Concepts of Emergency and trauma nursing - chapter 8

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THE ER NURSE IS GIVEN 5 PATIENTS WAITING FOR ORDERS TO BE IMPLEMENTED. WHICH CLIENT DO YOU SEE FIRST?

-60 year old man waiting to go to the operating room for an emergency appendectomy. -abdominal pain is a urgent matter. -someone sleeping your fine -laceration to the arm your fine for now -closed femur fracture can wait

the impact of homelessness

-636k people in 2011 -increases -adults and children -crisis or persistent poverty -they usually know they will gain entrance despite their ability to pay -ER can not decline you of care -ED is a safe place with food, shelter, and care -avoid stereotyping -watch for mental illness or substance abuse -watch for potential violent behavior -standard precautions -TB concerns (negative room) -demonstrate behaviors of trust is key

triage

-ED triage is an organized system for sorting or classifying patient priority levels depending on illness or injury severity -highest acuity needs receive the quickest evaluation, treatment, and resources (ct scan) -lower level acuity issue may wait longer in the ED because people with more severe issues move "ahead of line" -answer questions of i've been here for..." -RN is typically the person assigned to perform triage function in most hospitals. -appropriate training and experience is needed for this

case management

-RN case managers who intervene to arrange appropriate referral and follow up -chronic conditions the case manager is used for referral into appropriate disease management programs in the community -desired outcome of this is to keep people out of the hospital and keep them educated on their disease. (COPD, kidneys, heart) -health teaching is the key component of these programs. -ED case manager is also used for disposition for homeless people, safe environment for domestic violence

interdisciplinary team collaboration

-a team approach must be used -EMS, Dr, hospital staff

most common causes of care

-abdominal pain -chest pain -breathing difficulties -injuries (especially falls in older people) -headache and fever -pain (most common symptom)

protecting skin integrity

-assess the skin -especially with older adults -promote clean, dry skin for incontinent patients -routine turning

disposition

-at the conclusion of the assessment, physician must make a decision regarding disposition (where should you go after being discharged from the ED) -admit? go home? follow up? -usually the answer is pretty straight forward -stroke, heart pains, surgery needs your staying -decision may be less clear -someone who suffered a head injury and lost consciousness needs someone around for 12 to 24 hours. do you have someone to do that? -domestic violence is also tricky. -may be admitted for further evaluation

ACTION ALERT

-be alert for volatile situations of aggressive or violent tendencies -verbal abuse or acting out -follow a security plan -de escalation strategies

death in the emergency department

-can be expected by families -death can also be sudden and unexpected event that produces a state of crisis and chaos for families -one or two family members may be given the opportunity to be present during lifesaving procedures. -gaining wider acceptance. -this is still not a clear policy. -if the patient dies before family arrives, ED may prepared the body and room for viewing by the family. -forensic investigation may be needed and IV lines and indwelling tubes do not get removed due to evidence. -trauma, homicide, abuse cases -cover the body with a light sheet and leave the face exposed. -use words like death or died. -seems harsh, creates less confusion -avoid "passed" or "expired" -crisis staff may be needed (social workers or psych nurses) -offer this to the family -anxiety and a family member may have chest pain and need an admit -bereavement committees that focus on meeting the needs of grieving families -this helps communication and care

CRITICAL RESCUE

-clear airway of secretions or debris -protect cervical spine in any trauma or risk of injury to the spine -keep the body neutral, mid line -jaw thrust to maintain airway -o2 as needed

mechanism of injury (MOI)

-describes how the injury occurred -high speed accident or a fall -provides insight into the care -most common injury producing mechanisms are blunt trauma and penetrating trauma BLUNT TRAUMA; -mva -a fall -assault with fists, kicks, a baseball bat -blast effect from a bomb -acceleration deceleration forces produces tearing, shearing, and compressing PENETRATING TRAUMA; -knives -ice picks -bullets -metal, glass, fragments from an explosion

pre hospital care providers

-first caregivers that someone sees before they are transported to a hospital -EMS responders EMT offer basic life support interventions like; -o2 -basic wound care -splinting -spinal immobilization -monitor of vital signs -may be authorized to use epi pen or AED PARAMEDICS; -advanced life support providers -perform many advanced techniques -cardiac monitor -advanced airway management -intubation -establish IV lines -give drugs -this pre hospital support is imperative. -get plenty of data from these people -communication must be clear

other multi tiered models

-four and five stages exist -there is no universal approach to this -no standard of triage acuity data -no matter the model the process remains, highest acuity to lowest acuity

potential of errors or adverse events

-get as much information as possible -check for medical wallet or bracelet -get info from family -2 person search for patient belongings for medication containers, name of their doctor, pharmacy or someone to contact -obtain thorough history -check medical alert bracelet or necklace -search patient's belongings for weapons or harmful devices with an altered mental status

patient and family education

-health teaching is a key component -review discharge instructions -wellness and injury prevention -wear your seat belt (mva) -smoke detectors or carbon monoxide detector -fall prevention tips -how to much blood sugar -control of your blood pressure

demographic and vulnerable populations

-homeless -poor -older adults -can be a cardiac, geri, psych nurse all in one shift. very demanding job -life threatening issue to minor

patient identification

-identification bracelet at point of entry -"john or jane doe" for unconscious people -always use 2 identifiers -provide a ID bracelet for every patient -use 2 identifiers -if identity is unknown, use a special ID system

secondary survey and resuscitation intervention

-insertion of gastric tube for decompression of GI tract to prevent vomit and aspiration insertion of catheter for output measurements -secondary survey is done to identify other injuries or medical issues. -this is basically a more comprehensive head to toe assessment

emergency care basics

-its a growing need -act as a safety net for communities -emergency disaster preparedness -119 million people each year to the ED -the longer people stay in the ED, the more it becomes crowded

emergent, urgent, nonurgent categories

-many triage systems can be used by a hospital -three tiered model of emergent, urgent, nonurgent emergent example; -SOB, chest pain, diaphoretic -this person would get immediate care -actively bleeding urgent example; -should be treated quickly but an immediate threat to life does not exist right now. -can be upgraded to emergent -new onset pneumonia, renal colic, complex lacerations not associated with hemorrhaging, displaced fractures or dislocations, temp above 101 nonurgent; -tolerate waiting several hours for services with no major risk to health -sprain and strains -cold symptoms -skin rashes

core competencies cont.

-must be very good at multitasking -deal with high stress -cardiac or trauma resuscitation -proficient with critical care equipment

the ED nurse

-must communicate with every aspect of the health team -accountable for communicating pertinent staff considerations, patient needs, and restrictions to support staff (physical limitations) -must give an extremely detailed report to the inpatient unit if the patient is going to stay provide all information; -situation -medical history -assessment and findings -transmission based precautions as needed -interventions -response to those interventions -SBAR method is preferred -ER nurses and floor nurses usually get mad at each other. have empathy which every floor you work on.

trauma centers

-not all EDs that have an around the clock emergency services are considered trauma centers -categorized from level 1 to 4

hospital acquired infection

-older adults in particular for UTI or respiratory infections -immune suppressed patients (steroids) -wash your hands

D (disability)

-rapid baseline assessment of neuro status. AVPU; Alert Voice response Pain response Unresponsive -another way to determine LOC is with GCS -lowest score is 3 which is total unresponsive -highest is 15

the emergency department environment of care

-rapid change is the standard -fast paced and appears chaotic -patients can receive treatment in hallways and waiting rooms if needed for initial treatment -interruptions and distractions are normal -people who work in ED enjoy this type of work

E (exposure)

-remove all clothing for a complete assessment -prevent hypothermia (cover with blankets) -always cut clothing with scissors -watch for evidence (bullets, drugs, objects) -handle evidence appropriately (policy) -nurses are often called upon to show up in court

primary survey and resuscitation interventions

-scene safety is basic tenet of er care -watch for their blood, contamination -treat everyone as infected with someone -blood or fluids? precautions -gown, gloves, eyes, face, cap, shoes

core competencies

-skilled in assessment, priority setting, and clinical decision making, multitasking, communication is a big one -sound knowledge base is essential -flexibility and adaptability -assessment is the foundation -rapidly and accurately interpret assessment findings according to acuity and age -priority settings is another big one -essential in triage process -assessment, thinking, decision making skills -must understand legalities to things like abuse and violence -nurse often initiates collaborative protocols for lifesaving interventions like cardiac monitoring and o2 therapy or IV catheters -nurses function under clearly defined medical protocols that allow them to initiate drug therapy for emergent conditions like shock or cardiac arrest.

emergency medicine physician

-specialized education -directs the overall care in the department

TRAUMA CLIENT BROUGHT TO THE ER POST A MVA. SEVERE INJURIES ARE PRESENT. WHAT ACTION DO YOU DO FIRST?

-start 2 large bore IVs and run normal saline -apply o2 and oximeter probe -stabilize the spine and assess airway -place pressure on bleeding wound to the forehead -stabilize the spine and airway. -airway is priority.

fall prevention

-start with identifying people at risk -drugs, pain medications, weak -orthostatic hypotension and heart meds -can be waiting as long as 2 days for a bed. monitor the skin and hygiene, nutrition, safety -keep rails up on a strecher -keep strecher at lowest position -remind the use of call lights -reorient a confused patient -have family stay with a confused patient -implement skin integrity measures

common ED procedures include

-the nurse collaborates and assists a physician with a number of procedures -knowledge and skills r/t the procedural setup, preparation, teaching, and post op care are key aspects. -suturing for wound closure -foreign body removal -central line insertion -endotracheal intubation and initiation -pacemaker insertion -LP -pelvic exam -chest tube insertion -paracentesis -fracture management -all part of the emergency nursing practice -more than 1 nurse may be needed -communication is another large part of a ED nurse -this is a complex environment

B (breathing)

-this determines weather ventilatory efforts are effective or not. -listen to breath sounds -chest expansion -respiratory effort -chest wall trauma or other issues -BVM support for apneic patients or with poor ventilatory effort. -BVM is used until tube intubation is done. -if CPR is needed, mech vent is disconnected and manually ventilated with BVM.

A (airway)

-this is the highest priority -establish a patent airway -bag valve mask ventilation with 100% o2 is indicated for ventilatory assistance during resuscitation -consciousness that is altered you tube them

staff safety

-transmission of disease -dealing with aggressive people -standard precautions at all times -TB or airborne issues are placed in negative pressure room if available -usually a cop or security in the ED -metal detectors are used -panic buttons hidden -canine units may be used for high risk areas

trauma centers and trauma systems

-trauma centers have their roots in military medicine -injured soldiers from the fields -today's trauma center provides competent and timely trauma care

trauma nursing principles

-trauma refers to bodily injury. -not psychological stress -this is the policy in the ED -intentional (shot, stabbed) -unintentional (accident, mva) -unintentional are much more common -mva is the most common cause of death for people younger than 35 in the ED

training and certification

-two general types of certification are referred to in emergency nursing practice -certification marks successful completions of a course of study -emergency nursing specialty certification is part of the orientation and requirements of the building -advanced concepts in cardiac monitoring -invasive airway management skills -pharmacologic and electrical therapies -access techniques that are invasive -special resusciation situations

C (circulation)

-when effective ventilation is ensured, priority shifts to circulation -hr, bp, perfusion becomes the focus -cardiac arrest, heart issues, hemorrhage all can lead to circulation issues external hemorrhage; -direct pressure on bleeding site -thick, dry dressing material -toruniquets for severe bleeding internal hemorrhage; -more hidden complication -suspected when shock state -antecubital area is preferred for IV -femoral, subclavian, or jugular sites can be used for central venous catheters -RL and normal saline are fluids of choice for resuscitation -anticipate the need for blood for someone with an active hemorrhage -hypotension persists with infusion of 2l, you need a transfusion of blood.

LEVELS AND FUNCTIONS CHART

1; -large teaching hospital -full continuum of trauma services -research is a requirement of this 2; -community hospital -provides care to most injured people -transports people as needed if resources are overwhelmed. 3; -stabilize major injuries and shipped 4; -extreme rural areas -basic trauma stabilization -arranges transport to high trauma centers

How does the nurse ensure a patent airway for a client with significantly impaired consciousness?

Apply a nasal cannula. Apply a non-rebreather mask. Provide bag-valve-mask (BVM) ventilation. Provide an endotracheal tube and mechanical ventilation.@@@ The client with significantly impaired consciousness is provided an endotracheal tube and mechanical ventilation. A nasal cannula and non-rebreather mask is used for a client who is able to breathe spontaneously. Bag-valve-mask (BVM) ventilation with the appropriate airway adjunct and a 100% oxygen source is indicated for a client who needs ventilatory assistance during resuscitation.

The provider is planning to discharge a client home. The nurse suspects domestic violence as the cause of injury, although the client denies this. What is the best course of action for the nurse to take?

Call the police. Consult with Social Services. Discharge the client as instructed. Instruct the client to go to a safe place. If discharge home is not deemed safe, the client may be admitted to the hospital until resources can be organized to provide a safe environment. Social workers or case managers are consulted to investigate resource needs and plan accordingly. Calling the police is not an appropriate response. Letting the client go home could place the client in danger. The client may not have a safe place to go.

The triage nurse is assessing the acuity level of clients rushed to the emergency department. What sign or symptom reported by the client prompts the nurse to classify the client as emergent?

Chest pain with diaphoresis Severe abdominal pain Multiple soft tissue injuries Strains and sprains The client having chest pain with diaphoresis should be classified as emergent. The "emergent" category indicates that the client has a condition that poses immediate threat to life or limb. The client with severe abdominal pain and multiple soft tissue injuries are classified as "urgent" indicating that the client needs to be treated quickly but an immediate threat to life does not exist at the moment. A client with strains and sprains is classified as "nonurgent" indicating that the client could wait for several hours without a significant risk for deterioration. Test-Taking Tip: Pace yourself during the testing period and work as accurately as possible. Do not be pressured into finishing early. Do not rush! Students who achieve higher scores on examinations are typically those who use their time judiciously.

The forensic nurse examiner is assessing a client who is a victim of intimate partner violence (IPV). What interventions does the nurse perform for this client?

Document injuries and collect photographic evidence. Offer basic life support interventions and wound care Perform advanced airway management and intubation. Evaluate emotional behavior and admit the client to a psychiatric facility. The forensic nurse examiner documents injuries and collects photographic evidence. Emergency medical technicians offer basic life support interventions and wound care. Paramedics provide advanced life support system such as advanced airway management and intubation. The psychiatric crisis nurse team evaluates emotional behavior and admits the client to a psychiatric facility if needed.

What is the nurse's first step when caring for any client in an emergency?

Establishing a patent airway. Splinting fractures. Dressing wounds. Evaluating the level of consciousness. Issues identified in the primary survey, an organized system to rapidly identify and effectively manage immediate threats to life, are managed first when caring for a client in the emergency department (ED). The primary survey includes airway, breathing, circulation, disability, and exposure. Therefore, establishing a patent airway is the priority for the client. Splinting fractures and dressing wounds are addressed after evaluating the consciousness level of the client.

special nursing teams

FORENSIC NURSE EXAMINERS; -professionals for rape, abuse of children or domestic -trained to recognize signs -sexual assault nurse examiners are people who do forensic nursing but specialized training for this -interventions by these people is collected and used for evidence -they may provide testimony in court PSYCHIATRIC CRISIS NURSE TEAM; -another type of specialty team -mental health nurses -can be emotional or mental illness -sudden illness, serious injury, death of a loved one. can be a crisis

levels of trauma

LEVEL 1; -regional resource facility that is capable of providing leadership and total care for every aspect of injury -from prevention to rehab -responsibility of offering professional and community programs -usually your large hospital or dense population area LEVEL 2; -located in community hospitals -vast majority of injured patients -may not meet the resource needs of people who require very complex injury management -advanced surgical care? may not be avail. -these people are generally transferred to a level 1 for specialty care. LEVEL 3; -critical link to higher capability trauma centers in communities that do not have access to level 1 or 2 centers. -primary focus is initial injury stabilization and patient transfer. -found in smaller, rural areas -they do have surgeons and such ready to work -major injuries and you may be shipped out LEVEL 4; -offer advanced life support care in rural or remote settings that do not have access -such as a ski area -stabilized and transferred -resources even like a physician is extremely limited at all times.

What are the duties of the nurse case manager in the emergency department (ED)?

Obtain and record the client health history. Provide discharge teaching. Coordinate the triage process with the triage nurse. Arrange appropriate referrals for the client. The nurse case manager in the ED arranges for appropriate referrals and follow-up for the client. The emergency nurse obtains and records the client history. The nurse provides discharge teaching to the client and client's family. The primary healthcare provider and assistant may coordinate the triage process with the triage nurse.

Who is said to be the gatekeeper in the emergency care system?

Physician Physician assistant (PA) Triage nurse Nurse practitioner (NP) The triage nurse is a registered nurse (RN) and is said to be the gatekeeper in the emergency care system because the triage nurse is normally assigned to perform the triage function in the emergency department. The triage nurse may seek the input of an emergency physician, NP, or PA to help establish the acuity level if the client's presentation is highly unusual.

A client with stab wounds to the abdomen is rushed to a Level III trauma center. What care does the nurse provide for the client in this facility?

Stabilize and arrange to transfer the client to a Level I trauma center. Give first aid and transfer the client to the community hospital. Provide life support and transfer the client to a Level IV trauma center. Provide the full gamut of health care at the trauma center. A Level III trauma center would be able to stabilize this client and arrange to transfer the client to a Level I trauma center. Level III trauma centers are usually found in smaller, rural hospitals and are not equipped to provide complete care for clients with traumatic injuries. A community hospital may not be able to provide further care, so there is no need to transfer the client to such a facility. The client would not be transferred to a Level IV trauma center as they are located in remote areas and do not have the capabilities to care for this client till complete recovery. Only a Level I trauma center can provide this client with the full gamut of health care.

Which protective gear is most important when caring for clients with tuberculosis or other airborne pathogens?

Surgical cap Impervious cover gown Eye protection Powered air-purifying respirator (PAPR) The nurse uses a PAPR or a specially fitted face mask when caring for a client with airborne pathogens. These clients are preferably placed in a negative pressure room if available. When there is a high risk of contamination from blood and body fluids, other safety precautions may be used. These include use of a surgical cap, an impervious cover gown, and eye protection.

The nurse in the emergency department is often required to care for clients from various cultural and language backgrounds. What belief comes in the way of caring for a Jehovah's Witness client?

Tendency to be very family-oriented Inability to converse in a language spoken by the staff Dislike of their bodies being exposed Refusal of blood transfusions Jehovah's Witness clients do not accept blood transfusions; this belief can affect delivery of care. Some Mexican-Americans tend to be very family-oriented; however, this may not be a barrier for health care. If a client cannot converse in a language spoken by the staff, dedicated interpreters can help to communicate with the client either through telephone or in person. Clients from the Middle East and some Mexican-American clients may be modest and not like their bodies to be exposed; the nurse should take adequate care to maintain the privacy of these clients.

How is an unconscious male client who is brought to the emergency department (ED) eventually identified?

The family is asked to provide details about the client. The client is provided a "John Doe" identification tag. Identification is made after the client regains consciousness. The client is identified by the date and time of arrival to the hospital. Hospitals commonly use a "Jane/John Doe" identification system for clients with unknown identity and those with emergent conditions. All clients are issued an identity bracelet at the point of entry to the ED. The nurse does not wait until the family arrives for details or until the client regains consciousness. The client is not identified by the date and time of arrival to the hospital. Other appropriate identifiers include date of birth, agency identification number, home telephone number or address, and/or Social Security number.

TRAINING AND CERTIFICATIONS NEEDED FOR ED NURSE

basic life support; -noninvasive assessment and management of skills for airway maintenance and CPR advanced cardiac life support; -invasive airway management skills, pharmacology, electrical therapies, special resuscitation certified emergency nurse; -validates core emergency nursing knowledge base

patient safety

common patient safety issues are; -patient identification -fall risk -skin breakdown in vulnerable populations -risk for medical errors or adverse events

TIERS AND EXAMPLES CHART

emergent (life is threatened); -respiratory distress -chest pain with diaphoresis -stroke -active hemorrhage -unstable vital signs urgent (treatment needed, currently safe); -severe abdominal pain -renal colic -displaced or multiple fractures -respiratory infection (pneumonia) nonurgent (could wait hours); -skin rash -colds -simple fracture -strain and sprains