Colon Cancer - Austin Community College
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Transcript Colon Cancer - Austin Community College
Focus on
Emergency and
Disaster Nursing
Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Emergency Nursing
Patients- with life-threatening/potentially lifethreatening problems enter hospital through
the emergency department (ED).
•Triage
Process of rapidly determining patient
acuity
Represents a critical assessment skill
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Emergency Nursing
Triage system: categorizes patients so most
critical treated first
Emergency Severity Index:
Five-level triage system that incorporates
illness severity and resource utilization
Emergency System
Index Triage
Algorithm
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Who to see first?
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Emergency Nursing
Primary survey- focus on airway,
breathing, circulation, and disability,
exposure (ABCDE)
Identifies life-threatening conditions
If life-threatening conditions related
to ABCD identified during primary
survey interventions started immediately before procede to next step of
survey.
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Primary Survey
Airway with cervical spine stabilization and/or
immobilization
Signs/symptoms compromised airway
Dyspnea
Inability to vocalize
Presence of foreign body in airway
Trauma to face or neck
•Maintain airway: least to most invasive method
Open airway using jaw-thrust maneuver.
Suction and/or remove foreign body.
Insert nasopharyngeal/oropharyngeal airway.
Provide endotracheal intubation
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Primary Survey
Rapid-sequence intubation
Preferred procedure for unprotected
airway- Involves sedation or
anesthesia and paralysis
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Jaw-Thrust
Maneuver
Fig. 69-2. Jaw-thrust maneuver is the recommended
procedure for opening the airway of unconscious patient with
a possible neck or spinal injury. Patient should be lying
supine with rescuer kneeling at top of the head. Rescuer
places one hand on each side of patient’s head, resting his or
her elbows on the surface. Rescuer grasps the angles of
patient’s lower jaw and lifts the jaw forward with both hands
without tilting the head.
Cricoid Pressure
Fig. 69-3. Cricoid pressure. Firm downward pressure on
the cricoid ring pushes the vocal cords downward toward
the field of vision while sealing the esophagus against
vertebral column
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Primary Survey
Stabilize/immobilize cervical spine.
Face, head, or neck trauma and/or
significant upper torso injuries
•Breathing
Assess for dyspnea, cyanosis, paradoxic/
asymmetric chest wall movement, dec/absent
breath sounds, tachycardia, hypotension
•Adm high-flow O2 via a non-rebreather
mask; Bag-valve-mask (BVM) ventilation
with 100% O2 and intubation for lifethreatening conditions
•Monitor patient response.
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Primary Survey
Circulation
Check central pulse (peripheral pulses may
be absent dt injury or vasoconstriction).
Insert two large-bore IV catheters.
Initiate aggressive fluid resuscitation using
normal saline or lactated Ringer’s solution
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Primary Survey
Disability: measured by patient’s level of
consciousness
AVPU
A = alert
V = responsive to voice
P = responsive to pain
U = unresponsive
Glasgow Coma Scale
Pupils
Exposure/environmental control
Remove clothing to perform physical
assessment.
Prevent heat loss.
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Secondary Survey
Brief, systematic process to identify all injuries
Full set of vital signs/Five interventions/
Facilitate family presence
Complete set of vital signs
Blood pressure (bilateral)
Heart rate
Respiratory rate
Oxygen saturation
Temperature
Initiate ECG monitoring.
Insert indwelling catheter.
Insert orogastric/nasogastric tube.
Collect blood for laboratory studies.
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Secondary Survey
Full set of vital signs/Five
interventions/Facilitate family presence (cont’d)
*Family presence: family members who wish
to be present during invasive
procedures/resuscitation view themselves as
participants in care-Their presence should be
supported.
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Secondary Survey
Give comfort measures.
Pain management strategies— combination
of
Pharmacologic measures
Nonpharmacologic measures
History -head-to-toe assessment
Obtain history of event, illness, injury from
patient, family, and emergency personnel.
Perform head-to-toe assessment to obtain
information about all other body systems
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Secondary Survey
Inspect the posterior surfaces.
Logroll patient (while maintaining cervical
spine immobilization) to inspect posterior
surfaces.
Evaluate need for tetanus prophylaxis.
Provide ongoing monitoring, and evaluate
patient’s response to interventions.
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Secondary Survey
Prepare to
Transport for diagnostic tests (e.g., x-ray)
Admit to general unit, telemetry, or intensive
care unit
Transfer to another facility
Must recognize importance of hospital rituals
in preparing the bereaved to grieve (e.g.,
collecting belongings, viewing the body)
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Death in the Emergency
Department
Determine if patient-a candidate for non–
heart beating donation.
Tissues and organs (e.g., corneas, heart
valves, skin, bone, kidneys) can be
harvested from patient after death.
UNOS
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Gerontologic Considerations:
Emergency Care
Elderly-at high risk for injury—esp from falls.
Causes
Generalized weakness
Environmental hazards
Orthostatic hypotension
Important- determine if physical findings may
have caused fall or may be due to fall
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Heat Exhaustion
Prolonged exposure to heat
over hours or days
•Tachycardia
Leads to heat exhaustion
•Dilated pupils
Clinical syndrome characterized
•Mild confusion
by
•Ashen color
Fatigue
•Profuse diaphoresis
Light-headedness
Nausea/vomiting
•Hypotension
Diarrhea
•Mild to severe temp
Feelings of
inc (99.6º to 104º F
impending doom
[37.5º to 40º C]) due
Tachypnea
to dehydration
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Heat Exhaustion
Place patient in cool area and remove
constrictive clothing.
Place moist sheet over patient to dec core
temperature.
Provide oral fluid.
Replace electrolytes.
Initiate normal saline IV solution if oral
solutions are not tolerated.
*Salt tablets not used dt potential gastric
irritation and hypernatremia.
Potential hospital admission if not improved in
3-4 hrs
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Heatstroke
Failure of hypothalamic thermoregulatory
processes
Vasodilation, inc sweating, respiratory rate
>deplete fluids/electrolytes esp sodium.
Sweat glands stop functioning, and core
temperature inc (>104º F [40º C]).
Treatment: stabilize ABCs/rapidly reduce temp
Cooling methods
Remove clothing; cover with wet sheets.
Place patient in front of large fan.
Immerse in ice water bath.
Administer cool fluids or lavage with cool
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fluids.
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Heatstroke
Shivering: inc core temperature, complicates
cooling efforts, treated with IV chlorpromazine
Aggressive temperature reduction until core
temperature reaches 102º F (38.9º C)
Monitor for signs of rhabdomyolysis,
myoglobinuria, and disseminated intravascular
coagulation.
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Hypothermia
Core temperature <95º F (<35º C)
Risk factors
Elderly; Certain drugs
Alcohol; Diabetes
Core temperature <86º F (30º C)-potentially
life-threatening.
Mild hypothermia (93.2º to 96.8º F
[34º to 36º C])
Shivering; Lethargy; Confusion
Rational to irrational behavior
Minor heart rate changes
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Hypothermia
Moderate hypothermia (86º to 93.2º F [30º to
34º C])
Rigidity
Bradycardia, bradypnea
Blood pressure by Doppler
Metabolic and respiratory acidosis
Hypovolemia
Shivering disappears at temperature
86º F (30º C).
Severe hypothermia (<86º F [30º C])-person
appears dead.
Bradycardia
Asystole
Ventricular fibrillation
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Hypothermia
Warm patient to at least 90º F (32.2º C) before
pronouncing dead.
Cause of death—refractory ventricular
fibrillation
Treatment of hypothermia
Manage and maintain ABCs.
Rewarm patient.
Correct dehydration and acidosis.
Treat cardiac dysrhythmias.
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Hypothermia
Mild hypothermia: passive/active external re-warming
Passive external rewarming: Move to warm, dry
place; remove damp clothing; apply warm blankets
Active external re-warming: body-to-body contact,
fluid- or air-filled warming blankets, radiant heat
lamps
Moderate to severe hypothermia
Use heated, humidified oxygen; warmed IV fluids
Peritoneal, gastric, colonic lavage with warmed fluids
Consider cardiopulmonary bypass or continuous
arteriovenous rewarming in severe hypothermia.
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Hypothermia
Risks of rewarming
Afterdrop, a further drop in core temperature
Hypotension
Dysrhythmias
Rewarming should be discontinued
once core temperature reaches 95º F (35º C).
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Submersion Injury
Results when person becomes hypoxic as result
of submersion in substance, usually water
Drowning: death from suffocation after
submersion in fluid
Immersion syndrome occurs with immersion
in cold water > leads to stimulation of vagus
nerve and potentially fatal dysrhythmias.
Near-drowning: survival from potential
drowning
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Aggressive resuscitation efforts
and the mammalian diving reflex
improve survival of near-drowning
victims.
Treatment of submersion injuries
Correct hypoxia.
Correct acid-base/fluid
imbalances.
Support basic physiologic
functions.
Rewarm if hypothermia
present.
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Submersion Injury
Initial evaluation: ABCD
Mechanical ventilation with PEEP or CPAP to
improve gas exchange when pulmonary
edema is present
Deterioration in neurologic status: cerebral
edema, worsening hypoxia, profound acidosis
Observe for minimum of 4 to 6 hours.
Secondary drowning-a concern with
patients who are essentially symptom-free-
pulmonary complications.
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Animal Bites
Children at greatest risk
Animal bites from dogs and cats- most common,
followed by bites from wild or domestic rodents.
Complications
Infection
Mechanical destruction of skin, muscle,
tendons, blood vessels, bone
Dog bites-usually occur on extremities
May involve significant tissue damage
Deaths are reported, usually children
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Animal Bites
Cat bites: deep puncture wounds that can
involve tendons and joint capsules
Greater incidence of infection
Septic arthritis
Osteomyelitis
Tenosynovitis
Result in puncture wounds or lacerations
High risk of infection
Oral bacterial flora
Hepatitis virus
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Animal and Human Bites
Initial treatment: clean with copious irrigation,
debridement, tetanus prophylaxis, and
analgesics
Prophylactic antibiotics for bites at risk for
infection
Wounds over joints
Wounds less than 6 to 12 hours old
Puncture wounds
Bites on hand or foot
Puncture wounds left open
Lacerations loosely sutured
Wounds over joints splinted
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Animal and Human Bites
Rabies prophylaxis essential in mgt of
animal bites
Initial injection: rabies immune
globulin
Series of five injections of human
diploid cell vaccine: days 0, 3, 7,
14, and 28
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Poisonings
Chemicals that harm the body accidentally,
occupationally, recreationally, or intentionally
Severity depends on type, concentration, and
route of exposure.
Management
Dec absorption.
Enhance elimination.
Implement toxin-specific interventions per
poison control center.
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Poisonings
Dec absorption
Gastric lavage
Intubate before lavage if altered level of consciousness
or diminished gag reflex
Perform lavage within 2 hours of ingestion of most
poisons.
Contraindicated
Caustic agents
Co-ingested sharp objects
Ingested nontoxic substances
Activated charcoal
Most effective intervention: adm orally or via gastric
tube within 60 minutes of poison ingestion
Contraindications
Diminished bowel sounds
Paralytic ileus
Ingestion of substance poorly absorbed by charcoal
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Poisonings
Activated charcoal
Charcoal can absorb/neutralize antidotes: do
not give immediately before, with, or shortly
after charcoal
Dermal cleansing/eye irrigation
Skin/ocular decontamination: removal of
toxins from skin/eyes using water or saline
With the exception of mustard gas, toxins
can be removed with water/saline.
Water mixes with mustard gas and
releases chlorine gas .
**Decontamination takes priority over all
interventions except basic life support
measures.
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Poisonings
Enhance elimination.
Cathartics (e.g., sorbitol)
Give with first dose of charcoal to
stimulate intestinal motility/increase
elimination.
Whole-bowel irrigation
Hemodialysis/hemoperfusion
Reserved for severe acidosis
Urine alkalinization
Chelating agents
Antidotes
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Violence
Acting out of emotions (e.g., fear or anger) to
cause harm to someone or something
Organic disease
Psychosis
Antisocial behavior
Pattern of coercive behavior in a relationship;
involves fear, humiliation, intimidation,
neglect, and/or intentional physical,
emotional, financial, or sexual injury
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Family and Intimate
Partner Violence
Found in all professions, cultures,
socioeconomic groups, ages, and genders
Most victims are women, children, elderly
Screening for domestic violence is required in
ED.
Appropriate interventions
Make referrals.
Provide emotional support.
Inform victims about options
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Terrorism
Involves overt actions for expressed purpose of
causing harm
Disease pathogens (e.g., bioterrorism)
Chemical agents
Radiologic/nuclear, explosive devices
Anthrax, plague, and tularemia: trt with
antibiotics, assuming sufficient supplies/
nonresistant organisms
Smallpox-can prevent or ameliorated by
vaccination even when first given after exposure.
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Chemical Agents of Terrorism
Categorized by target organ or effect
Sarin: toxic nerve gas >cause death within
minutes of exposure
Enters body through eyes/skin
Acts by paralyzing respiratory muscles
Antidotes for nerve agents: atropine,
pralidoxime chloride
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Chemical Agents of
Terrorism
Phosgene: colorless gas normally used in
chemical manufacturing
If inhaled at high concentrations for long
enough period >severe respiratory distress,
pulmonary edema >death
Mustard gas: yellow to brown in color with
garlic-like odor
Irritates eyes and causes skin burns/blisters
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Radiologic/Nuclear Agents of Terrorism
Radiologic dispersal devices (RRDs) (“dirty bombs”):
mix of explosives and radioactive material
When detonated, blast scatters radioactive dust,
smoke, and other material into
environment>radioactive contamination.
Main danger from RRDs: explosion
Ionizing radiation (e.g., nuclear bomb, damage to
nuclear reactor): serious threat to safety of casualties
and environment
Exposure may or may not include skin contamination
with radioactive material.
Initiate decontamination procedures
immediately if external radioactive
contaminants are present.
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Explosive Devices as Agents of
Terrorism
Result in one or more of following types of injuries:
blast, crush, or penetrating
Blast injuries from supersonic overpressurization
shock wave that results from explosion
Damage to lungs, middle ear, gastrointestinal
tract
Emergency: any extraordinary event that requires
a rapid and skilled response and can be managed
by a community’s existing resources
Mass casualty incident (MCI)
Manmade or natural event or disaster that
overwhelms community’s ability to respond
with existing resources
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American Red Cross
Fig. 69-8. American Red Cross.
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Emergency and Mass Casualty
Incident Preparedness
When an emergency or MCI occurs, first responders
(e.g., police, emergency medical personnel)
are dispatched.
Triage of casualties differs from usual ED triage-is
conducted in <15 seconds.
System of colored tags designates both seriousness of
injury and likelihood of survival.
Green (minor injury)
Yellow (urgent tag-noncritical injury.
Red tag- life-threatening injury.
Blue tag indicates those who are expected to die.
Black tag identifies the dead.
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Emergency and Mass Casualty
Incident Preparedness
Casualties need to be treated/stabilized.
If known or suspected contamination,
decontaminate at scene, then transport to
hospitals.
Many casualties will arrive at hospitals on their
own (i.e., “walking wounded”).
Total number of casualties a hospital can
expect-est by doubling #casualties that arrive
in 1st hour.
Generally, 30%-require admission to
hospital, 1/2 will need surgery within 8
hours.
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Emergency and Mass Casualty
Incident Preparedness
Communities have initiated programs to
develop community emergency response
teams (CERTs).
CERTs-partners in emergency
preparedness-training helps citizens to
understand their personal responsibility in
preparing for natural/manmade disaster.
All health care providers have role in
emergency and MCI preparedness.
Knowledge of the hospital’s emergency
response plan
Participation in emergency/MCI
preparedness drills is required
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Emergency and Mass Casualty
Incident Preparedness
Response to MCIs often requires aid of federal agency such as
the National Incident Management System (NIMS).
Section within U.S. Department of Homeland Securityresponsible for coordination of federal medical response to
MCIs
National Disaster Medical System: organizes and trains
volunteer disaster medical assistance teams (DMATs)
DMATs: categorized according to ability to respond to an
MCI
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Question
While performing triage in the emergency department, the
nurse determines that which of the following patients should
be seen first?
1. A patient with a deformed leg indicating a fractured tibia;
blood pressure 110/60 mm Hg, pulse 86 beats/min,
respirations 18 breaths/min.
2. A patient with burns on the face and chest; blood pressure
120/80 mm Hg, pulse 92 beats/min, respirations 24
breaths/min.
3. A patient with type 1 diabetes in ketoacidosis; blood
pressure 100/60 mm Hg, pulse 100 beats/min,
respirations 32 breaths/min.
4. A patient with a respiratory infection with a cough
productive of greenish sputum; blood pressure 128/86
mm Hg, pulse 88 beats/min, respirations 26 breaths/min.
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Question
Assessment of the patient during the primary survey
indicates that the patient has delayed capillary refill of the
extremities and cannot explain the events prior to
admission to the emergency department. The nurse should
first:
1. Insert one or two large-bore IV catheters to start
intravenous fluid resuscitation.
2. Continue the primary survey to complete it with a brief
neurologic examination.
3. Apply leads for electrocardiogram (ECG) monitoring.
4. Initiate pulse oximetry.
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Question
Several patients are admitted to the emergency
department after exposure to an aerosolized agent that is
believed to be a hemorrhagic fever virus used as a
bioterrorism agent. The nurse plans care for the patients
with the knowledge that:
1. No known treatment is available for this disease.
2. A vaccine is available to prevent the disease in those
who have been exposed.
3. The disease can be spread from person to person only
by vectors such as mosquitoes or fleas.
4. Ciprofloxacin (Cipro) is the treatment of choice and is
stockpiled by government agencies for use against the
virus.
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Case Study
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Case Study
32-year-old female arrives to ED via
paramedics.
A neighbor found her lying on the rocks in the
rock garden. She had fallen off the roof while
fixing the shingles on her house.
A large stick is protruding through the skin at
lower leg.
The paramedics report that she was found in
large pool of blood. Unresponsive, BP 60/42,
HR 168
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Discussion Questions
1. What potential life-threatening injuries does
she have?
2. What is the priority of care?
3. What interventions are needed immediately?
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