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What is Left Shift?
An increased number of Band cells.
Left shift indicates more immature cells (neutrophils) are in blood
what is an emergency?
an emergency is whatever the patient and family consider it to be
Airborne (particles smaller than 5 mcg)
N95 mask, negative pressure room, patient must wear mask when leaving room
TB, covid, measles, varicella (chickenpox)
Contact
gloves, gown, hand sanitizer (until dry)
wound drainage, feces, bodily discharge, VRE, MRSA
Contact plus
gloves, gown, soap (20 sec)
C-DIFF
Pain management
Patient controlled analgesia (pca)- continuous medication
IV medications- morphine sulfate, hydromorphone, fentanyl
ASSESS RESPIRATIONS
droplet (particles larger than 5 mcg)
surgical mask (required when 3 feet from patient)
influenza, meningitis, pneumonia, mumps, rubella
Under- Resuscitation
leads to shock, ischemic complications, mods
Over-Resuscitation
Leads to heart failure and pulmonary edema
Triage patient
Opposite for mass casualty
which pt should i see first?
Emergent- immediate threat to life, critical
ex: car crash, stroke
Urgent- major injuries require immediate treatment
ex: heart attack, severe trouble breathing, broken long bones
Nonurgent- minor injuries
ex: stitches, cough, congestion
Standard precautions
Gloves, mask, gown, goggles
when you may come into contact with body fluids, skin that isn't intact or mucous membranes
Burn Interventions
maintain airway-humidified oxygen as prescribed
monitor vitals- watch for hypothermia
maintain cardiac output
provide IV fluid replacement- parkland formula
monitor urine output- red color urine with deep burns (muscle) 30-50ml/hr
IV analgesic- around the clock (PCA pump)
Nutritional support- high protein, high calories (5000) some need parenteral feeding
Restraints
4 point- both wrists and both ankles
mitts- for iv pickers
leathers- for violent pt, have key before you put them on
posey- belt, pt will try to shimmy to get out, cloth
Where does emergency nursing care often start?
the site of the emergency
Restraint Must Know
must obtain an order prior to applying restraints
must obtain an order renewal after 24 hours
must assess & document on pt behavior
must reassess to see if the pt can come out of restraints
assess & document q15min
Infection prevention:
utilize PPE
environmental cleaning/ equipment
topical antibiotics, antimicrobials, and antifungals
EARLY CLEANING & CLOSING OF WOUND
hyperglycemia control
no flowers
wash hands
Violence in the ED
patient & families can become violent because of drugs, alcohol, or grieving
prisoners are NEVER left unattended: always at least 1 ankle or wrist cuffed to bed
patient biting or spitting- surgical mask
Edema treatment
Elevation
Eschar removal- escharotomy
Reabsorption of edema- begins 4 hours post injury and completed 4 days post injury
Fasciotomy- gets rid of pressure
Fluid Resuscitation
Not for first degree burns
24 hour process
subtract however much fluid was given in the ambulance
starts AFTER respiratory need are addressed and stabilized
initiated in burns >20% TBSA
Obtain labs & weight
larger burns- central venous access
Lactated ringers (crystalloids)- ph and osmolality resembles plasma
Patient Education
assess skin daily
exercise regularly
elevate affected extremity
moisturize skin
cool baths
loose cotton clothing
avoid sun exposure
high protein
skin appearance- scares face from red to natural color
Types of wound debridement
Natural- devitalized tissue separates viable tissue, takes weeks-months (bodies own way)
Mechanical- surgical tool (escharotomy)
Chemical- topical enzymatic agents promote debridement (initiates the process)
Surgical- skin grafting
Antimicrobial cream agents
-silver nitrate 0.5%- soaks
-Bacitracin Ointment- face & ears
-Silver sulfadiazine (silvadene) 1%- broad-spectrum, water soluble
-Mafenidine Acetate Crea- broad spectrum, penetrates tissue wall, never use dressing, breakdown of med causes heavy acid load- acidosis- painful
Skin Grafting
cant do this for 4th degree burns
Human tissue- homograft or allograft
Animal- xenograft or heterograft
Amniotic membrane
biosynthetic or synthetic- transparent
biologic dressings & tissue grafts
Wound Debridement
removal of devitalized tissue for grafting, wound healing, removal of contaminated tissue: bacteria & foreign bodies
Dressing
cover wound with several layers of dry dressings
lighter layers over joints
wraps applied distal to proximal- optimal circulation with excess fluid monitor pulses
document wound characteristics- odor, color, sixe, exudate