Emergency And Disaster Nursing 66e12

EMERGENCY AND DISASTER NURSING USE: Trauma - Intentional or unintentional wounds/injuries on the human body from particular mechanical mechanism that exceeds the body’s ability to protect itself from injury Emergency Management - traditionally refers to care given to patients with urgent and critical needs.

Disaster - Any catastrophic situation in which the normal patterns of life (or ecosystems) have been disrupted and extraordinary, emergency interventions are required to save and preserve human lives and/or the environment. Mass Casualty Incident - situation in which the number of casualties exceeds the number of resources.

Triage - process of assessing patients to determine management priorities.

Post Traumatic Stress Syndrome characteristic of symptoms after a psychologically stressful event was out of range of an normal human experience.

First Aid - an immediate or emergency treatment given to a person who has been injured before complete medical and surgical treatment can be secured.

EMERGENCY – IT IS WHATEVER THE PATIENT OR THE FAMILY CONSIDERS IT TO BE.

BLS - level of medical care which is used for patient with illness or injury until full medical care can be given. ACLS ADVANCE CARDIAC LIFE Set of clinical interventions for the urgent treatment of cardiac arrest and often life threatening medical emergencies as well as the knowledge and skills to deploy those interventions. Defibrillation - Restoration of normal rhythm to the heart in ventricular or atrial fibrillation

EMERGENCY NURSING - It is the nursing care given to patients with urgent and critical needs EMERGENCY NURSE - has a 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, s and attends to families, supervises allied health personnel, and teaches patients and

families within a time-limited, highpressured care environment DISASTER NURSING - a branch of emergency nursing, 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 informed about any deviation from the established plan

SCOPE AND PRACTICE OF EMERGENCY NURSING  The emergency nurse has had specialized education, training, and experience.  The emergency nurse establishes priorities, monitors and continuously assesses acutely ill and injured patients,

s and attends to families, supervises allied health personnel, and teaches patients and families within a time-limited, high-pressured care environment.  Nursing interventions are accomplished interdependently, in consultation with or under the direction of a licensed physician.  Appropriate nursing and medical interventions are anticipated based on assessment data.  The emergency health care staff work as a team in performing the highly technical, hands-on skills required to care for patients in an emergency situation.  Patients in the ED have a wide variety of actual or potential problems, and their condition may change constantly.  Although a patient may have several diagnosis at a given time, the focus is on the most life-threatening ones ISSUES IN EMERGENCY NURSING CARE  Emergency nursing is demanding because of the diversity of conditions

and situations which are unique in the ER.  Issues include legal issues, occupational health and safety risks for ED staff, and the challenge of providing holistic care in the context of a fast-paced, technologydriven environment in which serious illness and death are confronted on a daily basis.  The emergency nurse must expand his or her knowledge base to encom recognizing and treating patients and anticipate nursing care in the event of a mass casualty incident.  Legal Issues Includes:  Actual Consent  Implied Consent  Parental Consent

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Alleviate Suffering Do No Further Harm Restore to Optimal Function

Golden Rules of Emergency Care  Do’s - Obtain Consent - Think of the Worst - Respect Victim’s Modesty & Privacy  Don’ts - let the patient see his own injury - Make any unrealistic promises Guidelines in Giving Emergency Care  A – Ask for help  I – Intervene  D – Do no Further Harm

 “Good Samaritan Law”  Gives legal protection to the rescuer who act in good faith and are not guilty of gross negligence or willful misconduct. Focus of Emergency Care  Preserve or Prolong Life

Stages of Crisis 1. Anxiety and Denial  encouraged to recognize and talk about their feelings.  asking questions is encouraged.  honest answers given

 prolonged denial is not encouraged or ed 2. Remorse and Guilt  verbalize their feelings 3. Anger  way of handling anxiety and fear  allow the anger to be ventilated 4. Grief  help family work through their grief  letting them know that it is normal and acceptable Core Competencies in Emergency Nursing  Assessment  Priority Setting/Critical Thinking Skills  Knowledge of Emergency Care  Technical Skills  Communication Assess and Intervene Check for ABCs of life  A – Airway  B – Breathing  C - Circulation Team  Rescuer  Emergency Medical Technician  Paramedics  Emergency Medicine Physicians  Incident Commander

 Staff  Inpatient Unit Staff Emergency Action Principle I. Survey the Scene  Is the Scene Safe?  What Happened?  Are there any bystanders who can help?  identify as a trained first aider! II. Do a Primary Survey - organization of approach so that immediate threats to life are rapidly identified and effectively manage.

Primary Survey

C – Circulation - Monitor VS - Maintain Vascular Access - Direct Pressure Estimated Blood Pressure SITE

SBP

Radial

≥ 80

Femoral

≥ 70

Carotid

≥ 60

A - Airway/Cervical Spine - Establish Patent Airway - Maintain Alignment - GCS ≤ 8 = Prepare Intubation B – Breathing - Assess Breath Sounds - Observe for Chest Wall Trauma - Prepare for chest decompression

Control of Hemorrhage

 Interview the Patient S – Symptoms A – Allergies M – Medication P – Previous/Present Illness L – Last Meal Taken E – Events Prior to Accident  Check Vital Signs

D – Disability - Evaluate LOC - Re-evaluate clients LOC - Use AVPU mnemonics E – Exposure - Remove clothing - Maintain Privacy - Prevent Hypothermia III. Activate Medical Assistance  Information to be Relayed: • What Happened? • Number of Persons Injured • Extent of Injury and First Aid given • Telephone number from where you’re calling IV. Do Secondary Survey

2. Urgent – have serious health problems but not immediately life threatening ones. Must be seen within 1 hour  Maxillofacial wounds without airway compromise, eye injuries, stable abdominal wounds without evidence of significant hemorrhage, fractures 3. Non-urgent – patients have episodic illness than can be addressed within 24 hours without increased morbidity

V. Triage  comes from the French word ”trier”, meaning to sort  process of assessing patients to determine management priorities Categories: 1. Emergent - highest priority, conditions are life threatening and need immediate attention  Airway obstruction, sucking chest wound, shock, unstable chest and abdominal wounds, open fractures of long bones

 Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding, behavioral disorders or psychological disturbances. 3. Non-urgent – patients have episodic illness than can be addressed within 24 hours without increased morbidity  Upper extremity fractures, minor burns, sprains, small lacerations without significant bleeding, behavioral disorders or psychological disturbances.

TRIAGE CATEGOR Y

PRIORIT Y

COLOR

IMMEDIA TE DELAYED MINIMAL EXPECTA

1

RED

2 3 4

YELLOW GREEN BLACK

Field TRIAGE 1. Immediate:  Injuries are life-threatening but survivable with minimal intervention. Individuals in this group can progress rapidly to expectant if treatment is delayed. 2. Delayed:  Injuries are significant and require medical care, but can wait hours without threat to life or limb. Individuals in this group receive treatment only after immediate casualties are treated. 3. Minimal:  Injuries are minor and treatment can be delayed hours to days. Individuals in this group should be moved away from the main triage area. 4. Expectant:  Injuries are extensive and chances of survival are unlikely even with definitive care. 5. Fast-Track:

 Psychological needed FIRST AID Role of First Aid  Bridge the Gap Between the Victim and the Physician  Immediately start giving interventions in pre-hospital setting Value of First Aid Training  Self-help  Health for Others  Preparation for Disaster  Safety Awareness BASIC LIFE - an emergency procedure that consists of recognizing respiratory or cardiac arrest or both the proper application of R to maintain life until a victim recovers or advance life is available. Artificial Respiration  a way of breathing air to person’s lungs when breathing ceased or stopped function.

Respiratory Arrest

 a condition when the respiration or breathing pattern of an individual stops to function, while the pulse and circulation may continue. Causes: Choking, Electrocution, strangulation, drowning and suffocation.

WAYS TO VENTILATE THE LUNGS 1. MOUTH-TO-MOUTH = a quick, effective way to provide O2 and ventilation to the victim. 2. MOUTH-TO-NOSE = recommended when it is impossible to ventilate through the victim’s mouth. (Trismus, mouth injury) 3. MOUTH-TO-NOSE and MOUTH = if the pt. is an infant 4. MOUTH-TO-STOMA = used if the pt. has a stoma; a permanent opening that connects the trachea directly to the front of the neck. For Rescue Breathing Alone:  Rate is 10-12 breaths in ADULT  (1.5 - 2 sec/breath) ( 1 breath every 4 to 5 secs)  Rate is 20 breaths for a CHILD and INFANT  (1 – 1.5 sec/breath) ( 1 breath every 3 secs)

Approach Assess for Response

Table of Cardiopulmonary Resuscitation for Adult, Child & Infant Compressi on Area

Depth How to compress Compressi onventilation ratio Number of cycles per minute

Adult Lower half of the sternum but not hitting the xiphoid process: measure up to 2 fingers from substernal notch. Approximately 1 ½ to 2 inches Heel of 1 hand, other hand on top.

Child Lower half of the sternum but not hitting the xiphoid process: measure up to 1 finger from substernal notch. Approximat ely 1 to 1 ½ inches Heel of 1 hand.

Infant Lower half of the sternum but not hitting the xiphoid process: 1 finger width below the imaginary nipple line.

30:2 (1 or 2 rescuers)

30:2 (1 or 2 rescuers)

Approximate ly ½ to 1 inch 2 fingers (middle & ring fingertips) 30:2 (1 or 2 rescuers)

5 cycles in 2 minutes

5 cycles in 2 minutes

5 cycles in 2 minutes

Positionin g Open the Airway

Child(1 -8 yrs)

Adult

Infant(0-1yr)

Safe

Approach and assess situation

Gently shouting “are you ok?” then shake the victim Placed Supine on a firm and flat surface

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Assess for Breathing

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The Casualty is Go for Help

Give Rescue Breaths

Procedur e

Shout and gently pinch

of the infant look for chest rising

look for chest rising

Check for foreign bodies then remove using finger sweep Head-tilt-chin-lift maneuver Jaw-thrust Maneuver Bring cheek over the mouth and nose of the casualty Look for chest movement Listen for breath sounds Feel for breathing on your cheek NOT Breathing:

 if someone responds to your shout for help send that person to phone for ambulance  if you’re on your own, leave the casualty and make the phone call for yourself * never leave if the patient has collapsed as a result of trauma or drowning or if the casualty is a child 5 rescue breaths 2 rescue breaths Place mouth over the nose and mouth

pinch nose and ventilate via mouth

seal lips around the mouth and blow

The Casualty is Breathing: • Place in recovery position

steadily for 1.5 – 2 seconds look for chest rising

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Before moving casualty remove any objects safely from her pockets Kneel beside casualty, place arm nearest at right angles, and then bend elbow keeping the palm uppermost. Bring far arm across the casualty’s chest and hold back of the casualty’s hand against the nearest cheek With your other hand grasp the far thigh just above the knee, then pull the casualty towards you and on to his or her side

CRITERIA FOR NOT STARTING R - All patients in cardiac arrest receive resuscitation unless: 1. The pt. has a valid DNR order 2. The pt. has signs of irreversible death: rigor mortis, livor mortis, algor mortis, decapitation 3. No physiological benefit can be expected because the vital functions have deteriorated despite maximal therapy 4. Witholding attempts to resuscitate in the DR is appropriate for newly born infants with: - Confirmed gestation less than 23 weeks or birthweight less than 400 grams - Anencephaly When to Stop

 when the patient has spontaneous breathing  when the first aider is too exhausted to continue  when another first aider takes over  when EMS arrives and takes over

 EARLY BLS – prevent brain damage, buy time for the arrival of defibrillator  EARLY DEFIBRILLATION - 7-10% decrease per minute without defibrillation  EARLY ACLS – technique that attempts to stabilize patient

When to STOP R: S – SPONTANEOUS BREATH RESTORED T – TURNED OVER THE MEDICAL SERVICES O – OPERATOR IS EXHAUSTED TO CONTINUE P – PHYSICIAN ASSUMES RESPONSIBILITY COMPLICATIONS OF R:    

RIB FRACTURE STERNUM FRACTURE LACERATION OF THE LIVER OR SPLEEN PNEUMOTHORAX, HEMOTHORAX

CHAIN OF SURVIVAL  EARLY ACCESS – early recognition of cardiac arrest, prompt activation of emergency services

AIRWAY OBSTRUCTION KINDS OF AIRWAY OBSTRUCTION: 1. Anatomic Airway Obstruction 2. Mechanical Airway Obstruction TYPES OF AIRWAY OBSTRUCTION 1. Partial Airway Obstruction with Good Air Exchange 2. Partial Airway Obstruction with Poor Air Exchange 3. Complete Airway Obstruction Clinical Manifestations: UNIVERSAL DISTRESS SIGNAL (patient may clutch the neck between the thumb and fingers), choking, stridor, apprehensive appearance, restlessness.

CYANOSIS and LOSS of CONSCIOUSNESS develop as hypoxia worsens.

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MANAGEMENT FOR AIRWAY OBSTRUCTION HEIMLICH MANEUVER (Subdiaphragmatic Abdominal Thrusts) For Standing or sitting conscious patient: • Stand behind the patient; wrap your arms around the patient’s waist • Make a FIST, placing thumb side of the fist against the pt’s abdomen, in the midline SLIGHTLY ABOVE the UMBILICUS and WELL BELOW the XIPHOID PROCESS • Make a quick INWARD and UPWARD thrust. Each thrust is separated.

For patient lying (unconscious): • position patient at the back (supine); kneel astride the patient’s thigh • Place HEEL of one HAND against the pt’s abdomen, place the second hand directly on the top of the fist. • Make a quick UPWARD thrust FINGER SWEEP: used only in unconscious adult client • Make a TONGUE-JAW LIFT. Opening the pt’s mouth by grasping both tongue and lower jaw between the thumb and fingers, and lifting the mandible.

Insert index finger of other hand to scrape across the back of the throat Use a hooking action

CHEST THRUST: used only in patients in advanced stages of pregnancy or in markedly obese clients a. Conscious Patient standing or sitting • Stand behind the client with arms under patient’s axilla to encircle patient’s chest • Place thumb side of fist on the MIDDLE of STERNUM, grasp with the other hand and perform BACKWARD thrust until foreign body is expelled. MEASURES TO ESTABLISH AIRWAY A. HEAD-TILT-CHIN-LIFT MANEUVER B. JAW-THRUST MANEUVER C. OROPAHRYNGEAL AIRWAY

D. ENDOTRACHEAL INTUBATION Indications:  To establish an airway for patients cannot be adequately ventilated with an oropharyngeal airway  To by upper airway obstruction  To permit connection to ambubag or mechanical ventilator  To prevent aspiration  To facilitate removal of tracheobronchial secretions E. CRICOTHYROIDOTOMY

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• •

a puncture or incision of the cricothyroid membrane to establish an emergency airway in certain emergency situations where endotracheal intubation or tracheostomy is not possible. indicated to pts. with trauma to head and neck, and in allergic reaction causing laryngeal edema use of gauge 11 needle or scalpel blade

Nursing Actions: • Extend the neck. Place towel roll beneath the shoulders • Insert the needle at a 10 to 30 degree caudal direction in the midline jest above the upper part of the cricoid cartilage • Listen for air ing back and forth • Direct the needle downward and posteriorly, and tape it.

INJURIES TO HEAD, SPINE, AND FACE A. 1. 2. 3.

HEAD INJURIES OPEN HEAD INJURY – skull is fractured CLOSED HEAD INJURY – skull is intact CONCUSSION – temporary loss of consciousness that results in transient interruption if the brain’s normal functioning 4. CONTUSSSION – bruising of the brain tissue

5. INTRACRANIAL HEMORRHAGE – significant bleeding into a space or potential space between the skull and the brain a. Epidural hematoma  the most serious type of hematoma; forms rapidly and results from arterial bleeding  forms between the dura and the skull from a tear int the meningeal area b. Subdural hematoma  forms slowly and results from a venous bleed  a surgical emergency c. Intracerebral hemorrhage  bleeding directly into the brain matter ALERT: Assume cervical spine fracture for any patient with a significant head injury, until proven otherwise. PRIMARY ASSESSMENT: Assess for ABC SECONDARY ASSESSMENT:  Change in LOC – most sensitive indicator in the pt’s condition  CUSHING’S TRIAD ( bradypnea, bradycardia, widened pulse pressure) – indicating increased intracranial pressure

unequal or unresponsive pupils; impaired vision  Battle’s sign – bluish discoloration of the mastoid, indicating a possible BASAL SKULL FRACTURE  Rhinorrhea or otorrhea – indicative of CSF leak  Periorbital Ecchymosis – indicates anterior basilar fracture 

ALERT: If basilar skull fracture or severe midface fractures are suspected, a nasogastric tube(NGT) is CONTRAINDICATED!

MANAGEMENT:  Open airway by Jaw-Thrust Manuever, suction orally if needed  ister 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; don’t 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

B. SKULL FRACTURES • SIMPLE – closed • COMPOUND – open • LINEAR Fx – common hairline break, w/o displacement of structure • COMMINUTED Fx – splinters or crushes the bone in several fragments • DEPRESSED Fx – pushes the bone toward the brain • CRANIAL VAULT Fx – top of the head • BASILAR Fx – base of the skull and frontal sinuses ALERT: • Damage to the brain is the first concern, it is considered a neurosurgical condition • In children, skull’s thinness and elasticity allows a depression w/o a break in the bone CAUSES: Traumatic blows to the head, VA, severe beatings • S/Sx: scalp wounds, agitation and irritability, loss of consciousness, labored breathing, abnormal deep tendon reflexes, altered pupillary and moor response IF CONSCIOUS: complains of persistent localized headache IF JAGGED BONE FRAGMENTS: may cause cerebral bleeding HALO SIGN – blood-tinged spot surrounded by lighter

ring IF SPHENOIDAL Fx: damages the optic nerve and may cause BLINDNESS IF TEMPORAL Fx: may cause unilateral deafness or facial paralysis TREATMENT: For LINEAR FRACTURES:  supporative (mild analgesics)  cleaning and debridement of wounds  If conscious: observed for 4 hours; if not, it for evaluation  if VS stable, may go home with instruction sheet For VAULT and BASILAR FRACTURES:  Craniotomy to remove fragemnts  anti-biotics  Dexamethasone  Osmotic Diuretics (MANNITOL) if increased I is present NURSING CONSIDERATIONS:  maintain patent airway; nasal airway contraindicated to basilar fx  with O2 istration  suction pt. through mouth not nose if CSF leak is present  RHINORRHEA – wipe it, don’t let him blow it!  OTORRHEA – cover it lightly with sterile gauze, don’t pack it!  Position head on side  Maintain a supine position with bed elevated to 30 degrees

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don’t give narcotics or sedative assist in surgery, maintaining sterile technique

C. CERVICAL SPINE INJURIES PRIMARY ASSESSMENT: • immediate immobilization of the spine • A B C ( Intercoastal paralysis w/ diapragmatic breathing) SUBSEQUENT ASSESSMENT: • Hypotension, bradycardia, hypothermia - suggests SPINAL 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 D. MAXILLOFACIAL TRAUMA 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 INFERIOR ORBIT 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 •