Professional Documents
Culture Documents
Emergency Nursing
Characteristics of Emergency Departments:
y y y Chaotic and rapidly changing Safety net by providing services to insured and uninsured seeking immediate help Critical access hospitals = provide around the cock emergency care services 24-7 & necessary providers of health care to residents not close to other hospitals y y y y y Fast paced Chaotic & many distractions Variety of acuity levels Often over crowded May be temporary bridge to establishing relationship w/care provider room for errors
Characteristics of ED Nurses
y y y Dislike routine Broader knowledge of disease processes Broader client base from young to old y y Comfortable treating patients anyway Able to wear many hats cardio, peds, phsych, trauma
Interdisciplinary Team
y y Prehospital Care Providers = EMT/paramedics = valuable source for data Support Staff = techs (radiology, lab, etc) + social workers + other therapists (respir, etc) + case managers
Staff safety concerns => focus on potential for transmission of disease & personal safety (violent pt, aggressive, agitated, etc) standard precautions at all times + recognizing hazardous plan options for violence, s.a. security conditions and behaving accordingly
Pt Safety:
Patient identification:
y Id bracelet genlly issued @ triage or bedside y y 2 unique identifiers (name, dob) Use of special id system if pt id unknown
Injury prevention:
y y y y Keep rails up on stretcher Stretcher in lowest position Remind pt to use call light Reorient confused pt y y y If confused pt, ask family member, friend, etc. to remain w/him or her Implement retentive measures if @ risk for skin breakdown NPO check for dehydration Search pt belongings when/if have altered mental status
Fall Prevention:
y y y Starts with identifying people at risk for falls then applying appropriate precautions Vulnerable group = older adults + pain meds + sedation + lower extremity injury + syncope Assist pt when moving from supine (flat) position to upright position y y y Siderails up and locked Call light/bell w/n reach Fall risk communicated clearly to visitors & staff members
Older adults:
o o o Always have all siderails up Bed/stretcher in lowest position Instruct pt to call for nurse if need assistance Not to ambulate independently o May have issues of confusion reorient Ask family member/sig other, sitter to stay w/pt to prevent falls
Broad knowledge base Critical care emergencies to less common problems Must learn to recognize and manage legal implications of societal problems May initiate interdisciplinary protocols for interventions Cardiac monitoring Oxyten therapy May have protocols that all initiation of drug therapy for emergent conditions y y y y o Anaphylactic shock Cardiac arrest When needed Obtaining them IV caths and infusions
Proficiency in variety of skills Critical care equipment Familiarity w/Procedural skills: y y y y y Simple & complex suturing Foreign body removal Central line insertion Endotracheal intubation Transvenous pacemaker insertion y y y y y y y Lumbar puncture Pelvic exams Chest tube insertion Peritoneal lavage Paracentesis Fracture management Etc
Training/certification:
y y y y Basic Cardiac Life Support (BCLS) = CPR + noninvasive airway maintenance Advanced Cardiac Life Support (ACLS) = invasive airway management, pharm, electrical therapies, special resuscitation Pediatric Advanced Life support (PALS) = neonatal + ped rescucitation Certified Emergency Nurse (CEN) = validation core emergency nursing knowledge base
Principles of ED Nursing:
Triage = sorting or classifying pat into priority levels based on illness or injury severity needs quickest eval, tx, prioritization, etc. Use of nursing process:
y assess and dx o accurate and quick assessments needed y y acuity o quickest care acuity has to wait Independently perform triage Following protocols Presentation suspicious for pneumonia y o y Rapid dx and tx w/ATB w/n 4h Administration of Oxygen Cardiac monitoring IV ACCESS Collecting samples (urine, blood, etc) before seeing physician Triage nurse initiation for lab work or dx tests before pt seen by physician o o sorting information planning and implementing
highest acuity
RN as gatekeeper o o
Initiation of care while pt on stretcher in hallway of overcrowded ED To see if anything changes, develop therapeutic relationship, vital signs change, etc. Obligation to profession and community
3 Tiers of triage:
Emergent = condition poses immediate threat to life or limb
Study Guide Emergency and Trauma Nursing Urgent = pt should be treated quickly but no immediate threat to life at this moment reassessed d/t changes Nonurgent = can tolerate waiting w/o significant risk of deterioration = sprains, strains, simple factures, colds, rashes Emergency Severity Index = 5 tier system from level 1 (=emergent) to level 5 (=nonurgent) y y Rapid, reliable, clinically pertinent Uses both acuity and prediction of resources to categorize priorities
Examples Respiratory distress Chest pain with diaphoresis Active hemorrhage Unstable vitals Severe abdominal pain Renal colic Displaced or multiple fractures Complex or multiple soft tissue injuries New onset respiratory infections, esp in older adults w/suspected pneumonia Skin rash Strains and sprains colds Simple fractures
pt must be
Nonurgent
Care of Patient:
Many different reasons for patient to visit ED, commonalities = y y y Maintaining privacy and dignity o Double gown pt + sheet or blanket Keeping voice low when discussing Medication administration Specimen collection Assistance w/bedside procedures Discharge planning What to delegate to techs Maintaining confidentiality o Nurse responsible for follow up care o o o o o y y
May need to reassess and reprioritize whenever necessary Awareness of cultural values o o Language barriers Religious prohibitions Jehovahs witnesses cannot have blood transfusions
Study Guide Emergency and Trauma Nursing Patient disposition = conclusion of work up by physician
o Admit to facility or different facility o o o Usually physician call but often in collaboration w/nurse someone stays with pt for 1st 12-24h to be sure no sx neuro deterioration Communicate with next step Head injury w/LOC Potential risk to pt w/actual or suspected domestic violence May admit pt to hospital if home unsafe
Case managers
y y y y Intervene when necessary to provide referral and follow up Use technology Relationship/decisions, etc. Interventions: o o o o o o Look at insurance, documentation, referrals to primary care, disease managment, medications, appropriate resources including nutrionist, organization o o o o disposition for homeless ppl, victims of domestic violence, etc home health agency referrals Community resources True emergency support as well
Some ED deaths require forensic investigation or medical examiner case Communication = simple, concrete, direct language o Use death or died Intense grief can provoke wide range of responses silence violence Be caring, compassionate, empathetic o
Trauma Centers = based on MASH system = specialty care facility with competent and timely trauma services to patients, based on designated capacity level. 3 levels: Level I
y y Usually in large teaching hospital in densely populated area Full continuum of care for all pateient care = prevention through rehab y y y y Responsibility to offer professional and community edu programs Conduct research Participate in system planning Often play leadership role in community o o o o Injury management Education Prevention Emergency preparedness planning
Level II
y y y Generally community hospital Capable of providing care to vast majority May not have resources for complex injury management o Transfer to Level I center for care
Level III
y y y Critical link to higher capacity centers Stabilizes injuries Smaller, rural hospitals
Level IV
y y Advanced life support care in rural or remote settings Transports to higher trauma centers when able y
All levels:
y y Personnel required to participate in performance improvement Patient safety initiatives Enhancement of quality of care and solve identified problems
Trauma System = organized and integrated approach to trauma care designed to ensure all critical elements of trauma care deliver aligned to meet injured needs including:
Access to care through communication technology (enhanced 911 services) Timely availability of prehospital emergency medical care Rapid transport to qualified trauma center Early provision of rehab services System wide injury prevention, research, edu initiative Also provides structure for disaster readiness Community emergency preparedness
Two most common MOI = blunt force trauma + penetrating trauma Blunt force trauma = result of impact forces like mva, falls, assault w/fists, kicks, baseball bat
y y Blast effect (from exploding bomb, etc) also causes Acceleration-deceleration forces o o High speed crashes, falls, Injury by tearing, shearing, compressing anatomic structure Trauma to bones, blood vessels, soft tissue
o body
y
Penetrating Trauma = injury from sharp objects and projectiles something physically penetrates
Examples = knives, ice picks, bullets, pellets, etc. o Fragments (shrapnel) from explosion
Trauma activation criteria = rapid coordinated resuscitation response d/t injuries associated with life threatening consequences such as gunshot wound to torso or stab wound to neck Primary survey and resuscitation interventions
y Scene safety = basic tenet of emergency care in any environment standard precautions must be worn in all resuscitation situations & @ other times w/exposure to blood and body fluid
If Glasgow Coma Scale score 8 or pt at risk for airway compromise intubation + mechanical ventilation
B= Breathing
y y y y After airway secured, this is next priority Assess breath sounds and respiratory effort Observe chest wall trauma or physical abnormality Assessment determines whether or not ventilatory efforts are effective NOT whether or not pt is breathing o Focus = auscultation of breath sounds + evaluation of chest expansion+ respiratory effort + evidence of chest wall trauma/physical abnormalities y y y Until endotracheal intubation, BVM (Bag Valve Mask for positive pressure ventilation) support esp w/apneic & poor ventilatory efforts CPR disconnect mechanical ventilator and use BVM o Lung compliance assess by sense degree of difficulty w/BVM
Chest Decompression (w/needle or chest tube to vent trapped air) Main indication of need = clinical evidence of tension pneumothorax Critical threat to breathing and circulation SX = or absent breath sounds over affected area Respiratory distress Hypotention Jugular vein distention Tracheal deviation (late sx) Unrelieved mediastinal shift + death cardiovascular collapse
Causes = barotraumas from BVM/other positive pressure ventilation + blunt or penetrating chest trauma + expansion of simple pneumothorx
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Tube thoracostomy y Chest tube inserted into 5th intercostals space anterior to medaxillary line o o Promotes air and fluid drainage If hemothorax capabilities prepare chest tube drainage system w/autotransfusion collected pleural blood can be transfused into pt if needed
C=Circulation
y Adequacy of HR, BP, overall perfusion o o o y Monitor VS, esp BP + pulse Maintain vascular access by using large bore catheter Use direct pressure for external bleeding Cardiac arrests Myocardial dysfunction Hemorrhage shock
Common threats: o o o
Interventions: targeted to restore effective circulation through: o o o Cardiopulmonary resuscitation Hemorrhage control IV vascular access w/fluid & blood as necessary y o o Best with large bore (16 gauge) peripheral IV line in AC area Other spots = central veins of femoral, subclavian or jugular sites Larger bore needle (8.5 or lower) Intraosseous for critically ill patients o o Drug therapy External hemorrhage = best controlled with firm, direct pressure on site w/thick dry dressing o o WORKS even w/amputations DO NOT USE TOURNIQUETS UNLESS HEMORRHAGE IS SO SEVERE THAT RISK TO LIMB IS JUSTIFIED TO SAVE LIFE Internal hemorrhage = more hidden complication must be suspect in injured pt or w/shock ROT to assess BP via pulses (when no time for cuff) o Radial pulse present = BP 80+ systolic Femoral pulse present = BP 70+ systolic Carotid pulse present = BP 60+ systolic Lactated ringers or NS Warm before adm to prevent hypothermia ROT: significant hypotention after 2L infused consider need for blood product
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D = Disability
y y Evaluate LPC via: AVPU o o o o y A:Alert V: Voice responsive to voice P: Pain responsive to pain U:Unresponsive to assess LOC Scores eye opening, verbal & motor response Normal = 15, totally unresponsive = 3 o o Neuro injury Intoxicants
E=Exposure
y y Remove clothing for complete physical assessment Always cut away clothing with scissors in these situations: o o y When rapid access to pt body is critical When manipulating limbs o further damage o Thermal or chemical burns cause fabric to melt into pt skin
Evidence preservation: handle items per institutional policy Collection vital in cases of rape, elder abuse, domestic violence, homicide, suicide, drug overdose, assult risk of hypothermia
Body temperature 97oF (36oC) Especially issue w/burns o o o Coagulopathy Increased bleeding Slowed drug metabolism Set room temp 75-80O Use heat lamps, warming blankets, etc
Hypothermia complicates management by: o o Vasoconstriction Difficulty w/venous access and arterial assessment
Interventions for hypothermia: o o o Remove wet sheets/clothing Cover pt with blankets Infuse only warm solutions and blood products o o
Secondary Survey =by resuscitation team to identify other injuries or medical issues needed to be managed or impact on the course of treatment