Copyright © 2008 Lippincott Williams & Wilkins. 1 Emergency Nursing.

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Copyright © 2008 Lippincott Williams & Wilkins.

Emergency Nursing

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Scope and Practice of Emergency Nursing

• Emergency management traditionally refers to urgent and critical care needs; however, the ED has increasingly been used for non-urgent problems, and emergency management has broadened to include the concept that an emergency is whatever the patient or family considers it to be

• The emergency nurse has special training, education, experience, and expertise in assessing and identifying health care problems in crisis situations

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Scope and Practice of Emergency Nursing

• Nursing interventions are accomplished interdependently in consultation with or under the direction of a physician, physician’s assistant, or nurse practitioner

• The emergency room staff works as a team

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Priority Emergency Measures for All Patients

• Make safety the first priority

– For patients, family and staff

• Preplan to ensure security and a safe environment

– Potential for violence in the ER

– May be related to emotional stress, substance abuse, violent injuries

• Closely observe patient and family members in the event that they respond to stress with physical violence

• Assess the patient and family for psychological function

• Documentation of consent– If patient or next of kin unable to consent, nurse must

carefully document circumstances

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Priority Emergency Measures for All Patients (cont.)

• Patient and family-focused interventions– Relieve anxiety and provide a sense of

security– Allow family to stay with patient, if possible, to

alleviate anxiety– Provide explanations and information– Provide additional interventions depending

upon the stage of crisis

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Triage

• Triage (“to sort”) sorts patients by hierarchy based on the severity of health problems and the immediacy with which these problems must be treated– Emergent, urgent, non life-threatening, fast track

– Emergency Severity Index (see table 69-2)

• The triage nurse collects data and classifies the illnesses and injuries to ensure that the patients most in need of care do not needlessly wait

• Protocols may be initiated in the triage area• ED triage differs from disaster triage in that patients who

are the most critically ill receive the most resources, regardless of potential outcome

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Triage

• Systematic approach to manage emergent or urgent situations. Primary survey includes:– Airway with cervical spine stabilization– Breathing– Circulation– Disability (neurological)

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Triage

• Secondary Survey– Exposure/environmental control– Full set of vital signs– Five interventions

• EKG, pulse ox, indwelling catheter, NG tube, labs

– Family presence– Give comfort measures– History and head-to-toe assessment– Inspect posterior surfaces

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Common Emergencies

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Airway Obstruction• Partial airway obstruction• Complete airway obstruction• Causes may include aspiration of foreign bodies or

food, anaphylaxis, infection, trauma, sedative meds, neurologic dysfunction

• Management– Establish an airway!

• Abdominal thrusts• Head tilt, chin lift maneuver/jaw thrust maneuver (if cervical

spin injury suspected)• Oropharyngeal airway• Endotracheal intubation• Cricothyroidectomy

– Maintain ventilation

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Hemorrhage

• Management– Fluid replacement

• Blood, crystalloids, colloids• If large volume rapid infusion, need to warm fluids to

prevent hypothermia

– Control of external hemorrhage, via direct pressure; tourniquet used as a last resort

– Control of internal hemorrhage, usually via emergent surgery; administer PRBCs while awaiting surgery

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• Level 1 Rapid Infuser

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Trauma• An unintentional or intentional wound or injury

inflicted on the body from a mechanism against which the body cannot protect itself

• Collection of forensic evidence– A critical role of the nurse!– Documentation may be used in legal proceedings– If criminal activity suspected, bag clothes and

belongings and give to law enforcement; document the name of officer

– If suicide or homicide, must notify medical examiner

• Multiple trauma– Priority managements

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Management of Patients With Intra-Abdominal Injuries

• Blunt trauma (eg, fall) or penetrating injuries (eg, gunshot wound)

• Abdominal trauma can cause massive life-threatening blood loss into abdominal cavity

• Assessment – Obtain history of injury– Perform abdominal assessment and assess other

body systems for injuries that frequently accompany abdominal injuries

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Management of Patients With Intra-Abdominal Injuries (cont.)

• Assessment (cont.)– Assess for referred pain that may indicate

spleen, liver, or intraperitoneal injury

– Perform laboratory studies, CT scan, abdominal ultrasound and diagnostic peritoneal lavage

– Assess stab wound via sonography

– Assess for hematuria (possible GU injury)

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Management of Patients With Intra-Abdominal Injuries (cont.)

• Ensure airway, breathing, and circulation

• Immobilize cervical spine

• Continually monitor the patient

• Document all wounds

• If viscera are protruding, cover with a sterile, moist saline dressing

• Hold oral fluids

• NG to aspirate stomach contents

• Provide tetanus and antibiotic prophylaxis

• Provide rapid transport to surgery if indicated

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Priorities of Care for the Patient With Multiple Trauma

• Use a team approach

• Determine the extent of injuries and establish priorities of treatment

• Assume cervical spine injury

• Assign highest priority to injuries interfering with vital physiologic function

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Priorities in the Management of the Patient With Multiple Injuries

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Priorities in the Management of the Patient with Multiple Injuries

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Trauma

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Environmental Emergencies—Heat Stroke

• A failure of heat regulating mechanisms of the body

• Elderly, very young, ill, or debilitated—and persons on some medications—are at high risk (see table 39-7)

• Leads to thermal injury at the cellular level

• Manifestations:

– Initially, the body attempts to compensate with increased sweating, vasodilation, and increased respiratory rate; mechanisms become DEPLETED

– HEATSTROKE manifests as neurological dysfunction, elevated temperature (may be > 104), hot dry skin, anhydrosis (no sweating) , tachypnea, hypotension, and tachycardia

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Management of Patients With Heat Stroke

• Use ABCs and reduce temperature to <102 as quickly as possible

• Cooling methods

– Cool sheets, towels, or sponging with cool water

– Apply ice to neck, groin, chest, and axillae

– Cooling blankets

– Iced lavage of the stomach or colon

– Immersion in cold water bath

• Monitor temperature, VS, ECG, CVP, LOC, urine output

• Use IVs to replace fluid losses

–Hyperthermia may recur in 3 to 4 hours; avoid hypothermia

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Environmental Emergencies—Frostbite

• Trauma from freezing temperature and actual freezing of fluid in the intracellular and intercellular spaces; leads to cellular and vascular damage

• Manifestations: hard, cold, and insensitive to touch; may appear white or mottled; and may turn red and painful as rewarmed

• The extent of injury is not always initially known– 1st to 4th degree

• Controlled but rapid rewarming; 37° to 40° C circulating bath for 30- to 40-minute intervals

• Administer analgesics for pain

• Do not massage or handle; if feet are involved, do not allow patient to walk for 24-48 hours

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Frostbite

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Environmental Emergencies—Frostbite

• After rewarming:– Observe for development of infection (high

risk)• May require amputation

– Active ROM to restore function and prevent contractures

– Avoid tobacco, ETOH, caffeine

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Environmental Emergencies—Hypothermia

• Internal core temperate is 95 degrees F or less– Severe if less than 86 degrees F

• Elderly, infants, persons with concurrent illness, the homeless, and trauma victims are at risk

• Alcohol ingestion increases susceptibility

• Hypothermia may be seen with frostbite; treatment of hypothermia takes precedence

• Physiologic changes in all organ systems; manifestations correlate with degree of severity– Shivering, lethargy, confusion; rigidity, bradycardia,

metabolic and respiratory acidosis, hypovolemia; may progress to dysrhythmia, renal failure, thrombi

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Management of Patients With Hypothermia

• Use ABCs, remove wet clothing, and rewarm

• Rewarming

– Active core rewarming

Cardiopulmonary bypass, warm fluid administration, warm humidified oxygen, and warm peritoneal lavage

– Passive external rewarming

Warm blankets and warm place

Active external rewarming

Warming blankets, radiant heat lamps

• Cold blood returning from the extremities has high levels of lactic acid and can cause potential cardiac dysrhythmias and electrolyte disturbances

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Management of Patients With Hypothermia

• Supportive care during rewarming:– Cardiac compression– Defibrillation for V fib - ineffective in patients with a

core temperature < 31 degrees (88)• The patient is not dead until he is warm and dead!

– Airway support– Warm IV fluids– Sodium bicarbonate to correct acidosis– Foley insertion to monitor UOP

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Management of Patients With Poisoning

See table 69-12 • Poison is any substance that when ingested,

inhaled, absorbed, applied to the skin, or produced within the body in relativity small amounts injures the body by its chemical action

• Treatment goals:

– Remove or inactivate the poison before it is absorbed

– Provide supportive care in maintaining vital organ systems

– Administer specific antidotes

– Implement treatment to hasten the elimination of the poison

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• Options for decreasing absorption

– Gastric lavage via NGT with saline

• Contraindicated in ingestion of caustic agents, coingested sharp objects, ingested nontoxic substances

• Must be done within 2 hours of ingestion

– Activated charcoal

• Some toxins will adhere to charcoal and are excreted via the GI tract

• Does NOT absorb ethanol, alkali, iron, lithium, methanol or cyanide

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• Skin and ocular decontamination

– Removal of toxins from eyes and skin with water and saline

– Do not use for mustard gas

• Cathartics

– Stimulate intestinal motility and increase elimination

• Dilution (with water or milk)

• Hemodialysis

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Assessment of Patients With Ingested Poisons

• Use ABCs

• Monitor VS, LOC, ECG, and UO

• Assess laboratory specimens

• Determine what, when, and how much substance was ingested

• Assess signs and symptoms of poisoning and tissue damage

• Assess health history

• Determine age and weight

• *If details about specific poison are unknown, call the local poison control center*

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Management of Patients With Ingested Poisons (cont.)

• Corrosive agents such as acids and alkalis cause destruction of tissues by contact; DO NOT induce vomiting with corrosive agents!

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Management of Patients With Ingested Poisons (cont.)

• Specific poison management in Table 69-12– Acetaminophen– Acids and alkali– Carbon monoxide– Tricyclic antidepressants

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Management Patients With Carbon Monoxide Poisoning

• Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin, which does not transport oxygen

• Manifestations: CNS symptoms predominate due to hypoxia– Other - headache, muscle weakness, dizziness, palpitations

– Skin color is not a reliable sign and pulse oximetry is not valid - need ABG and carboxyhemoglobin level

• Treatment– Get to fresh air immediately

– Perform CPR as necessary

– Administer oxygen: 100% or oxygen under hyperbaric pressure

• Monitor patient continuously

• May cause permanent brain damage

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Management of Patients With Food Poisoning

• A sudden illness due to the ingestion of contaminated food or drink

• Food poisoning, such as botulism or fish poisoning, may result in respiratory paralysis and death; most of the time it involves the GI tract, such as N/V, diarrhea

• ABCs and supportive measures

• Determination of food poisoning source

• Treat fluid and electrolyte imbalances

• Control nausea and vomiting

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Management of Patients With Substance Abuse

• Acute alcohol intoxication:a multisystem toxin (See table 12-11)– Alcohol poisoning may result in death

– Maintain airway and observe for CNS depression and hypotension

– Rule out other potential causes of the behaviors before it is assumed the patient is intoxicated (eg, hypoglycemia)

– Use a nonjudgmental, calm manner

– Patient may need sedation if noisy or belligerent - careful use

– Examine for withdrawal delirium, injuries, and evidence of other disorders

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Management of Patients With Substance Abuse

• OVERVIEW OF SUBSTANCE MANAGEMENT

• Cocaine and Amphetamines(see table 12-7)– Airway

– Seizure control

– Cardiac effect management; defib, antiarrhythmics

– Benzodiazepines or haloperidol for psychosis

– Treatment of hypertension

• Opiates (see table 12-11)– Support respiratory and cardiovascular function

– Antagonist - Narcan (naloxone)• Administer slowly; watch for rebound depression

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Alcohol Withdrawal - Delirium Tremens

• Acute toxic state that occurs as a result of sudden cessation of ETOH intake after a heavy bout or prolonged intake of ETOH

• Manifestations– Anxiety, irritability, agitation, hallucinations, signs of

autonomic overactivity; VS are elevated– High mortality rate

• Give adequate sedation and support to allow the patient to recover without danger of injury

• Sedation with benzodiazepine and others– Lorazepam, chlordazepoxide, clonidine, haloperidol

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Alcohol Withdrawal - Delirium Tremens

• Calm, quiet environment

• Close observation

• Restraints if necessary, but only if no other alternative

• Physiologic– Monitor for fluid loss and lyte imbalance, monitor

for seizures, treat hypertension, hypoglycemia

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Sexual Abuse• Rape is defined as forcible penetration act on

a person without his or her consent

• Patients reaction to rape - rape trauma syndrome (Post traumatic stress disorder)– Disorganization phase– Denial and unwillingness to talk– Reorganization phase

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Crisis Intervention—Rape Victims• How the patient is received and treated in the ED is

important to his or her psychological well-being

• Crisis intervention begins as soon as the patient enters the facility; the patient should be seen immediately

• Goals are to provide support, reduce emotional trauma, and gather evidence for possible legal proceedings

• Patient reaction; rape trauma syndrome• History taking and documentation• Physical examination and collection of forensic

evidence• Role of the sexual assault nurse examiner (SANE)

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Family Violence, Abuse and Neglect

• 5.3 million domestic violence cases in US every year

• PREGNANCY is a major risk factor for domestic violence– 4-14% suffer violence from intimate partner– Severity and frequency of abuse increases

during pregnancy

• 1-2 million cases of elder abuse each year– May include physiologic and pychological abuse,

neglect, and financial abuse

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• Clinical manifestations– Physical injuries

• Multiple injuries or injuries that are not well explained• Common injuries include bruises, lacerations,

fracutes, head injuries

– Psychologic manifestations• Anxiety, insomnia, vague GI complaints

– Usually do not identify abuser– Neglect may manifest as poor hygiene,

dehydration, inattention to known medical needs

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Family Violence, Abuse and Neglect• Assessment

– Acute awareness for signs of possible abuse/neglect– Question patient in private, away from possible abuser– Careful documentation

• May include quotations and photographs - may be used in legal proceedings

• Management– If abuse or neglect is suspected, primary concern is for

the safety of patient– Multidisciplinary

• MD, RN, social worker, authorities

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• Mandatory reporting laws– If child or elder abuse is SUSPECTED, health

care workers must report suspicion to Child or Adult Protective Services

– Proof is not required– If report made in good faith, no criminal or civil

liability against HCW

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