Download TX.009 Emergency Medical Care / First Aid Procedures (PDF: 51KB/6 pages)

POLICY/PROCEDURE
Title:
Issued By: Clinical Services
Emergency Medical Care / First
Aid Procedures
•
Hanging
•
Bleeding
•
Poison/Overdose
•
Nose Bleeds
•
Drowning
•
Foreign Bodies in the
Eye
•
Burns
•
Fractures
•
Fainting
•
Anaphylactic Reactions
•
Hypoglycemic Reaction
Policy No.: TX.009
Reference: Code 99 - TX.012
Date Issued: 2/99
Date Reviewed/Revised: 6/02, 4/04
Approved:
Clinical Services Function – 7/15/02, 6/21/04
Medical Executive Committee – 7/18/02,
8/19/04
Board of Trustees – 7/18/02
Board of Governors – 8/19/04
Policy:
To provide basic emergency care to the patient as described below.
To transfer the patient to an acute care facility for further treatment when indicated. (See
policy # CC.008 - Transfer to Another Facility)
Procedure:
1.0
Hanging: Support the body weight to relieve pressure in the neck, even as you call
for help. When the patient is released, check ABC’s (Airway, Breathing,
Circulation), initiate CPR, if indicated.
1.1
Call 9-911 to initiate emergency personnel
1.2
Notify psychiatrist / designee
1.3
Notify AOC
2.0
Drowning: A patient can drown in any amount of water in which he can immerse
his nose and mouth. Remove him from the water as soon as possible; however, if
he is in the tub, release the drain, hold the patient’s head above water level and get
help to remove the patient from the tub. Check ABC’s. Initiate CPR, if indicated.
2.1
Call 9-911 to initiate emergency personnel
2.2
Notify psychiatrist / designee
Emergency Medical Care, 1
2.3
3.0
Notify AOC
Bleeding: Never leave a bleeding patient alone.
3.1
Capillary Bleeding -- oozing -- Apply cold. Control bleeding by applying firm
pressure with sterile dressing and bandage. Elevate injured part. Immobilize
injured extremity to control blood loss.
3.2
Venous Bleeding -- steady flow of deep red -- To control bleeding use sterile
dressing and bandage. Apply firm steady pressure directly to the wound and
hold until bleeding stops, or until rescue personnel assume control of the
situation
3.2.1 Call 9-911 to initiate emergency personnel
3.2.2 Notify psychiatrist / designee
3.2.3 Notify AOC
3.3
Arterial Bleeding -- spurting stream of bright red blood -- Elevate the
affected area above heart level. Apply pressure with sterile dressing and
bandage directly to the wound. Apply pressure to nearest pressure point if
bleeding is unable to be stopped. A tourniquet is available on all units, but
a handkerchief or stocking may be used (ONLY TO BE USED IF BLEEDING
CAN NOT BE STOPPED OTHERWISE).
3.3.1 Call 9-911 to initiate emergency personnel
3.3.2 Notify psychiatrist / designee
3.3.3 Notify AOC
3.4
Hypovolemic Shock -- Hemorrhage or loss of body fluid. Most common in
psychiatric nursing from lacerated wrists or possible esophageal varices.
3.4.1 Symptoms
3.4.1.1
3.4.1.2
3.4.1.3
3.4.1.4
3.4.1.5
3.4.1.6
3.4.1.7
3.4.1.8
3.4.1.9
3.4.1.10
3.4.1.11
3.4.1.12
Restlessness, irritability
Decrease in arterial pressure (systolic drop more rapid
than diastolic)
Increased pulse rate and respiratory rate
Cold clammy skin
Pallor
Nausea and vomiting
Thirst
Alterations in mental status
Decrease in renal function, low urine output.
Weakness
Lethargy
Blue tinge to lips and nail beds
3.4.2 Management: Maintain an open airway. Elevate legs (after
Emergency Medical Care, 2
hemorrhage is controlled) to improve cerebral circulation and increase
venous return. Avoid placing patient in Trendelenburg position1.
Maintain body temperature. Increased heat can cause vasodilation
which counteracts the body's compensatory mechanism of
vasocontriction.
3.4.2.1
Call 9-911 to initiate emergency personnel
3.4.2.2
Notify psychiatrist / designee
3.4.2.3
Notify AOC
3.5
Documentation includes all of the following, but is not limited to:
3.5.1 Type of wound (i.e. incision, laceration, abrasion, puncture, avulsion /
amputation)
3.5.2 Size of wound
3.5.3 Location of wound
3.5.4 Depth of wound
3.5.5 Circumstances and patient’s view of what happened
3.5.6 Vital signs
3.5.7 Date of last tetanus
3.5.8 Pain rating
3.5.9 Treatment given
3.5.10 Level of consciousness
3.5.11 Distal peripheral pulses
4.0
Epistaxis / Nose Bleeds: Place the patient in a sitting position with the head bent
forward. Attempt to control the bleeding by squeezing the nostrils with a 4x4
gauze pad continuously for five minutes to allow time for clot formation. Monitor
the vital signs of the patient document until the bleeding subsides. Notify the
attending psychiatrist / designee.
5.0
Poison Ingestion / Overdose: The nurse in charge assesses the condition of the
patient and follows appropriate procedures if life-support emergency care is
required. Contact the poison control center for advice and information (1-800-2221222 ). The Registered Nurse communicates with on call psychiatrist the information
learned from poison control as well as medical assessment information and receives
orders for further treatment. Antidotes and other agents used in the treatment of
poison ingestion/overdose are located either in the Emergency Kit or on the unit as
floor stock which includes Ipecac and activated charcoal. (see TX.078 Medication
Administration by Various Routes)
Inducing vomiting or instituting lavage, is dependent on the condition of the
patient. If the patient is comatose, institute supportive therapy to maintain
adequate cardiac and respiratory function. Notify the psychiatrist / designee, who
determines the method of transfer to an emergency room for treatment. Complete
1 Trendelenburg Position - A supine (chest down) position on the operating table, which is inclined at varying
angles so that the pelvis is higher than the head with the knees flexed and legs hanging over the end of the
table; used during and after operations in the pelvis or for shock.
Emergency Medical Care, 3
the appropriate notification procedures and documentation.
6.0
Foreign Bodies in the Eye: Instruct the patient not to rub. Rubbing may drive the
foreign body deeper. Pull the lower lid down. If you can see the object, use an
applicator moistened in water to remove it. Always moisten the applicator before
touching it to the eye. If you cannot see the object, grasp the lashes of the upper
lid and ask the patient to look up. Pull the lid forward and down. Often this will
dislodge the body and tears will wash it away. Notify the psychiatrist / designee.
7.0
Burns:
7.1
7.2
Major and Minor Burns: Do not remove clothing which adheres to the burn
area. Remove all jewelry adjacent to the burn area. Do not apply ointments
to the burn area and do not administer analgesics if the burn is extensive.
Irrigate minor burns with copious amounts of cool water and apply a dry,
sterile dressing. Cover major burns with a sterile sheet. Initiate measures to
prevent burn shockimmediately. Notify the psychiatrist / designee, who
determines the method of transfer for emergency treatment.
Burns Caused by Acids and Alkalize: Irrigate the burn area with copious
amounts of cool water. Do not apply ointments to the burn area. Notify the
psychiatrist / designee, who determines the method of transfer to an
emergency room for treatment. Complete the appropriate notification
procedures and documentation.
If the patient is transferred to an emergency room, always include a notation
if medication is given. Superficial burns are more painful than deep burns
because a burn involving the upper layer of skin only will leave the nerves
exposed. When all the layers are destroyed, the nerves are destroyed with
them. First degree burns--reddened area, pain, swelling. Second degree
burn--more extensive, with blistering. Third degree burn--charred flesh.
7.3
Documentation includes all of the following, but is not limited to:
7.3.1 Circumstances and patient’s view of what happened
7.3.2 Type of burn (1st, 2nd, 3rd degree)
7.3.3 Cause of burn (thermal, chemical, electrical, radiation, acids, alkalis)
7.3.4 Size of burn
7.3.5 Location of burn
7.3.6 Vital signs
7.3.7 Critical burn? (i.e. red, white, black, charred)
7.3.8 Blisters / lack of blisters
7.3.9 Drainage
7.3.10 Breathing difficulties
7.3.11 Pain rating
7.3.12 Other injuries
7.3.13 Shock, or cardiac distress
7.3.14 Treatment given
Emergency Medical Care, 4
7.3.15 Date of last tetanus
7.3.16 Level of consciousness
8.0
Fractures: If a fracture is suspected, staff assessment includes all of the following,
but is not limited to:
8.0.1 degree of pain
8.0.2 swelling in the soft tissue
8.0.3 loss of limb function
8.0.4 laceration
8.0.5 presence of pulse and sensation below the injury.
Do not allow weight bearing on the extremity and do not attempt to realign the
extremity. Check the area distal to (beyond) the suspected fracture site for pulses,
circulation and neurological status, etc.. Immobilize injured extremity. Avoid
moving injured extremity. Apply ice to the site of the suspected fracture. If a bone
is protruding through the skin, apply a large sterile dressing. Notify the psychiatrist /
designee, who determines the method of transfer to an emergency room for
diagnosis and treatment. Complete the appropriate notification procedures and
documentation.
8.1
9.0
Documentation includes all of the following, but is not limited to:
8.1.1 Determination of how injury occurred
8.1.2 Patient’s view of what happened
8.1.3 Snap or pop heard at time of injury?
8.1.4 Bruising or ecchymosis
8.1.5 Crepidation
8.1.6 Lumps or deformity in area of injury
8.1.7 Location of injury
8.1.8 Tenderness or swelling
8.1.9 Impaired mobility in area of injury
8.1.10 Pain at or near area of injury
8.1.11 Numbness, tingling, weakness in area of injury
8.1.12 Peripheral pulse absent or present
8.1.13 Skin over injury site open or intact
8.1.14 Last tetanus given
8.1.15 Vital signs
8.1.16 Level of Consciousness
8.1.17 Other injuries
8.1.18 Treatment given
Anaphylactic Reactions: An anaphylactic reaction is a symptom complex associated
with a sudden onset of shortness of breath, hypotension, generalized skin eruption,
laryngeal edema, etc., and may progress to death. The reaction may be due to
numerous causes. (Refer to policy # CC.005.1 Epinepherine Auto-Injector: Use of an
Epi-pen in an Emergency.)
The Registered Nurse assesses the severity of the anaphylactic reaction and follows
Emergency Medical Care, 5
the procedures of life-support if emergency medical care is required. Medications
may be administered to the patient per the physician’s order. Complete the
appropriate notification procedures and documentation.
10.0
Hypoglycemic Reaction to Insulin/Oral Agent: Observe the patient for the following
signs of hypoglycemia:
10.1
10.2
10.3
10.4
10.5
10.6
10.7
10.8
10.9
10.10
10.11
10.12
Rapid onset of symptoms
Excessive sweating
Ataxia, anxiety
Feeling faint, weakness
Headache
Pounding of heart, trembling, impaired vision (blurred or double vision)
Hunger
Irritability, personality changes
Stupor
Numbness of lips, tongue
Convulsions
Coma
Glucose: oral glucose gel and glucogen for injection is available for treatment of
hypoglycemic reactions. The nurse notifies the physician for appropriate orders.
(Refer to policy # TX.034, Diabetic Care)
11.0
Fainting: Keep victim lying down. Loosen any tight clothing and keep others away.
If the victim vomits, roll him onto his side or turn his head to the side and, if
necessary, wipe out his mouth with your fingers, preferably wrapped in cloth.
Maintain airway. Keep patient NPO until fully awake. Do not move victim until
examined for injuries. Seek medical assistance 9-911, unless recovery is prompt.
Emergency Medical Care, 6