Harizza Pertiwi

§What comes to your mind when you hear the word emergency or emergency nursing?

§All patients feel that their problems are emergencies! §Emergency nurse : making sure that all patients and members of their families receive close attention and the best care possible

Emergency Nurse Fast -paced Stressful environment Critical Thinking • Knowledge • Intuition • Logic • Common sence • Experience Nursing Process

Primary Survey Secondary Survey

§A : Airway §B : Breathing §C : Circulation §D : Disability §E : Exposure and environment

§ Assessment : airway patency § Immobilize cervical spine à apply neck-collar § Position the patient § Open airway à head tilt chin lift or jaw thrust § Obstruction can be tongue, blood, loose teeth, or vomitus § Use airway adjuncts, such as an oropharyngeal or a nasopha- ryngeal airway, an endotracheal tube, an esophageal–tracheal combitube, or cricothyrotomy, as indicated.

§ Assessment : Respirations (rate, depth, effort), Breath sounds, Chest wall movement and chest injury, Position of trachea (mid- line or deviation) § Administer 100% oxygen with a bag valve mask. § Suction the patient as needed. § Remove foreign bodies that may obstruct breathing. § Treat life-threatening conditions, such as pneumothorax or tension pneumothorax.

§Assessment : Pulse and blood pressure, Bleeding or haemorrhage, Capillary refill and color of skin and mucous membranes, Cardiac rhythm § Start cardiopulmonary resuscitation, medications, and defibrillation. § Control haemorrhaging with direct pressure § Establish intravenous (IV) access and fluid therapy (isotonic fluids and blood). § Treat life-threatening conditions such as cardiac tamponade.

§Assessment : Neurologic assessment, including level of consciousness (GCS), pupils, and motor and sensory function § Institute cervical spine immobilization until X-rays confirm the absence of cervical spine injury.

§Assessment : Expose for injuries and maintain a warm environment once exposed. §Examine the patient to determine the extent of injuries. §Provide warm blankets, warmed fluids, or use overhead warmer. If an environmental exposure is determined, the use of institute-appropriate therapy (warming therapy for hypothermia or cooling therapy for hyperthermia) may be indicated.

Primary ABCDE survey is a rapid assessment intended to identify life-threatening emergencies that must be treated before the assessment continues

§ Identify all injuries sustained § Develop care plan and order diagnostic test § Obtain a full set of vital signs § Initiate cardiac monitoring § Obtain continuous pulse oximetry readings § Insert a urinary catheter to monitor accurate intake and output measurements § Insert a nasogastric (NG) tube for stomach decompression § Obtain laboratory studies as ordered

§Patient’s family may need emotional and spiritual support. They may wish to present during resuscitation §Maintain communication towards patient and their family §Obtain the patient’s history