INTRODUCTION: ASSESSMENT OF ABC

ABC- acute biological crisis Assessment 1. Primary Assessment: The initial, rapid, ABCD assessment of the patient is meant to identify life threatening problems: -Airway -Breathing -Circulation = gunshot, multiple stab -Disability (Level of Consciousness) = fracture nasabugan 2. Secondary Assessment Brief thorough, systematic assessment designed to identify all injuries. 2.1 Expose/Environmental Control o It is necessary to remove the patient s clothing in order to identify all injuries. o Prevent heat loss by using warm blankets, overhead warmers, and warmed I.V. fluid. 2.2 Full Set of Vital Signs: o Obtain a full set of vital signs including blood pressure, heart rate, respiratory rate and temperature.

2.3 Five Interventions: o Pulse oximetry to measure the oxygen saturation o Indwelling urinary catheter (do not insert if you note blood at the meatus, blood in the scrotum, or if you suspect a pelvic fracture). o Gastric tube (if there is a evidence of facial fractures, insert the tube orally). o Laboratory studies frequently include type and crossmatching Hgb, Hct, Urine drug screen, blood alcohol, electrolytes, prothrombin time (PT) and partial thromboplastin time, and pregnancy test if applicable. 2.4 Facility Family Presence: o It is important to assess the family s needs. If any member of the family wishes to be present during the resuscitation, it is imperative to assign a staff member to that person to explain what is being done and offer support. 2.5 Give Comfort Measures: o These include verbal reassurance as well as pain management as appropriate. o Do not forget to give comfort measures to the family during the resuscitation process 3. Focused Assessment: o Any injuries that were identified during the primary and secondary surveys require a detailed assessment, which will typically

include a team approach and radiographic studies.

TRIAGE
-is a French verb meaning sort . -Most patients entering an emergency department (ED) are greeted by a triage nurse, who will perform a brief evaluation of the patient to determine a level of acuity or priority of care. Thus, the role of the triage nurse is to make acuity determinations and set priorities.

EMERGENCY ASSESSMENT AND INTERVENTION

o Remove the patient from potential source of danger, such as live electrical current, water or fire. Determine whether patient is conscious. Assess airway, breathing and circulation in systemic manner. Assess for pupilary reaction and level of responsiveness to voice or touch as indicated. If the patient is unconscious or has sustained a significant head injury, assume there is a spinal cord injury and ensure proper handling. Undress the patient to assess for wounds and skin lesions as indicated Immediate intervention is needed for such conditions as compromised airway respiratory arrest, compromised respirations, cardiac arrest, and profuse bleeding.  Provide emergency airway management, cardiopulmonary resuscitation, and measures to control haemorrhage as needed. Call for help as soon as possible Assist with transport and further assessment and care as indicated.

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IMPORTANT FUCTION OF TRIAGE: 1. Provide an initial assessment of patients 2. Assign triage urgency category 3. Direct each person to the right place and right time

PRIORITY CARE AND TRIAGE CATEGORY

Level 1 Resuscitation: o Conditions requiring immediate nursing and physician assessment. Any delay in treatment is potentially lifeor limbthreatening. Includes conditions such as:  Airway compromise  Cardiac arrest  Severe shock  Cervical spine injury  Multisystem trauma  Altered level of consciousness (LOC) (unconsciousness)  Eclampsia

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Level 2 Emergent: o Conditions requiring nursing assessment and physician assessment within 15 minutes of arrival. Conditions include:  Head injuries  Severe trauma  Lethargy or agitation  Conscious overdose  Severe allergic reaction  Chemical exposure to the eyes  Chest pain  Back pain  GI bleeding with unstable vital signs  Stroke with deficit  Severe Asthma  Abdominal pain in patient older than age 50  Vomiting and diarrhoea with dehydration  Fever in infants younger than 3 months.  Acute psychotic episode

 Moderate trauma  Abuse or neglect  GI bleed with stable vital signs  History of seizure, alert on arrival Level 4 Less Urgent: o Conditions requiring nursing and physician assessment within one hour o Conditions include:  Alert head injury without vomiting  Minor trauma  Vomiting and diarrhoea in patient older than age 2 without evidence of dehydration  Earache  Minor allergic reaction  Corneal body  Chronic back pain

STANDARDIZED COLOR CODED DISASTER TRIAGE SYSTEM 1. Black: Dead 2. Red: Critical or Life Threatening -These victims have a reasonable chance of survival only if they receive immediate treatment -Respiratory Insufficiency, Cardiac arrest, Haemorrhage and Severe Abdominal Injury. 3. Yellow: Serious -These victim can wait for transportations after they receive initial emergency treatment. -Immobilized Closed Fracture, Soft Tissue Injuries without Haemorrhage, Burn <40% of the body 4. Green: Minimal

-Becomes the centre of operations for organization, planning, and transport of patients in the event of a specific MCI (Mass Casualty Incident) Disaster Level: o Level 1:  Local emergency response personnel and organizations can contain and effectively manage the disaster and its aftermath  Hostage taking o Level 2  Regional efforts and aid from the surrounding communities are sufficient to manage the effects of disaster o Level 3  Local or regional assets are overwhelmed; state-wide or federal assistance is required  Ex. bagyong ondoy

Level 5 Non Urgent: o Conditions requiring nursing and physician assessment within two hours. Conditions include:  Minor trauma, not acute  Sore throat  Minor symptoms  Chronic abdominal pain

-Victims are ambulatory, have Minor tissue injuries and maybe dazed -They can treated with non professional and held for observation.

Level 3 Urgent: o o Conditions requiring nursing and physician assessment within 30 minutes of arrival . Conditions include:  Alert head injury with vomiting  Mild to moderate asthma

INCIDENT COMMAND SYSTEM -The local organization that coordinates personnel, facilities, equipment and communication in any emergency situation.

BISYCHRONOUS POSITIVE AIRWAY PRESSURE MECHANICAL VENTILATION VENTILATION

Modes of Mechanical Ventilation Positive End Expiratory Pressure (PEEP) Ventilator delivers additional positive pressure at the end of expiration, which maintains the alveoli in an expanded state.

Assessment of Tubing or Machine Is there leak around the endotracheal cuff? Is there excess condensation in the tubing? (Always remove water from the tubing sy/stem. Do not empty back into the humidifier reservoir) NOTE: Not all ventilators have humidifiers Are all ventilator settings and read outs correct?

-Is performed by mechanical means in individual who are unable to maintain normal levels of oxygen and carbon dioxide in the blood. TIDAL VOLUME: volume of air in the normal breath FiO2: oxygen concentration delivered through mechanical ventilation. Indication: -COPD -Neuromuscular disease -Severe neurologic depression -Thoracic trauma -ARDS -Client who undergone thoracic or open heart surgery Types: Positive pressure-cycled ventilator -Pushes air into the lungs until a predetermined pressure is reached within the tracheobronchial tree; expiration occurs by passive relaxation of the diaphragm. -

The nurse observes the patient for signs of respiratory distress and reconnects the ventilator e=when the patient indicates fatigue. Time off the ventilator is gradually increased.

Interventions during weaning process Before initiating weaning, prepare the patient Teach effective breathing techniques Inform the patient that weaning may require several attempts for a longer period, before the ventilator can be discontinued. Obtain baseline VS, tidal volume and vital capacity.

Continuous Positive Airway Pressure (CPAP) Achieves the same results as PEEP except CPAP is used on adult clients who are on a T piece.

Weaning -is initiated when the patient meets certain physiologic criteria: - acceptable ABG s - Vital capacity >15ml/kg - Tidal volume >10ml/kg -Fraction of inspired oxygen (Fi10) <0.5 - Maximum inspiratory pressure >220cm H2O - Normal hematorcrit (weaning is successful when the patient hematocrit is 30% or higher) T-piece weaning The nurse places the patient in an upright position, disconnects the ventilator, and connects a T-piece to the endotracheal tube cuff to provide oxygenated humidified air.

General Care of Patient on a Ventilator The nurse assesses the patient regularly and anytime a ventilator alarm sounds. If the alarm continues to sound and the cause cannot determined or the patient is in respiratory distress, the nurse disconnects the patient from the machine and manually ventilates with ambu Bag with oxygen air until the problem can be resolved.

Patient and Ventilator Assessment Patient Assessment Does the patient appear to be in respiratory distress? Is the person s chest moving with machine cycled inspiration? Is the chest moving bilaterally? Are the breath sounds present? Are adventitious sounds present? Are breath sounds coordinated with ventilator inspiration?

INJURIES TO SOFT TISSUE, BONES, AND JOINTS SOFT TISSUE INJURIES

Soft Tissue Injury - involves & underlying subcutaneous tissue & muscles -They can be classified as open or closed injuries 1. Closed wound- an injury to soft tissue but without a break in the skin. - Contusion bleeding beneath the skin into soft tissue. The bleeding can be minor or extensive. Extensive bleeding can cause severe pain & swelling, leading to a compromise of vital structures -Hematoma well-defined pocket of blood & fluid beneath the skin. 2. Open wound- injury to soft tissue with a break in the skin. Generally, they are more serious than closed injuries due to the potential for blood loss & infunction. a. Abrasion- superficial loss of skin resulting from rubbing or scraping skin over a rough or uneven surface. b. Laceration- tear in the skin. Can be a partial or full thikness cut. Can be defined as incisional or jagged.

c. Puncture- occurs when the skin is penetrated by a pointed object. Can be penetrating (entrance wound only) or perforating (entrance and exit wound). Generally, puncture wounds do not cause serious external bleeding, but there may be significant internal bleeding and damage to vital organs. d. Avulsion- involves a tearing off or loss of flap skin. e. Amputationtraumatic cutting or tearing off a finger, toe, arm or leg ASSESSMENT: o Always ensure the adequacy of airway, breathing, and circulation before initiating treatment. Assess for arterial or venous bleeding. Arterial bleeding is bright red and usually spurts from the wound. Venous bleeding is darker red and will flow steadily from a wound. If the bleeding from the injury has been significant, be aware of the clinical symptoms and signs of shock.  Skin pale, mottled, cold, and diaphoretic.

 Tachycardia (rapid, weak pulse).  Tachypnea (rapid shallow breathing).  Hypotension (falling of blood pressure is a late sign of shock).  Restlessness, confusion, and anxiety. o INTERVENTION: o Direct pressure:  Most external bleeding can be controlled by direct pressure  Cover the injury with sterile dressings  Apply firm direct pressure to the site of injury  Pressure should be maintained until the bleeding stops, a pressure dressing is applied, or definitive treatment is undertaken. If the dressing becomes saturated, reinforce the dressing; do not remove the dressing. After bleeding has stopped, apply a pressure dressing.  A pressure bandage is made by securing several gauze pads over the injury with a rolled gauze bandage.  A pressure dressing allows the nurse freedom to continue assessing the

patient or attend to other injuries.  After applying a pressure dressing, always ensure that the patient has a pulse distal to the dressing. If no pulse is present, the dressing may be too tight. Elevation:  Elevating the injured are while applying direct pressure helps to control bleeding. This measure uses gravity to slow the blood flow.  If possible, the injured area should be elevated above the level of the heart.  Do not raise a limb if a fracture is suspected or if elevation causes the patient pain or discomfort Wound Preparation:  Shave the area surrounding the wound, but shave only what is necessary. Eyebrows are never shaved.  Irrigate gently and copiously with isotonic sterile saline solution or sterile water to remove dirt and debris.  A catheter-tip syringe may be used to create a hydraulic action.

General rule irrigate with 50ml/ inch of wound per hour of age of wound. Use more irrigant for grossly contaminated wounds.

Sprains- injuries in which ligaments are partially torn or stretched. y These types of injuries are usually caused by a twisting of a joint beyond its normal range of motion. The severity can range from mild to severe. The more seriously injured ligaments may resemble a fracture.

Management dislocation

for:

Sprain.

Strain,

R-est I- ce compress C- ompression E-levation R-eferral to management

Closed/Simple Fracture o Does not cause break in the skin Open/Compound/Complex o Skin or mucous membrane wound extends to the fractured bone

y Medical

Pharmacological Management y Give antimicrobial treatment as directed, depending on how the injury occurred, age of wound, presence of soil infection potential Give tetanus prophylaxis as indicated, based on patient s immunization status and wound. For inadequate primary immunization, tetanus toxoid and tetanus immune globulin (TIG) are given. Strains- stretching or tearing of muscle tendon fibers. y Usually caused by overexertion or overextension

FRACTURE
y is a break in the continuity of the bone and is defined according to its type and extent Occurs when the bone is subjected to stress greater than it can absorb

Manifestation: y Signs and symptoms Dislocations: o Loss of joint motion o Obvious deformity o Severe pain of

Types of Fracture: y Complete Fracture o A break across the entire cross section of the bone and is frequently displaced (removed from its normal position) Incomplete Fracture o Involves a break through only part of the cross section of the bone o Green stick Comminuted Fracture o Fracture that produces several bone fragments

Manifestations:  Pain  Loss of function  Deformity (Displacement, angulations or rotation of the fragments in a fracture arm or legs)  Shortening (muscle contraction)  Swelling and Discoloration (ecchymosis)  Crepitus (grating sensations) Emergency Management:  Immobilize the body part before the patient moved  Splints can be applied, the extremity is supported distal and proximal to the fracture site  Neurovascular status is distal injury should be assessed both before and after splinting to determine the adequacy of peripheral tissue perfusion and nerve function  Open fracture, wound is covered with sterile dressing to prevent contamination of deeper tissue  Emergency Room: Patient evaluated completely, clothes gently removed from uninjured side then to the affected side

Dislocation- complete displacement or separation of a bone from its normal place of articulation. y It may be associated with a tearing of the ligaments. The shoulder, elbow, fingers, hips, and ankles are the joints most frequently affected.

Signs and symptoms of Sprains: o Pain in the joint area o Swelling o Limited use or movement o Discoloration Signs and symptoms of Strains: o Pain located in a muscle or its tendon, not a bone or a joint. o Swelling is usually minimal.

Subfluxation- partial disruption of the articulating surfaces

POISONING
o Any substance that, when ingested, inhaled, applied to the skin, absorbed or produced within the body in relatively small amounts, injures the body by its chemical reaction

concentration of drug or poison)  ECG  Vital signs and neurologic status MANIFESTATION:

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o  Pain or burning sensations  Evidence of redness or burn in the mouth, throat, pain on swallowing or an inability to swallow  Vomiting or drooling MANAGEMENT:  Prevention o Child proofing  Store all potentially poisonous substances in locked out of reach area o Increased awareness of precipitating factors:  Growth and development  Changes in household routine  Condition that increase emotion tension of family members

TYPES: 1. INGESTED POISON: o Corrosive poison: o Alkaline products: -Lye, drain cleaners, toilet bowl cleaner, bleach, non phosphate detergents, oven cleaner and button batteries (batteries used to power watches, calculators, or cameras) o Acid Products: -Metal cleaners, rust removers and battery acid

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Never take medicine in front of the children Never leave medicine in front of the children Never leave medication in purse, on table or an kitchen counter Leave medicines, cleaning supplies in original containers Provide activities and play materials for children Teach need for supervision of small children

Contraindication of Inducing Vomiting: o When the child is in danger of aspiration  Decreased level of consciousness, severe shock, seizure and diminished gag reflex When substance is petroleum distillate (lighter fluid, kerosene, paint remover)  Increased risk of aspiration pneumonia or strong corrosive which may redamage esophagus and pharynx

Ipecac:
o Direct stimulation of vomiting center and gastric irritant; store in locked out of reach area as with any other medication; toxic if ingested inappropriately. Dose  9-12 months (10ml and do not repeat)  1-12 years old (15ml)  >12 years old (30ml) Follow each dose with a small amount of clear liquids Position child s head lower than the chest to prevent aspiration Repeat once every 30 minutes for child > 12 months If no vomiting after 2 doses, transfer to ER

ASSESSMENT: o ABC  Treat the patient before the poison o Identify the poison  Amount ingested  Time of ingestion  Save the vomitus

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GENERAL CONSIDERATION: o Water may used to dilute the toxin; avoid giving large amounts of fluids when medication has been ingested since this may accelerate gastric emptying and speed drug absorption o Milk delay vomiting o Do not attempt to neutralize a strong acid/alkali since this may cause a heat producing reaction that can burn tissue o There are only a few specific antidotes and there is no universal antidote

Diagnostic:  Urinalysis and serum analysis (to determine

 Prevention of Accidental Poisoning in Children: o Proper storage- locked cabinets

ACTIVATED CHARCOAL:
o o o o Absorbs compounds, forming a non absorbable complex 5-10 gram for each of toxin Give within 1 hour of ingestion and after emetic Mix with water to make a syrup; given PO or via gastric tube

2. CARBON MONOXIDE POISONING (Inhaled poison) o May occur as a result of industrial or household incidents or attempted suicide. o Carbon monoxide exerts its toxic effect by binding to circulating haemoglobin and thereby reducing the oxygen carrying capacity of the blood. o Hemoglobin absorbs carbon monoxide 200x more rapidly than it absorbsoxygen. o Carboxyhemoglobin = carbon monoxide + haemoglobin (does not transport oxygen) MANIFESTATIONS: o Cerebral hypoxia o Headache o Muscular weakness o Palpitations o Dizziness o Confusion which can progress rapidly to coma o Skin color range from pink to cherry red (not a reliable sign)

MANAGEMENT o Carry the patient to fresh air immediately; open all doors and windows o Loosen all tight clothing o Initiate CPR if required o Administer 100% oxygen until carboxyhemoglobin level is <5% o Prevent chilling; wrap patient in a blanket o Keep patient as quiet as possible o Do not give alcohol in any form or permit the patient to smoke

CHEMICAL BURNS: o The skin should be drenched immediately in running water from a shower, hose or faucet, except in the case of lye and white phosphorous which should be brushed off the skin