EMERGENCYBy: Diana Blum MSN Metropolitan Community College

Environment of CareRapid changeNoisyUnpredictable

DemographicMultiple specialtiesIncreasing visits to 123.8 million in 2011Avg age of patient is 35.7 yrs old75 + years old highest visit rateCommon reasons for healthcare seeking:

Chest painAbd painHeadachefever

Team MembersER nurseEMTsParamedicsPhysciansAncillary members: admissions, radiology, etc.Special teams: forensic nurse, psychiatric team

Client SafetyAll patients have ID number and if unconscious they are named John or Jane Doe

If unconscious the nurse plays detectivePrevent falls and breakdownGet med list if available Always ask allergies if ableLook for medic alert bracelets, necklacesStandard precaution alwaysRecognize volatile situations (plan escape route)

Priority Emergency Measures for All Patients

• Make safety the first priority• Preplan to ensure security and a safe environment• 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

• 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

ER Nursing6 months to 1 year acute care/ICU trainingSome ERs will hire new grads using intern program

Technical SkillsMultitaskingAssist with:

Wound closureForeign body removalCentral line insertionTransvenous pacemaker insertionLumbar puncturePelvic examChest tube insertionLavageFracture management

http://www.youtube.com/watch?v=n5Zw4ZARvNg

Core Competencies

Knowledge of ER CareBroad basedMulti disease process/insects/snakes/animalsMandatory reporting for sexual assault, abuseBLS, ACLS, PALS

AssessmentRapid recognition of abnormal findingsMust be aware of comorbiditesAct Quickly

CommunicationComplex barriersUse professional languageProtect HIPPA related information

TriageMeans: to sort: ED triage differs from disaster triage in that patients who are the most critically ill receive the most resources, regardless of potential outcome

1.Across-the-room assessmentstarts with visual contact, general appearance, work of breathing, skin color

2.Determine chief complaint3. Focused assessment

(Subjective data) demographics, onset of symptoms, past medical history, LMP, current meds, allergies(Objective data) inspection, palpation, auscultation, obtain vital signs

Basic Elements

Assign acuity levelEmergent: immediate threat to life or limb

CODE, Respiratory Failure, Chest pain, hemorrhageUrgent: treat quickly but life no immediate threat present at this time

Pneumonia, abd pain, fracturesNon-Urgent: can wait for several hours if needed

Strains, sprains, toothaches, cold, some rashes

5 Level TriageLevel 1- immediate life saving interventions, many resourcesLevel 2- high risk, many resourcesLevel 3- urgent, two or more resources, wait 30 minLevel 4- non-urgent one resource, wait up to 1 hourLevel 5-no resources, wait up to 2 hours

ExamplesLevel 1- CPR, intubation requiredLevel 2- chest pain, dyspnea, suicidal with plan or attempt, stroke, pregnant with active bleedingLevel 3-abdominal pain, closed fractures, dislocationsLevel 4- sore throat, strains, sprains, URI, Level 5- suture removal, medication refill, certain rashes

ResourcesLabs IV fluidsXRAY ConsultsEKG Simple procedureCT/MRI Complex procedureIV/IM medications

Primary SurveyA: Airway

patency, watch for tripod, stridor, inability to speak, rise and fall of chest

B: Breathing rate and depth, breath sounds, chest expansion, skin color, spontaneous breathing

C: Circulationheart rate, pulses, blood pressure, skin, cap refill

D: DisabilityAlertness, Responsive to Voice, Responsive to pain, Unresponsiveness

E: ExposureRemove clothing, keep pt warm

2nd ary SurveyIdentifies other injuries or medical issues that needs to be managed

Secondary Survey

• Before beginning Secondary survey• Attach EKG leads, Pulse ox, C02 device to ETT, foley cath if not

contraindicated, NG, radiographs-Full set of vital signs/Focused interventions

FAST scan-focused assessment-Give comfort measures-History/Head to toe assessment

Pre-hospital info AMPLE

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-log roll protect spine

• Assign highest priority to injuries interfering with vital physiologic function

Hemorrhage Control

Care of ClientPlace client in hospital gownEnsure privacyMed administration as ordered Assist with proceduresReprioritize and reassess as needed

DispositionAdmitted or discharged is the questionWhat is the nurses role?

Case ManagementNurse case managers intervene when necessary to assist in making follow up and referral arrangements especially with elderly and homeless, and abused clients

Teaching review D/C instructionsReinforce safety (sealtbelt wearing)Discuss home safety (detectors, fall prevention) teach new procedures that will continue at home

Priority SettingTriaging client careCritical thinker

Go to Prioritization PPT