Emergency nursing care

Under supervision of Dr/Saadia amin

Critical care & emergency nursing department
Third
First semester
Faculty of nursing
Cairo university
Student name
1.Doha Ashraf saad abd el moteleb
2.Omar taha naas
3.Doha khaled Mohamed
4.Sara ramadan abdel razeq
5.Essam seif eldien hassan
6.Shaimaa hamed abdel mged
7.Shaimaa mohamed Ali
8.Sobhi mohamed sobhi
9.Amr sami Ramadan
10. Ghada ragab Mohamed
11. Salma Amer Dakhly Abd El gaber
 Emergency care nursing

Case scenarios (4) Triage

Identify the category of each victim – MINOR/GREEN, YELLOW/DELAYED, RED/

IMMEDIATE, or BLACK NON-SALVAGEABLE - and the action that a rescuer might take in

accordance with START protocols, such as opening of airways, application of direct pressure for

bleeding, elevation of legs, recovery position. Write your answers below each victim.

Key – “Resp. rate” means ‘respiratory rate’. “Cap. refill” means ‘Capillary refill’

Notes – (1) GREEN means “walking” wounded; a leg injury that prevents walking categorizes

victim YELLOW/DELAYED, not GREEN. (2) Any major fracture (broken bone) makes a victim

YELLOW/ DELAYED because victim does need assistance sooner then a GREEN would need

assistance. (3) Try to find green volunteers to stay with young victims.

1. 30-year-old male with a compound fracture of left femur, bleeding significantly. Resp. rate

24. Cap. refill less than 2 sec. Alert and oriented. Delayed Yellow triage

Stop the bleeding.

Frist action of bleeding
Cover the wound with sterile gauze or a clean cloth. Press on it firmly with the palm of
your
Hand until bleeding stops
Nursing interventions
Cardiac monitor
Apply pressure to sites of external hemorrhage
Establish IV access
2 large bore IVs
Central lines if indicated
Volume resuscitation
Have blood ready if needed

Foley’s catheter to monitor resuscitation3

 Action of compound femur fractures
Surgical Treatment
. Most femur fractures are fixed within 24 to 48 houres
Nursing interventions of fractures
1- Maintain bed rest or limb rest as indicated. Provide support of joints above and below
the fracture site, especially when moving and turning.
2- Secure a bed board under the mattress or place the patient on the orthopedic bed.
3- Support fracture site with pillows or folded blankets. Maintain a neutral position of the
affected part with sandbags, splints, trochanter roll, footboard.
5. Observe and evaluate splinted extremity for resolution of edema.
6. Maintain position or integrity of traction.
7. Position the patient, so that appropriate pull is maintained on the long axis of the bone.
8. Assess the integrity of the external fixation device.
9. Review follow-up and serial X-rays.

2. 18-year-old female with abrasion to forehead and a bloody nose. Resp. rate 23. Cap. refill less

than 2 sec. Disoriented. Immediate

1- recovery position before leaving ( move as one unit and stabilize head and neck)

2- 2- control bleeding

3- 3- connect PT to monitor device ( o2 saturation and vital signs)

4- 4- IV fluids like ( normal saline and Ringer lactate)

5- 5- monitor sanitation of Lower extremits

6- 6- x-ray of head and neck

3. 50-year-old male complaining of chest pain and shortness of breath. Panting. Cap. refill is

greater than 2 seconds. Alert and oriented immediate recovery position if leaving victim alone

because he could be having heart attack and/or going into shock and lose airway if he loses

consciousness.

4. 23-year-old male with impaled metal pole through right chest. Resp. rate 22. Cap. refill less

than 2 sec. Alert and oriented. Delayed treat major bleeding if present.

5. 50-year-old male with 2nd/3rd degree burns over 70% of body. Resp. rate 35. Cap. refill more

than 2 sec. Unconscious.

Immediate *Provide humidified oxygen, and monitor arterial blood gases (ABGs), pulse oximetry,
and carboxyhemoglobin levels. *Report labored respirations, decreased depth of respirations, or
signs of hypoxia to physician immediately; prepare to assist with intubation and escharotomies.
*For patient with inhalation injury, regularly monitor pulmonary function, and ability to ventilate; if
patient required placed on a ventilator, frequent suctioning and assessment of the airway are
priorities *Check cardiac output and blood pressure

6. -75year-old male lying on the ground. Gurgling respirations. Resp. rate 8. Cap. Refill greater

than 2 secs. Unconscious Immediate

1_ Maintain open airway (jaw thrust manuver)

2_maintain cervical spine immobilized

3_Insertion of endotracheal tube (ETT)

4_ Oxygen supplement

5_ Begin CPR

6_Observe Color of skin if it pale or blue

7_Cardiac monitor

7. .8 -40year-old male lying on the ground w/ blood coming out of ears and nose. Not breathing .

Unresponsive If not breathing after 2 jaw thrust maneuver, non-salvageable. Black triage

.But if breathing resumes on opening airway, Red triage Scan for major bleeding and place in

recovery position.

8. 42-year-old female with an open fracture left ankle. Resp. rate 24. Cap. Refill less than 2 sec
alert and oriented Delayed -The women in yellow category and need second priority
9. - allow rapid assessment of victims.
10. Should not take more than 15 sec/patient .
11. Apply start (simple triage And rapid treatment system):
12. First action :
13. -Support the injured leg with a wooden board from all directions.
14. -should not moved injured leg.
15. - assess if there is infection or bleeding.
16. -stop bleeding.
17. -apply pressure to the wound using a sterile cloth.
18. -Call an ambulance and transfer the injured to the emergency department to take the
necessary measures.
19. First Aid, Nursing intervenation:
20. -assess bleeding (amount -color).
21. -assess vital sings.
22. -Documents patients complaints,past medical history.
23. -documents arrergies, medications.
24. -conituosly monitors patients until further placement.
9/21-year-old female abrasion to forehead, 8 months pregnant and in labor. Panting. Cap.

refill less than 2 sec. Alert and oriented. (respiration > 30 per minute) . Immediate _ check

the respiratory tract _check rate of breathing and breathing sound _observe the color of skin

and sign of cyanosis _ maintain airway clearance and open _ observe chest movement and

symmetry _observe patient for use accessory muscles _ check oxygen saturation _ observe
injury in face, mouth and neck _ observe level of consciousness _ apply pressure on the sites

of hemorrhage _ observe sites of bleeding _ insert two I.V lines to give necessary fluid and

blood if it needed _ check vital signs frequently _ observe sins of fetal distress _ observe the

capillary refill _ observe signs of labor _ observe uterine contractions and fetal distress _

prepare women for labor if signs of labor appears

10/64-year-old female walking around crying. No injuries seen. Resp. rate 20. Cap. refill less

than 2 sec. Disoriented. Immediate if possible, ask volunteer or GREEN to sit with and comfort

her and keep her from wandering. Volunteer can encourage - but not push - her to lie on her

side if she will cooperate