NSEEMERGENCY NURSINGLecture TOMASITO M. DEMEGILLO JR, RN. MAN
EMERGENCY NURSING • Is a specialty area of the nursing profession like no other. • Provide quality patient care for people of all ages, emergency nurses must possess both general and specific knowledge about health care. • Emergency nurses must be ready to treat a wide variety of illnesses or injury situations, ranging from a sore throat to a heart attack.
II. HISTORICAL DEVELOPMENT OF EMERGENCY NURSING The Emergency Nurses Association (ENA) • Is the specialty nursing association serving the emergency nursing profession through research, publications, professional development, and injury prevention. • ENA's mission is to provide visionary leadership for emergency nursing and emergency care. • ENA is an organization seeking to define the future of emergency nursing and emergency care through advocacy, expertise, innovation, and leadership.
Emergency Nurses CARE (EN CARE) (Virginia, USA) • Is a not-for-profit organization with more than 6,000 trained emergency health care professionals who volunteer their time in their local communities in 50 states. • EN CARE's mission is to reduce preventable injuries and deaths by educating the public to increase awareness and promote healthy lifestyles.
The ENA Foundation (ENAF) (Illinois, USA) • Is the philanthropic arm of ENA and its affiliates. • Provides support for emergency nursing scholarships, research, and injury prevention. (Note: Applicants must be members of ENA) Philippine Society of Emergency Care Nurses, Inc. (PSECN) (Emergency Medical Services Department Philippine General Hospital Taft Avenue, Manila) • Is a duly-recognized specialty organization of the Philippine Nurses Association (PNA). • The current president is VIRGINIA DUCUSIN
III. TRIAGE • [French, from trier, to sort, from Old French.] • Is the process of determining the priority of patients' treatments based on the severity of their condition. • A method of quickly identifying victims who have immediately life-threatening injuries and who have the best chance of surviving.
Emergent • Divided into two: 1.Immediate -unstable and requiring attention within 15 minutes. Examples: • Airway obstruction/compromise (actual or potential) • Uncontrolled bleeding • Shock 2. Urgent - temporarily stable butrequiring care within a few hours. Examples: • Threatened loss of limb or eyesight • Multiple long-bone fractures.
Nonemergency Situations - would require intervention, however, could standsignificant delay. Examples: • Walking wounded. • Single long-bone fractures. • Closed fractures. • Soft tissue injuries without significant bleeding. • Facial fractures without airway compromise.
IV. Roles of Emergency Nurse A. Care Provider Emergency nurses care for patients and families in hospital emergency departments, ambulances, helicopters, urgent care centers, cruise ships, sports arenas, industry, government, and anywhere someone may have a medical emergency or where medical advances or injury prevention is a concern.
B. Educator Emergency nurses provide education to the public through programs to promote wellness and prevent injuries, such as alcohol awareness, child passenger safety, gun safety, and domestic violence prevention. C. Manager Emergency nurses also work as administrators, managers, and researchers who work to improve emergency health care.They find time to provide excellent care for pts.
D. Advocate Emergency nurses defend or plead a cause or issue on behalf of another. A nurse advocate has a legal and ethical obligation to safeguard the patient’s interests and rights. • The Patient’s Bill of Rights a.k.a Patient Care Partnership • Developed by the American Hospital Association in 1972 • Goal is to promote the public’s understanding of their rights and responsibilities as consumers of health care.
V. Qualifications of ER Nurse • A Graduate of Bachelor of Science in Nursing • A Registered Nurse • Knowledgeable and Skillful for technology and equipments used in emergency care setting • Must have a basic understanding of triage nursing • Must be calm and collected under pressure and must be sympathetic to patients and their families
They must be detail-oriented, as doctors' orders must be carried out instantly and correctly in emergency rooms. • They must also be able to emotionally handle the daily sight of physical suffering and the reality that some patients may not be able to be saved, despite everyone's best efforts.
VI. Legal Issues Affecting the Provision of Emergency Nursing CONSENT NEGLIGENCE CONFIDENTIALITY AUTONOMY GATHER EVIDENCE TREATMENT MALPRACTICE FIDELITY REPORT DECISION MAKING
VII. Management of Care ANTHROPOMETRIC – is the measurement of the human individual for the purposes of understanding human physical variation. 1. Weight • Accurate weight is required for: • Pregnant patients • Infants • Children • Elderly individuals • Patients who have been prescribed certain medications
Scale • Should be placed in a spot that the patient is comfortable with • Measured in pounds or kilograms Types: • Balance beam scale • Digital scale • Dial scale 2. Height • Can be measured using a • Movable ruler on the back of most balance beam scales • Graph ruler mounted on the wall • Parallel bar moved down against the top of the patient’s head
The Three Types of Scales Used in Medical Offices Include the Digital, Dial, and Balance Scale
VIII. Safety & Infection Control Disease can be directly transmitted in two ways: • Vertical disease transmission – passing a disease causing agent vertically from parent to offspring, such as perinatal transmission. • Horizontal disease transmission – from one individual to another in the same generation (peers in the same age group).
AIRBORNE TRANSMISSION • Occurs when bacteria or viruses travel on dust particles or on small respiratory droplets that may become aerosolized when people sneeze, cough, laugh, or exhale. • They hang in the air much like invisible smoke. • They can travel on air currents over considerable distances. Examples: - Anthrax (inhalational) - Pertussis (whooping cough) - Smallpox - Chickenpox - Tuberculosis - Influenza - Measles
Airborne Precautions: • Be in a different room from the person who is ill, with a closed door in between. • If you need to be in the same room, wearing a mask may help for a brief exposure. • Covering the mouth or nose when coughing or sneezing decrease the risk of transmission.
DROPLET TRANSMISSION • Occurs when bacteria or viruses travel on relatively large respiratory droplets that people sneeze, cough, drip, or exhale. • They travel only short distances before settling, usually less than 3 feet. • They can be spread directly if people are close enough to each other. • The droplets land on hands, toys, tables, mats, or other surfaces, where they sometimes remain infectious for hours.
Examples: • Common cold • Diphtheria • Influenza • Meningitis • Mumps • Pertussis (whooping cough) • Plague • Rubella • Strep (strep throat, scarlet fever, pneumonia)
Droplet Precautions: • Frequent hand washing help prevent transmission. • Covering the mouth or nose when coughing or sneezing decreases droplet transmission. • Using disposable towels and cups reduces the risk for infection. • Cleaning or disinfecting commonly touched infected surfaces (doorknobs, faucet handles, shared toys, mats in daycare) can also help.
CONTACT TRANSMISSION • Requires some form of touch to spread an infection. • It is divided into two: • Direct contact transmission - involves immediate contact between two people (or with an animal). • Indirect contact transmission - involves fomites ; an object that becomes contaminated by touch then spreads the infection by touch. Examples: • Abscesses • Diphtheria (cutaneous) • Lice • Scabies • Athlete’s foot • Conjunctivitis (“pink eye”)
Contact Precautions: • Avoid direct contact with infected person especially when there is a break in the skin. • Frequent hand washing • Surface disinfecting can interrupt some disease transmission. • Avoid sharing hairbrushes, combs, and hats.
REVERSE TRANSMISSION • The patient is being protected from the nurse and all the people in contact with the patient. Examples: • Immunocompromise patients • Cancer patients undergoing chemotherapy
IX. Prevention & Early Detection ASSESSMENT 1. Glasgow Coma Scale • Is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment.
Generally, brain injury is classified as: • Severe GCS ≤ 8 • Moderate GCS 9 – 12 • Minor GCS ≥ 13 and above • The GCS has limited applicability to children, especially below the age of 36 months (where the verbal performance of even a healthy child would be expected to be poor). • Pediatric Glasgow Coma Scale - a separate yet closely related scale, was developed for assessing younger children.
2. Palpatory • The sensory skills developed by trained physicians and used in diagnosis and manipulative techniques. 3. Pulse Pressure • Is the difference between the systolic and diastolic pressure. • It represents the force that your heart generates each time it contracts. In a person with a systolic blood pressure of 120 mmHg and a diastolic pressure of 80 mmHg, the pulse pressure would be 40 mmHg.
When the Pulse Pressure is greater than 60 mm Hg there is an increased incidence of adverse cardiovascular events especially in the older population. • Several studies have identified that high pulse pressure: • Causes more artery damage compared to high blood pressure with normal pulse pressure • Indicates elevated stress on a part of the heart called the left ventricle • Is affected differently by different high blood pressure medicines
4. Level of Consciousness (LOC) • Is a measurement of a person's arousability and responsiveness to stimuli from the environment. Levels: • Conscious - Oriented to time, place, name and date. • Somnolent - Shows excessive drowsiness and responds to stimuli only with incoherent mumbles or disorganized movements. • Obtunded - Has decreased interest in their surroundings, slowed responses, and sleepiness.
Stuporous - People with an even lower level of consciousness, stupor, only respond by grimacing or drawing away from painful stimuli. • Comatose - Do not even make this response to stimuli, have no corneal or gag reflex, and they may have no pupillary response to light.
5. Reflexes • Stretch or Deep Tendon Reflexes (DTRs) • Measurement of the DTRs reflects the integrity of the reflex at specific spinal levels as well as the cerebral cortex function. • For valid responses, the limbs should be relaxed and the muscles partially stretched. • Elicit the reflex by applying a short, quick blow of the reflex hammer onto the muscle’s insertion tendon. • Use a relaxed hold on the reflex hammer. • Use the pointed end of the reflex hammer when testing a smaller target such as thumb on the tendon site. • Use the flat end of the reflex hammer when the target is wider or to diffuse the impact and prevent pain. • Compare the right and the left sides – the response should be equal.
The reflex response is graded on a 4 – point scale as follows: 4+ Very brisk, hyperactive with clonus, pathologic 3+ Brisker than average, may be pathologic 2+ Average, normal 1+ Diminished, low normal 0 No response Abnormal Findings: • Clonus is a set of rapid, rhythmic contractions of the same muscle. • Hyperreflexia is the exaggerated reflex seen when the patient has upper motor neuron lesions (e.g., stroke). • Hyporeflexia is the absence of a reflex. This is a lower motor neuron problem (e.g., spinal cord injury).
Biceps Reflex (C5 to C6) • Support the patient’s forearm. Use he patient’s forearm on yours. To relax and partially flex the patient’s arm. • Place your thumb on the biceps tendon and strike a blow on your thumb. Use the pointed end of the reflex hammer. • Normal response is contraction of the biceps muscle and flexion of the forearm. b. Triceps Reflex (C7 to C8) • Instruct the patient to let the arm fully relax as you suspend it by supporting the upper arm. • Strike the triceps tendon directly just above the elbow. Use the pointed end of the reflex hammer. • Normal response is extension of the forearm.
c. Brachioradialis Reflex (C5 to C6) • Hold the patient’s thumb to suspend the forearm in relaxation. • Strike the forearm directly about 2 to 3 cm. above the radial styloid process. Use the pointed end of the reflex hammer. • Normal response is flexion and supination of the forearm. d. Quadriceps Reflex (“Knee Jerk”) (L2 to L4) • Let the lower legs dangle freely to flex the knee and stretch the tendons. The popliteal area (back of the knee) should be few inches away from the edge of the bed.
Place your hand above the patient’s knee. • Strike the tendon directly just below the patella. Use the flat end of the reflex hammer. • Normal response is extension of the lower leg. Contraction of the quadriceps (muscle of the thighs) may also be palpated. Note: if the patient is unable to sit, place him/her in supine position. Use your own arm as a lever to support the weight of one leg against the other leg. (Place your arm under the patient’s knee near you, and your hand above the knee of the other leg).
. Achilles Reflex (“Ankle Jerk”) (L5 to S2) • Position the patient with the knee flexed and the hip externally rotated. • Hold the foot in dorsiflexion, and strike the Achilles tendon directly. • Normal response is plantar flexion against your hand. Note: For the patient in supine position, flex one knee and support that leg. (Place the leg to be tested on top of the other leg, and externally rotated to have easy access on the Tendon of Achilles). Dorsiflex the foot and tap the tendon.
f. Clonus. Test for clonus when the reflexes are hyperactive. • Support the lower leg (under the knee) with one hand. • With the other hand, move the foot up and down a few times to relax the muscle. • Then, stretch the muscle by briskly dorsiflexing the foot. • Hold the stretch. • Normal response is no further movement is felt. • Abnormal Finding: • When clonus is present, you feel and see rapid, rhythmic contractions of the calf muscle and movement on the foot. • A hyperactive reflex with sustained clonus (lasting as long as the stretch is held) occurs with upper motor neuron disease.
2. Superficial (Cutaneous) Reflexes • These reflexes test the sensory receptors in the skin. The motor response is localized muscle contraction. • Abdominal Reflexes – Upper (T8 to T10), Lower (T10 to T12) • Place the patient is supine position with the knees slightly bent. • Use the handle end of the reflex hammer, or a wood applicator tip, or the end of a split tongue blade to stroke the skin of the abdomen. • Move from the side of the abdomen to the midline at both the upper and lower abdominal levels. • Normal response is ipsilateral (same side) contraction of the abdominal muscle, with an observed deviation of the umbilicus toward the stroke.
Abnormal Finding: • Superficial reflexes are absent in diseases of the pyramidal tracts (e.g., stroke). b. Cremasteric Reflex (L1 to L2) • This is not routinely done. • It is done only on an unconscious male patient. • Lightly stroke the inner aspect of the thigh with handle of reflex hammer or tongue blade. • Normal response is elevation of the ipsilateral testis. • Abnormal Finding: • Absent in both upper motor neuron (UMN) and lower motor neuron (LMN) lesions.
c. Plantar Reflex (Babinski Reflex) (L4 to S2) • Position the thigh in slight external rotation. • Use the handle of the reflex hammer to lightly stroke the lateral side of the foot from the hee, upward and inward across the ball of the foot (“inverted J fashion”). • Normal response is plantar flexion of the toes and inversion and flexion of the forefoot (Negative Babinski Reflex). • Abnormal Finding: • Dorsiflexion of the big toe and fanning of all toes (positive Babinski). This indicates UMN disease of the corticospinal (or pyramidal) tract. • Note: Positive Babinski is normal only among infants, which disappears by age 1 year.
OBTAINING SPECIMEN 1. Stool • A stool analysis is a series of tests done on a stool (feces) sample to help diagnose certain conditions affecting the digestive tract . • These conditions can include infection (such as from parasites, viruses, or bacteria), poor nutrient absorption, or cancer.
2. Urine • Urine test checks different components of urine, a waste product made by the kidneys. • The test can give information about your health and problems you may have. 3. Sputum • A sputum culture is a test to detect and identify bacteria or fungi (plural of fungus) that are infecting the lungs or breathing passages. • A sample of sputum is placed in a container with substances that promote the growth of bacteria or fungi. • If no bacteria or fungi grow, the culture is negative. • If organisms can cause infection grow, the culture is positive.
COMPLETE BLOOD COUNT • One of the most commonly ordered blood tests. • The complete blood count is the calculation of the cellular (formed elements) of blood. CAPILLARY BLOOD GAS • Capillary Blood is an attractive substitute sample that is routinely used in some clinical settings. • The gold-standard sample for blood-gas analysis is arterial blood obtained via an indwelling arterial catheter or by arterial puncture.
Blood-gas analyzers measure blood pH, and the oxygen and carbon-dioxide tensions of blood. • Blood-gas analysis is helpful for assessment and monitoring of patients suffering a range of metabolic disturbances and respiratory diseases.
ELECTROCARDIOGRAPH • Derived from the Greek electro,(electrical activity), cardio, (heart), and graph, ("to write“). • Is a transthoracic interpretation of the electrical activity of the heart over time captured and externally recorded by skin electrodes. • It is a noninvasive recording produced by an electrocardiographic device. • ECG works mostly by detecting and amplifying the tiny electrical changes on the skin that are caused when the heart muscle "depolarizes" during each heart beat.