Emergency Triage/Trauma Flashcards
Nursing Concepts
✓ Comfort
✓ Collaboration
✓ Oxygenation
✓ Perfusion
✓ Safety
✓ Stress
✓ Teamwork
✓ Trauma
✓ Violence
EDs
☞ Provide services to all seeking care
☞ Responsible for safety via public surveillance & emergency disaster preparedness
☞ Interprofessional speciality teams
☞ Critical Access Hospitals
☞ Multi-specialty environment
Common Reasons People Seek ED Care
✂ Abd pain
✂ Breathing difficulty
✂ CP
✂ Fever
✂ HA
✂ Injuries (esp falls in older adults)
✂ Pain (the most common sx)
Demographic Data and Vulnerable Populations
Care provided across the lifespan
Vulnerable populations
- Homeless
- Poor
- Mental health issue
- Substance abuse issue
- Older adults
- Pt acuity varies from life-threatening to minor issues
Emergency Nursing Principles
✭ Triage
* Process of rapidly determining pt acuity
* Represents a critical assessment skill
* Categorizes pts so most critical are treated first
Common system is Emergent / Urgent / Non-urgent
Different types of triage SYSTEMS, but the PRIORITIES ARE UNIVERSAL
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Pt can usually wait several hrs for care w/o risk
e.g., skin rash, strains/sprains, cold, simple fx’s
Non-urgent
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Pt has immediate threat to life or limb, & req immediate treatment
e.g., resp distress, CP w/diaphoresis, stroke, active hemorrhage, unstable VS
Emergent
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Pt should be treated quickly but immediate threat to life does not exist @ the moment
e.g., severe abd pain, renal colic, displaced or mult fx’s, complex or mult soft tissue inj, new onset resp infectons, esp in older adults
Urgent
Trauma Nursing Principles
- Trauma - bodily injury
- Unintentional injury - leading cause of death in US for individuals under 35 y.o.
🌟 Trauma-informed care (TIC) - is a model of care that ensures pt safety through 4 key practices:
✨ realizing the widespread effect of trauma
✨ recognizing the s/s of trauma
✨ responding by fully integrating trauma knowledge into practices & procedures
✨ seeking to actively resist re-traumatization
Trauma Centers
Mechanism of Injury (MOI)
Manner in which traumatic event occurred:
- Blunt trauma
- Blast effect
- Acceleration-deceleration forces
- Penetrating trauma
Trauma Assessment
- Primary survey
(A) Airway
(B) Breathing
(C) Circulation
(D) Disability
(E) Exposure
! Exception
- In presence of excessive bleeding, use CAB (circulation, airway, breathing
Primary Survey - Airway/CSpine
- Airway w/cervical spine stabilization and/or immobilization
- s/s in pt w/compromised airway
> Dyspnea
> Inability to vocalize
> Presence of foreign body in airway
> Trauma to face or neck
- Maintain airway: least to most invasive method
- Open airway using the jaw-thrust maneuver
- Suction and/or remove foreign body
- Insert nasopharyngeal/oropharyngeal airway
- Endotracheal intubation
Rapid-sequence intubation
- Preferred procedure for unprotected airway
- Involves sedation or anesthesia & paralysis
Stabilize/immobilize c-spine
- Face, head, or neck trauma and/or significant upper torso injuries
Primary Survey - Breathing
✓ Assess for dyspnea, cyanosis, paradoxic/asymmetric chest wall movement, decreased/absent breath sounds, tachycardia, hypotension
! Fractured ribs, pneumothorax, penetrating injuries, allergic reactions, pulmonary emboli, asthma attacks, flail chest
Primary Survey - Circulation
✓ Check central pulse (peripheral pulses may be absent b/c inj or vasoconstriction)
✓ Insert two large-bore IV catheters (16g) AC
✓ Initiate aggressive fluid resuscitation using NS (0.9%) or LR’s; crystalloid solutions
- Hypertonic saline may be used for head trauma (higher than physiologic 0.9% w/2%, 3%, 5%, 7%, & 23% NaCl preparations)
- Fluids warmed
- Blood products can also be given BUT priority is to stop the bleeding
! AMS & delayed cap refill (>3 sec) are the most significant signs of shock (consider factor of a cold environment)
Presence of a radial pulse = BP @ least ___ mmHG systolic
Presence of a femoral pulse = BP @ least ___ mmHG systolic
Presence of a carotid pulse = BP @ least ___ mmHG systolic
80
70
60
Primary Survey: Disability
Measured by pt’s LOC
AVPU -
A = alert
V = responsive to voice
P = responsive to pain
U = unresponsive
GCS lowest score 3, highest 15
Pupils
Primary Survey: Exposure/environmental survey
☞ Remove clothing to perform physical assessment
☞ Prevent heat loss
☞ Preserve evidence whenever possible
☆ Preservation of evidence is often needed for rape, elder abuse, domestic violence, homicide, suicide, drug overdose, & assault
Secondary Survey - Brief Systematic Process to id all injuries
Full set of VS/5 interventions/facilitate family presence
- BP (bilat)
- HR
- RR
- O2 sat
- Temp
Full set of VS
- Initiate ECG monitoring
- Initiate pulse oximetry
- Insert indwelling catheter
- Insert orogastric/nasogastric tube
- Collect blood for lab studies
Secondary Survey - full set of VS/5 interventions/facilitate family presence
☆ Family presence: family members who wish to be present during invasive procedures/resuscitation view themselves as participants in care
☆ Their presence should be supported
☆ Give comfort measures
- Pain management strategies
- Combination of:
> Pharmacologic measures
> Nonpharmacologic measures
☞ History & head-to-toe assessment (ONLY IF VS ARE STABLE)
- Obtain history of event, illness, inj from pt, family, & emergency personnel
- Perform head-to-toe assessment to obtain info about all other body systems
AMPLE
A = Allergies to drugs, food, environment
M = Medication hx
P = Past health hx
L = Last meal
E = Events/environment leading to the illness or inj
☞ Inspect the posterior surfaces
- Logroll pt (while maintaining c/s immobilization) to inspect the posterior surfaces
☞ Evaluate need for tetanus prophylaxis
☞ Provide ongoing monitoring & evaluate pt’s response to interventions
Secondary Survey & Resuscitation Interventions
- Comprehensive head-to-toe assessment
- Identifies other inj/issues (after immediate life threats have been addressed)
- The nurse anticipates:
> Insertion of gastric tube & urinary catheter
> Preparation for diagnostic studies
> Application of splints, temporary dressings
Disposition
- Transport to OR or interventional radiology suite
- Admission to inpatient unit
- Transfer to a higher lvl of care
- Before disposition is determined
> Assess psychosocial needs
> Consult w/social services & rehab team
> Coordinate w/other support services as needed
> Be alert for signs of human trafficking
> Implement SBIRT
⤷ Assessing for problem drinking = screening, brief intervention, & referral to treatment
Gerontologic Considerations Emergency Care
➙ Older adults are @ high risk for inj - primarily from falls
Causes
- Generalized weakness
- Environmental hazards
- Orthostatic hypotension (e.g., s/e of rx’s, dehydration)
- Important to determine whether physical findings may have caused fall or may be d/t fall
