Focus on Emergency and Disaster Nursing在紧急情况和灾难护理重点.pptVIP

Focus onEmergency and Disaster Nursing (Relates to Chapter 69, “Nursing Management: Emergency and Disaster Nursing” in the textbook) Emergency Nursing Patients with life-threatening or potentially life-threatening problems enter the hospital through the emergency department (ED) Emergency Nursing Triage Rapid assessment skill to determine acuity Threat to life, vision, or limb are treated before other patients Emergency Severity Index Triage Algorithm Five-level triage system that incorporates illness severity and resource utilization See Table 69-2 on p. 1822 for additional information Emergency Severity Index Triage Algorithm Emergency Nursing –  Primary Survey Airway, breathing, circulation, and disability (ABCD) Identifies life-threatening conditions Necessary interventions started immediately before proceed to next step of the survey Primary Survey Airway with cervical spine stabilization and/or immobilization Signs/symptoms of compromised airway Dyspnea Inability to vocalize Presence of foreign body in airway Trauma to face or neck Primary Survey Maintain airway: Least to most invasive method Open airway using the jaw-thrust maneuver Primary Survey Maintain airway: Least to most invasive method cont. Suction and/or remove foreign body Insert nasopharyngeal/oropharyngeal airway Endotracheal intubation Cricothyroidotomy or tracheostomy Primary Survey Stabilize/immobilize cervical spine: Face, head, or neck trauma and/or significant upper torso injuries Primary Survey Breathing: Assess for dyspnea, cyanosis paradoxic/asymmetric chest wall movement, decreased/absent breath sounds, tachycardia, hypotension Administer high-flow O2 via a nonrebreather mask Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for life-threatening conditions Monitor patient response Primary Survey Circulation: Check central pulse (peripheral pulses may be absent because of injury or vasoconstriction) Assess skin for color, temperature, moist