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Guia d’Intervencions d’Infermeria a Problemes de Salut ◦ EAP Can Bou

V 1.2 ● 12/2012 Castelldefels Agents de Salut d’Atenció Primària ◦ CASAP 3

© Castelldefels Agents de Salut (CASAP)

Av. Ciutat de Màlaga, 18-20 08860 Castelldefels (Barcelona) Translation by Clara Martí Aguasca

Nursing Interventions Guide to Health Problems - Can Bou EAP


Authors and contributors ............................................................................................................................................ 7

Presentation .................................................................................................................................................................. 9 11

Introduction ................................................................................................................................................................ 11

Commitment letter .................................................................................................................................................... 13

Circuit care demands............................................................................................................................................... 15

Acute health problems Oral thrush ............................................................... 18 Emergency contraception ................................... 20 Burn ........................................................................... 22 Anxiety attack ........................................................ 24 Diarrhea ................................................................... 26 Blood pressure elevation ....................................... 28 Epistaxis .................................................................... 30 Wound .................................................................... 32 Herpes ...................................................................... 34 Dermal lesion of skin folds ..................................... 36 Sore throat ............................................................... 38 Backache ............................................................... 40

Toothache ......................................................... 42 Distress when urinating .................................... 44 Animal bite ........................................................ 46 Stye ..................................................................... 48 Bite ...................................................................... 50 Mosquito bite .................................................... 52 Allergic reaction ............................................... 54 Respiratory symptoms in upper airways ....... 56 Sprained ankle .................................................. 58 Trauma .............................................................. 60 Whitlows ............................................................. 62

Urgent health problems

Aggressions ............................................................. 66 Cardiac arrest ......................................................... 68 Seizures ..................................................................... 70 Heatstroke ............................................................... 72 Severe abdominal pain ........................................ 74 Chest pain ............................................................... 76 Fever > 39º ............................................................... 78 Intoxications ............................................................ 80 Serious eye injury .................................................... 82

Intens headache .............................................. 84 Dizziness .............................................................. 86 Drowning ........................................................... 88 Loss of conscience ........................................... 90 Gastrointestinal bleeding ................................ 92 Traumatic brain injury ...................................... 94 Severe trauma .................................................. 96 Vomiting ............................................................. 98 Anaphylactic shock ....................................... 100

Drugs guide

Analgesics and antipyretics .............................................................................................................................. 105 Antibiotics ............................................................................................................................................................ 107 Topical treatment ............................................................................................................................................... 109 Others .................................................................................................................................................................... 110

Annex Pain scale ............................................................................................................................................................. 113 Radiographic projections .................................................................................................................................. 114 Nursing assessment ............................................................................................................................................. 115 Neurological assessment ................................................................................................................................... 116 Assessment of burn lesions ................................................................................................................................. 117

Bibliography ............................................................................................................................................................. 121

index



Direction

Brugués Brugués, Alba Peris Grao, Antoni

Authors: working group of non scheduled demand management

Gascón Ferret, Jordi Gímenez Jordan, Laura Mateo Viladomat, Enric Pavón Rodríguez, Francisca Vilalta García, Susana

Coordination edition Pavón Rodríguez, Francisca

Contributors

Nurses Campoy Sanchez, Ana Casado Montañés, Isabel Fernández Delgado, Maite Fernández Molero, Sònia Hernández Escriche, Carmen Laserna Jimenez, Cristina Malo Verde, Agustina Moya Calaf, Griselda Mulero Madrid, Ana Noguera Argelès, Mª Antònia Osuna Gomera, Yolanda Raventós Jurado, Paola Rodríguez Hernández, Yolanda Sancho Domènec, Laura Tàpia López, Montserrat Torres Roca, Dolors

Doctors Bernades Carulla, Carlos

Bosch Romero, Emilia Chiriac, Ionut Garcia Tristante, Daniel Gomez Fernandez, Claudia Gonzalez Azuara, Sílvia Jareño Sanz, Mª José Manzotti, Carolina Santamaria Martín, Maribel Silvestre Puerto, Víctor

Dentistry Prunera Badosa, Núria

Health administrative Hurtado Colmenero, Natàlia Ibáñez Mancebo, Sandra Madrid Ramón, Miguela Muñoz Roldan, Araceli Osuna Muñoz, Susana Santana Cabrera, Maite Sevillano Palma, Victòria Tello Pérez, Alicia Vilaseca Ortiz Urbina, Maite

Nursing assistant Burgos Casado, Sònia Santana Cabrera, Imma

Reviewers

Amat Camats, Gemma. “Associació d’Infermeria Familiar i Comunitària de Catalunya” (AIFiCC) Flores Mateo, Gemma. “Institut d’Investigació en Atenció Primària” (IDIAP) Morera Castell, Ramon. “Societat Catalana de Medicina Familiar i Comunitària” (CAMFiC)

Technical support and design

Cubells Asensio, Irene Mateo Viladomat, Enric

authors



A few years ago we proposed that one of the priority objectives of the primary health care is to solve maximum problems of population with better accessibility. The current economic situation makes it much more necessary to move towards this goal. A few years ago, the Primary Care Team Can Bou and the Consortium Castelldefels Health Agents (CASAP) developed this project which now we present in a new version. The document "Guide of nursing interventions to Health Problems" is the result of a teamwork. At first was based on the scientific evidence for diagnostic and therapeutic procedures and the will to streamline the care process of the known as spontaneous demands. It has served us to promote the integration of customer care professionals as health care professionals in the care process and within the team itself, with nurses and doctors. These are Guidelines based on various documents of scientific rigor, and in turn, the tools to facilitate problem solving by nurses, referred professionals to solve different acute health problems, both to expedite the resolution and being professionals with demonstrated skills. With the experience given us by years of working with this tool, with the review and improvement made through the analysis and the recommendations made by the same professionals who use them daily, we offer this update guideline that we trust you find illuminating, interesting and, over all, useful for the daily task with population that requires our service.

Dr. Antoni Peris i Grao

Family physician - Director Manager Health Center Can Bou

presentation



Nurses here and abroad have initiated measures to enhance the role of nurses in the care of acute health problems, with the goal of becoming the gateway to the health system and also in giving response to much of the demands presented on the population. It is necessary to adapt activity and resolution capability of the primary attention nurse to these demands for increasing system’s efficiency and sustainability. This project aims to provide all team members, the use of a methodology agreed on circuits, decision making and interventions, based on available scientific evidence and methodological nursing tools. By consensus of the working group and the rest of the team, have been chosen a number of health problems that go straight to the consultation of spontaneous attention. The nurse, after making the assessment, can give the user the right treatment (cure, tips, drug ...) or to quote the reference professional (doctor or nurse) to do the monitoring. To carry through demand management in a efficiently and operationally way, it is necessary to coordinate the actions of the nurse who attends care consultation of spontaneous visits with the receiving of the user by the health administrative team that prioritize and manage demands to the indicated professionals, and also with the team of family physicians and pediatricians who provide support and assistance in cases that require their intervention. Other health problems, considered as emergencies, pass to the consultation of spontaneous attention directly, where they are valued by the nurse who once made the history, contact the doctor on call and will agree the action to follow. How was the document elaborated The first document was edited in September 2007. After 5 years, we have made a second edition, with a complete overhaul of the protocols, circuits and treatments according to the latest scientific evidence. Health problems, described according signs and symptoms, have been prioritized from a selection of the most frequent problems, which most of the nurses working in primary care resolve in daily practice. In this review we have identified 23 health problems solvable by nurses and 18 emergency possible intervention. Each health problem is divided into three sections: the first contains a brief definition of the problem, the second describes an algorithm of actuation which includes the history, assessment, intervention, alert causes and revisiting criteria and, finally, a third section includes most common nursing diagnoses NANDA (Norh American nursing Diagnosis Association).for each common health problem and possible nursing interventions-NIC (nursing Interventions Classification). NIC’s are divided into two blocks: the first block found those deemed essential or primary to be made to make the situation of health, and in the second block, the secondary or optional, that can be performed depending on the situation and nurse assessment. In the Annex there is a guide of all those drugs which are indicated in the protocols, indicating the active ingredient, presentation, route of administration, trademarks and properties of each, the pain scales most commonly used, the radiological projections, nursing assessment according to V.Herderson pattern and neurological assessment scales. Parallel to the development of the guide, work meetings have been done monthly with administrative, in order to identify weak points of the circuit. These sessions served to specific training on nomenclature, identification of warning signs and correct processing and referral of patients.

introduction



During the seven years we've been developing this project, the drive group, consisting of nurses, family physicians and administrative, has maintained regular work meetings, and have made the agreed modifications, both circuit and content according to a quality methodology. After closing the guide by the authors and agreed with contributors, there has been a review by three external professionals from three scientific entities: the Association of Family and Community Nursing of Catalunya (Aificc), the Catalan Society of Family and Communitary Medicine (Camfic) and Jordi Gol Foundation (Idiap)

Alba Brugués i Brugués

Nurse Attached to Direction-Management

Health Center Can Bou CASAP



With the aim of giving the best service to the population served, the members of the Primary Care Team Can Bou pledge to continue the “nursing interventions guide to health problems” developed with the consensus of all team professionals. This Guide is based on current protocols and in the evidence recommended in our country by scientific societies and public health services entities.

With the same intention and willingness to offer a solving and efficient service, we agree to follow the circuits and procedures detailed in this compendium adapted for acute pathology attention and based on those documents. These circuits will be extended and procedures will be updated depending on the disposition of new scientific evidence and the degree of resolution of our Primary Care Team deems necessary.

Healthcare team of EAP Can Bou

Castelldefels, december de 2012

commitment letter



p

circuit care demands

3

Possible nursing solving problems

4

Shared intervention emergency problems

Aggressions Cardiac arrest Seizures Heatstroke Severe abdominal pain Chest pain Fever >39ºC Intoxications Serious eye injury Intens headache Dizziness Drowning Loss of conscience Gastrointestinal

bleeding Traumatic brain injury Severe trauma Vomiting Anaphylactic shock

Oral thrush Emergency

contraception Burn Anxiety attack Diarrhea Blood presure elevation Epistaxis Wound Herpes Dermal lesion of skin

folds Sore throat Backache Toothache Discomfort when

urinating Animal bite Stye Bite Mosquito bite Allergic reaction Respiratory symptoms in

upper airways Sprained ankle Trauma Whitlows

2

Family physician non scheduled services

portfolio

Clínic visit Drop Genital herpes & zoster Eye injuries: - Conjunctivitis - Slight lesions - Red eye

Otalgia Varicella Other acute health

problems non protocolized on 1, 3 i 4 group

RX Interpretation Administrative gestion Hospital discharges maternal IT IT with hospital report Recipes: - hospital report - > 72 h. delay

diary - morphics - antidepressants - benzodiazepines

DOCTOR APPOINTMENT

ADMINISTRATIVE REFERRAL

DEMAND OF NON SCHEDULED VISIT

1

Nurse non scheduled services portfolio

Programming techniques on Diary Box: - Injection

Tracking cures Control BP Control OAT

(displaced)

Other acute health problems non protocolized on 3 & 4 groups

Pediatrician

emergency: - Telephone call to

pediatry nurse

NURSE

APPOINTMENT

DIARY BOX APPOINTMENT

TELEPHONE CALL & DIARY BOX

APPOINTMENT

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Date: 09/2007 Revision:: 08/2012 Version: 1.2

• Personal History • Drugs and allergies • Time of evolution • Clinical companion • Characteristics of pain • State vaccine (Td)

anamnesis

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• Vital Signs (Temp) • properties injury Oral thrush: • <7 days duration • One or few lesions smaller than 1cm. in diameter, whitish background and red outline • not have a high fever or malaise

assessment

• Analgesia if required as guideline: 1 gr/8h Paracetamol and /or Ibuprofen 600mg/8h • Topical Treatment: Carbenoxolone 2% gel 1 aplicación/8h. (6 days)

intervention

alert causes

• Other cases outside the oral cavity • At the discretion of the nurse

• If no improvement in 4-5 days

revisiting criteria

doct

or

There are many possible causes: superficial erosions, superinfections, nonspecific, inflammatory bowel disease, sexually transmitted diseases, secondary lesions, odonto-dental pathology, immunosuppression, allergies, drug intolerance, herpes, etc.. Most of the time the diagnosis is not confirmed and the lesions tend to disappear spontaneously.

oral thrush

1 Check drugs guide

Explanatory notes



NURSING INTERVENTIONS (NIC) INDISPENSABLE OPTIONAL 1400 Pain management 1710 Oral Health maintenance 2390 Medication prescribing 5616 Teaching: prescribed medication 5510 Health education 8100 Referral 7920 Documentation

NURSING DIAGNOSES NANDA 00132 Acute pain 00045 Impaired oral mucous membrane

oral thrush



• Age • Personal history • Drugs and allergies • Time from intercourse (<72 h.) • Other unprotected intercourse in the same cycle • Clinical companion • Last rule • Regular contraceptive method • Known hypersensitivity • Intestinal malabsorption syndrome

anamnesis

Date: 09/2007 Revision: 08/2012 Version: 1.2 Revisió

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• General condition • Pregnancy test if I delayed menstruation • Psychological and emotional maturity in girls 13-16 years

valoration

• 1500 mcg Levonorgestrel - Taken in front of us • Report: - If vomits before 2 h, must return to take another dose - If doesn’t have rule in 21 d. need to do a pregnancy test • Recommend a visit with ASSIR

intervention

alert causes

• If time since intercourse> 72 h • If positive pregnancy test

• If a history of hypersensitivity to the drug • If intestinal malabsorption syndrome • Under 13 years old • If treatment with broad-spectrum antibiotics, antiepileptics, antifungals, antiretrovirals and/or tuberculostatic • At the discretion of the nurse

• If vomits before 2 h, must return to take another dose • If doesn’t have rule in 21 d. need to do a pregnancy test

revisiting criteria

nurs

e

The "morning after pill" is an emergency contraception and can be used in unprotected sexual intercourse or suspected that the contraceptive method used may have failed.

emergency contraception



NURSING DIAGNOSES NANDA 00188 Risk-prone health behavior 00126 Deficient knowledge: contraception and safe sex

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 2300 Medication administration 5248 Sexual counseling 5510 Health education 5616 Teaching: prescribed medication 7920 Documentation 8100 Referral

emergency contraception



Date: 09/2007 Revision: 08/2012 Version: 1.2

• Age • Causal agent • Personal history • Drugs and allergies • Time evolution • Clinical companion • Characteristics of pain • State vaccine (Td)

anamnesis

med

ical

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• General condition • Vital Signs (temp and HR) • Grade, location, extension (see Annex 5) • Pain (see Annex 1) • Signs of infection • Presence of other lesions

valoration

• In all cases: - Assess the removal of clothing and objects - Wash and reduce local heat with physiological saline - Debride flictenas - Cures in wet environment with hydrocolloid with silver hydrofibre dressing or hydrophilic polyurethane gel or silver sulfadiazine - No compression elastic bandage - Tetanus prophylaxis if necessary • If pain: - Paracetamol 500 mg - 1 gr/6-8h. - Assess analgesia im d/p (if Metamizol im, telephone consultation)1 • If signs of infection: - Amoxi/clavulanate 500/125 mg c/8h. during 8 d. - If allergic to penicillin: Erythromycin 500 mg every/6 h during 8-10 d. • To tar: Dissolve with olive oil • Electrical burn: do ECG • Sunburn: - Moisturizer - Hydrocortisone Lotion 1%

intervention

alert causes

• Shock • Circulars and mucous • Skull, car, neck and genitals • Locations with significant aesthetic / functional compromise • 2nd grade> 10% body surface • 3rd grade> 2% body surface • power • inhalation • polytrauma • Suspected abuse or non-accidental origin • At the discretion of the nurse

• Signs of infection • Pain not controlled with scheduled analgesia • Reappearance of flictenas • Paresthesias • Signs of vascular compression • Malaise • Fever appearance • An incident occured with dressing

revisiting criteria

nurs

e

It is the tissue injury caused by thermal, chemical, radioactive or physical contact that causes cell destruction, edema and fluid loss.

burn

1 Check drugs guide

Explanatory notes



NURSING DIAGNOSES NANDA 00046 Impaired skin integrity 00044 Impaired tissue integrity 00132 Acute pain 00004 Risk for infection

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 3660 Wound cure 2390 Medication prescribing 1400 Pain management 1380 Heat/Cold application 6530 Immunization/vaccines management 3584 Skin care: topical treatments 5510 Health education 2300 Medication administration 7920 Documentation 8100 Referral

burn



• Age • Personal history • Drugs and allergies • Time evolution • Clinical companion • CVR factors • Mental health diagnoses • Psychological manifestations1 • Physical manifestations2

anamnesis


med

ical

val

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• General condition • Vital signs (BP, HR, RR, SatO2) • Breathing type

valoration

• If oppressive chest pain: - Do ECG • If hyperventilation - Breaths with bag or mask - Tips and breathing exercises / relaxation3 • Diazepam 5 mg sbl./8h (give tt for 48h) • Report side effects • Preview / spontaneous appointment with referring doctor

intervention

alert causes

• ECG interpretation • Persistence of the clinic in 30' • If has already established a psychiatric treatment: telephone assessment • At the discretion of the nurse

• Exacerbation of symptoms

revisiting criteria

is de reconsulta

1 Alert, fear, worry, fatigue, hypervigilance, distraction, lack of concentration, insomnia, stress ... 2 Tachycardia, palpitations, elevated BP, dyspnea, tachypnea, sweating, tremors, pain, muscle

tension, tingling, dizziness, gastrointestinal disorders... 3 Deep diaphragmatic breathing: inspire slowly and deeply for 5'', hold the air during 5-7'’ and

exhale slowly during 10'' Relaxed diaphragmatic breathing: nose inspiration by 2-3'', pause briefly, exhale slowly for 4-6'' and do another short break before returning to inspire.

explanatory notes

doct

or

Episode of sudden and unexpected occurrence that manifests itself with fear of losing control or that something bad must happen, or even fear of dying. It is accompanied by symptoms such as difficulty breathing, chest pain, palpitations, sweating, trembling, dizziness and unsteadiness, tingling, nausea, and abdominal discomfort.

anxiety attack



NURSING DIAGNOSES NANDA 00146 Anxiety 00148 Fear 00032 Ineffective breathing pattern

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 5820 Anxiety reduction 6160 Crisis intervention 6680 Vital signs monitoring 2300 Medication administration 3350 Respiratory monitoring 5230 Coping enhacement 5510 Health education 5880 Relaxation techniques 7920 Documentation 8100 Referral

anxiety attack



• Age • Personal history • Drugs and allergies • Time evolution • Clinical companion • Presence of vomiting • Stool characteristics (blood, pus or mucus) • Number and types of stools • Recent trips • Recent drugs • Others affected

anamnesis


med

ical

val

orat

ion

• General condition • Vital signs (temp, HR and BP) • Diabetic patient: capillary glycemia • Pain (see Annex 1) • Abdominal examination: soft belly and increased peristalsis • Hydration, skin and mucous

valoration

• Diet: - Oral Rehydration (water and infusions) - Dietary recommendations for the gradual reinstatement of food • Relative rest • If fever or pain: - Paracetamol 500 mg - 1gr/6-8h. o • If vomiting: - Metoclopramide 10 mg im /o • Hygiene standards • If necessary, provide IT (Telephone consultation. MF, N, print IT )

intervention

alert causes

• Important malaise • Fever> 38 ° C • immunosuppression • Fecal pathological products (blood, pus, mucus) • Duration of more than 3 days • Frequent vomiting> 5/12h or bloody • oral intolerance • Suspected food toxoinfección collective or pharmacological • DM with altered capillary glycemia • Signs of dehydration • Altered abdominal palpation • severe pain • Inflammatory bowel disease • Pain located at a point • At the discretion of the nurse

• If fever> 38 º C • Presence of blood, mucus and / or pus in stool • Onset of frequent vomiting (> 5/12h) • Persistence of symptoms after 5 days

revisiting criteria

doct

or

Acute gastroenteritis (AGE) is considered the increased number of stools, with or without abdominal discomfort and/or vomiting with or without fever, of less than 5 days duration and no prior drug treatment. Keep in mind the possibility of food toxicoinfections.

diarrhea



NURSING DIAGNOSES NANDA 00013 Diarrhea 00134 Nausea 00028 Risk for deficient fluid volume

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 2390 Medication prescribing 5602 Teaching: desease process 0460 Diarrhea management 5614 Teaching: prescribed diet 1450 Nausea management 5510 Health education 1570 Vomit management 7920 Documentation 2080 Liquids management 5616 Teaching: prescribed medication 8100 Referral

diarrhea



When a sudden increase in blood pressure takes place, in relation to normal pressure values of the person.

• Age • Personal history • Drugs and allergies • Time evolution • Clinical companion • CVR factors • HTA known with therapeutic fulfillment • Reasons and conditions of its encounter (how it was identified)

anamnesis

med

ical

val

orat

ion

• General condition • Vital signs (temp, HR, RR, SatO2) • Confirm arm control: - 2 mesures in a interval of 5' • Presence of alert signs1

valoration

• If TAS 140-179 and TAD 90-109 without warning signs - Rest 30 ' - New control • Preview appointment with referring nurse on 24/48 h.

intervention

alert causes

• In case of presence of alert signs1 • TAS ≥180 and TAS ≥ 110 • At the discretion of the nurse

• Case of appearance of alert signs1 • TAS ≥180 and TAS ≥ 110

revisiting criteria

doct

or

blood pressure elevation


1 Sudden headache, syncope, blurred vision, chest pain or acute abdominal pain, palpitations, dyspnea, tachypnea, tachycardia, and edema in lower limbs

explanatory notes



NURSING DIAGNOSES NANDA 00204 Ineffective peripherial tissue perfusion 00146 Anxiety 000079 Noncompliance

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 2390 Medication prescribing 5510 Health education 5616 Teaching: prescribed medication 7920 Documentation 2300 Medication administration 5820 Anxiety reduction 5040 Therapy of simple relaxation 4420 Patients contracting 5240 Counseling 8100 Referral

blood pressure elevation



It is bleeding originated in the nostrils. Anterior and posterior epistaxis: two clinical variants we can differ.


epistaxis

• Age • Personal history • Drugs and allergies (anticoagulants, antiplatelet and antihypertensive) • Time evolution and prior history of epistaxis • Clinical companion • Cause: - Local (erosion, trauma, contusion, mucosal dryness, rhinitis, cold) - General (bleeding disorder, HBP and use of anticoagulants)

anamnesis

med

ical

val

orat

ion

• General condition • Vital signs (BP, HR, Temp) • Warning signs and symptoms: headache and systemic involvement • Amount of bleeding • INR if anticoagulation treatment • Nasal cavity exploration • Location of bleeding: anterior or posterior

valoration

• Position: bring chin to chest (avoid horizontal) • If contusion: local application of gel • Mechanical compression with 2 fingers for 10 ' in the nostrils • If does not yield with compression, value doing nasal anterior tamponade with nasal gauze + vaseline or tranexamic acid • Keep nasal tamponade up to 2 days and re-evaluate • Recommended cure of tamponade • If not yield: valoration of a doctor • Preview appointment with referring nurse on 48 h

intervention

alert causes

• Case of presence of warning signs • TAS ≥150 and TAS ≥ 95 • Suspected posterior epistaxis (nasal bleeding non stop with compression) • Bleeding bilateral • Use of oral anticoagulant drugs or patients with bleeding disorders. • At the discretion of the nurse

• Case of appearance of warning signs • Reappearance of bleeding • TAS ≥150 and TAS ≥ 95 + symptoms of HBP added

revisiting criteria

doct

or



NURSING DIAGNOSES NANDA 00132 Acute pain 00146 Anxiety

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 5880 Relaxation techniques 4160 Control of bleeding 2300 Medication administration 4024 Bleeding reduction: nasal 1400 Pain management 5510 Health education 8100 Referral 7920 Documentation

epistaxis



• Age • Personal history • Drugs and allergies • Evolution time and date of injury • Causal agent of wound • Clinical companion • State vaccine (Td)

anamnesis


med

ical

val

orat

ion

• General condition • Vital signs (temp, BP) • Wound characteristics • Location, extension and depth • Signs of infection • Presence of foreign bodies • Presence of other injuries (fractures, bruises, tendon affectation)

valoration

• In all cases: - Haemostasis if necessary - Cleaning and disinfection with chlorhexidine - Prophylaxis Td if necessary - Occlusive dressing - Quote nurse cures for later • If open <6 h. evolution: - Anaesthesia mepivacaine and suture if necessary1 • If it is> 6 h. or no possibility of suture: - Wet cure with semi-occlusive dressing • If pain: - Paracetamol 500mg - 1gr/6-8h. • If signs of infection: - Cure in humid environment. Assess use of silver dressing or collagenase - Amoxi/clavulanate 500/125mg every/8h. during 8 d. • If allergic to penicillin: Erythromycin 500 mg every/6h during 8-10 d.

intervention

alert causes • BP <100/60 or HR> 100 • Presence of other lesions • Affectation: face, joints, nerves or tendons • If press injuries is necessary • Extensive hemorrhage • At the discretion of the nurse

• Appearance of infection signs • Pain not controlled with analgesia scheduled • Active bleeding • Paresthesias • Signs of vascular compression • Malaise • Appearance of fever • If an incident occurs with the dressing

revisiting criteria

1 Sutures Face: 5-6/0 Head: 2-3/0 or staples Chest and back: 3-4/0

Extremities: 3-4-5/0 Lower extremities: 3-4/0 Subcutaneus tissue: 3-4/0 (vicryl)

explanatory notes

nurs

e

The most common injuries in primary care are bruises on the head or extremities, caused basically by domestic or sports accidents, followed by injuries with cutting objects, usually on the hands.

wound



NURSING DIAGNOSES NANDA 00046 Impaired skin integrity 00044 Impaired tissue integrity 00132 Acute pain 00004 Risk for infection

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 3660 Wound cure 2390 Medication prescribing 6530 Immunization/vaccines management 1380 Heat/Cold application 5510 Health education 3584 Skin care: topical treatments 7920 Documentation 2300 Medication administration 1400 Pain management 3620 Suture 5618 Teaching: procedure/treatment 6550 Infection protection 8100 Referral

wound



• Age • Personal history • Drugs and allergies • Evolution time • Clinical companion • Characteristics of pain • State vaccine (Td)

anamnesis


med

ical

val

orat

ion

• General condition • Vital signs (temperature) • Lesion characteristics • Location and extension

valoration

Treatment of herpes simplex: - Analgesia if required by guideline: Paracetamol 1gr/8h and / or Ibuprofen 600mg/8h 1 - In active lesions (<48h) topical acyclovir every/4h (under development) - In dry lesions: calcareous liniment oil or 50% H2O - If signs of infection: Mupirocin ® - Prophylaxis (Td) if necessary

intervention

alert causes

• If suspicion of: - Herpes zoster - Ocular Herpes • Case of: - Extensive Herpes Simple - Genitals - Nose - Recurrent episodes (> 6 episodes / year) • At the discretion of the nurse

• If no improvement in 4-5 days

revisiting criteria

doct

or

Herpes is characterized by causing painful or itchy vesicular lesions produced by the virus of the same name. If the lesion is located in the path of a nerve (dermatome), it is caused by herpes zóster. If the lesion is located in the perioral /oral or genital area, the cause is herpes simple.

herpes

1 Check drugs guide

explanatory notes



NURSING DIAGNOSES NANDA 00132 Acute pain 00046 Impaired skin integrity

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 5510 Health education 2390 Medication prescribing 7920 Documentation 6530 Immunization/vaccines management 8100 Referral

herpes



Erythematous lesion in the area of skin folds: groins, armpits, inframammary regions and gluteal region.


dermal lesion of skin folds

• Age • Personal history • Drugs and allergies • Time evolution • Clinical companion • Lesion characteristics

anamnesis

med

ical

val

orat

ion

• General condition • Location • Features: erythematous plaque, bright red-edged • Presence of exudate and /or fissures • Presence of predisposing factors: humidity, poor hygiene

valoration

• Topical application of: Clotrimazole 1% every/12h during 2-3 weeks • Recommendations: - Proper hygiene - Keep the zone into the air and dry - Correction of predisposing factors

intervention

alert causes

• Atypical features of the lesions • Systemic involvement • Pregnancy or breastfeeding • Immunosuppression or DM • Presence of other disseminated lesions • Presence of cellulite • Suspected allergic component • Injury to genital area or oropharyngeal area • At the discretion of the nurse

• If no improvement in 1-2 weeks of treatment • Systemic involvement • Exacerbation of symptoms • If there are other injuries

revisiting criteria

doct

or



NURSING DIAGNOSES NANDA 00004 Risk for infection 00046 Impaired skin integrity

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6610 Risk identification 3590 Skin surveillance 5510 Health education 2390 Medication prescribing 7920 Documentation 5616 Teaching: prescribed medication 8100 Referral

dermal lesion of skin folds




• Age • Personal history • Drugs and allergies • Time evolution • Characteristics of pain • Clinical companion

anamnesis

med

ical

val

orat

ion

valoration

• Analgesia if required: - Paracetamol 650 mg-1 g. every/6-8h or Ibuprofen 600 every/6-8h1 • If presents pharyngeal tonsillar exudate and previous laterocervical lymphadenopathy: - Fever> 38 ° C: • Amoxicillin 500-750 mg ∙ every/8h. (7 days). If allergy: Erythromycin 500 mg every/6 h. (8-10 days) - Hygienic and dietary tips: • No smoking • Increased fluid intake • rinses with lemon juice, chamomile or thyme • Avoid excess sugar

intervention

alert causes

• Clinic> 7 days duration • Immunosuppression • Fever> 40 ° C or> 38 ° C and> 72 h. • COPD or asthma • Shortness of breath and / or severe aphonia • Heart disease and / or poorly controlled DM • Intense earache • Asymmetry of the soft palate • Malaise • No improvement with previous treatment • Pregnancy and lactation • Previous episodes the latest 15 days • At the discretion of the nurse

• If symptoms do not improve in 48 hours

revisiting criteria

1 Check drugs guide

explanatory notes

doct

or

• General condition • Vital signs (temp, BP, HR) • Examination of the oral cavity and pharynx (soft palate, tonsils, ...) • Exploration of submandibular and laterocervical lymphadenopathy

Odynophagia is painful swallowing, often accompanied by dysphagia (subjective feeling of difficulty in passing the alimentary bolus during swallowing).

sore throat



NURSING DIAGNOSES NANDA 00132 Acute pain 00007 Hyperthermia 00004 Risk for infection 00045 Impaired oral mucous membrane

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 2300 Medication administration 1400 Pain management 2380 Medication management 2390 Medication prescribing 1710 Oral Health maintenance 5616 Teaching: prescribed medication 5602 Teaching: desease process 5510 Health education 8100 Referral 7920 Documentation

sore throat



• Age • Personal and work history • Previous episodes and treatments • Drugs and allergies • Time evolution • Clinical companion - Constitutional symptoms - Urinary discomfort - Neurologic deficit • Pain features1 - Intensity of pain (see Annex 1) - Mechanical - Inflammatory

anamnesis


med

ical

val

orat

ion

• General condition • Vital signs (temp, BP, HR) • Maneuver Lasègue2 • Lumbar fist percussion

valoration

• Staying active as far as pain allows • Local heat • Treatment: Paracetamol 650mg-1g and / or Ibuprofen 400-600 mg every/8h. and / or Tetrazepam 50 mg / Diazepam 5 mg every / night. (3-4 days) 3

intervention

alert causes

• Age> 55. (only if it’s first episode) • Pregnancy or breastfeeding • Antecedent of trauma • History of previous backache with treatment that has not improved • Immunosuppressed • Osteoporosis • corticosteroid prolonged Taken • Functional impotence • Constitutional symptoms: - Fever, weight loss, malaise and / or asthenia • Neurological deficit - Incontinence of sphincter • Pain radiating to the lower extremities • Inflammatory characteristics pain • Pleuritic pain or pain in hemi-belt • Fever • Maneuver Lasègue positive • Positive lumbar fist percussion • At the discretion of the nurse

1 Features of pain: Inflammatory: not related to movement, no improvement or even worse over night rest and is accompanied by morning stiffness. Mechanical: increases with movement and does not improve with rest

2 Maneuver Lasègue: leg lifts with the knee in extension Positive: radiating pain appears in the leg Negative: there is pain in the lower back or in buttock

3 Check drugs guide

explanatory notes

doct

or

• If symptoms do not improve in 72 h.

revisiting criteria

Presence of pain localized at the dorso-lumbar spinal segment. Many of these pains are part of a complete rachialgia, most of them have an unknown etiology, are self-limited in time and have a benign prognosis.

backache



NURSING DIAGNOSES NANDA 00132 Acute pain 00085 Impaired physical mobility

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 1400 Pain management 2210 Analgesic administration 2390 Medication prescribing 2380 Medication management 5616 Teaching: prescribed medication 1380 Heat/Cold application 5510 Health education 5612 Teaching: prescribed exercice 7920 Documentation 8100 Referral

backache




• Age • Personal history • Drugs and allergies • Time evolution • Characteristics of pain • Clinical companion • State vaccine (Td)

anamnesis

med

ical

val

orat

ion

• General condition • Constant (temp) • Recent oral manipulations • Exploration of the oral cavity

valoration

• Prophylaxis if necessary • Analgesia, if necessary: - Paracetamol 650 mg-1g. every/6-8 h., Ibuprofen 600 every / 8 h. or Metamizol 575mg every / 8 h.1 • Manage: - IM Diclofenac or Metamizol vo blisters. if necessary. • Antibiotic treatment: - Amoxicillin / clavulanate 500/125 every / 8 h. (7 days) - If allergic: Clindamycin 300 mg every/ 6 h. (8-10 days) • Hygienic and dietary tips: - No smoking - Rinses with chlorhexidine 0.12% every/24 h. (15 days) - Avoid very hot or very cold drinks • Appointment with dentist

intervention

alert causes

• Immunosuppression • Fever> 38 ° C • Significant edema • Cellulitis or abscess • Systemic disturbance • Impaired swallowing • Pregnancy and lactation • At the discretion of the nurse

1 Check drugs guide

explanatory notes

dent

ist

doct

or

If no improvement in 48 h. • If intolerance to treatment

revisiting criteria

Toothache is the cause of the most primary care practices related to the oral cavity and accounts for up to 20% of acute pain treated in an emergency department.

toothache



NURSING DIAGNOSES NANDA 00132 Acute pain

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 1400 Pain management 1710 Oral Health maintenance 2390 Medication prescribing 2380 Medication management 5510 Health education 2300 Medication administration 7920 Documentation 5602 Teaching: desease process 8100 Referral

toothache



• Age • Personal history • Other UTI • Drugs and allergies • Time evolution • Clinical companion • Characteristics of pain

anamnesis


med

ical

val

orat

ion

• General condition • Vital signs: (temp) • Urine dipstick • Urine characteristics • Lumbar fist percussion

valoration

• If presents 2 or more signs or 2 or more symptoms: Signs Symptoms Nitrites + Dysuria Leukocytes + Pollakiuria Hematuria + Urinary urgency Dark urine suprapubic pain • Hygienic and dietary tips1

• Fosfomycin 3 g (single dose). If allergy, Amoxicillin-clavulanate 500-875 / 125 mg every/8h 5d • If pain: Paracetamol 500g - 1g every/6-8h

intervention

alert causes

• Man • Woman> 65. • Woman with DM • Pregnancy or breastfeeding • Temp> 37 ° • Chills • More than 7 days evolution • Patients with recurrent UTI - More than 2 episodes in 6 months - More than 3 episodes in 1 year • Positive lumbar fist percussion • ITU relapse treated in the latest 15 days • History of pyelonephritis in the last year • Alteration of vaginal discharge • Carrier urinary catheter • Nephrology malformations or abnormalities of the urinary tract • Frank hematuria • At the discretion of the nurse

1 Emptying the bladder c/2-3h, perianal hygiene, urination before / after intercourse, cotton underwear 2 Reference nurse will request a urine culture after 5 days of treatment and will end giving telephone appointment with their FP to pick the outcome / TT

explanatory notes

doct

or

nurs

e • Appearance of: - Fever - Frank hematuria - Low back pain - Nausea or vomiting • Anury

• Persistence of symptoms after finishing treatment 2

revisiting criteria

An uncomplicated urinary tract infection (UTI) is the lower urinary tract infection presenting exclusively local symptoms.

distress when urinating



NURSING DIAGNOSES NANDA 00132 Acute pain 00016 Impaired urinary elimination 00004 Risk for infection

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 7820 Specimen management 0590 Urinary elimination management 2390 Medication prescribing 1750 Perineal care 5510 Health education 5616 Teaching: prescribed medication 7920 Documentation 5602 Teaching: desease process 8100 Referral

distress when urinating




• Age • Personal history • Drugs and allergies • Time bite • Time evolution • State vaccine (Td) • Clinical companion • Causal animal

anamnesis

med

ical

val

orat

ion

• General condition • Vital signs (BP and HR) • Lesion characteristics (location and extension) • Pain (see Annex 1) • Signs of infection

valoration

• Wash with soap and water + Chlorhexidine • Healing with silver dressing • Immobilization and / or occlusion of the affected area • No suturing. If necessary, approach points • Bacterial prophylactic treatment according to guideline: Amoxicillin- Clavulanate 500-875/125mg every/8h for 1 week. If allergies Erythromycin 500 mg. every/6h 8-10 days • Analgesia, if necessary1 • Prophylaxis Td + IGT (in wound without complete primary vaccination or unknown primary vaccination) • Discard rabies infection if bat bite • Appointment with reference nurse. 1rst cure in 24h

intervention

alert causes

• If is necessary a injuries press • Nausea and vomiting • Diarrhea and abdominal pain • Allergic reaction • Hypersensitivity to poison • At the discretion of the nurse

• Signs of infection • Pain not controlled with scheduled analgesia • Active bleeding • Paresthesias • Signs of vascular compression • Malaise • Onset of fever • If an incident occurs with the dressing

revisiting criteria

1 Check drugs guide Antirabies center: Hospital del Mar, Paseo Marítimo, 25-29-08003 Barcelona - Tel: 93 221 10 10 Toxicology Institute in Barcelona: C. Mercè, 1- 08002 Barcelona - Tel.93 317 44 00 Specialty Care: Hospital Vall d'Hebron, Paseo Vall d'Hebron, 119-129 08035 Barcelona - Tel. 93 489 30 00

explanatory notes

nurs

e

Keep in mind that according to the origin of the bite, the vector can transmit various infections. Cat bites and human are more likely to become infected than dog.

animal bite



NURSING DIAGNOSES NANDA 00046 Impaired skin integrity 00132 Acute pain 00004 Risk for infection

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 3660 Wound cure 1400 Pain management 6530 Immunization/vaccines management 2300 Medication administration 2390 Medication prescribing 3620 Suture 5510 Health education 6550 Infection protection 7920 Documentation 8100 Referral

animal bite




Localized infection in the glands of the eyelids or in the hair follicles of the eyelashes. Usually produced by Staphylococcus aureus.

• Age • Personal history • Drugs and allergies • Date of injury • State vaccine (Td) • Clinical companion

anamnesis

med

ical

val

orat

ion

• General condition • Vital signs (temp) • Lesion characteristics • Location and extension

valoration

• Chlortetracycline (Aureomycin ointment) 1 applic/8h. 7 days. • Hot Rags 15 '3-4 times / day • Standards of hygiene (hand washing, not sharing towels, not handle injuries ...)

intervention

alert causes

• Impaired vision • Red eye • Fever> 38 ° C • Presence of flictenas, eyelid cellulitis or photophobia excess • At the discretion of the nurse

• If no improvement in 72 hours.

revisiting criteria

doct

or

stye



NURSING DIAGNOSES NANDA 00044 Impaired tissue integrity 00004 Risk for infection

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 1380 Heat/Cold application 8100 Referral 2390 Medication prescribing 5510 Health education 7920 Documentation

stye




• Age • Personal history • Drugs and allergies • Time of contact • Clinical companion

anamnesis

med

ical

val

orat

ion

• General condition • Vital signs (BP and HR) • If dyspnea assess uvula and SatO2 • Pain (see Annex 1) • Lesion characteristics: - Dysesthesia (altered sensation) - Edema, redness and heat - Lymphatic route and regional adenopathy

valoration

In all cases: • Remove rests of animal without scrubbing • Wash with physiological saline • Apply local cold except weeverfish (warm compresses gradually hot to 45°C for 30-90 ') • Application: - Chlorhexidine every/6-8h - Hydrocortisone Lotion 1% every/8- 12h 3d • Assess antibiotic treatment • Analgesia, if necessary 2 • Prophylaxis (Td), if necessary • Immobilization of limb, if necessary • Treatment depending on etiologic agent1

intervention

alert causes

• Anaphylactic shock (see protocol) • Possible bone alteration • Paresthesia • At the discretion of the nurse

• At the discretion of the nurse • Persistence of symptoms after treatment is finished

revisiting criteria

1 Treatment depending on etiologic agent: • Paparra: Put Vaseline and after a minute remove it with tweezers by smooth and continuous traction. • Bee: Remove the stinger carefully as it carries the venom (without pressure). • Scorpio: Inmersion of the affected part in cold water. • Spider: May require anesthesia and muscle relaxants sc, vo corticosteroids. • Medusa: Avoid friction and contact with fresh water • Weeverfish: Bathing the affected area with warm water or hot physiological saline (thermolabile toxin). • Assess IM administration of corticosteroids (tel. Doctor on-call) in all cases if significant reaction. 2 Check drugs guide

explanatory notes

nurs

e

Wound mainly by insects, arthropods and marine animals through which inject toxic substances that act locally and / or systemically depending on etiology, the amount of toxin injected and the organic response of the person.

bite



NURSING DIAGNOSES NANDA 00132 Acute pain 00044 Impaired tissue integrity 00004 Risk for infection

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 1400 Pain management 1380 Heat/Cold application 2390 Medication prescribing 2380 Medication management 3584 Skin care: topical treatment 2300 Medication administration 3680 Wound irrigation 6530 Immunization/vaccines management 5510 Health education 8100 Referral 7920 Documentation

bite



Data: 09/2007 Revisió: 08/2012 Versió: 1.2

• Age • Personal history • Drugs and allergies • Evolution time • Clinical companion

anamnesis

med

ical

val

orat

ion

• General condition • Vital signs (temp) • Mobility difficulties in case of limbs bite • If dyspnea assess uvula and SatO2 • Characteristics of the lesions (erythema, edema, induration, warmth, pain, itching ...) • Lymphatic route and regional adenopathy • Pain (see Annex 1)

valoration

• If presents edema, itching, induration, erythema:

- Washed (physiological saline) - Local desinfection Clorhexidina - Lotion hidrocortisona 1% with

guiding home every/12h max. 7 days.

- Vacunal state valoration(Td) - Local cold

• If intense itching assess Antihistamine im/orally1 • If ampules:

- Open flictena, remove serous content and the rests of skin

- Cure with silver dressing - Treatment valoration in 24h

• If infection signs: - Valorate an Antibiotic orally2

• If intense pain: - Analgesia depending on

guideline(Paracetalmol/Ibuprofen)3

intervention

alert causes

• In case of shock anaphylactic (look at protocol) • View nurse criterion

1 Dexchlorpheniramine im puntual and/or by guideline orally every/8h making some variations on the guideline depending on the sleepiness from 1 to 3 tablets/ day.

2 Antibiotic treatment: Amoxicilina- Clavulánic 500-875/125 mg. every/8h during 8 days. If allergy to penicilin: Clindamycin 300mg every/6h during 8 days.

3 Check drugs guide.

explanatory notes

nurs

e

• View nurse criterion • Persistence of symptomatology when the treatment finished

revisiting criteria

Wound produced by the injection of toxic substances that act in a local and/or systemic way depending on etiology, the quantity of toxins injected and the organic response.

mosquito bite



NURSING DIAGNOSES NANDA 00132 Acute pain 00044 Impaired tissue integrity 00004 Risk for infection

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 1400 Pain management 1380 Heat/Cold application 2390 Medication prescribing 2380 Medication management 3584 Skin care: topical treatment 2300 Medication administration 5510 Health education 8100 Referral 7920 Documentation

mosquito bite



allergic reaction

• Age • Personal history • Drugs and allergies • Time evolution • Clinical companion


For mild itching: • Remove jewelry • Antihistamine treatment by guideline: - Loratadine 10 mg every/24h vo - Dexchlorpheniramine 2mg every/8h. orally or im for 7 days. • Appointment with referring physician (24/72h.)

intervention

• In case of severe urticaria *, prepare: - Dexchlorpheniramine 5mg im - Methylprednisolone 40-60 mg lm - Actocortina 100 mg im • In case of anaphylactic shock: - Check protocol • Edema of uvula • Alteration of the airway • At the discretion of the nurse

• Persistence of symptoms • At the discretion of the nurse

revisiting criteria

* Etiologic agent of urticaria: Immunologic IgE: food, drugs or pollen. No immunological: antibiotics, aspirin, contrasts or nonsteroidal anti-inflammatory. Idiopathic: unknown cause. For the complement system: angioedema or urticaria-vasculitis.

explanatory notes

doct

or

• General condition • Vital signs (BP-HR-RR-Temp) • Lesion Characteristics • Intensity of pruritus • Oropharyngeal examination (edema) • Dyspnea (Sat O2)

valoration

It is a response of the body when it comes into contact with certain substances (allergenic or allergens) from exterior.

anamnesis alert causes

med

ical

val

orat

ion



NURSING DIAGNOSES NANDA 00044 Impaired tissue integrity 000204 Ineffective tissue perfusion: peripheral

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 3590 Skin surveillance 2390 Medication prescribing 2380 Medication management 6410 Allergy management 2300 Medication administration 3350 Respiratory monitoring 6412 Anaphylaxis management 5820 Anxiety reduction 3140 Airway management 6650 Surveillance 8100 Referral 5510 Health education 7920 Documentation

allergic reaction



• Age • Personal history • Drugs and allergies • Time evolution • Clinical companion (cough, expectoration, earache, pleuritic pain, dyspnea, rhinorrhea, myalgia, sore throat) • Severe headache, vomiting, and skin lesions

anamnesis


med

ical

val

orat

ion

• General condition • Constants: (HR, RR, SatO2, Temp.) • Respiratory auscultation • Oropharyngeal exploration • Probing latero-cervical lymphadenopathy and submandibular

valoration

• If fever, myalgia, malaise or headache: - Abundant water intake - Sleep / hygienic measures - Paracetamol 650 mg-1g. every/6- 8h. or Ibuprofen 600 every/8h. • If dry cough: - Dextrometorfano1 15 to 30 mg every 6-8h (max 120 mg / day) • If severe sore throat: - Protocol sore throat • If nasal congestion: - Nasal washes with hypertonic fluids - Oxymetazoline every/12h (max 5 days) - Loratadine every/24h • Anti-smoking Counseling • Facilitate Temporary Disability if necessary

intervention

alert causes

• Patients with risk factors - COPD - Asthma - Diabetes - Immunosuppression - Pregnancy • Fever> 38 º maintained> 72h. • Fever> 40 ° • Sat O2 <95 • Altered respiratory auscultation • Pleuritic pain • Dyspnea • Stabbing pain in side • Presence of severe headache, vomiting, and skin lesions • Earache or drainage • Recent hospitalization • Prostration • At the discretion of the nurse

• Persistence of fever> 39 ° C at 48 hours and antipyretics resistance • Dyspnea • Progressive deterioration • Appearance of sharp pain in the side

revisiting criteria

1 Dextromethorphan is contraindicated in cases of taking MAOI

explanatory notes

doct

or

Set of acute inflammatory processes affecting the respiratory mucosa of the upper airways. The most common symptom is dysthermic, nasal congestion, cough and malaise among others.

respiratory symptoms in upper airways



NURSING DIAGNOSES NANDA 00132 Acute pain 00031 Ineffective cleansing of upper airways 00004 Risk for infection

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 1800 Self-care assistance 2390 Medication prescribing 2380 Medication management 5510 Health education 2300 Medication administration 7920 Documentation 1400 Pain management 5602 Teaching: desease process 5616 Teaching: prescribed medication 8100 Referral

respiratory symptoms in upper airways



Injury of parts of the ankle by a mechanism of transmitting forces and crushing.


sprained ankle

• Age • Personal history • Drugs and allergies • Time evolution • Clinical companion: pain and / or functional impotence • Trigger mechanisms

anamnesis

med

ical

val

orat

ion

• Pain (see Annex 1) • Degree of local edema and hematoma • Rule Ottawa1 • Define degree of esguince2 • Suspected associated fracture and need of Rx • If Rx advise not walking until the assessment

valoration

• Local gel • Dressing according degree sprain - Grade I or loosening: taping - Grade II: compression bandage, boot or plaster - Grade III: plaster (acting as directed by your doctor) • Recommend: - Elevation of limb - Rest • Antiinflammatory Ibuprofen 400- 600mg every/6-8 hours3 • Review with nurse / physician referral in a week

intervention

alert causes

• If is necessary a injuries press • Presence of other lesions • Suspected grade III sprain •At the discretion of the nurse

• In case onset of: - Signs of vascular compression - Paresthesias - Pain not controlled with scheduled analgesia

revisiting criteria

doct

or

1 Rule of Ottawa: Ability to maintain weight / Inability to take four steps / pain palpation. 2 Sprain degree:

Degree inability Pain swelling inestability Recurrence I Minimum Punctual Minimum No No II Moderate Diffuse slight slight unfrequent III Severe Important Important Yes Frequent

3 Check drugs guide

explanatory notes

• If an incident occurs with bandage

nurs

e



NURSING DIAGNOSES NANDA 00132 Acute pain 00046 Impaired physical mobility

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 1380 Heat/Cold application 5820 Anxiety reduction 0910 Immobilization 8100 Referral 2390 Medication prescribing 5616 Teaching: prescribed medication 1400 Pain management 5510 Health education 7920 Documentation

sprained ankle



• Age • Personal history • Drugs and allergies • Evolution time and date of injury • Lesional mechanism1 • Clinical companion

anamnesis

med

ical

val

orat

ion

• General condition • Vital signs (TA) • Pain (see Annex 1) • Lesion characteristics • Lesion localization - Rib cage: auscultation + SatO2 • Hematuria (lumbar contusion) • Functional impotence • Deformity, swelling, edema • Ecchymosis, hematoma, paresthesia • Presence of other lesions • If sprain: define degree2

valoration

• If only bruise: - Local Gel - Analgesia, if necessary, according to guideline (Ibuprofen 400-600mg/6- 8h)3 - Immobilization: ∙ Toes: Imbricated ∙ Fingers: Finger splint ∙ Sprain grade I-II: elastic adhesive bandage ∙ Sprain grade III: pressure dressing (acting as directed by your doctor) • Suspected fracture: RX request (see Annex 2)

intervention

alert causes

• BP <100/60 or HR> 100 • Afectation to: skull / face, joints, or abdomen • Trauma imp. abdominal / trunk • Extensive hemorrhage • Suspected grade III sprain • Assessment RX • Auscultation altered and / or SatO2<96% • If is necessary a injuries press • At the discretion of the nurse

• Not controlled pain with scheduled analgesia • Paresthesias • Signs of vascular compression • Malaise • Onset of fever> 38 º C

revisiting criteria

1 Lesional mechanism: Accident or assault: notify the physician on call for the release of injuries press. Occupational accident: making the 1st cure initial assessment and refer the mutual labor. If labor or traffic accident: Need notifying center management. 2 Sprain degree:

Degree Inability Pain Swelling Inestability Recurrence I Minimum Punctual Minimum No No II Moderate Diffuse Slight Slight unfrequent III Severe Important Important Yes Frequent

3 Check drugs guide

explanatory notes

doct

or

There are three types of injuries: bruise, sprain and fracture. The treatment will be in function of the severity of the injury.

trauma Date: 09/2007 Revision: 08/2012 Version: 1.2 Revisió



NURSING DIAGNOSES NANDA 00132 Acute pain 00046 Impaired skin integrity 00085 Impaired physical mobility

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 2390 Medication prescribing 6680 Vital signs monitoring 1400 Pain management 2380 Medication management 5510 Health education 2300 Medication administration 7920 Documentation 3680 Wound irrigation 3660 Wound cure 0910 Immobilization 1380 Heat/Cold application 8100 Referral

trauma




• Age • Personal history • Drugs and allergies • Date of injury • State vaccine (Td)

anamnesis

med

ical

val

orat

ion

• General condition • Vital signs (temp) • Lesion features 1 • Location and extension

valoration

• Wash with soap and water + Chlorhexidine • Assess debridement, drainage and cultivation takes • Cure with fusidic acid or silver dressing • Assess antibiotic treatment according guideline1 • Immobilization and / or occlusion of the affected area • Prophylaxis (Td), if necessary

intervention

alert causes

• If presents lymphangitis • Alteration of the nail bed • At the discretion of the nurse

• At the discretion of the nurse • If an incident occurs with the dressing

revisiting criteria

1 Lesion features: • Greenish exudate (suspected pseudomonas: Ciprofloxacin 500mg/12h 10d orally) • Vesicles (suspected herpes: herpes see protocol) • If recurrent / chronic ingrown, fungal are suspected • Purulent / whitish exudate (suspects Staphylococcus: Cloxacillin 500mg every/6-8h orally 7- 10d.)

explanatory notes

nurs

e

whitlows

It is an acute infection in the nail area due to bacteria, fungi or herpes. The predisposing factors are: local trauma, ingrown toenails, diabetic patients, immunosuppressed or bitten nails. It is characterized by redness, swelling and pain, and in severe cases, cellulitis or lymphangitis may reach occur.




NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 3600 Wound cure 1380 Heat/Cold application 2390 Medication prescribing 2380 Medication management 5510 Health education 2300 Medication administration 7920 Documentation 6530 Immunization/vaccines management 8100 Referral

whitlows

purg

ent h

ealth

prob

lem

s



Act or violent attack that aims to cause injury to whom it is addressed.

• Age • Personal history • Drugs and allergies • Time evolution • Injury mechanism1 • Clinical companion

anamnesis


• General condition • Vital signs (BP, RR, HR) • Emotional state • Presence of wounds and/or anxiety • Imminent proximity of the aggressor • Suspected fracture

valoration

• If anxiety, act according to protocol • If injured, act according to the protocol • If gender-based violence, containment, information and referral to social services and/or equipment. • If life-threatening, call the police(112)

intervention

referral

• Call to doctor on call to release injuries press2

1 If sexual violence: Always refer to the hospital for assessment by gynecologist/forensic Violence (GBV): it’s necessary to derive to social services and inform the team If VG injury: physical examination always made by 2 professional 2 Press emited by GBV court: it is provided to the Customer Care and handled by fax and regular mail (eCAP / patients / statement to the court)

explanatory notes

aggressions



NURSING DIAGNOSES NANDA 00141 Post-trauma syndrome 00148 Fear

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 5380 Security enhancement 4920 Active listening 6400 Abuse protection support 5240 Counseling 6403 Abuse protection support: spouse 5510 Health education 7920 Documentation 8100 Referral

aggressions



It is stop breathing and heartbeat in an individual. The arrest of the heart implies immediate (if it has not preceded it) stop breathing. This involves stopping the flow of blood and therefore oxygen delivery to the brain.


cardiac arrest

• If possible: - Causes giving rise to the SCA - Personal history - Drugs and allergies

anamnesis

• Consciousness • Airway • Breathing

valoration

• Enable health scare • If unconscious and not breathing normally: - Call 112 • Airway: - Liberate -Place Guedel cannula • Chest compressions - 30 chest compressions in middle chest • Breaths of air - 2 breaths with resuscitator manual • Place DEA • Alternate 30:2 following indications DEA until help arrives

basic intervention

referral

• Enable health scare - Doctor - Nurse

• Prepare O2 - Connect O2 to 10 l. /min to reservoir manual resuscitator • Peripheral venous via access - Physiological Saline • Prepare medication: - Adrenalin1 - Amiodarona2 - Serum glucose • Acting on medical Counselings or from emergency medical service

advanced intervention

1 Adrenalin will be administered in 9 cc physiological saline followed by 20 cc of physiological saline, before the 3rd electric shock, subsequently will be administered every 3-5 minutes (each two loops of CPR 30:2)

2 Amiodarone 300 mg diluted in 9 cc of SG before the 4th electric shock will be given (if available)

explanatory notes

Med

ical

Em

erge

ncy

Serv

ice

SEM



NURSING DIAGNOSES NANDA 00204 Ineffective peripherial tissue perfusion (cardiopulmonary) 00035 Risck for injury

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 6610 Risk identification 3320 Oxygen Therapy 6650 Surveillance 4200 Intravenous therapy 4150 Hemodynamic regulation 4254 Cardiac shock management 2380 Medication management 2300 Medication administration 6320 Resuscitation 5510 Health education 7920 Documentation 8100 Referral

cardiac arrest



It is the clinical expression of cerebral excessive neuronal discharge that may cause various symptoms and signs such as loss of consciousness, involuntary movements, abnormal sensory phenomena or sensory, autonomic hyperactivity and / or behavioral disturbances.


seizures

• Age • Personal and family history - Toxic, neoplasms, CVA, DM, epilepsy, TBI - Ask if 1st episode • Drugs and allergies • Time duration of the crisis • Present signs 1 • Clinical companion • Subsequent neurological deficit

anamnesis

• General condition • Vital signs (BP-HR-RR-Temp - SatO2) • Capillary glucose • ECG • State post-critical • Level of consciousness: test of Glasgow (see Annex 4)

valoration

• Enable health scare • Security: - Insert Guedel cannula - Remove nearby objects to prevent injury • Prepare suction and probes • Adm. O2 with ventimask 50% • Intravenous access • Prepare emergency medication: - Diazepam 10mg iv or Midazolam 5 mg im/intranasal • Repeat the dose of drug if no cease at 5 ' • Lateral security post-seizure position • Notify the SEM (if necessary)

intervention (active convulsion)

referral

• Enable health scare - Doctor - Nurse

1 Prior Aura, unconsciousness, automatisms, tongue bite, sphincter incontinence

explanatory notes



NURSING DIAGNOSES NANDA 00035 Injury risk 00036 Risk for suffocation

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 6610 Risk identification 2680 Seizure management 2690 Seizure precatiutions 6200 Emergency care 6490 Fall prevention 6654 Surveillance: safety 3390 Ventilation assistance 3350 Respiratory monitoring 0840 Positioning 3140 Airway management 3200 Aspitarion precautions 3320 Oxygen Therapy 5820 Anxiety reduction 5510 Health education 7920 Documentation 8100 Referral

seizures



Displayed when there are extreme temperatures or intense exercise. Body temperature can reach ≥ 40.6 ° C and produces alterations on the CNS such as headache, dizziness, lethargy, disorientation, delirium, convulsions or coma. Causing frequently anhidrosis (hot red skin without sweating), shock, tachycardia and hypertension. Mortality is up to15%.


heatstroke

• Age • Personal history • Drugs and allergies • Onset of symptoms • Identify if risk1 group belonging • Clinical companion

anamnesis

• General condition • Vital signs (BP-HR-Temp- RR - SatO2, determine Temp every 5-10min) • Level of consciousness: test of Glasgow (see Appendix 4)

valoration

• Lower temperature with physical means (wet compresses / gel - no alcohol because of absorption) • Do not give ASA • In conscious patients: - Rehydration with isotonic drinks (Oral Serum) • In patients with impaired consciousness: - Intravenous access

intervention

referral

• Call a doctor on call

1 Risk group: • Senior people, especially> 75 years • People with certain social circumstances: living alone, poverty ... • People with mental or physical disabilities with limited self-care • People with chronic diseases (DM, hypertension, heart disease) • People taking drugs that affect the CNS (Benzodiazepines, Neuroleptics, Antidepressants) • People with insufficient hydration and doing too much physical activity

explanatory notes



NURSING DIAGNOSES NANDA 00028 Risk for deficient fluid volume 00007 Hyperthermia

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 0590 Urinary elimination management 3780 Heat exposure treatment 6650 Surveillance 3740 Fever treatment 2300 Medication administration 4140 Fluid resuscitation 1380 Heat/Cold application 3900 Temperature regulation 5510 Health education 7920 Documentation 8100 Referral

heatstroke



Abdominal pain with less than 72 h evolution, which can be very intense and present obvious malaise. The source can be very diverse: renal colic, intestinal occlusion - subocclusion, appendicitis, cholecystitis, pelvic inflammatory disease, inflammatory bowel disease, pancreatitis, vascular (intestinal ischemia, aortic dissection, vasculitis), ectopic pregnancy, metabolic (diabetic ketoacidosis), neurogenic, referred (AMI, pneumonia), fecaloma, psychogenic ...


severe abdominal pain

• Age • Personal history • Drugs and allergies • Day last menstrual • Time evolution • Clinical companion - Diarrhea, vomiting and / or constipation - Acholia / coluria / jaundice - Bleeding (hematemesis / melena / metrorrhagia) - Vegetatismo (sweating / nausea) - Sd voiding and / or colic pain radiating to F. renal • Characteristics of pain - Intensity of pain (see Annex 1) - How was it started to appear - Circumstances that modifies it

anamnesis

• General condition • Vital signs (BP-Temp - HR - RR) • Depending on etiology of pain - ECG (provided if: DM patient and / or epigastric pain) - Urine dipstick - Pregnancy test • Abdominal exploration - Inspection - Auscultation - Percussion - Palpation

valoration

referral

Call a doctor on call




NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 2400 Patient-controlled analgesia assistance 1400 Pain management 6482 Environmental management: comfort 6650 Surveillance 2380 Medication management 5510 Health education 2300 Medication administration 7920 Documentation 5616 Teaching: prescribed medication 8100 Referral

severe abdominal pain



Chest pain is the reflection of chest or extra-thoracic disease of varying gravity, which can cause anything from trivial to life threatening emergencies.


chest pain

• Age • Personal history (cardiovascular risk factors) • Drugs and allergies • Ask if 1st Episode • Time evolution • Clinical companion - Vegetatismo (sweating / nausea) - Dyspnea • Characteristics of pain - Intensity of pain (see Annex 1) - Oppressive - Mechanical - Start time - Location - Irradiation - Intensity - How worsens - Starting when rest or when exercise

anamnesis

• General condition • Vital Signs: (BP-HR-RR- SatO2) • ECG • Monitorize - ECG - Pulse oximetry

valoration

referral





NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 6610 Risk identification 1400 Pain management 6140 Code management interventions 4010 Bleeding precautions 6482 Environmental management: comfort 4044 Cardiac care: acute 5820 Anxiety reduction 6650 Surveillance 5510 Health education 7920 Documentation 8100 Referral

chest pain



Increase in body temperature above 39° C, which shows the reaction of the organism to a pathological process.


fever > 39ºC

• Age • Personal history • Drugs and allergies • Time evolution • Presence chills • Cocaine consumption • Precipitating causes and recovery • Immune status and immunizations performed • Epidemiological history (interview for detection of focus) 1 • Clinical companion

anamnesis

• General condition • Constants: (BP-HR-RR-Temp - SatO2) • Skin condition - Macules - Papules - Vesicles - Blisters - Petechiae • Signs of dehydration • ECG (if cocaine consumption or suspected cardiac origin) • Urine Strip • Basic exploration (Respiratory, ear&nose...) • Maneuver exploration neck stiffness

valoration

• Paracetamol 500 - 1g orally. • No excess shelter • Tell adequate fluid intake • Give treatment depending on the cause

intervention

referral


1 If founded focus: act as appropriate protocol (discomfort when urinating, sore throat, flu, diarrhea, insect bites, respiratory symptoms in upper airways)

explanatory notes



NURSING DIAGNOSES NANDA 00007 Hyperthermia

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 4260 Shock prevention 3900 Temperature regulation 2300 Medication administration 3740 Fever treatment 2380 Medication management 6650 Surveillance 5510 Health education 7920 Documentation 8100 Referral

fever > 39ºC



The entry into the body of any living substance capable of causing pathological changes in the vital functions of the person. 70% of poisonings are voluntary and about 60% are because of drugs, followed by overdose drug abuse, domestic accidents, and working accidents finally.


intoxications

• Age • Personal history • Drugs and allergies • Toxic type • Time evolution and exposure time • Way of exposure to toxic (orally, inhalation, intravenous, percutaneous ...) • Clinical companion - Pain - Dizziness - Dyspnea - Headache

anamnesis

• General condition • Constants: (BP-HR-RR-Temp - SatO2) • Unconscious and not breathing normally: act as Cardiac arrest guideline • Unconscious and breathing normally: act as loss of consciousness guideline • Level of consciousness: test of Glasgow (see Annex 4)

valoration

• Treatment of alterations as specific protocols • Acting on doctor's orders

intervention

referral




NURSING DIAGNOSES NANDA 00044 Impaired tissue integrity 00134 Nausea 00013 Diarrhea 00028 Risk for deficient fluid volume 00035 Risck for injury

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 5820 Anxiety reduction 1450 Nausea management 6482 Environmental management: comfort 5510 Health education 5246 Nutritional counseling 7920 Documentation 4140 Fluid resuscitation 8100 Referral 2080 Fluid/Electrolyte management 4200 Entravenous therapy 4060 Shock prevention 2380 Medication management 5616 Teaching: prescribed medication 2300 Medication administration 4120 Fluid management

intoxications



Need to assess the origin of the pathology. If it is a trauma, it may be periorbital (hematoma or wound around the orbit with possible eye edema, blurred vision or loss of vision and painful eye) or ocular either with or without foreign body. There may be eye pain, redness, blurred vision, loss of vision and tearing.


serious eye injury

• Age • Personal history • Drugs and allergies • Time evolution • Clinical companion • Injury mechanism • State vaccine (Td)

anamnesis

• General condition • Vital Signs: (BP) • Pain (see Annex 1) • Lesion characteristics • Causal agent: - Organic foreign body - Non-organic foreign body - Substance • Hemorrhage and/or hematoma • Eyelid edema • Tearing • Blurred vision

valoration

• Ocular trauma and/or foreign body: - Washing with saline - Application of Fluorescein (if MF is down to box) • Acting on doctor's orders

intervention

referral


• If labor or traffic accident: Need to notify to center administration • If labor accident: do initial assessment on the 1st cure and refer to the work insurance

explanatory notes



NURSING DIAGNOSES NANDA 00044 Impaired tissue integrity 00132 Acute pain

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 3680 Wound irrigation 3590 Skin surveillance 2310 Medication administration: eye 6550 Infection protection 6680 Vital signs monitoring 1400 Pain management 1650 Eye care 6530 Immunization/vaccines management 5510 Health education 8100 Referral 7920 Documentation

serious eye injury



It is the intense painful sensation localized between orbital and sub-occipital region. Tension headache and migraine account for over 80% of primary headaches. Secondary headache may be accompanied of any febrile and/or infectious process (GEA, flu, sinusitis, toothache, trauma, vascular disorders, metabolic ...)


intens headache

• Age • Personal history (if usually suffers, from what age) • Drugs and allergies • Time evolution of the episode • Establishment (sudden or gradual) • Location (hemicranial, holocraneal, front) • Quality (pulsating, oppressive) • Clinical companion - Nausea, vomiting, photophobia, intolerance to noise - Hemiparesis, diplopia, unsteadiness - Vertigo, aphasia, confusion • Characteristics of pain - Intensity of pain (see Annex 1)

anamnesis

• General condition • Vital Signs: (BP-Temp - HR-RR) • Level of consciousness: test of Glasgow (see Annex 4) • Acting on doctor's orders

referral

Call a doctor on call Neurological examination, if

necessary

valoration




NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 6482 Environmental management: comfort 1400 Pain management 2400 Patient-controlled analgesia assistance 6650 Surveillance 5270 Emotional support 5510 Health education 2380 Medication management 7920 Documentation 2300 Medication administration 8100 Referral 5616 Teaching: prescribed medication

intens headache



dizziness

• Age • Personal history • Drugs and allergies • Time evolution • Clinical companion (nausea, sweating, palpitations, rotation of subjects, dizziness, cephalic mov ...) • Track start and exacerbation of symptoms • Discard neurological pathology or TBI

anamnesis


• General condition • Constants: (BP-HR-RR – Temp.) • Capillary glucose • ECG

valoration

• If BP>= 210/120 mmHg symptomatic: act according to physician orders • If BP>= 210/120 mmHg asymptomatic: rest and check BP • If glucose <60 mg/dl: - Urine dipstick (ketonuria) - Glucose orally (conscious patient) • If glucemia > 300 mg/dl: - Urine dipstick (ketonuria) • If other etiologies1: - Psychogenic - Pre-syncope or syncope - Vertigo - Mixed - Hypovolemic • Acting on doctor's orders

intervention

referral


1 Etiology: Psychogenic: anxiety, agoraphobia ... Pre-syncope or syncope: vasovagal, orthostatic. Valvular and arrhythmias Vertigo: central or peripheral (rotation of objects, nausea ...) Mixed: gait disorders and multiple sensory deficits in the elderly Hypovolemic: severe liquid loss (hematemesis, melena ...)

explanatory notes

Unpleasant sensation of weakness, having an empty head, to be floating in the air, insecurity when lying or walking, but no sense of displacement.



NURSING DIAGNOSES NANDA 00134 Nausea 00035 Risck for injury

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 5616 Teaching: prescribed medication 6490 Fall prevention 6610 Risk identification 6654 Surveillance: safety 5820 Anxiety reduction 5510 Health education 6482 Environmental management: comfort 7920 Documentation 1450 Nausea management 8100 Referral 1570 Vomit management 2380 Medication management

dizziness



Subjective sensation of difficulty in breathing associated with increased effort to breathe.


drowning

• Age • Personal history • Drugs and allergies • Time evolution • Clinical companion • Causes of diyspnea1 (COPD, heart disease) • Features of dyspnea

anamnesis

• General condition • Constants (BP-HR-RR – Temp.) • Pulse Oximetry • Auscultation • ECG

valoration

• Prepare O2 • Prepare bronchodilators • Act depending on SatO2: SatO2 (%) Acting > 95 No immediate action 90-95 treatment if necessary and monitoring 80-90 severe hypoxia. O2 + bronchodilator <80 Emergency situation • Acting on doctor's orders

intervention

referral


1 Causes of dyspnea: Acute: Blockage of the airway (foreign body, edema of the glottis, asthma attack, tumors ...); chest causes (pneumothorax, pleural effusion and traumatism); cardiogenic edema (arrhythmias, AMI and CHF) and secondary hyperventilation in panic attacks. Chronic: Chronic obstructive pulmonary disease; pulmonary fibrosis; cardiovascular causes (pulmonary hypertension and decreased cardiac volume) and metabolic causes (acidosis, hypo-hyperthyroidism)

explanatory notes



NURSING DIAGNOSES NANDA 00033 Impaired spontaneous ventilation 00032 Ineffective breathing pattern

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 3200 Aspitarion precautions 3350 Respiratory monitoring 3230 Chest physiotherapy 3140 Air way management 3180 Artificial airway management 6200 Emergency care 3160 Airway suctioning 3390 Ventilation assistance 2300 Medication administration 3320 Oxygen Therapy 2380 Medication management 6650 Surveillance 5510 Health education 7920 Documentation 8100 Referral

drowning



Occurs when the person, for a time, no longer alert and respond to environmental stimuli. It may occur transiently and spontaneously recovery (syncope) or in a sustained time without spontaneous recovery (coma).

Data: 09/2007 Revisió: 08/2012 Versió: 1.2

loss of conscience

• Age • Personal history (Heart Failure, syncope or sudden death) • Number of episodes • Drugs and allergies • Time evolution • Witnessed loss of consciousness or not • Pródromes: inestability sensation, visual disturbances, nausea, sweating, ... • Precipitating causes and recovery • Clinical companion: - Chest pain - Fever - Dyspnea - Headache - Palpitations

anamnesis

• General condition • Constants: (BP-HR-RR - Temp.) • Level of consciousness: test of Glasgow (see Annex 4) • Skin (petechiae and venipuncture) • Capillary glucose • ECG (discard cardiogenic syncope)

valoration

• If NOT breathing normally: see protocol of cardiac arrest. • If breathing normally: - Lateral safety position - Guedel cannula - Prepare O2 (intravenous access) - Prepare emergency medication 1 • If no recovery, warn 061 • Acting on doctor's orders

intervention

referral


1 Emergency medication prepared according to etiology: Hypoglycemia: Glucose 50% ev (Glucosmon R50®) Benzodiazepine Overdose: Flumazenil 0.2 mg ev in 30'' and repeat up to 2 mg Opiate overdose: Naloxone 0.4 - 0.8 mg ev

explanatory notes



NURSING DIAGNOSES NANDA 00035 Risck for injury 00204 Ineffective peripherial tissue perfusion (cerebral) 00039 Risk for aspiration

NURSING INTERVENTION (NIC) 6680 Vital signs monitoring 4250 Shock management 3320 Oxygen Therapy 2550 Cerebral perfusion promotion 6610 Risk identification 0840 Positioning 6650 Surveillance 3200 Aspitarion precautions 5510 Health education 3160 Airway aspiration 7920 Documentation 1570 Vomit management 8100 Referral 4200 Intravenous therapy 2380 Medication management 2300 Medication administration

loss of conscience



Blood from the digestive apparatus which, according to their location, will have one aspect or another and with varying degrees of severity. We need to stress the fact differential of hemoptysis that although out of the mouth, is blood from the respiratory tract.


• Age • Personal history (gastric ulcer) • Drugs and allergies • Time evolution • Clinical companion

anamnesis

• General condition • Constants: (BP-HR-Temp - RR) • Color and condition of the skin and mucous • Location of the bleeding1

valoration

• If rectal bleeding with no gravity signs2: - Analgesia, if necessary, according guideline3 - Hygienic tips - Hygiene and dietary Counseling for constipation - Appointment with physician referral • Rest of bleeding (hematemesis, rectal bleeding imp, melena, hemoptysis): - Intravenous Access - Acting on doctor's orders • If there is no recovery, Warn 112

intervention

referral


1 Location of bleeding: Rectal: Red Blood coming from the anus alone or accompanied by stool Melena: black stools, bright, colored and fetid sticky (tarry stools) Hematemesis: Red blood without gastric contents from the digestive system. Also vomiting have blackish appearance Hemoptysis: Red Blood coming from the mouth, usually accompanied by cough, from the respiratory tract.

2 Rectal bleeding without signs of severity: Hemorrhoids Fissures Red blood at the end of stool

3 Check drugs guide

explanatory notes

gastrointestinal bleeding



NURSING DIAGNOSES NANDA 00204 Ineffective peripherial tissue perfusion (gastrointestinal) 00028 Risk for deficient fluid volume 00132 Acute pain

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 4022 Bleeding reduction: gastrointestinal 4180 Hypovolemia management 4260 Shock prevention 6650 Surveillance 4258 Shock management: volume 4160 Control of bleeding 6482 Environmental management: comfort 5510 Health education 5270 Emotional support 7920 Documentation 4200 Intravenous therapy 8100 Referral 2380 Medication management 2300 Medication administration 4190 Intravenous insertion 4140 Fluid resuscitation 5616 Teaching: prescribed medication

gastrointestinal bleeding



A traumatic brain injury is any injury caused by external mechanical action on the head regardless of possible neurological repercussions. Should this occur would speak about traumatic encephalic brain injury.


traumatic brain injury

• Age • Personal history • Drugs and allergies • Time evolution • Lesional mechanism1 • Clinical companion - Pain - Dizziness - Dyspnea - Headache

anamnesis

• General condition • Vital Signs: (BP-Temp- RR-HR-SatO2) • Unconscious and not breathing normally: act as cardiac arrest guideline • Unconscious and breathing normally: act as loss of consciousness guideline • Level of consciousness: test of Glasgow (see Annex 4) • Skin condition

valoration

• Recovery position • Prepare material for cures • Acting on doctor's orders

intervention

referral


1 Lesional mechanism: Accident or aggression: notify the physician on call for the release of injuries press Labor accident: Make initial assessment and first cure, and refer to labor insurance

Case of labor or traffic accidents: need to communicate at administration of the center

explanatory notes




NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 5616 Teaching: prescribed medication 1400 Pain management 2400 Patient-controlled analgesia assistance 6650 Surveillance 6482 Environmental management: comfort 3660 Wound cure 3620 Suture 5510 Health education 3590 Skin surveillance 7920 Documentation 6530 Immunization/vaccines management 8100 Referral 2380 Medication management 2300 Medication administration

traumatic brain injury



Any person with a traumatic injury involving significantly or potentially compromise to the respiratory function and/or cardiocirculatory, and therefore with high life-threatening


severe trauma

• Age • Personal history • Drugs and allergies • Time evolution • Lesional mechanism 1 • Clinical companion - Pain - Dizziness - Dyspnea - Headache

anamnesis

• General condition • Vital signs: (BP-HR - RR-Temp - SatO2) • Hemorrhage (open wounds / signs of shock) • Permeable airway • Level of consciousness: test of Glasgow (see Annex 4)

valoration

• Prepare material for cures • Acting on doctor's orders

intervenció

referral


1 Lesional mechanism: Accident or aggression: notify the physician on call to release injuries press Labor accident: Make initial assessment and 1st cure, refer to laboral insurance Case labor or traffic accidents: need to communicate to the administration of the center

We must imagine the potential injuries not apparent (hidden). Considering the apparently healthy patient as a serious injuried patient until the contrary is proved. 5-10% of patients who do not have anatomical lesions or alterations in vital signs in the first review, and have suffered an accident at high energy, subsequently suffer serious injuries.

explanatory notes




NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 3660 Wound cure 1380 Heat/Cold application 1400 Pain management 3680 Wound irrigation 6680 Vital signs monitoring 2300 Medication administration 6650 Surveillance 6530 Immunization/vaccines management 5510 Health education 6482 Environmental management: comfort 7920 Documentation 3620 Suture 8100 Referral 0910 Immobilization 2380 Medication management 5616 Teaching: prescribed medication

severe trauma



It is the oral violent expulsion of gastric contents.


vomiting

• Age • Personal history • Drugs and allergies • Time evolution • Vomiting features

- A fetid odor - Hematemesis - Gastric Contents (food)

• Associated diarrhea stools: GEA protocol

anamnesis

• General condition • Vital signs: (BP-HR-Temp - RR) • Level of consciousness: test of Glasgow (see Annex 4) • Capillary glucose • Urine strip (if DM / if lumbar pain) • Signs of dehydration (mucosal, fold...)

valoration

referral


• Safety position to prevent aspiration • Acting on doctor's orders

intervention



NURSING DIAGNOSES NANDA 00134 Nausea

NURSING INTERVENTION (NIC) INDISPENSABLE OPTIONAL 6680 Vital signs monitoring 5820 Anxiety reduction 1450 Nausea management 6482 Environmental management: comfort 5510 Health education 2380 Medication management 7920 Documentation 5616 Teaching: prescribed medication 8100 Referral 2300 Medication administration

vomiting



Syndrome Initiated by acute systemic hypoperfusion, which leads to tissue hypoxia and dysfunction of vital organs.


anaphylactic shock

• Age • Personal history • Drugs and allergies • Time evolution of the initial • Etiology by hypersensitivity • Clinical companion - Tachycardia - Hypotension - Seizures - Oliguria - Erythema - Urticaria - Nausea - Diarrhea - Hypo-perfusion tissue

anamnesis

• General condition • Vital Signs: (BP-HR - RR - Temp - SatO2) • Skin and mucous membranes: ictericia, pale mucous membranes, hives, petechiae • Edema of glottis • Hyperthermia, chills • Hypoventilation • Level of consciousness: test of Glasgow (see Annex 4)

valoration

• Supine position with 20 ° elevation of lower limbs • Prepare material for cures • Venous access placement • Prepare medication: - Methylprednisolone 40-60 mg im - Adrenalina ½ amp sc • Insert Guedel cannula if necessary • Acting on doctor's orders

intervention

referral





NURSING INTERVENTION (NIC) INDISPENSABLE OPCIONALS 6680 Vital signs monitoring 1380 Heat/Cold application 6650 Surveillance 2380 Medication management 5510 Health education 2390 Medication prescribing 7920 Documentation 2300 Medication administration 8100 Referral

anaphylactic shock

drug

s gu

ide



Analgesics are drugs used to relieve pain relatively independently of its cause or origin.

DRUGS

Date: 09/2007 Revision: 08/2012

Anamnesis:

Allergies Other drugs Features of pain Personal history

In case of:

Allergies Gastrointestinal problems Gestation and lactation Anticoagulant treatment

Paracetamol orally

If needs more

Consult a doctor on call

Assess intensity of pain (growing):

Paracetamol orally Ibuprofen orally Diclofenac orally – im Metamizol orally – im

analgesics and antipyretics



ACTIVE PRINCIPLE DOSE ADMINISTRATION WAY TRADEMARKS

PARACETAMOL 500 mg-1 g/4-6 h.

- (max. 4 g/day)

Oral

Paracetamol EFG® Termalgin® Efferalgan® Xumadol® Gelocatil®

IBUPROFEN 400-600 mg/4-6 h.p

- (màx. 2400 mg/day)

Oral Ibuprofen EFG® Espidifen® Neobrufen®

DICLOFENAC

50 mg/8 h. -

(max. 150 mg/day)

Oral Diclofenac EFG® Voltaren®

75 mg Intramuscular

METAMIZOL

575 mg/6-8 h. Oral Metamizol EFG® Nolotil® Lasain®

2 g Intramuscular

In case of intolerance to AINES, renal insuficiency, ulcer background, asthma, hiatal hernia, 65 and older, IC or HTA, Paracetamol only.

We can alternate paracetamol with AINE (Ibuprofen or Diclofenac) every 3 or 4 hours.

If contraindications, Metamizol can replace AINE, or being used as a rescue (alternated with paracetamol/AINE).

In case of oral anticoagulant teraphy (OAT), AINE and Metamizol can alter its action.

analgesics and antipyretics



When antibiotic treatment for a presumptive diagnosis is given, the choice will be made according to the most probable organisms, choosing antibiotic regimens that adequately cover the narrowest possible spectrum. It must be considered the location of the infection, the age of the patient, the severity of symptoms and possible allergies or intolerances.

DRUGS

Date: 09/2007 Revision: 08/2012

Anamnesis:

Allergies Other drugs Features of the infection Personal history

In case of:

Allergies Gastrointestinal problems Gestation - Lactation Anticoagulant treatment

Consult a doctor on call

Penicilines:

Amoxiciline – clavulanic Cloxaciline

Other antibiotics:

Claritromicine Clindamicine Eritromicine Fosfomicine

antibiotics



ACTIVE PRINCIPLE DOSE ADM. WAY TRADEMARKS INDICATIONS

AMOXICILINE AC. CLAVULANIC

500-875/125 mg c/8 h. -

(8-10 days) o

Amoxiciline - clavulanic acid EFG®

Augmentine® Clavumox®

Infections of skin and soft tissues: Dental abscess Celulitis Animal bites

CLINDAMICINE

150-300 mg c/6 h.

- (8-10 days)

o Dalacin® 150 mg Dalacin® 300 mg

Antibiotic choice in case of allergie to peniciline

CIPROFLOXACINE

500 mg c/12 h.

- (8-10 days)

o Ciprofloxacino EFG® Pseudomones Infection

CLOXACILINE 500 mg/ 6-8 h.

- (8-10 days)

o Orbenin® 500 mg

Infections of skin and soft tissues: Furunculosis, Wound and infected burn Celulitis Piomiositis

ERITROMICINE 250-500 mgr every/6h 8-10d o

Bronsema® 500 mgr sobres env 12

Eritorgobens® 500 mgr comprim env 12

Eritromicina estedi EFG 250 mgr env 12 i 24 caps

Antibiotic

FOSFOMICINE 3 g -

(single dose) o Monurol® 3 g Urinary infections

antibiotics



ACTIVE PRINCIPLE TRADEMARK PROPERTIES

ACICLOVIR Aciclovir EFG® Zovirax® Antiviric

FUSIDIC ACID Fucidine® Antibacterian

TRANEXAMIC ACID Amchafibrin® Antihemorrhagic

CARBENOXOLONE Afta juventus® Sanodyn gel® Oral antiulcer

CLORHEXIDINE Cristalmina® Antiseptic

CLOTRIMAZOL 1% Canesten® Clotrimazol byfarma EFG ® Fungistatic

FLUORESCEÏNE Fluoresceïna oculos® Eye contrast

HIDROCORTISONE Dermosa Hidrocortisona® Lactisona® Antiinflammatory

HIDROFIVER Aquacel® Aquacel Ag® Hydrosorb ®

Antibacterian and epithelium

CALCAREOUS OIL LINIMENT Calcareous oil liniment + oxid of zinc 250 cc Topical antiseptic

ARGENTIC SULFADIAZINE Silvederma® Antibacterian

VASELINE Vaseline Emollient and dermoprotector

Date: 09/2007 Revision: 08/2012

topical treatments



ACTIVE PRINCIPLE PRESENTATIONS ADM. VIA TRADEMARK PROPERTIES

ACICLOVIR Tablets 200 mg o Aciclovir 200 EFG® Zovirax 200® Antiviric

ADRENALINE Blister 1 mg sc Adrenaline Braun® Adrenaline Level® Vasoconstrictor

AMIODARONE Blisters 150 mg ev Trangorex® Antiaritmic

DEXCLORFENIRAMINE

Tablets 2 mg -

Blisters 5 mg

o -

im Polaramine® Antihistaminic

DEXTROMETORFANE Syrup Tablets o Romilar jarabe®

Romilar tablets 15 mgr® Antitussive

DIAZEPAM Tablets 5 mg

- Blisters 10 mg

o -

im

Diazepam EFG® Valium® Anxiolytic

FLUMACENIL Blisters 0,5mg Blisters 1 mg im Anexate®

Flumacenilo EFG® Antidot of benzodiazepines

GLUCOSE 33% Blisters 10 ml im Glucosmon® For hipoglucemia

HIDROCORTISONE FOSFAT SODIC Blisters 100 mg im Actocortina® Antiinflamatori

Antiallergic

LEVONORGESTREL Tablet 1’5mgr 1 x container o Norlevo®

Postinor® Progestagen Day after pill

LORATADINE Tablets 10 mg o Loratadine EFG® Antihistamínic

MEPIVACAINE Blisters 2% sc Scandinibsa® Local anesthetic

MIDAZOLAM Blisters 5 mg Im intranas

Dormicum® Midazolam EFG® Hipnothic

METILPREDNISOLONE

Blisters of: 8 mg 20 mg 40 mg

im Urbason® Solu Moderin®

Antiinflammatory Antiallergic

METOCLO- PRAMIDE

Tablets 10 mg -

Blisters 10 mg

o -

im Primperan® Antiemethic

NALOXONE Blisters 0,4 mg ev -

im Naloxona® Antídot opioide

OXIMETAZOLINE Drops

- Spray

topical nasal

Respir® Utabon® Nasal decongestant

GLUCOSE SERUM Blisters 250 ml Blisters 500ml ev Glucosed serum Way maintenance

ORAL SERUM Envelopes o Oral serum Casen® Oral serum Hiposódico® Oral rehydration

TETRAZEPAM Tablets 50 mg o Myolastan® Myorelaxant

Date: 09/2007 Revision: 08/2012

others

anne

x



Pain scales are a resource that is used to describe the amount of pain a person is feeling. These scales include numerical rating scale, visual analogy, categories and faces pain scale:

NUMERICAL RATING SCALE

0 1 2 3 4 5 6 7 8 9 10

(0) No pain The worst pain imaginable (10)

It has to be asked the person to choose a number between 0 and 10, depending on the intensity of pain he/she has.

VISUAL ANALOGY

No pain The worst pain imaginable

It has to be asked the person to choose a point in the line that corresponds to the pain he/she feels.

CATEGORIES SCALE

None (0) Mild (1–3) Moderated (4–6) Severe (7–10)

It is asked the person to select the categorie reflexing much better the pain he/she feels.

FACES PAIN SCALE

0

Happy No pain

2 Just feels a little

pain

4 feeling a little more

pain

6 Feels even more

pain

8 Feels a lot of pain

10 Pain is the worst imaginable (no

need to mourn for feeling this strong

pain)

It is asked the person to select the face that best describes how he/she feels. This scale can be used with patients older than 3 years.

1. pain scales



The following table shows the most common projections when simple radiography is requested for possible fractures assessment. In case of children, they are always bilateral.

RADIOGRAPHIC PROJECTIONS

ZONE TO EXPLORE REQUESTED PROJECTIONS

Skull and face Frontal and profile

Column Frontal and profile

Pelvis Frontal

Fémur Frontal and profile

Knee Frontal and profile (± axial of patella)

Tibia and fibula Frontal and profile

Foot and toes Frontal and oblique (± axial of patella)

Thorax Rib cage

Clavicle Frontal, axial and AP acromioclavicular

Back Frontal and axial

Humerus, elbow and forearm Frontal and profile

Wrists Frontal and profile

Scaphoid Sneck

Hand Frontal and oblique

Fingers and thumb Frontal and profile

2. radiographic projections



We base nursing assessment on the Virginia Henderson model, where we identify the manifestations of dependence in every need. To simplify the evaluation we have considered using the Likert scale where 1 is dependence and 5 is independence.

14 NEEDS OF VIRGINIA HENDERSON

NEED LIKERT SCALE

1 2 3 4 5

1 – Breathe

2 – Nourish and hydrate

3 - Remove

4 – Move and mantain good posture

5 – Rest and sleep

6 – Using adequate clothes

7 - Thermoregulation

8 - Hygiene and skin protection

9 – Avoid risks

10 - Communicate

11 - Live according to their values and beliefs

12 – Work and perform

13 - Play / participate in recreational activities

14 - Learn

3. nursing assessment



Consciousness is the state in which the person becomes aware of itself and the environment. This means that the subject is alert and sufficient intellectual and emotional mental attitude that allows the integration and response to internal and external stimuli. The elaborated scales and responses to various stimuli, are usefull for us to get a measure of the level of consciousness reproducible in subsequent checks.

TEST OF GLASGOW

Ocular response Motor response Verbal response

Spontaneous 4 Strong voice 3 To pain 2 Null 1

Obeys orders 6 Localizes pain 5 Removes the pain 4 Flex the pain 3 Abnormal extension to pain 2 Null 1

Oriented 5 Confusing conversation 4 Inappropriate words 3 Incomprehensible sounds 2 Null 1

CONSCIOUSNESS STATE PUPIL ASSESSMENT (mm)

Conscious Unconscious Clouded Oriented Disoriented

1 2 3 4 5 6 7 8

4. neurological assessment



Depending on depth

Degree I Degree II superficial or dermal

Degree II deep Degree III or thick

Affected layer Epidermis Capilar dermis Capilar dermis + reticular dermis Hypodermis

Image

Features Redness Lack of ampules Hiperestesia or

acute pain

Flictenas Redness Hiperestesia

No flictenas Whitish colored Hiposensibility

No flictenas Pale colour or yellow

to black Thrombossed vessels Anesthesia

Depending on extension Wallace Rule (use only with adults)

Rule of 1: as reference of the palm of the hand of the patient (can be used in adults and children)

Land & Browder rule (used with children until 14-16 years): on this rule, proportions of children in relation to age are specified.

4. burn lesions assessment

bibl

iogr

aphy



Brugués Brugués A, Peris Grao A. ¿Cómo organizar la consulta del centro de salud? En: Guia de Actuación en Atención Primaria. (4a edic). semFYC, Barcelona, 2011. 15.3: 1369-1373 Brugués Brugués A et al. Abordaje de la demanda de visitas espontáneas de un equipo de atención primaria mediante una guía de intervenciones de enfermería. Aten Primaria. 2008;40(8):387-91 Camfic. Guia d’actuació en urgències per a l’Atenció Primària. Semfyc Ediciones. 2009 Casajuana Brunet J. En busca de la eficiencia: dejar de hacer para poder hacer. FMC. 2005;12(9):579-81 Generalitat de Catalunya – Departament de Salut. Llibre Blanc: consens sobre les activitats preventives a l’edat adulta a l’Atenció Primària. 1a edició. Barcelona: Generalitat de Catalunya; 2005 García I. ¿Conoce la población los servicios que ofrece la enfermería comunitaria? Enfermería Comunitaria 2006, 2 (1): 17-23 Hernández-Faba E,Sanfeliu-Julia C. Atención de la patologia aguda de enfermería en atención primaria: caso clínico en la odinofagia. EnfermClin. 2010;20:197-200. –vol.20 núm 03 Institut Català de la Salut. Gestió de la demanda espontània.[Internet] Disponible en: http://www.gencat.cat/ics/professionals/pdf/gestio_demanda_espontania_2011.pdf Johnson M. & col. Diagnósticos enfermeros, resultados e intervenciones. Interrelaciones NANDA, NOC y NIC. 2a edició. Madrid: Elsevier Mosby; 2007

Johnson M. et al. Vínculos de NOC y NIC a NANDA-I y diagnósticos médicos. 3a edició. Elsevier: 2012 Kilpatrick K. Nurs Inq. Praxis and the role development of the acute care nurse practitioner.2008 Jun;15(2):116-26. Lalanda, M. De Okupas, Efer-mesas y Nurse Practitioners. ENE. Revista de Enfermería. 5(3):69-72 [Internet] Disponible en: http://enfermeros.org Laurant M, Reeves D, Hermens R, Braspenning J, Grol R, Sibbald B. Sustitución de médicos por enfermeras en la atención primaria. Reproducción de una revisión Cochrane, traducida y publicada en La Biblioteca Cochrane Plus, 2008, Número 2 Lluís MT. Los diagnósticos enfermeros. Revisión crítica y guía práctica. 8a edició. Barcelona: Elsevier Masson; 2008 Martin Santos FJ, Morilla Herrera JC, Morales Asencio JM, Gonzalo Jimenez E. Gestión compartida de la demanda asistencial entre médicos y enfermeras en Atención Primaria. Enfermeria Comunitaria. 2005; 1 (1): 35-42 McCloskey Dochterman J, Bulechek GM. Clasificación de NURSING INTERVENTION (NIC). 5a edició. Madrid: Elsevier Mosby; 2009 Millas Ros J, et al. Consulta de atención primaria: ¿todo es del médico? Atención Primaria. 2011. Morales Asencio JM, Martin Santos FJ, Morilla Herrera JC, Contreras Fernández E. Prescripción de medicamentos y productos sanitarios por enfermeras comunitarias. Enfermería Comunitaria. 2006; 2 (1) Morilla Herrera JC, Morales Asencio JM, Martin Santos FJ, Cuevas Fernádez-Gallego M. El juicio clínico enfermero: conjugación de modelo, lenguaje y efectividad de las intervenciones enfermeras. Metas de enfermeria. 2005; 9 (2): 6-12 Moorhead S, Johnson M, Maas M. Clasificación de resultados de enfermería (NOC). 4a edició. Madrid: Elsevier Mosby; 2009 NANDA International. Diagnósticos enfermeros: definiciones y clasificación 2009-2011. Barcelona: Elsevier; 2010 Ruiz Téllez A. La organización de un equipo de Atención Primaria. Centro de Salud 1999; 7: 592-606. semFYC. Guía de Actuación en Atención Primaria. (4a edic). semFYC, Barcelona, 2011 Villa LF. Medimecum. Guía de terapia farmacológica. 17a edició. Adis Internacional; 2012 WY Chin, Cindy LK Lam, SV Lo. Quality of care of nurse-led and allied Health personnel–led primary care clinics. Hong Kong Med J 2011;17:217-30

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