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Emergency Nursing

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Patients with life-threatening or potentially life-threatening problems enter the hospital through the emergency department (ED)

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Emergency Nursing care

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is guided by the ABCDE Principal

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Triage

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Process of rapidly determining patient acuity Represents a critical assessment skill

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Triage system

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Categorizes patients so most critical are treated first

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Primary survey

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Focuses on airway, breathing, circulation, and disability, exposure (ABCDE) Identifies life-threatening conditions

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If life-threatening conditions related to ABCD are identified during primary survey, interventions are started immediately and before proceeding to the next step of the survey

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Primary survey

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Signs/symptoms in patient with compromised airway

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- Dyspnea - Inability to vocalize - Presence of foreign - body in airway - Trauma to face or neck

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Airway with cervical

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spine stabilization and/or immobilization

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If suspect airway obstruction

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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

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Rapid-sequence intubation

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- Preferred procedure for unprotected airway - Involves sedation or anesthesia and paralysis

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When to Stabilize/immobilize cervical spine

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Face, head, or neck trauma and/or significant upper torso injuries

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Assess for dyspnea,

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cyanosis paradoxic/asymmetric chest wall movement, decreased/absent breath sounds, tachycardia, hypotension

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Breathing

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1. Administer high-flow O2 via a nonrebreather mask 2. Bag-valve-mask (BVM) ventilation with 100% O2 and intubation for life-threatening conditions 3. Monitor patient response

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Circulation

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Check central pulse (peripheral pulses may be absent because of injury or vasoconstriction)

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Circulation

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1. Insert two large-bore IV catheters 2. Initiate aggressive fluid resuscitation using normal saline or lactated Ringer's solution

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Disability

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Measured by patient's level of consciousness

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Measure level of consciousness

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AVPU A = alert V = responsive to voice P = responsive to pain U = unresponsive Glasgow Coma Scale Pupils

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Exposure/environmental control

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1. Remove clothing to perform physical assessment 2. Prevent heat loss

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Is a rapid assessment of life threatening conditions SHould not take longer than 60 seconds.

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Primary Survey

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Secondary Survey

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Brief, systematic process to identify all injuries

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Secondary Survey

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Full set of vital signs/five interventions/facilitate family presence Complete set of vital signs Blood pressure (bilateral) Heart rate Respiratory rate Oxygen saturation Temperature

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Secondary Survey History and head-to-toe assessment

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Obtain history of event, illness, injury from patient, family, and emergency personnel Perform head-to-toe assessment to obtain information about all other body systems

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Inspect the posterior surfaces

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Logroll patient (while maintaining cervical spine immobilization) to inspect the posterior surfaces

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...

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Evaluate need for tetanus prophylaxis Provide ongoing monitoring and evaluate patient's response to interventions

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Secondary Survey Prepare to:

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Transport for diagnostic tests (e.g., x-ray) Admit to general unit, telemetry, or intensive care unit Transfer to another facility Case Study 32-year-old man arrives in ED via paramedics. A neighbor found him lying on the rocks in the rock garden. He had fallen off the roof while fixing the shingles on his house.

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Death in the Emergency Department

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Must recognize importance of hospital rituals in preparing the bereaved to grieve (e.g., collecting belongings, viewing the body)

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Death in the Emergency Department Determine if patient could be candidate

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for non-heart beating donation

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Tissues and organs (e.g., corneas, heart valves, skin, bone, kidneys)

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can be harvested from patients after death

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Gerontologic ConsiderationsEmergency Care

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Older adults are at high risk for injury—primarily from falls Causes Generalized weakness Environmental hazards Orthostatic hypotension

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Important to determine

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whether physical findings may have caused fall or may be due to fall

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Heat Exhaustion is

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Prolonged exposure to heat over hours or days Leads to heat exhaustion

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Heat Exhaustion Clinical syndrome characterized by

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Fatigue Light-headedness Nausea/vomiting Diarrhea Feelings of impending doom Tachypnea

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Clinical syndrome of heat exhausted is characterized by

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Tachycardia Dilated pupils Mild confusion Ashen color Profuse diaphoresis Hypotension and mild to severe temperature elevation (99.6º to 104º F [37.5º to 40º C]) due to dehydration

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Interventions for heat exhaustion

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1. Place patient in cool area and remove constrictive clothing 2. Place moist sheet over patient to decrease core temperature 3. Provide oral fluid 4. Replace electrolytes 5. Initiate normal saline IV solution if oral solutions are not tolerated

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Cause of heat stroke

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1. Failure of the hypothalamic thermoregulatory processes 2. Vasodilation, increased sweating and respiratory rate deplete fluids and electrolytes, specifically sodium 3. Sweat glands stop functioning and core temperature increases (>104º F [40º C]

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Treatment for heat stroke

answer

stabilize patient's ABCs and rapidly reduce temperature

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Cooling methods

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1. Remove clothing 2. Cover with wet sheets 3. Place patient in front of large fan 4. Immerse in ice water bath 5. Administer cool fluids or lavage with cool fluids

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For Heat stroke avoid the patient from

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1. Shivering: increases core temperature, complicates cooling efforts, treated with IV chlorpromazine 2. Aggressive temperature reduction until core temperature reaches 102º F (38.9º C

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Risk factors for hypothermia

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Elderly Certain drugs Alcohol Diabetes

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Hypothermia

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Core temperature <95º F (<35º C)

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Core temperature <86º F (30º C)

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is potentially life threatening

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signs of rhabdomyolysis, myoglobinuria, and disseminated intravascular coagulation

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Heat Stroke Monitor for

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Mild hypothermia (93.2º to 96.8º F [34º to 36º C])

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Shivering Lethargy Confusion Rational to irrational behavior Minor heart rate changes

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Moderate hypothermia (86º to 93.2º F [30º to 34º C])

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Rigidity Bradycardia, bradypnea Blood pressure by Doppler Metabolic and respiratory acidosis Hypovolemia

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Shivering disappears at

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temperature 86º F (30º C)

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Severe hypothermia (<86º F [30º C])

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makes the person appear dead Bradycardia Asystole Ventricular fibrillation

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Warm patient to atleast

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90º F (32.2º C) before pronouncing dead

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Hypothermia Cause of death

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refractory ventricular fibrillation

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Treatment of hypothermia

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1 Manage and maintain ABCs 2 Rewarm patient 3 Correct dehydration and acidosis 4 Treat cardiac dysrhythmias

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Passive external rewarming:

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move patient to warm, dry place; remove damp clothing; place warm blankets on patient

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Rewarming with Mild hypothermia

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passive or active external rewarming

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Active external rewarming:

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body-to-body contact, fluid- or air-filled warming blankets, radiant heat lamps

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Moderate to severe hypothermia:

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active core rewarming

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For moderate to severe hypothermia active core rewarming

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1 Use of heated, humidified oxygen 2 Warmed IV fluids 3 Peritoneal, gastric, or colonic lavage with warmed fluids

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Risks of rewarming

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1 Afterdrop, a further drop in core temperature 2 Hypotension 3 Dysrhythmias

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Rewarming should be discontinued

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once the core temperature reaches 95º F (35º C)

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Results when person becomes hypoxic due to submersion in substance, usually water

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Submersion Injury

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Submersion injuries are

answer

1. drowning 2. Immersion syndrome 3. Near drowning

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Drowning

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death from suffocation after submersion in fluid

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Immersion syndrome

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occurs with immersion in cold water, which leads to stimulation of the vagus nerve and potentially fatal dysrhythmias

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Near-drowning

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survival from potential drowning

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Aggressive resuscitation efforts

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and the mammalian diving reflex improve survival of near-drowning victims

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1 Correct hypoxia 2 Correct acid-base and fluid imbalances 3 Support basic physiologic functions 4 Rewarm if hypothermia present

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Treatment of submersion injuries

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Mechanical ventilation with PEEP or CPAP to

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improve gas exchange when pulmonary edema is present

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submersion injury initial evaluation

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ABCD

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signs of submersion injury

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1 Deterioration in neurologic status: cerebral edema, worsening hypoxia, profound acidosis 2 Observe for minimum of 4-6 hours 3 Secondary drowning is a concern with patients who are essentially symptom free

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Usually with Animal Bites

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Children at greatest risk

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Complications of animal bites

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1 Infection 2 Mechanical destruction of skin, muscle, tendons, blood vessels, bone

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Animal bites

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1. dogs and cats are most common, 2. followed by bites from wild or domestic rodents

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Dog bites

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- Usually occur on extremities - May involve significant tissue damage - Deaths are reported, usually children

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Cat bites:

answer

- are deep puncture wounds that can involve tendons and joint capsules - has Greater incidence of infection

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infection due to cat bites

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Septic arthritis Osteomyelitis Tenosynovitis

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Human bites

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- Result in puncture wounds or lacerations - High risk of infection Oral bacterial flora Hepatitis virus

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Prophylactic antibiotics for

answer

bites at risk for infection

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Bites at risk for infection

answer

1. Wounds over joints 2. Wounds less than 6-12 hours old 3. Puncture wounds Bites on hand or foot

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Initial treatment for animal/human bites:

answer

clean with copious irrigation, debridement, tetanus prophylaxis, and analgesics

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Animal and Human Bites

answer

Puncture wounds left open Lacerations loosely sutured Wounds over joints splinted

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Rabies prophylaxis essential in management of animal bites

answer

- Initial injection: rabies immune globulin - Series of five injections of human diploid cell vaccine: days 0, 3, 7, 14, and 28

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Series of five injections of human diploid cell vaccine:

answer

days 0, 3, 7, 14, and 28

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Poisonings are

answer

Chemicals that harm the body accidentally, occupationally, recreationally, or intentionally Severity depends on type, concentration, and route of exposure

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Poisonings Management

answer

1. Decrease absorption 2. Enhance elimination 3. Implement toxin-specific interventions per poison control center

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Decreasing absorption

answer

1. Gastric lavage 2. Activated charcoal 3. Dermal cleansing/eye irrigation

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Gastric lavage

answer

Intubate before lavage if altered level of consciousness or diminished gag reflex Perform lavage within 2 hours of ingestion of most poisons Contraindicated Caustic agents Coingested sharp objects Ingested nontoxic substances

question

Activated charcoal

answer

Most effective intervention: administer orally or via gastric tube within 60 minutes of poison ingestion

question

Contraindications for activated charcol

answer

Diminished bowel sounds Paralytic ileus Ingestion of substance poorly absorbed by charcoal

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Dermal cleansing/eye irrigation

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Skin and ocular decontamination: removal of toxins from skin and eyes using water or saline With the exception of mustard gas, toxins can be removed with water or saline Water mixes with mustard gas and releases chlorine gas. takes priority over all interventions except basic life support measures

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Enhance elimination Cathartics (e.g., sorbitol)

answer

Give with first dose of charcoal to stimulate intestinal motility/increase elimination Whole bowel irrigation

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Hemodialysis/hemoperfusion

answer

Reserved for severe acidosis Urine alkalinization Chelating agents Antidotes

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Decontamination

answer

takes priority over all interventions except basic life support measures

question

Left at violence section

answer

...

question

Resuscitation triage requires

answer

immediate treatment to prevent death

question

Minor triage is a

answer

non-life threatening condition requiring simple evaluation and treatment of care.

question

Emergent triage indicates

answer

a life or limb saving situation

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If the client is unresponsive without suspision of trauma

answer

the airway should be open with the head-tilt/chin-lift maneuver

question

This the most effective way to open a client's airway

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The Head-tilt/Chin-lift procedure

question

The head-tilt/chin-lift maneuver

answer

Do not perform on clients with suspected cervical spine injuries

question

When performing the head-tilt/chin-lift maneuver

answer

The nurse should assume a position at the head of the client place one hand on the forehead, place the other hand on the chin. Tilt head while lifting chin superiorly(UP) This will lift the tongue out of the laryngopharynx and provides for a patent airway.

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If client is unresponsive with suspision of trauma

answer

The airway should be opened using the modified jaw thrust maneuver

question

When performing the modified Jaw thrust maneuver

answer

The nurse should assume a position at the head of the client place both hands on either side of client's head Locate the location between the Maxilla and the Mandile Lift the jaw up, while maintaining alignment of the cervical.

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Nurses should consider

answer

cardiac arrest, myocardial infarction and hemorrhage as a precursors to shock and leading into ineffective circulation

question

Interventions geared toward restoring effective circulation

answer

CPR Assessing for external bleeding obtain IV access Infuse Iv

question

If suspected hemorrhage

answer

Apply direct pressure to visible, significant external loss Apply tourniquet distal to a traumatic amputation

question

Hemmorhage control

answer

Apply direct pressure to visible, significant external loss Apply tourniquet distal to a traumatic amputation

question

How is mechanical ventilation with positive end expiratory pressure of CPAP used in submersion injuries?

answer

Used to improve gas exchange across the aveolar-capillary membrane when significant edema is present

question

What are the primary techniques for treating respiratory failure?

answer

Ventilation and oxygen

question

What drugs treat cerebral edema or free water ?

answer

Mannitol(osmitrol) or lasix

question

What does deterioration in neurological status indicate?

answer

Either cerebral edema, worsening hypoxia, or profound acidosis

question

What should the nurse assess for near drowning victims?

answer

Head and neck injuries with profound alterations in LOC

question

What complications can occur in patient with no symptoms?

answer

Delayed death from drowing d/t pulmonary complications

question

How long will patient be observed in hospital after near drowning?

answer

A minimum if 23 hours, but there may be additonal times with clients with comorbidities like HA, HTN, CVA

question

What is the patient teaching for water safety to decrease risk of drowning?

answer

NO alcohol/drugs while using pool Lock all swimming pools Remind all to use life jackets on water crafts Learn swimming and survival skills while in water

Chapter 69 ATI Adult Medical/surgical 2 ATI fundamental 36 – Flashcards

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