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. EMERGENCY NURSING needs It is the nursing care given to patients with urgent and critical
EMERGENCY NURSE
has a specialized education, training, and experience to gain expertise in assessing and identifying patients health care problems in crisis situations
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, highpressured care environment
DISASTER NURSING a branch of emergency nursing, it refers to nursing care given to patients who are victims of disasters, whether it is manmade or natural phenomena. INCIDENT COMMAND SYSTEM It is a management tool for organizing personnel, facilities, equipment, and communication for any emergency situation.
He must be continuously informed of all the activities and informed about any deviation from the established plan
Deactivation Response
Post- Incident Response Plan for Practice Drills
it is used to sort patients into groups based on the severity of their health problems and the immediacy with which these problems must be treated
TRIAGE NURSE acts as a gatekeeper, sorting patients into categories, ensuring that the more seriously ill are treated first
Conditions requiring immediate medical intervention, any delay in treatment is potentially life or limb threatening. Must be seen IMMEDIATELY! EXAMPLES: AIRWAY COMPROMISE
CARDIAC ARREST SEVERE SHOCK CERVICAL SPINE INJURY MULTISYSTEM TRAUMA
PATIENTS WHO PRESENT AS STABLE BUT WHOSE CONDITION REQUIRES MEDICAL INTERVENTION WITHIN A FEW HOURS.
PATIENTS WHO PRESENT WITH CHRONIC OR MINOR INJURIES NO DANGER TO LIFE OR LIMB PATIENTS ARE IN NO OBVIOUS DISTRESS
EXAMPLES:
CHRONIC LOW BACK PAIN DENTAL PROBLEMS MISSED MENSES
TRIAGE CATEGORY
PRIORITY 1 2 3 4
TYPICAL CONDITIONS:
Sucking chest wound airway obstruction secondary to mechanical cause,
shock
hemothorax, tension pneumothorax asphyxia unstable chest and abdominal wounds, incomplete amputations, open fractures of long bones 2nd / 3rd degree burns of 15-40% TBSA
TYPICAL CONDITIONS:
Stable abdominal wounds w/o evidence of significant hemorrhage soft tissue injuries
TYPICAL CONDITIONS:
Upper extremity fractures Minor Burns Sprains Small Lacerations w/o significant bleeding Behavioral disorders or Psychological disturbances
TYPICAL CONDITIONS:
Unresponsive patients w/ penetrating head wounds High spinal cord injury
IRWAY
REATHING
IRCULATION
ISABILITY
XPOSE
SECONDARY ASSESSMENT: Systematic, brief (2-3 mins) examination from head to toe; Purpose is to detect and prioritize additional injuries and detect signs of underlying medical conditions What is the mechanism of injury? When did the symptoms appear? Was the patient unconscious after the accident? How did the pt. reach the hospital?
What was the health status of the patient prior the accident or illness?
Is there history of present illness? Is the patient taking any medications?
Understand and accept basic anxieties, be aware of patients fear Accept the rights of the patient and family, to have and display their feelings Maintain a calm and reassuring manner Treat the unconscious patient as if CONSCIOUS. (Touch, call by name, explain every procedure)
take them on a private place and talk to them so they can mourn together
assure the family that everything was done avoid giving sedation to family members
1. BASIC LIFE SUPPORT - an emergency procedure that consists of recognizing respiratory or cardiac arrest or both the proper application of CPR to maintain life until a victim recovers or advance life support is available.
- the use of special equipment to maintain breathing and circulation for the victim of a cardiac emergency.
1.The FIRST LINK: EARLY ACCESS It is the event initiated after the patients collapse until the arrival of Emergency Medical Services personnel prepared to provide care. 2.The SECOND LINK: EARLY CPR If started immediately after the victims collapse, the probability of survival approximately doubles when it is initiated before the arrival of EMS.
1.What to DO:
2.What Not to DO: Do not let the victim see his/her own injury. Do not leave the victim alone except to get help. Do not assume that the victims obvious injuries are the only ones. Do not make any unrealistic promises. Do not trust the judgment of a confused victim and require them to make decision.
-is a rapid movement of patient from unsafe place to a place of safety. Indications for emergency Rescue: 1. Danger of fire or explosion. 2. Danger of toxic gases or asphyxia due to lack of oxygen. 3. Natural Disasters 4. Risk of drowning.
5. Danger of electrocution.
6. Danger of collapsing walls. Methods of Rescue: 1. For immediate rescue without any assistance, drag or pull the victim. 2. Most of the one-man drags/carries and other transfer methods can be used as methods of rescue.
-is moving a patient from one place to another after giving first aid.
2. Hemorrhage is controlled.
3. Victim is safely maintained in the proper position. 4. Regular check of the victims condition is made. 5. Supporting bandages and dressings as remain effectively applied. 6. The method of transfer is safe, comfortable and as speedy as circumstances permit. 7. The patients body is moved as one unit. 8. First aiders/bearers must observed ergonomics in lifting and moving of patient.
Triangular bandages
- a technique of basic life support for the purpose of oxygenating the brain and heart until appropriate, definitive medical treatment can restore normal heart and ventilatory function. INDICATIONS: 1. Cardiac Arrest c. Foreign-body obstruction d. Smoke inhalation e. Electrocution f. Suffocation
a. Ventricular Fibrillation
b. Ventricular Tachycardia c. Asystole d. Pulseless electrical activity 2. Respiratory Arrest a. Drowning b. Stroke
g. Drug Overdose
i. Accident/Injury
j. Coma h. Epiglottitis
ASSESSMENT:
Immediate loss of consciousness Absence of breath sounds or air movement Absence of palpable carotid or femoral pulse; pulselessness in large arteries
COMPLICATIONS: Rib Fracture (most common) Postresuscitation Distress Syndrome Neurologic Impairment; Brain Damage
I.
RESPONSIVENESS/AIRWAY Determine unresponsiveness; ARE YOU OKAY? Activate Emergency Medical Assistance Place patient supine on a firm, flat surface. Kneel at the level of the patients shoulders Open the airway: HEADTILT/CHIN LIFT MANEUVER, JAW THRUST MANEUVER
WAYS TO VENTILATE THE LUNGS 1. MOUTH-TO-MOUTH = a quick, effective way to provide O2 and ventilation to the victim. 2. MOUTH-TO-NOSE = recommended when it is impossible to ventilate through the victims mouth. (Trismus, mouth injury)
Adult
Compression Area
Lower half of the sternum but not hitting the xiphoid process: measure up to 2 fingers from substernal notch. Approximately 1 to 2 inches Heel of 1 hand, other hand on top. 30:2 (1 or 2 rescuers)
Child
Lower half of the sternum but not hitting the xiphoid process: measure up to 1 finger from substernal notch. Approximately 1 to 1 inches Heel of 1 hand.
Infant
Lower half of the sternum but not hitting the xiphoid process: 1 finger width below the imaginary nipple line.
30:2 (1 or 2 rescuers)
5 cycles in 2 minutes
5 cycles in 2 minutes
5 cycles in 2 minutes
CRITERIA FOR NOT STARTING CPR All patients in cardiac arrest receive resuscitation unless:
2. The pt. has signs of irreversible death: rigor mortis, livor mortis, algor mortis, decapitation
3. No physiological benefit can be expected because the vital functions have deteriorated despite maximal therapy 4. Witholding attempts to resuscitate in the DR is appropriate for newly born infants with: Confirmed gestation less than 23 weeks or birthweight less than 400 grams Anencephaly
Clinical Manifestations: UNIVERSAL DISTRESS SIGNAL ( patient may clutch the neck between the thumb and fingers), choking, stridor, apprehensive appearance, restlessness. CYANOSIS and LOSS of CONSCIOUSNESS develop as hypoxia worsens.
For Standing or sitting conscious patient: Stand behind the patient; wrap your arms around the patients waist Make a FIST, placing thumb side of the fist against the pts abdomen, in the midline SLIGHTLY ABOVE the UMBILICUS and WELL BELOW the XIPHOID PROCESS Make a quick INWARD and UPWARD thrust. Each thrust is separated. For patient lying (unconscious): position patient at the back (supine); kneel astride the patients thigh Place HEEL of one HAND against the pts abdomen, place the second hand directly on the top of the fist. Make a quick UPWARD thrust
CHEST THRUST: used only in patients in advanced stages of pregnancy or in markedly obese clients a. Conscious Patient standing or sitting Stand behind the client with arms under patients axilla to encircle patients chest Place thumb side of fist on the MIDDLE of STERNUM, grasp with the other hand and perform BACKWARD thrust until foreign body is expelled.
A. HEAD-TILT-CHIN-LIFT MANEUVER
B. JAW-THRUST MANEUVER
C. OROPAHRYNGEAL AIRWAY D. ENDOTRACHEAL INTUBATION Indications: To establish an airway for patients cannot be adequately ventilated with an oropharyngeal airway To bypass upper airway obstruction To permit connection to ambubag or mechanical ventilator To prevent aspiration To facilitate removal of tracheobronchial secretions
E. CRICOTHYROIDOTOMY
a puncture or incision of the cricothyroid membrane to establish an emergency airway in certain emergency situations where endotracheal intubation or tracheostomy is not possible.
indicated to pts. with trauma to head and neck, and in allergic reaction causing laryngeal edema use of gauge 11 needle or scalpel blade Nursing Actions: Extend the neck. Place towel roll beneath the shoulders Insert the needle at a 10 to 30 degree caudal direction in the midline jest above the upper part of the cricoid cartilage Listen for air passing back and forth Direct the needle downward and posteriorly, and tape it.
1. OPEN HEAD INJURY skull is fractured 2. CLOSED HEAD INJURY skull is intact 3. CONCUSSION temporary loss of neurologic function with no apparent structural damage to the brain. 4. CONTUSSSION bruising of the brain tissue 5. INTRACRANIAL HEMORRHAGE significant bleeding into a space or potential space between the skull and the brain a. Epidural hematoma b. Subdural hematoma c. Subarachnoid hemorrhages ALERT: Assume cervical spine fracture for any patient with a significant head injury, until proven otherwise.
ALERT: If basilar skull fracture or severe midface fractures are suspected, a nasogastric tube(NGT) is CONTRAINDICATED!
MANAGEMENT:
Open airway by Jaw-Thrust Manuever, suction orally if needed Administer high flow oxygen: most common death is CEREBRAL ANOXIA In general, hyperventilate the patient to 20-25 bpm, causing cerebral vasoconstriction and minimizing cerebral edema Apply a bulky, loose dressing; dont apply pressure IV line of PNSS or Plain LR prepare to manage seizures
maintain normothermia
Medications: a. Diazepam b. Steroids c. Mannitol Prepare of immediate surgery if pt. shows evidence of neurologic deterioration
ALERT:
Damage to the brain is the first concern, it is considered a neurosurgical condition In children, skulls thinness and elasticity allows a depression w/o a break in the bone
PRIORITY NURSING DIAGNOSIS: ALTERED CEREBRAL TISSUE PERFUSION r/t increased ICP
TREATMENT:
For LINEAR FRACTURES: supporative (mild analgesics) cleaning and debridement of wounds If conscious: observed for 4 hours; if not, admit for evaluation if VS stable, may go home with instruction sheet
For VAULT and BASILAR FRACTURES: Craniotomy to remove fragemnts anti-biotics Dexamethasone Osmotic Diuretics (MANNITOL) if increased ICP is present
NURSING CONSIDERATIONS: maintain patent airway; nasal airway contraindicated to basilar fx support with O2 administration suction pt. through mouth not nose if CSF leak is present RHINORRHEA wipe it, dont let him blow it! OTORRHEA cover it lightly with sterile gauze, dont pack it! Position head on side Maintain a supine position with bed elevated to 30 degrees dont give narcotics or sedative assist in surgery, maintaining sterile technique
PRIMARY ASSESSMENT: Immobilization of spine while performing assessment ABC (tongue swelling, bleeding, broken or missed teeth) SUBSEQUENT ASSESSMENT: Paralysis if the upward gaze indicative of INFERIOR ORBIT FX Crepitus on nose indicates nasal fracture Flattening of the cheek and loss of sensation below the orbit indicates ZYGOMA (cheekbone) FX Malocclussion of teeth, trismus indicative of MAXILLA FX PRIMARY INTERVENTIONS: Insertion of oral airway or intubation Nasopharyngeal airway should only be used if no evidence of nasal fracture or rhinorrhea Apply bulky, loose dressing; apply ice to areas of swelling
1. CLOSED WOUND A. CONTUSION bleeding beneath the skin into the soft tissue B. HEMATOMA well-defined pocket of blood and fluid beneath the skin 2. OPEN WOUND A. ABRASION superficial loss of skin from rubbing or scraping B. LACERATION tear in the skin, can be insicional or jagged C. PUNCTURE penetration of a pointed object, can be penetrating or perforating D. AVULSION tearing off or loss of a flap of skin E. AMPUTATION traumatic cutting or tearing off of a finger, toe, arm or leg
PRIMARY MANAGEMENT:
- IRECT PRESSURE
- LEVATION
- RESSURE POINTS
- NTI-TETANUS, ANTIBIOTICS
- RRIGATE
- RESS
1. FRACTURE a break in he continuity of the bone; occurs when stress is placed on a bone is greater than the bone can absorb
ALERT: fractured cervical spine, pelvis and femur may produce life threatening injuries; posterior dislocations of the hip are life- and limb-threatening emergencies due to potential blood loss.
Clinical Manifestations:
Pain and tenderness over fracture site Crepitus or grating over fracture site swelling and edema Deformity, shortening of an extremity or rotation of extremity
-EDUCTION
-setting the bone; refers to the restoration of the fracture fragments into anatomic position and alignment -MMOBILIZATION
NURSING CONSIDERATIONS: Elevate to prevent or limit swelling Apply ice packs or cold compress; not place directly in skin Splint and maintain in good alignment, immobilize the joint above and below the fracture Give pain medications as ordered Assist in casting; use the palm of your hands in holding a wet cast Avoid resting cast on hard surfaces or sharp edges Do neurovascular checks hourly for the first 24 hours Assess for COMPARTMENT SYNDROME check for 6 Ps If Compartment syndrome is suspected, do not elevate limb above the level of the cast Notify the physician Bivalve the cast
2. TRAUMATIC JOINT DISLOCATION - occurs when the surfaces of the bones forming the joint no longer in anatomic position
ALERT: this is a medical emergency because of associated disruption of surrounding blood and nerve supplies * Subluxation partial disruption of the articulating surfaces Clinical Manifestations: Pain and deformity Loss of normal movement X-ray confirmation of dislocation w/o assoc. fracture
Management: Immobilize part, Secure reduction of dislocations manually (usually preferred under anesthesia) Nursing Considerations:
3. SPRAIN an injury to the ligamentous structure surrounding a joint; usually caused by a wrench or twist resulting in a decrease joint stability Clinical Manifestations:
-OMPRESSION (Elastic Bandage) -EST -CE (for the first 24 hrs; 1 hr on, 2 hrs off during waking hours) -EDICATIONS ( NSAIDs) -LEVATION -UPPORT (Use of crutches, splints)
NURSING CONSIDERATIONS: Apply ice compress for the first 24 hrs to produce vasoconstriction, decrease edema, and reduce discomfort
Apply warm compress after 24 hrs to promote circulation and absorption (20 to 30 minutes at a time)
Educate to rest injured part for a month to allow healing Educate to resume activities gradually and to warm up
Inadequate tissue perfusion, resulting in failure of one or more of the ff: c. arterial resistance levels d. capacity of venous beds
A. HYPOVOLEMIC - occurs when significant amount of fluid is lost in the intravascular space (Ex. Hemorrhage, burns, fluid shifts) B. CARDIOGENIC occurs when the heart fails as a pump. Primary causes includes MI, dysrhythmias; Secondary causes includes mechanical restriction of cardiac function or venous obstruction like in Cardiac Tamponade, tension pneumothrorax, VCO C. SEPTIC SHOCK from bacteria and their products circulating in the blood
MANAGEMENT: Administer O2 via ET or nonrebreather face mask (if intubated, may be hyperventilated to control acidosis)
-It is a useful tool in the diagnosis of those conditions that may cause abberations in the electrical activity
WAVE INTERPRETATIONS: P WAVE : Atrial Depolarization; first positive deflection Q WAVE: first negative deflection R WAVE: first positive deflection S WAVE: negative deflection, after R wave QRS COMPLEX: Ventricular Depolarization T WAVE: Ventricular Repolarization
Check order for ECG, in cases of arrest, prepare the machine at the bedside at ER
Provide Privacy Instruct patient to lie still and avoid movement
- It is a trauma in the chest without an open wound - usually cause by VA, blast injuries SIGNS/SYMPTOMS: RIB FRACTURES: tenderness, slight edema, pain that worsens with deep breathing and movement, shallow and splinted respirations STERNAL FRACTURES: persistent chest pain MULTIPLE RIB FRACTURES: -FLAIL CHEST (loss of chest wall integrity) - decreased lung inflation, paradoxical chest movements
- extreme pain
- rapid and shallow respirations - hypotension, cyanosis - respiratory acidosis
COMPLICATIONS:
1. TENSION PNEUMOTHORAX - a condition in which air enters the chest but cant be ejected during exhalation -There is lung collapse and mediastinal shift S/Sx: tracheal deviation, cyanosis and severe dyspnea, sound on the affected side, agitation, JVD absent breath
2. HEMOTHORAX collection of blood in the pleural cavity, usually results from ribs, lacerating lung tisssue or an intercoastal artery -It is the most common cause of shock following chest trauma 3. LACERATION or RUPTURE of AORTA immediately fatal 4. DIAPHRAGMATIC RUPTURE causes severe respi. Distress; if untreated abdominal viscera may herniate, compromising both circulation and vital capacity of lungs
5. CARDIAC TAMPONADE rapid unchecked rise in intrapericardia pressure that impairs diastolic filling of the heart
- results from blood or fluid accumulation in the pericardial sac
Auscultation:
- Tension Pnemothorax: PMI is deviated - Cardiac tamponade: muffled heart tones X-ray Thoracentesis yeilds blood and serosanguinous fluid ECG Retrograde aortography reveals aortic laceration Echocardiography Computed Tomography
TREATMENT:
Simple Rib Fractures mild analgesics, bed rest, apply heat incentive spirometry deep breathing, coughing and splinting Severe Rib Fractures intercoastal nerve blocks position for semi-fowlers, administer O2 Hemothorax Chest tube insertion at 5th-6th ICS anterior to MAL administer IV fuids, O2, Blood Transfusion Thoracotomy Thoracentesis
TREATMENT: Tension Pneumothorax insertion of spinal, 14G or 16G needle into the 2nd ICS at MCL to release pressure Chest Tubes Surgical Repair Aortic Rupture/Laceration immediate surgery - synthetic grafts - aortic anastomosis
O2, BT, IV
NURSING CONSIDEARTIONS: monitor VS, (q 15, first hour post thoracentesis and post CTT) After CTT insertion, encourage cough and breathing exersises
1. PENETRATING ABDOMINAL INJURY usually the result of gunshot wound or stab wounds; may cross the diaphragm and enters the chest 2. BLUNT ABDOMINAL INJURY caused by vehicular accidents or falls PRIMARY ASSESSMENT AND INTERVENTIONS: ASSESS ABC
SUBSEQUENT ASSESSMENT:
Obtain hx of the mechanism of the injury Evaluate signs and symptoms of hemorrhage Note tenderness, rebound tenderness, guarding, rigidity and spasm
KEHRS SIGN pain radiating to the left shoulder; a sign of blood beneath the diaphragm. Pain in right shoulder can result from liver laceration
CULLENS SIGN slight bluish discoloration around the navel; a sign of hemoperitonium
Rebound tenderness and boardlike rigidity are indicative of a significant intraabdominal injury
Loss of dullness over solid organs; Dullness over regions containing gas may indicate presence of blood Look for increasing abdominal distention, measure abdominal girth the umbilical level Rectal and pelvic examination
GENERAL INTERVENTIONS:
Keep pt. quiet in the stretcher, any movement may dislodge a clot
Cut the clothing, count the number of wounds, look for entrance and exit wounds Apply compression to external bleeding wounds double IV line and infuse Ringers Lactate Insert NGT to decompress the abdomen Cover protruding abdominal viscera w/ sterile saline dressings; dont attempt to place back the protruding organs
It is the inadequacy or the collapse of peripheral circulation due to volume and electrolyte depletion ASSESSMENT: temperature may be normal or slightly elevated, hypotension, tachycardia, tachypnea, pale and moist skin, fatigue, headache, dizziness, syncope DIAGNOSTICS: hemoconcentration, hyponatremia or hypernatremia, ECG may show dysrhythmias MANAGEMENT: Move patient to a cool environment, remove all clothing Position the patient supine with the feet slightly elevated Monitor VS every 15 mins and cardiac rhythm Educate to avoid immediate reexposure to high temperatures
- It is a combination of hyperpyrexia and neurologic symptoms. It caused by a shutdown or failure of the heat-regulating mechanisms of the body
CLINICAL MANIFESTATIONS: bizarre behavior or irritability, progressing to confusion, delirium and coma 40.6 degrees Celcius, hypotension, tachycardia, tachypnea
skin may appear flushed and hot; at start it maybe moist progressing to dryness (Anhidrosis)
NURSING ALERT: Elderly clients are high-risk to develop heat-stroke Once diagnosis is confirmed, it is imperative to reduce patients temperature
MANAGEMENT:
EVAPORATIVE COOLING, most effective, by spraying tepid water on skin while fans are used to blow Apply ice packs to necks, groin, axillae, and scalp Soak sheets/towels in ice water and place on patient If temp. fails to decrease, initiate core cooling: iced saline lavage, cool fluid peritoneal dialysis, cool fluid bladder irrigation Discontinue active cooling when the temp. reaches 39 degrees Celcius
-It is a condition where the core temp. is less than 35 degrees Celcius as a result in the exposure to cold.
- 3 compensatory mechanisms:
a. shivering produces heat thru muscular activity b. peripheral vasoconstriction to decrease heat loss c. raising basal metabolic rate NURSING ALERT: Elderly are greater risk for hypothermia due to altered compensatory mechanisms Extreme caution should be used in moving or transporting hypothermic pts., because the heart is near fibrillation threshold
CLINICAL MANIFESTIONS:
slow, spontaneous respirations heart sounds may not be audible even if its beating BP is extremely difficult to hear
MANAGEMENT:
Passive External Rewarming (temp above 28 degrees) -Remove all wet clothing, and replace with warm clothing - Provide insulation by wrapping the patient in several blankets
3. An increased in metabolic demands before the heart is warmed to meet these needs.
-It is a survival for atleast 24 hours after submersion, with most common consequence of hypoxemia. -Hypoxia and acidosis are common problems of the victim. -Resultant pathophysiologic changes and pulmonary injury depend on type of fluid and the volume aspirated. a. Fresh water aspiration- results in loss of surfactant, hence an inability to expand lungs b. Saltwater aspiration- leads to pulmonary edema from the osmotic effect of salt within the lungs. Clinical Manifestations: -difficulty of breathing -cyanosis -chills -hypothermia
ASSESSMENT: ABC Identify the poison Obtain blood and urine tests; gastric contents may be sent to laboratory Monitor neurologic status Monitor fluid and electrolytes GENERAL INTERVENTIONS:
MINIMIZING ABSORPTION Administration of activated charcoal with a cathartic to hasten secretion. Induction of emesis with syrup of ipecac; done only in patients with good gag reflex and is conscious. Adult dose is 30 ml by mouth followed by 2 glasses of water; Pedia dose is15 ml followed by 8 16 oz. of water. NURSING ALERT: Do not induce emesis after ingestion of caustic substances, hydrocarbons, iodides, silver nitrates, petroleum distillates; to a patient having seizure or to pregnant patient.
Gastric lavage for the obtunded patient. Save gastric aspirate for toxicology screen.
Procedure to enhance the removal of ingested substance if the patient is deteriorating. 1. Forced diuresis with urine pH alteration to enhance renal clearance.
2. Hemoperfusion (process of passing blood through an extracorporeal circuit and a cartridge containing an adsorbent, such as charcoal, after which the detoxified blood is returned to the patient) 3. Hemodialysis to purify and accelerate the elimination of circulating toxins. 4. Repeated dose of charcoal. 5. Providing an antidote antidote is a chemical or physiologic antagonist that will neutralize the poison.
PURPOSES: 1. To remove unabsorbed poison after ingestion. 2. To diagnose and treat gastric hemorrhage and for the arrest of hemorrhage. 3. To cleanse stomach before endoscopic procedures. 4. To remove liquid or small particles of material from the stomach. NURSING CONSIDERATIONS Insertion of NGT or OGT. Place patient on left lateral position with head lower 15 degrees downward. Elevate funnel and pour approx. 150 200 ml. Lavage fluid is left in place for about one minute before allowed to drain
Save samples of first two washings. Repeat lavage procedure until the returns are relatively clear and no particular matter is seen. At the completion of the lavage: 1. Stomach may be left empty. 2. An Adsorbent may be instilled in the tube and allowed to remain in the stomach. 3. A saline cathartic may be instilled in the tube. Pinch off the tube during removal or maintain suction while tubing is being withdrawn. Give the patient a cathartic if prescribed. Warn patient that stool will turn black from the charcoal.
-It is an example of inhaled poison and results in the incomplete hydrocarbon combustion - Carbon monoxide exerts its toxic effects by binding to circulating hemoglobin to reduce the oxygen carrying capacity of the blood. - Carbon monoxide and hemoglobin is 200 300 times affinity compared to oxygen and hemoglobin. - Creation of carboxyhemoglobin resulting to tissue anoxia. CLINICAL MANIFESTATIONS - Respiratory depression, stridor. - Confusion progressing to coma. - Headache, muscular weakness, palpitation, and dizziness. - Skin is pink in color, cherry red, or cyanotic. - ABG: carboxyhemoglobin level is 12% (Normal), 30 40% severe carbon monoxide poisoning.
MANAGEMENT: Provide 100% oxygen by tight-fitting mask (the elimination half life of carboxyhemoglobin, in serum, for a person breathing room air is 5 hours and 20 minutes. If patient breaths 100% oxygen the half life is reduced to 80 minutes 100% oxygen in hyperbaric chamber reduces halflife to 20 minutes. Intubate if necessary to protect airway. Continuous ECG monitoring, treat dysrhythmias.
-These are injected poisons that can produce either local or systemic reactions. - Local reactions are characterized by pain, erythema and edema at the site of injury. - Systemic reactions usually begin within minutes. (Unconsciousness, laryngeal edema, bronchospasm, and cardiovascular collapse. MANAGEMENT:
ABC
Epinephrine is the drug of choice give SQ. Administer bronchodilator. Initiate IV with Ringers Lactate. Prepare for CPR.
NURSING CONSIDERATIONS: Apply ice packs to site to relieve pain. Elevate extremities with large edematous local reaction. Administer anti histamine for local reaction. Clean wounds thoroughly with soap and water or antiseptic solution. Educate patient. - Have epinephrine on hand
CLINICAL MANIFESTATIONS: -Burning pain, swelling, and numbness of the site. - Hemorrhagic blisters may occur after few hours of bite and entire extremity may become edematous. - WOF signs of systemic reactions (nausea, sweating, weakness, lightheadedness, initial euphoria followed by drowsiness, dysphagia, paralysis of various muscle groups, shock, seizures, and coma).
MANAGEMENT: Wash the site of bite, keep the patient calm and immobilize extremity. Administer O2 and start IV line. Administer anti-venin and be alert to allergic reaction. Administer vasopressors in the treatment of shock.
- a.k.a Delirium Tremens or Alcoholic Hallucinosis -An acute toxic state that follows a prolonged bout of steady drinking or sudden withdrawal from prolonged intake of alcohol. - Symptoms begins as early as 4 hours after reduction of alcohol intake and peaks at 24 - 48 hours but may last up to 2 weeks.
CLINICAL MANIFESTATIONS:
Shakes, seizures, and hallucinations. History of drinking episodes. N/V, malaise, weakness, anxiety. Autonomic hyperreactivity (tachycardia, diaphoresis, increase temperature, dilated but reactive pupils).
ALCOHOLISM a chronic disease or disorder characterized by excessive alcohol intake and interference in the individuals health, interpersonal realtionship and economic functioning -Considered to be present when there is .1% or 10 ml for every 1000 ml of blood - At .1 - .2%, there is low coordination - At .2 - .3%, there is ataxia, tremors, irritability, and stupor - At .3 and above, there is unconsciousness
-REMORS
-WEATING AND SIEZURE
- DISULFIRAM (antabuse)
Instruct patient to avoid, when taking Disulfiram: -OUTH WASH
MANAGEMENT: Protect patient from injury, diazepam or phenytoin for seizure control as prescribed. Monitor VS every 30 minutes. Use a non-alcohol skin preparation, draw blood for measurement of ethanol concentration, toxicologic screen for other drug abuse. Maintain electrolyte balance and hydration. Observe for hypoglycemia. Administer thiamine followed by parenteral dextrose if liver glycogen is depleted. Give orange juice, gatorade, or other carbohydrates to stabilize blood sugar. Place patient in a private room with close observation.
-It is an urgent, serious disturbances of behavior, affect, or thought that makes the patient unable to cope with his life situation and interpersonal relationship
-Is usually episodic and is a means of expressing feelings of anger, fear and hopelessness about a situation.
- Manage through: a. Establish control, keeping the door open, and be in clear veiw of staff
-Ultimate form of self-destruction; cry for help -Major Interventions: PREVENTION and LISTEN - RISK FACTORS -EX (female attempts, male commits suicide) -NSUCCESSFUL PREVIOUS ATTEMPT
NURSING INTERVENTIONS: Provide one-on-one monitoring Have frequent unscheduled rounds Avoid use of metals and glass utensils Remove shampoos, perfumes, medicines at the bedside Monitor for signs of impending suicide (giving away of valued possession)
According to RA 8353, RAPE refers to the insertion of penis into the mouth, vagina, anus of a victim
RAPE TRAUMA SYNDROME It refers to a group of signs and symptoms experienced by a victim in reaction to rape 4 Phases