Emergency Nursing

EMERGENCY NURSING
AND
DISASTER NURSING

GILBE RT T. SALACUP RN,MSN

Emergency Action Principles
Use to get an accident situation under control
quickly.
Survey the scene
CALL 911/ EMERGENCY RESPONSE TEAM
Do a primary survey
A-- AIR WAY
B-- BREATHING
C-- CIRCULATION
D-- DISABILITY
E-- EXPOSURE
H-- HEMORRHAGE
S-- SPINALCORD INJURY

GILBERT T. SALACUP RN,MSN

AIRWAY:
IS IT OPEN? MINIMIZE NECK MOVEMENTS MUCH
AS POSSIBLE; APPLY CERVICAL COLLAR IF
AVAILABLE.

2 WAYS IN OPENING THE AIRWAY

**HEAD TILT – CHIN LIFT MANEUVER
**JAW THRUST MANEUVER

BREATHING:
IS THE VICTIM BREATHING? CHECK ( 3 – 5 SEC.)
L ---- LOOK,
L ---- LISTEN,
F ---- FEEL.


CIRCULATION
IS THERE A PALPABLE CAROTID PULSE
FOR ADULT
AND BRACHIAL PULSE FOR CHILD AND
INFANT.
CHECK ( 10 SEC. )

DISABILITY
IS THERE INJURY TO THE NERVOUS
AND MUSCULOSKELETAL SYSTEMS?
STABILIZE “C”-
SPINE.


EXPOSURE:
REMOVE VICTIM FROM OFFENDING
ENVIRONMENT. IF NECESSARY,
PLACE TENT OVER VICTIM.

HEMORRHAGE :
LOOK FOR SEVERE BLOOD LOSS, CSF
LEAK.

SPINALCORD INJURY :
CHECK FOR THE SENSORY
RESPONSE, AND OBVIOUS
DEFORMITY ON THE SPINE.

Triage
Categories of severity

Black / Expectant
–Last priority**Dead person

Red / Immediate
**first priority**"cannot wait"


YELLOW / OBSERVATION
**2ND PRIORITY**
THEIR CONDITION IS STABLE FOR THE MOMENT
BUT
REQUIRES WATCHING.

GREEN / WAIT (WALKING WOUNDED)*
*3RD PRIORITY**
REQUIRE A DOCTOR'S

WHITE / DISMISS (WALKING WOUNDED)
*4RTH PRIORITY*
DOCTOR'S CARE IS NOT REQUIRED


RED
A - irway Compromise,
E - clampsia
I - mmediate Chest wounds,
O - pen fractures,
U –n Severe shock,
2-3 burns
Ca - rdiac arrest,
S - pine injury cervical,
M -ultiple system trauma,
A - ltered level of consciousness

YELLOW
S - table abdominal wound
E - ye
C - NS injuries
GREEN
M - inor burns
M- inor fractures
M-inor bleeding
BLACK
U - nresponsive
H - igh spinal cord injury

GILBERT T. SALACUP , RN

Shock
is a critical physical condition due to failure of the circulatory system to
maintain adequate blood flow in the body and
ceases the delivery of oxygen and nutrients to vital organs.

BASIC CAUSES OF SHOCK

. Pump-failure . Hypovolemia Relative Hypovolemia


THREE STAGES OF SHOCK
 THE COMPENSATORY STAGE OF SHOCK
BP normal limits. shunted from the kidney, skin and
GIT to the vital organs- brain, liver.
 PROGRESSIVE STAGE OF SHOCK
regulate blood pressure can no longer compensate and
the mean arterial The overworked heart becomes
dysfunctional.
 IRREVERSIBLE STAGE OF SHOCK
there is severe organ damage that patients do not
respond anymore to treatment. Survival is almost
impossible


TYPES OF SHOCK

1.   CARDIOGENIC – HEART STOP TO PUMP DUE TO HEART DSE.

2.   ANAPHYLACTIC --- SEVERE ALLERGIC REACTION

3.   HYPOVOLEMIC --- SEVERE FLUID LOSS

4.   PSYCHOGENIC --- CAUSE BY ANXIETY, FEARS, ALTERED
ADAPTATION IN
TRAUMATIC EXPERIENCE

5.   NEUROGENIC --- CAUSE BY SPINAL FRACTURE OR
DISLOCATION

6.   METABOLIC --- LOSS OF BODY FLUIDS

7.   RESPIRATORY ---- AIR WAY OBSTRUCTION AND
HYPERVENTILATION

8.   SEPTIC --- SEVERE BACTERIAL INFECTION


SIGNS AND SYMPTOMS

3. Early Stage:
Pa- llor/cyanosis,
Co- ld/clammy skin,
Sha- llow and irregular breathing,
Ra- pid and weak pulse,
Dilated pupil.
N - /V, Thirst,

2. Late Stage:
V - acant eye,
A - pathetic/unresponsive,
De - creased blood pressure,
De - creased temperature.
MO - ttled appearance,


TRIAD SYMPTOMS OF SHOCK
Hypo - tension;
Tachy - cardia
Tachy - pnea
Co - nsciousness Altered

Nsg Dx:
FLD VOLUME DEFICIT r/t dec in blood Vol.

Priority Intervention:

Fld replacement (D5Lr, NSS. Bld Trans – for jehova’s
use plasma expander)


BODY RESPONSE TO
SHOCK
Hyven - Hyper ventilation ->
Respiratory alkalosis
Flu - Fluid Shifts Intracellular to
intracellular
V - Vasoconstriction
CT - Tachycardia
IM - Impaired metabolism and organ

function

DRUGS USED TO TREAT SHOCK
C – Corticostiroids – use in septic shock protect cellmembranes and decrease
inflammatory response to stress

A – Antibiotics –infectious process related to septic shock
N - Norephineprine (levophed) improve cardiac contractility and
cardiac output potent vasoconstrictor

D – Dopamine (Intropin) perfusion of kidneys &
urine output

D - Dobutamine (Dobutrex) increase myocardial
contractility, vasodilator.

D - Digitalis preparation improve cardiac performance
I - Isoproterenol (Isuprel)increase myocardial contractility
S - Sodium Nitropusside Vasodilator, increase cardiac
output, use in cardiogenic shock, and hypertensive emergency.


EMERGENCY NURSING
MANAGEMENT
A - irway
P - Promote restoration of blood volume;administer
fluid and blood replacement as ordered
A - Administer drugs as ordered
M - Minimize factors contributing to shock.

Best Position
Modified trendelenburge


WOUND GILBERT T. SALACUP , RN

A BODILY INJURY
CAUSED BY PHYSICAL
MEANS, WITH DISRUPTION
OF THE NORMAL
CONTINUITY OF
STRUCTURES.


CLOSED WOUND

Cause by a damage of a tissue with in the layer of the skins and to the
layer of the skin without breaking the continuity of the skin.

 Contusions (more commonly known as a bruise)
caused by blunt forc trauma that damages tissue under the skin.

Hematoma- (also called a blood tumor)
caused by damage to a blood vessel that in turn causes blood to
collect under the skin.

Crushing Injuries
caused by a great or extreme amount of force applied over
a long period of tissue


NURSING MANAGEMENT
I – ICE APPLICATION (10 – 15 MIN )
C -- COMPRESSION ( DIRECT PRESSURE )

E – ELEVATION ( ABOVE THE HEART )

OPEN WOUND
IS A BREAKE IN THE CONTINUITY OF THE SKIN
RESULTING
IN SHEDING OF BLOOD, AND CREATATING A PORTAL OF ENTRY FOR
MICRO ORGANISM.


A – ABRAISION *( GRAZES) - A SUPERFICIAL WOUND IN WHICH
THE
TOPMOST LAYER OF THE SKIN (THE EPIDERMIS) IS
SCRAPED OFF.

S – SUCKING WOUND * A PENETRATING WOUND OF THE
CHEST THROUGH WHICH AIR IS
DRAWN IN AND OUT.

A – AVULSION *THE FORCIBLE TEARING AWAY OF A BODY
PART BY
TRAUMA.

L – LACERATION *TISSUES ARE TORN. AN EVEN CUT.

I – ISCISION * ONE CAUSED BY A CUTTING INSTRUMENT.
CLEAN CUT.


EMERGENCY CARE PROCEDURES:

Wash --wash the wound

Co – Control bleeding

co – Cover the wound

Lo – Look for drop BP and TEMP.

Co – Consult a doctor


BRUISES, STRAINS, SPRAINS,
DISLOCATIONS.
 Use rice.
Amputation
3. Control Bleeding
4. Find the severed part Seek Immediate medical attention.
Chest Injuries
6. Check ABC
7. Stabilize Chest using pillow, coat or blanket.
8. Seek medical attention
9. Do not remove impaled object.
Eye injuries
1. Protect injured eye
2. Patch unaffected eye
3. Do not remove object stuck on the eye
Do not apply hard pressure


FRACTURE
A -- Avoid putting pressure on he affected area
R – Rest ( 20-30 min q 2 – 3 hrs. in 1st 24 – 48 hrs )
I – Ice application
S – splint ( use to stabilize )

Head and Spinal Injury
S - Stabilized the spine
Co - Control bleeding
As - Asses for bladder distention and pineal erection
Do - Do not irrigate or clean the skull wounds
Do - Do not stop the flow of blood or CSF from the ear or nose
N - NPO
Co - Consult a doctor


CLASSIFICATION
FIRST DEGREE: “ SUPERFICIAL” ONLY INVOLVES
EPITHELIAL LAYER.
OFTEN VERY PAINFUL BUT RESOLVES
WITH NO
RESIDUAL SCARRING. SKIN IS RED AND
PAINFUL
BUT NO BLISTERS.
SECOND DEGREE:* PARTIAL THICKNESS* INVOLVES
EPITHELIUM
AND PART OF DERMIS. PAIN AND
SCARRING
VARY ACCORDING TO DEPTH OF BURN.
WITH
BLISTER FORMATION.
THIRD DEGREE : *FULL THICKNESS*. USUALLY
PAINLESS.
USUALLY DRY AND HAVE MILKY WHITE OR TANNED
LEATHER
APPEARANCE.


EMERGENCY CARE PROCEDURES
So -- Soak in cold water/ apply cold dressing
( w/o open wound or prick blister)
1st degree do not cover w/ dressing
SO -- Soak in cold water/ apply cold dressing
Cover the wound w/ non sticky dry
sterile dressing /clean cloth
( 2nd degree w/ open wound and)

CO -- Cover the wound w/ non sticky dry
sterile dressing /clean cloth
3rd degree

A – a blister has formed,

Co -- Consult you Physician.


CHEMICAL BURNS
Wa – wash with water for 15 min.

Kee – Keep eye open, flush with water
or milk immediately.

Fluid Replacement Formula
Consensus Formula
LRS: 2-4ml x kg wt x % tbsa
½ 1st 8 hrs
½ 16 hrs
Parkland Formula
LRS: 4ml x kg wt x % tbsa
Day 1.
½ 1st 8 hrs
½ 16 hrs
Day 2
Colloid is added

SILVER SULFADIAZINE - (MOST bactericidal Agent)
1-3x/day
Acticoat – for yeast and molds( againts gram + & - )

Mafenide actate 5-10% - Easily absorb (against gram +
& - ) 2x a day

Silver Nitrate- Anti bacterial does not penetrate escar
fungicide, Cover dry gauze remoisten it q 2 hrs

•HEAT EMERGENCIES IN HUMANS
UNEXPECTED CHANGES IN THE WEATHER

2 BASIC ENVIRONMENTAL EMERGENCIES
2E
EXPOSURE TO HEAT
EXPOSURE TO COLD

SIGNS AND SYMPTOMS
** RAPID, SHALLOW BREATHING ** COLD,
CLAMMY SKIN,
**HEAVY PERSPIRATION **GENERAL
WEAKNESS,
** POSSIBLE LOSS OF CONSCIOUSNESS.

Heat Cramps
CAUSE BY ELECTROLYTES IMBALANCE,
ARTICULARLY EXESIVE LOSS OF SALT.

Move - Move victim to a cool place.
Give - Give fluids, preferably
with electrolytes.
Massage - Massage affected muscles (firm
pressure massage).
Apply - Apply moist towels to forehead and
cramped muscles.
Call - Call for transportation to medical care
if symptoms persist.

HEAT SYNCOPE
RESULT FROM INTENSE SWEATING WHICH LEAD TO DEHYDRATION FOLLOWED
BY PERRIPHERAL VASODILATION.

HEAT EXHAUSTION
HEAT EXHAUSTION IS A MORE SERIOUS RESULT OF
HEAT EXPOSURE.
CAUSE BY ELECTROLYTES IMBALANCE,PARTICULARLY
EXESIVE LOSS OF SALT.

HEAT STROKE
CAUSE BY A EXTREME BODY TEMP. THAT THE
BODY WAS NOT ABLE TO REGULATE IT AND
RELATED ALSO TO IMPAIRED SWEATING
MECHANISM.

Activate EMS system (call 911)
Move - Move victim to a cool place.
Rest - Rest victim.
Remove - Remove enough clothing to cool.
Give - Give fluids with electrolytes
(to conscious victims only).Treat for shock.
Victim - Victim needs high concentration of
oxygen.
Call - Call for transportation to definitive
medical care.

HYPOTHERMIA
1. Get the victim out of the cold
2. Replace wet cloths with dry warm
cloths.
3. Keep flat and provide other source of
heat.
NO. No. Things
 Do not give warm drinks
 Do not wrap with blanket unless with
out other source of heat.
 Do not engage with physical exertion.

STROKE
 **occurs when a blood vessel in the brain is blocked
or bursts. Without blood and the oxygen it carries,
part of the brain starts to die.
S/S
 Numbness, weakness, or paralysis of the face, arm,
or leg, especially on one side of the body.
 Trouble seeing in one or both eyes. You may have
double vision, or things may look dim or blurry.
 Confusion or trouble understanding.
 Slurred or garbled speech.
 Trouble walking. You may feel unsteady, dizzy, or
clumsy.
 Severe headache.

 Causes
** thrombus/ ischemic/ clot**
Risk factors
4. Atrial fibrillation
5. Hypertension
6. DM
7. Smoking

S/S of affected part of the Brain

Left hemisphere Right hemisphere

Language problem/ Perceptual deficit
aphasia
Pt is cautious Impulsive behavior

 2 type of stroke
ischemic stroke develops when a blood clot
blocks a blood vessel in the brain.
hemorrhagic stroke develops when an artery
in the brain leaks or
bursts.
TIA – Acute neurogical deficit lasting for 24 hrs.
S/S
 Pt is irritable
2. Pt appears in a deist
3. Disarchia
4 Temporary blindness

** Check for ABSDEHS**
** keep in side lying position**
**Seek immediately medical help.

SEIZURES
due to uncontrolled electrical activity in the brain
causes involuntary muscle contraction.

1. Do not move/stimulate the victim
2. Ensure safety “ remove all near by objects”
3. after seizure ‘’ loosen tight clothing's turn to
side’’
4. Consult a doctor

DIABETIC EMERGENCY
** provide sugar (candy, soda,frit juice)
**Consult a doctor
ASTHMA
1. RELAXATION TECHNIQUES ‘pursed lip breathing’
2. SIT Up RIGTH
3.Assist the victim in his meds.
4. Consult a doctor

CARDIAC heart stop pump, or it pumps insufficient blood causing
-- Occurs when the
ARREST
deprivation of o2 to the vital organs.

THREE CONDITIONS OF CARDIAC ARREST
1. CA -- CARDIO VASCULAR COLLAPSE
2. VE -- VENTRICULAR FIBRILLATION
3. CAR -- CARDIAC STANDSTILL

Myocardial Infarction Angina Pectoris
Pain at rest Pain upon Exertion
Not Relive by Nitroglycerin Relive by Nitroglycerin
Crushing pain Same
Severe Mild
Not Relive above 15 min. Relive by rest 2 -3 min.
Severe chest pain Diaphoresis

L --Limit Stressful activity
S -- Stop the victim from what his doing
O -- Open the airway
A -- Assist the victim in taking the his prescribe meds
P -- Perform CPR If – P and – B (30:2)

Priority Nx diagnosis
Decrease cardiac output
Cause of death in MI
12. Arrhythmias
13. Ventricular fibrillation
Choking
Infant – 5 Back blows and 5 chest Thrust
Adult & Child – Heimlich maneuver, abdominal
and chest thrust.

Poisoning

Poisoning

Poisoning

Poisoning

Poisoning

ANY SUBSTANCE THAT CAUSING ILLNESS OR DEATH WHEN
EATEN, DRUNK, OR ABSORBED EVEN IN RELATIVELY SMALL
QUANTITIES.

INGESTED/ SWALLOWED – BY MOUTH
1. SYRUP OF IPECAC IS NOT A ROUTINE TREATMENT FOR
POISONING.
2. ACTIVATED CHARCOAL IS NOT RECOMMENDED
FOR HOME
USE.
3. GIVE MILK OR WATER IMMEDIATELY
4.. POSITION THE VICTIM IN LEFT SIDE LYING.
5. IDENTIFY THE POISON AND HOW MUCH AND
WHEN TAKEN.
6. CALL POISON CONTROL CENTER.

 Inhaled – by breathing
1. Remove the victim form the toxic environment
and into fresh air immediately.
2. Give 100% of O2
3. Call poison control center.

Injected poisoning
poison that enters the body through a bite, sting,
or syringe.
1. Remove the stinger
2. Wash the wound
3. cold compress

Absorbed poisoning

1. Remove the cloth ( cut the cloth )
2. Flash it w/ water away from the body part
3. observe for allergic reaction.

VENOMOUS NON VENOMOUS
Movement Cortina, Semi cortina
or locomotion

Head Semi-triangular Round

Skin Rough Smooth

Manner Non-constrictor Constrictor
of attack

Pupil Vertical sphere/Oblong

Body Semi-triangular Oblongated

Bite mark fang mark Horseshoe shape
visible

SNAKE BITE
1. Keep the affected area lower than the heart
2. Clean w/ soap and water
3. Splint part to reduce movement
4. Limit annescerary movement

5. Call poison control center.

Motor Vehicle Accident
 Do not rush to get the victims out, contrary to opinion most
vehicle crashes do not involve fire

Internal bleeding
 Check ABC
 Lie on side
 Treat shock
 Seek medical attention
External bleeding
7. Direct wound pressure
8. Elevate
9. Pressure points
10. Tourniquet

AIR WAY OBSTRUCTION
1. Types
b. Anatomical b. Mechanical

2. Classification

f. Mild b. Severe
Management
8. Head tilt chin lift 2. jaw thrust
3. Heimlich 4. Chest and
abdominal thrust

NOSE BLEEDING
Sit upright , head bent slightly forward, pinch the nostrils,
breath trough our mouth.

Water rescue – “Reach, Throw, Row, Go”


The End?

Hindi pa !.


TEST TAKING TECHNIQUES
1. Discern The Exam
 Concentrate on fundamentals
 Therapeutic Communication
 Aseptic Techniques
 Safety
 Nursing Priority
 Basic law touching the practice
 lot of Question from Community
 Ethical Practice select ans. Respecting
human Rights

2. Prepare your self
 Get enough rest
 Eat right
 Drink your vit.
 Exercise
 Avoid negative talk
 Release anxiety to your friends
 Seek help and verbalize
 Relaxation techniques

3. Organize your study time.
There maybe no two individuals who will have the
same way of studying. Some prefer studying at
night while some, early in the morning or during the
day. Some, may have so much work at home, they
can only spare a few hours studying. Whatever is
your circumstances is, there are the basic rules in
organizing study time:


 Make a checklist of all the things to review.
 Make a schedule of this checklist.
 Don’t overkill. Do not give so much time on one area
while forgetting the others. Don’t just use your favorite
area, give equal time even on those that you feel are
not coming out of exam.
 Organize your study time by reviewing on the basic
first, then at the last part of your schedule, make sure
you test yourself by answering exam question.
 Allow much flexible to accommodate your other
important activities.
 I always help to remove all distraction like cell phones
and television. Boyfriends and girlfriends may
schedule later.


4. let’s dissects the Monkey.
 Read the question carefully from the first word to
the last word. Remember not to miss out on key
words that would lead you to what the question is
really asking for.
 look for hints…

-“most, first, best, initial”- indicate you must establish
priorities.
-“further teaching is necessary”- answer will contain
incorrect information.
-“understand the teaching”- answer will be correct
information.

3. rephrase the question in your own words so that it can be
answered w/a ”yes” or a “no”, or w/ a specific bit of
information.
-“what”.”when”, “why”

Example:
The nurse should teach the patient who was
cirrhosis of the liver to avoid w/c of the ff. food in
the diet?

a. Baked chicken
b. Apple pie
c. Macaroni
d. Spinach

Rephrase: what is the metabolic problem of the patient
w/ liver cirrhosis?
Answer: he cannot digest fat
What food is contraindicated for the patients w/ liver
cirrhosis
Answer: fatty foods. Thus, among the choices,
baked chicken should not be given.


HOW TO SCORE POINTS

 Step1. Read the question. Spend more time on
reading the question. learn to rephrase. Underline
the key words to increase tour understanding on the
important aspect of the problem.

 Step2: after reading the question, stop. Before
looking at the options, think of an answer.

 Step3: selection pass. In selecting the correct answer,
read each option carefully and do this.

Step 3.1 cover all answer choices except one.

Step3.2 read answer choices
1. then repeat the REWORDED QUESTION after reading
answer choice. As yourself…
“does this answer the REWORDED QUESTION.
If it does not – eliminate
Not sure- leave the answer choice for consideration

Step 3.3 repeat the above process w/ each
remaining answer choices.

Step 3.4 note w/c answer choice remain.

Step 3.5 reread the question to make sure you have
correctly identified the REWORDED QUESTION


REWORDED QUESTION.
STEP 3.6 ask yourself “ w/c answer choices best
answer the question?:
THAT IS YOUR ANSWER!!!
R E M E M B E R ! ! !
1. eliminate only what you know is wrong. Once
choice has been eliminated.. PUT IT OUT OF
YOUR MIND!!!
2. stay focus on the REWORDED QUESTION. Not
on the back information!!! Don’t fall for
distraction!!!
3. if your “ideal” answer choice is not there… well
don’t sit and moan because it will get you
nowhere… read the question again, rephrase,
and select the best answer.


Look for Qualifiers
“Never, always, all, none” Most often absolute terms, generalizations. Do not choose
these options.

Look for contrasting options.
Usually contrasting option lead you to correct answer.
1 of this is the right answer.

Example.
Mr. bean is suffering from gastric ulcer. As a nurse, you have to prevent
dumping syndrome. Which of the ff. preventive measures should noy be
taken?
a. allow him to lie down after eating
b. avoid giving fluids after meal.
c. allow him to talk after eating.
d. serve dry meals only.

Choices a & c are contrasting option, thus one of these may be the
correct option, eliminating b& d. the question may be rephrase
to” what is the best position after meals to prevent dumping
syndrome?” the answer is… a. allow him to lie down after meal,
but the question is asking for the measure that should not be
advice, thus the answer is… c
3. PRIORITIES. The board exam is testing your ability to decide
your priorities in patient care. The most common bases of
prioritization are:
a. ABC’s – airway, breathing & circulation
b. Safety and protection- decide what will cause the least amount of
harm. DO NO HARM!!!
c. Rights of patient- will of the patient is the basis for action. We
are safeguards and advocates of the patient well being.
d. Assessment comes before any intervention.
e. The less invasive procedures first before invasive one.
f. Remember MASLOW!!! Physiologic needs comes as a priority
g. Patient first before equipment.


4. NORMALS-decide if the assessment data
being presented in the question is within
normal range. If the answer is yes, you
just have to look for the option that will
not need further intervention..
only continue monitoring or assessment. If
the answer is otherwise ,then go ahead and
rephrase the question…and follow the steps in
answering a question. Familiarize yourself
with the values will be much easier than
memorizing. Post them on your walls where
you see them everyday.


5. Always be therapeutic.
Therapeutic simply means choosing the options that will solicit
information from the patients and make him/her express his
feelings. Usually, we eliminate options that will:

6. It is your business not others
Eliminate choices that what doctors midwife or social
workers do

7. Do every thing by the book.
Every thing is taken from the books, based on
ideal settings.

Emergency Nursing

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