emergency and critical care management

8/3/2019 Emergency and Critical Care Management

http://slidepdf.com/reader/full/emergency-and-critical-care-management 1/50

Emergency and critical care

management



Emergency Nursing Management

care to patient with urgent and critical needs

emergency is whatever the patient and family

considers it to be

care without delay

the strength of nursing and medicine are

complementary in an emergency situation



Issues in Emergency Nursing

Carelegal issues

occupational health and safety risk for EDstaff

challenge of providing holistic care in the

context of a fast-paced technology driven

environment



Patient focused

interventions:act confidently and

competently

Explanations that the

patient can understand

Human contact and

reassuring words

unconsious patient betreated consciously

reorientation as patient

regains consciousness

Family focused

interventions:

encouraged the fam

members to talk about

feelings

Encourage asking

Encourage verbalization

of feelingsAllow anger to be

ventilated



Principles of Emergency Care

Rapid assessment, treatment and

referral to appropriate setting for

ongoing career

Triageto sort

used to sort patients into groups based on theseverity of their health problems and the

immediacy with which these problems must be

treated



Assesss and intervene

Airway

adequate ventilation

and resuscitation

Evaluate and restore

cardiac output

neurologic disability

Primary survey

focus on stabilizing lifethreatening conditions

Secondary survey

done after primary survey areaddressed

health history

head to toe assessment

diagnostic findings

application of monitoring

devices

splinting of fractures

wound dressing



Roles and responsibilities

expert in assessing and identifying patients health care problems

Specialized education training and expertise

establishes priorities

monitors patient continuouslysupport and attends to families

collect crucial initial data

maintain privacy and confidentiality

good communication

use all resources

health teaching

crowd control

Emergency nurse



Q ualifications to become an ER nurse

possess valid RN license

certified Basic Life support

minimum of 2 years critical care nursing

experience with at least 6 months of this being in

emergency department

have at least 3 evaluation shifts in role of triage

be able to function well under stressful situation

able to make accurate assessment regarding

patient care

have working knowledge on internal operations

of emergency department



have firm convictions

possess good communication skillsbe able to offer emotional support

able to think ahead

a spot teacher

control traffic flow

possess good crisis intervention skills

assist in discharge planning

able to deal with patient communication

problems



Critical Care Nursing

- is the field of nursing with a focus on

the utmost care of the critically ill or

unstable patients. Critical care nursescan be found working in a wide variety

of environments and specialties, such

as emergency departments andthe intensive care units.



Functions of the critical care nurse

1. Assesses and implements treatment for patient

2. Provides direct measures to resuscitate

3. Uses independent, dependent, and

interdependent interventions

4. Provides health education

5. Supervises patient care and personnel

6. Supports patient adaptation, restores health, and

preserves the patients rights



Legal issues affecting the

provision of critical care nursing

1. Negligence

2. MALPRACTICE

3. INFORMED CONSENT

4. Implied consent

5. Advanced directives, including

DURABLE POWER OF ATTORNEY and living wills



Q ualifications of a Critical Care Nurse

A diploma in nursing, an associates degree in nursing (ADN)

or a bachelors degree in nursing (BSN) and pass a national

licensing exam.

Certification is not mandatory

A required number of clinical hours

Certified critical care nurses (CCRN) must have been in

critical care practice for a minimum of two years to be eligible

for the examination.



Emergency Conditions



WoundTypes:

Laceration-skin tear with irregular edges

Avulsion-tearing away from supporting structures

Abrasion-denuded skin

Ecchymosis/contusion-blood trapped under the skin

Hematoma-tumor-like mass of blood trapped under skin

Stab wound-incision of skin with well-defined edges

cut/incision-incision of skin with well definededges,usually longed and deep

patterned-wound representing the outline of object



assessment

when and how the wound occurred

extent of damage

sensory motor and vascular function changes

managementhair around the wound is clipped or shaved

normal saline solution or polymer agent

antibacterial agent (betadine) not allowed

to get deep into wound without rinsing



primary closure

wound suturing depends on:

.nature of wound

.time since the injury sustained

.degree of contamination

.vascularity of tissue



Sutures:

- placed near the wound edges with

the skin edges elevated carefully to

promote optimal healing

Sterile strips:

- for close and clean superficial

wounds



Delayed primary closure

Indication:

high potential for infection

loss of tissues



Poisoning

- any substance that when ingested,

inhaled or injected can injure the body

Accidental poisoning are common in

children

Intentional poisoning are common inadolescent and adult



Ingested poisons

-maybe an alkaline or acidic substanceAssessment:

Substance taken

Amount

time of ingestion

signs and symptoms ( pain or burning sensation)

any evidence of redness or burning in the throat,pain on swallowing

inability to swallow, vomiting or drooling, age and

weight of patient, pertinent history



Management:

Control airway, ventilation, oxygenation

Stabilize cardiovascular and other functions

Remove toxins or decrease absorption

Corrosive poison- give water or milk fordilution

Dilution is not attempted if theres:

Acute airway edema or obstruction

Clinical evidence of esophageal or gastric

damage



Gastric emptying procedures

- syrup of Ipecac

-gastric lavage

-activated charcoal-cathartic

Antidote

- specific chemical or physiologic

antagonist administered as early as

possible



Inhaled poisons: Carbon Monoxide

poisoning- industrial, household incidence CO binds to

hemoglobin reducing its O² carrying capacity

Assessment:

Skin color ( pink or cherry red to cyanotic)- not a

reliable sign

Pulse oximetry not valid (blood may appear

saturated based on reading but not with O²)



Management:

Immediate treatment

Carry patient to open space with fresh air

immediately

Open all doors and windows

Keep patient as quiet as possible

Admin. 100% O²



Skin contamination poisoning

Management:

Drenche immediately with running water

Water should not be applied to burns from

lye- potential for explosion or deepening of

wound

Skin of health care provider should be

protected as well



Food poisoning

- sudden illness after ingestion of contaminatedfood or drinks

- botulism

Assessment:

How soon S/Sx occur?

How does food smell?

Diarrhea? Neurologic symptoms?

Fever?



Management:

Determine source and type of food poisoning

Bring suspected food to medical facility

Support respiratory system

Admin. Fluid and Electrolytes

Control nausea to prevent vomiting

- mild nausea ( give sips of weak tea, carbonated drinks,

tap water)

After nausea subsides give clear liquids for 12 hrs.



Environmental emergencies



Heat stroke

- Heat stroke is a form of hyperthermia

- Heat stroke is a medical emergency and

can be fatal if not promptly and

properly treated.



Management:

Reduce high temp as quickly as possible

Apply ice to neck, chest , axilla, groin while

spraying with tepid water

Cooling blankets, ice saline lavage

Massage patient



Frost bites

trauma from exposure to freezing temp

cellular and vascular damage

commonly affected: feet, nose, hands, ears

First degree ( redness and erythema) to fourth

degree ( full depth tissue destruction)

Frozen extremities are hard, cold and insensitive to

touch



Management:Remove constrictive clothing and accessories

Early ,controlled,and rapid rewarming

Do not massage

Once rewarmed, affected part is elevated

Gauze placed between fingers to avoid maceration

Do not rupture bleb

Whirlpool bath

Tetanus prophylaxis

Movement of affected extremities



Triage system: hierarchy based on

potential loss of life

1. Routine Emergency Triage Protocols(civilian type): directs all available

resources to patients who are most

critically ill, regardless of potentialoutcome

2. Field Triage/ Hospital triage during a

disaster (military type): scarce resources

must be used to benefit the most people

possible or to those with and increased

risk of survival



French doctors during World War I:

Likely to live, regardless of what care to

receive

Likely to die, regardless of what care to

receive

Whom immediate care might make a

positive difference in the outcome



Types of triage1. Simple

- used in mass casualty incidents

-sorts those who need critical attention and

immediate transportation to hospital and those with

less serious injuriesSTART model (Simple Triage And Rapid Treatment)

-performed by lightly trained individual and

emergency personnel but not intended to supersedeor instruct medical personnel or techniques

-developed at Hoag Hospital in Newport Beach,

California



4 groups:

-Expectant who are beyond help (Black)

-Injured who can be helped by immediate

transportation (Red)

-Injured whose transportation can be delayed

(Yellow)

-With minor injuries who need help less

urgently (Green)



2.Advanced

-has ethical implications-to divert scarce resources to patient who dont

have the chance to live

-Western EuropeTriage Revised Trauma Score

-medical validated scoring system

incorporated some triage conditionsInjury Severity Score

-assign score from 0-75 based on severity

of injury



Emergent: highest priority; life-

threatening; immediate

Urgent: Severe Health Problems but not

immediately life threatening but must be

seen within 1 hour

Non-urgent: episodic illness can be

addressed within 24 hours without

increasing morbidityFast-track: require simple first aid or

primary care



North Atlantic Treaty Organization

(NATO)

-widely used-according to the severity of injury

Immediate (Red):injuries are life-threatening;

survivable with minimum intervention

sucking chest wound; airway obstruction; shock;

hemothorax; asphyxia; abdominal wounds;

incomplete amputations; open fractures; 2 or 3

degree burns; pneumothorax



Delayed (Yellow): injuries are significant and

require medical care but can wait for hours

without threat to life or limb

stable abdominal wounds without significanthemorrhage; soft tissue injuries; maxilla-

fascia wounds without airway compromise;

vascular injuries with adequate collateral

circulation; genitourinary tract injuries



Minor (Green): minor; treatment delayed byhours to days

upper extremity fracture; minor burns;sprains; small lacerations withoutsignificant bleeding; behavioral disorders/

psychologic disturbances

Expectant (Black): chances of survival are

unlikely; person is separated but notabandoned; comfort measures provided

unresponsive; spinal cord injury; MODS



Regional Variation

1. United States of AmericaNATO evacuation priority:

>Urgent: within 2 hours to save

>Priority: within 4 hours or will casually

deteriorate to urgent>Routine: within 24 hours to complete treatment

Methods of Field assessment

Secondary survey categories:

Class 1: minor treatment can return to dutyClass 2: injuries require immediate threat to life

Class 3: injuries are serious but not a threat to life

Class 4: expectant



2. Canada (Primary Care Level Paramedics)

Canadian Triage and Acuity Scale: injury andphysiologic findings are ranked by severity from 1 5

3. United Kingdom (Smart Incident Command System)

Major Incident Medical Management and Support: armed forces;

prioritized 1 4

Categories:

Dead: trauma score0

-2; beyond helpImmediate: trauma score 3-10;need immediate attention

Urgent: trauma score 10-11; medical care can be delayed

Delayed: trauma score 12; does not need immediate care

i l d



3. Finland(Red) cannot wait

(Yellow) has to wait(Green) can wait

(Black) lost

4. France-performed by doctors4 level scale:

DCD: deceased; beyond urgencyUA: absolute urgency; treatment on

siteUR: relative urgency; waiting forevacuationUMP:medical psychological emergency;

lightly wounded but psychologically

shocked



5. Germany

-preliminary assessment done at the ambulance

-no CPR done so if person cannot breathe, considerdeceased

T1 (Red) immediate transportation ASAP

T2 (Yellow) constant observation and rapidtreatment, transportation as soon aspractical

T3 (Green) treatment when practical, diagnosewhen possible

T4 (Brown) observation and administration of analgesia

T5 (Black) collection of bodies; identify if possible



6. Israel

-simplified description of START

Immediate: injure who are lying on

ground silently

Delayed: injured lying on ground

but screaming

Walking wounded: help less urgent



6. JapanI life threatening

II non- life threatening but urgent treatment requiredIII minor injuries

O dead; survival unlikely

Evacuation Field triageDeceased left where they fell, covered if

necessary

Immediate (Priority 1)

Delayed (Priority 2)

Minor (Priority 3)



In hospital triage

(Black) - expectant

(Red) immediate;likely to survive;

crippling injuries

(Yellow) observation

(Green) walking wounded

(White) Dismiss; first aid

emergency and critical care management

Documents