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Menard - 08 Emergency Nursing
Menard - 08 Emergency Nursing
EMERGENCY NURSING
• It is the nursing care given to patients with urgent and critical
needs
EMERGENCY NURSE
• has a specialized education, training, and experience to gain
expertise in assessing and identifying patients’ health care problems in crisis
situations
• establishes priorities, monitors and continuously assesses acutely ill
and injured patients, supports and attends to families, supervises allied health
personnel, and teaches patients and families within a time-limited, high-
pressured care environment
DISASTER NURSING
• a branch of emergency nursing, it refers to nursing care given to
patients who are victims of disasters, whether it is manmade or natural
phenomena.
INCIDENT COMMANDER
• The head of the incident command system
• He must be continuously informed of all the activities and
informed about any deviation from the established plan
EMERGENCY OPERATIONS PLAN (EOP)
-It is done by a planning committee, composed of local/national administrators,
safety officer, ED manager, evaluating the community to anticipate the type of
disaster that might occur.
COMPONENTS of EOP
Activation Response
Internal/External Communication Plans
Plan for coordinated patient care
Security Plans
Identification of external resources
A plan for people management and traffic flow
Data Management Strategy
Anticipated Resources
Deactivation Response
Mass Casualty Incident Planning
Post- Incident Response
Educational Plan
Plan for Practice Drills
• from French word meaning “to sort”
• it is used to sort patients into groups based on the
severity of their health problems and the immediacy with which
these problems must be treated
EXAMPLES:
• AIRWAY COMPROMISE
• CARDIAC ARREST
• SEVERE SHOCK
• CERVICAL SPINE INJURY
• MULTISYSTEM TRAUMA
EXAMPLES:
• FEVER
• MINOR BURNS
• MINOR MUSCULOSKELETAL INJURIES
• LACERATIONS
PATIENTS WHO PRESENT WITH CHRONIC OR MINOR
INJURIES
NO DANGER TO LIFE OR LIMB
PATIENTS ARE IN NO OBVIOUS DISTRESS
EXAMPLES:
• CHRONIC LOW BACK PAIN
• DENTAL PROBLEMS
• MISSED MENSES
PRINCIPLE OF TRIAGE IN A DISASTER:
• DO THE GREATEST GOOD FOR THE GREATEST NUMBER
• Decisions are based on the likelihood of survival and
consumption of available resources.
DELAYED 2 YELLOW
MINIMAL 3 GREEN
EXPECTANT 4 BLACK
TYPICAL CONDITIONS:
IRWAY
REATHING
IRCULATION
ISABILITY
XPOSE
SECONDARY ASSESSMENT: Systematic, brief (2-3 mins) examination from head to
toe; Purpose is to detect and prioritize additional injuries and detect signs of underlying
medical conditions
3. PROLONGEDLIFE SUPPORT
- for post resuscitative and long term resuscitation.
1.The FIRST LINK: EARLY ACCESS
It is the event initiated after the patient’s collapse until the arrival of
Emergency Medical Services personnel prepared to provide care.
2.The SECOND LINK: EARLY CPR
If started immediately after the victim’s collapse, the probability of survival
approximately doubles when it is initiated before the arrival of EMS.
3.The THIRD LINK: EARLY DEFIBRILLATION
It is most likely to improve survival. It is the key intervention to increase the
chances of survival of patients with out-of-hospital cardiac arrest.
4.The FOURTH LINK: EARLY ACLS
If provided by highly trained personnel like paramedics, provision of advanced
care outside the hospital would be possible.
1.What to DO:
•Do obtain consent when possible.
•Do think the worst. It’s best to administer first aid for the gravest possibility.
•Do provide comfort and emotional support.
•Do respect the victim’s modesty and physical privacy.
•Do be as calm and as direct as possible.
•Do care for the most serious injuries first.
•Do assist the victim with his/her prescription medication.
•Do handle the victim to a minimum.
•Do loosen tight clothing.
2.What Not to DO:
•Do not let the victim see his/her own injury.
•Do not leave the victim alone except to get help.
•Do not assume that the victim’s obvious injuries are the only ones.
•Do not make any unrealistic promises.
•Do not trust the judgment of a confused victim and require them to make decision.
-is a rapid movement of patient from unsafe place to a place of safety.
Indications for emergency Rescue:
1. Danger of fire or explosion.
2. Danger of toxic gases or asphyxia due to lack of oxygen.
3. Natural Disasters
4. Risk of drowning.
5. Danger of electrocution.
6. Danger of collapsing walls.
Methods of Rescue:
1. For immediate rescue without any assistance, drag or pull the victim.
2. Most of the one-man drags/carries and other transfer methods can be used as
methods of rescue.
-is moving a patient from one place to another after giving first aid.
INDICATIONS:
1. Cardiac Arrest
c. Foreign-body obstruction
a. Ventricular Fibrillation
d. Smoke inhalation
b. Ventricular Tachycardia
e. Electrocution
c. Asystole
f. Suffocation
d. Pulseless electrical
activity g. Drug Overdose
a. Drowning j. Coma
b. Stroke h. Epiglottitis
ASSESSMENT:
• Immediate loss of consciousness
• Absence of breath sounds or air movement
• Absence of palpable carotid or femoral pulse; pulselessness in large
arteries
COMPLICATIONS:
• Rib Fracture (most common)
• Postresuscitation Distress Syndrome
• Neurologic Impairment; Brain Damage
I. RESPONSIVENESS/AIRWAY
• Determine unresponsiveness; “ARE YOU OKAY?”
• Activate Emergency Medical Assistance
• Place patient supine on a firm, flat surface. Kneel at the level of the
patient’s shoulders
• Open the airway: HEADTILT/CHIN LIFT MANEUVER, JAW THRUST
MANEUVER
2. BREATHING
• Look, Listen and Feel
• Rescue breathing: 2 full breaths
3. CIRCULATION
• Check carotid pulse
WAYS TO VENTILATE THE LUNGS
1. MOUTH-TO-MOUTH = a quick, effective way to provide O2 and ventilation
to the victim.
2. MOUTH-TO-NOSE = recommended when it is impossible to ventilate through
the victim’s mouth. (Trismus, mouth injury)
3. MOUTH-TO-NOSE and MOUTH = if the pt. is an infant
4. MOUTH-TO-STOMA = used if the pt. has a stoma; a permanent opening that
connects the trachea directly to the front of the neck.
Nursing Actions:
• Extend the neck. Place towel roll beneath the shoulders
• Insert the needle at a 10 to 30 degree caudal direction in the midline jest
above the upper part of the cricoid cartilage
• Listen for air passing back and forth
• Direct the needle downward and posteriorly, and tape it.
1. OPEN HEAD INJURY – skull is fractured
2. CLOSED HEAD INJURY – skull is intact
3. CONCUSSION – temporary loss of consciousness that results in transient
interruption if the brain’s normal functioning
4. CONTUSSSION – bruising of the brain tissue
5. INTRACRANIAL HEMORRHAGE – significant bleeding into a space or
potential space between the skull and the brain
a. Epidural hematoma
b. Subdural hematoma
c. Subarachnoid hemorrhages
ALERT: Assume cervical spine fracture for any patient with a significant head
injury, until proven otherwise.
PRIMARY ASSESSMENT: Assess for ABC
SECONDARY ASSESSMENT:
Change in LOC – most sensitive indicator in the pt’s condition
CUSHING’S TRIAD ( bradypnea, bradycardia, widened pulse pressure) –
indicating increased intracranial pressure
unequal or unresponsive pupils; impaired vision
Battle’s sign – bluish discoloration of the mastoid, indicating a possible BASAL
SKULL FRACTURE
Rhinorrhea or otorrhea – indicative of CSF leak
Periorbital Ecchymosis – indicates anterior basilar fracture
ALERT:
• Damage to the brain is the first concern, it is considered a neurosurgical
condition
• In children, skull’s thinness and elasticity allows a depression w/o a break in the
bone
CAUSES: Traumatic blows to the head, VA, severe beatings
S/Sx: scalp wounds, agitation and irritability, loss of consciousness, labored
breathing, abnormal deep tendon reflexes, altered pupillary and moor response
IF CONSCIOUS: complains of persistent localized headache
IF JAGGED BONE FRAGMENTS: may cause cerebral bleeding
HALO SIGN – blood-tinged spot surrounded by lighter ring
IF SPHENOIDAL Fx: damages the optic nerve and may cause BLINDNESS
IF TEMPORAL Fx: may cause unilateral deafness or facial paralysis
- IRECT PRESSURE
- LEVATION
- RESSURE POINTS
- NTI-TETANUS, ANTIBIOTICS
- RRIGATE
- RESS
1. FRACTURE – a break in he continuity of the bone; occurs when stress is placed
on a bone is greater than the bone can absorb
ALERT: fractured cervical spine, pelvis and femur may produce life threatening
injuries; posterior dislocations of the hip are life- and limb-threatening
emergencies due to potential blood loss.
Clinical Manifestations:
• Pain and tenderness over fracture site
• Crepitus or grating over fracture site
• swelling and edema
• Deformity, shortening of an extremity or rotation of extremity
-EDUCTION
-setting the bone; refers to the restoration of the fracture fragments
into anatomic position and alignment
-MMOBILIZATION
- maintains reduction until bone healing occurs
- EHABILITATION
- Regaining normal function of the affected part
NURSING CONSIDERATIONS:
Apply ice compress for the first 24 hrs to produce vasoconstriction, decrease
edema, and reduce discomfort
Apply warm compress after 24 hrs to promote circulation and absorption (20
to 30 minutes at a time)
Educate to rest injured part for a month to allow healing
Educate to resume activities gradually and to warm up
- Inadequate tissue perfusion, resulting in failure of one or more of the ff:
a. pump failure of the heart c. arterial resistance levels
b. Blood volume d. capacity of venous beds
- Can be classified as:
A. HYPOVOLEMIC - occurs when significant amount of fluid is lost in the
intravascular space (Ex. Hemorrhage, burns, fluid shifts)
B. CARDIOGENIC – occurs when the heart fails as a pump. Primary causes
includes MI, dysrhythmias; Secondary causes includes mechanical restriction
of cardiac function or venous obstruction like in Cardiac Tamponade, tension
pneumothrorax, VCO
C. SEPTIC SHOCK – from bacteria and their products circulating in the blood
PRIMARY INTERVENTIONS:
Assess for ABC
Resuscitate as necessary
Administer O2 to augment O2-carrying capacity of arterial blood
Start cardiac monitoring
Control hemorrhage
SUBSEQUENT ASSESSMENT:
o Assess LOC, decreasing LOC indicates progression of shock
o Monitor arterial blood pressure (narrowing pulse pressure, fall in systolic
pressure)
o Assess pulse quality and rate change (tachycardia, weak and thready)
o Assess urinary output (25ml/hr may indicate shock)
o Assess capillary perfusion
o Assess for metabolic acidosis due to anaerobic metabolism of cells
o Assess for excessive thirst, hyperthermia on septic shock
MANAGEMENT:
Administer O2 via ET or nonrebreather face mask (if intubated, may be
hyperventilated to control acidosis)
Fluid resuscitation (2 large-bore IV lines, Ringer’s Lactate, BT)
Insertion of an indwelling catheter
Maintain patient in a supine position with legs elevated
Continue to monitor VS, ECG, CVP, ABG, UO, HCT, Hgb,and electrolytes;
refer changes on the following
Maintain normothermia (high fever will increase the cellular metabolism
effects of shock
Medications: Inotropics, Vasopressor, and Anti-biotics
-It is a useful tool in the diagnosis of those conditions that may cause
abberations in the electrical activity
WAVE INTERPRETATIONS:
P WAVE : Atrial Depolarization; first positive deflection
Q WAVE: first negative deflection
R WAVE: first positive deflection
S WAVE: negative deflection, after R wave
QRS COMPLEX: Ventricular Depolarization
T WAVE: Ventricular Repolarization
Check order for ECG, in cases of arrest, prepare the machine at the bedside at ER
Provide Privacy
Instruct patient to lie still and avoid movement
Remove metal objects on the patients (jewelries)
Place Chest leads as labeled:
Lead 1: Red, Right Arm
Lead 2: Yellow, Left Arm
Lead 3: Green, Left Foot
Neutralizer: Black, Right foot
V1: Red, 4th ICS, Right Sternal Border
V2: Yellow, 4th ICS, Left sternal border
V3: Green, midway between V2 and V4
V4: Brown, 5th ICS, Left MCL
V5: Black, 5th ICS, LAAL
V6: Violet, 5th ICS, LMAL
- It is a trauma in the chest without an open wound
- usually cause by VA, blast injuries
SIGNS/SYMPTOMS:
RIB FRACTURES: tenderness, slight edema, pain that worsens with deep
breathing and movement, shallow and splinted respirations
STERNAL FRACTURES: persistent chest pain
MULTIPLE RIB FRACTURES:
-FLAIL CHEST (loss of chest wall integrity)
- decreased lung inflation, paradoxical chest movements
- extreme pain
- rapid and shallow respirations
- hypotension, cyanosis
- respiratory acidosis
COMPLICATIONS:
1. TENSION PNEUMOTHORAX - a condition in which air enters the chest
but can’t be ejected during exhalation
-There is lung collapse and mediastinal shift
S/Sx: tracheal deviation, cyanosis and severe dyspnea, absent breath
sound on the affected side, agitation, JVD
2. HEMOTHORAX – collection of blood in the pleural cavity, usually results
from ribs, lacerating lung tisssue or an intercoastal artery
-It is the most common cause of shock following chest trauma
3. LACERATION or RUPTURE of AORTA – immediately fatal
4. DIAPHRAGMATIC RUPTURE – causes severe respi. Distress; if untreated
abdominal viscera may herniate, compromising both circulation and vital
capacity of lungs
5. CARDIAC TAMPONADE – rapid unchecked rise in intrapericardia
pressure that impairs diastolic filling of the heart
- results from blood or fluid accumulation in the pericardial sac
ASSESSMENT AND DIAGNOSIS:
• Percussion:
- Hemothorax: Dullness
- Tension Pnuemothorax: tymphany
• Auscultation:
- Tension Pnemothorax: PMI is deviated
- Cardiac tamponade: muffled heart tones
• X-ray
• Thoracentesis – yeilds blood and serosanguinous fluid
• ECG
• Retrograde aortography – reveals aortic laceration
• Echocardiography
• Computed Tomography
TREATMENT:
Simple Rib Fractures
mild analgesics, bed rest, apply heat
incentive spirometry
deep breathing, coughing and splinting
Severe Rib Fractures
intercoastal nerve blocks
position for semi-fowlers, administer O2
Hemothorax
Chest tube insertion at 5th-6th ICS anterior to MAL
administer IV fuids, O2, Blood Transfusion
Thoracotomy
Thoracentesis
TREATMENT:
Tension Pneumothorax
insertion of spinal, 14G or 16G needle into the 2nd ICS at MCL to release
pressure
Chest Tubes
Surgical Repair
Aortic Rupture/Laceration
immediate surgery
- synthetic grafts
- aortic anastomosis
O2, BT, IV
NURSING CONSIDEARTIONS:
monitor VS, (q 15, first hour post thoracentesis and post CTT)
After CTT insertion, encourage cough and breathing exersises
Chest tubes should have continuous FLUCTUATIONS
if BUBBLING, air leak is suspected
if FLUCTUATION STOPS, mechanical blockage or lung has already
expanded
have an extra bottle with PNSS, clamps and sterile gauze at bedside
in case of dislodgment, cover the opening with sterile/petroleum gauze to
prevent rapid lung collapse
Assist with proper positioning
Bed Rest
1. PENETRATING ABDOMINAL INJURY – usually the result of gunshot
wound or stab wounds; may cross the diaphragm and enters the chest
2. BLUNT ABDOMINAL INJURY – caused by vehicular accidents or falls
PRIMARY ASSESSMENT AND INTERVENTIONS:
• ASSESS ABC
• INITITATE RESUSCITATION AS NEEDED
• CONTROL BLEEDING AND PREPARE TO TREAT SHOCK
• IF THERE IS AN IMPALED OBJECT IN THE ABDOMEN, LEAVE
IT THERE AND STABILIZE THE OBJECT WITH BULKY
DRESSINGS
SUBSEQUENT ASSESSMENT:
• Obtain hx of the mechanism of the injury
• Evaluate signs and symptoms of hemorrhage
• Note tenderness, rebound tenderness, guarding, rigidity and spasm
• KEHR’S SIGN – pain radiating to the left shoulder; a sign of blood beneath
the diaphragm. Pain in right shoulder can result from liver laceration
• CULLEN’S SIGN – slight bluish discoloration around the navel; a sign of
hemoperitonium
• Rebound tenderness and boardlike rigidity are indicative of a significant
intra-abdominal injury
• Loss of dullness over solid organs; Dullness over regions containing gas may
indicate presence of blood
• Look for increasing abdominal distention, measure abdominal girth the
umbilical level
• Rectal and pelvic examination
GENERAL INTERVENTIONS:
Keep pt. quiet in the stretcher, any movement may dislodge a clot
Cut the clothing, count the number of wounds, look for entrance and exit wounds
Apply compression to external bleeding wounds
double IV line and infuse Ringer’s Lactate
Insert NGT to decompress the abdomen
Cover protruding abdominal viscera w/ sterile saline dressings; don’t attempt to
place back the protruding organs
Cover open wounds with dry dressings
Insert indwelling catheter; if pelvic fracture is suspected, catheter should not be
placed until integrity of urethra is ensured.
Meds: Tetanus Prophylaxis, Antibiotics
Assist in peritoneal lavage
Prepare pt. for surgery if the condition persists. (Exploratory Laparotomy)
It is the inadequacy or the collapse of peripheral circulation due to volume and
electrolyte depletion
ASSESSMENT: temperature may be normal or slightly elevated, hypotension,
tachycardia, tachypnea, pale and moist skin, fatigue, headache, dizziness,
syncope
DIAGNOSTICS: hemoconcentration, hyponatremia or hypernatremia, ECG
may show dysrhythmias
MANAGEMENT:
Move patient to a cool environment, remove all clothing
Position the patient supine with the feet slightly elevated
Monitor VS every 15 mins and cardiac rhythm
Educate to avoid immediate reexposure to high temperatures
- It is a combination of hyperpyrexia and neurologic symptoms. It caused by a
shutdown or failure of the heat-regulating mechanisms of the body
CLINICAL MANIFESTATIONS:
• bizarre behavior or irritability, progressing to confusion, delirium and
coma
• 40.6 degrees Celcius, hypotension, tachycardia, tachypnea
• skin may appear flushed and hot; at start it maybe moist progressing to
dryness (Anhidrosis)
NURSING ALERT:
• Elderly clients are high-risk to develop heat-stroke
• Once diagnosis is confirmed, it is imperative to reduce patient’s
temperature
MANAGEMENT:
EVAPORATIVE COOLING, most effective, by spraying tepid water on skin
while fans are used to blow
Apply ice packs to necks, groin, axillae, and scalp
Soak sheets/towels in ice water and place on patient
If temp. fails to decrease, initiate core cooling: iced saline lavage, cool fluid
peritoneal dialysis, cool fluid bladder irrigation
Discontinue active cooling when the temp. reaches 39 degrees Celcius
Oxygenate the pt. via ET or nonrebreather mask
Monitor VS, ECG, and neurologic status
Start IV infusion using Ringer’s Lactate
Anti-pyretics are not useful
Indwelling catheterization
WOF hypokalemia, metabolic acidosis, seizures
-It is a condition where the core temp. is less than 35 degrees Celcius as a result in
the exposure to cold.
- 3 compensatory mechanisms:
a. shivering – produces heat thru muscular activity
b. peripheral vasoconstriction – to decrease heat loss
c. raising basal metabolic rate
NURSING ALERT:
• Elderly are greater risk for hypothermia due to altered compensatory
mechanisms
• Extreme caution should be used in moving or transporting hypothermic
pts., because the heart is near fibrillation threshold
CLINICAL MANIFESTIONS:
• slow, spontaneous respirations
• heart sounds may not be audible even if its beating
• BP is extremely difficult to hear
• fixed dilated pupils, no pulse, no BP; initiate CPR
• drowsiness progressing to coma
• shivering is suppressed on temp. below 32.3 degrees
• ataxia
• cold diuresis
• fruity or acetone odor of breath
PURPOSES:
1. To remove unabsorbed poison after ingestion.
2. To diagnose and treat gastric hemorrhage and for the arrest of
hemorrhage.
3. To cleanse stomach before endoscopic procedures.
4. To remove liquid or small particles of material from the stomach.
NURSING CONSIDERATIONS
Insertion of NGT or OGT.
Place patient on left lateral position with head lower 15 degrees
downward.
Elevate funnel and pour approx. 150 – 200 ml.
Lavage fluid is left in place for about one minute before allowed to
drain
Save samples of first two washings.
Repeat lavage procedure until the returns are relatively clear and no
particular matter is seen.
At the completion of the lavage:
1. Stomach may be left empty.
2. An Adsorbent may be instilled in the tube and allowed to remain in the
stomach.
3. A saline cathartic may be instilled in the tube.
Pinch off the tube during removal or maintain suction while tubing is being
withdrawn.
Give the patient a cathartic if prescribed.
Warn patient that stool will turn black from the charcoal.
-It is an example of inhaled poison and results in the incomplete hydrocarbon
combustion
- Carbon monoxide exerts its toxic effects by binding to circulating hemoglobin to
reduce the oxygen carrying capacity of the blood.
- Carbon monoxide and hemoglobin is 200 – 300 times affinity compared to
oxygen and hemoglobin.
- Creation of carboxyhemoglobin resulting to tissue anoxia.
CLINICAL MANIFESTATIONS
- Respiratory depression, stridor.
- Confusion progressing to coma.
- Headache, muscular weakness, palpitation, and dizziness.
- Skin is pink in color, cherry red, or cyanotic.
- ABG: carboxyhemoglobin level is 12% (Normal), 30 – 40% severe carbon
monoxide poisoning.
MANAGEMENT:
Provide 100% oxygen by tight-fitting mask (the elimination half life of
carboxyhemoglobin, in serum, for a person breathing room air is 5 hours and 20
minutes. If patient breaths 100% oxygen the half life is reduced to 80 minutes
100% oxygen in hyperbaric chamber reduces halflife to 20 minutes.
Intubate if necessary to protect airway.
Continuous ECG monitoring, treat dysrhythmias.
Correct acid-base and electrolyte imbalances.
Continuous observation of psychoses, spastic paralysis, visual disturbances, and
deterioration of personality may persist after resuscitation and may be symptoms
of permanent CNS damage.
-These are injected poisons that can produce either local or systemic reactions.
- Local reactions are characterized by pain, erythema and edema at the site of
injury.
- Systemic reactions usually begin within minutes. (Unconsciousness, laryngeal
edema, bronchospasm, and cardiovascular collapse.
MANAGEMENT:
ABC
Epinephrine is the drug of choice give SQ.
Administer bronchodilator.
Initiate IV with Ringers Lactate.
Prepare for CPR.
NURSING CONSIDERATIONS:
Apply ice packs to site to relieve pain.
Elevate extremities with large edematous local reaction.
Administer anti histamine for local reaction.
Clean wounds thoroughly with soap and water or antiseptic solution.
Educate patient.
- Have epinephrine on hand
- Wear emergency medical bracelet indicating hypersensitivity.
- If sting occurs, remove stinger with one quick scrape of fingernail.
- Do not squeeze venom sack, because this may cause additional venom to
be injected.
- Avoid insect feeding areas.
CLINICAL MANIFESTATIONS:
-Burning pain, swelling, and numbness of the site.
- Hemorrhagic blisters may occur after few hours of bite and entire extremity may
become edematous.
- WOF signs of systemic reactions (nausea, sweating, weakness, lightheadedness,
initial euphoria followed by drowsiness, dysphagia, paralysis of various muscle
groups, shock, seizures, and coma).
MANAGEMENT:
Wash the site of bite, keep the patient calm and immobilize extremity.
Administer O2 and start IV line.
Administer anti-venin and be alert to allergic reaction.
Administer vasopressors in the treatment of shock.
- a.k.a Delirium Tremens or Alcoholic Hallucinosis
-An acute toxic state that follows a prolonged bout of steady drinking or sudden
withdrawal from prolonged intake of alcohol.
- Symptoms begins as early as 4 hours after reduction of alcohol intake and peaks at
24 - 48 hours but may last up to 2 weeks.
CLINICAL MANIFESTATIONS:
Shakes, seizures, and hallucinations.
History of drinking episodes.
N/V, malaise, weakness, anxiety.
Autonomic hyperreactivity (tachycardia, diaphoresis, increase temperature, dilated
but reactive pupils).
ALCOHOLISM – a chronic disease or disorder characterized by excessive
alcohol intake and interference in the individuals health, interpersonal
realtionship and economic functioning
-Considered to be present when there is .1% or 10 ml for every 1000 ml of
blood
- At .1 - .2%, there is low coordination
- At .2 - .3%, there is ataxia, tremors, irritability, and stupor
- At .3 and above, there is unconsciousness
COMMON BEHAVIORAL PROBLEMS: 5 D’s
D-enial
D-ependency
D-emanding
D-estructive
D-omineering
COMMON WITHDRAWAL SIGNS AND SYMPTOMS:
-ENIAL
-ATIONALIZATION
-SOLATION
-ROJECTION
PRIORITY NURSING DIAGNOSIS:
- INEFFECTIVE INDIVIDUAL COPING
-OUTH WASH
-VER THE COUNTER COLD REMIDIES
-OOD SAUCES MADE UP OF WINE
-RUIT FLAVORED EXTRACTS
-FTERSHAVE LOTIONS
-INEGAR
-KIN PRODUCTS
MANAGEMENT:
Protect patient from injury, diazepam or phenytoin for seizure control as
prescribed.
Monitor VS every 30 minutes.
Use a non-alcohol skin preparation, draw blood for measurement of ethanol
concentration, toxicologic screen for other drug abuse.
Maintain electrolyte balance and hydration.
Observe for hypoglycemia.
Administer thiamine followed by parenteral dextrose if liver glycogen is depleted.
Give orange juice, gatorade, or other carbohydrates to stabilize blood sugar.
Place patient in a private room with close observation.
-It is an urgent, serious disturbances of behavior, affect, or thought that makes
the patient unable to cope with his life situation and interpersonal relationship
-Is usually episodic and is a means of expressing feelings of anger, fear and
hopelessness about a situation.
- Manage through:
a. Establish control, keeping the door open, and be in clear veiw of staff
b. Ask if he has a weapon, avoid touching an agitated pt.
c. Adopt a calm, nonconfrontational approach
d. Provide emotional support; CRISIS INTERVENTION
-Ultimate form of self-destruction; “cry for help”
-Major Interventions: PREVENTION and LISTEN
- RISK FACTORS
NURSING INTERVENTIONS:
Provide one-on-one monitoring
Have frequent unscheduled rounds
Avoid use of metals and glass utensils
Remove shampoos, perfumes, medicines at the bedside
Monitor for signs of impending suicide (giving away of valued possession)
• According to RA 8353, RAPE refers to the insertion of penis into the
mouth, vagina, anus of a victim
• Insertion of any object into the mouth or anus
• It is generally considered as an act of hostility, anger, or violence
ELEMENTS OF RAPE:
• Use of threat/force
• lack of consent of the victim
• Actual penetration of the penis into the vagina
Different Kinds of Rape:
• POWER – done to prove one’s masculinity
• ANGER – done as a means of retaliation
• SADISTIC – done to express erotic feelings
RAPE TRAUMA SYNDROME
- It refers to a group of signs and symptoms experienced by a victim in
reaction to rape
- 4 Phases
1. ACUTE PHASE – characterized by shock, numbness and disbelief
2. DENIAL – characterized by victim’s refusal to talk about the event
3. HEIGHTENED ANXIETY – characterized by fear, tension, and nightmares
4. REORGANIZATION – victim’s life normalizes