ministry of health, general directorate of · pdf file · 2012-11-19ministry of...

Ministry Of Health, General Directorate Of Nursing

anual of

ursing

olicies and

rocedures

Prepared by:

Nursing Policies and Procedures’ Committee 2011

Supervised by:

Dr. Munira Al Oseimy

General Director of Nursing-MOH

2nd Edition EMERGENCY CARE

Ministry of Health, General Nursing AdministrationFunctions and Duties Policies and Procedures______________________________________________

TABLE OF CONTENTSINDEX

NUMBERPOLICY TITLESNSNR-ER- 001NURSING ROLE IN TRIAGE1.SNR-ER- 002SAFE PRACTICE IN EMERGENCY DEPARTMENT2.SNR-ER- 003ADMISSION OF PATIENT FROM ER3.SNR-ER- 004NURSING EMERGENCY ASSESSMENT PROCESS4.SNR-ER- 005NURSING CARE OF DYING PATIENT5.SNR-ER- 006DEAD ON ARRIVAL (DOA)6.SNR-ER- 007SHOCK AND NURSING EMERGENCY MANAGEMENT7.SNR-ER- 008SYNCOPE, EMERGENCY MANAGEMENT8.SNR-ER- 009NURSING EMERGENCY MANAGEMENT OF CHEST PAIN9.SNR-ER- 010NURSING EMERGENCY MANAGEMENT FOR

HYPERTENSIVE CRISIS10.

SNR-ER- 011NURSING EMERGENCY MANAGEMENT OF RESPIRATORYDISTRESS11.

SNR-ER- 012NURSING EMERGENCY MANAGEMENT OF BRONCHIALASTHMA12.

SNR-ER- 013NURSING EMERGENCY MANAGEMENT OF CHRONICOBSTRUCTIVE PULMONARY DISEASE13.

SNR-ER- 014NURSING EMERGENCY MANAGEMENT OF COMA14.SNR-ER- 015NURSING EMERGENCY MANAGEMENT OF SPINAL CORD

INJURY15.

SNR-ER- 016NURSING EMERGENCY MANAGEMENT OF SEIZURESDISORDERS16.

SNR-ER- 017NURSING EMERGENCY MANAGEMENT OF STATUSEPILEPTICUS17.

SNR-ER- 018NURSING EMERGENCY MANAGEMENT OF EPISTAXIS18.SNR-ER- 019NURSING EMERGENCY TREATMENT SOFT TISSUE

INJURIES19.

SNR-ER- 020NURSING EMERGENCY MANAGEMENT OF MULTIPLEINJURIES20.

SNR-ER- 021NURSING EMERGENCY MANAGEMENT OF HEADTRAUMA (SKULL AND BRAIN)21.

SNR-ER- 022NUSRING EMERGENCY MANAGEMENT OF ABDOMINALTRUMA22.

SNR-ER- 023NURSING EMERGENCY MANAGEMENT OF BURNS23.SNR-ER- 024NURSING EMERGENCY MANAGEMENT OF SICKLE CELL

CRISIS24.

SNR-ER- 025NURSING EMERGENCY MANAGEMENT OF NEAR-DROWNING25.

SNR-ER- 026NURSING EMERGENCY MANAGEMENT OF DIARRHEA ANDVOMITING26.

SNR-ER- 027NURSING EMERGENCY MANAGEMNT OF CARBONMONOXIDE POISONIING27.

SNR-ER- 028NURSING EMERGENCY MANAGEMENT FOR INGESTIONOF POISONOUS SUBSTANCES (DRUG, FOOD, CHEMICAL)28.

SNR-ER- 029NURSING EMERGENCY MANAGEMENT OF ALCOHOLINTOXICATION/ WITHDRAWAL29.

SNR-ER- 030NURSING EMERGENCY MANAGEMENT OF ANIMALBITES/STINGS30.

SNR-ER- 031NURSING EMERGENCY MANAGEMENT OF TETANUS31.









INJURY15.




INJURIES19.





CRISIS24.
















INJURY15.




INJURIES19.





CRISIS24.








SSSPPPEEECICICIAAALLLIIIZZZEEEDDD NUNUNURSRSRSIIINGNGNG::: EEEMEMEMERGRGRGEEENCYNCYNCY CACACARRREEE

Ministry of Health, General Nursing AdministrationFunctions and Duties Policies and Procedures______________________________________________SPECIALIZED NURSING: EMERGENCY CARE

TABLE OF CONTENTS

INDEXNUMBERPOLICY TITLESN

SNR-ER- 032NURSING EMERGENCY MANAGEMNT OF HYPOTHERMIA32.SNR-ER- 033ENVIRONMENTAL EMERGENCY OF FROSTBITE33.SNR-ER- 034NURSING EMERGENCY MANAGEMENT OF ACUTE

KIDNEY FAILURE34.SNR-ER- 035NURSING EMERGENCY MANAGEMENT OF HEMORRHAGE35.SNR-ER- 036DIABETIC EMERGENCIES36.SNR-ER- 037NURSING EMERGENCY MANAGEMENT OF FRACTURES37.


TABLE OF CONTENTS





TABLE OF CONTENTS





INTERNAL POLICY AND PROCEDURENURSINGAPPLIES TO:SNR-ER- 001POLICY NUMBER:

DPP NURSING ROLE IN TRIAGETITLE:

EFFECTIVE DATE:APPROVAL DATE:

1 of 5NUMBER OF PAGESDUE FOR REVIEW

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1.0 PURPOSE1.1 To ensure that treatment is appropriately and timely1.2 To allocate the patient to the most appropriate assessment and treatment area1.3 To gather information that facilitates the description of the departmental case mix

2.0 DEFINITION2.1 Triage is an essential function in Emergency Departments (EDs), where many patients may

present simultaneously. Urgency refers to the need for time-critical intervention - it is not

synonymous with severity. Patients triaged to lower acuity categories may be safe to wait

longer for assessment and treatment but may still require hospital admission.

2.2 The assessment/triage area must be immediately accessible and clearly sign-posted. Its

design should allow for :

2.2.1 patient examination

2.2.2 means of communication between entrance and assessment area

2.2.3 privacy

3.0 RESPONSIBILITIESRegistered Nursing staff in Emergency Department

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4.0 POLICY

4.1 All patients presenting to an Emergency Department should be triaged on arrival by a

specifically trained and experienced registered nurse.

The triage assessment should generally take no more than two to five minutes

The nurses should be remembered however that a symptom reported by an adult may be less

significant than the same symptom found in a child and may render a child's urgency greater.

4.2 Victims of trauma should be allocated a triage category according to their objective clinical

urgency. As with other clinical situations, this will include consideration of high-risk history

as well as brief physical assessment (general appearance +/- physiological observations.

4.3 Patients presenting with mental health or behavioral problems should be triaged according to

their clinical and situational urgency, as with other ED patients. Where physical and

behavioral problems co -exist, the highest appropriate triage category should be applied

based on the combined presentation.

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5.0 PROCEDURE RATIONALE

5.1 On arrival assess the patient .

5.2 Balance the need

5.3 Measure vital signs at triage if required

5.4 Determine the clinical urgency of the patient.

5.5 Notify doctor on call of patient's arrival

5.6 Meet any immediate care needs.

5.6.1Position the patient5.6.2 Administer O2 immediately resuscitation, if

necessary5.6.3 Initiate fluid replacement as order

5.6.4Cleansing and dressing of wounds.5.6.5 Apply cervical collar for patients suspected of

spinal cord injury.5.6.6As appropriate, initiate appropriate

investigations (e.g. x-rays) or initialmanagement according to hospital protocol.

5.7 Document details of the triage assessmentInclude at least the following details :5.7.1 Date and time of assessment5.7.2 Name of triage nurse

5.1 To be able to determine patient'scondition and

5.2 for speed against the needto be thorough.

5.3 To determine neurological disability

5.4 to estimate urgency, and if timepermits.

5.6.1 To establish patent airway.5.6.2 To provide adequate

Ventilation5.6.3 To maintain CO5.6.4 To prevent infection5.6.5 To prevent cervical injury

5.7 To provide clear report aboutprocedure steps for continuousnursing care

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5.7. Chief presenting problem5.7.4 Limited, relevant history5.7.5 Relevant assessment findings5.7.6 Initial triage category allocated5.7.7 Any diagnostic, first aid or treatment

measures initiated.

5.8 Ensure continuous reassessment of patientswho remain waiting .

5.9Re-triage a patient if :5.9.1 his/her condition changes while they are

waiting for treatment5.9.2 Additional relevant information

becomes available that impacts on thepatient's urgency

6.0 MATERIALS & EQUIPMENT

6.1 The following equipment must be available in triage area:

6.1.1 Cervical collar

6.1.2 ECG machine

6.1.4 cardiac monitor

6.1.5 Suction machine

7.0 ATTACHMENTSN/A

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8.0 REFERENCES8.1 Ministry of Health, General Nursing Administration Functions and Duties Policies and Procedures for

Specialized Nursing: Emergency Care 2006 (SNR-ER-049)8.2 Tambimuttu J. Hawley R. Marshall A. 2002. Nurse-initiated x-ray of isolated limb fractures

in Hewson P. Poulakis Z. Jarman F. Kerr J. McMaster D. Goodge J. Silk G. 2000. Clinicalmarkers of serious illness in young infants: a multicentre follow-up study. Journal ofPaediatrics & Child Health. 36:3: 221-5 .

8.3 Royal Perth Hospital. Division of Critical Care. 2003. Zero tolerance to patient and visitorinitiated workplace aggression at Royal Perth Hospital Emergency Department. Perth: RoyalPerth Hospital.

NAME DATE

Prepared By: Central Committee Of NPP 2006 -General Directorate Of Nursing-MOH.KSA 2007

Reviewed By: Ashwag Omar shaibah.- BSN -Head of nursing education KFH-J 2010

Approved By: Central Committee Of NPP 2010 - General Directorate Of Nursing-MOH.KSA 2010

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INTERNAL POLICY AND PROCEDURE

NURSINGAPPLIES TO:SNR-ER- 002POLICY NUMBER:

DPPSAFE PRACTICE IN EMERGENCY DEPARTMENTTITLE:


1 of 3NUMBER OF PAGESDUE FOR REVIEW:

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1.0 PURPOSE1.1 To ensure patients and staff safety and prevent accidents.1.2 To prevent spread of infection from patients with communicable disease

2.0 DEFINITIONN/A

3.0 RESPONSIBILITIES3.1 Registered Nurses Staff in Emergency Department.

4.0 POLICY4.1 All staff involved with the patient must practice standard precaution, following the principlethat blood and body fluids are potentially infected4.2 Strict hand washing must be maintained.4.3 staff nurses shall observe safety practices to assist in preventing accidents in the Emergency

Department (E.D).4.4 Electrical cords, extended leads must be placed away from the traffic of patients and staff.4.5 Patients with these conditions must never be left alone:

4.5.1 Seizuring patient.4.5.2 Head injuries.4.5.3 Attempted suicide.4.5.4 Comatose.4.5.5 Restless.4.5.6 Children under the age of 12.4.4.7 Intoxicated or those under the influence of drugs.

4.6 Wheels must be locked and brakes applied on all beds and stretchers.4.7 Patients must be assisted in mounting and dismounting of all beds and stretchers .4.8 Patients who have received narcotics, hypnotic or sedative must be assessed by the nurses

and not be discharged unless accompanied by responsible adult or until the full effects of themedication have been assessed by observation.

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4.9 Patients who receive Antibiotics, Gamma Globulin and Tetanus Toxoid must not be releaseduntil after 20 minutes by observation.

4.10. Any accidental spillage must be mopped up and cleaned immediately.4.11 Physical isolation of the patient must be applied to patients who are infected and are

hazardous to others.4.12 Narcotics/ Sedative drugs must be double checked by the incoming and outgoing assigned

registered staff nurse.4.13 Safe key of all controlled drugs must be kept and endorsed to the registered staff nurse.4.14 There must be a qualified person from the BioMed. And safety Department available at alltimes in the

event of equipment failure that falls within their responsibility.4.15 A back up tank of oxygen cylinder must be available in the event of wall oxygen failure.4.16 A portable suction must be available at all times in the E.D in the event of wall suction

failure.4.17 A battery power light must be available in the E.D in the event of power failure.4.18 There must be a member of the facilities department available daily for 24 hours to care the

equipment that falls within their scope of job description.4.19 An extra battery and bulb for the laryngoscope must be always available.

5.0 PROCEDURES RATIONALE

5.1 Remove all non- essential broken furniture andfailed pieces of equipment in the work area as soonas it’s discarded.

5.1.1 Label the broken equipment with asign plainly marked (Broken).

5.1.2 Initiate a Job Order.5.1.2.1 Use “Request For Repair” for

BioMed.or safety Department, thensend it with broken items.

5.1.2.2 Call General Maintenance forother type of repair and

5.1 to maintain safety environment

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continuous follow up

5.2 Put on disposable gloves if you tend to deal withblood extract or contaminated materials.

5.3When sharp container is 2/3 full, placed inpolythane bag (yellow/red) securely sealed and sendfor incinerations.

5.2 To prevent infection

5.3 To provide overload and providesafety practice for staff

6.0 ATTACHMENTS

N/A

7.0 MATERIALS & EQUIPMENTNon

8.0 REFERENCESMinistry of Health, General Nursing Administration Functions and Duties Policies and Procedures forSpecialized Nursing: Emergency Care 2007.

NAME DATE


Reviewed By: Ashwag Omar shabah.- Head of nursing education KFH-J 2010


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DPP ADMISSION OF PATIENT FROM ERTITLE:



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١ .

1.0 PURPOSE1.1 To ensure that the patients receive efficient and effective care and care through the

admission procedure without stress.

1.2 To ensure continuity of care through stabilization of condition and effective communication.

2.0 DEFINITIONNA


4.0 POLICY4.1 The patient is admitted only on the order of the physician on call for the appropriate service.

4.2 Attending physician or his designate must assess patient for admission and orders writtenbefore transfer to ward.

4.3 Patient's condition is stabilized in ER prior to transfer except in cases of direct transfer,deliveries.

4.4 All patients will admitted to Critical car unit (ICUs), cardiology unit, burn unit must betransfer with nurse and doctor.

4.5 If the patient is to have I.V. therapy, laboratory works, x-rays, it must be started in ER, bloodwill be drawn for laboratory works. The patient will pass by in x-ray for necessary films onway to the ward, unless contra-indicated by doctor's order.

4.6 Referral cases from outside hospital with early notification provide then send directly to therespective units e.g. MI, pediatric cases with respiratory distress and intubated patients.

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5.0 PROCEDURE RATIONALE5.1 Prepare patient for admission:

5.1.1 Explain procedure5.1.2 Arrange and ensure all document and

examinations are complete5.1.3 Document valuables received according to

hospital system.5.2 Ensure patient information are registered foradmission according to hospital or institution system.

5.3 Implement all "Stat" orders – I.V., laboratorywork, x-rays and medications as ordered.

5.4 Notify ward nurse of impending admission andsecure bed assignment.

5.5 Check patient record for thorough documentationof tests, treatment, medicine sign off with legalsignature and title when complete.

5.6 Accompany patient to the unit, depending onpatient condition(wheelchair, stretcher) and acomplete verbal report be give to the nurse in-charge of the receiving unit.

5.7 For medico-legal cases:5.7.1 Inform the police officer

5.1.2 Write in the file that the patient is a

5.4 To arrange any special equipmentneeded for patient.

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police case.5.8 For immediate surgical management:

5.8.1 Inform operating room staff

5.8.2 Secure consent

5.8.3 Prepare the patient for surgery

5.9 Proper nursing Document

5.8.2 For patient right.


6.0MATERIALS & EQUIPMENT

6.1 Trolley or wheelchair6.2 Patient's gown6.3 Patient's file6.4 Laboratory reports and x-ray films

7.0 ATTACHMENTSN/A


Specialized Nursing: Emergency Care 2006 (SNR-ER-08)

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NAME DATE


Reviewed By: Ashwag Omar shaibah.- Head of nursing education KFH-J 2010


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DPP NURSING EMERGENCY ASSESSMENT PROCESSTITLE:



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1.0 PURPOSE1.1 To provide all patients entering emergency department with nursing care based on

documented assessment of their needs.1.2 To provide proper nursing care and implementation of nursing process.

2.0 DEFINITIONNA


4.0 POLICY4.1 ED nurses must provide assessment to all patient arrive to ED.

4.2 The emergency department nurses shall initiate accurate and ongoing assessment of physical

and psychosocial needs of patient within the emergency department.

4.3 It should be decided whether those who accompany the patient have a stabilising or

destabilising influence. People who appear to provoke the patient should be asked to leave.

4.4 Re-consider the mechanism of injury. If there is significant mechanism of injury, perform a

RapidTrauma Assessment.

4.5 The nurse should identify priority patient Is the patient:CriticalUnstablePotentially UnstableStable

4.6 Staff who sense feelings of danger, however vague, should discontinue the assessment andseek assistance. So called 'gut feelings' should not be ignored.

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4.7 If a 'dangerous' person leaves the Emergency Department alert security and policeimmediately. Do not attempt to chase the person.

4.8 Do not assess people in confined or isolated areas. Ensure there is easy access to the door.

4.9 Alert police as required, police may provide assistance during the assessment .

5.0 PROCEDURE RATIONALE5.1 Assess all patients' coming to emergency

department.

5.2 Collect data for nursing assessment

5.3 Place the patient in a comfortable position and

provide privacy.5.4 Require immediate intervention to Emergent

patient .

5.5 Urgent Patients with motor illness/ injury whohas a serious problem but is stable enough to beunattended for up to two hours. (Urgent patient –patient with major injury who is not ambulatory).

5.6 GENERAL IMPRESSION5.6.1 Mechanism of injury or nature of illness, Age,

sex.

5.6.2 Find and treat life threatening conditions (anyobvious problems that may kill the patientwithin seconds). Problems with Airway, Breathing,

5.2 To establish plan of care.5.3 To reduce anxiety

5.5 To safe patient life and provide careneeded

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or Circulation5.7 Assessment of Mental status:

5.7.1 If the pt. appears to be unconscious, check forresponsiveness, (“Hey! Are you OK )؟”

5.7.2 Obtain a chief complaint, if possible5.8 Assessment of Air way:

5.8.1 Is the pt. talking or crying؟5.8.2 Do you hear any noise؟5.8.3 Will the airway stay open on it’s own؟5.8.4 Does anything endanger it؟5.8.5 Open the airway - head-tilt-chin-lift or jaw

thrust – as needed5.9.6 Clear the airway – as needed5.9.7 Suction - as needed

5.9 Assess breathing:5.9.1 Do you see any signs of inadequate

respirations؟5.9.2 Is the rate and quality of breathing

adequate to sustain life؟5.9.3 Is the patient complaining of difficulty

breathing؟5.9.3.1 Quickly inspect the chest for impaled

objects, open chest wounds, and bruising(trauma)

5.9.3.2 Quickly palpate the chest for unstablesegments, crepitation (trauma), and equalexpansion of the chest

5.9.3.3 If the pt. is unresponsive and breathingis adequate, administer oxygen.

5.9.3.4 Apply pulse oximetery

5.10 CIRCULATION

To provide nursing intervention asappropriate

5.9.3.4 for oxygen saturation

5.10 To maintain CO and oxygen supply

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5.10 .1 If the pt. is unresponsive, assess forpresence and quality of the carotid pulse.

5.10.2 If the pt. is responsive, assess the rate andquality of the radial pulse.

5.10.3 If radial pulse is weak or absent, compareit to the carotid pulse.

5.10.4 For patients 1 year old or less, assess thebrachial pulse.

5.10.5 Is there life threatening hemorrhage؟5.10.5.1 Control life threatening hemorrhage5.10.5.2 Assess the patient’s perfusion by

evaluating skin for color, temperatureand check the conjunctiva and lips

5.10.5.3 Assess capillary refill in infant or child< 6 yrs. old

5.10.5.4 Cover with blanket and elevate the legsas needed for shock (hypoperfusion)

5.11 Expose / environmental control:5.11.1 Remove the patient's clothing in order >>

you must prevent heat loss by using warmblankets .

5.12 Facilitate family presence

5.13 Proper nursing Document

to brain

5.11.1 to identify all injuries

5.12 to explain what is being done andoffer support


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6.0MATERIALS & EQUIPMENT

6.1 Stethoscope

6.2 Torch

6.3 Pulse oximetery

6.4 oxygen slender

6.5 Gloves

7.0 ATTACHMENTSN/A


Specialized Nursing: Emergency Care 2006 (SNR-ER-08)8.2 Hewson P. Poulakis Z. Jarman F. Kerr J. McMaster D. Goodge J. Silk G. 2000. Clinical

markers of serious illness in young infants: a multicentre follow-up study. Journal ofPaediatrics & Child Health. 36:3: 221-5 .

٨.3 Royal Perth Hospital. Division of Critical Care. 2003. Zero tolerance to patient and visitorinitiated workplace aggression at Royal Perth Hospital Emergency Department. Perth: RoyalPerth Hospital.

8.4 http://mufon.yoo7.com/montada-f28/topic-t591.htm

NAME DATE




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http://mufon.yoo7.com/montada-f28/topic-t591.htm



DPP NURSING CARE OF DYING PATIENTTITLE:



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1.0 PURPOSE1.1 To help ease fear and loneliness.

1.2 To provide comfort.

1.3 To maintain the highest possible quality of life.

2.0 DEFINITION2.1 (ED) Emergency department.2.2 ( LOC) Level of consciousness


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4.0 POLICY

4.1 The nurse must assess the signs and symptoms of impending death while the body arrive

to ED include the following:

4.1.1 Reduced respiratory rate and depth.

4.1.2 Decreased or absent blood pressure.

4.1.3 Week or erratic pulse rate.

4.1.4 Lowered skin temperature.

4.1.5 Decreased level of consciousness (LOC).

4.1.6 Diminished sensorium and neuromuscular control.

4.1.7 Diaphorsis, pallor, cyanosis and mottling.

4.2 Emergency nurses have an important role in providing life-sustaining treatment as well as

care and comfort measures to patients at the end of life.

4.3 Emergency nurse should use culturally appropriate measures that are consistent with patient

preferences to relieve pain, dyspnea, and other symptoms during the patient’s end of life.

4.4 Family Presence Position Statement, emergency nurse should consider and respect familypresence during resuscitation and invasive procedures.

4.5 Emergency nurse shall provide Emotional support for a dying patient means simplereassurance and nurse’s physical presence to help ease fear and loneliness.

4.6 The patient should be kept warm, maintain hydration and avoid stressful situations todiminish occurrence of attacks.

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5.1 Check Vital signs are obtained and monitored.

5.2 Administer oxygen by mask or cannula asordered.

5.2 Encourage fluid intake orally, if not tolerated,initiate I.V fluids as ordered.

5.3 Provide a quiet and comfortable environment .

5.4 Administer medications as ordered.

5.5 Monitor the patient for below signs and symptoms

5.5.1 Infection.

5.5.2 Active cellulites.

5.5.3 Leg ulcers.

5.5.4 Swollen joints.5.5.5 Osteomyelitis.

5.6 Keep the patient warm and maintain adequatehydration.

5.7 Teach the patient to avoid factors that precipitatepain crisis.

5.8 Document nursing care provided

5.2 To enhance oxygenation and preventhypoxia.

5.2 Decreased blood viscosity andimprove perfusion.

5.3 To provide rest and relieve pain.

5.5 To be able to administer prompttreatment and prevent furthercomplications

5.7 to diminish the occurrence andseverity of attacks.


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5.9 To increase patient’s knowledge


6.1 Oxygen

6.2 IV fluids

6.3 Medications as prescribed

7.0 ATTACHMENTSN/A


Specialized Nursing: Emergency Care 2006 (SNR-ER-049).

8.2 Emergency Nurses Association. (2005). Position statement: Family presence at the

bedside during invasive procedures and/or resuscitation. Des Plaines, IL: Author.

8.3 Holleran, R. S. (2002). When is dead, dead? The ethics of resuscitation in emergency

care. Nursing Clinics of North America, 37(1), 11-18.

8.4 Emergency Nurses Association. (2002). Position statement: Stress management

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NAME DATE




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NURSINGAPPLIES TO:SNR-ER- 006POLICY NUMBER

DPP DEAD ON ARRIVAL (DOA)TITLE:

EFFECTIVE DATEAPPROVAL DATE:


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1.0 PURPOSE1.1 To assess and confirm death.1.2 To provide immediate resuscitative measures before confirming death.

2.0 DEFINITION2.1 (DOA) Dead on Arrival: A person brought to a hospital lifeless and confirmed dead after the

physician legally pronounced it.2.2 (ED) Emergency Department.

3.0 RESPONSIBILITIES3.1 Nursing Supervisor , Head Nurse ,Charge Nurse , Registered Nurse at Emergency

Department

4.0 POLICY4.1 Dead- on- Arrival" patients must be assessed, examined and resuscitative measures must be

done before confirming death.4.2 All emergency resuscitative measures will be carried out to save the patient's life.4.3 Vital signs are obtained and monitored continuously.4.4 When all resuscitation efforts have been exhausted, the physician will examine and confirm

the death.4.5 Police department must be informed by information personnel

5.0 PROCEDURE RATIONALE5.1 Inform the physician on the arrival of the dead

body.5.2 Initiate resuscitative measures and administer

emergency treatment as ordered, do ECG.5.3 Stop resuscitation when all efforts have been

5.2 To provide immediate resuscitative

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NURSINGAPPLIES TO:SNR-ER- 006POLICY NUMBER

DPP DEAD ON ARRIVAL (DOA)TITLE:



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exhausted as ordered.5.4 Document in the nurse's note to determinepatients are response to treatment.

5.4 Inform the police

5.4To provide clear report aboutprocedure steps for continuousnursing care

5.4 To investigate the case and completepolice report.

6.0 ATTACHMENTSNA

7.0 MATERIALS & EQUIPMENT7.1 Crash cart.

7.2 Resuscitative equipment.

7.3 Oxygen.7.4 Suction machine and equipment .

8.0 REFERENCESMinistry of Health, General Nursing Administration Functions and Duties Policies and Procedures forSpecialized Nursing: Emergency Care 2007 (SNR-ER-013).

NAME DATE


Reviewed By:Ashwag Omar shabah.- BSN-Head of nursing education KFH-J

2010Mr.Mamdouh Al-Enizi - Charge Nurse ED, KFH-J


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INTERNAL POLICY AND PROCEDURENURSINGAPPLIES TO:SNR-ER-007POLICY NUMBER:

DPP SHOCK AND NURSING EMERGENCY MANAGEMENTTITLE:

1 of 5EFFECTIVE DATE:APPROVAL DATE:

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1.0 PURPOSE1.1To initiate priorities in the assessment for all types of shock.

1.2To restore and maintain tissue perfusion.

1.3 To restore the patient to a stable physical condition.

2.0 DEFINITION2.1 Shock: It is a complex life threatening condition, characterized by inadequate blood flow to

the tissue and cells of the body.

2.2 (CO): Cardiac Output.

2.3 (RR.) Resuscitation Room.

3.0 RESPONSIBILITIESE.D Nursing Supervisor, Head Nurse, Charge Nurse, Nursing Staff.

4.0 POLICY4.1 The nurse provide care to patient with shock must be qualified, knowledgeable and

competent to provide care and assessment .

4.2 The nurse must be acknowledge and aware that Shock may occur as a complication of many

disorder and therefore all patients have the potential to develop shock.

4.3 All nurses assigned to provide care to patient with shock must be certified BLS and ASLS.

4.4 The nurse will anticipate doctor’s order as they need to be executed with speed and

accuracy.

4.5 the nurse will Convey Physician order.

ER-26





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4.7 Start initial priorities in the assessment are the same for all types of shock.

4.7.1 Is the airway open?

4.7.2 Is the patient breathing?

4.7.3 Is there a circulation problem.


5.1 Assess level of consciousness:

5.2 .1.1 Confusion.

5.1.2 Irritability.

5.1.3 Anxiety.

5.1.4 Agitation.

5.1.5 Inability to concentrate.

5.1.6 Increased lethargy, progressing to coma,

indicating progression of shock.

5.2 Obtain blood samples as ordered.

5.3 Monitor arterial blood pressure, the blood

pressure may initially rise approximately 20 %. If the

patient is compensating for shock.

5.4 Assess urinary output. Urine output should not be

less than 30 ml/hour may indicate shock.

5.1 To assess indicator of shock because

it reflects cerebral perfusion.

5.2 As routine for investigation.

ER-27





EMER

GEN

CY

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N

5.5 Administer 100% O2.

5.6 Prepare equipment for Intubation if the

patient is unable to manage or is

ventilating poorly, and assess the doctor..

5.7 Initiate I.V fluid therapy as ordered.

5.8.Two large I.V lines should be established.

5.8.1 Assess patient needs for fluid or /and

blood replacement .

5.9 Insert an indwelling urinary catheter as order and

record output every 15-30 minutes.

5.9 Maintain patient in a supine position with legs

elevated.

5.10 Monitor ECG. Dysrythmias may contribute to

shock.

5.11 Immobilize fractures.

5.12 Maintain Normothermia. A patient who is in

5.4 To monitor CO.

5.5 To maintain the PaO2 at 80-100 This

will augment oxygen carrying capacity

of arterial blood.

5.6 To improve cardiac and tissue

oxygenation and to restore intravascular

volume.

5.6.2 To prevent hypovolemic shock

5.9facilitates venous return and

excessive abdominal viscera. Shift and

restriction of the diaphragm.

5.12 Because high fever will increase the

ER-28





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septic shock should be kept cool.

5.13 Administer medication to the patient as

ordered:

5.14 Maintain the ongoing surveillance of the total

patient for continuous monitoring of patient’s status.

5.14.1 Blood Pressure.

5.14.2 Heart rate.

5.14.3 Temperature.

5.14.4 Color and urinary output.

5.16 Document all procedure in the patient’s file.

Allow the nurse to assess and evaluate changes in the

patient’s condition.

cellular metabolic effects of shock.


6.0 ATTACHMENTS

N/A

7.0 MATERIALS & EQUIPMENT7.1 Crash cart.

7.2 Suction machine.

7.3 Oxygen.

7.4 Cardiac monitor.

7.8 Intavenous cannulation equipment.

ER-29





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7.9 I.V fluids, and medications as ordered.

7.10 Urinary catheter equipment.


Specialized Nursing: Emergency Care 2006.

8.2 Minidictionary for Nurses 5th edition (Oxford University Press).8.3 Answers.com -wikianswers 2010

NAME DATE


Reviewed By: Ashwag Omar shaibah.- BSN -Head of nursing education KFH-J 2010


ER-30



DPP SYNCOPE, EMERGENCY MANAGEMENTTITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 To maintain patient life and provide adequate oxygenation.

1.2 To restore the patient to a stable physical condition.

2.0 DEFINITION2.1 Syncope: It is a sudden, spontaneous, transient loss of consciousness caused by

vasovagal event (classical fainting). After a short recovery period, all signs return to

normal

2.2 (CO) Cardiac Output


4.0 POLICY4.1 The nurse must be competent

The nurse must completely assess the patient while arrived to ED. Patient with syncope must

be assessed for the following:

4.3 Any condition that results in a sudden reduction of CO and thus reduced cerebral

blood flow could cause a syncopal episode.

4.4 Suction machine and oxygen must be ready at bedside.

4.5 l.V. fluids must be initiated as ordered and medications administered as prescribed.

4.6 ECG must be monitored.

ER-31






EMER

GEN

CY

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RSI

N

4.7Vital signs and neurological assessment must be checked and monitored frequently.

4.8 Patients who do not recover quickly after lying supine with his feet elevated, should

be reported to the physician.


5.1 Assess the patients for the followingsymptoms:

5.1 1 Inadequate oxygenation.

5.1.2 Hypoglycemia.

5.1.3 Seizures.

5.1.4 Drug/alcohol intoxication.

5.1.5 Pulmonary embolus.

5.1.6Infection.

5.1.7 Carebrovascular disease.

5.1.8 Hypotension.

5.1.9 Pallor.

5.1.10 Slow pulse.

5.1.11 Hypotension.

5.1.4 Seizure activity.

5.1.5 Chest pain.

5.1.6 Dyspnea.

5.1 To provide immediate nursing careor intervention, and maintain patient life.

ER-32






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5.1.7 Palpitations.

5.2 Check vital signs and ensure adequate airway

and breathing:

5.2.1 Oxygen.

5.2.2 Suction.

5.3 Start I.V. fluids as ordered to correct

hypotension and keep the vein open .

5.4 Place the patient in a supine position.

5.5 Connect patient on cardiac monitor and

check ECG and monitor frequently.

5.6 Administer emergency drugs as ordered.

5.7 Obtain further history as patient’s level of

consciousness improves treatment.

5.8 Document the procedure in the nurses’ notes

and inform physician to treatment.

for any abnormalities noted.

5.3 To sustain CO.

5.4 To facilitate air enters to long. And

provide adequate oxygenation

5.5.for contentious assessment

5.8 for continuousness of care

ER-33






EMER

GEN

CY

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RSI

N

6.0 ATTACHMENTS

N/A

7.0 MATERIALS & EQUIPMENT71 Oxygen therapy equipment


7.3 I.V. fluids and medications as ordered.



NAME DATE


Reviewed By: Ashwag Omar shaibah.- BSN- Head of nursing education KFH-J 2010


ER-34




DPP NURSING EMERGENCY MANAGEMENT OF CHEST PAINTITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 To relieve pain and anxiety.

1.3 To provide emergency care to patient who present acute chest pain.

1.4 To detect early diagnosis of myocardial infarction or cardio-vascular disorders.

1.5 To distinguish between minor causes of chest pain and potentially life-threatening causes

2.0 DEFINITION2.1 Chest pain: A state in which and individual experiences and reports the presence of sever

discomfort or unpleasant sensation to the chest and generally disappears when the bodily

injury heals or painful results resolves. Chest pain or discomfort maybe associated with

pulmonary or cardiac disease. Chest pain associated with pulmonary condition maybe sharp,

stabbing and intermittent, or it maybe dull, aching and persistent.

2.2 Classification of chest Pain

2.2.1 Unstable angina –chest pain associated with decreased coronary blood flow .Pain

lasts for 30 minutes, increased in frequency and duration.

2.2.2 Myocardial Infarction (MI): Indicated by a crushing restrosternal pain lasting

longer than 30 minutes unrelieved by rest or nitroglycerin.

2.2.3 Acute pericarditis: Indicated by pleuritic restrosternal pain of gradual onset which is

often relieved By leaning forward associated with fever.

2.2.4 Dissecting aortic aneurysm – Indicated by an excruciating tearing retrosternal back

pain with sudden onset and may radiate to the head, back and abdomen.

ER-35







EMER

GEN

CY

NU

RSI

N

2.2.5 Pneumonia: Indicated by pleuritic pain with a productive cough, associated with

fever, dyspnea and riles.

2.2.6 Pulmonary embolus: Indicated by pleuritic or crushing chest pain of sudden onset,

associated with dyspnea, dry cough and hemoptysis. The pain increases on

inspiration.

2.2.7 Pneumothorax: Indicated by pleuritic or crushing pain with dyspnea of sudden

onset associated with decrease breath sounds or tracheal shift.

2.2.8 Stable angina: Retrosternal chest pressure lasting a few minutes, relieved by rest and

nitroglycerin within 5 minutes .The ECG may show ST depression or T-wave

inversion during pain.

2.2.9 Non-cardiac causes: Musculoskeletal strain, calcific tendonitis, costochondritis, rib

fractures, G.I. Problems, tracheo-bronchitis and pleurisy.

2.3 (ECG) Electrocardiogram.

2.4 (RR) Resuscitation Room.

3.0 RESPONSIBILITIESE.D Registered Staff Nurses

4.0 POLICY

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N

4.1 The nurse should provide Quick assessment to patient which include the following:

4.1.1 Description of chest pain, including location, intensity, radiation, duration, nausea,

sweating.

4.2 Provide nursing management according to type of pain and patient descripation.

4.3 Maintain patient comfort, and relive anxiety.

4.4 Maintain patient safety and privacy.

4.5 The nurse will Push the patient to RR. according to out com of nursing assessment and

doctors order

4.6 Nursing assessment should be accurate and assessment form must be completed.

4.7 The nurse will be assigned and provide patient care in RR should be BLS and ACLS

Certified.

4.8 Follow doctors order

4.2 Oxygen should be administered along with the medication therapy to assist with relief of

symptoms for e.g. pain.

4.3 Vital signs are assessed frequently as long as the patient is in pain and other signs of acute

ischemia.

4.4 ECG must be obtained within 10 minutes from the time the patient arrives in the Emergency

Department.

4.5 I.V. fluids should be administered to monitor intake and output.

ER-37







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GEN

CY

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N

4.6 Physical rest and comfort are providing to relieve pain and discomfort.

4.7 Alleviating anxiety and fear reduce the sympathetic stress response, thereby decrease the

workload of the heart.

4.8 Myocardial infarction is considered an acute emergency and should be given treatment.

4.9 The patient with myocardial infarction is pushed to resuscitation room where resuscitation

equipment is ready and available.

4.10 If the plan to admit the patient to ICU nurse and doctor should transfer the patient

together.


5.1 Take Past medical history.

5.2 Prepare the patient for cardiopulmonary studies,such as an ECG, chest X-ray, magnetic resonanceimaging, and a lung perfusion scan.

5.3 Collect a serum sample

5.4 Provide emotional support because chest painproduces increased

5.5 Asses the patient for the following symptoms:

5.5.1 Dyspnea.

5.1 To verify patient main compline.

5.2 To confirm medical diagnosis andmanagements

5.3 For cardiac enzyme and electrolytelevels

5.4 To reduce anxiety.

5.5 For continuity of care

ER-38







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N

5.5.2 Heaviness over chest.

5.5.3 Cold, clammy skin.

5.5.4 Paller.

5.5.5 Facial appearance if in severe pain.

5.6 Administer oxygen immediately not more the

2ml before the doctor order and attach to cardiac

monitor.

5.7 Chick vital sings frequently as ordered and

record.

5.8 Keep the patient calm and provide a quiet

environment.

5.9 Observe patient closely for:

5.6.1 Altered pain.

5.6.2 Altered cardiac output-decreased.

5.6.3 Activity intolerance.

5.6.4 Anxiety.

5.10 Administer medication as ordered.

5.11 Provide I.V. access for :( large –bore needle )

5.11.1 I.V. fluids.

5.11.2 I.V. medication.

5.7 For continuous observation andassessment.

5.8To reduce anxiety

5.10 To safe patient life, and stabilize pt.condition.

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5.11.3 Blood sampling.

5.12 Explain the procedure to the patient and

encourage him to verbalize his fears regarding

illness.

5.13 Document all procedures in the nurses' notes

and notify physician for any abnormality noted.

5.14 prepare patient for admission according to

doctor order.

5.15 Explain the purpose and procedure of each

diagnostic test and teach the patient about the cause

of his chest pain once a diagnosis is established.

Stress the importance of reporting symptoms to allow

for the adjustment of treatment.

5.16 If the pan to discharge the patient the nursesmust Provide patient teaching:

5.16.1 Explain the purpose of any prescribeddrugs, and make sure that the patientunderstands the dosage, schedule, andpossible adverse effects.

5.12 To help alleviate his/her anxiety.

5.13 For the continuity of care and toprovide complete report

5.14 For hospitalize care.

5.15 To help alleviate his/her anxiety.

5.16 To seek immediate medicalattention.

ER-40







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5.16. 2 Teach the patient with coronary arterydisease about the typical features ofcardiac ischemia as well as the symptomsthat should prompt him.

5.16.3 Discuss lifestyle changes that can reducethe risk of coronary artery disease.

6.0 ATTACHMENTS

N/A

7.0 MATERIALS & EQUIPMENT7.1 Resuscitation equipment.


7.3 ECG machine.

7.4 Blood containers or (tubes)

6.5 Oxygen therapy equipment.

7.6 Portable X-ray. If available.

7.7 I.V. fluids and medications as ordered


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http://nursing-careplans.blogspot.com/2010/01/nursing-care-plan-chest-pain.html

NAME DATE




ER-42

http://nursing-careplans.blogspot.com/2010/01/nursing-care-plan-chest-pain.html



DPPNURSING EMERGENCY MANAGEMENT FOR

HYPERTENSIVE CRISISTITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 To reduce blood pressure to acceptable limits as rapidly and safely to prevent further

hypertensive episodes.1.2 To reduce the possibility of complications.

2.0 DEFINITIONHypertension (high blood pressure): It is a disease of vascular regulation in which themechanisms that control arterial pressure within the normal range is altered. The blood pressureis elevated when there is increased cardiac output plus peripheral vascular resistance. It is asituation in which blood pressure must be lowered immediately (not necessarily to less than140/90 mmHg) to halt to prevent damage to the target organs.

3.0 RESPONSIBILITIESE.D Registered Staff Nurses

4.0 POLICY4.1 Nurse must provide direct general assessment to patient while arrived in ED

4.2. check Vital signs, monitored and assessed for presence of:

4.2.1. Hypotension .

4.2.2. Tachycardia .

4.2.3. Tachypnea .

4.2.4. Shock.

4.2.5 Hemorrhage.

4.3 Collect data about the causes and patient history

4.4. Provide ABC assessment and management needed

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4.5 Maintain patient privacy and safety measured

4.6 Complete patient record and document if ordered for any procedures or admission.

4.7 Complete patient record and document if ordered for any procedures or admission.


5.1 Obtain history of the patient's present illness,including nature of onset and length and severity ofsymptoms.

5.2 Take and record BP in both the left and right arms,also sitting and standing. Anxiety may cause BP to rise.

5.3 Inform the physician for any elevated BPHypertensive patient may need immediate medicaltreatment.

5.4 Check and record ECG continuously for rhythm .

5.5 Maintain bed rest, with head elevated in highfowler's position.

5.6 Establish I.V. line as per doctor's order

5.7 Collect blood samples: CBC, chemistry, PT and PTT.

5.8 Monitor BP and document to determine patient'sresponse to medications and interventions.

5.1 To provide data baseline. Patient'soften decrease or stop theirmedication completely when theyhave been asymptomatic for a periodof time.

5.4 To check for ischemia or evidenceof left ventricular hypertrophy or anyabnormal changes.

5.6 to facilitate access for I.V.medication administration.

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5.9 Maintain intake and output to ensure prevention offluid overload.

5.10 Record all procedures and medications.

5.11 Instruct the patient and family to eliminate foodshigh in sodium.

5.11.1 Control weight and maintain low-cholesteroldiet.5.11.2 Encourage the patient to comply with hismedication.

5.12 Document patient's condition to provide continuityof care.

5.1.2 To reduce cardiac risk factors


6.0 ATTACHMENTSN/A

7.0 MATERIALS & EQUIPMENT.1 Cardiac monitor.

6.2 BP apparatus.

6.4 Emergency medications as ordered.

8.0 REFERENCES8.1 Ministry of Health, General Nursing Administration Functions and Duties Policies and Procedures

for Specialized Nursing: Emergency Care (SNR-ER-019).).

ER-45







EMER

GEN

CY

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N

٨٫2 Medical Surgical Nursing, Brunner & Siddhartha’s, 10th edition, Lippincott Williams&Wilkins

NAME DATE


Reviewed By: Mrs. Ashwag Omar shibah.- BSN- Head of nursing education KFH-J 2010


ER-46



DPPNURSING EMERGENCY MANAGEMENT OF RESPIRATORY

DISTRESSTITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1To provide breathing support and treat the underlying cause of ARDS. This may involvemedications to treat infections, reduce inflammation, and remove fluid from the lungs.

2.0 DEFINITION2.1 Respiratory Distress (Respiratory failure) is an alteration in the function of the respiratory

system that causes the PaO2 to fall below 50mmHg (hypoxemia) or the PaCO2 to rise above

50mmHg (hypercapnia) as determined by arterial blood gas (ABG) analysis.

2.2 (ARDS) or acute respiratory distress syndrome.


4.0 POLICY4.1 Respiratory distress is life-threatening and must be treated as medical emergency.

4.2 Resuscitation equipment shall be ready at bedside and ready for intubation.

4.3 Equipment for blood gas analysis must be prepared.

4.4 Oxygen therapy must be administered via face mask to relieve hypoxia and dyspnea.

4.5 I.V. fluids shall be administered as ordered.

4.6 The patient must maintain an upright position, head and shoulders up.

4.7 Emotional support and reassurance must be provided as respiratory distress may be

terrifying to the patient.

ER-47




DISTRESSTITLE:



EMER

GEN

CY

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N

4.8 Assessment, observation and ventilation of patient's condition must be obtained


5.1 Obtain and record vital signs to provide as data

baseline.

5.2 Assess patient's condition and report the following

signs and symptoms:

5.2.1 Wheezing, rales and rhonchi.

5.2.2 Severe dyspnea, tachycardia.

5.2.3 Frothy, blood-tinged sputum.

5.2.4 Edema, peripheral or around the eyes.

5.2.5 Signs of heart failure.

5.2.6 Altered level of consciousness.

5.2.7 Cyanosis, diaphoresis.

5.3 Provide airway to reduce respiratory distress by:

5.3.1 Elevate the head.

5.3.2 Suction.

5.3.3 Humidification.

5.4 Administer oxygen via face mask.

5.5 Administer emergency medication as ordered

5.6 Measure intake and output and record.

5.3.1To facilitate air entrance

5.3.2To clear the air way from secretion

5.6. To prevent pulmonary congestion

ER-48




DISTRESSTITLE:



EMER

GEN

CY

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RSI

N

5.7 Collect blood samples immediately:

5.8 Attach patient to:

5.8.1 Cradiac monitor

5.8.2 Pulse oximetry

5.9 prepare patient for Chest x-ray and ECG

5.10 Assess level of consciousness and ability, rapid,

shallow breathing abdominal paradox suggests

inability to maintain adequate minute ventilation.

5.11 Document patient's condition to provide

continuity of care.

5.13 prepare patient for admission if ordered

5.8.1 to monitor cardiac dysrhythmias.

5.8.2 to evaluate oxygen saturation.

5.9 for medical diagnosis and continuity

of management

5.10 To tolerate increased work of

breathing. Confusion


6.0 ATTACHMENTS

N/A

7.0 MATERIALS & EQUIPMENT7.1 Oxygen.

7.2 Face mask or Nasal cannula.

7.3 Blood samples for ABG.

ER-49




DISTRESSTITLE:



EMER

GEN

CY

NU

RSI

N

7.4 Airway.

7.5 I.V. fluids as ordered.

7.6 Medications, I.V. medications as ordered.


7.8 Ventilator, if indicated.

8.0 REFERENCES8.1 Ministry of Health, General Nursing Administration Functions and Duties Policies and Procedures forSpecialized Nursing: Emergency Care 2007.8.2 Goldman L, Ausiello D, eds. Cecil Medicine. 23rd ed. Philadelphia, Pa: Saunders; 2008.

NAME DATE


Reviewed By: Mrs. Ashwag Omar shaibah.- BSN-Head of nursing education KFH-J 2010


ER-50



DPPNURSING EMERGENCY MANAGEMENT OF

BRONCHIAL ASTHMATITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 To determine hypoxia and respiratory distress.

1.3 To provide adequate breathing.

2.0 DEFINITION2.1 Bronchial Asthma: It is a chronic inflammatory disorder of the airways in which many cells

and cellular elements play a role. This inflammation causes episodes of wheezing,

breathlessness, chest tightness, and coughing particularly at night or early in the morning, and

airway hyperactivity to various stimuli.


4.0 POLICY4.1 Nurse shall provide assessment patient when arrived to ED.

4.1.1 Start initial priorities in the assessment are the same for all types of shock.

4.1.1.1 Is the airway open?

4.1.1.2 Is the patient breathing?

4.1.1.3 Is there a circulation problem.

4.2 The nurse will anticipate doctor’s order as they need to be executed with speed and

accuracy.


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GEN

CY

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RSI

N

5.1 Observe and assess rate, dept and character of

respiratory especially on expiration, hypoxia.

5.2 Monitor vital signs, skin color reactions, and

degree of baseline analysis.

5.3 Administer oxygen as ordered.

5.4 Provide nebulization and oxygen therapy as

ordered.

5.6 Instruct the patient to have a sitting upright

position to facilitate breathing.

5.7 Explain the procedure to patient to gain

cooperation and reduce anxiety.

5.8 Administer medications as ordered

5.9 Reassess the patient and provide

5.10 Document all procedure in the nurse's notes to

determine patient's response to treatment.

5.11 prepare patient and all documents for admission

if ordered.

5.1To determine hypoxia and respiratory

distress.

5.4 To humidify bronchial tree and

liquefy sputum.

5.5 To liquidity secretions.

5.9 to provide care as needed


6.0 ATTACHMENTS

N/A6

ER-52







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GEN

CY

NU

RSI

N

7.0 MATERIALS & EQUIPMENT7.1Oxygen and oxygen cannula.

7.2 Nebulizer


NAME DATE


Reviewed By: Mrs.Ashwag Omar shaibah.- BSN-Head of nursing education KFH-J 2010


ER-53



DPPNURSING EMERGENCY MANAGEMENT OF CHRONIC

OBSTRUCTIVE PULMONARY DISEASETITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.2 To improve gas exchange.

1.3 Airway clearance.

1.4 To improve breathing pattern.

1.5 To improve activity tolerance.

1.6 To improve coping ability.

1.7 Absence of complications.

2.0 DEFINITION(COPD) coronary obstructive pulmonary disease: is a disease characterized by airflow

obstruction that is not fully reversible. Airflow limitation is usually progressive and associated

with an abnormal inflammatory response of the lungs to noxious particles and gases. Its results

from emphysema, chronic bronchitis, asthma, or any combination of these disorders.


4.0 POLICY4.1 Patient with COPD must be assessed for the following:

4.1.1 Obtain history of dyspnea, smoking, environmental factors, occupation.

4.1.2 Chronic productive cough or any change in sputum.

4.1.3 Medication (bronchodilators, antibiotics) and effects.

ER-54







EMER

GEN

CY

NU

RSI

N

4.1.4 Onset and duration of present exacerbation or presence of chest pain.

4.2 A patient with COPD is considered an emergency and must be assessed and attended to

immediately.

4.3 Patient with COPD must be assessed for various complications include:

4.3.1 Life- threatening respiratory insufficiency and failure.

4.3.2 Respiratory infection.

4.3.3 Atelectasis.

4.3.4 Pneumothorax.

4.3.5 Pneumonia.

4.3.6 Pulmonary hypertension.

4.4 Vital signs must be monitored for fever, tachycardia, and tachypnea.

4.5 Blood samples must be taken.

4.6 Oxygen is administered to provide adequate airway and ventilation or assist in intubation or

mechanical ventilation if acute.

4.10 Medications and administrated as prescribed:

4.10.1 Nebulization to humidity bronchial tree and liquidity sputum if necessary.

4.10.2 Bronchodilators to control bronchospasm.

4.10.3 Antibiotics to control secondary bacterial infections.

4.11 If the patient develops rapid onset of shortness of breath, the nurse should quickly evaluate

the patients for a potential pneumothorax by assessing the symmetry of chest movement,

differences in breath sounds and pulse oximetry.

ER-55







EMER

GEN

CY

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RSI

N


5.1 Assess the patients to determine the condition of

the patient and administer immediate treatment, notes

the following:

5.1.1 Dyspnea,

5.1.2 Chronic cough or any color of sputum.

5.2 Administer oxygen as required to increased P02

and provide adequate ventilation.

5.2.1 Monitor O2 saturation

5.3 Check and monitor vital sings, breathing pattern

and level of consciousness.

5.4 Collect specimen samples as ordered:

5.4.1 Blood and blood gas

5.4.2. Sputum

5.4.3: CBC

5.5 Administer medications order :

5.8 Encourage fluid intake (at least 8-10 glasses) to

liquefy secretions.

5.9 Place the patient in comfortable position to

decrease dyspnea.

5.10 Provide intravenous access for immediate

5.2 To correct hypoxemia.

5.3 To promote bronchospasm.

5.4.1to correct hypoxemia.

5.4.2For culture.

ER-56







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CY

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RSI

N

management and possible IV fluid therapy as

ordered.

5.11 Assist in ventilation or mechanical ventilation if

required. If acute respiratory failure or CO2 retention

occurs.

5.12 Monitor Oxygen saturations are continuously

5.13 Document all procedures in the nurse's notes to


5.14 Expedite admission if required and prepare the

patient .

5.15 Instruct the patient to stop smoking and

medication used if patient for discharge.

5.5.2 To control bronchospasm.

5.5.3 To control secondary bacterial

Infection.

5.12 To assess the patient's need for

oxygen and administer supplemental

oxygen as prescribed.

5.13 To provide clear report about

procedure steps for continuous

nursing care

6.0 ATTACHMENTS

N/A

ER-57







EMER

GEN

CY

NU

RSI

N

7.0 MATERIALS & EQUIPMENT7.1 Oxygen and oxygen cannula.


7.3 Nebulizer.

7.4 I.V. fluids as orederd

7.5 Specimen containers, blood, sputum, ABG syringe


NAME DATE


Reviewed By: Mrs.Ashwag Omar shaibah.- BSN -Head of nursing education KFH-J 2010


ER-58



DPP NURSING EMERGENCY MANAGEMENT OF COMATITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 To maintain vital functions.

1.2 To protect the patient from injury.

1.3 To provide assessment which will ensure rapid diagnosis, treatment and the safety of

the comatose patient while in emergency room

2.0 DEFINITION

2.1 (ABC) Air way, Breathing , Circulation

2.2 (GCS).Glasgow Coma scale

3.0 RESPONSIBILITIES3.1 Registered Nursing

4.0 POLICY4.1 The nurse must provide ABC assessment to patient while arrived.

4.2 Crash cart must be available and complete.

4.3 Patent airway must be maintained:

4.3.1 Inspection of airway, suction if needed.

4.3.2 Remove dentures, if loose.

4.3.3 Risk of aspiration is lessened, if the patient can be positioned on his/ her

side.

Consider the possibility of head/ neck injury.

ER-59






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4.3.4 An oral airway may aid in maintaining a patent airway and facilitate

suctioning.

4.4 Breathing pattern must be observed, poor air exchange and periods of apnea

indicate the need for oxygen administration and possible intubation:

4.4.1 Fluid administration.

4.4.2 Monitor intake and output.

4.4.3 I.V medications.

4.5 the nurse should provide complete assessment of patient's level of consciousness must

be performed according to Glasgow Coma scale (GCS).

4.5.1 Neurologic system.

4.5.2 Evaluation of mental status.

4.5.3 Cranial nerve function.

4.5.4 Cerebellar function (Balance and coordination).

4.5.5 Reflexes, motor and sensory function.

4.6 prepare patient for any Procedures used to identify the cause of unconsciousness

include: Scanning, Imaging, Tomography (CT Scan, MRI) and EEG.

4.7 Assess patient for Respiratory failure signs .

5.0 PROCEDURES RATIONALE

5.1 Ensure clear, patent airway

5.1.1 Inspect airway and suction, if needed

to promote gas exchange.

5.1 To lessen the risk of aspiration.

ER-60






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5.1.2 Remove dentures, if loose. To

prevent the tongue form obstructing the

airway.

5.1.3 Position the patient on his RT side.

5.1.4 Insert oral airway to maintaining patent

airway.

5.2 Ensure adequate respiration:

5.2.1 Observe for breathing pattern.

5.2.2 Prepare for intubation.

5.3 Start I.V. fluid administration as ordered.

5.4 Monitor vital signs and continue ECG.

5.5 Assess level of consciousness to asses motor and

sensory function:

5.5.1 Glasgow coma scale.

5.5.2 Neurological observation.

5.6 Correct blood samples for analysis.

5.7 Check head for signs of trauma :

5.7.1 Apply cervical collar- if positive

5.8 Never leave the patient unattended put-up side

rails.

5.9 Document the procedure and report any

unusual findings in the patient's condition

5.1.3 To encourage drainage of

respiratory secretions.

5.3 To measure intake and output.

5.7.1 to immobilize affected area.

5.8 to Provide patient's safety

5.9 To provide clear report aboutprocedure steps for continuous

nursing care

ER-61






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6.0 ATTACHMENTS

N/A


7.1Oxygen and oxygen cannula.

7.2 Airway (Emergency cart).


7.4 ECG machine.


7.6 Urinary catheter.


NAME DATE


Reviewed By:Mrs.Ashwag Omar shibah.- BSN-Head of nursing education KFH-J



ER-62



DPPNURSING EMERGENCY MANAGEMENT OF SPINAL CORD

INJURYTITLE:


1 of 5NUMBER OF PAGES:DUE FOR REVIEW:

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1.0 PURPOSE1.1 To prevent further trauma.

1.2 To observe symptoms of progressive neurologic deficits.

1.3 To improve breathing pattern and airway clearance.

1.4 To improve sensory and perceptual awareness.

2.0 DEFINITION2.1 Spinal cord injury (SCI): It is a traumatic injury to the spinal cord that may vary from a mild

cord concussion with transient numbness to immediate and complete tetraplagia.

3.0 RESPONSIBILITIESRegistered Nursing

4.0 POLICY4.1 . Patient with spinal cord injury must be assessed for the following:

4.1.1 Patent airway.

4.1.2 Location and severity of cord damage.

4.1.3 Neurologic level of injury.

4.1.4 Vital signs.

4.2 the nurse shall provide assessment spinal injury for any unconscious patient who is the

victim of accident must .

4.3 the nurse must conceder All unconscious trauma patients and all patients with possiblespinal injuries should be rigidly immobilized.

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4.5 Nurse should be able to identify and assess following Signs and symptoms :

4.5.1 Pain without movement.

4.5.2 Pain with movement.

4.5.3 Tenderness.

4.5.4 Deformity.

4.5.5 Impaired breathing.

4.5.6 Priapism.

4.5.7 Characteristic positioning of the arm.

4.5.8 Involuntary loss of bowel and bladder control.

4.5.9 Nerve impairment to the extremities.

4.5.10 Nerve shock.


5.2 Assess the following:

5.2.1 Cardiopulmonary status.

5.2.2 Loss of consciousness.

5.2.3 Note signs and symptoms of spinal

shock such as: flaccid, paralysis, urinary retention,

absent reflexes.

5.2.4 Bowel and bladder function.

5.1 To determine data baseline.

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5.2.5 Quality, location, severity of pain.

5.2.6 Depression, powerlessness, dependence,

passivity.

5.2.7 Changes in motor and sensory

function.

5.3 Maintain patent airway and be prepared

5.4 Administer oxygen as ordered

5.4.1 Monitor saturation through pulse

oximetry.

5.5 Immobilize the head and neck to prevent an

incomplete injury from becoming complete.

5.5.1 Placing the hands on both sides of the

patient's head at about the ear.

5.5.2 Apply cervical collar.

5.5.3 Provide sand bags.

5.6 Check and monitor vital signs Patient with SCI

can be hypotensive due to the effect of injury on the

sympathetic nervous system.

5.7 Provide I.V. access for to facilitate immediate

administration of emergency drugs as ordered.

4.5 to maintain a high arterial

ER-65




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5.8 Place patient on firm bed until spinal cord

stabilization to ensure good alignment.

5.9 Measure intake and output:

5.10.1 Intermittent catheterization prevents

over distention of the bladder and UTI.

5.10.2 Encourage fluid intake

5.11 Expedite admission to ICU Patients.

5.12 Document all procedures in the nurse's notes to


5.10.2 to prevent infection and urinarycalculi.


6.0 ATTACHMENTS

N\A.

7.0 MATERIALS & EQUIPMENT7.1 Spinal bed.7.2 Cervical collar.7.3 Sand bags.

ER-66




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7.4 Oxygen equipment.7.5 Suction machine.7.6 Cardiac monitor.7.7 Pulse oximetry.7.8 Nasogastric tube.7.9 Urinary catheter

8.0 REFERENCES1 Ministry of Health, General Nursing Administration Functions and Duties Policies and Procedures for

Specialized Nursing: Emergency Care 2007.

NAME DATE




ER-67




DPPNURSING EMERGENCY MANAGEMENT OF SEIZURES

DISORDERSTITLE:



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1.0 PURPOSE1.1 To control seizure immediately.

1.2 To prevent patient from injury and complications.

2.0 DEFINITION2.1 Seizures: (also known as epileptic seizures, and if recurrent, epilepsy) are defined as a sudden

alteration in normal brain activity that causes distinct changes in behavior and body function. It

is the result from disturbances in the cells of the brain that causes them to give off abnormal,

recurrent, uncontrolled electrical discharges.

2.2 Seizures are Classified as:

2.2.1 Simple Partial Seizure: Can have motor, somatosensory psychic or autonomic

symptoms without impairment of consciousness.

2.2.2Complex Partial Seizure: Have an impairment (but not a loss) of consciousness with

simple partial features, automatisms or impairment of consciousness only.

2.2.3 Generalized Seizures: Have a loss of consciousness with convulsive or nonconvulsive

behaviors.

3.0 RESPONSIBILITIESRegistered Staff Nursing

4.0 POLICY5.1 Seizure disorder is an emergency and needs immediate medical treatment.

ER-68





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5.2 Resuscitative equipment must be ready at all times.

5.3 The patient in seizure must not be left alone and will be protected from injury.

5.5 nurse must provide Assessment of patient with seizures .


5.1 Maintain a patent airway until patient is fully

awake after a seizure.

5.2 Provide oxygen during the seizure if color change

occurs.

5.3 Protect the head of the patient by paddling side

rails. Remove any equipment that may injure the

patient during the seizure.

5.4 Do not restrain the patient during the seizure.

5.5 Place the patient on side during a seizure.

5.6 Do not attempt to insert anything into the patient's

mouth once a seizure has begun.

5.7 Suction secretions if necessary.

5.8 Establish a vascular access as ordered:

5.1 for effective airway clearance.

5.2 To prevent hypoxia to the brain.

5.5 This allows the tongue to fall

forward and facilitates drainage of

saliva and mucous.

5.7 To prevent aspiration.

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5.8.1 Blood samples for investigations.

5.8.2 Start I.V. line for drug

administration anticonvulsant, antipyretic.

.5.9 If patient is unconscious:

5.9.1 Open the airway.

5.9.2 Initiate breathing.

5.9.3 Maintain circulation.

5.10 Continuous assessment and monitoring of:

5.10.1 Vital signs.

5.10.2 Recurrence of seizures.

5.10.3 Incontinence.

5.10.4 Duration of each phase of attack.

5.10.5 Behavior of attack.

5.10.6 Respiratory and blood pressure.

5.10.7 Depression included by drug

therapy.

5.11 Document all assessment intervention and

patient's response to ensure continuous monitoring of

patient's response to medications and therapy.

5.12 Expedite admission if required



nursing care

ER-70





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5.13 provide patient education if order for discharge:

5.13.1 Importance of following medication regimen.

5.13.2 Encourage a moderate lifestyle that includes

exercise, mental activity and nutritional diet

5.13.4 Allow the patient and family to discuss about

epilepsy.

6.0 ATTACHMENTS

N/A

7.0 MATERIALS & EQUIPMENT7.1 Suction machine.7.2 Oxygen equipment.7.3 Padded rails.7.4 Anticonvulsants as prescribed.7.5 Cardiac monitor


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NAME DATE




ER-72





STATUS EPILEPTICUSTITLE:



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1.0 PURPOSE1.1 To control seizure immediately.1.2 To ensure adequate cerebral oxygenation1.3 To prevent patient injury

2.0 DEFINITIONStatus epilepticus (acute, prolonged, repetitive seizure activity): It is a series of generalizedseizures without return to consciousness between attacks. It is considered a serious neurologicemergency.

3.0 RESPONSIBILITIESRegistered Nurse,

4.0 POLICY4.1 Patent airway and adequate oxygenation are established and if the patient remainsunconscious and unresponsive, endotracheal tube is inserted.4.2 nurse must be aware about the factors that precipitate status epilepticus include:

4.3.1 Withdrawal of anti-seizure medication.4.3.2 Fever.4.3.3 Concurrent infection.

4.3 During the seizure, the patient must not be left alone and will be protected from injury.4.4 Resuscitative equipment must be ready at all times.4.5 Attempt should not be done to open jaws that are clenched to insert a pad.4.6 The patient is turned to a side-lying position to assist in draining pharyngeal secretions.4.7 Suction equipment must be available for risk of aspiration.4.8 An intravenous line is established to obtain samples and should be closely monitored becauseit maybe dislodged during seizures.4.9 Vital signs and neurologic signs are monitored continuously.

ER-73








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5.1 The nurse initiates on-going assessment andmonitoring of respiratory and cardiac function.

5.2 Suctioning the secretions.

5.3 Maintain patent airway and oxygenation foreffective airway clearance.

5.4 Protect the head of the patient by paddling siderails and remove any equipment.

5.5 apply restrain after doctor order

5.6 Place the patient on side-lying position duringseizure.

5.7 Establish a vascular access:5.7.1 Blood samples for investigations.5.7.2 Start I.V. line for drug administration; as

ordered.

5.8 Continuous assessment and monitoring of:

5.8.1 Vital signs and neurologic signs.

5.8.2 Recurrence of seizures.

5.8.3 Duration of each phase of attack

Patient's responsiveness.

5.2 To prevent risk of aspiration.

5.4 to prevent fall down and injury

5.5 Because muscular contractions arestrong and restraint can produce injury.

5.6 This allow the tongue to fall forwardand facilitate drainage of saliva andmucous.

ER-74








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5.9 Document all assessment intervention and

patient's response to ensure continuous monitoring of

patient's response to medications and therapy.

5.10 Expedite admission if required to administer

immediate treatment.



nursing care

6.0 ATTACHMENTS

N/A

7.0 MATERIALS & EQUIPMENT7.1 Suction machine.

7.2 Oxygen.

73 Airway - intubation set, if necessary.

7.4 Cardiac monitor.7.5 Padded rails.

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NAME DATE


Reviewed By: Mrs Ashwag Omar shaibah.- BSN-Head of nursing education KFH-J 2010


ER-76





EPISTAXISTITLE:



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1.0 PURPOSE1.1 To control nasal bleeding.

1.2 To assess etiology .

2.0 DEFINITIONEpistaxis ( nasal Bleeding) : It is a hemorrhage from the nose caused by rupture of tiny,

distended vessels in the mucus membrane of any area of the nose.

3.0 RESPONSIBILITIESRegistered Nurse,

4.0 POLICY4.1 Patient with Epitaxis must be assessed for the following:

4.1.1 Airway status.4.1.2 Nasal bleeding.4.1.3 Site of bleeding.

4.2 Vital signs are monitored and recorded.

4.3 Gloves must be worn throughout the procedure.

4.4 The nurse assists physician during the procedure.

4.5 Suction is done to remove excess blood and clots from the site of infection.

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5.1 Monitor vital signs and record as data baseline.

5.2 Wash hands and wear gloves.

5.3 Inspect with nasal speculum.

5.4 Collect blood for laboratory analysis.

5.5 Explain the procedure to the patient instruct to

breath gently.

5.6 Pressure to the soft portion of the nose 5-10

minutes. If the patient is a child or not able to do it,

the nurse will apply pressure on the nasal septum for

5-10 minutes.

5.7 Place the patient in an upright position leaning

forward.

5.8 Assist the physician during the procedures to

detect blood dyscrasias.

5.2 To prevent infection

5.3 To determine site of bleeding.

5.4 to exclude blood dyspraxia.

5.5 to reduce anxiety and gain

cooperation.

5.7 To reduce venous pressure.

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5.9 Provide IV access and draw blood for laboratory

analysis to identify bleeding site.

6.10 Insert a gauze t into each nostril and removed

after (5-10) minutes. If bleeding continues, nasal

packing maybe applied to apply pressure over the

large area.

5.11 Provide tissue and emesis basin

5.13 Teach the patient to avoid forceful nose

blowing, straining, high altitudes and nasal trauma

5.14 Clean the patient's face and check vital signs

after the procedure and report any abnormalities

5.15 Clean the equipments for autoclaving.

5.16 Document the procedure in the nurse's notes to


5.17 prepare patient for admission, if required.

6.10 To minimize bleeding

5.11 to allow patient expectorate any

excess blood.

5.13 to prevent Epistaxis

5.14 to provide comfort.



nursing care

ER-79





EPISTAXISTITLE:



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6.0 ATTACHMENTS

N/A

7.0 MATERIALS & EQUIPMENT7.1 Suction.

7.2 Nasal pack tray – 3 sizes posterior packs.

7.2.1 NO. #12 RR catheters.

7.2.2 Two dental bolster.

7.2.3 Scissors.

7.2.4 Mayo clamp.

7.3 Anterior nasal pack – Nasal speculum.

7.3.1 Flashlight or ENT headlight.

7.3.2 Packing forceps.

7.3.3 2 x 2 gauze.

7.4 Goose neck lamp with head mirror.

7.5 Gloves.

7.6 Bowel of water.

7.7 Emesis basin with tissue.


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NAME DATE




ER-81

Ministry of Health, General Nursing AdministrationFunctions and Duties Policies and Procedures______________________________________________SPECIALIZED NURSING: EMERGENCY CAR


DPPNURSING EMERGENCY TREATMENT SOFT TISSUE

INJURIESTITLE:



EMER

GEN

CY

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1.0 PURPOSE1.1 To control severe1.2 To prevent wound infection and complication

2.0 DEFINITION2.1 Soft tissues injuries involve the skin and underlying subcutaneous tissue and muscles

classified as open or closed injuries.

2.2 Closed Wound: An injury to the soft tissue but without a break in the skin, which include:

2.2.1 Contusion: Bleeding beneath the skin into the soft tissue, bleeding can be minor or

extensive.

2.2.1.1 Extensive bleeding can cause severe pain and swelling, leading to a compromise

of vital structure.

2.2.2 Hematoma: A well defined pocket of blood and fluid beneath the skin.

2.3 Open Wound: An injury to soft tissue with a break in the skin, it's more serious to the

potential for blood loss and infection.

2.3.1 Abrasion: A superficial loss of skin resulting from rubbing or scraping the skin

over a rough or uneven surface.

2.3.2 Laceration: Tear in the skin can be partial full thickness cut can be defined as

incision or jagged.

2.3.3 Puncture: Occur when the skin is penetrated by a pointed object.

2.3.4 Avulsion: Involves tearing off of loss of a flap of skin.

2.3.5 Amputation: Traumatic cutting or tearing off of a finger, toe, arm or leg.

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3.0 RESPONSIBILITIESRegistered Staff Nurses

4.0 POLICY4.1 Patient with soft tissue injuries must be assessed for the following:

4.1.1 Adequacy of airway, breathing and circulation.

4.1.2 Clinical signs and symptoms of shock:

4.1.2.1 Skin pale, mottled, cold and/or diaphoretic.

4.1.2.2 Tachycardia (rapid, weak pulse).

4.1.2.3 Tachypnea (rapid, shallow breathing).

4.1.2.4 Hypotension.

4.1.2.5 Restlessness, confusion and anxiety.

4.1.3 Arterial and venous bleeding:

4.1.3.1 Arterial bleeding is bright red and usually spurts from the wound.

4.1.3.2 Venous bleeding is darker red and will flow steadily from a wound.

4.1.4 Vascular status distal to the injury and compare it to the uninjured extremity:

4.1.4.1 Color of the injured extremity.

4.1.4.2 Test capillary refill time.

4.1.4.3 Test pulses distal to the injury.

4.1.5 Neurological assessment of the injured extremity to determine peripheral nerve

insult caused by direct injury, compression or edema.

4.1.4.1 Sensory function – lightly touch the area distal to the injury.

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4.1.4.2 Motor function – have the patient move the extremity distal to the injury.

4.2 Wounds that result in severe arterial bleeding should be considered life-threatening and CPR

must be initiated.

4.3 Tetanus immunization status should be determined including drug allergy to administer

prophylaxis as indicated.

4.4 This physician must be informed for signs and symptoms as:

4.4.1 Bleeding.

4.4.2 Rapid swelling.

4.4.3 Sudden and persistent onset of pain.

4.4.4 Fever and chills.

4.5 Standard precaution must be observed when assisting in wound closure such as wearing

gloves and gowns.

4.6 Checking and continuous monitoring of vital signs should be done.

4.6.1 Hypotension: Falling BP is a late sign of shock.

4.6.2 Tachypnea.

4.6.3 Tachycardia.

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5.1 Explain the procedure to the patient

5.2Assure adequate airway, breathing and circulation

before initiating treatment for effective airway

clearance.

5.3 Obtain history, reacquisition, associated disease,

allergy and tetanus immunization after condition is

stable.

5.4 check all patient body from any injuries.

5.5 Keep close watch for significant bleeding from

the injury and be aware of the clinical symptoms and

signs of shock.

5.5.1 Skin pale, mottled, cold or diaphoretic.

5.5.2 Tachycardia (rapid, weak pulse).

5.5.3 Tachypnea (rapid shallow breathing).

5.5.4 Hypotension (falling blood pressure is a

late sign of shock).

5.5.5 Restlessness, confusion and anxiety.

5.1 To allay anxiety and gain patient'scooperation.

5.3 to assess and evaluate patient'scondition prior to medicationadministration.

5.5. to be able to initiate immediate

intervention:

ER-85




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5.6 Assess for arterial or venous bleeding:

5.6.1 Arterial bleeding is bright red and usually

spurts from the wound.

5.6.2 Venous bleeding is darker red and will

flow steadily from a wound.

5.7 apply wound care aseptically to prevent risk of

infection:

5.7.1 Control bleeding by applying direct

pressure.

5.7.2 Cover the injury with sterile dressings.

5.7.3 Apply firm direct pressure to the site of

injury.

5.7.4 Pressure should be maintained until the

bleeding or definitive treatment is undertaken.

5.9.5 Reinforce the dressing if it becomes

saturated; do not remove the dressing.

5.7.6 Apply a pressure dressing after the

bleeding stop.

5.7.7 Pressure bandage are made by securing

several gauze pads over the injury with a rolled gauze

bandage.

5.6 to prevent hypovolemic shock

ER-86




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5.7.8 A pressure dressing allows the nurse

freedom to continue assessing the patient or attend to

other injuries.

5.7.9 After applying a pressure dressing,

always ensure that the patient has a distal pulse to the

dressing site.

if no pulse is present, the dressing may be too

tight.

5.7.9.1 Elevate the injured while

applying direct pressure.

5.7.9.2 Help to control bleeding. This

measures uses gravity to slow the

blood flow and promote clotting.

5.7.9.3 Elevate injured area above the

level of the heart.

5.7.9.4 Do not raise a limb if a fracture

is suspected or if elevation causes the

patient discomfort.

5.7.9.5 Use pressure points when

direct pressure and elevation cannot

control bleeding above or Can not be

ER-87




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applied to a bleeding site due to

protru- ding bone or an embedded

object.

5.7.9.6 Locate pressure points between

the site of injury and the heart where a

main artery passes over a bone or

underlying mass.

5.7.9.7 Locate pressure points and

apply firm steady pressure with the

finger or the heel of the hand.

5.7.9.8 Apply a vascular clamp if

heavy bleeding is not controlled and

tourniquet is a last resort.

5.8 Cleanse area and irrigate wound with saline to

remove dirt and debris .

5.9 Drape area to prevent from contamination.

5.10 clipped or shaved hair around the wound

5.11 Assist physician in debridement, remove foreign

material and excise dead tissue, cleaning or debriding

the wound.


ER-88




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5.13 Patient education:

5.13.1 Inform the patient if swelling subsides

in 24 hours.

5.13.2 Prescribed analgesic must be taken as

odrered.

5.13.3 Suspect for wound infection, if pain

reappears.

5.13.4 Recommend to elevate the wound to

limit accumulation of fluid in the wound's interstitial

spaces.

5.13.4.1 Elevate extremity for48hours.

5.13.4.2 Sleep with the head elevated

if facial lacerations are present.

5.13.4.3 Advise that health care

provider be contacted if there is sudden or persistent

onset of pain, fever, chills, bleeding, rapid swelling,

foul odor, purulent fluid or redness surrounding the

wound.

5.14 Document all procedure in the nurses' notes to


5.15 prepare patient for admission, if required.

5.13 For the continuity of care and to

provide complete report

ER-89




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6.0 ATTACHMENTS

Non

7.0 MATERIALS & EQUIPMENT7.1 Dressing set if not available:

7.1.1 Pressure dressing pads.

7.1.2 Sterile gauze

7.1.3 Two Forceps

7.2 Irrigating syringe – catheter tip.

7.3 Irrigating solution – Isotonic sterile saline.7.4 Adhesive tapes.


Specialized Nursing: Emergency Care 2007.8.2 Medical Surgical Nursing, Burnner & Suddarth’s ,Lippincott Williams &Wilkins 10th

Edition.

NAME DATE




ER-90



DPPNURSING EMERGENCY MANAGEMENT OF MULTIPLE

INJURIESTITLE:



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1.0 PURPOSE1.1 To prevent and control shock

1.2. To preserve life

1.3 To prevent deterioration

2.0 DEFINITIONMultiple Injuries (Multiple traumas) potentially affect body system and require a team approach,

with one person responsible for coordinating the treatment.

3.0 RESPONSIBILITIESRegistered Nurses in ED

4.0 POLICY4.1 Patients with multiple injuries require rapid and definitive intervention during the first hour

after trauma .

4.2 nurse must provide direct general assessment to patient while arrived in ED

4.3 The nurse must assess the singes and symptoms of internal and external bleeding

4.4 Patient with multiple injuries must be assessed for the following :

4.4.1 Observation for improvement or deterioration.

4.4.2 Vital signs and neurological assessment.

4.4.3 Skin warmth.

4.4.4 Speed of capillary filling.

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٤٫5 Collect data about the causes and patient history

٤٫6 Provide ABC assessment and management needed

٤٫7 Check Vital signs, monitored and assessed for presence of:

٤٫7 .١ Hypotension .

٤٫7 .٢ Tachycardia .

٤٫7 .٣ Tachypnea .

٤٫7 .٤ Shock.

٤٫7 .٥ Hemorrhage.

٤٫8 Fluid administration is started immediately with a large gauge cannula according the doctor

order.

٤٫9 Maintain patient privacy and safety measured

٤٫10 Maintain stander prosecutions if patient has open wound.

٤٫11 Complete patient record and document if ordered for any procedures or admission.

4. 12 Secure consent to protect patient from untoward procedures


5.1 Perform a rapid, initial assessment of the patient

5.2 Perform essential life saving measures:

5.2.1 Establish airway and ventilation

5.2.1.1 Open the airway using Head- tilt,

5.1 To identify injuries to provide early

and prompt treatment.

ER-92




INJURIESTITLE:



EMER

GEN

CY

NU

RSI

N

lift- chin and Jaw thrust for cervical spine injury.

5.2.1.2 Suction secretions and remove

debris from mouth.

5.2.1.3 Insert oropharyngeal airway.

5.2.1.4 Prepare for endoctracheal

intubation if adequate airway cannot be

maintained.

5.2.1.5 If upper airway trauma or edema

exists, a circothyroidectomy maybe

indicated.

5.2.2 Establish airway and ventilation:

5.2.2.1 Note the character and symmetry of

chest wall, motion and pattern of

breathing, assess for open wounds,

deformity and flails segment.

5.2.2.2 Auscultate the lungs and assess for

tracheal deviation.

5.2.2.3 Ask the conscious patient if

experiencing difficultly in breathing or

chest pain with breathing.

5.2.2.4 Administer oxygen by mask as

ER-93




INJURIESTITLE:



EMER

GEN

CY

NU

RSI

N

ordered.

5.2.3 Circulation:

5.2.3.1 Assess cardiac function and treat

cardiac arrest.

5.2.3.2 Start chest compression for cardiac

arrest.

5.2.3.3 Control hemorrhage applies

pressure over bleeding points,

5.2.3.4 Palpate carotid pulse, and note its

rate and quality.

5.2.3.5 Administer medication as ordered.

5.2.3.6 Start blood immediately.

5.2.3.7 Initiate central venous line.

5.2.3.8 Blood sampling.

5.3 Assess level of responsiveness, pupil size and

reactivity, motor power and reflexes.

5.4 Monitor ECG continuously.

5.5 Insert indwelling catheter and measures urinary

output.

5.6 Examine the patient for:

5.7.1 Abdominal pain.

5.8 To immobilize and prevent further

trauma.

5.9 To determine patients response to

treatment.

ER-94




INJURIESTITLE:



EMER

GEN

CY

NU

RSI

N

5.7.2 Muscular rigidity.

5.7.3 Tenderness.

5.7.4 Rebound Tenderness.

5.7.5 Diminished bowel sounds.

5.7.6 Hypotension.

5.7.7 Shock.

5.8 Splint fracture and cervical collar for spinal cord

injury.

5.9 Monitor and record vital signs and neurological

assessment.

5.10 Prepare for surgery (laparotomy) if the patient

shows continuous signs of hemorrhage

5.11 Administer medications as prescribed:

5.11.1 Tetanus immunization as ordered .

5.12 Carry out a more thorough and ongoing

assessment and examination .

5.13 Document in the nurse's note to determine

patients are response to treatment.

5.13 prepare patient for admission if ordered.


ER-95




INJURIESTITLE:



EMER

GEN

CY

NU

RSI

N

6.0 ATTACHMENTS

NA

7.0 MATERIALS & EQUIPMENT7.1 Dressing set if needed

7.2 Splints, cervical collar.

7.3 ECG Montero

8.0 REFERENCES8.1 Ministry of Health, General Nursing Administration Functions and Duties Policies and

Procedures for Specialized Nursing: Emergency Care 2007.8.2 www.eng.hi138.com/?i264078_Emergency_care_of_multiple_trauma

NAME DATE




ER-96

www.eng.hi138.com/



DPPNURSING EMERGENCY MANAGEMENT OF HEAD

TRAUMA (SKULL AND BRAIN)TITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 To provide immediate care to the patient.1.2 To prevent further trauma.1.3 To prevent complications

2.0 DEFINITIONHead injury, as a generic term, is commonly defined as any injury of the scalp, skull(incorporating the cranium and facial bones) or brain.

3.0 RESPONSIBILITIESRegistered Nurses in ED

4.0 POLICY4.1 Patients with head injuries require immediate assessment for prompt and rapid treatment andmanagement.4.2 Stabilization of airway is the first priority for patients with head injury.4.3 For cervical spinal injury, head and neck immobilization had to be maintained.4.4 Head trauma patients are assessed for the presence of:

4.6.1 Ineffective airway clearance from secretions and vomitus.

4.6.2 Ineffective breathing pattern.

4.6.3 Alteration in sensory perception and though process due to injury.4.5 Oxygen is administered immediately and vital signs are obtained and monitored includingneurological assessment. (Glasgow Coma Scale).4.6 Fluid administration is initiated and intake and output is measured to prevent excess fluidadministration.4.7 control Bleeding and administer started medications as ordered.4.8 obtained Blood for baseline laboratory analysis and x-rays for any signs or cervical trauma

ER-97







EMER

GEN

CY

NU

RSI

N

٤.9 The nurse must assess the singes and symptoms of internal and external bleeding


4.11 check Vital signs, monitored and assessed for presence of:

4.11.1 Hypotension .

٤٫11.2 Tachycardia .

٤٫11.3Tachypnea .

٤٫11.4 Shock.

٤٫11.5 Hemorrhage.

٤٫12 Fluid administration is started immediately with a large gauge cannula according the doctor

order.

٤٫13 Maintain patient privacy and safety measured

٤٫14 Maintain stander prosecutions if patient has open wound.




5.1 Monitor and assess neurologic and vital signsfrequently as ordered.5.2 Stabilize the airway: Inability to effectively clearthe airway may results in anoxia, hypercapnea andaspiration.

5.2.1 Insert airway.5.2.2 Suction secretions.5.2.3 Immobilize head and neck.

5.1 To prevention, early recognition andprompt treatment of complications.

ER-98







EMER

GEN

CY

NU

RSI

N

5.3 Place the patient in a safe and comfortableposition to protect from injury.5.4 Start neurological examination Glasgow ComaScale.

5.5 Talk to the patient, if conscious.

5.6 Provide IV access for:5.6.1 I.V. fluid administration.5.6.2 IV medications.

5.7 Administer Oxygen.5.8 Proper patient for ECG.5.9 Control bleeding by:

5.10 Apply cervical collar if spinal cord injury issuspected to immobilized head and neck and preventfurther trauma.5.11 Avoid stimulation of pain response suctioning,loud noise and elevated temperature notes cause andincrease intracranial pressures.5.12 Document in the nurse's note to determinepatients are response to treatment.5.13 Expedite admission helps assess patient'sresponse to treatment.

5.4 To observations and assesses"consciousness: arousal, which dependson the brainstem; and cognition orawareness

5.5 To help detects changes in level ofconsciousness.

5.7 To prevent hypoxia and assess forrespiratory compromise.


6.0 ATTACHMENTS

N/A

ER-99







EMER

GEN

CY

NU

RSI

N

7.0 MATERIALS & EQUIPMENT7.1 Oxygen- cannula /mask.

7.2 dressing set.

7.3 Suction machine.7.4 IV fluids and medications as prescribed


Specialized Nursing: Emergency Care (SNR-ER-031).8.2 www.ciap.health.nsw.gov.au/hospolic/.../Kturner.htm

NAME DATE




ER-100

www.ciap.health.nsw.gov.au/hospolic/



DPPNUSRING EMERGENCY MANAGEMENT OF ABDOMINAL

TRUMATITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 To provide immediate care to patient.

1.2 To control bleeding.

1.3 To prevent further trauma.

1.4 To minimize and prevent complications

2.0 DEFINITIONAbdominal trauma is an injury to the abdomen. It may be blunt or penetrating and may involve

damage to the abdominal organs. Signs and symptoms include abdominal pain, tenderness,

rigidity, and bruising of the external abdomen

3.0 RESPONSIBILITIESRegister Nurses in E.D


4.2 The nurse must assess the singes and symptoms of internal and external bleeding


4.4 Provide ABC assessment and management needed

4.5 check Vital signs, monitored and assessed for presence of :

4.5.1 Hypotension.

4.5.2 Tachycardia.

ER-101




TRUMATITLE:



EMER

GEN

CY

NU

RSI

N

4.5.3 Tachypnea.

4.5.4 Shock.

4.5.5 Hemorrhage.

4.6 Fluid administration is started immediately with a large gauge cannula according the doctor

order.


4.8 Maintain stander prosecutions if patient has open wound.

4.9 Complete patient record and document if ordered for any procedures or admission .




5.1 Obtain history of the patient's injury to assess and

early prompt treatment of the complications:

5.1.1 Time of injury.

5.1.2 Initial treatment given.

5.2 Monitor and record the vital signs.

5.3 Observe and assess for signs and symptoms of :

5.3.1 Hemorrhage to assess for the presence

of shock.

5.3.2 Tenderness in abdomen.

ER-102




TRUMATITLE:



EMER

GEN

CY

NU

RSI

N

5.3.3 Guarding or splinting of abdominal wall

on palpitation.

5.3.4 Absence of decreased bowel sounds.

5.3.5 Shoulder pain.

5.3.6 Abrasions, contusion, ecchymosis.

5.4 Start I.V. fluids immediately with a large bore

needle as ordered

5.5 Collect blood for:

5.5.1 Cross- matching.

5.5.2 Laboratory investigations.

5.6 Insert urinary catheter to ascertain presence of

hematuria to measure intake and output.


continuity of care.

5.5 for Potential hypovolemic shock due

to blood loss.



nursing care

6.0 ATTACHMENTS

N/A

ER-103




TRUMATITLE:



EMER

GEN

CY

NU

RSI

N

7.0 MATERIALS & EQUIPMENT7.1 Crash cart as needed.

72 Suction machine.

7.3 Dressing set and Thick dressing.

7.4 I.V. fluids and medication as ordered.


Specialized Nursing: Emergency Care 2007.8.2 http://en.wikipedia.org/wiki/Abdominal_trauma8.3 Medical Surgical Nursing, Brunner & Siddhartha’s, 10th edition, Lippincott Williams

&Wilkins

NAME DATE




ER-104

http://en.wikipedia.org/wiki/Abdominal_trauma



DPPNURSING EMERGENCY MANAGEMENT OF BURNSTITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 To properly assess and provide immediate management for further treatment.1.2 To minimize and prevent complications

2.0 DEFINITIONA burn is a type of injury to flesh caused by heat, electricity, chemicals, light, radiation or

friction.


4.0 POLICY4.1 Provide ABC assessment :

4.1.1 Airway, breathing, circulation.

4.2 The ER nurse must be able to estimate roughly the extent of burns using the according to:

4.2 .1 Depth – first, second, third.

4.2.2 Extent- percentage of TBSA.

4.2.3 Age.

4.2.4 Area of the body burned.

4.2.5 Inhalation injury.

4.3 Vital signs should be monitored for hypotension leading to shock.

4.3.1 Assessed level of pain.

ER-105






EMER

GEN

CY

NU

RSI

N

4.3.3 The patient with burns is potential for hypovolemia and reduced perfusion;

therefore IV fluid therapy should be administered immediately to replace

fluids and electrolytes lost by the body as doctor order.

4.4 Potential for infection is great so preventive measures must be observed. Dressing of

burn must be done under aseptic technique by a registered/qualified nurse is ordered.


4.6 An indwelling catheter is inserted for accurate monitoring or urine output and renal

function

٤٫٧Maintain patient privacy and safety measured



4.10 There must have a police clearance for medico- legal case.


ER-106






EMER

GEN

CY

NU

RSI

N

5.1 Assess for the following to help determinethe patient's condition and render immediatetreatment.

5.1 Airway: Burn patient is potential forimpaired gas exchange and shouldreceive high flow,humidified oxygen(100%).

5.2 Breathing.

5.3 Circulation.5.4 Vital signs.

5.2 Check hydration status to give sufficient fluid.

5.3 Administer pain medications/ narcotics for painas oredered

5.4 Assess the severity of burns to give appropriatetreatment as needed.

5.6.1 Depth – First, Second, Third.

5.6.2 Extent.

5.6.3 Severity.5.6.4 Inhalation Injury.

5.7 Obtain laboratory samples:5.7.1 Collect wound swabs from all

areas of burn injury to determine presenceof Microorganisms.

5.7.2 Blood samples.5.7.3 X-ray, ECG.

5.8 Monitor vital signs and assess respiratory and

5.2 To allow perfusion of vital organsand replace lost body fluids andelectrolytes.5.3 To reduce pain and alleviate

suffering.

ER-107






EMER

GEN

CY

NU

RSI

N

cardiovascular status.5.8.1 Ensure patient is well- wrapped and

kept warm.

5.9 Insert urinary catheter as ordered byphysician to Measures intake and output andassess urinary output.

5.10 Dress the burned areas as ordered under aseptictechnique.

5.10.1 Explain the procedure to thepatient.5.10.2 Undress the patient and remove allclothing.5.10.3 Administer analgesic as prescribe priorto dressing to reduce pain as ordered.5.10.4 Provide a safe and cleanenvironment to prevent infection.5.10.5 Wash hands and wear glovesbefore and after each patient contact toprotect patient from source ofcontamination.

5.12 Assist the physician in the insertion ofendotracheal tube, if needed.

5.13 Assess the pain level.5.14 Document all procedures in the nurse'snotes.5.15 Expedite admission to burn unit or as required.

5.8.1To prevent hypothermia.

5.10.2 To properly clean the woundand prevent infection.

5.12 To provide adequate and patientairway.

ER-108






EMER

GEN

CY

NU

RSI

N

6.0 ATTACHMENTS

7.1 Charts for Estimating Severity of Burn Wound.

7.2 Transfer Information Chart

7.0 MATERIALS & EQUIPMENT7.1 Suction.

7.2 Oxygen.

7.3 Dressing Tray.

7.4 IV fluids as ordered.

7.5 Dressing set ,Sterile gauze, adhesive tape.

7.6 Saline solution.

7.7 Burn dressing pack.

7.8 Sterile wound swabs.7.9 Gloves.

8.0 REFERENCES8.1Ministry of Health, General Nursing Administration Functions and Duties Policies and Procedures forSpecial ized Nursing: Emergency Care 2007 (NR-ER-033).8.2 http://en.wikipedia.org/wiki/ trauma

NAME DATE




ER-109

http://en.wikipedia.org/wiki/



DPPNURSING EMERGENCY MANAGEMENT OF SICKLE CELL

CRISISTITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 To relieve pain.

1.2 To enhance sense of self- esteem and power.

1.3 To replace blood loss.

2.0 DEFINITIONSickle cell crisis results from tissue hypoxia and necrosis due to inadequate blood flow to aspecific region of tissue or organ. It is an inherited disorder or abnormal hemoglobin synthesis.


4.0 POLICY4.1 Nurse must provide direct general assessment to patient while arrived in ED4.2 Pain levels should always be monitored. Assessment includes quality of pain (shard, dull,burning) and frequency of and severity pain

4.3 Vital signs and neurological assessment are monitored and recorded to elicit symptoms ofhypoxia.

4.4 The patient should be placed in a quit and comfortable position to relieve pain.

٤٫ 5 The nurse must assess the singes and symptoms of internal and external bleeding


4.7 The patient should be kept warm, maintain hydration and avoid stressful situations todiminish occurrence of attacks.

ER-110




CRISISTITLE:



EMER

GEN

CY

NU

RSI

N


5.1 Administer oxygen by mask or cannula asordered.

5.2 Encourage fluid intake orally, if not tolerated,initiate I.V fluids as ordered.

5.3 Provide a quiet and comfortable environment toprovide rest and relieve pain.

5.4 Administer medications as ordered

5.5 Monitor the patient for below signs and symptoms

5.5.1 Infection.

5.5.2 Active cellulites.

5.5.3 Leg ulcers.

5.5.4 Swollen joints.5.5.5 Osteomyelitis.

5.6 Elevate the affected joint and encourage thepatient to do relaxation techniques and breathingexercises.

5.7 Keep the patient warm and maintain adequatehydration to diminish the occurrence and severity ofattacks.

5.1 To enhance oxygenation and preventhypoxia.

5.2 Decreased blood viscosity andimprove perfusion.

5.4 To relive pain

5.5 to be able to administer prompttreatment and prevent furthercomplications

5.6 To reduce swelling and elevation andcontrol acute pain.

ER-111




CRISISTITLE:



EMER

GEN

CY

NU

RSI

N

5.8 Monitor vital signs and record the patient shouldhave normal temperature.

5.9 Document patient's condition to providecontinuity of care.

5.10 Teach the patient to avoid factors that

precipitate pain crisis



nursing care

6.0 ATTACHMENTS

N/A

7.0 MATERIALS & EQUIPMENT7.1 Oxygen

7.2 IV fluids

7.3 Medications as prescribed

8.0 REFERENCESMinistry of Health, General Nursing Administration Functions and Duties Policies and Procedures forSpecialized Nursing: Emergency Care 2007 (SNR-ER-049

NAME DATE


ER-112




CRISISTITLE:



EMER

GEN

CY

NU

RSI

N

Reviewed By: Mrs.Ashwag Omar shaibah.- Head of nursing education KFH-J 2010


ER-113



DPPNURSING EMERGENCY MANAGEMENT OF NEAR-

DROWNINGTITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 To maintain cerebral perfusion.1.2 To provide adequate oxygenation.1.3 To prevent further damage to vital organs.

2.0 DEFINITIONNear drowning is the survival of a drowning event involving unconsciousness or water inhalationand can lead to serious secondary complications, including death, after the event


4.0 POLICY4.1 Provide ABC assessment and management neededImmediate resuscitation must be done to victims of near-drowning after prolonged submersion

in cold water.4.2 The patient must be observed for risk of complications :

4.2.1 Hypoxic or Ischemic Cerebral Injury.

4.2.2 Acute Respiratory Distress Syndrome.

4.2.3 Pulmonary Damage Secondary to Aspiration.

4.2.4 Life-Threatening Cardiac Arrest.4.3 The patient becomes hypothermic because of submersion, so pre-warming procedures areprescribed:

4.3.1 Warming Blankets.

4.3.2 Over-the-Bed Heaters.

4.3.3 Warm Humidified Oxygen.4.4 Continuous ECG monitoring is performed because cold-induced myocardial irritability leads

to conduction disturbances especially ventricular fibrillation.

ER-114




DROWNINGTITLE:



EMER

GEN

CY

NU

RSI

N

٤٫5 Maintain patient privacy and safety measured٤٫6 Maintain stander prosecutions if patient has open wound.٤٫7 Complete patient record and document if ordered for any procedures or admission.4. 8 Secure consent to protect patient from untoward procedures


5.1 Initiate CPR immediately. It is the greatestinfluence of survival :

5.1.1 Endotracheal Intubation.

5.1.2 Ensures patent airway.5.1.3 Administer oxygen .

5.2 prepare syringe to Perform ABG analysis bydoctor .

5.3 Continuous monitoring of:5.3.1 Vital signs rectal tube is inserted5.3.2 ECG to determine dysrrhythmias.5.3.3 ABG to evaluate oxygen saturation.5.3.4 Intake and Output to determine

urinary output.

5.4 prepare equipment for Insert nasogastric tube.

5.5 Insert indwelling catheter to measure intake andoutput.5.6 Observe the patient for complications such as:

5.6.1 Hypoxic or ischemic cerebral injury.

5.6.2 Acute Respiratory Distress Syndrome.

5.6.3 Pulmonary Damage secondary to

5.2 To evaluate oxygen, carbon dioxideand bicarbonate levels and Ph.

5.3.1 to determine the degree of

hypothermia..

5.4 To decompress the stomach and toprevent the patient from aspiratinggastric contents.

ER-115




DROWNINGTITLE:



EMER

GEN

CY

NU

RSI

N

aspiration.5.6.4 Life-Threatening Cardiac Arrest.

5.7 Apply re-warming devices such as :5.7.1 Warming blankets.

5.7.2 Over-the Bed heaters.5.7.3 Warm, humidified oxygen.

5.8 Provide venous access :5.8.1 I.V. fluid therapy.5.8.2 I.V. medications.

5.9 Document all procedures in the nurse's notes.

5.10 Proceed with admission, if required.


6.0 ATTACHMENTS

N/A.

7.0 MATERIALS & EQUIPMENT7.1 Oxygen.

7.2 Crash cart.

7.3 equipment of Nasogastric tube

7.4 Prescribed re-warming devices

7.5 ECG machine.

7.7 equipment of Foley's catheter.

ER-116




DROWNINGTITLE:



EMER

GEN

CY

NU

RSI

N

8.0 REFERENCES8.1 Ministry of Health, General Nursing Administration Functions and Duties Policies and Procedures forSpecialized Nursing: Emergency Care 2007 (NR-ER-035).8.2 http://en.wikipedia.org/wiki/Near_drowning

NAME DATE


Reviewed By: Mr. Ashwag Omar shaibah.- BSN-Head of nursing education KFH-J 2010


ER-117

http://en.wikipedia.org/wiki/Near_drowning



DPPNURSING EMERGENCY MANAGEMENT OF DIARRHEA AND

VOMITINGTITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 To prevent fluid and electrolyte imbalance, controlling symptoms and treating the underlyingcause.1.2 To prevent dehydration and promote bed rest.1.3 To regain normal bowel pattern.

2.0 DEFINITION2.1 Diarrhea: is increase frequency of bowel movement(more than three per day), increaseamount of stool(more than 200g per day) and altered consistency(ie, looseness) of stool2.2 Vomiting: A reflex act of expulsion of the stomach contents via the esophagus and mouth.

3.0 RESPONSIBILITIESRegistered Staff Nurses in ED

4.0 POLICY4.1 nurse must provide direct general assessment to patient while arrived in ED

4.1.1 Assessment of patient with diarrhea includes:4.1.1.1 Determination of hydration status.4.1.1.2 Evaluation for thirst, sunken eyes, weakened pulse, loss of skin turgor.\

4.1.1.3 Assessment must be include abdominal auscultation and palpation for abdominaltenderness.4,3 Collect data about the causes and patient history4,4Provide ABC assessment and management needed4,5 check Vital signs, monitored and assessed for presence of:4,6 Fluid administration is started immediately with a large gauge cannula according the doctororder.4,7 Maintain patient privacy and safety measured4,8 Maintain stander prosecutions if patient has open wound.4.9 Complete patient record and document if ordered for any procedures or admission.

ER-118




VOMITINGTITLE:



EMER

GEN

CY

NU

RSI

N

4.10 Infection Control Officer must be informed with the outbreak of the illness.


5.1 Assess the patient for the following:5.1.1 Signs and symptoms of dehydration.5.1.2 Degree of dehydration.5.1.3 Abdominal cramp.5.1.4 Tenesmus.5.1.5 Abdominal distention.

5.2 Assess the patient for signs and symptoms ofdiarrhea:

5.2.1 Frequency of stool.5.2.2 Consistency.5.2.3 Color.5.2.4 Amount.

5.3 Monitor and record vital signs:5.3.1 Temperature is elevated.

5.4 Administer IV fluids as ordered.5.5 Collect specimen for:

5.5.1 Blood.5.5.2 Stool.5.5.3 Vomitus.

5.7 Record intake and output.5.8 Through hand washing and meticulous personalhygiene.5.9 Report any signs of:

5.9.1Increasing pain.5.9.2 Fever.5.9.3 Change in stool.5.9.4 Vomiting.

5.3.1To early detection of infection

5.4 To maintain fluid and electrolyteimbalance

5.7 To measure fluid balance

5.10To provide clear report about

ER-119




VOMITINGTITLE:



EMER

GEN

CY

NU

RSI

N

5.10 Document all procedures. procedure steps for continuousnursing care

6.0 ATTACHMENTS

NA

7.0 MATERIALS & EQUIPMENT7.1 Specimen containers for urine and stool.

7.2 IV fluid therapy (please see administration of IV therapy) as ordered .


Specialized Nursing: Emergency Care (SNR-ER-038).

8.2 Medical Surgical Nursing, Brunner & Siddhartha’s, 10th edition, Lippincott Williams

&Wilkins

NAME DATE


Reviewed By: Mrs. Ashwag Omar shaibah.-BSN- Head of nursing education KFH-J 2010


ER-120



DPPNURSING EMERGENCY MANAGEMNT OF CARBON MONOXIDE

POISONIINGTITLE:

EFFECTIVE DATE:APPROVAL DATE


EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 For urgent removal of ingested substance to decrease systemic absorption1.2 To empty the stomach before endoscopic procedure1.3 To diagnose gastric hemorrhage and arrest hemorrhage..

2.0 DEFINITION2.1 Carbon Monoxide Poisoning: It may occur as a result of industrial or household incidents orattempted suicide, It is implicated in more deaths than any other toxin except alcohol.


4.0 POLICY4.1 A person suffering from carbon monoxide poisoning appears intoxicated and requiresimmediate treatment.

4.2 The police must be informed.

4.3 Resuscitation equipment must be ready at all times.

4.4 A thorough history should be determined as to the type and length of exposure as well asfumes inhaled.4.4 All patients should be placed at 100% oxygen by non-breathing mask or via endotrachealtube, if necessary in order to reverse tissue hypoxia and eliminate carbon monoxide from theblood.

4.6 Level of consciousness should be determined.4.6.1 The patient may appear intoxicated from cerebral hypoxia.

4.6.2 Confusion may progress rapidly to coma.

ER-121




POISONIINGTITLE:



EMER

GEN

CY

NU

RSI

N


5.1 Administer 100% oxygen at atmospheric orhyperbaric pressures.

5.2 Determine a thorough history of the patient todetermine the type and length of exposure as well asfumes inhaled.

5.3 Assess airway, breathing and circulation andlevel of consciousness the patient may requireintubation and ventilation.

5.4 Observe for signs and symptoms of:5.4.1Headache.5.4.2 Muscle weakness.5.4.3 Palpitation.5.4.4 Dizziness.5.4.5 Dysrrhythmia.5.4.6 Mental confusion.5.4.7 Coma.

5.5 Continuous ECG monitoring.

5.6 Monitor vital signs for altered breathing patternsand respiratory failure.

5.7 Obtain arterial blood samples for carboxy-hemoglobin levels.

5.8 Prepare patient for Gastric lavage

5.1 To reverse hypoxia and accelerateelimination.

5.5 To assess patient condition

5.6 To assess patient condition

5.7 to maintain Normal level

ER-122




POISONIINGTITLE:



EMER

GEN

CY

NU

RSI

N

59 Document all procedures.5.9 For the continuity of care and to

provide complete report


6.1 Oxygen and 02 mask.

6.2 ECG machine.6.3 Cardiac Monitor.

6.4 Gastric Lavage Equipment.

7.0 ATTACHMENTSN/A

8.0 REFERENCES8.1Ministry of Health, General Nursing Administration Functions and Duties Policies and

Procedures for Specialized Nursing: Emergency Care 2007 (SNR-ER-039).8.2 Medical Surgical Nursing, Brunner & Siddhartha’s, 10th edition, Lippincott Williams

&Wilkins

NAME DATE


Reviewed By: Mrs.Ashwag Omar shabah.- BSN-Head of nursing education KFH-J 2010


ER-123



DPPNURSING EMERGENCY MANAGEMENT FOR INGESTION OFPOISONOUS SUBSTANCES (Drug, Food, Chemical)TITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE11.1 To identify the toxic substance.1.2 To reverse effect of or eliminate substance from the patient's body.1.4 To prevent further absorption, enhance drug elimination and reduces its toxicity

2.0 DEFINITIONPoisonous substances (Toxic substance) are substances that are harmful to the body no matterhow much or in what manner they enter the body.

3.0 RESPONSIBILITIESRegistered Staff Nurses in ED .

4.0 POLICY4.1 All cases of poisoning must be treated as an acute emergency.

4.2 Police must be informed by the physician of cases of ingestion of poisonous substances.

4.3 History of patient's condition must be obtained:

4.3.1 Substance ingested.

4.3.2Amount of substance.

4.3.3 Time, interval between ingestion and examination.

4.3.4 Recent illness.

4.3.5 Allergy.

4.4 Assessment of patient's condition includes:4.4.1 Airway and ventilation, oxygenation.

4.4.2 Vital signs and level of consciousness.

ER-124






EMER

GEN

CY

NU

RSI

N

4.5 All specimen must be collected, labeled properly and send to the laboratory:4.5.1 Vomitus.

4.5.2 Gastric contents.

4.5.3 Food/drug/chemical substance.

4.5.4 Rectal swab for food poisoning only.

4.5.5 Blood samples for toxicology studies.

4.5.6 Urine test for toxicology.4.6 The health officer and infection control officer must be informed of any ingestion ofpoisonous substance.

4.6.1 Checking and monitoring of vital signs must be done frequently according topatient's condition.

4.6.2 Gastric lavage must be done immediately to prevent further absorption of thepoisonous substance.

4.6.3 Toxicology form must be completed by the physician and submitted to the healthofficer.

4.7 Ensure privacy; raise side rails Provides comfort and safety to patient.4.8Observe all cases for 4-6 hours minimum.

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5.1 Assist ED physicians in the rapid physicalexamination of the patients help the nurse.

5.1.1 Monitor vital signs

5.1.2 Neurologic assessment as directed by the

physician and record on neuro flow sheet.

5.2 Stabilize patient's condition to provide patentairway.

5.2.1 Establish airway and ventilation.

5.2.2 Have suction and oxygen equipment

nearby.

5.2.3 Initiate oxygen therapy, if indicated.

5.2.4 Have padded tongue blade available.

5.3 Draw blood for laboratory studies as ordered

5.4 Start I.V. infusion as ordered to keep vein open.

5.5 Prepare and assist doctor for gastric lavage

5.6 Provide psychological and emotional support.

5.7 Document in nurse's progress notes to assesspatient's response to treatment:

5.8 Expedite admission, if necessary.

5.1 To determine the changes in patient'scondition.

5.3 to rule out hypoglycemic coma.

5.4 For fluid replacement and to preventhypovolemic shock

5.6 To reduce anxiety and fear.


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6.0 ATTACHMENTS

6.1 Reporting Form For Over Dosage or Chemical Poisoning.6.2 "Suspected" FBDO Reporting Form.

7.0 MATERIALS & EQUIPMENT71 Specimen containers for blood, stool, vomitus, aspirate, urine.

7.2 Specimen swab.

7.3 Suction apparatus.

7.4 Kidney basin.

7.5 I.V. fluids and medications as ordered.7.6 Oxygen.7.7Gastic Lavage Equipment

8.0 REFERENCES8.1Ministry of Health, General Nursing Administration Functions and Duties Policies and Procedures forSpecialized Nursing: Emergency Care 2007 (SNR-ER-040).8.2 Medical Surgical Nursing, Brunner & Siddhartha’s, 10th edition, Lippincott Williams

&Wilkins

NAME DATE


Reviewed By: Mrs. Ashwag Omar shabah.- BSN-Head of nursing education KFH-J 2010


ER-127



DPPNURSING EMERGENCY MANAGEMENT OF ALCOHOL

INTOXICATION/ WITHDRAWALTITLE:



1.0 PURPOSE1.1 To give adequate sedation and support to allow the patient to rest and recover without dangerof injury or peripheral vascular collapse.

2.0 DEFINITIONAlcohol is psychotropic drug that affects mood, judgment, behavior, concentration, andconsciousness .

3.0 RESPONSIBILITIES3.1 Nursing Emergency Department.

4.0 POLICY٤٫١ nurse must provide direct general assessment to patient while arrived in ED4.2 Provide ABC assessment and nursing management needed4.3 The nurse must provide assess to patient includes:

4.3.1 Pre- existing or contributive illness or injuries (e.g. Head injury).

4.3.2 Drug history to facilitate adjustment of any sedative needed.

4.3.3 Vital signs

4.3.4 Adequate Airway.4.4 Maintain electrolyte balance and hydration through oral or IV fluids Maintain patient

privacy and safety measured

4.5 The patient should be placed in a comfortable and safe environment with bed rails up.



4.9 The police are informed and necessary procedures performed for legal purposes

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5.1 Place the patient in a calm, quiet environmentand observe closely to provide patient's safety.

5.2 Inform the physician for shakes, seizures andhallucinations to help determine changes in patient'scondition and administer immediate treatment.

5.3 Monitor vital signs frequently.

5.4 Start IV fluids for dehydration due to profuseperspiration, vomiting and agitation.

5.5 Talk to the patient in a calm and slow mannerthat helps to interferes with thought process.

5.6 Obtain blood samples for alcohol level.

5.7 Sedation maybe given as ordered

5.8 Document all procedures in the nurses notes tohelp the nurse assess patient's response to treatment.

5.7 To provide adequate relaxation andto reduce agitation prevent exhaustion,an promote sleep.


6.0 ATTACHMENTS

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7.0 MATERIALS & EQUIPMENT71Oxygen.

7.2 Sedation as prescribed.7.3 Specimen tube for blood sample

8.0 REFERENCES8.1Ministry of Health, General Nursing Administration Functions and Duties Policies andProcedures for Specialized Nursing: Emergency Care 2007 (SNR-ER-041).8.2 Medical Surgical Nursing, Brunner & Siddhartha’s, 10th edition, Lippincott Williams

&Wilkins

NAME DATE


Reviewed By: Mrs Ashwag Omar shabah.- Head of nursing education KFH-J 2010


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DPPNURSING EMERGENCY MANAGEMENT OF ANIMAL

BITES/STINGSTITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 To provide prompt emergency care.1.2 To competently administers initial wound treatment.1.3To safe patient live.1.4 To prevent tetanus and it’s complication .

2.0 DEFINITION2.1 Insect stings or bites: are injected poisons that can produce either local or systemic reactions.2.2 Local Reactions: Characterized by pain, erythema and edema at the site of injury.2.3 Systemic Reactions – Begin within minutes and produce mild to severe and life threateningreactions.


4.0 POLICY٤٫١nurse must provide direct general assessment to patient while arrived in EDProvide ABC assessment and nursing management needed

Collect data about the causes and patient history4.5 check Vital signs, monitored and assessed for presence4.2 All incidences of animal bites/ stings shall be reported to the health officer4.3 Resuscitative equipment is ready at all times.4.4 Medication should be administered as ordered:

4.4.1 I.V. fluids.

4.4.2 Bronchodilators.

4.4.3 Tetanus Immunizations.

4.4.4 Antihistamine for local reactions.4.5 Maintain stander prosecutions if patient has open wound.

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The wound should be cleansed thoroughly with soap and water or an antiseptic solution.4.7 Inspection of sites of bites:

4.7.1 Area of bites.

4.7.2 Swelling.

4.7.3 Pain.

4.7.4 Ecchymosis.

4.8 Children need immediate care and action, as they become hysterical and need to be in a quiet,isolated area with parents.

4.9 Blood is taken for blood analysis and ECG is monitored to treat dysrhythmias.

4.10 administer Tetanus immunization as ordered by doctor.

4.11 RABIES:

4.11.1 The wound should not be sutured unless unavoidable for cosmetic or tissuesupport reasons.4.11.2 Topical antibiotics should not be used, but oral penicillin maybe prescribed toprevent bacterial infections in patient with extensive wounds.4.11.3 Anti-rabies immunization is initiated as prescribed.4.11.4 The patient is advised to bring the animal if possible.4.11.5 The patient is directed to come for vaccination

4.12 Snake bites:

4.12.1 Absence of distinct fang punctures and local pain, edema, numbness orweakness to appear within 20 minutes are strong evidence against snake venompoisoning.

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4.13 Scorpion sting:

4.13.1 Skin test is a must prior to administration of antiscorpion venom.

4.13.2 Anti- scorpion venom should be given immediately as doctor orderedand slowly IV at least 5x1 ml ampoule diluted in 50ml of Saline after skintest. If clinical features don’t improve after two hours, repeat the same doseof antiscorpion venom.


5.1 Place the patient in a comfortable position andprovide a quit environment.

5.2 Assess for the severity of wound to determineand assess prompt immediate treatment:

5.2.1 Obtain history of bite / sting.

5.2.2 Previous exposure.

5.2.3 Allergies.

5.2.4 Inspect skin for local reaction erythema,

edema and pain at site of injury.

5.3 Monitor vital signs and record.

5.4 Assess airway, breathing and circulation ifpatient is not alert to asses for the need ofresuscitation measures.

5.5 Collect blood for analysis.

5.1 To reduce anxiety and providecomfort and rest.

5.3 To ascertain, dyspnea, wheezing and

stridor.

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EMER

GEN

CY

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RSI

N

5.6 Cleanse the wound with sterile water or asordered by the physician to prevent infection.

5.7 Give antitetanus immunization as ordered.

5.8 Report the incident to the health officer andcomplete the incident form as ordered Fordocumentation.

5.9 Document all procedures in the nurse's notes andif for admission, refer to P/P and, if for discharge,instruct patient to follow- up injections and dressings5.10 Apply ice packs to the site to relieve pain.

5.11 Elevate extremity with large edematous localreaction to reduce swelling.

5.7 To prevent tetanus.

5.9 to help the nurse to assess thepatient's response to treatment.

6.0 ATTACHMENTS

N/A7

7.0 MATERIALS & EQUIPMENT.1 Crash cart.

7.2 Oxygen.


7.4 Dressing tray.7.5 Soap and water

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EMER

GEN

CY

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RSI

N

8.0 REFERENCESMinistry of Health, General Nursing Administration Functions and Duties Policies and Procedures forSpecialized Nursing: Emergency Care 2007 (NR-ER-042).

NAME DATE


Reviewed By:Ashwag Omar shabah.- BSN-Head of nursing education KFH-J



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DPP NURSING EMERGENCY MANAGEMENT OF TETANUSTITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 To prevent hypoxia.1.2 To prevent and treat convulsions.1.3 To protect the patient from injury.

2.0 DEFINITIONTetanus: It is a clinical syndrome caused by the release of a potent neurotoxin produced byclostridium tetani.


4.0 POLICY

4.1 Nurse must provide direct general assessment to patient while arrived in ED

٤٫٢The nurse must assess the singes and symptoms

٤٫٣Collect data about the causes and patient history

٤٫ 3 .١ Type of injury.

٤٫ 3 .٢ Conditions under which injury occurred.

٤٫ 3 .٣ Time elapsed since injury.

4.3.4 Previous history of immunization.

4.4 Provide ABC assessment and management needed4.4.1 Assessment of patient includes:

4.4.1.1 Lockjaw (stiffness of the jaw).

4.4.1.2 Convulsions, twitching.

4.4..1.3 Difficulty of swallowing.

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4.4.1.4 Excessive yawning.

4.4.1.5 Muscle spasms.

4.4.1.6 Opisthotonus (extreme arching of the back and retraction of the head).

4.5 The patient should be placed in a quiet and dark room a possible to avoid triggering spasms.

4.6 The patient should be positioned properly to facilitate drainage of oral secretions.

4.6 Tetanus immunization should be administered immediately as ordered, and tetanusprophylaxis topatients who have been immunized and have superficial wounds.

4.7 All patients with generalized tetanus need immediate critical care.

4.8Maintain patient privacy and safety measured

4.9 Maintain stander prosecutions if patient has open wound.


5.1 Assess patient to provide emergency measuresfor treatment such as:

5.1.1 Stiffness of the jaw.

5.1.2 Convulsions, twitching.

5.1.3 Difficulty of swallowing

5.1.4 Excessive yawning.

5.1.5 Muscle spasm.

5.2 Obtain history of the injury to ascertain the

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possibility of tetanus.

5.3 Maintain airway and adequate breathing patternto prevent hypoxia by:

5.3.1 Administer oxygen.5.3.2 Insert endotracheal tube Intubation as

ordered.

5.4 Keep the patient's room as quiet and dark aspossible.


5.6 Raise up the side rails and stay with the patient to

protect hem/her from injury.

5.8 Encourage the patient to complete his/herimmunization.

5.9 Monitor vital signs frequently and report anyabnormality.


5.11 Expedite admission, if required.

5.4 To avoid triggering spasm.


6.0 ATTACHMENTS

N/A

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N

7.0 MATERIALS & EQUIPMENTN/A

8.0 REFERENCES8.1 Ministry of Health, General Nursing Administration Functions and Duties Policies andProcedures for Specialized Nursing: Emergency Care 2007 (SNR-ER-043).8.2 Medical Surgical Nursing, Brunner & Siddhartha’s, 10th edition, Lippincott Williams

&Wilkins

NAME DATE


Reviewed By:Mrs. Ashwag Omar shaibah.- BSN-Head of nursing education KFH-J

2010


ER-139



DPP NURSING EMERGENCY MANAGEMNT OF HYPOTHERMIATITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSETo maintain body temperature

2.0 DEFINITIONHypothermia: It is a condition in which the core (internal) temperature is 350 C (950 F) or less asa result of exposure to cold. It occurs when a patient loses the ability to maintain bodytemperature.

3.0 RESPONSIBILITIESRegister Nurses in E.D.

4.0 POLICY4.1 nurse must provide direct general assessment to patient while arrived in ED ٤٫٣ Collect dataabout the causes and patient history4.2 Provide ABC assessment and nursing management needed

4.2.1 Airway and breathing: Spontaneous respiration maybe extremely slow andimperceptible.4.2.2 Circulation: If temperature falls below 86° F (30° C), the heart sounds may not beaudible even if the heart is still beating. Blood pressure maybe difficult to hear.

4.3. provide general Assessment of patient includes:4.3.1. Progressive deterioration with apathy, poor judgment, ataxia, drowsiness,pulmonary edema, eventually coma.

4.3.2. Shivering.

4.3.3. Heart beat and blood pressure maybe weak.

4.3.4. Cardiac irregularities.

4.3.5. Hypoxemia and acidosis.44.4 ensure Intravenous access is obtained:

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4.3.1 I.V. fluid administration.

4.3.2 Blood sampling.

4.3.3 I.V. medications as ordered.



5.1 Obtain and monitor vital signs and put patient oncardiac monitor.

5.2 Assess the patient for:5.2.1 Airway and breathing –give oxygen100%.

5.2.2 Circulation.

5.4 Start I.V. fluid as ordered

5.5 Perform CPR, if needed.5.6 Perform re-warming measures:

5.6.1 Active core (internal) re-warming:

5.6.1.1 Cardiopulmonary bypass.

5.6.1.2 Warm fluid administration.

5.6.1.3 Warm humidified oxygen by

ventilator.5.6.2 Passive (external) re-warming Increases

blood flow to the acidotic, anaerobic extremities.

5.6.2.1 Warm blankets.5.6.2.2 Over-the-bed mattress.

5.7.4 Administration of medications asordered:

5.1 To determine vasoconstriction andarrhythmias.

4.5 for fluid replacement and correct

hypotension.

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5.8 Insert urinary catheter.

5.9 document and Record all procedures in the nurses'notes.

5.10 Notify physician for any abnormalities noted.

5.11 prepare patient for admit patient, if required.

6.0 ATTACHMENTSN/A

7.0 MATERIALS & EQUIPMENT7.1 Warming blankets.7.2 Over-bed heaters.7.3 Oxygen.7.4 Warm I.V. fluids.7.5 Medications as ordered.7.6 Thermometer (rectal thermostat).7.7 7.8 ECG machine.

8.0 REFERENCES8.1 Ministry of Health, General Nursing Administration Functions and Duties Policies and Procedures forSpecialized Nursing: Emergency Care 2007 (SNR-ER-045).٨٫2 Medical Surgical Nursing, Brunner & Siddhartha’s, 10th edition, Lippincott Williams

&Wilkins

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NAME DATE




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DPP ENVIRONMENTAL EMERGENCY OF FROSTBITETITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 To restore normal body temperature.1.2 To safe patient live.

2.0 DEFINITIONFrostbite: It is a trauma from exposure to freezing temperatures and actual freezing of the tissuefluids in the cell and intercellular spaces.


4.0 POLICY4. ١Nurse must provide direct general assessment to patient while arrived in ED٤٫٣ Collect data about the causes and patient history٤٫٤ Provide ABC assessment and nursing management needed4.5 Check Vital signs, monitored and assessed for presence of :4.2 Assessment of patient include:

4.2.1 Frozen extremity is hard, cold and insensitive to touch and may appear white ormottled blue-white.

4.2.2 Extent of injury.

4.2.3 History of patient which include environmental temperature, duration of exposure,

presence of wet conditions.

4.3 Constrictive clothing that could impair circulation are removed.

4.4 The patient should be allowed to ambulate.4.5 Controlled yet rapid re-warming is instituted and repeated until circulation is effectivelyrestored.4.6 Maintain patient privacy and safety measured

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٤٫7 Complete patient record and document if ordered for any procedures or admission.4.8 Complete patient record and document if ordered for any procedures or admission.4.9 Strict aseptic technique must be observed.


5.1 Assess the patient for :5.1.1 Hard, cold, insensitive to touch

extremity most frequently affected by frostbite.5.1.2 Extent of injury.5.1.3 History of the patient:

5.1.3.1 Environmental temperature.5.1.3.2 Duration of exposure, humidity.5.1.3.3 Presence of wet conditions.

5.1.4 Temperature.5.2 Remove constrictive clothing.5.3 Wash hands and wear gloves.5.4 Start re-warming procedure:

5. circulating bath in a 36C to 40 C for 30-40minutes span and repeated as ordered restorecirculation and decrease tissue loss.

5.4.2 Do not massage affected area to avoidfurther mechanical injury.

5.4.3 Elevate re warmed part to help controlswelling.

5.4.4 Place sterile gauze.

5.4.5 Use foot cradle to prevent foot in

contact with bed linens.

5.5 Monitor and record vital signs to evaluate coretemperature.

5.4.4 To prevent maceration between

affected fingers or toes.

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5.6 I.V. fluids are initiated as ordered5.7 After re-warming, perform active motion exerciseof affected part.

5.8 Advise the patient to avoid tobacco, and caffeinewith vasoconstrictive effects; which reduce deficientblood supply to injured tissues.

5.9 Document the procedure in the nurses' notes toevaluate patient's response to treatment.

5.10 Notify the physician for any alteration.

5.6 to prevent dehydration.

5.7 To promote maximal restoration offunction and prevent contractures.

٥٫9 To provide clear report aboutprocedure steps for continuousnursing care

6.0 ATTACHMENTS

NA

7.0 MATERIALS & EQUIPMENT7.1 Whirlpool bath.

7.2 Warming blankets.

7.3 Sterile gauze.

7.4 Foot cradle.

7.5 Gloves.

7.6 Medications as ordered

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Specialized Nursing: Emergency Care 2007 (SNR-ER-046).٨٫2 Medical Surgical Nursing, Brunner & Siddhartha’s, 10th edition, Lippincott Williams

&Wilkins

NAME DATE


Reviewed By: Mrs. Ashwag Omar shabah.- BSN-Head of nursing education KFH-J 2010


ER-147



DPPNURSING EMERGENCY MANAGEMENT OF ACUTE

KIDNEY FAILURETITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 Maintain nearly normal kidney function for the body1.2 Maintain normal fluid and electrolyte levels1.3 Prevent complication1.4 Implements health teaching after discharge.

2.0 DEFINITIONAcute renal failure (ARF) or Acute Kidney Injury (AKI) is a rapid loss (breakdown or decrease)of renal function due to damage to the kidneys, resulting in retention of nitrogenous (urea andcreatinine) and non-nitrogenous waste products that are normally excreted by the kidney.


4.0 POLICY

4.1 Nurse must provide direct general assessment to patient while arrived in ED


٤٫3 The nurse must assess the singes and symptoms of acute renal failure related to patient

condition:Anorexia, Nausea, Vomiting, Costovertebral plain, Headache, diarrhea or constipation,

Irritability, Restlessness, Lethargy, Drowsiness, Stupor, Coma, Pallor, Ecchymosis, Stomatitis,

Thick tenaciouse sputum, Urine output less than 400 ml/day for 1 to 2 weeks and then followed

by diuresis (3 to 5 L/day) for 2 to 3 weeks, Weight gain.

٤٫4 Maintain patient privacy and safety measured.

٤٫٩ Complete patient record and document if ordered for any procedures or admission.

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5.1 Maintain the client on complete bed rest,

organize care

5.2 Continues Check Vital signs

5.3 Observe the client for metabolic acidosis to

identify complication of renal failure

5.4 Observe the fluid and electrolyte balance hourly

5.5 Insert an indwelling urinary catheter and measure

output and specific gravity hourly.

5.6 Provide only enough fluid intake

5.7 Provide emotional reassurance to the client and

family members

5.8 Continue interventions used during the oliguric

phase.


continuity of care.

5.10 Prepare patient for admission if ordered.

5.11 provide Teach the client and family

5.1to provide long rest periods

5.5 to monitor the kidneys, which havethe major role in regulating fluid andelectolyte balance.5.6 to replace urine output to avoid anedema caused by excessive fluid intake.

5.7 to help decrease anxiety levelscaused by the fact that the client has anacute illness with unknown prognosis.

5.9To provide clear report about


nursing care.

5.11 to prevent infection and to avoid the

factors that caused renal failure to help

prevent a recurrence.

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6.0 ATTACHMENTS. N/A

7.0 MATERIALS & EQUIPMENT7.1 Urinary catheter – According to size.7.2 Catheterization set.7.3 Urine and blood tubes for investigation.

8.0 REFERENCES8.1Ministry of Health, General Nursing Administration Functions and Duties Policies and Procedures for

Specialized Nursing: Emergency Care (SNR-ER-048).8.2 www.enotes.com/nursing-encyclopedia/acute-kidney-failure.

NAME DATE




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www.enotes.com/nursing-encyclopedia/acute-kidney-failure




HEMORRHAGETITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 To control bleeding.

1.2 To maintain an adequately circulating blood volume for tissue oxygenation.

1.3 To prevent shock.

2.0 DEFINITIONHemorrhage: It is a loss of more than 500ml. of blood, which maybe internal or external.


4.0 POLICY4.1 Nurse must provide direct general assessment to patient while arrived in ED٤٫٤ Provide ABC assessment and management needed٤٫٥ Check and monitored Vital signs,:

٤٫٦ Fluid administration is started immediately with a large gauge cannula ٤٫٧Maintain patientprivacy and safety measured٤٫٨ Maintain stander prosecutions if patient has open wound.٤٫٩ Complete patient record and document if ordered for any procedures or admission.٤ .١٠ Secure consent or family for blood transfusion4.11 Complete patient record and document if ordered for any procedures or admission .

4.4 The patient is maintained in a supine position and monitored closely until hemodynamiccirculatory parameters are stable.

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HEMORRHAGETITLE:



EMER

GEN

CY

NU

RSI

N

4.5 Oxygen is administered according to doctor's order.

4.6 Blood samples are collected for:4.6.1 CBC, blood chemistry, PT, PTT.4.6.2 Blood grouping, cross- matching.4.6.3 Blood gas determination.


5.1 Assess the patient for the following symptoms.Patients with hemorrhage are at risk for cardiac arrestcaused by hypovolemia with secondary anoxia.

5.1.1 Cool, moist skin (resulting from poorperipheral perfusion).5.1.2 Falling blood pressure.5.1.3 Increased heart rate.5.1.4 Delayed capillary refill.5.1.5 Decreasing urine volume.

5.2 Initiate fluid replacement as ordered

5.3 Obtain blood samples for analysis, bloodgrouping and cross-matching for blood replacement

5.4 Perform rapid assessment of hemorrhage:5.4.1 Cut patient's clothing and identify areaof hemorrhage.5.4.2 Apply direct, firm pressure over thebleeding area, elevate the injured part andimmobilize.

5.5 Administer immediate blood transfusion as

5.2 Because a loss of circulating bloodleads to a fluid volume deficit anddecreased cardiac output.

5.5 to replace blood loss as initial

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HEMORRHAGETITLE:



EMER

GEN

CY

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prescribed

5.6 Obtain blood gas determination

5.7 Place the patient in a supine position and monitorclosely

5.8 Administer oxygen as ordered.

5.9 Monitor vital signs frequently and record themand giving large quantity of I.V fluids rapidly, mayraise blood pressure.

5.10 Most bleeding can be stopped by applyingdirect pressure or a firm pressure dressing.

5.11 A tourniquet is applied as a last resort whenexternal hemorrhage cannot be controlled.


5.13 Expedite admission.

therapeutic measure.

5.6 to evaluate pulmonary function andtissue perfusion and to establish baselinehemodynamic parameters.5.7 to improved and evaluate circulation.

10 To provide clear report aboutprocedure steps for continuousnursing care

6.0 ATTACHMENTS7.1 Oxygen

7.2 Pressure dressing.


ER-153




HEMORRHAGETITLE:



EMER

GEN

CY

NU

RSI

N

7.4 Blood and / or blood products.

7.5 Intravenous fluids.

7.6 Blood containers for blood samples.

7.7 Medications are ordered.

7.8 Sphygmomanometer and stethoscope.

7.9 Tourniquet.

7.10 Large-bore intravenous cannula.

7.0 MATERIALS & EQUIPMENTN/A


NAME DATE


Reviewed By: Mrs. Ashwag Omar shaibah.-BSN- Head of nursing education KFH-J 2010


ER-154




DPP DIABETIC EMERGENCIESTITLE:



EMER

GEN

CY

NU

RSI

N

1.0 PURPOSE1.1 To restore normal cerebral function .

1.2 To prevent recurrence of hypoglycemic reaction.

1.3 To correct fluid and electrolyte imbalance.

1.4 To normalize insulin activity and blood glucose levels to reduce the development of vascularand neuropathic complications.

2.0 DEFINITION2.1 Diabetic emergencies are categorized as:

2.1.1 Hypoglycemia: It is low blood sugar (blood glucose) below 60mg /100 ml. Usually,resulting from imbalance in food intake or excessive exercise.

2.1.2 Hyperglycemia: It is an elevated blood sugar level over 120mg/100 ml. It occurs whenglucose cannot be transported to the cells because of lack of insulin.

2.1.3 Diabetic ketoacidosis (DKA): It is lack of insulin resulting in a derangement ofcarbohydrates, fat and protein metabolism with dehydration and electrolyte imbalance.

2.1.4 Hyperglycemic Hyperosmolar Nonketotic Coma (HHNK): It is an acute diabeticcomplication more variant than ketoacidosis. It is characterized by extreme hyperglycemia(800-2000mg/100ml.) mild or undetectable ketonuria and the absence of acidosis.


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4.2. The nurse must assess the singes and symptoms of hyperglycemia :

4.2.1 Mild hypoglycemia: cold, clammy skin (sweating), weakness, drowsiness or any

degree of change in level of consciousness, headache, hunger, palpitation, pallor,

nervousness, shakiness, trembling and blurred visio

4.2.2 Moderate hypoglycemia: vertigo or dizziness, slurred speech, unsteady gait, mood/

behavioral changes, inability to concentrate.

4.2.3 Severe hypoglycemia: convulsions, coma.


4.4 Provide ABC assessment and management needed

4.5 monitored and assessed Vital signs

4.6 Fluid administration is started immediately with a large gauge cannula according the doctor

order.

4.7 Immediate treatment must be initiated when hypoglycemia occurs orally or parentally.


4 .٩ Complete patient record and document if ordered for any procedures or admission.

4.10 Secure consent to protect patient from untoward procedures


5.6 Urine output is monitored to ensure adequate renal function.

5.7 ECG is obtained for dysrhythmias as orderd.

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5.8 Blood glucose and urine level is obtained and recorded.

5.9 ABG is taken to evaluate oxygenation.


5.1 Obtain a history of current problems, familyhistory, and general health history.

5.2 Perform a review of systems and physicalexamination

5.2.1 General: recent weight loss or gain,increased fatigue, tiredness, anxiety

5.2.2 Skin: skin lesions, infections,dehydration, evidence of poor woundhealing

5.2.3 Eyes: changes in vision”floaters, halos,blurred vision, dry or burning eyes,cataracts, glaucoma * 5.2.4Cardiovascular: orthostatic hypotension,cold extremities, weak pedal pulses, legclaudication

5.2.5 GI: diarrhea, constipation, early satiety,bloating, increased flatulence, hunger orthirst

5.2.6 Genitourinary (GU): increased urination,nocturia, impotence, vaginal discharge

5.2.7 Neurologic: numbness and tingling of theextremities, decreased pain and temperatureperception, changes in gait and balance

5.3 Closely monitor blood glucose levels

5.2 to assess for signs and symptoms ofdiabetes, general health of patient, andpresence of complications.

5.3 to detect hypoglycemia.

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5.4 Assess patient for the signs and symptoms ofhypoglycemia.

5.5 Assess and manage according to diagnosis toensure proper emergency management.

5.6 Hypoglycemia:5.6.1 If the patient is able to swallow, give 10-15

mg. of fast acting sugar, commerciallyprepared glucose tablets, orange fruit orregular soda, candies or honey. Repeat ifsymptoms persist more than 10-15minutes.

5.6.2 In severe hypoglycemia, unconscious orunable to swallow or refuse treatment,administer hypertonic dextrose solution I.Vas ordered or insulin subcutaneous.

5.7 DKA:5.7.1 Administer I.V fluids as ordered5.7.2 Monitor vital signs and report any

abnormalities.5.7.3 Measures intake and output. Obtain blood

glucose and urine level.5.7.4 Administer medication as ordered

potassium replacement.5.7.5 connect patient with cardiac monitor .

5.7 Prepare patient for admission


5.6.2 to stimulate the liver to releaseglucose

5.7 to correct fluid imbalance,dehydration and hypoglycemia.


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6.0 ATTACHMENTS

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7.0 MATERIALS & EQUIPMENT7. I.V fluids are medications as ordered.

7.2 Glucometer.

7.3 ECG monitor .7.4 Blood containers7.5 Medication as ordered


Specialized Nursing: Emergency Care 2007 (SNR-ER-051).8.2 http://www.lifenurses.com/nursing-care-plans-for-diabetes-mellitu

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http://www.lifenurses.com/nursing-care-plans-for-diabetes-mellitu



DPP NURSING EMERGENCY MANAGEMENT OF FRACTURESTITLE:



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1.0 PURPOSE1..1 To maintain proper alignment and immobilization.

1.2 To relieve pain.

1.3 To prevent patient from further injury.

2.0 DEFINITION2.1 A fracture: It is a break in the continuity of bone. A fracture occurs when the stress placed ona bone is greater than the bone can absorb. Muscles, blood vessels, nerves, tendons, joints, andother organs may be injured when fracture occurs.

2.2 Types of Fractures:2.2.1 Complete Fracture: Involves the entire cross section of the bone, usually displaced (not

normal position).2.2.2 Incomplete Fracture: Involves a portion of the cross section of the bone or may be

longitudinal.2.2.3 Closed (Simple) Fracture: Skin (mucous membranes) not broken.2.2.4 Open (Compound) Fracture: Skin broken, leading directly to fracture.

2.2.4.1 Grade (1) minimal soft tissue injury.2.2.4.2 Grade (2) laseration greater than 1 cm without extensive soft tissue flaps.2.2.4.3 Grade (3) extensive soft tissue injury, including skin, muscle, neurovascular

structure, with crushing.

3.0 RESPONSIBILITIES

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٤٫٢The nurse must assess the singes and symptoms of internal and external bleeding

٤٫٣Collect data about the causes and patient history

٤٫٤Provide ABC assessment and management needed; airway, breathing and circulation is

conduct.

4.5 check Vital signs, monitored and assessed

When examining the patient with fracture, the body part is handled gently and as little aspossible. Clothing is cut off to visualize the body.

4.2 Assessment is conducted for pain over or near a bone, swelling (from blood, lymph, andexudates infiltrating the tissue) and circulatory disturbance.

4.3 A splint must be applied before moving the patient.


5.1 Assess the patient’s airway, breathing andcirculation to determine and give prompt emergencymeasures.

5.2 Position the patient to proper alignment toprovide comfort and relieve pain.

5.3 Perform a head to toe assessment and inspect thefracture body part for:

5.3.1 Laceration.5.3.2 Swelling.5.3.3 Deformities including angulations,

shortening, rotation or asymmetry.

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5.4 Apply splint before moving the patient Splintingimmobilize the joint above and below the fracture,relieve pain, restores or improved circulation,prevents further tissue injury and prevents a closedfracture from becoming open.

5.5 Evaluate for other injuries re-assess head andneck, chest, assess abdomen, back and extremities.

5.6 Obtain vital signs and monitor frequently, mayblood pressure increases in response to pain.

5.7 Collect blood samples and take series of x-rays.

5.8 Evaluate affected .

5.9 Administer oxygen as ordered to provideventilation.

5.10 Assess type and location of pain and administeranalgesics as ordered to reduce pain.

5.11 Document the procedure and expediteadmission.

5.5 To determine the extent of injury tobe able to administer treatment.

5.8 To minimize dependent edema.


6.0 ATTACHMENTS

N/A

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7.0 MATERIALS & EQUIPMENT7. 1 Traction.

6.2 Splints.

7.3 Sterile gauze.

7.4 Bandages.

7.5 Resuscitative equipment, if needed.7.6 Endotracheal tube.


Specialized Nursing: Emergency Care 2007(SNR-ER-013)8.2 Medical Surgical Nursing, Brunner & Siddhartha’s, 10th edition, Lippincott Williams

&Wilkins

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Reviewed By: Mrs Ashwag Omar shabah.- BSN-Head of nursing education KFH-J 2010


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ministry of health, general directorate of · pdf file · 2012-11-19ministry of...

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