NURSING

CARE MANAGEMENT
104
EMERGENCY
AND
DISASTER
NURSING
 Q AND A
Critical Thinking

1. The following clients present to a walk-in clinic at the

same time. Which should the nurse schedule to be seen
first?
A. 25 year old with high fever, vomiting and diarrheab. 38 year old
with sore throat, fever, and swollen lymph glandsc. 40 year old
with severe headache, vomiting and stiff neckd. 44 year old
limping on a very swollen bruised ankle
 Q AND A
Critical Thinking

2. The nurse just received report on the following clients.

Who should the nurse see first?
a. 35 year old with suspected acute tubular necrosis, urine output
totaled 25ccs for the last two hours.b. 49 year old with cancer of the
breast, 2 days post mastectomy, reported to be having difficulty
coping with the diagnosis.c. 54 year old with TB in respiratory
isolation, requesting pain medicationd. 36 year old with chest tube
insertion after a spontaneous pneumothorax, respirations 16
 Q AND A
Critical Thinking

3. As a nurse working the ER, which client needs the most

immediate attention?
a. a 3 yr old with a barking cough, oxygen sat of 93 in room air, and
occasional inspiratory stridorb. a 10 month old with a tympanic
temperature of 102, green nasal drainage, and pulling at the earsc. an
8 month old with a harsh paroxysmal cough, audible expiratory
wheeze and mild retractionsd. a 3 year old with complaints of a sore
throat, tongue slightly protruding out his mouth, and drooling.
 Q AND A
Critical Thinking

4. The charge nurse is apporached by a new graduate nurse

who has been assigned four clients: a diabetic with a 4:00 pm
blood sugar of 99, a cardiac client with a potassium of 3.3,; a
client with pyelonephritis with a temperature of 100.8, and an
adult client with a 20% second degree burn of the legs. Which
client should the charge nurse suggest to assess first?
a. the diabeticb. the cardiac clientc. plelonephritis clientd. burn client
 SCOPE AND PRACTICE OF
EMERGENCY NURSING

1. The emergency nurse has had specialized education, training,

and experience.

2. The emergency nurse establishes priorities, monitors and

continuously assesses acutely ill and injured patients,
supports and attends to families, supervises allied health
personnel, and teaches patients and families within a time-
limited, high-pressured care environment.
SCOPE AND PRACTICE OF
EMERGENCY NURSING

3. Nursing interventions are accomplished interdependently, in

consultation with or under the direction of a licensed
physician.

4. Appropriate nursing and medical interventions are anticipated

based on assessment data.

5. The emergency health care staff members work as a team in

performing the highly technical, hands-on skills required to
care for patients in an emergency situation.
SCOPE AND PRACTICE OF
EMERGENCY NURSING

6. Patients in the ED have a wide variety of actual or potential

problems, and their condition may change constantly.

7. Although a patient may have several diagnosis at a given

time, the focus is on the most life-threatening ones
 Q AND A
Critical Thinking

1. A nurse on the cardiac unit is caring for four clients in the

emergency room. Which client should the nurse assess first?a) a
client scheduled for cardiac ultrasound this morningb) a client with
syncope being discharged todayc) a client with chronic bronchitis
on nasal oxygend) a client with a diabetic foot ulcer that needs a
dressing change
 Q AND A
Critical Thinking

2. A nurse enters a room and finds lying face down on the floor,
bleeding from a gash in the head. Which action should the nurse
perform first?a) determine level of consciousnessb) push the call
button for helpc) turn the client face up to assessd) go out in the
hall to get the nursing assistant to stay with the client while the
nurse calls the physician
 Q AND A
Critical Thinking

2. A nurse enters a room and finds lying face down on the floor,
bleeding from a gash in the head. Which action should the nurse
perform first?a) determine level of consciousnessb) push the call
button for helpc) turn the client face up to assessd) go out in the
hall to get the nursing assistant to stay with the client while the
nurse calls the physician
 Q AND A
Critical Thinking

You are on duty in the ED when a code is called overhead.

As the code nurse, you grab the crash cart and run to the
code, which is in the employees lounge of the operating
room. On the couch you find a nurse unconscious, cyanotic
and barely breathing. His scrub shirt has been cut off, and
you attach ECG leads to his chest. His pulse is 45;
respirations are 8 and shallow.
 Q AND A
Critical Thinking

You are on duty in the ED when a code is called overhead.

As the code nurse, you grab the crash cart and run to the code, which is in the employees
lounge of the operating room. On the couch you find a nurse unconscious, cyanotic and
barely breathing. Her scrub shirt has been cut off, and you attach ECG leads to her chest.
Her pulse is 45; respirations are 8 and shallow.

A. INTUBATION
B. IV LINE INSERTION
C. DEFIBRILLATION
D. CHEST TUBE INSERTION
E. SURGICAL PREPARATION
 Q AND A
Critical Thinking

You are on duty in the ED when a code is called overhead.

As the code nurse, you grab the crash cart and run to the code, which is in the employees
lounge of the operating room. On the couch you find a nurse unconscious, cyanotic and
barely breathing. Her scrub shirt has been cut off, and you attach ECG leads to her chest.
Her pulse is 45; respirations are 8 and shallow.

A. MORPHINE
B. NALOXONE
C. ATROPINE
D. DEXAMETHASONE
E. D5 LR
F. 0.9% NaCl
G. D5W
H. LASIX
 Q AND A
Critical Thinking

You are on duty in the ED when a code is called overhead.

As the code nurse, you grab the crash cart and run to the code, which is in the employees
lounge of the operating room. On the couch you find a nurse unconscious, cyanotic and
barely breathing. Her scrub shirt has been cut off, and you attach ECG leads to her chest.
Her pulse is 45; respirations are 8 and shallow.

A. MORPHINE
B. NALOXONE
C. ATROPINE
D. DEXAMETHASONE
E. D5 LR
F. 0.9% NaCl
G. D5W
H. LASIX
FOCUS OF EMERGENCY
CARE
Preserve or prolong life

Alleviate suffering

Do no further harm

Restore to optimal function

 GUIDELINES IN GIVING
EMERGENCY CARE

A - ASK FOR HELP

I - INTERVENE

D - DO NO FURTHER HARM
CORE COMPETENCIES IN
EMEGENCY NURSING
Assessment
Priority setting/critical thinking skills
Knowledge of Emergency Care
Technical skills
Communication skills
CHAIN OF SURVIVAL

EARLY ACCESS early recognition of

cardiac arrest, prompt activation of
emergency services

EARLY BLS prevent brain damage, buy

time for the arrival of defibrillator

19 DaRRaN
CHAIN OF SURVIVAL

EARLY DEFIBRILLATION

EARLY ACLS technique that

attempts to stabilize patient

20 DaRRaN
 Emergency Action Principle
I. Survey the Scene
A. Is the scene is safe?
B. What happened?
C. Are there any bystanders who can
help?
D. Identify as a trained first aiders.
II. Do a Primary Survey
A - Airway/Cervical Spine
Establish Patent Airway
Maintain alignment
Emergency Action Principle

B - Breathing
Assess breath sounds
Observe for chest wall trauma
Prepare for chest decompression
C - Circulation
Monitor VS
Maintain vascular access
Direct pressure
Control of
Hemorrhage

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24
Emergency Action Principle
D - Disability
Evaluate LOC
Re-evaluate clients LOC

E - Exposure
Remove clothing
Maintain privacy
Prevent hypothermia
Emergency Action Principle

III. Activate Medical Assistance

A. Information to be relayed:
- What happened?
- Number of persons injured
- Extent of injury and first aid given
- Telephone number from where you
are calling
Emergency Action Principle
IV. Do Secondary Survey
A. Interview the Patient
S - Symptoms
A - Allergies
M - Medication
P - Previous/Present Illness
L - Last Meal Taken
E - Events Prior to Accident
B. Check the vital signs

V. Triage
- Comes from the French word
trier, meaning to sort
 TRIAGE: Categories
1. Emergent
-highest priority, conditions
are life threatening and need
immediate attention
TRIAGE: Categories

2. Urgent
have serious health
problems but not immediately
life threatening ones. Must be
seen within 1 hour

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29
 TRIAGE: Categories

3. Non-urgent
patients have episodic
illness than can be addressed
within 24 hours without
increased morbidity

30
 FIELD TRIAGE

1. Immediate:
Injuries are life-threatening but
survivable with minimal
intervention. Individuals in this
group can progress rapidly to
expectant if treatment is delayed.
 FIELD TRIAGE

2. Delayed:
Injuries are significant and require
medical care, but can wait hours
without threat to life or limb..
 FIELD TRIAGE

3. Minimal:
Injuries are minor and treatment
can be delayed hours to days.
Individuals in this group should
be moved away from the main
triage area.
 FIELD TRIAGE
4. Expectant:
Injuries are extensive and chances
of survival are unlikely even with
definitive care.

5. Fast-Track:
Psychological support needed
T RAUM A
HEAD TRAUMA
Result of an external force
applied to the head and
brain causing disruption of
physiologic stability
locally, at the point of
injury

Trauma to the skull resulting

in mild to extensive
damage to the brain.
 TYPES
1. Open
- Scalp lacerations
- Fractures in the skull
- Interruption of the dura mater

2. Closed
Concussions
Contusions

3. Hemorrhage
causes hematoma or clot
formation
 TYPES OF
HEMATOMA

1. Epidural Hematoma

2. Subdural Hematoma

3. Intracerebral Hemorrhage
MANIFESTATIONS
Altered level of
consciousness
Confusion
Papillary abnormalities
Altered or absent gag reflex
or vomiting
Absent corneal reflex
Sudden onset of neurologic
deficits
MANIFESTATIONS
Vision and hearing
impairment
CSF drainage from ears or
nose
Sensory dysfunction
Spasticity
Headache and vertigo
Movement disorders or
reflex activity changes
Seizure activity
 INTERVENTIONS
GOAL: Maintain oxygen and
nutrient rich cerebral blood
flow
1.Monitor respiratory status
and airway
2.Neurologic status and VS
3.Monitor inc. ICP
4.Head elevation 20-30
degrees
5.Restrict fluids and monitor I
and O
6.Immobilization of neck
7.Initiate normothermia
measures
 INTERVENTIONS
GOAL: Maintain oxygen and
nutrient rich cerebral blood
flow
8. Assess cranial nerve fxn,
reflexes, and motor and
sensory fxns.
9. Initiate SZ precautions.
10. Monitor for pain and
restlessness
11. Avoid administration of
morphine sulfate
12. Monitor for drainage from
the nose or ears.
 INTERVENTIONS
GOAL: Maintain oxygen and
nutrient rich cerebral blood
flow
13. If there are leaks, monitor
for nuchal rigidity.
14. Do not attempt to clean
the nose, suction or allow the
client to blow the nose if
drainage occurs
15. do not clean te ear of
drainage when noted but
apply a loose, dry sterile
dressing
 MEDICAL
INTERVENTIONS
1.Osmotic diuretics
2.Loop diuretics
3.Opioids
4.Sedatives
5.Antiepileptic drugs
 CHEST TRAUMA
Approximately a quarter of deaths
due to trauma are attributed to
thoracic injury.
Reasons of immediate deaths
Reasons of early deaths
CLASSIFICATION OF
CHEST TRAUMA

1. BLUNT TRAUMA
Example: Rib fractures

2. PENETRATING TRAUMA
Management:

1. Rest

2. Ice Compress then Local Heat

3. Analgesia

4. Splint the chest during

coughing or deep breathing
FLAIL CHEST

The unstable segment moves separately and in

an opposite direction from the rest of the
thoracic cage during the respiration cycle.

Assessment:
- Paradoxical respirations
- Severe chest pain
- Dyspnea/ Tachypnea
- Cyanosis
- Tachycardia
Management:

1. High Fowlers position

2. Humidified O2
3. Analgesia
4. Coughing & deep breathing
5. Prepare for intubation with mechanical
ventilation
B. Penetrating Chest Trauma
- occurs when a foreign object penetrates the
chest wall
1.Pneumothorax
- Accumulation of atmospheric air in
the pleural space
may lead to lung collapse
Types:

1.Spontaneous Pneumothorax
2.Tension Pneumothorax
Assessment:
o Dyspnea
o Tachypnea
o Absent breathe sounds
o Sucking sound
o Cyanosis
o Sharp chest pain
o Tachycardia
Management:
1. Apply dressing over an open chest wound
2. O2 as Rx
3. High Fowlers
4. Chest tube placement
- Monitor for chest tube system
- Monitor for subcutaneous emphysema
Chest Tube Drainage System
- returns (-) pressure to the intra-pleural
space
- remove abnormal accumulation of air &
fluids serves as lungs while healing is going
on
Pulmonary Embolism

- Dislodgement of thrombus to the

pulmonary artery

- Caused by thrombus & pulmonary

emboli

- Other risk factors: deep vein

thrombosis, immobilization,
surgery, obesity, pregnancy, CHF,
advanced age, prior History of
thromboembolism
Assessment
Dyspnea
Chest pain
Tachypnea & tachycardia
Hypotension
Shallow respirations
Rales on auscultation
Cough
Blood-tinged sputum
Distended neck veins
Cyanosis
Management
1. O2 as Rx
2. High Fowlers
3. Maintain bed rest
4. Incentive spirometry as Rx
5. Pulse oximetry
6. Prepare for intubation & mechanical
ventilation
7. IV heparin (bolus)
8. Warfarin (Coumadin)
9. Monitor PT & PTT closely
10. Prepare the client for embolectomy, vein
ligation, or insertion of an umbrella filter as
Rx
ABDOMINAL TRAUMA

A. Penetrating Abdominal Trauma

Causes:
- Gunshot wound
- Stab wound
- Embedded object from explosion

Assessment:
- Absence of bowel sound - Hypovolemic shock
- Orthostatic hypotension - Pain and tenderness

Management:
1. Maintain hemodynamic status IVF & blood transfusion
2. Surgery- EXLAP
3. Peritoneal Lavage
B. Blunt Abdominal Trauma
Assessment:

- Left upper quadrant pain (Spleen)

- Right upper quadrant pain (liver)
- Signs of hypovolemic shock
Management:

1. Maintain hemodynamic status

2. Monitor VS and oxygen supplements
3. Assess signs and symptoms of shock
FOREIGN BODY
AND
AIRWAY
OBSTRUCTION
CAUSES:

improper chewing of large pieces of food

aspiraton of vomitus, or a foreign body

position of head, the tongue

resulting to difficulty of breathing or

respiratory arrest

60 DaRRaN
 Types of Obstruction

I. Anatomical
tongue and epiglottis

I. Mechanical
coins, food, toy etc
Assessment and Clinical
Manifestations

1. Mild airway obstruction

- can talk, breath and cough with
high pitch breath sound
- cough mechanism not effective
to dislodge foreign body
2. Severe airway obstruction
- cant talk, breath or cough
3. Nasal flaring, cyanosis, excessive salivation

62 DaRRaN
Intervention:
CONCIOUS PATIENT:

1. Ask the victim, are you choking?

2. If the victims airway is obstructed partially, a crowing
sound is audible; encourage the victim to cough.
3. Relieve the obstruction by heimlick maneuver
A. Heimlich maneuver:
- stand behind the victim
- place arms around the victims waist
- make a fist
- place the thumb side of the fist just above the umbilicus
and well below the xyphoid process.
- Perform 5 quick in and up thrusts.
- Continue abdominal thrusts until the object is
dislodged or the victim becomes unconscious.

63 DaRRaN
 UNCONSCIOUS PATIENT

1. Assess LOC
2. Check for ABCs
3. Open airway using jaw thrust technique
4. Finger sweep to remove object
5. Attempt ventilation
6. Reposition the head if unsuccessful; reattempt ventilation
7. Relieve the obstruction by the Heimlich maneuver with five
thrust; then finger sweep the mouth
8. Reattempt ventilation
9. Repeat the sequence of jaw thrust, finger sweep, breaths
and Heimlich maneuver until successful
10. Be sure to assess the victims pulse and respirations
11. Perform CPR if required

64 DaRRaN
 Choking Child or Infant

Choking is suspected in infants and children experiencing

acute respiratory distress associated with coughing,
gagging, or stridor.
Allow the victim to continue to cough if the cough is
forceful
If cough is ineffective or if increase respiratory difficulty is
still noted, perform CPR

65 DaRRaN
 Foreign Objects in the Ear
Dont probe the ear with a tool

Remove the object if clearly visible

Try using gravity and shake the head gently

Try using oil for an insect

Dont use oil to remove any other object than an

insect
 Foreign Objects in
the Eye

Flush eye clear with use of water

 Foreign Objects in the Nose

Dont probe at the object with cotton ball or other tool

Breathe thru your mouth until the object is removed

Blow your nose gently to try to free the object

POISONING

69 DaRRaN
 Poison

Any substance that impairs

health or destroys life when
ingested, inhaled or
otherwise absorbed by the
body.

70 DaRRaN
Suspect poisoning if:

1. Someone suddenly becomes ill for no apparent

reason and begins to act unusually
2. Is depressed and suddenly becomes ill
3. Is found near a toxic substance and is breathing any
unusual fumes, or has stains, liquid or powder in his
or her clothing, skin or lips

1. 71 1. DaRRaN
 Ingestion Poisoning

Botulism Clostridium botulinum. From canned foods

Staphylococcus Aureus from unrefrigerated pack filled

foods, fish

Petroleum Poisoning includes poisoning with a substance

such as kerosene, fuel, insecticides and cleaning fluids
 Acetaminophen Poisoning most common drug accidentally
ingested by children

Corrosive Chemical Poisoning strong detergents and dry

cleaners
results in drooling of saliva, painful burning sensation and pain and
redness in the mouth
Diagnostics:
1. Baseline ABG should be obtained periodically
2. Baseline blood samples
3. ECG

Assessment:
4. Headache
5. 2. Double vision
6. Difficulty in swallowing, talking and breathing
7. Dry sore throat
8. Muscle incoordination
9. Nausea and vomiting

74 DaRRaN
 Management

1. Check victims ABCs.

2. If victim starts having seizures, protect him
from injury
3. If victim vomits, clear the airway
4. Calm and reassure the victim while calling
for medical help

75 DaRRaN
P Prevention. Child Proofing
O Oral fluids in large amount
I - Ipecac
S Support respiration and
circulation
O - Oral Activated Charcoal
N - Never induce vomiting if
substance ingested is corrosive

76 DaRRaN
 Inhalation
Poisoning
Carbon Monoxide Poisoning
- Carbon monoxide is a colorless, odorless &
tasteless gas

Assessment:
- appears intoxicated
- Muscle weakness
- Headache & dizziness
 Management
1. Check ABCs

2. Remove victim from exposure

3. Loosen tight clothing

4. Administer O2 (100% delivery)

5. Initiate CPR if required

78 DaRRaN
BURN TRAUMA

Is the damage caused to skin

and deeper body structures by
heat (flames, scald, contact
with heat), electrical, chemical
or radiation.
FACTORS DETERMINING
SEVERITY OF BURN

1. Age

2. Patients medical condition

3. Location

4. Depth
 4. Depth

Affected Part Description of Wound What to Expect

Classification

1st degree Epidermis Pin, painful sunburn Discomfort last after 48 hrs; heals in 3-7 days
superficial Blisters form after 24
hours

2nd degree Pediermis and part of Red, wet blisters, bullae Heals in 2-3 weeks, in no complication
partial thickness the dermis very painful

2nd degree Only the skin Waxy white, difficult to Slow to heal 94-8 weeks) surgical incision and grafting unless has
deep partial thickness appendages in the hair distinguish from 3rd complication
follicle remain degree except hair
growth becomes
apparent in 7-10 days,
little or no pain

3rd degree Epidermis, dermis and -Dry, leathery, Requires excision and grafting.
Full thickness subcutaneous tissue . no may be red or 10- 14 days for graft to revascularize
skin appendages black
-May have
thrombosed
veins
-Marked edema
-Distal
circulation may
be decreased
-Painless

4th degree Skin, muscle, tendon, Dry, charred, bone may Requires excision, grafting and sometimes amputation
deep full thickness bonde be visible

81 DaRRaN
5. Size: Rule of nine

Child < 3 years Adult

Assessment old

Head and neck 18% 9%

1 arm 9% 9%

Posterior trunk 18% 18%

Anterior trunk 18% 18%

1 leg 14% 18%

Perineum 1% 1%

82 DaRRaN
6. Temperature
determines the extent of injury

7. Exposure to the Source

A. Thermal Burns caused by exposure to

flames, hot liquids, steam or hot objects
B. Chemical Burns caused by tissue contact
with strong acids, alkalis or organic compounds
C. Electrical Burns result in internal tissue
damaging, alternating current is more
dangerous than direct current for it is
associated with cardiopulmonary arrest,
ventricular fibrillation
D. Radiation Burns are caused by exposure to
ultraviolet light, x-rays or a radioactive source.
 Types of Burns and their
Treatment
Scald
1. Burn caused by hot liquid
2. Immediately flush the burn area with water (under a tap or hose
for up to 20 min)
3. If no water is readily available, remove clothing immediately as
clothing soaked with hot liquid retains heat
Flame
1. Smother the flames with a coat or blanket, get the victim on the
floor or ground (stop, drop, and Roll)
2. Prevent victim from running
3. If water is available, immediately cool the burn area with water
4. If water is not available, remove clothing; avoid pulling clothing
across the burnt face
Airway
1. If face or front of the trunk is burnt, there could be burns to the
airway
2. There is a risk of swelling or air passage, leading to difficulty in
breathing
 Smoke inhalation
1. Urgent treatment is required with care of the airway,
breathing and circulation
2. When 02 in the air is used up by fire, or replaced by
other gases, the oxygen level in the air will be
dangerously low
3. Spasm in the air passages as a result of irritation by
smoke or gases
4. Severe burns to the air passages causing swelling and
obstruction
5. Victim will show signs and symptoms of lack of O2. He
may also be confused or unconscious

Electrical
1. Check for Danger
2. Turn of the electricity supply if possible
3. Avoid any direct contact with the skin of the victim or
any conducting material touching the victim until he is
disconnected
4. Once the area is safe, check the ABCs
5. If necessary, perform rescue breathing or CPR

85 DaRRaN
 Chemical
1. Flood affected area with water for 20-30
min
2. Remove contaminated clothing
3. If possible, identify the chemical for
possible subsequent neutralization
4. Avoid contact with the chemical
Sunburn
1. Exposure to ultraviolet rays in natural
sunlight is the main cause of sunburn
2. General skin damage and eventually
skin cancer develops
3. The signs and symptoms of sunburn are
pain, redness and fever
86 DaRRaN
 FACT

When we treat man as he

is, we make him worse
than he is; when we treat
him as if he already were
what he potentially could
be, we make him what he
should be