Emergency Nursing Flashcards
Emergent Triage
Patients with the highest priority (life threatening illness/injury)
- Chest pain
- Hypoxia
- Hemorrhage
- Unstable VS
Urgent Triage
Patients with serious conditions; not life threatening (but needs to be seen within 1 hour)
- Abdominal pain
- Lacerations (with no active bleeding)
- Respiratory illness not associated with hypoxia
Non-Urgent Triage
Patients who can wait several hours for treatment without deterioration of conditions
- Simple skin rashes
- Colds
- Strains/sprains
- Physicals
What is the triage nurse responsible for?
- Assessing patients initially
- Monitoring patients
- Reassessing patients at regular intervals
- Acting as a patient liaison and advocate of care
* * The foundation of all emergency nursing skills is assessment
* * Triage is an advanced skill not for the novice nurse
Priorities of Emergency Care
- Assign to triage category (resuscitation, emergent, or urgent)
- Stabilization
- Provide critical treatment
- Prompt transfer to appropriate unit (ICU, OR, Med-Surg)
Primary Survey of Client Needs
A - airway B - breathing C - circulation D - disability E - exposure
A- Airway/Cervical Spine
- The highest priority intervention is to establish a patent airway
- Clear airway of secretions
- Supplemental O2
- Stabilize cervical spine with c-collar/backboard
Who gets supplemental O2?
- Non-rebreather mask for spontaneous breathers (100% O2)
- Bag valve mask (BVM) O2 for patient needing ventilator support
- Definitive airway: ET tube, with mechanical ventilation
- GCS < 8
- Patient with airway compromise
Airway Symptoms
- Obstructions
- Blood
- Vomit
- Foreign body
- Facial/neck trauma
- Allergic Reaction
B - Breathing
- Expose, inspect, and palpate neck and chest
- Ausculatation of breath sounds in all lobes
- Evaluation of chest expansion or wall trauma
- Respiratory effort
- Physical abnormalities
Why are chest injuries assessed with breathing immediately after airway is established?
If MVA, gun shot, or stabbed in the chest can cause breathing and airway issues very quickly if not addressed
- Pneumothorax
- Flail chest
- Pulmonary contusions
Emergency Breathing Symptoms
- Increased respiratory effort
- Nasal flaring
- Tachypnea or bradypnea
- Wheezing or stridor
- Hypo/Hyperventilation
- Accessory muscles use
- Paradoxical chest movement
- Tracheal deviation
Two Types of Chest Trauma
- Blunt trauma
2. Penetrating trauma
Characteristics of Blunt Chest Trauma
- More common than penetrating trauma
- Organs usually affected
- Liver, kidneys, spleen, or blood vessels
- Liver most common injured solid organ - Timing is critical
- Often difficult to identify because patients may not seek treatment
What is the most common type of blunt chest trauma?
Rib Fractures
Rib Fractures
- Fracture of ribs 1 & 2 are associated with cranial, major vascular, and thoracic injuries; high mortality
- Ribs 4-10 are the most common site for rib fracture
- Fractures of the lower ribs (8-12) are associated with liver and spleen injuries
- Elderly patients with 3+ ribs fractured have a 5-fold increase in mortality and a 4-fold risk of pneumonia
Rib Fractures: Clinical Findings
- Pain on movement or inspiration
- Crepitus at injury site
- Abdominal involvement
- Muscle spasms
- Bruising around fracture site
Rib Fractures: Interventions
- Adequate ventilation
- Pain management
- TCDB, incentive spirometry
What causes most sternal fractures?
MVAs
Sternal Fractures: Clinical Findings
- Pain at fracture site
- Palpable defect at fracture site
- Crepitus
- Swelling
- Ecchymosis
Sternal Fractures: Interventions
- Maintain ventilation
- Pulse oximetry
- ECG
Assessment of Sternal and Rib Fractures
- Closely evaluate for cardiac injuries
- CXR
- ECG
- Continuous pulse oximeter
- ABGs
- Pain: usually subsides in 5-7 days (ribs)
- Most rib fractures heal in 3-6 weeks
Flail Chest: Physiology
- Frequently a complication of blunt trauma
- It involves 3 or more consecutive rib fractures in 2 or more places
- Produces a free floating rib segment and unstable chest wall.
- Chest wall loses stability causing respiratory impairment and distress
- The detached part of the rib segment (flail segment) moves in a paradoxical manner in that it is pulled in during inspiration, and on expiration the flail segment bulges out
Treatment of Flail Chest: General
- Ventilatory support
- Clearing secretions (Nursing Priority!!)
- Pain control
- If only a small segment of chest is involved we try to clear the airway through:
- Positioning
- Cough/deep breathing
- Suctioning
Flail Chest Symptoms
The mediastinum shifts back to the affected side
- Paradoxical action results in dead space
- Reduction in alveolar ventilation
- Decreased compliance
- Retained airway secretions and atelectasis
- Patient has hypoxemia and respiratory acidosis can develop because of CO2 retention
- Hypotension, inadequate tissue perfusion and metabolic acidosis follows
Treatment of Mild-Moderate Flail Chest
- Treat underlying pulmonary contusion
- Pulmonary physiotherapy
- Secretion management
- Monitor for respiratory compromise and deterioration
Treatment of Severe Flail Chest
- Intubation with vent support based on patient’s condition
- Provide stabilization of thoracic cage to allow fracture to heal, improves alveolar ventilation, and decreases the work of breathing
- Surgery
Pulmonary Contusion
Abnormal accumulation of fluid in the interstitial and intra-alveolar spaces
- Hemorrhage occurs in and between the alveoli
- The resulting edema decreases lung movement and reduces the area for gas exchange
- Increased muscular effort needed to ventilate contused lung
- Patient tires easily and becomes progressively hypoxic.
- Respiratory failure develops over time.
- At first, the patient may be asymptomatic; symptoms onset usually 24-48 hrs. based on the severity of the contusion.
Pulmonary Contusion Symptoms
Vary from decreased breath sounds, tachypnea, chest pain, hypoxemia, and blood tinged secretions to severe tachypnea, tachycardia, crackles, frank bleeding, cyanosis, and respiratory acidosis
Signs of Hypoxemia
- Agitation
- Combative behavior
- Changes in sensorium
Treatment of Pulmonary Contusions
- Maintain airways
- Supplemental O2 (mask/cannula for 24-36 hours)
- Pain control
- Hydration
- Antimicrobial therapy to decrease the potential of pneumonia
- Diuretics or fluid restriction (based on edema)
- PEEP with ventilator support
- NGT to relieve gastric distention
Most Common Penetrating Traumas
GSW and stab wounds
How are penetrating traumas classified?
By velocity: low, medium, high
Low velocity penetrating traumas
Knives, switchblades, ice picks
- Pneumothorax
- Hemothorax
- Cardiac tamponade
- Severe hemorrhage
Penetrating Traumas: GSW
Are low, medium, high velocity
- Based on distance, caliber of weapon, size of the bullet, quantity of GSWs
Most Common Organs Injured in GSW
- Liver (solid organ)
2. Small bowel (hollow organ)
Treatment for Penetrating Trauma
- Airway management
- Restore and maintain cardiopulmonary function
- Determine if any thoracic/abdominal injuries (organs)
- Chest tube insertion
- Large bore IV (prevent shock)
- Infuse 3L of isotonic fluid to replace 1L of blood loss - Colloid solutions, large molecule IV solutions, blood components (PRBCs, FFP, Plasma, Hespan, Dextran)
- Crystalloid solutions
- Monitor for ACS
Crystalloid Solutions
- 0.9% normal saline, LR, hypertonic solutions
- Requires more fluid to restore intravascular volume
- Complications: Fluid overload
* LR can cause metabolic acidosis and fluid overload
* NS and hypertonic solutions can cause hypernatremia
Abdominal Compartment Syndrome (ACS)
- Fluid leaks into the abdominal cavity increasing pressure that is displaced on surrounding vessels/organs
- Complications with infusion of large amounts of IVF
- Requires surgical decompression
Three Types of Pneumothorax
- Simple
- Traumatic (Open)
- Tension
Simple Pneumothorax
- Spontaneous: occurs when air enters the pleural space through a branch of either the parietal or visceral pleura
- Most commonly as a result of a rupture of a bleb
- Can occur in healthy person in the absence of trauma
- Tall, thin, white males at greater risk
Traumatic Pneumothorax
- Occurs when air escapes from a laceration in the lung itself and enters the pleural space from a wound
- Blunt force trauma (rib fracture), GSW, invasive thoracic procedure (central line, lung biopsy, thoracentesis), or barotrauma from mechanical ventilation
- Often accompanied by hemothorax
Open Pneumothorax
- Occurs when wound in the chest wall is large enough to allow air to pass freely in and out of the thoracic cavity with each attempt respiration
- These types of wounds are termed sucking chest wounds
- Not only does the lung collapse, but the heart and great vessels also shift to the unaffected side with each respiration and in the opposite direction with each expiration: called mediastinal shift
- Causes circulatory collapse if not immediately treated
Treatment of Open Pneumothorax
Flutter-Valve Seal
- Apply sterile occlusive dressing over the defect
- Tape securely on 3 sides
- Provide Flutter-Type Valve Effect
- Breathe in: dressing occludes the wound and prevents air to enter from out and vice versa
- Breathe out: trapped air able to exit through the untaped section of dressing
Management of Open Pneumothorax: In an Emergency
- Fill the chest wound with anything large enough to cover the wound (gloved hand, towel)
- Cover with dressing on 3 sides (flutter-valve seal)
Management of Open Pneumothorax: In the Hospital
- Opening is plugged by sealing with petroleum gauze and dressing
- Chest tube
- Surgery
Tension Pneumothorax
- Occurs when air (blood) is drawn into the pleural space from a lacerated lung or through a small opening or wound in the chest wall
- Can be a complication of other types of pneumothorax - Air (blood) drawn into the chest cavity is trapped and cannot be expelled during expiration
- The positive pressure exerted with each breath cause the heart, great vessels, and trachea to shift to the unaffected side.
- Both respiratory and cardiac function is compromised
Symptoms of Tension Pneumothorax
- Air hunger (high O2 concentration)
- Central cyanosis
- Absence of breath sounds
- Hypotension
- Tachycardia
- Profuse diaphoresis
- Distended neck veins
- Visual/palpable tracheal shift (late sign)
Management of Tension Pneumothorax: Emergent Treatment
- Needle decompression by MD
- Chest tube insertion/reinsertion to establish negative pressure and re-expand the lung
Subcutaneous Emphysema
- Air enters the tissue and pass for some distance under the skin
* Usually found in face, neck, scrotum - The tissues give a cracking sensation when palpated
- If underlying air leak is treated the subcutaneous air will spontaneously be absorbed by the body
- In severe cases where there is widespread subcutaneous emphysema
* A tracheostomy may be indicated if airway patency is threatened
C - Circulation: Focus
- The adequacy of HR, BP, overall perfusion
- Interventions are targeted at restoring cardiac output by controlling hemorrhage, preventing and treating shock, and maintaining effective circulation
- Initiate IV access
Circulation focus can include what kind of situations?
- Prevention a management of hypothermia
- Examining peripheral pulses
- Any immediate closed reduction of fractures or dislocations are performed if an extremity is pulseless
Emergency Circulation Symptoms
- Tachycardia/bradycardia
- Pale or mottled skin
- Cyanosis
- Decrease output
- Cap refill > 2 seconds
- Obvious bleeding
- Weak pulses
IV access for circulation symptoms
- Best established in the antecubital with a large bore (18-16G)
- Begin IVF: NS or LR
In a resuscitation situation, how can BP be quickly estimated
- Presence of a radial pulse = BP at least 80 mm Hg systolic
- Presence of a femoral pulse = BP at least 70 mm Hg systolic
- Presence of a carotid pulse = BP at least 60 mm Hg systolic
- By the time hypotension occurs, compensatory mechanisms have been exhausted
Cardiac Tamponade
- Compression of the heart resulting from fluid or blood within the pericardial sac
- Can be caused by perforations of the heart or greater vessels after cardiac cath, pacemaker insertion, central line insertion, and cardiac surgeries (CABG)
Cardinal Signs of Cardiac Tamponade
- Falling systolic BP
- Narrowing pulse pressure
- Rising venous pressure (increased JVD)
- Distant (muffled) heart tones
Treatment of Cardiac Tamponade
Pericardiocentesis
D - Disability
- The disability exam provides a rapid baseline assessment of neurological status
- The APVU mneumonic
- Glasgow Coma Scale (3 = unresponsive, 15 = normal)
AVPU Mneumonic
A - Alert
V - Verbal response to voice
P - Pain response (able to verbalize)
U - Unresponsive
Symptoms of Emergency Disability
- Irritable
- Drowsy
- Pain response only
- High pitched cry
E - Exposure/Environment
All clothing is removed to allow a thorough assessment but avoid hypothermia
- Assess: bites (snake, tick, spider), assault, poisoning
- If forensic evidence is to be collected, put each piece of clothing in separate paper bag using gloves
- Be careful not to cut clothing through holes or tears in the clothing. (to preserve evidence)
- Know hospital policy regarding these issues:
* * Rape, elder abuse, domestic violence, homicide/suicide, drug overdose resulting in death, poisoning, and assault.
Interventions to prevent hypothermia
- Remove wet sheet/clothing
- Cover the patient with blankets
- Infuse only warm solutions/blood products
- Set room temperature to 75 degrees
- Use heat lamps/warming blankets
After life threatening conditions have been addressed, the ER nurse can anticipate:
- Comfort measures
- Insertion of NGT
- Foley catheter
- A more comprehensive head-to-toe assessment is performed to identify other injuries that may impact recovery and treatment
- Disposition: Pt transferred to OR, ICU, Med-Surg
- Complete all necessary paperwork
- Call report using SBAR
- Keep family updated as patient moves through treatment process
Trauma Nursing Principles
- Injury management is a key component of emergency services
- The trauma center has its roots in the MASH units from Korean and Vietnam wars; this has become the modern model
Nursing Responsibilities for Multiple Trauma
- Assessing and monitoring the patient
- Ensuring airway/IV access
- Administering blood products
- Collecting specimens
- Documentation - this is crucial (forensic evidence)
Multiple Trauma: Priority Management
- Establish airway/ventilation
- Control hemorrhage
- Prevent and treat hypovolemic shock
- Assess for head and neck injuries
- Evaluate for other injuries
- Splint fractures
- Perform secondary assessment
Pulmonary Embolism
- Refers to a collection of particulate matter (emboli, amniotic, fat) that enters the venous circulation and lodges in the pulmonary vessels
- Large emboli
- Obstruct pulmonary blood flow leading to reduced oxygenation
- Pulmonary tissue hypoxia
- Potential death
- Many patients die within 1 hour of onset of symptoms
Pulmonary Embolism Pathophysiology
- Most often from a DVT, where a clot travels in circulation, through the vena cava, into the R side of the heart, and lodges in the pulmonary branches.
- Platelets collect on the embolus, triggering substances that cause widespread vasoconstriction
- Deoxygenated blood is moved into the arterial circulation causing hypoxemia (low arterial blood o2 level)
- While the area continues to be ventilated, the area receives little or no blood flow (gas exchange is absent)
- Right ventricular failure occurs, leading to decreased cardiac output and systemic shock
Common Symptoms of Pulmonary Embolism
- Most common dyspnea
- Crackles (rales)
- Pleural friction rub
- Distended neck vein
- Cough
- Tachycardia and tachypnea
- Low grade fever
- Decreased SaO2
- Petechiae over chest and axillae
Less Common Symptoms of Pulmonary Embolism, but often present
- Diaphoresis
- Hemoptysis
- Syncope
- Cyanosis
- S3/S4 gallop
- Sudden death
Initial Diagnostic Workup for PE
- CXR (may show up if its large)
- ECG
- ABG
- Ventilation-perfusion scan (V/Q scan)
- Pulmonary angiography
Laboratory Findings for PE
- Respiratory alkalosis (initially) triggered by sudden onset of hyperventilation
- Respiratory acidosis (later) from lactic acid build up from tissue hypoxia
- Even if ABG and SaO2 show hypoxemia, this is not a definitive diagnosis
- Elevated D-dimer (tests for evidence of clots)
- CBC daily (blood loss)
VQ Scan
Used when pulmonary angiography is unavailable for PE imaging
- Minimally invasive, most commonly used due to low cost
- Involves IV administration of contrast agent
- Evaluates different regions of the lung and allows for comparison of ventilation/perfusion in each area
Pulmonary Angiography
The best method for diagnosing PE
- Catheter inserted into vena cava on R side of the heart
- Allows for direct visualization under fluoroscopy and accurate measurement of obstruction
- Not feasible or cost effective
Primary Goals for PE Management
- Increase gas exchange
- Improve lung exchange
- Reduce the risk related to further clot formation
- Prevent complication
- Heparin
- Enoxaparin
- Warfarin
Treatment of PE
- Oxygen therapy
- Improving cardiac output (increase myocardial contractility)
- Assessment
- Anticoagulant will be taken for approximately 3-6 month post discharge
How do you improve cardiac output for PE treatment?
- Milrinone
- Dobutamine
- VS, lung sounds, cardiac and respiratory status every 1-2 hours
Assessment for PE Treatment
You will see…
- Increasing dyspnea
- Dysrhythmias
- Distended neck veins
- Pedal/sacral edema
- Crackles
- Cyanosis of lips, conjunctiva, oral mucosa, nail beds
Heparin Sodium
- 5,000-10,000 units IVP initially, then dose adjustment by PTT
- Monitor platelets daily for thrombocytopenia
- Monitor PTT
- Assess for bruising, active bleeding
- Patient will be on bleeding precautions
Normal PTT
20-29 seconds
** Therapeutic = 2-2.5 times the patient’s normal
Antidote for Heparin
Protamine sulfate
Enoxaparin
- 1 mg/kg SQ every 12 hours
- CANNOT be given IM or IV only SQ
- Transitions patient to discharge
- Less side effects
- Requires less monitoring than heparin and warfarin
Side Effects of Enoxaparin
- Abnormal liver function (elevated liver enzymes)
- Allergic skin reactions
- Fever
Warfarin
- 10-15 mg orally for 3 days initially, then dose is adjusted based on PT
- Monitor PT/INR at regular intervals (daily, weekly, monthly)
- Monitor for bruising, active bleeding, bleeding precautions
- Monitor for fever and rash
Normal PT
- 5-12 seconds
* * Therapeutic = 2-2.5 times patient’s normal
Normal INR
1.0
Therapeutic INR for DVT/PE
2-3
Therapeutic INR for Heart Valves
2.5-3.5
Antidote for Warfarin
Vitamin K
** IF excessive bleeding, FFP is needed to replace the vitamin K dependent clotting factors
Foods that are high in Vitamin K
- Green leafy veggies
- Chili
- Prunes
- Paprika
- Green onions
- Cabbage
Thrombolytic Therapy
- Used in treating PE in patients who are severely compromised
- Hypotensive and hypoxemia with O2 supplementation - Thombolytic therapy resolves the thombi/emboli quickly and restores normal pulmonary circulation
- MAJOR side effect is bleeding
Thombolytic Drugs
- Urokinase
- Streptokinase
- Alteplase
Contraindications for Thrombolytic Therapy
- CVA in past 2 months
- Intracranial bleeding
- Active bleeding
- Surgery within 10 days
- Recent labor and delivery
- Trauma
- Severe hypertension
Surgical Interventions for PE
- Embolectomy
2. Vena cava interruption
Embolectomy
- Invasive procedure that removes the actual clot, performed by a CV surgical team with the patient on cardiopulmonary bypass
- Rarely performed, but indicated for massive PE or hemodynamic instability
Vena Cava Interruption
- Surgical technique used when PE recurs or unable to tolerate anticoagulation therapy
- Placement of filter in the vena cava prevents passage of clots
- Example: Greenfield filter
DVT Prevention
- Active leg exercises
- Early ambulation
- Anti-embolism stockings (TEDs)
- Sequential compression device (SCDs)
- Anticoagulation therapy
