MedicalSurgical Nursing An Integrated Approach 2 E NURSING

Medical-Surgical Nursing: An Integrated Approach, 2 E NURSING CARE OF THE CLIENT: RESPONDING TO EMERGENCIES

Emergency: Defined as: A medical or surgical condition requiring immediate or timely intervention to prevent permanent disability or death. n In the U. S. , trauma is the number one killer of those under the age of 37 and the fourth leading cause of death overall. n

Emergency Nursing The care of clients who require emergency intervention. n The emergency nurse must be capable of rapid assessment and history taking and immediate intervention formulation and implementation using the nursing process. n Clinical knowledge, communication, client teaching, and empathy skills are essential. n

Approaches to Emergency Care n There are three general approaches to emergency care: n Hospital triage. n Disaster triage. n Emergency medical services.

Hospital Triage refers to classification of clients to determine priority of need and proper place of treatment. n Each hospital with an emergency department (ED) has an established triage system in place. n

Golden Rules of Emergency Care 1. Establish the safety of the scene. 2. Remove the client from danger. 3. Establish airway, breathing, and 4. 5. 6. 7. circulation. Manage shock. Attend to eye injuries. Treat skin injuries. Call for help.

Triage Classifications Emergent (clients who require immediate care in order to sustain life or limb). n Urgent (clients who require care within 1 to 2 hours to prevent worsening of their condition). n Non-urgent (clients whose care can be delayed without the risk of permanent consequences). n

Disaster Triage CATEGORY CLIENT NEEDS EXAMPLES Immediate Simple injuries Chest wounds requiring immediate Crush injuries care Burns Delayed Multiple injuries requiring extensive care Open fractures of the long bones Minimal Minor injuries (the walking wounded) Sprains, minor cuts Contusions Expectant Severe injuries likely to cause death Massive head trauma, spinal cord injuries

Emergency Medical Services n n n Prior to admission to the ED, the client may have been cared for by an emergency medical technician (EMT) or paramedic. An EMT is a health care professional trained to provide basic lifesaving measures prior to arrival at the hospital. A paramedic is a more specialized health care professional trained to provide advanced life support to the client requiring emergency interventions.

Shock: Defined as: n A condition of profound hemodynamic and metabolic disturbance characterized by inadequate tissue perfusion and inadequate circulation to the vital organs.

Types of Shock TYPE CAUSES Hypovolemic Hemorrhage; Burns Cardiogenic Myorcardial Infarction Toxic Overwhelming Infection Medications, insect bites or stings, food Spinal cord injury Anaphylactic Neurogenic

Cardiopulmonary Emergencies Those that jeopardize the function of the hearts and lungs. n Include drowning, foreign body obstruction of the airway, chest trauma, and chest pain. n

Neurological/Neurosurgical Emergencies Head injuries are the most common type of neurological trauma. n Spinal cord trauma can also occur as a result of injuries sustained in a head injury. n Head injuries most common in motor vehicle collisions. n Cerebrovascular accidents, or stroke, also require emergency care. n

Abdominal Emergencies Abdominal emergencies can be diverse in nature. n Include trauma as well as illnesses that cause abdominal pain (gastroenteritis, gastrointestinal bleeding, etc. ). n

Genitourinary Emergencies Include rape. n Straddle injuries (those that occur when a client falls while straddling an object, such as a fence or metal bar, thereby injuring the perineum). n

Ocular Emergencies Most eye emergencies are urgent to emergent in nature. n Foreign bodies can cause damage to vision very rapidly and thus require immediate attention. n

Musculoskeletal Emergencies Can vary from simple strains to major trauma. n Includes sprains, dislocations, fractures. n

Soft Tissue Emergencies Most soft-tissue injuries are very common, including minor abrasions, lacerations, puncture wounds, contusions, bites of all varieties, and burn injuries. n Although most do not require emergency care, some are more severe than others and some are potentially fatal. n

Poisoning and Overdoses Can be accidental or intentional. n Ingested poisons are most common. n Important to obtain a clear history of the route of entry: inhalation, ingestion, topical, or injection. n

Environmental/Temperature Emergencies Exposures to extremes of heat and cold can be potentially life threatening. n Severe cold, or hypothermia, frostbite, extreme heat are examples. n

Degrees of Frostbite Severity DEGREE SYMPTOMS TREATMENT Mild Skin cold to touch, Use blankets, pale, tingling, numb warm clothing to warm cold flesh Moderate Affects deeper body tissue, skin waxy, puffy, itchy, burning with pain Use gloves, blankets, warm clothing to warm cold flesh Severe Blistering, soft tissue damage, flesh hard, lifeless, no pain Initiate emergency rewarming using warm water baths; observe for edema

Comparison of Heat Injuries TYPE SYMPTOMS TREATMENT Heat Cramps Muscle cramps in arms, leg, and abdomen Move client to cool, shady area. Slowly administer copious water. Reevaluate. Heat Exhaustion Diaphoresis, pale, moist, cool skin, headache, dizziness, etc. Move client to cool, shady area. Pour water over client. Elevate legs. Heat Stroke (medical emergency) Red, flushed, hot dry skin; no diaphoresis. Emergency treatment.

Multiple System Trauma Injury sustained in more than one body system. n During the initial care of the emergency client, the mechanism of injury is determined. n Blunt injuries and penetrating trauma are most likely to result in multiple-system involvement. n

Legal Issues n Nurses must be aware of the legal issues related to emergency care, such as Good Samaritan Laws and mandated reporting.

Death in the Emergency Department Death can occur in the ED at any time due to trauma, sudden illness, or even extended illness. n In the event of sudden death, the family is usually in a state of shock and will need further assistance to cope with the death of their loved one. n Special support groups are available for this assistance and should be contacted for the family. n