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