NCM-118-Lecture-PRELIM.pdf

Emergency and in some cases might involve completing a Urgent; Life Threatening; Critical; a serious, unexpected, and treatment, such as in the case of applying a plaster often dangerous situation requiring immediate acti...

Emergency and in some cases might involve completing a Urgent; Life Threatening; Critical; a serious, unexpected, and treatment, such as in the case of applying a plaster often dangerous situation requiring immediate action. to a small wound. EMERGENCY NURSING Emergency Management - Encompasses an unforeseen combination of - Traditionally refers to care given to patients with circumstances calling for immediate action (if no urgent and critical needs. Large numbers of people IA would cause worsen the condition or loose life) seek emergency care for serious life-threatening - Emergency Management - refers to care given to cardiac conditions, such as myocardial infarction, patients with urgent and critical needs (living in the acute heart failure, pulmonary edema, and rural environment just like health center the cardiac dysrhythmias. arrangement and situation they usually can't provide an emergency management due to lack of access health care needs) - Lack of access to health care - Emergency Department (ED) - used increasingly for non-urgent problem Broadened to: EMERGENCY: is whatever the patient or the family consider it to be First Aid - Provision of initial care for an illness or injury. It is usually performed by non-expert, but trained personnel to a sick or injured person until definitive medical treatment can be accessed. - Non-expert but trained professionally - Certain self-limiting illnesses or minor injuries may not require further medical care past the first aid intervention. - It generally consists of a series of simple and in - The need for professional nurses to be prepared some cases, potentially life-saving techniques in emergency and disaster nursing becomes more that an individual can be trained to perform with evident as the complexity of our lives increases minimal equipment. owing to the discovering of new scientific Emergency Nurse: knowledge and its application to the everyday - Has the specialized education, training, world. experience and expertise in - Because Nurses represent the largest group of - Assessing trained professional health worker available, their - Identifying patient’s health care problem in awareness of and preparation for emergency care crisis situation of the ill and injured are essential. - Nursing interventions are accomplished Nursing Intervention interdependently, in consultation with or under the Interdependently direction of a licensed physician or nurse Role of Nurse and Physician - complementary practitioner. Nursing and medical interventions are anticipated - The strengths of nursing and medicine are based on assessment data complementary in an emergency situation. Work as a TEAM - Appropriate nursing and medical interventions CURRENT MEDICAL, LEGAL AND ETHICAL ISSUES are anticipated based on assessment data. Medical Issues - Establishes priorities, monitors, and continuously Emergency nursing was officially recognized as specialty in assesses patients who are acutely ill and injured 1970. The National Association representing this nurse is the - Supports and attends to families (ENA) Emergency Nursing Association - Supervises allied health personnel, and educates ENA Definition of Emergency Nursing patients and families within a time-limited, high Assessment , pressured care environment Diagnosis and treatment of perceived actual or Three key points of First Aid potential, sudden or urgent, physical or 1. Preserve life: the overriding aim of all medical psychosocial problem that are primary episodic or care, including first aid, is to save lives acute these may require minimal care of life support 2. Prevent further harm: also sometimes called measure prevent the condition from worsening, or danger of Education of patient and significant others further injury, this covers both external factors, such Appropriate referral as moving a patient away from any cause of harm, Knowledge of legal implications. and applying first aid techniques to prevent Nurses employed in an ED must be prepared to provide care worsening of the condition, such as applying to client of all age group who may have any possible illness pressure to stop a bleed becoming dangerous. or injury. 3. Promote recovery: first aid also involves trying to start the recovery process from the illness or injury, It often cited that emergency nurse must have an - Objects should not be left within patient reach; even understanding of almost all disease process specific to any an intravenous (IV) line spike can become a tool of age group. violence Legal Issues - Courses on safety Any client who presents to an ED seeking treatment There is no advantage to protecting others if health must be rendered aid regardless of financial ability care providers are injured to pay for services. 4. Providing Holistic Care Requiring ED personnel to stabilize any client Sudden illness or trauma is a stress to physiologic considered medically unstable before transfer and psychological homeostasis that requires to another health care facility. This stabilization physiological and psychological healing. must occur regardless of the client financial ability Patients and families experience real and terrifying to pay for services. fear of death, mutilation, immobilization, and other PROFESSIONAL AND ETHICAL ISSUES assaults on their personal identity and body DOCUMENTATION OF CONSENT integrity. LIMITING EXPOSURE TO HEALTH RISK Assessment of the patient and family’s PROVIDING HOLISTIC CARE psychological function includes evaluating Issues in Emergency Nursing Care: emotional expression, degree of anxiety, and Emergency nursing is demanding because of the diversity of cognitive functioning. conditions and situations that present unique challenges. Patients and families experiencing sudden injury or These challenges include legal issues, occupational health illness are often overwhelmed by anxiety because and safety risks for ED staff, and the challenge of providing they have not had time to adapt to the crisis holistic care in the context of a fast-paced, technology-driven The stages begin with anxiety and progress through environment in which serious illness and death are denial, remorse and guilt, anger, grief, and encountered on a daily basis. reconciliation. 1. Documentation of Consent and Privacy The initial goal for the patient and family is anxiety Consent to examine and treat the patient is part of reduction, a prerequisite to effective and the ED record. The patient needs to give consent appropriate coping. for invasive procedures (e.g., angiography, lumbar 5. Patient-Focused Interventions puncture) unless he or she is unconscious or in a a. Those caring for the patient should act confidently critical condition and unable to make decisions. and competently to relieve anxiety. Patient must consent to invasive procedures unless b. Reacting in a warm manner promotes a sense of unconscious or in critical condition. security. If the patient is unconscious and brought to the ER c. Unconscious patient should be treated conscious without family or friends, this fact must be Clinicians caring for the patient should act documented. confidently and competently to relieve anxiety After treatment, notations are made on the record and promote a sense of security. about the patient’s condition on discharge or Human contact and reassuring words reduce the transfer and about instructions given to the patient panic and family for follow-up care. ○ Patient who is unconscious should be 2. Limiting Exposure to Health Risks treated as if conscious—that is, the patient Health care providers are at increased risk for should be touched, called by name, and exposure to communicable diseases through blood given an explanation of every procedure or other body fluids. This risk is further compounded that is performed in the ED because of the common use of invasive ○ Patient regains consciousness, the treatments. All emergency health care providers nurse should orient the patient by stating should adhere strictly to standard precautions for their name, the date, and the location. This minimizing exposure. basic information should be provided Increasing numbers of people infected with repeatedly, as needed, in a reassuring hepatitis, human immunodeficiency virus (HIV), way. tuberculosis, and other infectious diseases. ○ sentinel event (unanticipated events that 3. Violence in the Emergency Department result in patient harm) include delays to Staff members encounter patients who may be care and medication errors violent because of the effects of substance abuse, 6. Family-Focused Interventions injury, or other emergencies, they may also The family is kept informed about where the patient encounter other violent situations. is, how he or she is doing, and the care that is being Safety first health care provider given. SAFETY is the First PRIORITY Anxiety and denial (Family members are - For prisoners, the hand or ankle restraint (handcuff) encouraged to recognize and talk about their is never released feelings of anxiety. Asking questions is - Mask can be placed on the patient encouraged.) - Nonrestraint techniques - talking with the patient, Encouraging family members to stay with the minimizing environmental stimulation. patient, when possible, also helps allay their - Distance anxieties - Not wear items that can be grabbed by the patient  Helping Family Members Cope With Sudden THE ROLE OF THE NURSE IN THE EMERGENCY Death DEPARTMENT - Take the family to a private place. Emergency nurses specialize in rapid assessment and - Talk to the family together treatment when every second counts, particularly during the - Reassure the family that everything initial phase of acute illness and trauma. Emergency nurses possible was done must tackle diverse tasks with professionalism, efficiency, - Avoid using euphemisms such as and above all—caring. “passed on.” Emergency nursing is a specialty area of the - Encourage family members to support nursing profession like no other. To provide quality each other and to express emotions patient care for people of all ages, emergency - Avoid giving sedation nurses must possess both general and specific - Encourage the family to view the body knowledge about health care to provide quality - Show acceptance by touching the body to patient care for people of all ages. give the family “permission” to touch. Emergency nurses must be ready to treat a wide - Spend time variety of illnesses or injury situations, ranging from - Allow family members to talk about the a sore throat to a heart attack. deceased - Do not challenge initial feelings of anger or denial. - Avoid volunteering unnecessary information Stages of Crisis 7. Anxiety and Denial Encouraged to recognize and talk about their feelings of anxiety. Asking questions is encouraged. Honest answers given at the level of the family’s understanding must be provided. Although denial is an ego-defense mechanism that protects one from recognizing painful and disturbing aspects of reality, prolonged denial is not encouraged or supported. The family must be prepared for the reality of what has happened and what may come. 1. Patient Care—Emergency nurses care for patients (Family members are encouraged to recognize and and families in hospital emergency departments, talk about their feelings of anxiety. Asking questions ambulances, helicopters, urgent care centers, is encouraged.) cruise ships, sports arenas, industry, government, 8. Remorse and Guilt and anywhere someone may have a medical Expressions of remorse and guilt are common, with emergency or where medical advances or injury family members accusing themselves (or each prevention is a concern. other) of negligence or minor omissions. Family 2. Education—Emergency nurses provide education members are urged to verbalize their feelings to to the public through programs to promote wellness help them cope appropriately. and prevent injuries, such as alcohol awareness, (Expressions of remorse and guilt may be heard, child passenger safety, gun safety, bicycle and with family members accusing themselves of helmet safety, and domestic violence prevention. negligence or minor omissions). They are urged to 3. Leadership and Research—Emergency nurses verbalize feelings. also may work as administrators, managers, and 9. Anger researchers who work to improve emergency health The therapeutic approach is to allow the anger to be care. expressed and to assist the family members to Specialties: identify their feelings of frustration. Because emergency nurses must be prepared to provide (Allow the anger to be ventilated, assist the patient care for almost any situation they may encounter, family to identify their feelings or frustrations). specialization is rare. However, common areas of 10. Grief specialization include trauma, pediatrics, geriatrics, and The key nursing intervention is to help family injury prevention. members work through their grief and to support their coping mechanisms, letting them know that it Qualifications is normal and acceptable for them to cry, feel pain, Emergency nurses are registered nurses. Many emergency and express loss. nurses acquire additional certifications in the areas of trauma (Help family members to work through their grief nursing, peadiatric nursing, nurse practitioner, and various and support their coping mechanisms.) areas of injury prevention. 11. Reconciliation (Acceptance) Practice Settings 1. severity of their health problems Emergency Departments 2. immediacy with which these problems must be Hospitals treated Health Care Administration - based on hierarchy on the potential for loss of life Education - the highest priority, urgent patients had serious Research health problems but not immediately life-threatening Urgent Care Centers (Episodic Care Centers) ones, and nonurgent patients had episodic illnesses Schools of Nursing/Universities/Colleges Classify and injuries to ensure that patients most in EMS/Prehospital Transport need of care do not needlessly wait to receive it ○ Ambulances ED triage ○ Helicopters Field triage ○ Airplanes - Disaster and mass casualty incident FACTS ABOUT EMERGENCY DEPARTMENT UNITS A basic and widely used triage system that had been in use People age 75 years and older had the highest rate for many years utilized three categories: of ED visits. The national average is 39 visits per Emergent 100 persons per year. - Had the highest priority Stomach and abdominal pain, chest pain, and fever, - Their condition are life-threatening and they must were the most commonly recorded reasons for a be seen immediately visit in the ED. - Category must be reassessed at least every 15 Ages 15-24 years had the highest injury visit rate. minutes About 12% of patients seen in the ED were Urgent admitted to the hospital - patients had serious health problems but not Principles of Assessment and Emergency Management immediately life-threatening 1. Treat the potentially life threatening first. GOAL: - Must be seen within an hour a. Preserve life - category must be reassessed at least every 30 b. Prevent deterioration before definitive minutes, treatment can be given Less Urgent - category must be reassessed at least every 60 c. Restore patient to useful living minutes 2. Stabilize the pulmonary cardiovascular and central Resources: nervous system Imaging studies a. Maintain a patent airway and provide Medications IM or IV adequate ventilation. Employing Invasive procedures resuscitation measures when necessary Ex. indwelling catheter b. Control hemorrhage and its consequences ○ Vital signs deviates significantly from the c. Evaluate and restore cardiac output baseline they “up-triaging” to emergent d. Prevent and treat shock; maintain or Non-urgent restore effective circulation. - episodic illnesses that can be addressed within 24 - hours without increased morbidity a. Carry out rapid initial and ongoing physical - Non-life-threatening situation and need only one examinations. (The clinical course of the injured or resource to provide their evaluation and mgt seriously ill patient is not static). - category must be reassessed at least every 120 b. Assess whether or not the patient can follow minutes command. Evaluate the size and reactivity of the Minor pupils and motor responses. - No life-threatening conditions and likely requires no c. Splint suspected fractures resources to provide their evaluation and d. Protect wound with sterile dressings management e. Check to see if patient has a medic alert or similar “Fast Track” - patients require simple first aid or basic identification designating allergies etc. primary care and maybe treated in the ED or safety referred f. Start a flow sheet of the patient vital signs BP, PR, to a clinic or a physician’s office RR to guide decision making Community and Transitional Services Before discharge, some patients require the services of a social worker to help them meet continuing health care needs. Home care resources may be contacted before discharge to arrange services. This is particularly important for patients who are older adults or who have disabilities and who need assistance. PRINCIPLES OF EMERGENCY CARE Emergency care: - care that must be rendered without delay. Triage - comes from the French word “trier”, meaning “to sort.”  3. Airway: does the pt have an open airway? 4. Breathing: is the patient breathing? 5. Circulation: is circulation in immediate jeopardy? a. Is there a pulse? b. Is there profuse bleeding? 6. Disability: assess level of consciousness and pupils Complete neurologic survey will be in the secondary survey Assess level of consciousness using the AVPU scale A—alert. Is the patient alert and responsive? V—verbal. Does the patient respond to verbal stimuli? P—pain. Does the patient respond only to painful stimuli? U—unresponsive. Is the patient unresponsive to all stimuli, including pain? 7. Expose - undress the pt to look for clues to injury or illness, such as wound or skin lesions SECONDARY ASSESSMENT Secondary survey is systemic, brief (2-3 mins) Purpose: - To detect and prioritize additional injuries or to detect signs of underlying medical conditions 1. Complete health history, including the history of the current event 2. Head-to-toe assessment (includes a reassessment Primary Survey of airway and breathing parameters and vital signs) - Life threatening 3. Diagnostic and laboratory testing - Focuses on stabilizing life-threatening conditions 4. Insertion or application of monitoring devices such - After these priorities have been addressed, in the as ECG electrodes, arterial lines, or urinary ED catheters Nurse team proceeds to secondary survey 5. Splinting of suspected fractures 6. Cleansing, closure, and dressing of wounds The ED staff work collaboratively and follow the 7. Performance of other necessary interventions based on the patient’s condition ABCDE (airway, breathing, circulation, disability, Triage: exposure) method: - Sorting of patients to determine the priority of their 1. Establish a patent airway. health care needs and priority site treatment. 2. Provide adequate ventilation, employing NON-DISASTER situations resuscitation measures when necessary. - High priority and allocate the most resources to 3. Evaluate and restore cardiac output by controlling those who are the most critically ill. hemorrhage, preventing and treating shock, and Ex. chest injury, CPR, meds, IVF, intubation, blood maintaining or restoring effective circulation. This In an effort to save lives includes the prevention and management of hypothermia Large Number of Casualties 4. Determine neurologic disability by assessing - Fundamental guiding principle neurologic function using the Glasgow Coma Scale - To do greatest good for the greatest (GCS) number of people - Eye opening (4) - Decision are based on the likelihood of - Verbal response (5) survival and consumption of available - Motor (6) resources Primary Assessment: Low chance of survival - assigned a low triage priority 1. Initial rapid assessment - identify life-threatening Rationale: the expenditure of limited resources on people problem with a low chance of survival A - airway - Denial of those resources to others with serious but B - breathing treatable condition cannot be justified C - circulation Disaster Tag 2. 1st step - determine if patient is conscious Are number and include triage priority, name, address, age, a. Pt who is alert and talking indicated that location and description of injuries and treatment or there is breathing and circulation medication given are used to communicate information b. A conscious pt. Also indicates that - Secured place on the pt and remain with the pt at all circulation is adequate and enough blood times is being circulated to the brain - Recorded in disaster log c. If however the pt is not conscious, the primary assessment should proceed step by step  Conditions: - Unresponsive pt with penetrating head wounds - High spinal cord injuries - 2nd/3rd degree burns >60% of TBSA - Profound shock with multiple injuries Detailed Flow Chart Immediate - 1st priority RED - Injuries are life threatening but survivable with minimal intervention - Individuals can progress rapidly to expectant/deceased if treatment is delayed - Highest priority - Breathing but UNCONSCIOUS - Respiration over 30 - Perfusion Capillary refill >2 or NO RADIAL PULSE - Control bleeding TYPICAL CONDITIONS Sucking chest wound airway obstruction 2nd to mechanical cause, shock, hemothorax, tension pneumonia, asphyxia, unstable chest and abdominal wounds, incomplete amputations, open fractures of long bones, and 2nd/3rd degree burns of 15%-40% total body surface. Delayed - 2nd priority YELLOW - Injuries are significant and require medical care but can wait hours without threat to life or limb - Individuals receive treatment only after immediate casualties are treated - Stable abdominal wounds, maxillofacial injuries without airway obstruction, soft tissue injuries, Standards of Care Guidelines vascular injuries with adequate collateral circulation Emergency Assessment and Interventions - otherwise 1. Remove the patient from potential source of danger Minimal/Minor - 3rd priority - live electric current, water, fire GREEN 2. Determine whether patient is conscious; if not fully - Injuries are minor and can be delayed conscious assess A,B,C - Minor burns, lacerations, fractures without vascular 3. Assess pupillary reaction and level of compromise responsiveness to voices or touch as indicated - Move walking wounded 4. If the patient is unconscious, or has sustained a Expectant /Deceased - 4th priority significant head injury, assume there is spinal cord BLACK injury cord injury and ensure proper handling - Injuries are extensive and chances of survival are 5. Undress the patient to look for wounds and skin unlikely even with definite care. lesions - Persons not abdominal but separated from 6. Immediate intervention - airway mgt, CPR and casualties measures to control bleeding - Comfort measures 7. Call for help as soon as possible - No RESPIRATIONS after head tilt 8. Assist with transport and further assessment and care as indicated Head to Toe Assessment: 13. Posterior (Cervical Spine Precautions) 1. General Appearance - Soft tissue injury - Position, posture, gait - Spinal tenderness - LOC, restlessness is a danger sign - Pain or tenderness - Behavior and degree of distress - Cooperation - Skin condition and color 2. Head and Scalp - Bleeding - Deformity and depression - Facial symmetry 3. Ears - Blood - Clear fluid - CSF - Battle’s sign - bluish discoloration of mastoid area 4. Eyes - Pupil size and reaction to light - Extraocular motions - Orbital ecchymosis - Gross vision - Conjunctiva - pallor, cyanosis 5. Nose - Blood Epistaxis - CSF hemorrhage from the nose 6. Mouth caused by the rupture of tiny, distended vessels - Missing teeth in the mucous membrane of any area of the nose - Cyanosis of lips arteries - Foreign materials/vomits anterior ethmoidal artery 7. Neck sphenopalatine artery - Tracheal deviation internal maxillary branches - Jugular distention Risk factors - Tenderness local infections – vestibulitis, rhinitis, sinusitis 8. Chest systemic infections- scarlet fever, malaria - Symmetry drying of nasal mucous membrane - tenderness/pain nasal inhalation of illicit drugs - Ecchymosis trauma - Subcutaneous emphysema arteriosclerosis - Soft tissue injury hypertension - Breath sound tumor - Heart sound thrombocytopenia 9. Abdomen use of aspirin - distention / rigidity liver disease - Tenderness / pain Redu-Osler-Weber syndrome - Guarding - Bowel sounds - Soft tissue injuries 10. Pelvis - Stability - Tenderness 11. Genitalia - Bleeding - Wounds / trauma - Priapism - Rectal tone Medical Management - Pain depend on the cause and location 12. Extremities nasal speculum - Pain penlight - Deformity and bruises headlight – determine the site of bleeding - Pulses Initial Treatment - Sensation injury apply direct pressure - capillary refill sit upright with head tilted forward to prevent - Edema swallowing and aspiration of blood and is directed  to pinch the soft outer portion of the nose against - cardiac and pulse oximetry the midline septum for 5-10 min continuously HEALTH Teachings avoid forceful nose bleeding, straining, high altitude, nasal trauma adequate humidification to prevent drying of the nasal passages how to apply pressure bleeding does not stop – seek additional medical attention if unsuccessful Additional Treatment Anterior nosebleeds: - silver nitrate - gelfoam - electrocautery Topical vasoconstrictors - adrenaline 1:1000 - cocaine (0.5%) - phenylephrine Cotton pledgets – soaked with vasoconstricting solution, insert to nose reduce blood flow and improve the examiners view of the bleeding site cotton tampon- to stop bleeding suction – to remove excess blood clots bleeding cant be identified: nasal packing with gauze impregnated with - petrolatum jelly - antibiotic ointment - topical anesthetic spray - decongestant agent - balloon inflated catheter Packing – 48 º or 5-6 days to control bleeding Antibiotics – treatment to risk of sinusitis and toxic shock syndrome NSG MANAGEMENT 1. monitor v/s 2. Assist in the control of Bleeding 3. emesis basin – to expectorate excess blood assure calm and efficient manner that bleeding can be controlled – to help reduce anxiety assess airway and breathing significant hemorrhage- - IV infusions Pharmacology Close consideration of special situations Is the study of the biological effects of chemicals. Prevention and reporting of medication errors Drugs – chemicals that are introduced into the body Monitoring for therapeutic effects, side effects, toxic to cause some sort of change. effects The purpose of studying PHARMACOLOGY is to The nurse must understand the importance of proper drug help you learn about medicines and the WHY, storage in order to maintain medications at their optimum WHAT, HOW, WHEN, and WHERE they are used in potency. Some drugs must be refrigerated, some kept away daily life. from direct light, and some (narcotics) must be secured under double lock. Definition of Terms: Brand name – also called Trade name Documentation of medication administration should only be - given by the pharmaceutical company that completed after the client has taken the medication. If the developed it. nurse documents the medication as given and then the client Generic name – the original designation that the drug was refuses the medication, it is essentially a medication error. given when the drug company applied for the approval process. Calculation of drug dosages is the responsibility of the nurse. We will review the procedures for drug calculation a bit later. Generic name - Chemicals that are produced by companies who Dosage preparation involves pouring the medication or just manufacture the drugs. drawing it up in a syringe for administration. Some - They do not have the research, the advertising, or medications must be crushed and mixed with food or liquid sometimes, the quality control departments that for clients with difficulty swallowing. pharmaceutical companies have. Orphan drugs – are drugs that have been discovered but Transcription is an area that has a high potential for error. are not financially viable and therefore have not been Most facilities are moving from handwritten orders to adopted by any drug company. computer generated ones to reduce the error rate. Each of Over-the-counter Drugs – drugs that are available without these interventions has patient safety as its goal. prescription for self treatment of a variety of complaints. - Some of these agents were approved as Evaluation prescription drugs but later were found to be safe Ongoing part of the nursing process and useful for patients without the need for a Determining the status of the goals and outcomes prescription. of care Several problems related to over-the-counter drugs Monitoring the patient’s response to drug therapy (OTC): 1. Taking these drugs could mask the signs and symptoms of underlying disease, making diagnosis difficult. 2. Taking these drugs with prescription medications could result in drug interactions and interfere with drug therapy. 3. Not taking these drugs as directed could result in serious overdoses. Principles of Drug Administration Administering Medications 12 RIGHTS OF DRUG ADMINISTRATION 1. Right Patient /client 2. Right Medication /Drug 3. Right Dosage 4. Right Route 5. Right Time 6. Right Assessment 7. Right Motivation/Approach 8. Right to Refuse During the evaluation phase of the process, the nurse must 9. Right Of the Client To Know The Reason For The determine how much progress the client has made toward Drug the previously determined goals. 10. Right Evaluation 11. Right Documentation The nurse needs to ask: 12. Right Drug Preparation Is the medication doing what it was ordered to do? Other “Rights” Is it doing it as well as expected? Proper drug storage-refrigerated, some kept away Are there any unexpected effects? from direct light, and some (narcotics) Should the medication be changed, or continued as ordered? Careful checking of transcription of orders Patient safety Questions??? 5. Stat orders- given once immediately The day shift charge nurse is making rounds. A patient tells Types of Doctor’s Order the nurse that the night shift nurse never gave him his Prescription drug (Rx) medication, which was due at 11 PM. What should the nurse ○ A prescription drug (also prescription do first to determine whether the medication was given? medication or prescription medicine) is a 1. Call the night nurse at home. pharmaceutical drug that legally requires a 2. Check the Medication sheet. medical prescription to be dispensed. In 3. Call the pharmacy. contrast, over-the-counter drugs can be 4. Review the nurse’s notes. obtained without a prescription. Correct answer: 2 over-the-counter drug (OTC) Explanation: The Medication Administration Record is the ○ Drug products are approved by the legal documentation that the professional nurse uses to sign US-FDA, may be purchased from sellers of off medications that are given, so it should be checked first. all kinds. ○ Can be purchased without a prescription The patient’s Medication sheet lists two antiepileptic Veterinary drug products (VET) medications that are due at 0900, but the patient is NPO for ○ The Generic Animal Drug and Patent a barium study. The nurse’s coworker suggests giving the Restoration act requires that each sponsor medications via IV because the patient is NPO. What should of an approved animal drug must submit to the nurse do? the FDA certain information regarding 1. Give the medications PO with a small sip of water. patents held for the animal drug or its 2. Give the medications via the IV route because the method of use. The Act requires that this patient is NPO. information, as well as a list of all animal 3. Hold the medications until after the test is drug products approved for safety and completed. effectiveness, be made available to the 4. Call the physician to clarify the instructions. public. This list must be updated monthly Correct answer: 4 under the provisions of the Act. The list, Explanation: The dosage for the IV route would not be the known as the "Green Book," was first same as for the PO route. Holding the medications may published in January 1989. cause drug levels to drop and result in seizure activity, and Controlled Substances giving the medications PO without consent may alter the test ○ Controlled substances are drugs that have results. The nurse must never assume the route of some potential for abuse or dependence. medication administration and should consult the physician These drugs are regulated by the federal for clarification of the orders. Controlled Substances Act (CSA) – this Types of Doctor’s Order law helps the US Government fight against Doctor’s prescription the abuse of these drugs. The CSA divides COMPONENTS OF DRUG ORDERS: controlled substance drugs into five Date and time the order is written categories called schedules. Drug name Drug dosage Route of administration Frequency of administration Physician/ provider’s signature Medication Orders Full name of client Generic or trade name of drug Dose, route, frequency Date, time and signature of provider The nurse will need to look up the medication ordered to know it’s classification, safe dose, action, how to administer, and side effects The nurse should know why the medication is ordered Categories of Drug Orders 1. Standing order- protocols derived from guidelines created by healthcare providers for use in specific settings, for treating certain diseases or sets of symptoms 2. Standard order- may be an ongoing order, may be given for a specific number of doses or days. May include prn orders 3. One time or single order- given once and usually at a specific time 4. PRN orders- given at the client’s request and nurse’s judgment concerning need and safety  Airway Obstruction acute upper airway obstruction is a life-threatening medical emergency - completely or partially obstructed Partial Obstruction: 1. Progressive hypoxia 2. Hypercarbia 3. Respiratory and cardiac arrest Complete Obstruction: 1. Permanent brain injury 2. Death within 3-5 minutes secondary to hypoxia What is aspiration from dysphagia? Aspiration is when something enters your airway or lungs by accident. It may be food, liquid, or some other material. This can cause serious health problems, such as pneumonia. Aspiration can happen when you have trouble swallowing normally. Trouble swallowing is called dysphagia. Causes: 1. Aspiration of foreign bodies 2. Anaphylaxis 3. Viral or bacterial infection 4. Trauma 5. Inhalation or chemical burns Asphyxiation of food: 1. Older patient Clinical Manifestations: 2. Sedative and hypnotic medications Cannot speak/breath/cough 3. Diseases affecting motor coordination (Parkinson’s Choking 4. Mental dysfunction (dementia, intellectual disability) Apprehensive appearance Old => atrophy of the posterior pharynx => resulting in Refusing to lie flat aspiration and difficulty swallowing Inspiratory/expiratory stridor Adults- aspiration of bolus of meat Labored breathing Can result in airway obstruction: Use of accessory muscles - Peritonsillar abscesses Flaring of nostrils - Epiglottitis Increasing anxiety - Infections of the posterior pharynx Restlessness Most common: confusion Allergic reaction (laryngospasms) infection or angioedema  Oxygen Supplementation- immediately Management: Breath/cough- partial obstruction Universal Distress Signal: ○ Encourage to cough forcefully Clutch the neck between thumb and fingers ○ persist- with spontaneous coughing and breathing Manage as if there is complete obstruction: Wheezing but coughs Weak, ineffective cough High-pitched noise while inhaling Increase respiratory difficulty Cyanosis After obstruction is removed: Rescue breathing No pulse- cardiac compressions initiated - provide oxygen to the brain, heart and other vital organs - until medical treatment can restore and support normal heart and ventilatory support Late signs: Cyanosis Loss of consciousness * nursing actions be done before the late signs Assessment and Diagnostic findings: simply asking the person whether he or she is choking and requires help Unconscious- inspect oropharynx- reveal the offending object X-rays Laryngoscopy Bronchoscopy Establishing an Airway: Cricothyroidotomy Repositioning the patient’s head to prevent the Cricothyroid Membrane Puncture tongue from obstructing the pharynx ○ Opening the airway Jaw thrust Head tilt-chin lift Assess Breathing: - watching chest movement - listening and feelings for air movement Nsg. Diagnosis - Ineffective Airway Clearance - Ineffective Breathing Pattern Oropharyngeal Airway Maintaining Ventilation: Endotracheal Intubation - Checking bilateral breath sounds - Monitor pulse oximetry - Capnography - ABG Capnography- Capnography is an effective method to diagnose early respiratory depression and airway disorders, especially during sedation, leading to a reduction in serious complications (23, 24). Capnography provided more safety in monitoring patients during sedation. King Tube Intubation Heimlich Maneuver Make a fist with one hand, and clasp your other hand tightly around it. Place the thumb side of your fist just below your ribcage and about two inches above your belly button (navel). Sharply and quickly thrust your hands inward and Isotonic upward five times. Repeat this process until the object is - 0.9% Sodium Chloride (NS) freed (dislodged). - Lactated Ringers - Dextrose 5% in Water (D5W) Hypotonic HEMORRHAGE - 0.45% Sodium Chloride ➔ Reduction of the circulating blood volume Hypertonic Classification: - 5% dextrose in NS Capillary - Slow, even flow, easily controlled and - 5% dextrose in Lactated ringers stops spontaneously - 5% dextrose in 0.45% ½ NS Venous- Steady, slow flow, dark red color, easier to - 10% dextrose in Water control and low pressure system 2. Colloids (plasma expander) Arterial- Rapid and profuse, spurting with heart Albumin beat and most difficult to control Plasma Protein fraction Types of Bleeding Dextran External hetastarch Internal Minor Bleeding - venous Massive Blood loss: - Generally stops spontaneously Packed RBC - Patient has bleeding disorders Platelets - Taking anticoagulants Clotting factors Internal Hemorrhage: Control of External Bleeding - Can hide in anatomic spaces and compartments - Rapid physical assessment SHOCK - without external evidence of bleeding Cut away patient’s clothing - identify the area bleeding Direct firm pressure - bleeding area, involved artery, site proximal to the wound Most bleeding can be stopped or at least be controlled by application of the direct pressure Arterial bleeding - results in death Elevate - to stop venous and capillary bleeding Immobilize - if the area is an extremity Elevation Signs and Symptoms of Shock If the bleeding is from an arm or leg, elevate the Cool moist skin injured area above the level of the heart to reduce Decrease blood pressure blood flow as you continue to apply pressure Increase heart rate Elevation allows gravity to make it more difficult for Delayed capillary refill the body to pump blood to the affected extremity. Decreasing urine volume Elevation alone however will not stop bleeding and Goals of Emergency Management must be used in combination with direct pressure Control bleeding over the wound Maintain adequate circulating blood volume for Splints tissue oxygenation Immobilization of the injured extremity is one of the Prevent shock best ways to stop bleeding Hemorrhage > hypovolemic shock secondary to anoxia > Broken bone fragments may lacerate blood vessels cardiac arrest Muscular activity will increase rate of blood flow Control of bleeding Management: - Direct pressure 1. Fluid Replacement - Cold applications Hemorrhage > loss of circulating blood volume > - Elevation fluid deficit and decrease cardiac output - Pressure bandage - Replace fluids to maintain circulation Tourniquet - 2 large gauge catheters Applied when external hemorrhage cannot be - for fluid and blood replacements controlled and until surgery can be performed - isotonic solution - LR, NS Apply just proximal to the wound and tied directly - colloids and blood component therapy enough to control arterial blood flow Types of IV Fluids 1. Crystalloids vs Colloids The Types of Bleeding Crystalloids Colloids Arterial- Rapid and profuse, spurting with heart beat and most difficult to control Normal (0.9%) saline Human Albumin Capillary - Slow, even flow, easily controlled and stops spontaneously Ringer’s lactate solution Gelatin solutions Venous- Steady, slow flow, dark red color, easier to (Hartmann’s Solution) (Haemaccel, Gelafundin) control and low pressure system 5% dextrose Dextran Internal Hemorrhage Can result from - Blunt or penetrating trauma Hydroxyethyl starches - Acute or chronic medical illnesses (Hetastarch) 1. Crystalloids  Internal bleeding that can cause hemodynamic ❖ Administering prescribed medications instability usually occurs in one of four body ❖ Collecting lab specimens cavities: ❖ Patients responses - Chest - Abdomen ASSESSMENT & DIAGNOSTIC FINDINGS: - Pelvis - Patients w/ multiple trauma should be assumed to - Retroperitoneum have spinal cord injury until it is proven otherwise Control of Internal Hemorrhage - The injury regarded as the least significant in Signs and symptoms: appearance maybe the most lethal ○ no signs of external bleeding--- suspect ❖ Pelvic fracture - rapid & massive hemorrhage in internal hemorrhage the pelvic cavity ○ Tachycardia ❖ Amputation - bleeding might have stopped from ○ Falling BP the body’s normal response to vasoconstriction ○ Thirst ○ Apprehension Goals of Management ○ Cool, moist skin 1. Determine the extent of injuries ○ Delayed capillary refill 2. Establish priorities of treatment ○ Rapid rate of PRBC, plasma, platelets Any injuries interfering w/ a vital ○ ABG’s physiologic function (ABC) is an immediate ○ Supine position threat to life & hasten the highest priority Bleeding and Shock for immediate treatment. Internal Hemorrhage (2 of 3) Bleeding might have stopped from the Must be treated promptly body’s normal response to ○ Signs do not always develop quickly vasoconstriction ○ Pay close attention to patient complaints, Intra-abdominal Injuries and pallor - Categorized as penetrating or blunt ○ Be alert for the development of shock - Serious and requires surgery TRAUMA - Injury to hollow organs especially the small bowels - An unintentional or intentional wound or injury Penetrating: inflicted on the body from a mechanism against - Gunshot, stab wounds which the body cannot protect itself - liver - Meticulous documentation is very essential Gunshot - velocity at which the missile enters the body High velocity - produces extensive tissue damage Factors: Surgical exploration Alcohol Blunt Trauma Drug abuse - Motor vehicle accident Collection of forensic evidences: - Falls - Description of wound - Blows - Mechanism of injury - Explosions - Time of events Injuries - difficult to detect Nurse - careful w/ all potential evidences - Massive blood loss in the peritoneal area - Handle & document properly Assessment and Diagnostic Finding: Criminal Activity is suspected: History taking Removal of clothes- not to cut through or disrupt Secondary assessment - inspection of the abdomen any tears, holes, blood stains or dirt - injury auscultation of bowel sounds Each piece of clothing- individual paper bag Absent - intraperitoneal involvement Plastic bag – not used Stress can decrease or halt peristalsis - retain moisture- promote mold and mildew Signs of Peritoneal irritation: formation- destroy evidence - Abdominal distention - if wet- hung to dry tenderness pain Clothing should not be given to families - Involuntary guarding Muscular rigidity changes in Valuables - inventory BS - Hospital safe - Shock - Labeled & transferred to the custody of police Lab studies that aid in assessment: Tubes & lines remains in place Hgb and Hct Hand - cover w/ paper bag to protect evidence on Lactate - acidosis hand & fingernails ABGs\International normalized ratio to identify coagulopathy Survived: WBC to detect elevation (associated with trauma) - swab hands & nails for potential evidence Photograph - rules WOUNDS Documentation own words of client Injury to soft tissues Assists the judicial process Laceration - skin tear with irregular edges Avulsion - tearing away of tissues from supporting MULTIPLE TRAUMA structures - Caused by single catastrophic event that causes life Abrasion - denuded skin threatening injuries to at least 2 distinct organs or Ecchymotic/contusion - blood trapped under the organ systems surface of the skin - Team approach Hematoma - tumor like mass of blood trapped - Nursing staff under the skin ❖ Assessing & monitoring the pt. Stab - incision of the skin with well defined edges ❖ Ensuring/maintaining airway & IV access caused by a sharp instruments, deeper than long  Cut - incision of the skin with well defined edges, - Taking certain medications - tranquilizers, longer than deep anticholinergics, diuretics, beta blockers Patterned - wound representing the outline of the - Exertional heat stroke - occurs in healthy individuals object during sports and work activities Hyperthermia - results because of inadequate heat loss Goals of Management: Preventing heat-induced illnesses - Restore the physical integrity and function of the Avoid immediate re-exposure to high temperatures; injured tissue while minimizing scarring and hypersensitivity to high temperatures may remain preventing infection for a considerable time. Essential - documentation Maintain adequate fluid intake, wear loose clothing, Photographs - helpful - accurate and visible description and reduce activity in hot weather. of the wound Monitor fluid losses and weight loss during workout - For exigent wound (wound that will eventually heal) activities or exercise and replace fluids and Delay - increases infection risk electrolytes Aseptic technique when inspecting the wound Use a gradual approach to physical conditioning, Evaluate motor, sensory, vascular function allowing sufficient time for return to baseline temperature. Management: Plan outdoor activities to avoid the hottest part of Wound Cleansing the day (between 10am and 2pm) Clip hair - hair interfere wound closure Clean with NSS or polymer agent For older patients living in urban settings with high Betadine - initial cleansing environmental temperatures: ○ (-) deep wounds The nurse directs these patients to places where air Pain - intradermal anesthetic conditioning is available (e.g., shopping mall, library, church) Nurse assists in cleaning and debridement and advises them that fans alone are not adequate to - Irrigation with sterile saline solution to remove prevent heat-induced illness. surface dirt - Devitalized tissue and foreign materials - impedes Death in Older Adults: healing and promote infection Circulatory system unable to compensate for stress - Small bleeding vessels - clamped, tied, cauterized imposed by heat Non-adherent dressing: Decreased ability to vasodilate and vasoconstrict 1. Protect the wound Less subcutaneous tissue 2. Serves as splint Decreased thirst mechanisms 3. Reminder to the patient that the area is injured Diminished ability to concentrate urine to compensate for heat Primary Closure Do not drink adequate amounts of fluids - fear of Wound is sutured/stapled incontinence-thus greater risk of heat stroke Delayed primary closure Fear of being victims of crime- keep windows - Indicated - tissue has been lost closed despite high temp. And humidity, lacks air - Potential for infection conditioning. - No signs of suppuration - close - Antibiotics Assessment & Dx findings - Tetanus prophylaxis - Causes thermal injury at the cellular level — - Immobilize coagulopathies & widespread damage to the heart, - Elevation liver & kidneys. - Reports s/s of infection Symptoms: - sudden persistent pain - Profound CNS dysfunction - Fever or chills - Confusion, delirium, bizarre behavior, coma - Bleeding seizures - Rapid swelling - Elevated body T - 40.6 degrees centigrade - Foul odor - hoy,dry skin - Drainage - anhidrosis - redness - tachycardia, hypotension, & tachypnea Management: Environmental Emergencies Main goal: Heat induced illness: - To reduce the high body tempt. As quickly as Heat stroke - most serious possible - An acute emergency caused by failure to heat - Death is directly related to the duration of regulating mechanisms of the body hyperthermia - Inability to maintain CO in the face of the - Stabilize O2 using CABs of basic life support moderately high body T and is associated with - Establish access for fluid administration dehydration - Removing clothing - core T reduced - Non exertional, prolonged exposure to an Cooling procedures : environment T greater than 39.2 degrees 1. Cool sheets & towels or continuous sponging w/ centigrade cool water - Heat waves, high humidity 2. Ice applied to neck, groin, chest, axilla while w/ - Exertional heat stroke - caused by strenuous tepid water physical activity that occurs in hot environment 3. Cooling blankets Risk for nonexertional heat stroke 4. Immersion of the pt in cold water bath - Not acclimatized to heat During cooling procedures - electric fan is - Older or very young positioned so that it blows on the pt - Unable to care for themselves augment heat dissipation by convection & - With chronic and debilitative disease evaporation -Caution - avoid hypothermia & prevent hyperthermia - recur Alcohol ingestion increases susceptibility because it 3-4 hrs causes systemic vasodilation. -stop cooling process at 38 degrees centigrade - inorder to Medications- (phenothiazines) or medical conditions avoid iatrogenic hyperthermia (hypothyroidism, spinal cord injury) decreases the Monitor: ability to shiver, hampering the body's innate ability - v/s to generate body heat. - ECG Fatigue, sleep deprivation- also associated with the - CVP development of hypothermia. - LOC Wet clothing- accelerates heat loss Immersion in cold water- increases heat loss Seizure may may be followed by the recurrence of Victims of trauma – resulting from treatment with hypothermia 100% O2 - to meet tissue needs exaggerated cold fluids, unwarmed 02 and exposure during by hypermetabolic rate ET & MV - to support failing examination. cardio-pulmonary systems ASSESSMENT AND DIAGNOSTIC FINDINGS: - IV infusion NSLR - to replace losses & maintain Hypothermia leads to physiologic changes in all organ adequate circulation systems - Carefully bc of the danger of the myocardial injury & - Progressive deterioration poor kidney function - Apathy - Ataxia Cooling - redistribute the fluid volume from the - Poor judgment periphery to the core - Dysarthria Measure time urine output - Drowsiness Blood specimens - detect bleeding disorders - Pulmonary edema Dialysis - acute kidney injury - Acid base abnormalities Anticonvulsants - control seizures - Coagulopathy K for hypokalemia - Eventual coma NaHCO3 - to correct metabolic seizures Less than 32.2 degrees centigrade- shivering may be Benzodiazepines - diazepam (valium) to suppress suppressed seizures - Body’s self warming mechanism becomes Phenothiazines - chlorpromazine - to suppress ineffective shivering Heartbeat and BP may be so weak that peripheral pulses become undetectable. Cardiac Dysrhythmias Hypoxemia Acidosis Management: Removal of wet clothing Continuous monitoring Rewarming Supportive care Monitoring: Circulation- Airway- Breathing of basic life support v/s Central venous Urine output ABG Blood chem (BUN, creatinine, glucose, electrolytes) Chest x-ray Monitor core body temperature ECG Arterial Line HEAT STROKE Rewarming: Anxiety- Confusion Active internal (core) rewarming Skin hot & dry Passive (spontaneous) Impaired sweating Active external rewarming Listlessness Active internal rewarming Na & K depletion ➔ Used to moderate to severe hypothermia Increase Body temperature increase 40.6C or 105F (28-32.2 degrees centigrade) ➔ Cardiopulmonary bypass Cerebral edema: ➔ Warm fluid administration Seizures ➔ Warmed humidified 02 by ventilation Delirium ➔ Warmed peritoneal lavage Coma ➔ Monitor ventricular fibrillation as the patient increases from 31-32 degrees centigrade increase Pulse & Resp rate PASSIVE or ACTIVE EXTERNAL REWARMING Hypotension Used for mild hypothermia (32.2-35) Uses over the bed heaters to the extremities and Management – Cooling, rest, fluid & electrolyte support) increases blood flow to the acidotic, anaerobic extremities HYPOTHERMIA Cold blood- high lactic acid levels A condition in which the core (internal) T is 35 - As this returns to the core, it causes a degrees centigrade or less as a result of exposure significant drop in the core T, causes to cold or an inability to maintain body temperature cardiac dysrhythmias and electrolyte in the absence of low ambient temperature. disturbances. Uses forced air warming blankets- care to prevent burns A fasciotomy is an emergency procedure Supportive Care: used to treat acute compartment - External cardiac compression (typically performed syndrome. Compartment syndrome is only as directed in patient with temperatures higher when the pressure builds up in a than 31* C {88*F) non-compliant osseofascial compartment Defibrillation Of the ventricular fibrillation. A patient whose and causes ischemia leading to muscle temperature is less than 32*C (90*F) experiences and nerve necrosis. spontaneous ventricular fibrillation if moved or touched. After rewarming: Defibrillation is ineffective in patients with temperatures lower - Active motion - promote maximal restoration of than 31*C {88*F); therefore the patient must be rewarmed function and prevent contractures first. Discharge: Mechanical Ventilation with positive end- expiratory - Avoid tobacco, alcohol, caffeine pressure (PEEP) and heated humidified oxygen to maintain tissue oxygenation. NON - FATAL DROWNING Administration of antiarrhythmic medications - Survival for at least 24 hours after submersion that Insertion of an indwelling urinary catheter to monitor caused respiratory arrest urinary output and kidney function. - Hypoxemia - common consequence - 5 years and over 85-higher risk of drowning FROSTBITE AVOID: Trauma from exposure to freezing T and freezing of - Rip currents offshore intracellular fluids and fluids in the intercellular spaces - Pool-fence, self - latching/closing gate ↓ - Swimming lessons Cellular and vascular damage - Supervision - best Causes venous stasis and thrombosis - Personal floating device (PFD) Feet hands nose ears Factors: Assessment and diagnosis 1. Alcohol ingestion Frozen extremity: 2. Inability to swim - Hard 3. Diving injuries - Cold 4. Hypothermia - Intensive to touch 5. exhaustion - White and mottled blue-white - Efforts should not be abandoned prematurely Wet socks, exercise/movement - may diminish the protective - Successful resuscitation with full neurologic effects of insulation by 45% recovery has occurred in patients who have Management: experienced non - fatal drowning after prolonged Goals: submersion in cold water → - Restore normal body T 1. Decrease metabolic demand - Remove constrictive clothing and jewelry - impair 2. Diving reflexes circulation - Hypoxia, hypercapnia, bradycardia, dysrhythmias - Wet clothing is removed as rapidly as possible → hypoxia acidosis → apnea → loss of - Lower extremities - involved - not allowed to consciousness → final effort to breathe → terminal ambulate gasp → water moves passively into the airways → - Controlled yet rapid rewarming is instituted DEATH - Frozen extremities - placed in 37 - 40 degrees celsius in circulating bah for 30-40 minutes Major Complications: - Repeat until circulation is effectively restored 1. Hypoxia - Early rewarming - decrease tissue loss 2. Acidosis - During rewarming - give analgesics *depends on the type of fluid and volume aspirated - Rewarming - is a painful process - massage /body part is not handled - cause Fresh water - loss of lung surfactant - inability of the lungs to mechanical injury expand After rewarmed: Salt water - leads to pulmonary edema from the osmotic - Elevate - control swelling effects of the salt within the lungs - Sterile gauze, cotton is placed between affected finger or toes to prevent maceration Survives submersion - ARDS, resulting in hypoxia, - Foot cradle - prevent contact with bedclothes hypercarbia and respiratory or metabolic acidosis NSAIDs MANAGEMENT: - Additional measures Goal: maintain cerebral perfusion and adequate oxygenation - Whirlpool bath for the affected body parts to aid to prevent further damage to the vital organs. circulation debridement of necrotic tissue to help CPR - influences survival → ensuring adequate airway and prevent infection respiration → improves ventilation and oxygenation (correct - Escharotomy (incision through the eschar) to the respiratory acidosis) prevent further tissue damage, to allow for normal circulation, and to permit joint motion Monitor ABGs - Fasciotomy to treat compartment syndrome ET - if not breathing spontaneously An escharotomy is an emergency medical supplemental O2 by mask - if breathing spontaneously procedure that involves the removal of the Submersion - hypothermia - rectal probe to determine full-thickness burn (eschar) down to the degree of hypothermia subcutaneous fat to release it and Even if patient appears healthy - close monitoring - at risk for prevent further complications. It complications - hypoxic or ischemic cerebral injury, cardiac restores blood flow and allows adequate arrest ventilation. ANIMAL AND HUMAN BITES ❖ Abdominal rigidity Dog bites - majority of the death ❖ Nausea and vomiting Cat bites - presence of Pasteurella in their saliva ❖ HPN - Rabies prophylaxis ❖ Tachycardia Human bites: ❖ Paresthesia - Rape, sexual assults, battery Severe pain within 60 minutes and 1-2 days: - Human mouth contains more bacteria than other 1. Apply ice to site to decrease swelling and animals discomfort - Bite related infection 2. Elevation ED: 3. Tetanus immunization - Inspect for pus, erythema, necrosis 4. Muscles spasms: analgesics, benzodiazepines - Take photographs - evidence of criminal and legal proceedings TICK BITES - Cleanse with soap and water Grassy, wooded areas - Administer antibiotics Pathogens transmitted through saliva - Tetanus toxoid -rocky mountain spotted fever - tularemia SNAKEBITES - west nile virus Initial first aid at the site of the snakebite - lyme disease 1.Have the person lie down Remove with tweezers straight upward pull 2.Remove constrictive items Stage 1: Provide warmth “Bulls-eye” rash Cleansing the wound 5 cm diameter with bright red borders Cover with light dressing Flu like symptoms Immobilize Doxycycline ABC priorities of care Stage 2: 4-6 weeks after the bite Ice, incision and suction, tourniquet- is not Joint pain, memory loss, poor motor coordination applied Adenopathy PRN- tetanus and analgesics Cardiac abnormalities Where and when the bite occurred and the Facial nerve palsy circumstances of the bite Stage 3: Weeks to a year after the bite Sequence of events, pain, edema and erythema Arthritis Severity of poisonous effects Myalgia Call local poison control Neuropathy V/S myocarditis Circumference of the bitten extremity -compare with *Even with antibiotics- may persist for over 10 years the other extremity Labs- CBC,Urinalysis, Coagulation studies Ice, tourniquet, corticosteroids, heparin- not used during acute stage Corticosteroids- C/I 6-8 hours after the bite because they may depress the antibody production and hinders the action of the antivenin. Parenteral fluids to treat hypotension Observe closely for 6 hours. Patient is never left unattended Antivenin- antitoxin manufactures from the snake venom - For progressive - Most effective if given within 4 hours and no greater than 12 hours after the bite. Before Administration: Measure the circumference of the affected part every 15 minutes. Premedication: -Diphenhydramine -Cimetidine -IM/IV infusion Spider Bites Brown reclu