HN--ch.69: emergency, terrorism, and disaster nursing

assessing exposure/environmental control

-remove clothing to perform physical assessment -prevent heat loss, hypothermia -maintain privacy by using warming blankets, overhead warmers, and warmed IV fluids

submersion injury

-results when person becomes hypoxic due to submersion in substance -immersion in cold water stimulates vagus nerve and potentially fatal dysrhythmias

national incident management system (NIMS)

-section in US Dept. of homeland security

primary survey--ABCDE

ABCDE -airway -breathing -circulation -disability -exposure

Several patients are admitted to the ED after exposure to an aerosolized agent that is believed to be a hemorrhagic fever virus used as a bioterrorism agent. Which statement by the nurse is most appropriate? A. "Treatment for this viral disease is mostly supportive." B. "Ciprofloxacin (Cipro) is the best treatment for this disease." C. "This disease cannot be spread by contact with body fluids." D. "A vaccine is available to prevent transmission of this disease."

Answer: a Rationale: Only supportive treatment is available for hemorrhagic fever. A vaccine is available for Yellow fever only. The disease is carried by rodents and mosquitoes and through direct person-to-person contact with body fluids; the virus can be aerosolized. Ciprofloxacin is used to treat a bacterial infection.

chemical agents of terrorism

categorized by target organ or effect -sarin: toxic nerve gas that can cause death within minutes of exposure, enters body through eyes and skin; acts by paralyzing respiratory muscles -phosgene: colorless gas normally used in chemical manufacturing, cause severe respiratory distress, pulmonary edema, death -mustard gas: yellow to brown in color with garlic odor, irritates eyes and causes skin burns/blisters

how to maintain the airway

least to most invasive: -open airway using jaw thrust -suction/remove foreign body -insert nasopharyngeal/ oropharyngeal airway -endotracheal intubation -if unable to intake, emergency cricothyroidotomy or tracheotomy performed

radiologic/nuclear acts

radiologic dispersal devices (RRDs) ("dirty bombs"): mix of explosives and radioactive material -when detonated, blast scatters radioactive dust, smoke, and other material into environment, resulting in radioactive contamination -main danger from RRDs: explosion -ionization radiation (nuclear bombs) -serious threat to safety of casualties and environment -exposure may or may not include skin contamination with radioactive material

explosive devices as agents of terrorism

result in one or more of following types of injuries: blast, crush, or penetrating -blast: from supersonic over pressurization shock wave that results from explosion--damage to lungs, middle ear, GI tract -crush: explosions in confined spaces and result from structural collapse; blunt trauma -penetrating: material projected during explosion

who is at greatest risk for animal bites?

-children -animal bites from dogs and cats, then wild or domestic rodents -infection, destruction of skin, muscle, tendons, blood vessels, bone

what history should be obtained in ED?

-history of event -illness -injury from patient -family -emergency personnel -chief complaint, caused pt to seek action? -pt's subjective complaints? -pt's description of pain (location, duration, quality, character) -witnesses' descriptions of behavior since onset -pt's health history--AMPLE

terrorism

-involves overt actions for the expressed purpose of causing harm -bioterrorism: disease pathogens -chemical agents -radiologic/nuclear, explosive devices

what kind of patients are seen by the emergency department?

-life threatening, or potentially life threatening problems -less urgent conditions because inability to see primary care

mass casualty incident (MCI)

-manmade or natural event or disaster that overwhelms community's ability to respond with existing resources

assessing disability

-measured by patient's level of consciousness -AVPU: -Alert -V=responsive to voice -P=responsive to pain -U=unresponsive -Glasgow Coma Scale -pupils

passive external rewarming

-move patient to warm, dry place; remove damp clothing, place warm blankets on pt

gerontologic considerations for emergency care

-older adults are at high risk for injury--mainly from falls -causes: generalized weakness, environmental hazards (loose mats, furnitures), orthostatic hypotension (meds, dehydration)

what is triaging?

-process of rapidly determining patient acuity -represents a critical assessment skill -treat those with life threatening issues first regardless of time they enter

what to assess with breathing

-dyspnea -cyanosis -paradoxic/asymetric chest wall movement -decreased/absent breath sounds -tachycardia -hypotension -caused by: fractured ribs, pneumothorax, penetrating injury, allergic reactions, pulmonary emboli, and asthma attacks -administer high flow O2 via nonrebreather mask -bag-valve-mask (BVM) ventilation with 100% O2 and intubation for life threatening condition -monitor patient response

triage tags

-green: minor injury -yellow: non life threatening injury -red: life threatening injury -blue: expected to die -black: dead

what is AMPLE?

-Allergies to drugs, food, environment -Medication history -Past heart history -Last meal -Events/environment leading to the illness or injury

what makes up a complete set of vital signs?

-BP (bilateral) -HR -RR -oxygen saturation -temperate

violence

-acting out of emotions (fear or anger) to cause harm to someone or something -EDs are high risk areas for workplace violence -screening for domestic violence required in ED

compromised airway

-airway with cervical spine stabilization and/or immobilization -dyspnea -inability to vocalize -presence of foreign body in airway -trauma to face or neck -most at risk: seizures, near drowning, anaphylaxis, foreign body obstruction, or cardiopulmonary arrest

what are the most significant signs of shock

-altered mental status -delayed capillary refill, longer than 3 secs

bioterrorism

-anthrax, plague, tularemia: treated with antibiotics assuming sufficient supplies and nonresistant organisms -smallpox can be prevented or ameliorated by vaccination even when first given after exposure

emergency

-any extraordinary event that requires a rapid and skilled response and can be managed by a community's existing resources

active external rewarming

-body to body contact -fluid or air filled warming blankets -radiant heat lamps

what is the secondary survey?

-brief, systematic process to ID all injuries -full set of vital signs/five interventions/facilitate family presence -initiate ECG monitoring -initiate pulse oximetry -insert orogastric/nasogastric tube -collect blood for labs -give comfort measures -history and head to toe--including log roll to inspect posterior surfaces

assessing circulation

-check central pulse (peripheral pulses may be absent because of injury or vasoconstriction) -assess quality/rate if pulse is felt -assess skin color, temp, moisture -insert 2 large bore IV catheters -initiate aggressive fluid resuscitation using normal saline or lactated Ringer's solution

poisonings

-chemicals that harm the body accidentally, occupationally, recreationally, or intentionally -severity depends on type, concentration, and route of exposure -decrease absorption: gastric lavage, activated charcoal -dermal cleansing/eye irrigation -enhance elimination: cathartics, whole bowel irrigation -hemodialysis/hemoperfusion: severe acidosis, urine alkalization, chelating agents, antidotes

heat exhaustion

-prolonged exposure to heat over hours or days -when thermoregulatory mechanisms like sweating, vasodilation, and increased respirations cannot compensate for exposure to increased ambient temps -strenuous activities in hot or humid environments, clothing that interferes with perspiration, high fevers, and preexisting illnesses predispose individuals to heat stress -fatigue, light headed, nausea/vomiting/diarrhea, impending doom feelings, tachypnea, tachycardia, dilated pupils, mild confusion, ashen color, profuse diaphoresis, hypotension and temp elevation -failure of the hypothalamic thermoregulatory processes

what is the preferred procedure for unprotected airway?

-rapid sequence intubation -involved sedation or anesthesia and paralysis

While performing triage in the ED, the nurse determines that which patient should be seen first? A. A patient with burns on the face and chest; BP 120/80 mm Hg, HR 92, RR 24 B. A patient with a deformed leg indicating a fractured tibia; BP 110/60 mm Hg, HR 86, RR 18 C. A patient with type 1 diabetes in ketoacidosis; BP 100/60 mm Hg, HR 100 beats/min, RR 32 D. A patient with a respiratory infection with a cough productive of greenish sputum; BP 128/86 mm Hg, HR 88, RR 26

Answer: c Rationale: A triage system identifies and categorizes patients so that the most critical are treated first. The Emergency Severity Index (ESI) is a five-level triage system that incorporates concepts of illness severity and resource utilization to determine who should be treated first. Initially, the nurse would assess the patient for any threats to life or the presence of a high-risk situation. The patient with diabetic ketoacidosis is the most critical.

Assessment of a male patient during the primary survey indicates delayed capillary refill of the extremities. He cannot explain the events before admission to the ED. Which action should the nurse take immediately? A. Apply leads to the patient's chest to initiate ECG monitoring. B. Insert one or two large-bore IV catheters to start IV fluid resuscitation. C. Continue the primary survey to complete a brief neurologic examination. D. Initiate pulse oximetry by placing a monitoring device on the patient's index finger.

Answer: d Rationale: The primary survey focuses on airway, breathing, circulation, disability, and exposure/environmental control. It serves to identify life-threatening conditions so that appropriate interventions can be initiated. The nurse may identify life-threatening conditions related to airway, breathing, circulation (ABCs), and disability at any point during the primary survey. When this occurs, the nurse should start interventions immediately and before moving to the next step of the survey. The patient has decreased oxygenation, and further assessment with pulse oximetry is indicated.