
-The patient who has ingested a corrosive poison, which can be a strong acid or alkaline substance, is given water or milk to drink for dilution, however, dilution is not attempted if the patient has acute airway edema or obstruction or if there is clinical evidence of esophageal, gastric, or intestinal burn or perforation.
Other poison care management
-Syrup of ipecac to induce vomiting in the alert patient (never use with
corrosive poisons) using less as it is controversial
-Gastric lavage for the obtunded patient; gastric aspirate is saved and
sent to the laboratory for testing (toxicology screens)
-Activated charcoal administration if the poison is one that is absorbed
by charcoal
-Cathartic, when appropriate e. If there is a specific chemical or
physiologic antagonist (antidote), it is administered as early as
possible to reverse or diminish the effects of the toxin
Carbon monoxide poisoning patho
Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin.
(Carboxyhemoglobin does not transport oxygen)
-The affinity between hemoglobin and carbon monoxide is approximately 230 times stronger than the affinity between hemoglobin and oxygen
CO poisoning pulse ox use
not effective in diagnosis of carbon monoxide poisoning, may have normal o2 saturation
Manifestations of CO poisoning
CNS symptoms predominate
CO poisoning treatment
Get to fresh air immediately
CPR as necessary
Administer oxygen; 100% or oxygen under hyperbaric pressure
Management of patient with chemical burns
Immediately flush the skin with running water from a shower,
hose, or faucet.
Note: Lye or white phosphorus should be brushed off the skin
dry.
Protect health care personnel from the substance.
Determine the substance.
Some substances may require prolonged flushing or irrigation.
Follow-up care includes reexamination of the area at 24 hours, 72
hours, and 7 days.
Management of the Patients With Food
Poisoning
-A sudden illness caused by the ingestion of contaminated
food or drink
-ABCs and supportive measures
Note: Food poisoning, such as botulism or fish poisoning,
may result in respiratory paralysis and death.
-Determination of food poisoning
-Treat fluid and electrolyte imbalances
-Control nausea and vomiting
-Clear liquid diet and progression of diet after nausea and
vomiting subside
Management of the Patient With Substance Abuse
-Acute alcohol intoxication: a multisystem toxin
-Alcohol poisoning may result in death
-Maintain airway and observe for CNS depression and hypotension
-Rule out other potential causes of the behaviors before it is assumed
-the patient is intoxicated
-Use a nonjudgmental, calm manner
-May need sedation if noisy or belligerent
-Examine for withdrawal delirium, injuries, and evidence of other
disorders
Abuse and Neglect
-All suspected abuse must be reported to authorities, this includes
child abuse, elder abuse, domestic abuse (it's the law)
-Any physician or staff who suspects abuse, neglect or exploitation of
a child or adult will notify Adult Protective Services, Division of
Child and Family Service, and/or law enforcement as mandated by
law.
-Abuse and neglect can take on physical, psychological and financial
forms. The types of abuse and neglect are sexual abuse, physical
abuse and neglect, psychological abuse and neglect, and financial
abuse and neglect.
-Contact Police and Adult Protective Services alert providers
S/S of Abuse
-Any unexplained injury
-Many bruises on a child, especially if they're present on an infant or any child who isn't yet walking.
-Bruises in unusual places, including the ears, neck, abdomen or backs of arms and legs
-Frequent or unexplained broken bones
-Burns or bruises that display the pattern of an object
-Verbalizes abuse
-Frightened of parents, caregiver, etc.
-Malnutrition
-Neglect
Psych Emergencies
Overactive patients, violent behavior, underactive, or
depressed patients and suicidal patients
Psych emergency management
-Maintain the safety all persons and gain control of the situation
-Determine if the patient is at risk for injuring him- or herself or others
-Maintain the person's self-esteem while providing care
-Determine if the person has a psychiatric history or is currently under
care to contact that therapist
-Call Crisis Intervention team
Sexual Assault
All patients who report a sexual assault are entitled to prompt access to
emergency medical care and competent collection of evidence that will
assist in the investigation and prosecution of the incident
A victim of sexual assault should be offered prophylaxis for pregnancy
and for sexually transmitted diseases, subject to informed consent and
consistent with current treatment guidelines.
Physicians and allied health practitioners who find this practice morally
objectionable or who practice at hospitals that prohibit prophylaxis or
contraception should offer to refer victims of sexual assault to another
provider who can provide these services in a timely fashion.
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