Emergency Nursing

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & WilkinsCopyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 71

Emergency Nursing

Chapter 71

Emergency Nursing

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Objectives

• At the end of this session the student should be able to:

1.Define the terms: emergency nurse and triage;

2.Explain the process of triaging;3.Identify the priority disorders in triaging; and4.Discuss how patients are managed presenting

with emergency disorders.


Scope and Practice of Emergency Nursing

• Emergency management traditionally refers to urgent and critical care needs.

• The ED has increasingly been used for non-urgent problems

• Emergency management has broadened to include the concept that an emergency is whatever the patient or family considers it to be.

• The emergency room staff works as a team.


The Emergency NurseThe emergency nurse has had specialized

education, training, experience, and expertise in assessing and identifying patients’ health care problems in crisis situations.

Nursing interventions are accomplished interdependently in consultation or under the direction of a physician or nurse practitioner.


Priority Emergency Measures for all Patients

• Safety is the first priority• Preplanning to assure security and a safe environment• Close observation of patient and family members in

event that they respond to stress with physical violence• Assessment of patient and family psychological function • Patient and family focused interventions

– Actions to relieve anxiety and provide a sense of security– Allow family to stay with patient, if possible, to alleviate anxiety– Provide explanations and information– Additional interventions are provided depending upon the stage of crisis


Triage• Triage

– sorts patients – based on the severity of health problems – Takes in account the immediacy with which these

problems must be treated • 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.


Triage Categories

• Three levels• Emergent

– Highest priority– Life threatening conditions– Must be seen immediately

• Urgent– Serious problems– Not immediately life threatening


Triaging Contd.

• Nonurgent– Episodic illnesses– Address within 24hrs,

• “fast track”– Simple first aid/primary care– Can be referred


Triage

• Five level system– Resuscitation– Emergent– Urgent– Nonurgent– Minor


Triaging Contd.• The obvious first-priority patients are those

with multiple trauma:• Gunshot or stab wounds• Persons involved in motor vehicle accidents• Persons with obvious CVA • Persons with severe chest pain/heart attack• Patients in shock or who have unstable vital signs

• Persons presenting with respiratory symptoms


Principles of Emergency Care• Assess and Intervene

– A, B, C– Neuro– Health history – Head-to-toe assessment


Principles of Emergency Care (cont’d)

• Diagnostic and lab testing• Insertion of monitoring devices• Splinting• Wounds


Airway Obstruction

• Head-Tilt-Chin-Lift Maneuver• Jaw-Thrust Maneuver• Oropharyngeal Airway Insertion• Endotracheal Intubation• Alternative Intubation Method• Cricothyroidotomy


EFGHI =• 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.


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 management

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Wounds• Restore physical integrity and function of injured tissue, with

minimal scarring and without infection

• Wound cleansing

• Primary closure

• Delayed primary closure


Management of Patients with Intra-Abdominal Injuries

• Blunt trauma or penetrating injuries• Abdominal trauma can cause massive life-threatening blood

loss into abdominal cavity• Assessment

– Obtain history – Abdominal assessment and assess other body systems for

injuries that frequently accompany abdominal injuries– Assess for referred pain which may indicate spleen, liver, or

intraperitoneal injury– Laboratory studies, CT scan, abdominal ultrasound (FAST),

diagnostic peritoneal lavage – Stab wound—sinography


Management of Patients with Intra-Abdominal Injuries

• Assure airway, breathing, and circulation• Immobilize cervical spine• Continually monitor the patient • Document all wounds• If viscera are protruding cover with sterile, moist saline dressing• Hold oral fluids• NG to aspirate stomach contents • Tetanus and antibiotic prophylaxis• Rapid transport to surgery if indicated


Priorities of Care for the Patient with Multiple Trauma

• Requires a team approach• Determine extent of injuries and establish

priorities of treatment• Assume cervical spine injury• Injuries interfering with vital physiologic

function have highest priority


Priorities in the Management of the Patient With Multiple Injuries


Priorities in the Management of the Patient with Multiple Injuries (cont.)


Hemorrhage• Fluid Replacement• Control of External Hemorrhage• Control of Internal Bleeding


Hemorrhage• Management

– Fluid replacement• Blood, crystalloids, colloids• If large volume rapid infusion, need to warm fluids to prevent

hypothermia

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


Control of External Hemorrhage• Direct Pressure• Elevation• Compression of pressure points (arteries,

veins)• AVOID tourniquets…can compromise loss of

circulation and loss of limb


Environmental Emergencies: Hypothermia

• Internal core temperature is 35°C or less• Elderly, infants, persons with concurrent illness,

the homeless, and trauma victims are at risk • Alcohol ingestion increases susceptibility• Hypothermia may be seen with frost bite and

treatment of hypothermia takes precedence• Physiologic changes in all organ systems• Monitor continuously


Management of Patients with Hypothermia

• Use ABCs, remove wet clothing, and rewarm• Rewarming

– Active core rewarming• Cardiopulmonary bypass, warm fluid administration, warm

humidified oxygen, warm peritoneal lavage– Passive external rewarming

• Warm blankets and over the bed heatersNote: Cold blood returning from the extremities has high levels of lactic acid and can cause potential cardiac dysrhythmias and electrolyte disturbances


Management of Patients with Poisoning • 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 organs

systems– Administer specific antidotes– Implement treatment to hasten the elimination of the

poison


Management of Patients with Ingested Poisons—Assessment

• ABCs • Monitor VS, LOC, ECG, UO • Laboratory specimens • Determine what, when, and how much substance

was ingested • Signs and symptoms of poisoning and tissue

damage • Health history• Age and weight


Management of Patients with Ingested Poisons

• Measures to remove the toxin or decrease its absorption– Use of emetics– Gastric lavage– Activated charcoal– Cathartic when appropriate (sod. Sulphate, mag. Sul)– Administration of specific antagonist as early as

possible


Poision Ingestion: Contd.• Other measures may include diuresis, dialysis

or hemoperfusion • Corrosive agents such as acids and alkalines cause

destruction of tissues by contact. Do not induce vomiting with corrosive agents.


Management Patients with Carbon Monoxide Poisoning

• Inhaled carbon monoxide binds to hemoglobin as carboxyhemoglobin.

• Manifestations—CNS symptoms predominate– Skin color is not a reliable sign and pulse oximetry is not valid

• Treatment– Get to fresh air immediately– CPR as necessary– Administer oxygen; 100% or oxygen under hyperbaric

pressure • Monitor continuously


Management of Patients with Food Poisoning

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

• ABCs and supportive measuresNote: Food poisoning, such as botulism or fish poisoning, may result in respiratory paralysis and death

• Determination of food poisoning• Treat fluid and electrolyte imbalances• Control nausea and vomiting• Clear liquid diet and progression of diet after nausea

and vomiting subside


Management of Patients with Substance Abuse

• Acute alcohol intoxication—a multisystem toxin – 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– Use nonjudgmental, calm manner– May need sedation if noisy or belligerent– Examine for withdrawal delirium, injuries, and evidence of

other disorders


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


Psychiatric Emergencies• Overactive patients, violent behavior, underactive

or depressed patients and suicidal patients • Management

– Maintain the safety all persons and gain control of the situation

– Determine if the patient is at risk for injuring himself or herself or others.

– Maintain the person’s self-esteem while providing care– Determine if the person has a psychiatric history or is

currently under care to contact that therapist• Crisis intervention • Interventions specific to each of the conditions


Family Violence, Abuse and Neglect• Clinical manifestations

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

head injuries

– Psychological manifestations• Anxiety, insomnia, vague GI complaints

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

inattention to known medical needs36


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, authorities37


Family Violence, Abuse and Neglect• 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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Emergency Operations Plan (EOP)• Health care facilities are required to create a

plan for emergency preparedness and to practice this plan twice a year.

• Essential components of the plan:– An activation response– An internal/external communication plan– A plan for coordinated patient care– Security plans– Identification of external resources– A plan for people management and traffic flow


Emergency Operations Plan (EOP)• Essential components of the plan:

– A data management strategy– Deactivation response– Post-incident response– A plan for practice drills– Anticipated resources– Mass causality incident planning– An education for all of the above

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Emergency Nursing

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