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CRITICAL CARE AWARENESS: CRITICAL CARE AWARENESS: CRITICAL CARE AWARENESS: CRITICAL CARE AWARENESS: An Introduction to Emergency Nursing
CRITICAL CARE AWARENESS:CRITICAL CARE AWARENESS:CRITICAL CARE AWARENESS:CRITICAL CARE AWARENESS:An Introduction to Emergency Nursing
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About this course
Healthcare Australia (HCA ) is a leading healthcare recruitment solutions provider of nursing staff, aged care workers and medical specialist placements in Australia with operations in every State and Territory. HCA’s family of brands match healthcare professionals with temporary and permanent options, which are vastly available due to the national and regional preferred-provider agreements existing with leading public and private hospital groups.
HCA is unique amongst Australian recruitment solutions providers in its commitment to the provision of continuing professional development (CPD) opportunities for all its Care Workers, nurses and midwives. In September 2011 HCA established a National Education Unit (NEU), with the remit of providing a centralized, coordinated approach in order to provide sustainable, cost-effective education and training which is validated and benchmarked against national standards.
The course is benchmarked to national standards of best practice, and the reflective elements of the course allow nurses and midwives to add 23 hours of Continuing Professional Development (23 RCNA CNE Points) to their professional portfolio, though the individual nurse must document and account for the time they spent and this may be more or less than the guideline of 23 hours.
***THIS IS A SELF-DIRECTED LEARNING PACKAGE***
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About the authors
• The course has been written by Lyza Helps & Debbie Greenhead & has been reviewed by Michael Page as well as a number of external critical care experts.
• Lyza Helps RN/RPN/CCRN, MMHSc, BNG, BSW, Grad. Cert CCU, Grad. Cert PSyc, Grad DIP MMHN Grad DipICU,, has significant clinical and training experience in critical care having worked at Royal Adelaide Hospital ICU-Q4; City Hospital Birmingham UK as Senior Critical Care Nurse/Team Leader; Flinders Medical Centre ICU retrieval team and team leader and as an Advanced Practitioner in the RAH CCU. Lyza wrote units 1-4, 6 & 7.
• Debbie Greenhead RN, Postgrad. Dip Health Sciences, Dip HE (Nurs). Debbie has 20 years ED experience in the UK (Guys Hospital ED) & New Zealand, where she works as a Clinical Nurse at Taranaki Base Hospital.
• Michael Page RN, MRes, DipHE, Cert IV TAA, has worked in ICU, CCU and HDU in hospitals across the UK, New Zealand and Australia. He was Clinical Nurse Consultant at Mater Private Hospital, Brisbane where he set up an ICU outreach service which has won a national award for innovation. He has published a number of research papers, including in BMJ and Circulation. Michael is National Education & Training Manager at HCA.
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Advisory panel: January 2012Lyza Helps RN, MMHSc, Dip. TAE, Dip MH & Psychology, Grad Dip CCU/ ICU.
Debbie Greenhead RN, Postgrad. Cert Health Science (Auckland NZ,) DipHe (Nurs).
Michael Page RN, MRes, DipHE (Nurs), Cert IV TAA.
Raylene Good RN, Grad. Cert Crit. Care, Cert IV TAE.
Ian Blaber RN, Grad. Cert Crit. Care, DipHE (Nurs).
Created: January 2011 by Lyza Helps. Reviewed Januar y 2012.
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Pre-requisite knowledge
While this course is made available to all HCA nurses there are some pre-requisites which allow students to get the most from this package.
This course assumes a sound underpinning knowledge of anatomy and physiology and some understanding of acute and crit ical care concepts.
It is intended for acute nurses with limited experience of Emergency Nursing to begin to explore the concepts involved in this specialty. Students may have worked in Emergency some years ago and wish to refresh their knowledge, they may have some experience in other critical care areas like CCU or ICU, or they may be completely new to critical care and wish to expand their knowledge and skills in order to move into ED in the future. They may just wish to use the course to update their knowledge of critical care for their CPD portfolio.
The decision to commence the course must be yours and significant time must be allowed. Completion of the course does not guarantee work in ED.
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• This course is adapted from a practical course delivered over six, three hour teaching sessions;
• The course uses the principles of adult vocational education and training where the student is responsible for developing their own learning plan and is self-directing in their learning;
• Students learn in different ways and at different speeds, and may wish to complete their study around work commitments, therefore each unit can be taken separately and at different times;
• Students may wish to only access certain parts of the course as they are already competent in some of the topics;
How to complete this course
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How to complete this course (cont).• The teaching sessions are based around power point presentations which
give a brief overview of each topic. It is expected the student will research information outside these course materials to develop their understanding. This course provides a framework for developing a basic understanding of emergency nursing;
• Students should take time to complete the reflective activities and to reflect at the end of each unit on how the acquired knowledge has impacted on their individual practice;
• There is no tutor support for this online course as it is a self-directed learning package.
• After completion of the final multi-choice assessment students should use their documented reflections to self-determine how many CPD hours they have actively been involved in. This may be less or more than the guideline of 23 hours CPD but this course attracts 23 CNE points (RCNA endorsed).
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Suggested further reading
• As with any course the more background reading you do (pre or post course) will enhance your learningexperience. There is no set text for the course, however the following is recommended as a general reference text:
• Curtis, K., Ramsden, C., Friendship, J. (2007), Emergency & Trauma Nursing. Available from Elsevier Health:
http://www.elsevierhealth.com.au/
• You should also access a medical/nursing dictionary to look up any terms or concepts you do not understand.
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This course is endorsed by APEC No 061122359as authorised by Royal College of Nursing, Australia
(RCNA) according to approved criteria. Completion of the entire course attracts 23 RCNA CNE points as part of RCNA’s Life Long Learning
Program (3LP).
(Equivalent to 23 hours CPD)
Please note: 23 hours CPD is conditional on the student:
• Completing all units, reading and understanding this program
• Completing the reflection activities and assessment questions successfully
• Spending 10-15 minutes for each unit documenting a reflection on the relevance of the content
to their professional practice.
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Units of Competence
• Unit One: Nursing care in ED: Triage Assessment• Unit Two: Emergency presentations 1• Unit Three: Emergency presentations 2:
Multiple Trauma• Unit Four: Emergency presentations 3:
Chest pain & AMI• Unit Five: Emergency presentations 4: Burns• Unit Six: Communication & assessments
in ED• Unit Seven: Legal & ethical issues in ED
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Nursing care in the ED:
Triage assessment.
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Unit One:
This course is endorsed by APEC No 061122359as authorised by Royal College of Nursing, Australia (RCNA)
according to approved criteria. Completion of Unit One attracts 3 RCNA CNE points as part
of RCNA’s Life Long Learning Program (3LP).
(Equivalent to 3 hours CPD)
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• Australian Government Health Regulations http://www.legislation.sa.gov.au/
• Holloway, N, (2007),Nursing Care of the Critically Ill Adult, Addison-Wesley Publishing, USA.
• Curtis,K., Ramsden, C & Friendship, J., (2007), Emergency and Trauma Care Elsevier: Mosby Books Australia.
• http://www.nurseinaustralia.com/resources/
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References
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• A medical or surgical condition requiring immediate or timely intervention to prevent permanent disability or death.
• In the Australian trauma is the number one killer of those under the age of 37 and the fourth leading cause of death overall. Cardiovascular death and Cancer are the leading causes.
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Definition of Emergency
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• The care of clients who require emergency intervention.
• The emergency nurse must be capable of rapid assessment and history taking and immediate intervention formulation and implementation using the nursing process.
• Clinical knowledge, communication, client teaching, and empathy skills are essential.
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Time Matters!
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Intellectual Skills
• Emergency room nurses must have a thorough knowledge of medical science;
• Mathematical skills to calculate the amount of medicine to be administered to a patient;
• Pathophysiology and anatomy and microbiology.
Emergency Nursing Skills
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Personal Skills
• Working in an emergency room requires a variety of personal skills and character traits, including patience, sympathy, integrity, willingness to work hard, and ability to resolve conflicts;
• Nurses must be able to communicate clearly and effectively with medical staff, patients and their families;
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Emergency Nursing Skills
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• Often, nurses are caught in the middle of a conflict that arises from the emotionally charged atmosphere of an emergency room;
• They must exhibit strong leadership skills, along with the ability to make correct decisions under extreme pressure;
• Nurses should have strong administrative skills and be good at multitasking.
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Emotional Skills
• Including hardiness and resilience.
• Must be able to tolerate uncertainty and distress in others and demonstrate tolerance.
• They should also be able to put apprehensive patients at ease without neglecting the urgency of their health problems, in themselves.
• Nurses must also maintain awareness of their own emotional needs and know how to recognize the signs of stress and burnout their co-workers.
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Emergency Nursing Skills
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Physical Skills
• Emergency room nursing requires physical skills, including being able to walk and stand throughout a shift. Nurses are sometimes responsible for moving or transporting patients to other parts of the hospital. Normal hearing and vision, along with legible handwriting, are also important.
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Emergency Nursing Skills
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• Spend 10-15 minutes reflecting on your strengths and weaknesses and highlight any areas you require additional skills in. Document these and make a brief plan of how you might build on the strengths and address the weaknesses. Return to this list at the end of the course to document your progress for your CPD portfolio.
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Activity 1
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There are three general approaches to emergency care:
• Disaster triage
• Hospital triage
• Emergency medical services.
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Approaches to Emergency Care
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Definition
• A process for sorting injured people into groups based on their need for or likely benefit from immediate medical treatment.
Origin
• Triage originated in World War One by French doctors treating the battlefield wounded at the aid stations behind the front.
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History Of Triage
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• It should be remembered that a symptom reported by a child may be triaged more urgently than the same symptom in an adult.
• Identify life-threatening conditions and determine acuity level of each patient.
• To reduce the loss of life or limb by urgent assessment and intervention.
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Function Of Triage
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AUSTRALIANTRIAGE SCALE CATEGORY
ACUITY(Maximum waiting time
PERFORMANCEINDICATOR THRESHOLD
ATS 1 Immediate 100%ATS 2 10 minutes 80%ATS 3 30 minutes 75%ATS 4 60 minutes 70%ATS 5 120 minutes 70%
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Methods Of Triage
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• Level 1 = continuous• Level 2 = every 15 min • Level 3 = every 60 min• Level 4 = every 60 to 90 min• Level 5 = every 2 hours
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Assessment Of Triage
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Immediate Simple injuriesrequiring immediate care
Chest woundsCrush injuriesBurns
Delayed Multiple injuriesrequiring extensive care
Open fractures of the long bones
Minimal Minor injuries (the walking wounded)
Sprains, minor cutContusions
Expectant Severe injuries likely to cause death
Massive head trauma, spinal cord injuries
CATEGORY CLIENT NEEDS EXAMPLES
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Assessment Of Triage
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Emergency Severity Index
Is patient dying ?
Level II, III, IV, V
Can patient wait?
Yes No
Level I
Yes No
Level II
ONELevel IV
How many resources?
Level III, IV, V
TWOLevel III
NONELevel V
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Each Australian hospital with an emergency department (ED) has an established triage system in place eg:
• Resuscitation • Emergency• Urgent Flinders Medical Centre (SA)• Semi-urgent• Non-urgent
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Hospital Triage
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• Emergent:
clients who require immediate care in order to sustain life or limb.
• Urgent:
clients who require care within 1 to 2 hours to prevent worsening of their condition.
• Non-urgent:
clients whose care can be delayed without the risk of permanent consequences.
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Triage Classification
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• General appearance ----what are they doing?• Airway• Breathing• Circulation• Disability• Environment• Subjective and objective (AMPLE )• Focused assessment• Across the room ----how do they look ?• Pains scale (PQRST)
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How Do I Triage?
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• A = allergy• M = medications• P = pregnancy/ previous illness• L = last meal• E = environments/events leading to trauma
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Ample
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P = Provokes What causes pain? What makes it better? Worse?
Q = Quality Is it sharp? Dull? Stabbing? Burning? Crushing?
R = Radiates Where does the pain radiate? Is it in one place? Does it go anywhere else
S = Severity How severe is the pain on a scale of 1 - 10?
T = Time Time pain started? How long did it last?
PQRST Pain Scale
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Step 4: Pose HypothesisStep 5: Determine AcuityStep 6: Reassess the Acuity
Look – Feel - Listen
What you see?What they say?
What do you ‘think’ is ‘going on’?
What urgency?
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Triage Decision
Step 1: Visual AssessmentStep 2: Chief Complaints
Step 3:
Focused Assessment
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• Establish the safety of the scene.• Remove the client from danger.• Establish airway, breathing, and circulation.• Manage shock.• Attend to eye injuries.• Treat skin injuries.• Triage urgency and get help
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Golden Rules Of Emergency Care
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• Prior to admission to the ED, the client may have been cared for by a paramedic.
• A paramedic is a specialized health care professional trained to provide advanced life support to the client requiring emergency interventions.
• GET A GOOD HANDOVER
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Emergency Medical Services
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A client is admitted to ED Triage via Emergency Medical Services (ambulance) with severe central chest pain:
Spend 10 minutes listing some of the key processes of assessment you would go through to determine the category of care required?
Activity 2
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Emergency Presentations 1.
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Unit Two:
This course is endorsed by APEC No 061122359as authorised by Royal College of Nursing, Australia (RCNA)
according to approved criteria. Completion of Unit Two attracts 3 RCNA CNE points as part
of RCNA’s Life Long Learning Program (3LP).
(Equivalent to 3 hours CPD)
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A condition of profound haemodynamic and metabolic disturbance characterized by inadequate tissue perfusion and inadequate circulation to the vital organs.
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Shock
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TYPE: CAUSES:
HYPOVOLAEMIC: Haemorrhage; Burns
CARDIOGENIC: Myocardial Infarction
TOXIC: Overwhelming Infection
ANAPHYLACTIC: Medications, insect bites or stings, food
NEUROGENIC: Spinal cord injury
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Types Of Shock
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• Spinal cord trauma can also occur as a result of injuries sustained in a head injury.
• Head injuries most common in motor vehicle collisions.
• Cerebrovascular accidents, or stroke, also require emergency care.
• Head injuries are the most common type of neurological trauma.
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Neurological & Neurosurgical Emergencies
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Closed:Haematoma, Bruising, Bleeding, Concussion,Space Occupying, Pressure.
Open:Penetrating Objects, Severed Scalp, External Trauma.
Head Injuries
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• Nose (rhinorrhea) or ears (otorrhea)
• Basilar skull fractures are located at the base of the Are diagnosed based on the presence of CSF in the cranium and potentially involve 5 bones that form the base of the skull.
Most common fracture sites
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Head Injuries
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• Anoxia due to trauma/ illness• ICP monitoring/ Goal is less than 15mm Hg• Cerebral Perfusion Pressure=MAP(mean arterial
pressure) Minus Mean ICP and keep at 70mm Hg to decrease neurological disability.
White area demonstrates anoxic injury
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Head Injuries Continued :
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Haematoma Craniotomy
Types of Injuries
The head strikes a hard object creating a concussion-type injury
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• Initially: ABC’s, immobilization.• Triage to appropriate facility.• Complete sensory & motor.• Mechanism of injury can be:
hyperflexion, hyperextension, axial loading, rotation, penetrating trauma.
• Neurology exam.
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Spinal Cord Injuries
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• Lateral C-Spine films, possible Spinal CT to rule out occult fracture.
• Dislocations of the spine are reduced ASAP.
• Postural reduction with tongs, halo traction or surgical fusion.
• IV methylprednisolone within 8 hours.
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Spinal Cord Injuries
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• Seizures account for about 1% of all emergency department.
• In adult ED patients, common causes of seizure are alcoholism, stroke, tumour, trauma, and central nervous system infection. In children, febrile seizures are most common.
• Least likely cause: Epilepsy.
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Seizure Disorders
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Most Eye emergencies are:
• Urgent to emergent in nature.i.e. arising from accident or trauma.
• Foreign Bodies.These can cause damage to vision very rapidly and thus require immediate attention.
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Ocular Emergencies
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• Those that jeopardize the function of the heart and lungs.
• Leading cause AMI/ Asthma/ COPD.
• Include drowning, foreign body obstruction of the airway, chest trauma, and chest pain.
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Cardiopulmonary Emergencies
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• Tension Pneumothorax (TRAUMA ) - is rapidly fatal.
• Easily resolved with early recognition and intervention.
• Air enters the pleural cavity without a route of escape, with each inspiration, additional air enters the pleural space, INCREASING intra-thoracic pressure causing collapse of the lung.
• The increased pressure causes pressure on the heart and great vessels compressing them TOWARD the unaffected side.
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Chest Injuries
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Physical evidence:
• Mediastinal Shift & distended neck veins.
• RESULTS in: decreased Cardiac Output and alterations in gas exchange
• Manifested by: severe resp. distress, chest pain, hypotension, tachycardia, absence of breath sound on affected side, and tracheal deviation
• Cyanosis is a LATE manifestation.
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Tension Pneumothorax (continued)
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• Life threatening condition caused by RAPID accumulation of fluid (usually blood) in the pericardial sac.
• As intra-pericardial pressure increases, cardiac output is impaired because of decreased venous return.
Classic Signs are :
- Muffled or Distant Heart Sounds
- Hypotension & Elevated Venous Pressure…and may not present until the patient is Hypovolemic & Hypotensive
- Pulsus Paradoxus - a decrease in systolic blood pressure during spontaneous respiration.
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Cardiac Tamponade
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Results from blunt and/or penetrating trauma to the chest:
• One of the most common causes of death after trauma
• Predisposes the patient to pneumonia and ARDS.
• Can be difficult to detect.
• May not be seen on initial X-ray.
• Infiltrates and hypoxemia may not occur for hours of days.
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Pulmonary Contusion
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Clinical presentation includes :
• Chest abrasions, bloody secretions, PaO2 of 60mmHg or less on room air.
• Often associated with flail chest and rib fractures.
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• Usually caused by Blunt Force Trauma . (example: Chest hits steering wheel).
• Three or more adjacent ribs are fractured.• Flail section floats freely resulting in paradoxical chest
movement.• Flail section contracts INWARD with inspiration and
expands OUTWARD with expiration.
Treatment :
• Intubation/mechanical ventilation.• Frequent pulmonary care. • Aggressive pain management.
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Flail Chest
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Example:
Rapid deceleration from head-on MVA, Ejectionor Falls.
Four common sites of dissection:
• The LEFT subclavian artery at the level of the ligamentum arteriosum,
• The ascending aorta.• The lower thoracic aorta above the diaphragm. • Avulsion of the innominate artery at the aortic arch.
Produced by Blunt Trauma to the chest.
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Aortic Disruption
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Musculoskeletal Emergencies
Greenstick Spiral Comminuted Transverse Compound
Typical Bone Fractures
Vertebral Compression
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• Extremity Assessment = the 5 P’s
• Pallor Pain Pulses Parethesia Paralysis
Describes the neurovascular status of the injured extremity.
When possible the injured extremity is comparedwith the non-injured extremity.
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Musculoskeletal Injuries
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• Unstable Pelvic fractures can be life threatening secondary to potential for severe hemorrhage, exsanguination, damage to genitourinary system and sepsis.
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Musculoskeletal Injuries Continued
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• Although most do not require emergency care, some are more severe than others and some are potentially fatal.
• All wounds are considered contaminated .
• Tetanus -Toxoid and Antibiotics are always considered.
• Categorized as:
Contusions Abrasions Lacerations Punctures Haematomas Amputations Avulsions Burns & Bites.
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Soft Tissue Emergencies
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• Abdominal Emergencies can be diverse in nature.
• Includes Trauma as well as Illnesses that cause:
Abdominal Pain!
This can manifest as:-Gastroenteritis, Gastrointestinal Bleeding, Obstruction Perforation etc.
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Abdominal Emergencies
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• The Classic Sign = PAIN
• But may be obscured by AMS, drug or alcohol intoxication. Spinal cord Injury with impaired sensation
• The LIVER is the most commonly injured organ from blunt or penetrating trauma. Liver injuries are Graded I through VI.
• SPLENIC injury most commonly occurs from blunt trauma but can be caused by penetrating trauma.
PRESENTATION:
• LUQ tenderness, peritoneal irritation,
• Referred pain to the left shoulder (Kerr’s sign)
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Abdominal Injuries
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Hallmark Clinical Signs:
• Usually associated with long bone, pelvis, and multiple fractures.
• Development of lipuria (fat in the urine) indicates severe fat embolism syndrome.
• Low grade fever, new onset tachycardia, dyspnea, Increased resp rate and effort, Abnormal ABG’s, Thrombocytopenia and petechiae.
• Usually develops within 24 to 48 hours after injury.
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Fat Embolism
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• Includes Rape .
• Straddle Injuries:
Those that occur when a client falls while straddling an object, such as a fence or metal bar, thereby injuring the perineum.
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Genitourinary Emergencies
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• OR from actual injury to the renal system• There is a reduction in Renal Blood Flow in the trauma
patient associated with shock or low cardiac output.• From systemic effects of trauma
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Acute Renal Failure
Normal Kidney Acute Renal Failure Chronic Kidney
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• Nutritional/ Dehydration demands are increased in Trauma,
• Infection:- causes alterations in Metabolism• Metabolism is increased by activation of the
Sympathetic Response.
Likely Causes :-• Gastroenteritis, Meningitis, UTI (elderly), Vomiting, • Pregnancy (persistent vomiting)• Other Neoplasm's, Acopia
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Altered Nutrition / Dehydration
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Most likely:
PSYCHOSIS • Drug Induced• Schizophrenia - Bipolar 1st Pres.
SELF HARM• Personality Disorders. Intentional /Usually lethal• Depression/Suicide.
Intentional/Higher Non - Lethality in men
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Mental Health Emergencies
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• Stay safe yourself
• Maintain distance
• Identify cause
• De-escalation techniques
• Mental Health Patients are LEAST likely to be viol ent.
• More likely Drug/ Alcohol Affected or
Behaviourally Challenged Patients
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Challenging/Violent Behaviour
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Medical Causes of Violence and Aggression in patients:• Head injury• Substance abuse and intoxication• Hypoxia• Seizures: post-ictal or status epilepticus• Underlying mental illness• Metabolic disturbances/ Hypoglycaemia• Infection: meningitis, encephalitis, sepsis• Hyperthermia or hypothermia• Vascular: stroke or subarachnoid haemorrhage
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Don’t Assume Mental Health Issues!
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• Access the MIFA website at:http://www.mifa.org.au/fact-sheets
And refresh or update your knowledge of mental illness as well as learn about the support available from MIFA.
HCA staff can record this activity on eNursing as CPD.
Activity 3
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Accidental or Intentional?
• Ingested Poisons are most common.
Important to obtain a clear history of:
• Route of entry• Inhalation, • Ingestion,• Topical, or Injection .
When? How Much? Why? What?
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Poisoning and Overdoses
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• Must be 1:1 observations
• Aim to prevent further harm
• Aim transfer to Psych ASAP
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Safety – Risk Prevention
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• Severe Cold, or hypothermia, frostbite.
• Extreme Heat.
• Exposures to extremes of heat and cold can BE potentially life threatening.
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Environmental/Temperature Emergencies
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MILD Skin cold to touch, pale, tingling, numb
Use blankets, warm clothing to warm cold flesh
MODERATE Affects deeper body tissue, skin waxy, puffy, itchy, burning with pain
Use gloves, blankets, warm clothing to warm cold flesh
SEVERE Blistering, soft tissue damage, flesh hard, lifeless, no pain
Initiate emergency rewarming using warm water baths; observe for edema
DEGREE SYMPTOMS TREATMENT
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Degrees Of Frostbite Severity
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HEAT CRAMPS Muscle cramps in arms, leg, and abdomen
Move client to cool, shady area. Slowly administer copious water. Reevaluate.
HEAT EXHAUSTION
Diaphoresis, pale, moist, cool skin, headache, dizziness, etc.
Move client to cool, shady area. Pour water over client. Elevate legs.
HEAT STROKE(medical emergency )
Red, flushed, hot dry skin; no diaphoresis.
Emergency treatment.
TYPE SYMPTOMS TREATMENT
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Comparison Of Heat Injuries
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• Haematological toxins –Coagulation disturbance
• Myotoxins – cause Rhabdomyolysis
• Nephrotoxins —renal disturbances
• Neurotoxins —rapid centrally acting
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Envenomation In Australia
Brown Snake Funnel Web
Blue Ringed Octopus
Stone Fish
Box Jellyfish
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• Maintain immobilisation, splint and bandage until the situation is under control!
• Support airway, breathing and circulation. • Intubate and ventilate with 100% Oxygen if airway or
respiration fail. • Give antivenom immediately• Volume expansion may be necessary. • Severe coagulation disturbances, electrolyte
abnormalities, and muscle damage leading to acute renal failure are likely.
• Repeat antivenom as clinically indicated.
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Envenomation In Australia: Treatment
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• Past history of seizure disorder, on phenytoin• Presents with 12 hour history of fever/chills/rigors, lower
abdominal pain• VITAL SIGNS• 39.4 degrees C• HR 125, BP 75/40 --> 90/50 after 2L NS• Difficulty rousing patient• Urinalysis - NAD
• Bloods - Gram negative Staphylococcus
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Case Study: Shock
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• Started on antibiotics following cultures(Cefotaxime, Ampicillin, Flagyl)
• 2hrs later:• HR to 180, BP 65/P despite ++ fluids• Shortness of breath, RR 40+• Hypoxemia, bilateral pulmonary infiltrates• PH 7.23 PCO 33 PO 80 80% O2
• Metabolic acidosis, lactate 2.6• urine output 10 mls/phr• increased INR to 2.4
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Case Deterioration
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• Why does heart rate increase as the shock worsens and blood pressure goes down?
• Research septic shock and look at phases of shock.
• Using a medical/nursing dictionary look up all the terms you were not familiar with in this unit.
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Activity 4
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Emergency Presentations 2:Multiple System Trauma.
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Unit Three:
This course is endorsed by APEC No 061122359as authorised by Royal College of Nursing, Australia (RCNA)
according to approved criteria. Completion of Unit Three attracts 3 RCNA CNE points as
part of RCNA’s Life Long Learning Program (3LP).
(Equivalent to 3 hours CPD)
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• Injury sustained in more than one body system.
• During the initial care of the emergency client, the mechanism of injury is determined.
• Blunt injuries and penetrating trauma are most likely to result in multiple-system involvement.
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Multiple System Trauma
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• The FOURTH leading cause of death for ALL ages.
• Nearly 50% of all traumatic incidents involve the use of alcohol, drugs or other substance abuse.
• Is predominantly a disease of the young and carries potential for permanent disability.
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Trauma
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• FIRST PEAK - seconds to minutes from time of injury to death—
severe injuries: lacerations of the brain, brainstem, high spinal cord, heart aorta, large blood vessels.
• SECOND PEAK - minutes to several hours:
subdural, epidurdal hematomas, hemopneumothorax, ruptured spleen, lacerated liver, pelvic fractures, other injuries associated with major blood loss.
• THIRD PEAK - occurs several days to weeks after the initial injury:
most often the result of sepsis and multiple organ failure. At this stage, outcomes are affected by care previously provided.
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Trimodal Distribution Of Death
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• Most often results from vehicular accidents, but may occur in assaults, falls from heights, and sports related injuries.
• May be caused by accelerating, decelerating, shearing, crushing, and compressing forces.
• Contra -coup injury.
• Body tissues respond differently to kinetic energy…low density porous tissues and structures, such as lungs, often experience little damage because of their elasticity.
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Blunt Trauma
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• Results from the impalement of foreign objects into the body.
• More easily diagnosed because of obvious injury signs.
• Stab wounds are usually low velocity…the direct path, the depth and width determine injury.
• Women tend to have trajectories in a downward motion, men in an upward force.
• Injuries sustained from penetrating objects must be assessed for the potential for infection from the debris carried by the penetrating object.
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Penetrating Trauma
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• E - Expose the patient• F - Full set of vital signs, *five interventions
(cardiac monitor, pulse oximetry, urinary catheter, NG if not contraindicated, lab studies)
• G - giving comfort measures…pain control, reassurance to patient and family
• H - history/ head to toe assessment• I - inspect for hidden injuries-log roll patient to
inspect posterior aspect.
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EFGHI =
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Influenced by:
• Level of consciousness• Stability of patient’s condition• Mechanism of injury• Identified injuries
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Sequence Of Diagnostic Procedures
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• Essential to trauma management
• EVERY trauma patient has potential for airway obstruction
• Most common obstruction: Tongue
• Other common causes: blood or vomitus, secretions, structural impairment, depressed sensorium, absent gag reflex
90
Maintain Airway Patency
Page 91
• Endotracheal Intubation - Complete control of the airway
• Nasotracheal Intubation - INDICATED for the spontaneously breathing patient..CONTRAINDICATED in the patient with facial, frontal sinus, basilar skull or cribriform plate fractures.
91
Definitive Non - Surgical Airway
Page 92
• Clinical condition of the patient
• Familiarity of procedure
• Degree of hemodynamic stability
A PATENT AIRWAY IS THE CORNERSTONE OF SUCCESSFUL TRAUMA RESUSCITATION
92
Choice of Airway Management
Page 93
• Altered mental status (agitation)• Cyanosis( nail beds and mucous membranes)• Asymmetrical chest expansion• Use of accessory muscles/abdominal muscles• Sucking chest wounds• Paradoxical movements of the chest wall• Tracheal shift• Distended neck veins• Diminished or absent breath sounds
93
Life Threatening Conditions Exist
Page 94
• Follows airway obstruction as the nest most crucial problem for the trauma patient.
• Reasons: decreased inspired air, retained secretions, lung collapse or compression, atelectasis, accumulation of blood in the thoracic space.
94
Impaired Gas Exchange
Page 95
• Acute Blood loss—MOST common cause in acute trauma: May be external or internal(impaired venous return to the heart).
• Tension Pneumothorax.
• Pericardial Tamponade (from decreased filling and
ventricular ejection fraction).
95
Decreased Cardiac Output/Hypovolaemia
Page 96
• Patent airway
• Maintaining adequate ventilation.
• Adequate gas exchange.
• Then:
- Control haemorrhage. - Replace circulating volume. - Restore tissue perfusion.
96
Decreased Cardiac Output/Hypovolaemia
Page 97
• Elevation.
• Direct Pressure.
• Compression of pressure points (arteries, veins).
• AVOID tourniquets…can compromise loss of circulation and loss of limb.
97
Control of Haemorrhage
Page 98
• Identification and correction of underlying problem.
• SURGERY - normally emergency laparotomy.
98
Control of Haemorrhage
Page 99
• Chest and pelvis, extremity X-rays.• Imperative to locate etiology of hemorrhage:• Abdominal ultrasound.• Abdominal CT can be used but in the case of
hemodynamic instability. • Emergency laparotomy is the quick, invasive
test of choice.
99
During Resuscitation Phase
Page 100
Aspiration of greater than 10 ml blood and patient goes directly for surgery.
• If less than 10 ml of blood, 1 litre of warmed Normal Saline is infused into peritoneal cavity, then drained and sent for cell counts, amylase, bile, food particles, bacteria, faecal matter.
• Insertion of lavage catheter directly into the abdomen.
100
Peritoneal Lavage
Page 101
Venous Access and Volume infused are the key.
• Two large bore IV’s 14-16 gauge. (never less that 18 g, that is the smallest to give blood through rapidly and not have haemolysis)
• Forearm and anti-cubital veins are preferred
• Central lines are more beneficial as resuscitation MONITORING tools.
101
Fluid Resuscitation
Page 102
Isotonic fluids are used INITIALLY
• Hartmann's, Albumin or 5% Dextrose is first choice followed by Normal Saline.
• Then give O negative blood if needed (as prescribed).
• RULE: Venous access with largest bore catheter if possible.
Rapid infusion
pressure bag
102
Fluid Resuscitation Continued
Page 103
• An initial bolus of 2 litres of fluid is used unless there is contraindication…(Hartmann's)
• 3:1 Rule = 3ml of crystalloid for each 1ml of blood loss.
• Large bore catheters, short tubing, rapid infuser devise that warms fluids and blood.
• INITIAL response to fluid challenge is urine output, Output should = 50 ml in adult, Loss of consciousness (LOC), heart rate, BP and capillary refill.
103
Fluid Resuscitation Continued
Page 104
• Greater than 10 units of Packed red Blood Cells (PRBC’s) over 24 hours or the replacement of the patient’s total blood volume in less than 24 hours.
• It is associated with VERY poor outcomes.
Commonly develop ARDS and DIC
104
Massive Fluid Resuscitation
Page 105
• Acid base imbalances• Electrolyte imbalances• Hypothermia• Dilutional coagulopathies• Volume overload• SIRS (systemic inflammatory response syndrome)• ARDS (acute respiratory distress syndrome)
• MODS (multi-organ dysfunction syndrome)
105
Potential Complications of Massive Resuscitation
Page 106
• If unresponsive to fluid. Type Specific Blood is given.
IF LIFE THREATENING…may give O Negative Blood
• Based on patients response to initial fluid.
• Cross Matched - type specific, should be given as soon as possible.
106
Decision to Give Blood
Page 107
• Rapid Response
respond quickly to fluid challenge and remains stable at completion of bolus.
• Transient Response
responds quickly but declines when fluids are slowed (indicates continued blood loss)
• Non Response
fail to hemodynamically respond to crystalloid and blood…require immediate surgical intervention.
107
Three Response Patterns
Page 108
• Defined as a core temp of 35 degrees Celsius.
• Can occur year round.
• More susceptible person: older, using alcohol or sedatives, severe injury, massive transfusions.
• In presence of cooler atmospheric temps.
• Submersion in water.
Affects the myocardium and the coagulation system. Can result in bradycardia, atrial and ventricular fibrillation.
108
Hypothermia
Page 109
• Warm fluids
• Overhead warmers
• Warming blankets
109
Hypothermia
Page 110
• Deterioration of PaO2 and pH
• Rising base deficits
• Increasing Lactate levels
• Dramatic fall in cardiac output –
Resulting in falling BP and CVP
110
Ongoing Signs & Symptoms of Shock
Page 111
INDICATES:
• Inadequate tissue perfusion
• Indicates anaerobic metabolism—very inefficient cellular metabolism.
Result of hypovolemia and hypoxia
• MUST be interrupted or cellular dysfunction results in cellular swelling, rupture and death.
111
Ongoing Metabolic Acidosis
Page 112
• Hypocalcaemia
• Hypomagnesaemia
• Hyperkalaemia
May lead to changes in myocardial function, laryngeal spasm, neuromuscular and central nervous system hyper-irritability
112
Electrolyte Imbalance
Page 113
• Vessels become more permeable to fluids and molecules, leading a change in movement from the intravascular space to the interstitial space.
• Patients become more hypovolaemic requiring more fluid replacement.
113
Electrolyte Imbalance
Page 114
• Dilutional thrombocytopenia.
• Reduced fibrinogen.
• Reduced factor V, Factor VIII and other clotting components.
• High levels of citrate in blood products reduce calcium…leading to an ineffective clotting cascade. (calcium is a necessary co-factor for this process).
• Platelet dysfunction can occur secondary to hypothermia or metabolic acidosis
114
Dilutional Coagulopathy
Page 115
• Improve tissue perfusion.
• Resolve hypothermia.
• Administer clotting factors (FFP, cryoprecipitate, platelets).
• Monitor labs (INR, PLT count, fibrinogen, PT, PTT).
**Look up abbreviations for blood products**
115
Treatment Of Dilutional Coagulopathy
Page 116
• Initially helpful…release of inflammatory mediators…over time (can be a fairly short time) can result in SIRS, ARDS, MODS.
116
Changes In The Coagulation Cascade
Page 117
• Chest Injuries.
• Spinal Cord Injuries.
• Head Injuries.
• Musculoskeletal Injuries.
• Abdominal Injuries.
117
Assessment & Management Of Specific Organ Injuries
Page 118
Go to the BloodSafe website: https://www.bloodsafelearning.org.au/node/23
Refresh your knowledge of safe transfusion practice as necessary. The certified unit offers an optional 2 hours CPD additional to this course.Bookmark this site for future reference.
Activity 5
Page 119
Emergency Presentations 3: Chest Pain & AMI.
119
Unit Four:
This course is endorsed by APEC No 061122359as authorised by Royal College of Nursing, Australia (RCNA)
according to approved criteria. Completion of Unit One attracts 3 RCNA CNE points as part
of RCNA’s Life Long Learning Program (3LP).
(Equivalent to 3 hours CPD)
Page 120
• Acute Myocardial Infarction (AMI) or Acute Coronary Syndrome (ACS).
• Acute Aortic Dissection (usually thoracic).• Pulmonary Embolism.• Acute Pericarditis/Pericardial Tamponade.• Tension Pneumothorax.• Oesophageal Perforation.• Hypertensive Emergency/Crisis.
120
Chest Pain – initial approach
Page 121
• GORD• Oesophageal Spasm• Pleurisy• Bronchitis/Pneumonia• Muscle strain/Sprain• Panic Attack• Shingles/Zoster• Trauma (contusions, ecchymosis, rib/sternal Fx)• Lung Tumor/Cancer
121
Chest pain – non life threatening (initially)
Page 122
�Vital signs including O2 saturations.
�Obtain IV access.
�12-lead ECG: Done AND reviewed within 10 minutes!
�Brief, targeted history and physical.
�Initial Bloods (CBC, CKMB, coags, Troponin (I or T).
�Portable CXR.
122
Chest pain – initial approach
Page 123
�O2 2-4L via nasal cannula.
�Aspirin 150-300mg PO.
�NTG SL or spray.
�Morphine sulfate 2.5-5mg IV�If pain not relieved with NTG and pain is felt to be “the
real deal”
�Remember, MONA greets all patients:
�Morphine Oxygen Nitrates Aspirin
123
Initial treatment
Page 124
• Characteristics of pain– Location, radiation, quality, severity
• Time of onset
• Duration/frequency
• Associated symptoms– SOB/ OE??, diaphoresis, syncope, anxiety/gloom ‘n’
doom
• CAD or CAD risk factors: DM, HT, hyperlipidemia, smoking, +FMHx (premature)
124
Chest pain – initial history
Page 125
� Relationship of chest pain to…�Exertion�Position�Breathing (i.e. is it pleuritic?)�PO intake�NTG administration at home/in ED�Note timing, other associated NTG effects
� Illicit substance ingestion, e.g. cocaine
Where is it?When did it start?
How long have you had it?What makes it better or worse
125
L.R.3
Slide 125
L.R.3 LyzaHelps, 12/03/2011
Page 126
�Prior Angiogram/ or CABG or other surgery?
�Prior angina symptoms?�Similarity of current chest pain with prior angina
symptoms?
�Any GORD symptoms or history?�Bitter taste in AM, chronic heartburn?
�Any musculoskeletal symptoms or history?�Heavy lifting, trauma, change with arm movement?
�Any recent URTI-type symptoms?�Cough, sore throat, fever/chill, nasal congestion?
126
Chest pain – initial history
Page 127
� ST elevation or new/presumably new Left Bundle Branch Block.
�Adjunctive therapies.�Beta blockers IV (goal is HR in 50’s as BP/Sx tolerate).
�GTN IV.�Heparin IV).�ACE-I after 6 hours if stable (captopril/lisinopril).�Admit to CCU/ ICU.
� If Symptoms < 12 hours, reperfusion!�ANGIO.
� If Symptoms > 12 hours, further exam in CCU.
127
Chest pain – STEMI
Page 128
Normal Sinus Rythym ST Elevation 6-8 hours
ST elevation and T wave inversion deep Q wave
AMI FIRST 12 HOURS
128
ECG changes…
Page 129
�Will be admitted short term for referral and Investigate.
�2 serial ECG’s
�2 sets of cardiac markers2nd set ≥ 6-8 hours after onset of pain.
�Referral to Cardiology…?ANGIOGRAM +/- ANGIOPLASTY.
129
Chest pain - NSTEMI
Page 130
• The electrocardiogram (ECG) is a diagnostic tool that measures and records the electrical activity of the heart in detail. Being able to interpret these details allows diagnosis of a wide range of heart problems.
130
12 Lead ECG
Page 131
�The ECG records the electrical activity that results when the heart muscle cells in the atria and ventricles contract.
What it doesn’t measure
�The ECG does not say anything about the muscle of the heart.
131
What it measures
Page 132
Six chest leads V1-V6
4 Limb Leads
132
Setting up the leads
Page 133
�Atrial contractions show up as the P wave.
�Ventricular contractions show as a series known as the QRS complex.
�The third and last common wave in an ECG is the T wave. This is the electrical activity produced when the ventricles are recharging for the next contraction (repolarising).
133
What does it mean?
Page 134
• ECG Interpretation
�The graph paper that the ECG records on is standardised to run at 25mm/second, and is marked at 1 second intervals on the top and bottom.
134
Reading an ECG
Page 135
135
The horizontal axis correlates the length of each electrical event Each small block (defined by lighter lines) on the horizontal axis represents 0.04 seconds. Five small blocks (shown by heavy lines) is a large block, and represents 0.20 seconds.
The vertical axis measures amplitude of the wave
Page 136
P-R Interval: represents the time it takes an impulse to travel from the atria through the AV node, bundle of His, and bundle branches to the Purkinje fibres.
Location: Extends from the beginning of the P wave to the beginning of the QRS complex
Duration: 0.12 to 0.20 seconds.
136
Page 137
• Q-T Interval: represents the time necessary for ventricular depolarisation and repolarization.
• Location: Extends from the beginning of the QRS complex to the end of the T wave(includes the QRS complex, S-T segment, and the T wave).
Duration: Varies according to age, sex, and heart rate
137
Page 138
• S-T Segment: represents the end of the ventricular depolarisation and the beginning of ventricular repolarization.
• Location: Extends from the end of the S wave to the beginning of the T wave.
• Duration: Not usually measured.
138
Page 139
�T Wave: represents the repolarization of the ventricles. On rare occasions, a U wave can be seen following the T wave. The U wave reflects the repolarization of the His-Purkinje fibres.
�Location: Follows the S wave and the S-T segmentAmplitude: 5mm or less in standard leads I, II, and III; 10mm or less in precordial leads V1-V6.
Duration: Not usually measured.
139
Page 140
�In a normal heart rhythm, the sinus node generates an electrical impulse which travels through the right and left atrial muscles producing electrical changes which is represented on the electrocardiogram (ECG) by the P-wave.
�The electrical impulse then continue to travel through specialized tissue known as the atrioventricular node, which conducts electricity at a slower pace. This will create a pause (PR interval) before the ventricles are stimulated.
140
Normal ECG
Page 141
PWAVE Q WAVE R WAVE S WAVE T WAVE
141
Sinus Rythym
Page 142
142
Coarse VF Fine VF
Ventricular Tachycardia
Life -threatening dysrythmias
Page 143
�Produced by blunt trauma to the chest.
�Rapid deceleration from head-on MVA, ejection, or falls.
�Four common sites of dissection:
�the left subclavian artery at the level of the ligamentum arteriosum.
�the ascending aorta.
�the lower thoracic aorta.
�avulsion of the innominate artery at the aortic arch.
143
Acute aortic dissection
Page 144
�Signs: weak femoral pulses, dysphagia, dyspnea, hoarseness, pain.
�Chest x-ray shows wide mediastinum(greater or equal to 8mm), tracheal deviation to the right, depressed main stem bronchus, first and second rib fractures, left heamothorax.
�Confirmation is by aortogram.
�Treatment is SURGICAL.
144
Signs of aortic disruption
Page 145
�is rapidly fatal.
�Easily resolved with early recognition and intervention.
�Air enters the pleural cavity without a route of escape, with each inspiration, additional air enters the pleural space, INCREASING intrathoracic pressure causing collapse of the lung.
�The increased pressure causes pressure on the heart and great vessels compressing them TOWARD the unaffected side.
145
Tension pneumothorax
Page 146
�Physical evidence:
�Mediastinal Shift & distended neck veins.
�RESULTS in: decreased Cardiac Output and alterations in gas exchange
�Manifested by: severe respiratory distress, chest pain, hypotension, tachycardia, absence of breath sound son affected side, and tracheal deviation.
�Cyanosis is a LATE manifestation.
146
Tension pneumothorax
Page 147
�Collection of blood in the pleural space.
�From injuries to the heart, great vessels, or pulmonary parenchyma.
�Signs and symptoms: decreased breath sounds, dullness to percussion on affected side, hypotension, respiratory distress.
�Treatment: Placement of chest tube.
147
Haemothorax
Page 148
• Familiarise yourself with what the following represent on the ECG:
P-waveQ-waveR-wave
ST segment
Activity 6
Page 149
Activity 6 (continued).
• Describe the features of Normal Sinus Rythym.
• Discuss the cause and significance of an elevated ST-segment.
• What nursing care would you give to a patient whose ECG showed a significant elevation in ST segment?
Page 150
Emergency presentations 4: Burns.
150
Unit Five:
This course is endorsed by APEC No 061122359as authorised by Royal College of Nursing, Australia (RCNA)
according to approved criteria. Completion of Unit Seven attracts 3 RCNA CNE points as
part of RCNA’s Life Long Learning Program (3LP).
(Equivalent to 3 hours CPD)
Page 151
Objectives of this unit:
• To increase awareness & understanding of burn injuries.
• To provide a brief overview of the Management of Burn Injuries in ED.
• To increase confidence in caring for patients with severe burns.
Page 152
Definition of a burn
• A burn is defined as tissue damage caused by agents, such as heat, chemicals electricity, sunlight and flame.
Page 153
• Epidermal Burns.
• Superficial Dermal Burns.
• Deep Dermal Burns.
• Full Thickness Burns.
Depth of Burn Injury
Page 154
Diagnosis of Burn DepthDEPTH COLOUR BLISTERS CAPILLARY
REFILLSENSATION HEALING
Epidermal Red No Present Present Yes
SuperficialDermal
Pale Pink Small Present Painful Yes
Mid-Dermal
Dark Pink Present Sluggish +/- Usual
Deep Dermal
Blotchy Red +/- Absent Absent No
Full Thickness
White No Absent Absent No
Page 155
Types of burn
• Chemical
• Inhalation
• Electrical
• Thermal
Page 156
Chemical burns
• ACID or ALKALI.
• Tissue damage as a direct result of exposure to chemical.
• All chemical burns require copious irrigation with water.
• Ring your regional POISONS centre.
Page 157
Chemical burns
Page 158
Inhalation injury
Inhalation of hot gases and products of combustion causes respiratory tract damage.
-Airway injury above larynx
-Airway injury below larynx
-Systemic Intoxication injuries
Page 159
Airway injury above larynx
• Burns produced by the inhalation of HOTgases.
• Oedema occurs in the tissues which can lead to obstruction
• So early intervention think of intubation and/or close observation are needed.
• Look for signs of >resp rate, resp distress, swelling of neck, burns to face, singed nasal hair, soot in mouth/nose.
Page 160
Airway injury below the larynx
• Burns caused by the inhalation of products of combustion.
• Acids and alkalis are produced when these products dissolve in water contained in resp. mucous and tissue fluids resulting in a chemical burn.
• Factors implicated in pathogenesis of lung injury:
Secondary bacterial PneumoniaAcute respiratory distress syndromeImpaired gas exchange Pulmonary oedema.
Page 161
Systemic intoxication injury• Follows absorption of carbon monoxide, hydrogen
cyanide, hydrofluoric acid, and/or ammonia.
• The most common intoxication is carbon monoxide (CO) and cyanide.
• CO diffuses rapidly into the blood stream and reduces the O2 carrying capacity of the blood.
• Important if suspicious of systemic intoxication give 100% O2 & do an ABG.
– Pt with >COHb can displays signs of headaches, confusion, nausea, fatigue, Disorientation, syncope, hallucinations, convulsions and coma.
Page 162
Examination. Signs of inhalation:• Burns to mouth, nose, and pharynx• Change of voice, hoarse brassy cough• Inspiratory stridor• Tracheal tug• Indrawing• Singed Nasal hairs• Productive cough• Croup like breathing • Respiratory difficulty• Rib retraction• Nasal flaring
Page 163
Electrical burns
• Low voltage – Below 1000 volts.
• High voltage – Above 1000 volts (but often 11000 or 33000 volts).
• Lightening strike – Extremely high voltage.
Page 164
Low Voltage:
• Can cause a significant local contact wounds and can cause cardiac arrest but no deep tissue damage.
Page 165
High Voltage Burns:• High Voltage current causes injury in 2 ways:
• Flash Burn : A cutaneous burn without deep tissue damage results when there is a high tension discharge or ‘flash over’, the current not passing through the pt. The arc ignites clothes and causes deep dermal burns.
• Current transmission : Generally results in cutaneous & deep tissue damage & has entry & exit sites.
• Very important to test urine for discolouration, as heamochromogenuria is to be anticipated in HVB.
• A catheter should be inserted and if pigments appear in the urine, the infusion rate of fluids must be increased to maintain a urine output of 75-100ml/hr
• HVB have risks of dysrhythmias so cardiac monitoring & ECG’s should be obtained.
Page 166
Electrical burns
Page 167
Lightening Strike
• The pattern of injury is variable.
• A direct strike is where the discharge occurs directly through victim, this has a very high mortality.
• More commonly a side flash or splash occurs.
• Lightening can cause unusual skin damage which has a splashed on appearance, known as ‘Lichtenberg’ flowers.
Page 168
Lightening Strike
Page 169
Initial first aid:• Stopping the burning process.• Cooling the burn.• In a flame burn the flame extinguished, hot
charred clothes removed.• In a scald burn removal of wet clothes (clothing
soaked in fluid act as a reservoir of heat).• Also remove all jewellery.• The burn surface should be cooled with running
water, ideal temperature is 15°C useful range 8°C and 25°C.
Page 170
Emergency Examination/TreatmentRapid assessment & treatment can be lifesaving!
HISTORY:
-Road traffic accident (ejection/High speed)-Blast /explosion or fire-Electrocution -Jump or Fall
Non communicative pts, whether unconscious, intubated, psychotic, or under the influence of substances, should be regarded as potential multiply injured & treated accordingly.
Page 171
Primary survey:
• Immediate life threatening conditions are identified and emergency management can begin!
• A. Airway maintenance with cervical spine control
• B. Breathing and ventilation• C. Circulation with haemorrhage control• D. Disability-neurological status• E. Exposure + environmental control• F. Fluid resus proportional to burn size
Page 172
A. Airway Maintenance with C -spine Control
• Clear airway of foreign material and open the airway with chin lift/jaw thrust. Keep movement to a minimum and never hyperflex or hyperextend the head and neck.
• Injuries above the clavicle, such as facial injuries or unconsciousness, are associated with cervical fracture (#).
Page 173
B. Breathing and Ventilation
• Expose the chest and ensure that chest expansion is adequate and equal.
• Ventilate via bag and mask or intubate pt if nec.• Always provide supplemental O2.• Carbon Monoxide poisoning may give a cherry
pink, non-breathing patient.• Beware the resp. rate >20bpm.• Beware circumferential chest burns - is
escharotomy required?
Page 174
C. Circulation with Haemorrhage Control
• Check the pulse- is it strong or weak?
• Capillary Blanch test-normal return is 2 seconds. Longer indicates hypovolaemia or the need for escharotomy on the limb; check the other limb to compare.
• Stop bleeding with direct pressure.
• Mental confusion occurs with blood loss of 50% of blood volume.
• Pallor occurs with 30% loss of blood volume.
Page 175
D. Disability: Neurological Status• Pain relief – burns hurt! …….MORPHINE.
• Establish level of consciousness:
A- AlertV- Response to Vocal StimuliP- Responds to painful StimuliU- Unresponsive
Examine the pupil response to light. They should be brisk & equal.
Be aware of hypoxaemia and shock can cause restlessness and decreased level of consciousness.
Page 176
E. Exposure with Environmental control
• Remove all jewellery
• Keep pt warm
• Use ‘Bair hugger’ (warmer) or warmed fluids, or space blanket.
• Warm gradually to prevent sudden hypotension.
Page 177
F. Fluid resuscitation• Insert 2 large bore peripheral IV lines preferably through
unburned skin take blood for FBC, U&E’s, Coags, Amylase, Carboxyheamoglobin (arterially).
Fluids given initially as per formula (check protocols):
• 3-4mls Crystalloids (ie.hartmanns/plasmalyte)/kg/%of burn+maintenance for children
• Area burned is estimated by rule of nines
• Half calculated fluids is given in the first eight hours; the rest given over the next sixteen hours
• Time of injury marks the start of resuscitation.
Page 178
Estimation of Fluid Needs:
• Adults: 3-4mls/kg/%burn
• Children: 3-4mls/kg/%burn PLUSMaintenance with 4%glucose in ¼ or 1/5 normal saline100ml/kg up to 10 kg50ml/kg 10-20kg20ml/kg for each kg over 20kg
These calculation start from time of burn NOT from time of presentation!!!!!
*As always you need to check local protocols/prescriptions
Page 179
Rule of Nines:The Rule of Nines Is the estimated measurement of the % of Total Body Surface Area (%TBSA).
• The greater the surface area injured the greater the mortality rate.
• This divides the body into areas of nine % or multiples of nine.
• A method of estimating small burns is to use the area of the palmer surface of the pts hands, this approx. 1% body surface area.
• Epidermal burns are not included in the TBSA estimation.
Page 180
Secondary Survey:
• Monitor adequacy of resuscitation with:
-Urinary Catheter (HV electrical Burns)-ECG, Pulse, Blood pressure, Resp.rate, Pulse oximetry or ABG-Insert nasogastric tube for larger burns or associated injuries; gastroparesis is common
• Xray
-Lateral cervical spine-Chest-Pelvis
Page 181
Secondary Survey:
• This is a comprehensive, head to toe examination that commences after life threatening conditions have been excluded or treated.
• HISTORY:A- AllergiesM- MedicationsP- Past illnessesL- Last mealE- Events/Environment related to injury
Page 182
Mechanism of injury• Burn:
Duration of exposure, type of clothes worn, temp. & nature of fluids, first aid measures if any.
• Penetrating:
Velocity of missile, proximity, direction of travel, length of knife,
• Blunt:
Speed of travel and angle of impactUse of restraintsEjection?Height of fall Type of explosion or blast and distance thrown.
Page 183
Examination
• Head
• Scalp
• Face
• Neck
• Chest
Page 184
• Abdomen
• Perineum
• Rectal
• Vaginal
• Limbs
Examination
Page 185
• Pelvis: Test stability• Neurological:• GCS• Motor and sensory assessment of all limbs• Paralysis or paresis indicates a major injury and immobilisation with
spinal boards and rigid collars.
• NOTE:
Decreased level of consciousness could be due to:-Hypovolaemia from undiagnosed bleeding or under resuscitated burn shock
-Hypoxaemia
TAKE NOTES…SEEK CONSENT…TETANUS STATUS…RE-EVALUATE REGULARLY.
Examination
Page 186
Transfer criteria• Burns greater than 10% TBSA.• Burns of special Areas- Face, hands, Genitalia, Perineum and
major joints.• Full thickness burns greater than 5% TBSA.• Electrical Burns.• Chemical Burns.• Burns with an associated inhalation injury.• Circumferential burns of the limbs or chest.• Burns of extreme age- children and the elderly.• Burn injury with pts with pre-existing medical disorders which
could complicate management, prolong recovery or effect mortality.
• Any burns with associated trauma.
Page 187
Psychological Care
• Burns patient’s require a strong amount of empathy and understanding of their condition from Doctors and Nurses starting at time of admission in Emergency .Some of the challenges they face are:
• SEVERE PAIN!• Shock• Disorientation• Infection• Surgery, Skin Grafts, Plastic Reconstruction.• Changes in Quality of Life. Body Concept Deficit.• Loss of Control over their Life.
Page 187
Page 188
Psychological Care
Patients often go through stages of recovery :
• Critical –- ED (triage/trauma), ICU, Burns Unit
• Acute -- Recovery care in specialized areas.
• First 3 months – Recovery & rehabilitation
• Chronic – After the 1st trimester
• Delayed – Greater than 6 months
Page 189Page 189
Psychological CareBurns require long term care and can involve months/years of treatment which has an impact on the individuals physically/psychologically. It is life changing situation.
Immediate effects from burns can be:
• Severe pain. • Shock• Multiple debridement. Multiple surgeries .• Scarring - Disfigurement• Susceptibility to multiple infections ( Tetanus.Strep,MRSA.)• Amputation• Fear Stress disorders• Behaviour Regression
Page 190
Psychological Care
Psychosis can be induced by:
• Medication • Opioid/Analgesia medications• Infection • Electrolyte imbalance • Respiratory compliance
Will begin to manifest in the CRITICAL / ACUTE phase.
Page 190
Page 191
Risk Factors
• The Grieving Process• Personality Change, • Personal/Social Isolation• Post Traumatic Stress - Reactive depression• Need to develop appropriate adjustments after
acute/chronic burns• Itching, Sleep disturbances• Social anxiety disorders• Self deficit/body concept issues• Sexual dysfunction
Page 192
Psychological Care
Psychological factors such as:• Social Services, Medical Management Stress, • Family/Financial stressors, • Excitement & Distraction
can modulate pain intensity and unpleasantness.
Patients need to develop good rapport with the Doctors Nurses and other Health Care professionals involved in their care. They need to develop trust and honesty with them to feel a sense of control in their rehabilitation process, making it a positive progressive process.
Page 192
Page 193
Treat the whole patient not only the
clinical manifestations.
Psychological recovery parallels physical recovery.
PROVIDE HOLISTIC CARE
Page 194
• Consider the psychological care of a patient with severe burns.
• How would you communicate with the patient and their family?
• How would you feel about caring for a patient with severe burns?
Activity 7
Page 195
Reference
• EMSB (Emergency Management of Severe Burns) Course Manual. (2006). The Australian and New Zealand Burns Association Ltd. (9th Edition), March.
Page 196
Assessments & Communication in ED.
Lyza Helps Consulting19
6
Unit Six:
This course is endorsed by APEC No 061122359as authorised by Royal College of Nursing, Australia (RCNA)
according to approved criteria. Completion of Unit One attracts 3 RCNA CNE points as part
of RCNA’s Life Long Learning Program (3LP).
(Equivalent to 3 hours CPD)
Page 197
�Correct assessment of patients.
�Knowing what to report and when and to whom.
�Efficient and concise communications.
�Appropriate use of terminology.
�How to get help.
197
Assessment
Page 198
198
Pulses: use carotid or femoral
Use of accessory muscles in breathing
Pupil size + reactivity
Assessing & reporting vital signs
Page 199
199
Neurological
Page 200
�May also involve:
�Mental state examination.
�Mini-Mental.
�Social state.
�Risk assessment.
�Full neuro--------referral.
200
Assessing neuro/psych.
Page 201
• Bradycardia is a lower than normal heart rate. Bradycardia may be due to medical or trauma conditions such as a cardiac conduction defect, central nervous system depressant drug use or overdose, Cushing's reflex in a head-injured patient, poisoning, or an ominous sign of severe hypoxia and impending respiratory and cardiac arrest.
• Need to assess other signs CWS, LOC, WOB (look up these abbreviations if unsure).
201
Cardiovascular
Page 202
• Tachycardia is a higher than normal heart rate and may be due to pain or stress or panic, it may also be a sign of hypovolaemic shock (initially), ventricular arrhythmias, Wolfe-Parkinson-White Syndrome, or life threatening rhythm disturbance, AMI etc.
• Need to assess other signs.
202
Page 203
�The quality of the pulse may provide some information about cardiac output. A strong peripheral pulse usually indicates good left ventricular filling and contractility.
�A weak and thready pulse is usually an indication of an increased systemic vascular resistance, poor left ventricular filling, or an ineffective left ventricular contractile force.
�Thus, pulse quality can provide an indication of the effectiveness of cardiac contraction and blood volume.
203
Pulse quality
Page 204
�A systolic blood pressure of 80-90 mmHg is needed to produce radial pulses, a systolic blood pressure of 70 mmHg is needed to produce femoral and brachial pulses, and a systolic blood pressure of 60 mmHg is needed to produce carotid pulses.
�Be aware though this is not absolute….
204
Page 205
�On average, adult patients breathe between 12 and 20 times per minute. In order for a patient to be breathing adequately, (s)he must have a respiratory rate that is adequate and an adequate tidal volume.
�Bradypnoea (slower than normal respiratory rate) may be an indication of head injury, stroke or toxic syndromes involving central nervous system depressants. Bradypnoea may also be an ominous sign of respiratory failure or impending respiratory arrest.
205
Respiratory
Page 206
• Tachypnoea (faster than normal respiratory rate) usually indicates cellular hypoxia, acidosis or conditions that interfere with gas exchange, ventilation or perfusion, such as pulmonary oedema, pneumonia and pulmonary embolism.
�Tachypnoea can also be a normal response to pain.
206
Page 207
�The pulse oximeter works by reading the colour of haemoglobin. When oxygen is bonded to haemoglobin it turns the haemoglobin molecule red. Thus, the pulse oximeter compares oxygenated haemoglobin (red colour) to de-oxygenated haemoglobin to determine oxygen saturation. The result is a SpO2 percentage reading.
�It is dependent on normal perfusion.
�May be affected by many factors, anaemia, fluid retention etc.
207
Oxygen Saturations (Sp0 2)
Page 208
• When obtaining pulse oximetry readings, it is important to document the reading based on the FiO2 (fraction of inspired oxygen) the patient is breathing. A patient breathing room air (21% oxygen) who has a SpO2 reading of 95% would not be of great concern; however, a patient who has been on a non-rebreather at 15 Lpm for a period of time and has a SpO2 reading of 95% may be of great concern.
208
Page 209
• Access and read the following paper on recording vital signs:
https://www.mja.com.au/journal/2008/188/11/respiratory-rate-neglected-vital-sign
Reference: Cretikos M, Bellomo R, Hillman K, et al. (2008). Respiratory rate: the neglected vital sign. Medical Journal of Australia. 188 (11): 657-659.
Now list 3 reasons why it is vital to record Respiratory Rate correctly with every set of vital signs?
Activity 8
Page 210
• Urinalysis (u/a)------------dip stix on admission.
• (IDC) Catheter------as needed/ low output/ collection/ unstable patient/ pre-surgery.
• Bloods-----creatinine, phosphate, calcium, bicarbonate.
• Full Blood Count (FBC).
210
Renal
Page 211
211
Example blood & urine report
(NB values may vary between facilities)
Page 212
• Input/ output/ nutrition/ last meal?
• Vomitus- colour, consistency, +ve/ -ve blood, amount, frequency, adult/ child, meds.
• Bowels- open when how much, stool colour, consistency, changes, +ve/ -ve blood.
• FBC Special OBS chart.
212
Gastro -intestinal tract (GIT)
Page 213
�Position
�Quadrant
�Radiating
�Severity
�Time
213
Pain
Page 214
� HR =heart rate� RR =respiratory rate� T =temperature� BP =blood pressure� Wt =weight� Ht =height� TPRBP =temp, pulse, BP
and RR� BMI =body mass index
214
� CNS =central nervous system� CVS =cardiovascular� US= ultrasound� U/A =urinalysis� GCS =Glasgow coma scale� PERL or PEARL =pupils equal
and reactive to light� ECG =electrocardiograph� 1/24 =hourly� 15/60 =every fifteen minutes� 26/52 =26 weeks� 11/12 =eleven months
Standard acronyms
Page 215
Need to include:
�What happened?�When?�What was done about it?�Why?�What is expected from here?�Where is patient going?�What did you see/ hear/ feel/ examine etc?
215
Handovers
Page 216
�Waiting for reviews, letters referrals etc.
�Waiting for beds.
�Still require at least 4/24 obs in ED (exception MH patients).
�Remember a stable and non -urgent patient can suddenly turn into an unstable one so observation is essential.
216
Non-urgent & stable
Page 217
�Scheduled ‘obs’ as per orders or algorithms.�Regular monitoring.�Food/ water/ elimination.�Mobilization??�Visitors.
�Waiting for bed.�Waiting for results/ referral/ discharge (d/c).
217
Stable patient
Page 218
�Continuous observations (include all vitalsigns).
�Monitored bed.
�1:1 or 2:1 nursing care.
�Doctor in attendance.
�Do not leave patient at any time.
218
Unstable patient
Page 219
• Resuscitation (‘resus’) bay.
• Consultant and RMO (Registrar) in attendance.
• Transfer directly to ICU/ Theatre ASAP.
• Continuous monitoring.
• Arterial line/ Central Venous Catheter (CVC)/ ? Swan Ganz.
• 2:1 nursing whilst acute unstable then 1: 1
• Ventilated pt: 1:1 nurse do not leave unattended.
219
Critical patient
Page 220
• Children and infants deteriorate quickly - must be constantly watched.
• Know childrens’ vital sign parameters.
• Drugs = ml or mg per kg per hour?
• Resus = differing needs (e.g. uncuffed ET tubes).
220
Infant/Child patient
Page 221
• ASK supervisor (& know who that is).
• Work with a team/ another nurse.
• Introduce yourself & know your team mates.
• Emergency buzzer – where & how?
• RMO.
• Re-prioritize/ re-triage patient.
221
Getting assistance
Page 222
• Any change in mental status.• Any change in respiratory condition.• Any Chest pain.• Any episode of VT/ VF/ AF/ SVT or increased PVC’s.• Any significant change in BP.• urine output (less than 30 ml/hr).• Significant changes to perfusion.• Specific changes related to condition.• Blood loss.• If you don’t know what to look for ASK Doctor.
222
Reporting: Urgent
Page 223
• Gradually declining BP.
• Low urine output.
• New asymptomatic changes in hour.
• c/o pain that hasn’t changed in location/ nature.
• Pain not well controlled.
• Blood loss climbing (not haemorrhage this is urgent).
223
Reporting: Intermediate
Page 224
• Visitors wanting info.
• Wanting to go home.
• Referral letters/ discharge.
• Improving conditions.
• Still need to report but at regular assessments times.
224
Reporting: Low risk
Page 225
• Discuss the nursing care of a patient you have been asked to transfer to the Coronary Care Unit.
• What would you take with you?
• What would your handover include?
• The patient is on a portable cardiac monitor. On arrival in CCU how would you transfer the patient to the bed? Would you allow him to remove the leads to go to the bathroom first? Give your rationale.
Activity 9
Page 226
Legal & Ethical Issues in ED.
Lyza Helps Consulting22
6
Unit Seven:
This course is endorsed by APEC No 061122359as authorised by Royal College of Nursing, Australia (RCNA)
according to approved criteria. Completion of Unit One attracts 2 RCNA CNE points as part
of RCNA’s Life Long Learning Program (3LP).
(Equivalent to 2 hours CPD)
Page 227
Nurses must be aware of the legal issues related to emergency care, such as Good Samaritan Laws and mandated reporting…
�MH detention orders.�Good Samaritan Law.�Implied Consent, Informed Consent, Emergent
Consents.�Verbal Orders.�Coroners cases.�Mandated reporting.
227
Legal issues
Page 228
�Effective communication.�Correct documentation.�Timely recording of information.�Correct triaging.�Correct monitoring.�Correct referral.�Above all - correct decision pathways.
228
The keys to your safety in ED
Page 229
• Mental Health Act 2009
• Voluntary
• Division 1 —Level 1 community treatment orders.
• Level two order.
229
Mental Health detention
Page 230
“A medical practitioner or authorised health professional may make an order for thetreatment of a person if it appears to the medical practitioner or authorised health professional, after examining the person that:” —
230
Division 1 – Level 1 community orders
Page 231
�(a) the person has a mental illness; and
�(b) because of the mental illness, the person requires treatment for the person's own protection from harm (including harm involved in the continuation or deterioration of the person's condition) or for the protection of others from harm; and
�(c) there are facilities and services available for appropriate treatment of the illness; and
�(d) there is no less restrictive means than a community treatment order of ensuring appropriate treatment of the person's illness.
231
Page 232
�1. must be given a copy of the order�2. must be given opportunity to appeal brochure�3. must have rights explained�4. must be given a written statement of rights�5. information must be available in pts language
232
Patient rights under detention
Page 233
�Need quiet secure environments.�Low stimulation (not ignored).�ARE PATIENTS and as such require nursing attention
and time.�Have complex needs.�Are least likely to commit acts of violence contrary to
public opinion.�Are often highly anxious and confused.
233
Mental health clients
Page 234
�A Good Samaritan is generally defined as a person (including a medical practitioner, nurse, paramedic) who in good faith and without expectation of payment or reward comes to the aid of an injured person, or person at risk of injury, with assistance or advice. There is an ethical and professional obligation on medical practitioners to act as Good Samaritans.
�In South Australia this is THE CIVIL LIABILTY ACT.
234
The Good Samaritan Law
Page 235
235
State
SA
ACT
Civil Liability Act, 1936
Exclusion from Protection
Intoxication by substances
Page 236
236
� The principles contained in the Civil Liability Act 1936 essentially offers some protection for persons acting in emergency situations to offer care without consent and to offer protection from liability should problems occur, where those actions have not been influenced by alcohol etc.
� There is no Australian case in which a Good Samaritan has been sued by a person claiming that the actions of the Good Samaritan were negligent.
Page 237
�Medical and Nursing staff have a duty to inform a patient about their care and treatment wherever possible.
�What it is�What the alternatives are�What is involves�What risks are involved
237
Informed Consent
Page 238
�In emergencies this can be over ridden where the medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in;
�Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman of her unborn child) in serious jeopardy;
238
Implied Consent
Page 239
1. serious impairment to bodily functions; or,2. serious dysfunction of any bodily organ or part; or, (B) with respect to a pregnant woman who is having contractions;3. that there is inadequate time to effect a safe transfer to another hospital before delivery; or,4. that transfer may impose a threat to the health or safety of the woman and unborn child.
239
Page 240
�Does the ED physician write all orders except in anemergency?
�Verbal orders should be minimal and must be signed by the RMO with date and time within reasonable time bytwo RN’s in meantime.
240
Verbal orders
Page 241
Points to remember:
• Speak quietly or find a place to talk.
• Do not talk at the nurses station about clients.
• Put files/folders back at the central station.
• ONLY OBS charts at bedside-should be in a file.
241
Privacy and confidentiality
Page 242
�Always performed in the event of;
�Violence or unexpected death.
�Death within 24 hrs of admission.
�Where there are concerns raised.
�AS A RULE: do not remove ANY lines that are placed, all documentation should be contained within a satchel and be with the patient.
242
Coroner’s cases
Page 243
• If the event that lead to the patient’s death was sustained in a car accident or through other traumatic circumstances;
• If the patient has had an anaesthetic within the previous 24 hours up to the time death was diagnosed;
• If the patient is under a custodial order or under State care;
243
Page 244
244
If the patient had an accident within a year and a day, which may have contributed to the cause of death;
If the patient has not been under the care of a medical practitioner within the past three months;
If the Intensive Care doctors are unable to complete the death certificate because of unknown factors leading to the death.
Page 245
�Police will often attend or be involved in ED presentations;
�Where a prisoner is transferred for care.
�Where a mental health patient has been detained by them.
�Where there is a crime or suspected crime.
�There is a policy agreement on how to work effectively with police you should become familiar with it---called Memorandum of Understanding.
245
Police involvement
Page 246
�All Emergency workers are MADATED reporters of abuse;
�You need to be aware of your legal duty.
�You need to be updated if you don’t know.
�You need to know how and to whom you report.
�Mandated reporting is a separate course you can undertake (NB Mandatory reporting of abuse of the elderly and of suspicion of child abuse is a mandatory competence for HCA staff).
246
Mandated reporting
Page 247
�Need to know the signs of abuse and/or neglect�These are some……
�Bruising.�Listlessness.�Looks underweight.�No eye contact.�Confusing or inappropriate stories about the injury.�Blood around genitals.�Shaken baby syndrome.
247
Child abuse
Page 248
• Withdrawal of treatment
�Organ donation.
�Mental health detention.
�Brain death.
248
Ethical issues in ED
Page 249
• Withdrawal of treatment t in ED occurs where the injuries sustained are incompatible with life…or where deterioration is inevitable…..or where there is insufficient likeliness of recovery….
• But most often where brain death has occurred.
249
Withdrawal of treatment
Page 250
�At all the major hospitals there are teams specifically involved in organ donation and will evaluate and assist with talking with families about organ donation.
�There are special family rooms for discussions and protection of such families during this time.
250
Organ donation
Page 251
� Clinicians are guided by detailed ethical and professional standards and
guidelines some of which include:
� National Health and Medical Research Council (NHMRC) Guidelines,
Organ and Tissue Donation After Death, for Transplantation: Guidelines
for Ethical Practice for Health Professionals (2007).
� Australian and New Zealand Intensive Care Society, Statement on Death
and Organ Donation (1998 – currently under review).
� The Transplantation Society of Australia and New Zealand Organ
Allocation Protocols (2002, updated 2004).
� Australasian Transplant Coordinators Association National Guidelines for
Organ and Tissue Donation (2006).
251
Ethical & professional standards
Page 252
� The mean age of donors was 43.4 years, median 45.2 years with a
range of 0.7 - 80.4 years.
� In 2007, the major cause of death in 53% of donors was (CVA)
cerebrovascular accident, while road trauma caused 15% of all
donor deaths.
� The donation of more than one organ occurred in 82% of donors.
� The average number of organs transplanted per donor was 3.3.
252
Organ & tissue donation in Australia
Page 253
253
Page 254
�All potential donors are considered individually
but the patient must have:
�Suffered irreversible loss of brain function – brain death.
�Been maintained on a ventilator with intact circulation.
�No current malignancy except primary brain tumour or
minor skin lesions.
254
General organ donation donor criteria
Page 255
�Two appropriately qualified senior doctors perform separate tests:
�response to pain.
�response to light by the pupil of each eye.
�blinking response when each eye is touched.
�eye movement.
�response to ice cold water when it is put into the ear canal,
255
Brain death
Page 256
�cough or gag (swallowing) reaction when the back of the throat is touched.
�breathing when the person is disconnected from the ventilator .
�For a person to be declared brain dead they must not show any response to each and every one of these tests.
�In some cases CT blood flow to the brain will be checked.
256
Page 257
�Death can occur in the ED at any time due to trauma, sudden illness, or even extended illness.
�In the event of sudden death, the family is usually in a state of shock and will need further assistance there are special counseling services in ED.
�Coroners Case.
�Preparation of the deceased person.
257
Death in the ED
Page 258
�ED is a place where people often have to endure suffering, are brought after serious accidents or losses and is noisy, stimulating and sometimes impersonal…..we need to remember that we are dealing with PEOPLE.
�Managing grief and loss is a part of ED nurses duties and will require empathy and understanding that the process cant be rushed and may need referral to social/ mental health services to assist.
258
Loss & grief
Page 259
• Assessment:
• Look at the case study presented read all available information and reflect on the key points that stand out.
• Identify all information that is relevant to patient management and prioritize your care.
• Document your reflections on how you managed to use any new skills and knowledge gained since starting this course – this is CPD!
259
ED case study:
Page 260
�Mr Smith was brought to ED by ambulance he was found unconscious on the floor at home by a neighbour, no-one is sure how long he lay on the floor, although he is now conscious his speech is slurred and he appears confused. He also has right sided weakness.
�On admission his vital signs are as follows:�HR= 150 Sinus Tachycardia�RR =12 bpm & shallow�BP =190/110 mmHg�Bruising to left side of face�GCS= 11
260
Case study:
Page 261
�Describe the signs and symptoms of a CVA�What is your triage assessment?�What is your next course of action?�What is your nursing plan?�How would you care for the relatives of Mr Smith?�What follow up tests and observations would be
required?
261
Activity 10
Page 262
• Look back to the reflections you made during Activity 1at the start of the course. Spend 10-15 minutes reflecting on your strengths and weaknesses now, and highlight any areas you require additional skills in. List areas you feel you have improved upon as a result of this course. Document these and make a brief plan of how you might build on the strengths and address the weaknesses. Return to this list regularly during your nursing practise.
262
Activity 11
Page 263
Revision, reflection & final assessment
This course is endorsed by APEC No 061122359as authorised by Royal College of Nursing, Australia
(RCNA) according to approved criteria. Completion of revision of course materials, self-reflection activities and completion of the final
assessment attracts 2 RCNA CNE point as part of RCNA’s Life Long Learning Program (3LP).
(Equivalent to 2 hours CPD)
Each of the 7 units in this course attract 3 RCNA CNE points (3 hours CPD). Your reflections on how the course has improved your knowledge, confidence or skills will allow you to document this activity as CPD, which may be audited each year by NMBA. The revision process and taking the final assessment will
allow a further 2 CNE points or 2 hours CPD. Note: other activities you may have undertaken (eg MIFA or BloodSafe) may attract additional CPD.
Page 264
Assessment of competence
Page 265
Final assessment• After completing the units of this course as well as carrying out the self-directed activities you
should be ready to answer the multi-choice assessment for this course.
• There are no trick questions and all the answers are available from within the course materials.
• You are required to answer 80 multi-choice questions. The pass mark for achieving competence is 90% (72 out of 80).
• If you do not achieve 90% you will be able to repeat the test twice more, but are recommended to revise any topics you had difficulty with.
• When you have achieved 90% you will be able to print a certificate of theoretical competence, which also states the number of CNE points for this course. The actual number of CPD hours you document for NMBA audit will depend on how much actual time you took to complete the course (which could be more of less than 20 hours) and must include self-reflection.
• Please note that this course is intended as an Introduction to Emergency Nursing and does not constitute competence in practise, nor does it cover sufficient knowledge to claim competence as an Emergency Department nurse.
Page 266
Testimonial“In preparation for my latest Rural and Remote assignment in North Queensland I contacted Michael Page who is the Education Manager for Healthcare Australia. I was aware that Health Care Australia prepares their Nurses for unusual assignments and believed they could also help me. I explained to Michael Page that this assignment is different to previous in so far as the Registered Nurse is required to staff both the Ambulance and ED in a rural location. I am an Intensive Care and Coronary Care qualified nurse but have limited ED experience. Health Care Australia had recently produced an Online Emergency Nurse course and asked me to review and validate it from a user perspective.
I commenced the Introduction to Emergency Nursing course 2 weeks prior to departure. I have now been at my new assignment for 2 weeks, during which I have staffed the Emergency Department and the Ambulance for 000 call outs.
The Introduction to Emergency Nursing course I completed prior to this assignment, but have continued to use it as a reference. This course has proved to be among the most useful courses I have completed during my 20 year nursing career. As an experienced critical care nurse the bulk of the many assessments of the course were valuable and relevant. As a refresher the layout and structure ensured a smooth transition from critical care nurse to Emergency nursing. This was especially the case regarding the Triage and Initial Assessment element (unit 1) which was a completely new skill set for me. I have never had to formally “Triage” before as part of any previous role. Assessment I have found to been a lot simpler in the controlled environment of Intensive Care than in Rural and Remote areas and this course built my confidence in these skills. This course has taken me about 20 hours over one week to complete to my satisfaction. I am now working as the sole RN in a remote ED with the added pressure of being on call to staff the Ambulance for all emergency call outs in our designated area. This course has given me the confidence to take my previous ICU/CCU experience into a different environment. Whereas it does not make you a competent ED nurse by completing this course, it will ensure that the pupil is at least prepared to transfer previous skills into a new environment.
I cannot commend this course highly enough to any experienced critical care nurse who wants to take their skills to the next level. Thank you to Michael Page and Health Care Australia for providing me with this excellent resource.”
Ian Blaber RN, Grad Cert Crit Care, DipHE (Nurs), January 2012.
Page 267
Thank you for completing this course with NursEd. I hope you enjoyed the course and that it is the beginning of a
professional journey for you.
Michael PageNational Education
& Training Manager, Healthcare Australia.
Page 268
Other NursEd courses:Critical Care Awareness :
An introduction to Coronary Care Nursing
An introduction to Intensive Care Nursing
An introduction to Rural & Remote Nursing
