Week 6 - Start Exam 2 - ER Flashcards
Emergency management traditionally refers to urgent and critical needs, but …
the emergency dept (ED) has increasingly been used for non urgent problems and emergency management has broadened to include the concept that an emergency is WHATEVER THE PT OR FAMILY CONSIDERS IT TO BE
It is important that the ED staff works…
as a team
What is one of the few places where a co-pay is not needed first and you cannot be turned away for care
the emergency room
Emergency Care
the care of all encompassing injuries and sudden illnesses
Trauma Nursing
this can be described as a continuum of nursing care from resuscitation through to rehabilitation
Trauma typically is a ___ problem
surgical (so overall trauma is referring to surgical needs and specialties)
What are 5 important issues in emergency nursing?
- Legal Issues - Antidumping laws/EMTALA
- Occupational health and safety risks for ED staff
- Challenge of providing holistic care in context of fast paced, technology driven environment
- Treat patients exposure to biologic and other weapons
- Mass casualty incidents from natural causes or terrorist events
EMTALA/Anti Dumping Law
Federal Law in 1980s
Dictates that anyone who comes through the door wanting a medical screening has to get one - hospitals taking from CMS required to provide a medical screening exam, stabilization, and transport by a provider
___ is the first priority in the ED
safety
What are some sentinel events in the ED
delay in care
medication error
What greatly influences incidence of sentinel events in the ED
patient volume
What should be done for interventions that are patient and family focused in the ED
actions to relieve anxiety and provide a sense of security
allow family to stay with the patient if possible to alleviate anxiety
provide explanations and information
additional interventions are provided depending on stage of crisis
(All of these make a safe and confident environment)
TRIAGE
sorting patients by hierarchy based on the severity of health problems and the immediacy with which these problems must be treated
Triage means “To sort” in french
What things does the triage nurse do
collects patient data and classifies the illnesses and injuries to ensure that the patient most in need of care does no needlessly wait
How does ED triage differ from Disaster Triage
Patients that are most critically ill receive the most resources, REGARDLESS of potential outcome
IN a disaster the focus is saving as many people as possible
TRIAGE is a ___ not a __
process not a place - patient priorities and conditions change so constantly be traiging
In the Basic Triage System what are the 3 categories
- Emergent - highest priority
- Urgent - serious health problems but not life threatening
- Nonurgent - episodic illness
ESI
Emergency Severity Index
Assigns patients to one of 5 levels
Depends on condition of patient and allocation of resources
How does ESI level 1 compare to level 5
As you head toward one it is more urgent with 5 being least urgent
What ESI level is someone requiring immediate life saving intervention
level 1
What ESI level is someone not needing immediate life saving intervention but is in a high risk situation, confused/lethargic/disoriented, or in severe pain/distress?
Level 2
If someone is not level 2 ESI but requires many resources, one resource, or no resources - what level are they?
5 - no resources needed
4 - one resource needed
3 - many resources needed and stable vitals
What ESI level is someone if they need many resources but have danger zone vitals?
level 2 (not 3)
Often waiting rooms are sites where feelings of what kind occur?
feelings of dissatisfaction, fear, and anger are channeled violently
Clinicians caring for patients in the ED should act how?
Confidently and competently to relieve anxiety and promote a sense of security
ED Nurse should provide comfort, action, advice, and project a calm comfort - Be an expert to the patient - but do not be dishonest
What 2 things are done immediately for every new ED patient
A primary and secondary Survey
What is included in the Primary Survey
ABCDE
A- Airway
B - Breathing
C - Circulation
D - Disability (neuro status, AVPU mnemonic)
E - Exposure (undress and assess wounds or injury)
What does AVPU mnemonic stand for and mean
Alert, Verbal, Pain, Unresponsive
Done in D of the primary survey of triaging ED patients
“Deneuro”
What is included in the secondary survey
FGHI
F - Full set of VS, Family
G - Get adjunctive testing like diagnostics and labs, ECG, arterial lines, urinary catheters
H - Head to toe assessment: reassess airway, breathing, VS
I - Inspect POSTERIOR SURFACE
What are the priority emergency conditions where measures should be taken immediately
- Airway obstruction and establishing an airway and ventilation - anoxic brain injury only takes 3 minutes
- Hemorrhage
- Hypovolemic Shock (stop bleeding)
- Wounds
- Trauma and multiple trauma
What are some ways ED reestablishes airway and ventilation
Oropharyngeal or Nasopharyngeal Airway Insertion
ENDOTRACHEAL INTUBATION (definitive airway in ED)
King tube or laryngeal mask (more so on ambulance)
Cricothyroidotomy
Ventilation
Cricothyroidotomy
Opens airways below the upper airway
If someone has no airway or breathing what is the serious procedure to be done to help
Laryngoscope and Endotracheal intubation
What important aspects of the ET tube are there to note
- A suggested vocal cord marker
- Internal diameter in mm marked on the tube
- Depth markers in cm to indicate position at the level of the teeth to monitor and document slipping
Hemorrhage may present how on reassessment
changes in VS or LOC
What is the key to ED hemorrhage treatment
Fluid replacement (give isotonic solutions somewhat and then blood products as to not change the pH too much)
Trauma is housed in surgery - how does this apply to bleeding
internal bleeding requires surgery to fix
The goal of treating hemorrhage is
prevent improper volume and prevent hemorrhagic shock - cardiac events happen quick from hypovolemia so we want fluid and blood resuscitation
Belmont/Level 1 Mass Transfusion Device
a device that can put liters of fluid and blood into the body in moments
Pressure points for hemorrhage control on the body
Temporal
Facial
Carotid
Subclavian (near clavicle)
Brachial
Radial and Ulnar
Femoral
SAVE-A-LIFE
trauma program
provides education to the public on how to use tourniquets and apply pressure to bleeding
made in response to increases in mass shootings
Steps of “Save A Life” - What everyone should know to stop bleeding after an injury
- Ensure your own safety
- Look for life threatening bleeding
- Ask if Trauma kit is available
A. if no trauma kit –> use any clean cloth –> steady direct pressure directly on the wound
B. If there is a trauma kit –> ask where the wound is
B1: If the wound is arm of leg –> Ask if there is a tourniquet –> if not follow B2, but if there is apply above the bleeding site and tighten until bleeding stops
B2: if the wound is neck shoulder groin –> pack the wound with bleeding control (hemostatic) gauze (preferred), any gauze, or clean cloth) –> apply steady direct pressure
What sort of wound treatment is done in the ED
- ED wounds can be life threatening or not - but a lot of animal bites and lacerations are seen*
1. Cleaning
2. Primary Closure
3. Delayed Primary Closure (For Animal Bites)
4 Tetanus Prophylaxis (Shot)
Level 1 Trauma Center
comprehensive regional resource that is a tertiary care facil,ity central to the trauma system
capable of providing total care for every aspect of injury - from prevention through rehabilitation
research and residency also done here
Level 2 Trauma Center
able to initiate definitive care for ALL injured patients
needs a 24 hour OR available to be level 2
ex: Wilson Hospital, UHS
Level 3 Trauma Center
demonstrated an ability to provide prompt assessment, resuscitation, surgery, intensive care and stabilization of injured patients and emergency operations
ex: Lourdes Hospital
Level 4 Trauma Center
demonstrated an ability to provide advanced trauma life support (ATLS) prior to transfer of patients to a higher level trauma center
provides evaluation, stabilization, and diagnostic capabilities for injured patients
Level 5 Trauma Center
provide initial evaluation, stabilization, and diagnostic capabilities and prepares patients for transfer to higher levels of care
When dealing with a trauma assessment, how does this differ from normal ED triaging?
C-ABCDE
Circulation is now first OVER respiratory - we need to control hemorrhaging before anything else then move back into ABCDE
We stop any external hemorrhaging first - tourniquets, pressure, etc
What also should be considered with C-ABCDE of trauma assessment
- Does Pt needs a C Collar for surgical spine?
- GCS - Glascow Coma Scale - <8?
- Intervene during assessment as needed
What is the rule for intubation and glascow coma scales
If less than 8, intubate
Trauma Assessment needs to look at what?
1. Nature of the Emergency AND Chief Complaint bringing them to the ED - MVC, GSW, fall, burn, etc
What is the c/c
What caused the injury
Any treatments already initiated - From Pt or EMS?, did it help?
Is unlawful activity suspected?
What is reportable to law enforcement?
What are two other important aspects for treating trauma beside assessment and interventions?
- Collection of Forensic Evidence
2. Injury Prevention
Tips for Forensic Evidence Collection with Trauma Nursing
If a gunshot wound, maintain area around gunshot wound on clothes to maintain evidence
Put bullets and objects in a PAPER BAG, not plastic to not compromise the evidence
What ways should injury prevention be done (primary prevention) with trauma nursing
- Education
- Legislation
- Automatic Protections (ex: Airbags)
Automatic Protections
things existing in everyday life that we use to prevent trauma that does not rely on people and patients actually changing their behavior
Poison
Any substance that when ingested, inhaled, absorbed, applied to the skin, or produced within the body in relatively small amounts injures the body by its chemical action
Poisoning can include exposure, intentional, accidental, ingestion, overdose, or even ROH intoxication
Treatment goals for poisoning
remove or inactivate the poison before it is absorbed
provide supportive care in maintaining vital organs systems (if removal or inactivation not possible)
administer specific antidotes
implement treatment to hasten the elimination of the poison
Assessments for management of patients with ingested poisons
ABCs
monitor VS, LOC, ECG, UO (kidney fxn)
lab specimens
determine what when and how much substance was ingested
s/s of poisoning and tissue damage
health hx
age and weight
Why is weight so important to know with poisoning
Weight determines amount of medicine and antidotes used
What is the number 1 measure to remove the toxin/poison or decrease absorption
Activated Charcoal
Measures to remove a toxin/poison or decrease absorption
use of emetics (can cause aspiration risk and sepsis)
gastric lavage (stomach pumping - dangerous)
activated charcoal
cathartic when appropriate
administration of a specific antagonist as early as possible
other measures may include diuresis, dialysis or hemoperfusion
Why is it so important not to induce vomiting with poisoning occurrence
risk for aspiration and sepsis
if its corrosive agents like acids or alkalines there is destruction of tissue by contact so vomiting can make that worse
With drug overdose, clinical manifestations…
vary with the substances overdosed on
Overdose is a type of __ and __
ingestion and poisoning
Treatment Goals for Drug Overdose
support resp and cardiovascular fxn
enhance clearance of the agent
provide safety of patient and staff
IV drug users are at a high risk of what things
HIV
Hep B and C
tetanus
Alcohol si a ___ toxin
multisystem / neurotoxin
Management of Acute Alcohol Intoxication / Substance Abuse
Alcohol poisoning can cause death*
Maintain airway and observe for CNS depression and hypotension
Rule out other potential cause of the behaviors before it is assumed the patient is intoxicated
use a nonjudgmental and calm manner
may need sedation if noisy or belligerent
examine for withdrawal delirium, injuries, and evidence of other disorders
What is at a higher propensity with chronic drinking problems
Higher likelihood of falling normally - and due to having a smaller brain and more friable brain vasculature they risk bleeding and head injury
It is important to also try and find information on what two things with patients with substance abuse
- Occult Disorders and Injuries
2. Nutritional imbalances
Management Goals of Patients that are victims of sexual assault
provide support
reduce emotional trauma
gather available evidence for possible legal proceedings
What is needed in order to examine a sexual assault victim
SANE Certified / SART teams - training on examining sexual assault cases
What sort of interventions may be done for a patient that is a victim of sexual assault
physical examination
specimen collection
treating any potential consequences/issues - STIs, pregnancy
encouraging follow up care - work with victim advocates
Common Behaviors/Aspects of Victims of Human Trafficking in ED
Cowering
Frightened
Agitated
Deferring to the person accompanying them
May present to ED with injury and accompanied by boyfriend or travel partner
Hx of chronic runaway, homelessness, self mutilation
What are some common complaints from victims of human trafficking in the ED
injuries
poor healing
abdominal pain
dizziness
headaches
rashes or sores
What behaviors may victims of human trafficking demonstrate
addiction
panic attacks
impulse control
hostility
suicidal ideations
The nursing role and interventions for victims of human trafficking
- Offer opportunities for the patient to speak alone without the companion (ex: Speak to them while asking for urine sample)
- Use targeted appropriate questions: are you in control of your money? are you able to come and go as you please? who is the person(s) accompanying you?
- ID any potential issue here and offer help or resources - they may want to decline assistance (ex: The National Human Trafficking Hotline)
NYS Mental Health Law
Law that determines in what situations a referral and transportation can be made to get care from the ER - ex: intoxication, psych care, inebriated
9.41 NYSMHL
New York Mental Hygiene Law determines that police officers can bring someone to the ER
ex: if you think someone is going to commit suicide
9.45 NYSMHL
Indicates that a Psychologist, Psychiatrist, Community Director, or Social Workers can indicate a patient being brought to the ER if intoxicated, needs psych care, or is inebriated
9.57 NYSMHL
indicates a Physician can have a patient brought to the ER
NYSMHL 22.09
Emergency services for persons intoxicated, impaired, or incapacitated by alcohol and/or substances leading to them being unable to care for themselves are brought to ER until cleared
Overactive Patients
Patients with violent behavior, underactive behavior, depressed patients, and suicidal patients
Management of Overactive Patients
Maintain safety of all persons and gain control of the situation
Determine if the patient at risk for harming self or others
Maintain persons self esteem while providing care
Determine if the person has a psychiatric history or is currently under care to contact that therapist
Crisis intervention specific to each condition - least restrictive measures sued first
What is a common problem in the ER where up to 50% of healthcare professionals will experience it in their career?
Agitation and Violence
___ to ___% Psych ED Patients are armed
4-8%
In large urban EDs ___ weapons/day are confiscated and greater than ___% of major trauma patients are armed with lethal weapons
5.4 weapons/day; 26%
What is important to do as an ER Nurse to ensure careful interactions
- REMEMBER PERSONAL SAFETY
Keep your distance
Be non confrontational
Listen
Dont make false promises
Set boundaries with patient choice if possible
What are the patients expectations
Safe Room with safe exit
Security and help nearby
Ask for help if needed
Safe rooms with no ligament risks for suicidal Patients
3 Important ways to prevent violence in the ED
- Non violence crisis intervention training (primary tool)
- Emphasizing prevention among staff
- Safe staffing patterns
What is a non violence crisis intervention training program
program to train employees how to recognize cues of escalating behavior and stop aggressive acts before they start
When emphasizing prevention of violence among staff, they should think…
about personal safety and alert security when something seems suspicious
What are some safe staffing patterns
appropriate number of staff for the time of day
appropriate use of 1:1 observation/sitter
Ways to provide holistic care in the emergency setting
KEEPING PATIENT EXPERIENCE IN MIND:
Distraction and Guided imagery
Deep Breathing Techniques
Ambient or dimly lit rooms
Music
Nutrition education / NPO measures
Ambulation techniques and education
Social work consults
Family presence if available- advocates and helps a lot
Issues impacting self concept in the ED
Fear - of health, interventions, pain
Embarrassment
Lack of knowledge - on services available and how to access
No where else to go
Lacking support system
Caregiver role strain
The ER sees a lot of what
the large spectrum of society - heavy for the nurse
___ is sometimes the only place a person cannot be turned away
ED
Important Aspects of Discharge Teaching for ED Patients
Follow up with primary care
Understanding of current condition present
Caregiver understanding
Any resources needed and referred
Non pharmacological methods for Symptom release
Telling people what to watch for and when to come back
Tips for Being a Successful ED Nurse
- Learn everything you can - be hands on
- TEAM work
- Ask questions - even to other types of HCW
- Prioritize patients - not just who is easiest to care for but who has poorest potential outcomes
- Time management is key - be efficient and fast
- Keep it together, rely on others, stay organized
