ADMISSION PROCEDURE IN THE EMERGENCY - Evidence of pain, restlessness

ROOM - Emotional status including

attitudes/moods
Objectives: - General physical development
At the end of the lecture, the students will be able to: - Mental state
1. Understand the process of Admission procedure - Nutritional state
in an emergency room set up and be able to 6. Assist in the performance of procedures of the
apply it in an actual set up doctor and other health allies or even actual
2. Enumerate the list of things needed during the performance of different nursing procedures (to
admission of the patient care include the medications)
3. Review on pertinent physical assessment and 7. Assist in transporting client to room of choice
history taking techniques needed 8. Properly endorse patient to NOD of the specific
4. Review on different procedures during ER ward where the client is assigned (bring the
admission logbook)
5. Endorsed patient according to ER protocol What to endorse?
❖ Room and bed number
1. Place/Transfer the patient in stretcher or ❖ Patient name
wheelchair ❖ Age
- The moment the patient came in to ER, ❖ Chief complaint
you have to ask them what are their ❖ Attending physician
concerns why their in the ER ❖ Diet
- Assist them to be transferred in the ❖ TPR
stretchers in the ER ❖ Intervention and management
- Commonly, the patient arrived either in a ❖ Diagnostic done in ER
wheelchair or ambulatory (ga lakaw) or in ❖ IVF
the stretcher-- transfer the pt to our own 9. Return back to ER and perform after care
hospital bed; if bed/s are unavailable, pt 10. Be ready to receive patient again for admission
may transfer in the waiting area or in a
wheelchair BLS (BASIC LIFE SUPPORT)
Ways to transfer the patient:
❖ Carrying the patient Objectives:
❖ Lift sheet/sled ● Describe the importance of high quality CPR and
❖ Log rolling- common its impact on survival
❖ Sliding technique or slide board transfer ● Perform high quality CPR for an adult
❖ Pivot technique- help the patient to stand ● Describe the importance of early use of an
up and put them in the wheelchair automated external defibrillation (AED)
2. Record pertinent data of the patient ● Demonstrate the appropriate use of an AED
Record the following: ● Provide effective ventilations by using varrier
a. Name/age device
b. Chief complaint- important to ask the
patient about this for us to know where Why is this important?
we will transfer the patient ● Ischemic heart disease is the leading cause of
c. Admission/check-up- for admission, to death in the world
ensure that we will secure a room for ● 209,000 in hospital cardiac arrest
them, also check the ER if there are any ● Most victim die without immediate and
available rooms for them; for check up- if appropriate intervention
the patient is not necessary in immediate Basic Life Support- BLS is the foundation for saving
attention, refer them to OPD for check up lives after cardiac arrest
only Main components of CPR:
d. Name of physician - Chest compression
House case- patients who does not have - Airway
any attending physician, the hospital can - Breathing
assign a physician who is on duty SYSTEMATIC APPROACH
Private case- patient who have or knows 3 components:
the physician they want to be under their - BLS assessment
care - Primary assessment
e. Vital signs- one full minute of pulse rate, - Secondary assessment
RR, BP, and temperature How to get the initial impression of the patient:
f. Weight- if needed, if not, ayaw ipush si
patient na mutindog kung dili jud kaya
3. Assist the patient in a lying position on bed and
make them comfortable. Offer a blanket and
raise the side rails.
4. Change patient street clothes into gown (provide
privacy)- not necessary all patients to change, if
the patient is for OPD, they are not required to
change BLS ASSESSMENT
5. Perform your assessment (general survey) and ● Check responsiveness
history taking (PQRST/AMPLE) - By tapping and shouting “hey hey are
A. General Survey you okay?” “hey hey are you alright?”
- Age, race, sex - If the victim is not responsive, shout for
- Apparent state of health, in acute nearby help
distress ● Activate ERS and obtain AED
- Chronically ill (kindly include - If there is more than one rescuer, have
gadgets attached) the second person to activate emergency
- Body position, stature, gait response and get the AED/Defibrillation
- Clothes, hygiene, grooming
 - Or call your local emergency number
from your phone, mobilize the code team
or notify advanced life support
● Check breathing and pulse
- Check for carotid pulse. This pulse check
should not take more than 5-10 seconds.
If no pulse is not palpable, begin CPR
- If the victim is not breathing, monitor the
victim until additional help arrives
- If the victim is not breathing or is only
gasping, this is not considered normal
breathing and is a sign or cardiac arrest
- To perform pulse check in an adult,
palpate a carotid pulse. Begin with high
chest quality CPR.
- Locating the carotid pulse: Locate the
trachea (on the side closest to you, using
2 or 3 fingers). Slide these 2 or 3 fingers
into the groove between the trachea and
the muscle at the side of the neck, where
you can feel the carotid pulse.
● Chest Compression Technique
The foundation of CPR is chest compressions.
Position yourself at the victim’s side.
1. Make sure the victim is lying faceup on a firm,
flat surface. If the victim is lying face down,
carefully roll him faceup. If you suspect the
victim has a head or neck injury, try to keep the
head, neck, and torso in a line when rolling the
victim to a faceup position.
2. Position your hands and body to perform chest
compression
- Put the heel of one hand in the center of the
victim’s chest. On the lower half of the
breastbone (sternum)
- Put the heel of your other hand on top of the first
hand.
- Straighten your arms and position your
shoulders directly over the hands.
3. Give chest compressions at a rate of 100 to
120/min
4. Press down at least 5 cm with each compression
(this requires hard work). For each compression,
make sure you push straight down on the
victim’s breastbone.
5. At the end of each compression, make sure you
allow the chest to recoil completely
6. Minimize interruptions of chest compressions
ALTERNATE TECHNIQUE FOR CHEST
COMPRESSIONS
- If you have difficulty pushing deeply during
compressions, put one hand on the breastbone
to push on the chest. Grasp the wrist of that
hand with your other hand to support the first
hand as it pushes the chest. This technique may
be helpful for rescuers with joint conditions, such
as arthritis.
ADULT BREATHS: OPENING THE AIRWAY
For breaths to be effective, the victim’s airway must be
open. Two methods for opening the airway are:
● head tilt-chin lift
● Jaw thrust
1. If a head or neck injury is suspected, use the
jaw-thrust maneuver to reduce neck and spine
movement. Switch to a head-tilt chin lift
maneuver if the jaw thrust does not open the
airway.
2. If multiple rescuers are available, one rescuer
can perform a jaw thrust while another rescuer
provides breaths with a bag mask device. The
third person will give chest compression
HEAD TILT-CHIN LIFT - to relieve airway obstructions
bc the tongue blocks the airway
1. Place one hand on the victim’s forehead and
push with your palm to tilt the head back.
2. Place the fingers of the other hand under the
bony part of the lower jaw near the chin.
3. Lift the jaw to bring the chin forward
Note: do not close the mouth of the victim,&
check if may visible obstruction
JAW THRUST
- This jaw-thrust maneuver is used
when the head tilt-chin (to continue---)
● Rescuers may perform a jaw thrust to
open the airway in a victim with a head or
neck injury if a spinal injury is suspected.
If the jaw thrust does not open the
airway, use a head tilt-chin lift.
USE OF A POCKET MASK
- to use a pocket mask, position yourself at the
victim’s side. This position is ideal when
performing 1- rescuer CPR because you can
give breaths and perform chest compressions
without repositioning yourself every time you
change from compressions to giving breaths.
● Position yourself at the victim’s
● Place the pocket mask on the victim’s
face, using the bridge of the nose as a
guide for the correct position.
● Seal the pocket mask against the face
○ Using your hand that is closer to
the top of the victims head, place
the index finger and thumb along
the edge of the mask
○ Place the thumb of your hand
along the edge of the mask
● Place the remaining fingers of your second hand
along the bony margin of the jaw and lift the jaw.
Perform a head tilt chin lift to open the airway
● While you lift the jaw, press firmly and completely
around the outside edge of the mask to seal the
pocket mask against the face
● Deliver each breath over 1 second enough to make
the victim’s chest rise
BAG MASK DEVICES
- Is used to provide positive pressure
ventilation to a victim who is not
 breathing or not breathing normally. It
consists of a bag attached to a face
mask. If the bag is self inflating, a
bag-mask device may be used with or
without an oxygen supply
- Proper area of the face for face mask
application. Note that no pressure is
applied to the eyes.
BAG-MASK VENTILATION TECHNIQUE (1
RESCUER)
- Position yourself directly above the victim’s head
- Place the mask on the victim’s face, using the
bridge of the nose as a guide for correct
position.
- Use the E-C clamp technique to hold the mask
in place while you lift the jaw to hold the airway
open
- Squeeze the bag to give breaths (1 second
each) while watching for chest rise. Deliver each
breath over 1 second, whether or not you use
supplementary oxygen.
BAG-MASK VENTILATION TECHNIQUE (2
RESCUERS)
- When 3 or more rescuers are present, 2
rescuers can provide more effective bag mask
ventilation than 1 rescuer. When 2 rescuers use
the bag-mask device, 1 rescuer opens the
airway with a head tilt-chin (or jaw thrust) and
holds the mask to the face while the other
rescuer squeezes the bag.
USING AED
● AED is a lightweight, portable, computerized
device that can identify an abnormal heart
rhythm that needs a shock. The AED can deliver
a shock that can stop the abnormal rhythm (VF
or pVT) and allow the heart’s normal rhythm to
return. AEDs are simple to operate allowing lay
persons and healthcare providers to attempt
defibrillation safely.
AED ARRIVAL
● Once the AED arrives, place it at the victim’s
side, next to the rescuer who will operate it. This
position provides ready access to AED controls
and easy placement of AED
DEFIBRILLATION
● An AED analyzes the heart rhythm to identify the
presence of a rhythm that responds to shock
therapy (as so-called shockable rhythm). If VF or
PVT is identified, the device prompts the delivery
of an electrical shock to the heart. The shock
temporarily “stuns” the heart muscle. This stops
the VF or PVT and resets the electrical system
of the heart, so a normal (organized) heart
rhythm can return. If an organized rhythm
returns high quality CPR continues, the heart
muscle can begin to contract and pump blood
effectively. If circulation returns, a pulse is
palpable and this is called return of spontaneous
circulation (ROSC)
OPERATING AN AED
1. Open the carrying case. Power on the AED if
needed.
2. Attach AED pads to the victim’s bare chest.
Choose adult pads
3. “Clear: the victims and allows the AED to
analyze the rhythm
- Make sure no one is touching the victim.
4. If the AED advises a shock, it will tell you to
clear the victim and then deliver a shock
5. If no shock is needed, after any shock delivery,
immediately resume CPR, starting with chest
compressions.
6. After about 5 cycles or 2 minutes of CPR the
AED will prompt you to repeat steps 3 and 4,
then continue until advanced life support
providers take over or the victim begins to
breathe, move or otherwise react.
AED PAD PLACEMENT
1. Anterolateral placement (A)
● place one AED pad directly below the
right collarbone
● place other pad at the side of the left
nipple, with the top edge of the pad
approx. 7 to 8 cm below armpit
2. Anteroposterior Placement (B)
● Place one AED pad on the left side of the
chest, between the victim’s left side of
the breastbone and left nipple.
● Place other pads on the left side of
victims back next to the spine
SPECIAL CIRCUMSTANCES
May require the rescuers to take additional actions
when placing AED pads for a victim who:
● Has a hairy chest
● Is immersed in water or has water covering the
chest
● Has an implanted defibrillator or pacemaker
● Has a transdermal medication patch or the other
object on the surface of the skin where the AED
pads are to be placed
HAIRY CHEST
● If the victim has a hairy chest, the AED pads
may stick to the hair and not to the skin on the
chest. If this occurs, the AED will not be able to
analyze the victim’s heart rhythm. The AED will
display a “check electrodes” or “check electrode
pads” message
WATER
- Water is a good conductor of electricity. Do not
use an AED in water.
- If the victim is in water, pull the victim out of the
water.
- If the chest is covered with water, quickly wipe
the chest before attaching the AED pads.
 - If the victim is lying on snow or a small puddle,
you may use the AED after quickly wiping the
chest.
IMPLANTED DEFIBRILLATOR AND PACEMAKER
● victims with a risk for sudden cardiac arrest may
have implanted defib or pacemakers that
automatically deliver shocks directly to the heart.
● These devices are easy to identify because they
create a hard lump beneath the skin of the upper
chest or abdomen. Lumo is about half the size of
a deck of playing cards.
● If you identify:
○ If possible avoid placing the AED pad
directly over the implanted device
○ Follow the normal steps for operating
AED
TRANSDERMAL MEDICATION PATCHES
● Do not place AED pads directly on top of a
medication patch.
● If it does not delay delivery, remove the patch
and whip the area before attaching the AED
pads (use protective gloves to remove a medical
patch.
NOTE: always use gloves kay peede ta ma lipong
(glycerin pads, nicotine patch and pain meds) so we
must remove it. kay it may cause burn sa pt, another
injury.
What is HIGH QUALITY CPR?
1. Compress the chest hard and fast at the rate of
100-120 bpm with a depth of at least 2 inch
2. Allow complete chest recoil after each
compression
3. Minimize interruptions in compression for <10
seconds
4. Avoid excessive ventilation
5. Switch compressors about every 2 mins or
earlier if fatigue.
ROLES DURING A RESUSCITATION ATTEMPT
1. Knowing your limitations!
- Every member on the team should know his or
her limitations and the team leader should be
aware of them. Each team member should ask
for assistance and advice early not when the
situation starts to get worse
2. Constructive intervention
- Sometimes a member or team leader may need
to correct actions that are incorrect or
inappropriate. It's important to be tactful.
Especially, if you have to correct someone who
is about to make a mistake, whether it’s a drug,
dose or intervention. Any person on the team
should stop someone else from making a
mistake regardless of that person’s role on the
team.
WHAT TO COMMUNICATE
1. Knowledge sharing
- Knowledge sharing is important for effective
team performance. Team leaders should ask
frequently for observations and feedback. This
includes good ideas for management and
observations about possible oversights
2. Summarizing and reevaluating
- summarizing information during resuscitation
attempt for the following reasons
- provides an ongoing record of treatment
- acts as a way status, the interventions
performed, and the team’s progress within the
algorithm of care.
- Helps team members respond to the victim’s
changing condition.
★ Closed-loop communication
● Team Leader
- Call each team member by name and make
eye contact when giving an instruction
- Don’t assign additional tasks until you are
sure that the team member understands the
instruction
● Team Members
- confirm that you understand each task to
which you are assigned by verbally
acknowledging the task
Tell the team leader when you have finished the
task.
3. Clear messages
- Team leaders and team members should give
clear messages. Using concise, clear language
helps prevent misunderstandings. Speaking in a
tone of voice that is loud enough to hear, but is
also calm and confident, helps keep all team
members focused.
4. MUTUAL RESPECT
- All team members should display mutual respect
and a professional attitude to other team
members, regardless of their skill level or
training. Emotions can run high during a
resuscitation attempt. So it is especially
important for team leaders to speak in a friendly,
controlled voice and avoid shouting or
aggression.
ADVANCED CARDIAC LIFE SUPPORT
● “ACLS”
● Set of algorithms for the urgent treatment of:
- Cardiac arrest
- Stroke
- Myocardial infarction
- Others
● Outside North America, Advanced Life Support
(ALS) is used

● Only qualified health care providers can provide

ACLS, as it requires the ability to manage the
person’s airway, initiate vascular access, read
and interpret electrocardiograms, and
understand emergency pharmacology
- Physicians, pharmacists, paramedics,
advanced practice providers (physician
assistants and nurse practitioners),
respiratory therapists, and nurses
● CPR is still the core foundation of ACLS
● ACLS often starts with analyzing the patient’s
heart rhythms with a manual defibrillator
- The ACLS team leader makes those
decisions based on rhythms on the
monitor and the patient’s vital signs
● The next step in ACLS is insertion of intravenous
(IV) lines and placement of various airway
devices, such as an endotracheal tube
● Commonly used ACLS drugs are the
administered (epinephrine and amiodarone)
● Personnel quickly search for possible reversible
causes of cardiac arrest
● Based on the diagnosis, more specific
treatments are given
● Code Blue Teams (Roles)
- Airway management
- Backup chest compressor
- Chest compressor
- defibrillator/medication nurse
- Event recorder/timer
- First provider
- Go to
● Resuscitation Process
- Phase 1: Activation Period
- Phase 2: Disorganized Period
- Phase 3: Team Formation Period
● Resuscitation Team
- Roles planned in advance
- Identify team leader
- Importance of non-technical skills
➔ Task management
➔ Team working
➔ Situational awareness
➔ Decision making
- Structured Communication
➔ SBAR or RSVP
 ●
Series of electrodes placed on the patient’s
extremities and chest wall to assess the heart
from 12 different views
Composed of:

8 hovens triangle:

ADDITIONAL NOTES:
● Rhythm check= also known as pulse checking
● Ventilation (5-10 seconds) ; ventilate during
decompression of the patient
● Pulseless electrical activity- continue CPR (naa
rhythm but no pulse detected)
● Every hospital has protocol which is if you have
no watcher, we must give at least 30 epinephrine
before declaring the patient dead
● In a systematic approach in both ACLS and
BLS, if may mag arrest (BLS)- check pulse, cpr, Bipolar Leads- measures the electrical potential
defibrillator between 2 of the 3 limbs

ECG
I Right arm to left arm Left view
Objectives: II Right arm to left leg Inferior left view
At the end of the lesson, you will be able to:
● Define electrocardiography and its indication III Left arm to left leg Inferior right
● Identify parts of the electrocardiogram view
● Recognize the 12 lead ECG its importance and
components Unipolar Leads- used one electrode as the positive pile
● Locate placement of leads in the patient and its and takes the average inputs of the other 2 as the zero
corresponding color coding reference.
● Identify common ECG rhythm used in ER aVR Upper right side view
● Enumerate the procedures on how to do the
ECG aVL Upper left side view
● Simulate sample ECG rhythms provided
Electrocardiography aVF Inferior wall of the heart
- A cardiac monitor that enables continuous
observation of the heart’s electrical activity PRECORDIAL LEADS
- It is used to continually monitor patient’s cardiac ● Unipolar leads
status to enable rapid identification and ● View the heart in horizontal view
treatment abnormalities in rate, rhythm, or ● Corresponding chest electrodes serve as the
conduction positive poles
● Reference value with all chest leads calculated
as the average of inputs from the 3 limb
electrodes

12 LEAD ECG
● Measures the heart's electrical activity and
records it as waveform
● Used in conjunction with other test
ECG PLACEMENT
V9 Left pinal border, same
horizontal line as V4-6

V8 Midscapular line, same

horizontal line as V7 and
V9

V7 Posterior axillary line,

same horizontal line as
V4-6

● Lead cable V6 connects to electrode V9

● Lead cable V5 connects to electrode V8
● Lead cable V4 connects to electrode V7

COLOR CODING

Common ECG rhythm

RIGHT PRECORDIAL PLACEMENT

Right precordial lead placement
- Can provide specific information about the
function of the right ventricle. Place the six leafs
on the right side of the chest in a mirror image of
the standard precordial lead placement as
follows:
V1R 4th ICS, left sternal
border

V2R 4th ICS, right sternal

border

V3R Halfway between V2R

and V4R

V4R Fifth ICS, right

midclavicular line

V5R 5th ICS, right anterior

axillary line

V5R 5th ICS, right midaxillary

line

POSTERIOR PRECORDIAL PLACEMENT

Additional Notes:
- Artifact- alteration of the ECG
- Muscle tremor artifact- if the patient has
parkinson's disease
- How to address:
Wandering baseline- instruct client not to move
Remove any metals around the body