14 CEN: Professional issues

Question 1

Caregiver Burnout

Answer 1

Causes: significant deaths, chronic short staffing, violence.
Recognize burnout & post-traumatic stress in yourself and others.
Take a Break: self-reflection, self-monitoring, build resilience.

Question 2

Ethical Principles- Autonomy

Answer 2

Autonomy - right to make one’s own choices and have choices respected (DR).


Question 3

Ethical Principles- Beneficence

Answer 3

Beneficence - duty to help others, care for unresponsive patient, report suspected abuse.


Question 4

Ethical Principles- Nonmalficence

Answer 4

Nonmalficence - duty to do no harm, report discharge of unstable patient.

Question 5

Ethical Principles- Justice

Answer 5

Justice - to be fair and impartial, treat all equally (alcoholics/addicts).


Question 6

Ethical Principles- Utilitarianism

Answer 6

Utilitarianism - benefit of the majority (disaster triage).

Question 7

What is Drug diversion?

Answer 7

Drug diversion - Prevention is the key, train staff to “see something, say something.” If you suspect a nurse is diverting drugs, report to supervisor first. Report to drug enforcement agency (DEA) if you witness a nurse tampering with controlled substances.

Question 8

Just culture

Answer 8

blame-free reporting to increase reporting to uncover the source of the error.

Question 9

What needs to be done for Corneal donation ?

Answer 9

Corneal donation - elevate head 20-30 degrees, instill artificial tears and tape eyelids shut with paper tape, apply ice over eyes.

Question 10

Living Will -

Answer 10

Living Will - allows an individual to declare what treatments an individual does and does not want; applies only to terminal illness or a vegetative state.

Question 11

Durable power of attorney for health care

Answer 11

• designates a surrogate decision maker when an individual is unable to make their own decisions.

Question 12

Forensic evidence collection

Answer 12

-Be sensitive to family needs (female, allow washing of body and prayer).
-Use “quotation marks”, document statements verbatim.
-Avoid judgement, document facts only.
-Do NOT cut through any clothing tears, rips, holes, or stains.
-Place all evidence in paper bags or cardboard boxes, do NOT use plastic (mold).
-Double fold the bag and tape across, do not staple.
-Place paper bags over patient’s hands if suspected of recently discharging a firing arm (gunshot residue).
-Do not remove bullet with metal instrumentation, use gloved fingers or rubber-tip hemostats.
-Do not label wounds as entrance and exit wounds; label as wound 1 and wound 2.
-Chain of custody - Court evidence must be accompanied by documentation that demonstrates the item’s location and responsible party to prove integrity of evidence.

Question 13

Transfer and stabilization

Answer 13

The transferring facility is responsible for determining the best mode of transport, equipment needed in route, and qualified personnel based on patients’ needs.
Consider access, time, distance, weather, special needs.
Ground may take longer but allows for more room.
Rotor-wing (helicopter) allows rapid point to point transfer, but cabin not pressurized and small (air expands, vibration).
Fixed wing (airplane) is pressurized and can fly in inclement weather.

Question 14

Considerations prior to transport

Answer 14

Decompress the stomach with a gastric tube prior to rotor wing transport to decrease risk of aspiration.
Assure patent intravenous sites (a minimum of two are preferred).
Consider an indwelling urinary catheter for longer trips.
Air splints will expand and are NOT appropriate for rotor-wing, use regular splint.
May place chest tubes for smaller pneumothorax if rotor-wing.

Question 15

Professional Negligence

Answer 15

• 4 elements must be present to establish malpractice.
  * Duty - the nurse has a duty to pertorm care.
  * Breach of duty - the person failed to complete/ adequately complete the duty.
• Proximate Causation - the breach caused damage (physical, emotional, psychological, or social.
• Damages - damages exist.

Question 16

EMTALA

Answer 16

EMTALA

1. Congress-enacted National Law - Consolidated Omnibus Budget Reconciliation Act (COBRA) and Emergency Treatment and Active Labor Act (EMTALA) are meant to protect patients from «dumping” practices in which hospitals transferred patients based on their ability or lack of ability to pay.
2. COBRA applies to any patient “who comes to the emergency department requesting examination or treatment for a medical condition”. These patients must be provided with a medical screening exam performed by a “qualified medical provider”.
3. If a patient is to be transferred, the following must be secured in advance:
4. The patient has been stabilized to the extent possible by the transferring facility. A receiving hospital must be secured. The receiving hospital must have the following; the services and capacity to care for the patient. Have an accepting physician qualified to care for the patient.
5. The patient and/or legal representatives for the patient must be notified by the transferring physician of the risks and benefits of transfer and must have signed a certification that the benefits outweigh the risks (the transferring physician must certify that the benefits of transfer outweigh the risks). This certification must accompany the patient on the transfer.
6. The transferring hospital must send appropriate medical records, reports, and consultation records (or copies) with the patient. The transferring facility must arrange appropriate transportation with adequate life support equipment and assure trained personnel are on board suitable for the patient’s condition.

Question 17

Patient consent

Answer 17

Implied - allows appropriate treatment in an emergency, as in unresponsive patient.
Express - agreement to treatment, signs paperwork.
Informed - patient understands risks and benefits of the proposed treatment, is not under the influence, and has legal capacity to make the decision.
Involuntary - ensuring needed treatment when an individual refuse care, i.e., suicidal, delusional, dementia.
*Federal consent allows treatment of minor who is pregnant, has STI, requesting rehabilitation, suicidal.

Question 18

ESI triage

Answer 18

Use ESI triage and ABCD for prioritization questions.

* Level 1 - requires life-saving interventions immediately (overdose with respiratory rate of 8, unresponsive with blood sugar of 20, cardiac or respiratory arrest, trauma requiring fluid/blood).
* Level 2 - high-risk situation (pulmonary embolus risk, suicidal patient, victim of assault, sickle cell crisis, testicular torsion).
* Levels 3-5 based on resources.

Question 19

Disaster Triage

Answer 19

 START Triage based on ambulation “Green”, then RPM 30-2-can do (respiration between 10-30, perfusion of capillary refill < 2 seconds, mental status follows commands. Priority is to determine
* “Red” and get them treated ASAP. “Yellow” are delayed. “Black” are expectant to die.
JumpSTART is pediatric disaster triage. Give child 5 positive-pressure breaths before moving to “Black” tarp.
 Decontamination - patient flow is opposite of wind direction. HazMat gear in hot zone to provide life. saving treatment only. Decontamination occurs in warm zone. Provide patient care in “Cold” zone.

Question 20

Disaster Management Phases

Answer 20

Mitigation - to prevent or minimize potentially adverse effects (Hazard Vulnerability Assessment).
Preparedness - Emergency training (NIMS, HICS), mutual aid agreements, stockpile supplies.
Response - Evacuation, shelter, disaster triage (START, jump START).
Recovery - Restoring systems, replenish supplies, dispose of waste, CISM.

Question 21

Signs/Symptoms of Pediatric Abuse

Answer 21

• Fractures in various stages of healing, in a child < 3 year of age, or fingers in non-mobile child.
  * Burns bilateral with lines of demarcation “sock-like”.
  * Bruises in various stages of healing, shape of identifiable object, human bite marks.
  * Triad of subdural hematoma, rib (posterior) fractures, and retinal hemorrhages - probable shaken impact syndrome (shaken infant).

Question 22

Gender equity

Answer 22

• Sexual assignment at birth based on external genitalia.
  * Gender identity is internal sense of gender.
  * Transgender patient identifies with gender other than one assigned at birth. Ask what pronoun the patient would like to be referred to by and note it in the medical record.

Question 23

Types of Abuse

Answer 23

* Neglect - failure to provide basic needs - medical, physical, and/or educational. Physical - intentional injury (maltreatment). Sexual - inappropriate sexual contact. Emotional - mental anguish.
* Financial - mostly seen with developmentally disabled and elderly who require caregivers.
* Physiologic mimics of abuse - Cultural practices - cupping and coining; coagulation disorders; Mongolian spots (dark spots); Osteogenesis imperfecta “brittle bone”
* History (High Index of Suspicion)
–Does the story match the injury/illness? Description conflicting or improbable? Answers vague? Delay in seeking treatment or bypass of closer ED?
–Tension between caregivers? Caregiver demanding? Describes patient as clumsy or accident. prone. Refuses to leave patient alone with providers.