Exam #1 Study Guide: Nursing Care Of The Emergency Patient Flashcards
Triage
- “To sort”
- Process of rapidly determine patient acuity.
- Represents a critical assessment skill.
Triage System
Categorizes patients so most critical are treated first
Emergency Severity Index
…
Five-Levels ESI are based on
- Stability of vital functions (ABCs)
- Life threat or organ threat
- How soon patient should be seen by HCP
- Expected resource intensity (do they need people with them until they’re stable)
Examples are on Slide 9
ESI-1
- Most critical patient*
1. Stability of Vital Functions = Unstable
2. Life threat or organ threat = Obvious
3. How soon patient should be seen by HCP = Within 10 minutes
4. Expected resource intensity = High resource intensity; multiple, often complex diagnostic studies; frequent consultation; continuous monitoring
ESI-2
- High risk patient*
1. Stability of vital functions = Threatened (abnormal)
2. Life threat or organ threat = Likely by not always obvious
3. How soon patient should be seen by HCP = Up to 1 hour
4. Expected resource intensity - Medium to high resource intensity; multiple diagnostics studies; complex procedure
ESI-3
- Stability of Vital Functions = Stable (normal)
- Life threat or organ threat = Unlikely but possible
- How soon should be seen by HCP = Could be delayed
- Expected resource intensity = Low resource intensity; one simple diagnostic study
ESI-4
- Stability of vital functions = Stable
- Life threat or organ threat = No
- How soon should be seen by HCP = Could be delayed
- Expected resource intensity = Low resource intensity; examination only
ESI-5
- Stability of vital functions = Stable
- Life threat or organ threat = No
- How soon patient should be seen by HCP = Could be delayed
- Expected resource intensity = Low resource intensity; examination only
Emergency Nursing: After initial focused assessment to determine actual or potential threats to life, proceed with more detailed assessment including
- Systematic approach decreases the time needed to identify potential threats to life.
- Trauma patients: primary survey and secondary survey
- Nontrauma patients: primary survey and focused assessment
Emergency Nursing: ABCDEFGH
- Alertness and airway
- Breathing
- Circulation
- Disability
- Exposure and environmental control
- Facilitate adjuncts and family
- Get resuscitation adjuncts
- History and head-to-to assessment
Emergency Nursing: Primary Survey focuses on
- ABC’s
- Diability, exposure, facilitation of adjuncts and family, and other resuscitation aids
Emergency Nursing: If uncontrolled external hemorrhage is noted during a primary survey, what should be done?
- The usual ABC assessment format may be reprioritized to ABC for hemorrhage control. ( stands for catastrophic hemorrhage which needs to be controlled first)
- Apply direct pressure with sterile dressing followed by a pressure dressing to any obvious bleeding sites.
Emergency Nursing: If life-threatening conditions related to ABC’s are identified during primary survey, what should be done?
Interventions are started immediately and before proceeding to the next step of survey
Emergency Nursing: Alertness and airway
-Determine LOC
-Assess patient response to verbal and/or painful stimuli
(AVPU: A = alert, V = responsive to voice, P = responsive to pain, U = unresponsive)
Primary Survey: Airway Obstruction
- Cause of nearly all immediate trauma deaths
- Saliva, blood secretions, vomitus, laryngeal trauma, dentures, facial trauma, fractures and the tongue can obstruct the airway.
Patients at risk for airway compromise include
- Seizures
- Drowned
- Anaphylaxis
- Foreign body obstruction
- Cardiopulmonary arrest
Primary Survey: Signs and symptoms of a compromise airway
- Dyspnea
- Inability to speak
- Gasping (agonal) breaths
- Foreign body in airway
- Trauma to fake or neck
Treatment for a Compromised Airway
- Open airway using jaw-thrust maneuver (avoid hyperextending the neck)
- Suction and/or remove foreign body
- Insert nasopharyngeal or oropharyngeal airway (in unconscious patients only)
- Endotracheal intubation (ventilate patients with 100% O2 using a bag-valve mask before intubation)
If intubation is impossible because of airway obstruction, what can be done?
An emergency cricothyroidotomy or tracheotomy is performed (patient needs to be ventilated with 100% O2 using a bag-valve-mask device prior to cricothyroidotomy)
Rapid-sequence intubation
- Preferred procedure for securing an unprotected airway
- Involves sedation or anesthesia paralysis (these drugs aid intubation and reduce the risk of aspiration and airway trauma)
Primary Survey: You should suspect cervical spine trauma in any patient with
- Face, head or neck trauma
- Significant upper chest injuries
For patients with suspected cervical spine trauma, you must
- Stabilize cervical spine using a cervical collar and cervical immobilization device.
- Secure the patients forehead to the backboard.
Treatment for patients with trouble breathing include
- Administering high-flow O2 via a nonrebreather mask
- For life threatening conditions (i.e flail chest, tension pneumothorax):
- Bag-valve mask ventilation with 100% O2
- Needle decompression
- Intubation
- Treatment of underlying cause
Primary Survey: Circulation
- Check central pulse (because peripheral pulse may be absent d/t injury or vasoconstriction): assess quality and rate
- Assess skin: color, temperature, moisture
- Assess for signs of shock: mental status, delay capillary refill (longer than 3 seconds is a common sign of shock however cold temperature can delay refill)
Primary Survey: What to do if circulation is compromised?
- Insert 2 large-bore IV catheters
- Initiate aggressive fluid resuscitation using normal saline or lactated ringer’s solution.
-Give packed RBC’s if needed (in emergency situation, give uncrossmatched blood if immediate transfusion is warranted)
Primary Survey: Disability (Neurologic Examination)
- Measured by patient’s level of consciousness
- Glasgow Coma Scale
- Pupils: size, shape, equality, reactivity
Primary Survey: Exposure and environmental control. What should the nurse do for these patients?
- Remove clothing to perform physical assessment
- Do not remove impale objects
- Prevent heat loss
- Maintain privacy
Secondary Survey includes
- Facilitates adjuncts and family
- Complete set of vital signs
Primary Survey: Family Presence
- Beneficial for patients, caregivers and staff
- Provides comfort, advocate, remind staff of the person behinds the trauma
- Serve as staff helpers
- Remember to explain care and answer questions
Primary Survey: Getting Resuscitation adjuncts - LMNOP
- Laboratory studies
- Monitor ECG
- Nasogastric tube or orogastric tube (to decompress and empty the stomach, reduce the risk of aspiration and test contents for blood)
- Oxygenation and ventilation assessment
- Pain management
Primary Survey: Pain Management
- Primary complaint of most patients
- Combination of strategies: Pharmacologic or Nonpharmacologic
- General comfort measures: verbal reassurance, listening, reducing stimuli, developing trust
Secondary Survey is a
Brief systematic process to identify all injuries.
Secondary Survey: History and Head-to-Toe Assessment
- Obtain history and mechanism of injury, or illness from patient, caregivers, friends, bystanders, and emergency personnel
- Provides suggestions for specific assessment and intervention
Secondary Survey: SAMPLE
- Symptoms
- Allergies
- Medication History
- Past health history
- Last meal/oral intake
- Events or environmental factors leading to illness or injury
Secondary Survey: Head, neck and face
- General appearance, skin color and temperature
- Disconjugate gaze (indicates neurologic damage)
- Battle’s signs
- Raccoon eyes
- Assess ears for blood and CSF
- Airway
- Neck: assess for bruising, edema, bleeding, distended neck veins. Midline trachea?
Battle’s Sign
Bruising directly behind the ears that may indicate a fracture of the base of the posterior portion of the skull.
Raccoon eyes or periorobital ecchymosis
Usually an indication of a fracture of the base of the frontal portion of the skull
Secondary Survey: Assessment of the Chest
- Assess for paradoxic chest movements
- Assess for large sucking chest wounds
- Palpation of the sternum, clavicles and ribs for deformity, tenderness and crepitus.
- Ausculation: breath and heart sounds
- Assess for pneumothorax, open pneumothorax, rib fractures, pulmonary contusion, blunt cardiac injury, hemothorax (Chest x-ray, ECG)
Secondary Survey: Assessment of the abdomen and flanks
- Frequent evaluation for subtle changes is essential (blunt trauma, penetrating trauma, inspections/auscultation (bowel sounds)/percussion/palpation)
- FAST for intraabdominal hemorrhage
Secondary Survey: Assessment of the Pelvis and Perineum
- Gently palpate pelvis (do not rock the pelvis) to determine stability: pain may indicate pelvic fracture/x-ray
- Inspect genitalia: quality of or inability to void
- Rectal exam may be performed by HCP
Secondary Survey: Assessment of the extremities
- Assess for point tenderness, crepitus and deformities (Treat with RICE)
- A pulseless extremity is a time-critical emergency (should be realigned by the HCP and splinted)
- Compartment Syndrome
Secondary Survey: How to inspect the posterior surfaces
- Log roll patient (while maintaining cervical spine immobilization) to inspect the posterior surfaces
- Requires 3-4+ people
- Support head and assess for echymosis, abrasions, puncture wounds, cuts and obvious deformities.
- Palpate entire spine for misalignment, deformity and pain.
Acute Care and Evaluation
- Evaluate need for tetanus prophylaxis
- Provide ongoing monitoring
- Evaluate patient’s response to interventions
- Insert an indwelling catheter as indicated.
Depending on the patient’s injuries or illness, the patient may
- Be transported for diagnostic tests or to OR for surgery
- Admit to general unit, telemetry or ICU
- Transfer to another facility
Death in the Emergency Department: Prepare for the times when sudden death occurs
- Anticipate your own reactions/feelings
- Help caregivers grieve (collecting personal belongings, viewing the body, making mortuary arrangements, ensure privacy, offer chaplain visit)
Death in the Emergency Department: Autopsies may be arranged based
- Upon family request
- In case of death within 24 hours of ED admission
- When suspected trauma or violence has occurred
Considering Organ Donation
1. Organ procurement organizations (OPOs) assist in Screening potential donors Counseling donor families Obtaining informed consent Harvesting organs 2. Can be distressing 3. May be 1st positive step in grieving
Poisonings
- Chemicals that harm body accidentally, occupationally, recreationally or intentionally.
- Severity depends on type, concentrations and route of exposure.
- Toxins can affect every tissue of the body: symptoms can be seen anywhere
Poison Management
- Decrease absorption
- Enhance elimination
- Implement toxin-specific interventions per poison control center
Poisoning Management: Decreasing Absorption
Gastric Lavage which is performed within one hour of ingestion of moist poisons
What happens during a gastric lavage?
- Intubated before lavage if altered LOC or diminished gag reflex
- Involves oral insertion of a large-diabetes (36F-42F) gastric tube for irrigation of copious amounts of saline.
Gastric Lavage is contraindicated with
- Caustic agents
- Coingested sharp objects
- Ingested nontoxic substances
Problems associated with gastric lavage include
- Esophageal perforation
- Aspiration
Activated Charcoal
- Most effective intervention for management of poisonings.
- Toxins adhere to charcoal and pass through the GI tract rather than being absorbed into circulation.
- Administered orally or via gastric tube within 1 hour of poison ingestion.
What are contraindications of activated charcoal?
- Diminished bowel sounds
- Paralytic ileus
- Ingestion of substance poorly absorbed by charcoal
Activated charcoal can absorb and neutralize antidotes, therefore
Do not give immediately before, with, or shortly after charcoal.
Poisonings: Dermal cleansing/eye irrigation
- Removal of toxins from skin and eyes using copious amounts of water or saline.
- Most toxins, with the exception of mustard gas, can be safely removed with water and saline (this is because water mixes with mustard gas and releases chlorine gas)
- Brush dry substances front he skin and clothing before using water. (Do not remove powdered lime with water, should be brushed off)
During dermal cleansing/eye irrigation,
- Wear PPE
- Decontamination takes priority over all interventions except BLS measures
Poisoning Management: Enhance Elimination
- Cathartics (sorbitol)
- Whole bowel irrigation *high risk of electrolyte imbalance
Cathartics
Give with first dose of charcoal to stimulate intestinal motility/increase elimination
Poisoning Management: Hemodialysis/hemoperfusion
- Reserved for severe acidosis
-Urine alkalinization (Phenobarbital and salicylate poisoning) - Chelating agents (↑ Amphetamine and quinidine excretion)
- Antidotes (Very few available)
*check notes
Slide 53??
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Terrorism
- Involves overt actions for expressed purpose of cause harm.
- Includes Biologic agents, Chemical agents, Radiologic/nuclear, explosive devices
Bioterrorism
- Includes Anthrax, plague, and tularemia (Treated with antibiotics assuming sufficient supplies and nonresistant organisms)
- Smallpox can be prevented or ameliorated by vaccination even when given after exposure
- Botulism
*read notes
How is botulism treated?
Antitoxin
Chemical Agents of Terrorism
- Categorized by target organ or effect.
- Examples: sarin, phosgene, mustard gas
Chemical Agents of Terrorism: Sarin
- Toxic nerve gas that can cause death within minutes of exposure
- Enters body through eyes and skin
- Acts by paralyzing respiratory muscles
Antidotes for nerve agents include
- Atropine
- Pralidoxime chloride
Chemical Agents of Terrorism: Phosgene
- Colorless gas normally used in chemical manufacturing
- If inhaled at high concentrations for long enough period, causes severe respiratory distress, pulmonary edema, and death
Chemical Agents of Terrorism: Mustard Gas
- Yellow to brown in color with garlic-like odor
- Irritates eyes and causes skin burns/blisters
Radiologic/Nuclear Agents of Terrorism “Dirty Bombs”
- Mix of explosives and radioactive material
- When detonated, blast scatters radioactive dust, smoke, and other material into environment, resulting in radioactive contamination
- Main danger from RRDs: explosion
Radiologic/Nuclear Agents of Terrorism: Ionizing radiation
- (e.g., nuclear bomb, damage to a nuclear reactor)
- Serious threat to safety of victims and environment
- Exposure may or may not include skin contamination with radioactive material
Acute Radiation Syndrome develops after
a substantial exposure to ionizing radiation and follows a predictable pattern.
Explosive Devices as Agents of Terrorism: Results in one or more of the following types of injuries
- Blast, crush, or penetrating
- Blast injuries from supersonic overpressurization shock wave that results from explosion (Damage to lungs, middle ear, gastrointestinal tract)
Emergency
Any extraordinary event that requires a rapid and skilled response and can be managed by a community’s existing resources
Mass Casualty Incident
Manmade or natural event or disaster that overwhelms community’s ability to respond with existing resources
Emergency And Mass Casualty Incident Preparedness
- When an emergency or MCI occurs, first responders (e.g., police, emergency medical personnel) are dispatched
- Triage of casualties differs from usual ED triage and is conducted in <15 seconds
Emergency and Mass Casualty Incident Preparedness: System
-Colored tags designates both seriousness of injury and likelihood of survival
MCI colored tags: Green
Minor injury
MCI colored tags: Yellow
Non-life-threatening injury
MCI colored tags: Red
Life-threatening injury
MCI colored tags: Blue
Those who are expected to die
MCI colored tags: Black
Identifies the dead
Total number of casualties a hospital can expect is estimated by doing what
Doubling the number of casualties that arrive in the first hour.
CERT’s
are partners in emergency preparedness, and training helps citizens to understand their personal responsibility in preparing for natural/manmade disaster
Role of all HCP’s in emergency and MCI preparedness
- Knowledge of the hospital’s emergency response plan
- Participation in emergency/MCI preparedness drills is required
National Incident Managemetn System
Section within the U.S. Department of Homeland Security that is responsible for the coordination of the federal medical response to MCIs
DMATs: disaster medical assistance teams
- Categorized according to ability to respond to an MCI
- Have a critical incident stress management unit.
Critical Incident Stress Management Unit
- Unit arranges group discussions to allow participants to share and validate their feelings and emotions about the experience.
- This is important for emotional recovery.
