Module 15: Emergency Nursing

Question 1

CTAS SCORE

Answer 1

level 1 - resuscitation; see pt immediately
level 2 - emergency; see pt within 15 mins
level 3 - urgency; see pt within 30 mins
level 4 - less urgency; see within 60 mins
level 5- non urgency; see within 120 mins

Question 2

Code 66

Answer 2

• one or more criteria
  
  • airway threatened
  • breathing - RR < 8 or > 30, acutely decreased SpO2 <90 % on 5l/min O2
  • circulation - HR < 4, SBP <90 or >200 mmHg or acute decrease
  • neurological- sudden decrease in LOC, prolonged or repeated seizures
  • other - urine output decreased acutely, < 50ml/4 hrs

Question 3

Code Blue

Answer 3

• cardiac and respiratory arrest
• known the location of the crash cart at your facility
• primary nurse should stay in the room to provide information to the code team
• prior to code team arriving
  
  • bring the patient’s chart/work station on wheels to the bedside
  • clear the hallway, direct the code team to the room
  • close curtains, move other patients out of the room if possible
  • ensure suction and oxygen is set up and functioning
  • stay with patient and continue to provide care

Question 4

Define the practical nurse’s role in an emergency setting

Answer 4

• assessing pt and determining acuity
  
  • complete a quick check to patients condition and take immediate action if required
• need to do infection control screening
• communication with all health care professionals patients and family
• determines treatment location
• initiating protocols/ first aid treatments
• monitoring and reassessing
• documenting

Question 5

Primary Survey - Assessments

Answer 5

• Airway
• Breathing
• Circulation
• Disability
• Exposure
  
  • expose and heck entire body
  • protect primary and keep warmth
• full set of vital signs

Question 6

Secondary Survey

Answer 6

• Thorough head to toe assessment

- History using sample

Question 7

Nursing assessment

Answer 7

• patient is brought in alone for initial assessment
• all patients are asked about domestic abuse/violence and personal safety
• start with focused assessment related to patient’s diagnosis or cause of emergency
• with each system add more detail if abnormal findings
• an IV or blood work may be initiated depending on patient condition
  
  • follow facility protocols

Question 8

Documentation & reporting

Answer 8

• concise focused charting
• vital signs - most recent and trends
• medications - name of medication administered, time of admin and effect
• lab and diagnostic imaging tests / consults/ treatments
• what has been completed? what is pending? results?