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Ita Yuanita
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Non trauma and trauma room
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EMERGENCY NURSING the delivery of specialized care to variety of ill or
injured patient. Such as pt may be unstable, have
complex needs, required intensive and vigilant nrsgcare
practice of episodic, primary, critical and acute
nursing care of all ages who experience physical
emotional or psychological alterations in health.
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Priorities
Major Goals1. To preserve life
2. To prevent deterioration before more definitive
treatment can be given.3. To restore the patient to useful living
***injuries to face, neck and chest that impairs
respiration are the highest priorities
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Five key ethical principles (after Beauchamp and
Childress 1989) Respect for the individual
The need to ensure confidentiality and privacy
Respect for the autonomy of the individual
The need to ensure appropiate consent is given by the patient or relative Beneficence/non malfeasance
The need to ensure that decisions regarding treatment for the individualpatient are designed to be of benefit to patient, not merely to avoid harm
Honesty
That individual patients and families are given honest information regardingprogress and prognosis
Justice
Equity od access rather then postcode service
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PATIENTS SAFETY WHO/JCI Infection control
Correct patients identification
Effective communication (read back, repeat back)
High alert medication (look like, sound like drugs)
Prevent patients fall
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Role and responsibleliety of
emergency nurse
MAKING SURE THAT ALL PATIENTS AND MEMBER
OF THEIR FAMILIES RECEIVE CLOSE ATTENTION
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Role of Emergency NursesAdcovate
Surveillance
Safety officer Patient care
Triage
Risk Communication Forensics supervisor
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SC AHEC Sept. 10, 2004
Functional roles of emergency nurses
Functional role Triage Charge Nurse
Emergent Care ChargeNurse
Urgent Area ChargeNurse
Minor TreatmentLeader
Minor Treatment AreaCharge Nurse
Structural Position Triage Charge Nurse
Senior ED RN Urgent Area Charge RN
Nurse Practitioner
Medical/Surgical Nurse
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CONDITIONS OF EMERGENCY ROOM
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Triage Is a method of prioritizing patient care according to
the type of illness or injury and the urgency of thepatient's condition
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Tr iage Rating Systems: 3 Categories
a. Emergent (red)conditions requiring IMMEDIATE CARE and
intervention because of increased risk of mortality or threat to
life, limb or vision.
B-burns
C-chest pain-cardiac arrestR-respiratory distress
H-hemorrhage sec. to ectopic pregnancy
M-major blunt or penetrating trauma
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ENA guidelines for triage based on 5
tier system: Level I : Resuscitation - this level includes patients
who need immediate nursing and medical attention,such as those with cardiopulmonary arrest, majortrauma, severe respiration distress and seizures
Level II: Emergent - these patients need imadiatenursing assessment and rapid treatment. Patients whomay be assessed as level II include those with headinjuries, chest pain, stroke, asthma, and sexual assaulinjuries
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Level III : Urgent - these patients need quick attention,but can wait as long as 30 minutes for assessment andtreatment. Such as patient might report to ED withsign of infection, mild respiratory distress or moderatepain
Level IV : less urgent - patients in this category can
wait up to 1 hours for assessment and treatment; theymay include earache, those with chronic back pain,upper respiratory symptoms and mild headache
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NURSING RESPONSIBI L I TIES
Assessment:
a.Primary Assessmentrapid initial assessment of the
symptoms to determine life threatening conditions
while simultaneously intervening.
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PRIMARY SurveyCirculation
adequate circulation to maintain cellular tissue perfusion.
Abnormal : bradycardia or tachycardia. cool, pale and
diaphoresis, obvious uncontrolled external bleeding, decrease
LOC
Assess LOC, using mnemonic : A Very Practical Use(AVPU)
A = alert, oriented patientV = responds to VoiceP = respond to PainU = Unresponsive Patient
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Primary Survey Airway
with C spine immobilization, patent airway, ability to speak,
foreign body, chest expansion
Nursing diagnosis : ineffective airways clearance, risk for
aspiration, impaired ventilation spontaneous
Interventions : chin-lift / jaw thrust, suctioning, intubation,
cricothyroidectomy, tracheostomy, cervical spine neutral
position.
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Nursing diagnosis : Decreased cardiac output, risk forshock
Interventions :
direct pressure to control external bleeding
IV access
CPR
Pericardiocentesis-aspiration of blood from pericardial sac AutotransfusionBT of one s own blood
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PRIMARY SURVEY
Breathing- effectiveness of breathing and ventilation ability.Abnormal : apnea, weak, shallow/labored respiration
diminished /absent breath sounds
unequal chest expansion
retractions/ paroxysmal chest wall movementtracheal deviation
Open chest wound
Examples : chest trauma
Subcutaneous emphysema
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Nursing diagnosis : ineffective airways clearance,
ineffective breathing pattern, Impaired gas exchange,
impaired ventilation spontaneous
Nursing interventions
1. Oxygen therapy
2. Chest tube insertion, intubation
3. Pressure dressing on a flail segment of the ribs
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Disability
complete a brief neurological assessment todetermine baseline functioning, potential life
threatening complications, LOC.
Abnormal: Unresponsive
altered pupils : fixed pupils,
papillary respons abnormalities.
Expose- remove all clothing from the client to facilitate a
thorough complete secondary assessment
examination.
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Get other assessment aids : cardiac monitor, pulse
oxi,urinary catheter, NGT, lab. studies: CBC,
electrolytes, Fibrin degradation products
(coagulation), amylase, lactate; renal studies ;blood type and crossmatch; toxicology studies.
History
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References Emergency Preparedness and Response.
Explosions and Blast Injuries: A Primer forClinicians.http://www.cdc.gov/masstrauma/preparedness/primer.htm#key
Lippincott. Emergency Nursing Made
Incredibly Easy!
http://www.cdc.gov/masstrauma/preparedness/primer.htmhttp://www.cdc.gov/masstrauma/preparedness/primer.htmhttp://www.cdc.gov/masstrauma/preparedness/primer.htmhttp://www.cdc.gov/masstrauma/preparedness/primer.htm