POLICY/PROCEDURE. Issued By: Clinical Services. Policy No.: TX.009. Reference: Code 99 - TX.012. Date Issued: 2/99

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1 POLICY/PROCEDURE Title: 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 Issued By: Clinical Services 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 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 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 to initiate emergency personnel 2.2 Notify psychiatrist / designee Emergency Medical Care, 1

2 2.3 Notify AOC 3.0 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 Call to initiate emergency personnel Notify psychiatrist / designee 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) Call to initiate emergency personnel Notify psychiatrist / designee Notify AOC 3.4 Hypovolemic Shock -- Hemorrhage or loss of body fluid. Most common in psychiatric nursing from lacerated wrists or possible esophageal varices Symptoms 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 Management: Maintain an open airway. Elevate legs (after Emergency Medical Care, 2

3 hemorrhage is controlled) to improve cerebral circulation and increase venous return. Avoid placing patient in Trendelenburg position 1. Maintain body temperature. Increased heat can cause vasodilation which counteracts the body's compensatory mechanism of vasocontriction Call to initiate emergency personnel Notify psychiatrist / designee Notify AOC 3.5 Documentation includes all of the following, but is not limited to: Type of wound (i.e. incision, laceration, abrasion, puncture, avulsion / amputation) Size of wound Location of wound Depth of wound Circumstances and patient s view of what happened Vital signs Date of last tetanus Pain rating Treatment given Level of consciousness 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 ( ). 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

4 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 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. 7.2 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: Circumstances and patient s view of what happened Type of burn (1 st, 2 nd, 3 rd degree) Cause of burn (thermal, chemical, electrical, radiation, acids, alkalis) Size of burn Location of burn Vital signs Critical burn? (i.e. red, white, black, charred) Blisters / lack of blisters Drainage Breathing difficulties Pain rating Other injuries Shock, or cardiac distress Treatment given Emergency Medical Care, 4

5 Date of last tetanus Level of consciousness 8.0 Fractures: If a fracture is suspected, staff assessment includes all of the following, but is not limited to: degree of pain swelling in the soft tissue loss of limb function laceration 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 Documentation includes all of the following, but is not limited to: Determination of how injury occurred Patient s view of what happened Snap or pop heard at time of injury? Bruising or ecchymosis Crepidation Lumps or deformity in area of injury Location of injury Tenderness or swelling Impaired mobility in area of injury Pain at or near area of injury Numbness, tingling, weakness in area of injury Peripheral pulse absent or present Skin over injury site open or intact Last tetanus given Vital signs Level of Consciousness Other injuries Treatment given 9.0 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 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

6 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 Hypoglycemic Reaction to Insulin/Oral Agent: Observe the patient for the following signs of hypoglycemia: 10.1 Rapid onset of symptoms 10.2 Excessive sweating 10.3 Ataxia, anxiety 10.4 Feeling faint, weakness 10.5 Headache 10.6 Pounding of heart, trembling, impaired vision (blurred or double vision) 10.7 Hunger 10.8 Irritability, personality changes 10.9 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

QI. Read the following questions and choose the most correct answer (20 Marks):

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