Tag: neurological disabilities

Emergency nursing practice requires the nurse to provide immediate emergency care and interventions to preserve the life of individuals experiencing acute illness or injury.

Emergency nursing practice aims to:

1. Preserve Life through identification and management of life-threatening conditions
2. Prevent Complications to avoid deterioration of patient’s condition (eg. choking, cardiac arrest, & bleeding)
3. Promote Recovery by providing reassurance and comfort to the patient, seeing that the patient gets medical attention, as well as managing pain through interventions such as immobilising a fractured limb

What is the 1st thing you should do in Emergency Nursing Practice?

1. Assess the situation from a distance and look out for any possible danger
2. Determine what the emergency is and the extent of the emergency eg. number of apparent casualties.

Then use the S.A.F.E. approach…

Safety Tips for Emergency Nursing Practice

• BLEEDING – protect yourself from blood and other body fluids by using non-sterile gloves, or use non-touch technique eg. by holding the patient’s own hand onto the bleeding wound
• HAZARDS – careful about things such as being in a busy road, being close to hazardous substances, or harmful situations; avoid becoming a casualty yourself!
• CROWDS – be careful not to get pinned in!
• AGGRESSIVE BEHAVIOUR – aggressiveness could be the result of non-organic problems such as due to current emergency

Emergency Situations Requiring Special Attention…

1. CAR CRASH EMERGENCY – extra precautions include switching off the vehicle, pulling up the handbrake, removing the keys from ignition, and looking out for other vehicles
2. FIRE EMERGENCY – if fire has spreaded drastically, do not attempt to go in…call for assistance if it looks too dangerous
3. ELECTRIC SHOCK EMERGENCY – prior to attempting any first aid procedures, switch off the main and use a non-conductor to remove the electrical object in contact with the patient
4. DROWNING EMERGENCY – you are NOT expected to jump into the water to save a patient if not confident enough

Calling for an Ambulance

You should call an ambulance:

1. if you are dealing with a serious situation eg. car crash, fire emergency, and/or multiple casualties
2. if you are dealing with a situation where a life or a limb may be lost eg. difficulty breathing, severe chest pain, choking, and/or unconsciousness
3. if you are in doubt

If you are calling for an ambulance (Malta & Gozo):

1. dial 112
2. ask for an ambulance
3. stay calm
4. mention what happened, where it happened, and who you are
5. answer any questions in detail
6. DO NOT BE THE FIRST TO HANG UP!

The Vital Functions of the Human Body

The human body’s primary vital systems are the Respiratory (lungs), Circulatory (heart) and the Brain (oxygenated).

• The respiratory system includes the Airway and Breathing
• Circulation includes the Heart, Blood Vessels, and Blood
• The Brain includes the Neurological aspect of it

Anything affecting the ABCD of the patient can be life-threatening, requiring prompt action so that life is preserved!

Airway Problems

• obstruction by patient’s own tongue during unconsciousness period
• foreign body obstruction in a choking patient
• swelling of the airway due to an allergic reaction (anaphylactic shock) or inhalation of chemicals
• facial trauma following a maxillofacial injury

NOTE: The tongue in an unresponsive casualty can easily obstruct the airway. Hypoglycaemia and overdose are the two main causes of airway obstruction by tongue.

Breathing Problems

• compromised airway as mentioned above
• respiratory issues such as asthma
• cardiac issues such as congestive heart failure causing fluid build-up in the lungs
• chest injuries eg. in which ribs are broken, which then puncture the lungs
• environmental issues eg. strangulation, suffocation and/or drowning

Circulation Problems

• compromised airway and breathing problems as mentioned above
• internal bleeding
• external bleeding
• additional causes of shock
• cardiac illness eg. cardiac arrest, congestive heart failure, or myocardial infarction

Neurological Problems a.k.a. Neurological Disabilities

• compromised airway, breathing, and circulatory problems as mentioned above, leading to lack of oxygen in the brain and body
• neurological disorders eg. cerebrovascular accident or central sleep apnea
• brain injury following head trauma
• hypoglycaemia (low blood glucose level)
• poisoning
• serious infections
• serious illnesses that lead to organ failure

Assessing the Patient

Initial Patient Assessment

• Immediately identify and address life-threatening (ABCD) problems with the aim of preserving life
• Is the patient responsive? SHAKE & SHOUT & use AVPU scale
• Is the patient unresponsive? Check if his airway is obstructed, perform head-tilt chin-lift maneuver
• Is he breathing? Look, Listen & Feel!
• Are there evident serious bleeding signs eg. blood on the floor, blood on chest, abdomen, pelvis, thighs? REMEMBER: 50% Blood Loss = Unconscious Patient!
• Is the patient exhibiting signs of shock? (pale & cold, clammy skin; fast weak radial pulse, fast shallow breathing, weak & lethargic)

UNRESPONSIVE & NOT BREATHING = START CPR IMMEDIATELY

SERIOUS BLEEDING = PUT PRESSURE ON THE WOUND TO STOP BLEEDING

Emergency Nursing Practice Techniques that help Clear Airway Obstruction

Manual techniques:

No side effects, no equipment required – use the head tilt chin lift technique or the jaw-thrust maneuver.

Simple Adjuncts:

Minimal side effects – use of a hollow tube that holds tongue in place.

ENDOTRACHEAL INTUBATION (eti):

A medical procedure in which a tube is placed in the trachea via the mouth or nose. If performed wrongly, this may kill the casualty.

Airways:

Ventilation of the larynx with a laryngeal tube or mask.

SOMETHING STUCK IN WINDPIPE = HEIMLICH MANEUVER

sECONDARY PATIENT ASSESSMENT

A secondary patient assessment is performed with the aim to identify conditions that can worsen the primary issue – the 4 B’s…

1. Breathing
2. Bleeding
3. Burns
4. Bones

A secondary patient assessment can be performed in the following order:

Step 1: Complaint – signs & symptoms

Step 2: Perform a head-to-toe assessment using the D.O.T.S. method:

• Deformities
• Open Wounds
• Tenderness
• Swelling

Step 3: Vital Signs – include an accurate respiratory rate and pulse rate

Step 4: History – use the acronym S.A.M.P.L.E.

Signs of Breathing Problems

• Dyspnoea – check for visual breathing distress and use of accessory muscles
• Noisy Breathing
• Abnormal Breathing Pattern – notice the patient’s breathing rate and rhythm
• Cyanosis – check for bluish discolouration of the patient’s skin due to lack of oxygen circulation in the body
• Disorientation and Confusion
• Unusual Aggressiveness
• Respiratory Arrest a.k.a. respiratory failure – patient may stop breathing

Signs of Circulatory Problems

• Pale, Cold, Clammy Skin
• Internal / External Bleeding
• Rapid Shallow Breathing
• Fast OR Very Slow Pulse
• Inability to Palpate Radial Pulse (located at the wrist)
• Cardiac Arrest (heart stops pumping blood)

Signs of Neurological Problems

• Weakness, Paralysis or Loss of Sensation within the Limbs
• Assymetry within the patient’s Face
• Unequal and/or Unreactive Pupils
• Seizures
• Disorientation or Confusion
• Unusual Aggressiveness
• Altered Level of Response (patient may also be drowsy)

Summary…

1. Check ABCs
2. Gather Signs & Symptoms
3. Head to Toe Assessment (D.O.T.S.)
4. Measure Vital Signs (RR & PR)
5. History (S.A.M.P.L.E.)

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