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May work with patients involved with a sudden serious illness or the death of a loved one

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Psychiatric crisis nurse team

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Advanced life support provider who can perform advanced techniques, cardiac monitoring, airway management, intubation, or IV drugs in route to the hospital

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Paramedic

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Offers basic life support interventions such as oxygen, basic wound care, splinting, spinal mobilization, and may carry AED's

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EMT (emergency medical technician)

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Obtains patient histories, collects abuse and domestic violence evidence, and offers counseling and follow up for victims of rape and child abuse

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Forensic nurse examiner

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Physician with specialized education and training in emergency patient management

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Emergency medicine physician (EMP)

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Safety considerations

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-Patient identification: Unknown ID, use specialized system -Injury prevention for patients: Keep side rails up -Risk for errors and adverse events: Search for weapons if suspected -Injury prevention for staff: Assistance from security if necessary

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NCLEX Question: The ED nurse is caring for a patient who was found in an alley with no identification and no known family. The nurse must give medication to the patient. What is the correct procedure? A. emergent conditions prevent identification, so the nurse gives the medication as ordered. B. the patient is designated as John Doe and the nurse uses 2 unique identifiers. C. the nurse validates the order with another nurse and both verify that the patient is unidentified. D. the nurse gives the medication and identification is made as soon as possible

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ANS: B No rationale, sorry :(

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NCLEX Question: An 88-year-old man is admitted to the ED from home with weakness and acute confusion. What is the nurse's priority for his care to maintain client safety? A. Assess his mental status every 30 minutes. B. Ensure that siderails are raised on his stretcher. C. Check his bowel sounds for intestinal obstruction. D. Teach him to move slowly when walking.

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ANS: B Rationale: To maintain client safety, older adults who are on beds or stretchers, especially those who are confused, should always have all siderails up with the bed or stretcher in the lowest position. It is important to assess the client's mental status and bowel sounds and to teach him to move slowly when walking, but the greatest priority is maintaining safety.

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Basic life support

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Non-invasive assessment and management skills for airway maintenance and cardiopulmonary resuscitation

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Advanced cardiac life support

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Invasive airway management skills, pharmacology, and electrical therapies, special resuscitation

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Pediatric advanced life support

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Neonatal and pediatric resuscitation

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Certified emergency nurse

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Validates core emergency nursing knowledge

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Triage

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Organized system for sorting or classifying patients into priority levels depending on illness or injury severity

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Triage system categories

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Emergent, urgent, non-urgent (Most commonly used, but there are other system categories)

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Emergent

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A condition that causes an immediate threat to life or limb Example: chest pain or shortness of breath with diaphoresis, respiratory distress, active hemorrhage, unstable VS, anyone that says they are having an allergic reaction (even if it doesn't seem like it)

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Urgent

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Patient should be treated quickly but immediate threat to life does not exist at the moment Example: pneumonia (as long as respiratory failure does not appear eminent), severe abdominal pain, renal colic, complex lacerations not associated with major hemorrhage, soft tissue injuries, displaced fractures or dislocations, temperature greater than 101°F

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Non-urgent

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Can generally tolerate waiting several hours for healthcare services without a significant risk for clinical deterioration Example: sprains and strains, simple fractures, "cold" symptoms, skin rashes

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NCLEX Question: The nurse assesses five clients who are just admitted to the ED. Triage these clients in the order that they should receive care: 1. 27-year-old with flulike symptoms 2. 47-year-old with an abdominal gunshot wound 3. 55-year-old with crushing chest pain 4. 72-year-old with possible hip fracture 5. 90-year-old with a probable urinary tract infection

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2, 3, 4, 5, 1 Rationale: The client admitted with a gunshot wound to the abdomen is a trauma client who likely sustained organ trauma and is bleeding extensively. This client requires the greatest level of attention and must be prepared for the OR immediately. The second client to receive care would be the person experiencing crushing chest pain, because he or she may be experiencing a myocardial infarction and rapid assessment and intervention is required. The older adult with a hip fracture will likely be experiencing pain and will require an x-ray before further treatment can be given. The 90-year-old with a probable UTI may be experiencing confusion (a common symptom of a UTI in an older adult), so protecting this client's safety is a higher priority than the younger client with flu-like symptoms.

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NCLEX Question: Paramedics have arrived on the scene of an explosion at a local refinery. Numerous serious and life-threatening injuries have occurred. Which client is considered a priority for treatment? A. Child with an open fracture of the arm B. Man with a contusion on the head C. Teenager with a closed fracture of the leg D. Woman bleeding heavily

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Answer: D Rationale: The woman critically injured with trauma or an active hemorrhage is prioritized as emergent. The emergent triage category implies that a condition exists that poses an immediate threat to life or limb and should be treated immediately.

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For each patient listed indicate whether they should be triaged as emergent, urgent, or non-urgent A. 56-year-old man with severe unilateral back pain and previous history of kidney stone's B. 23-year-old woman with severe abdominal pain, positive home pregnancy test, blood pressure 90/50 C. 35-year-old man with chest pain and diaphoresis D. 10-year-old girl with vomiting, diarrhea, and abdominal pain onset four hours after eating fish E. 6-year-old with a temperature of 101°F and flu-like symptoms F. 44-year-old man with a dislocated elbow G. 85-year-old man with new onset confusion, BP elevated compared to his usual reading H. 65-year-old woman with redness and swelling on the forearm associated with a bee sting

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A. Urgent B. Emergent C. Emergent D. Urgent E. Non-urgent F. Urgent G. Emergent H. Non-urgent

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Deaths in the emergency department

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-One or two family members may be present during resuscitation efforts -If patient dies before family arrives prepare body and room for viewing -If death requires forensic investigation, cleaning of body and viewing may not be possible due to potentially contaminating evidence

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T or F All emergency department that offer around-the-clock emergency services are trauma centers

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F NOT all emergency departments are trauma centers. Trauma centers must be accredited and categorized from highest level of capability (level I) to lowest (level IV)

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Trauma level: Usually located in large teaching hospital systems in densely populated areas; provide full continuum of trauma care for all patients

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LEVEL I

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Trauma level: Located in community hospitals; provide care to most injured patient; transport patients to higher levels if patient needs exceed resource capabilities

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LEVEL II

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Trauma level: Located in community and rural hospitals; stabilize major injuries and transport to higher trauma level if patients needs exceed resource capabilities

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LEVEL III

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Trauma level: Located in rural and remote areas; provide support; transport to higher trauma center when able

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LEVEL IV

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Trauma system

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Organized and integrated approach to trauma care designed to ensure that all critical elements of trauma care delivery are aligned to meet the injured patients needs. Elements include: -Access to care communication technology (ex: 911 service) -Timely availability of prehospital emergency medical care -Rapid transport to a qualifier trauma center -Early provision rehabilitation services -System-wide injury prevention, research, and education initiatives

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Mechanism of injury (MOI)

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Describes how the patients Trumatic event occurred; knowing key details about the MOI can provide insight into the energy forces involved and may help trauma care providers predict injury types, and in some cases, patient outcomes

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Five mechanisms of injury

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Blunt trauma Blast effects Acceleration-deceleration forces Penetrating trauma Falls

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Results from impact forces

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Blunt trauma ex: Motor vehicle crash, a fall, assaults with fists or kicks, baseball bat

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Results from explosion which may also cause a blunt trauma

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Blast effect ex: Blast force from bomb explosion

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Results from the energy transmitted from blunt trauma mechanism Produces injury by tearing, shearing, and compressing anatomic structures Trauma to bones, blood vessels, and soft tissues occur

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Acceleration-deceleration forces ex: High-speed crash, fall from great height

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Injury from sharp object and projectiles

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Penetrating trauma ex: Knives, ice pick, bullet, shrapnel

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Most common mechanism of head and cervical spine injuries

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Falls

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Primary survey

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-Initial assessment of the trauma patient -Based on the standard "ABC" mnemonic plus a D and E for trauma patients - "What is going to kill my patient NOW?"

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A

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Airway/cervical spine -The highest priority intervention is always establish a patent airway -Protect the cervical spine and any trauma patient with the potential for spinal injury by manually aligning the neck in neutral -Provide supplemental oxygen for all patients regardless of comorbidities (per Michelle)

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B

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Breathing -After the airway is secured breathing becomes the next priority -Listen to breath sounds and evaluate chest expansion, respiratory effort, and any evidence of chest wall trauma or physical abnormalities -Chest decompression may be necessary in this phase if tension pneumothorax is indicated via chest tube or needle

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S/S of Tension pneumothorax

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Decreased or absent breath sounds over the affected side Respiratory distress Hypotension Jugular vein distention Tracheal deviation

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C

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Circulation -Is there active bleeding? if so, STOP IT with pressure -2 large bore IVs -Pull "rainbow" blood, No cultures right now -May insert central line depending on location and severity of injuries

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D

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Disability -"DA BRAIN" = Neurological -AVPU = Alert and oriented Voice; are they responsive Pain; are they responsive Unresponsive -Substance intoxication can impair proper measurement

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E

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Exposure -Remove all clothing for proper assessment -Cut away clothing only if necessary: Rapid access to body is critical; manipulation of limbs/body will cause further injury; burns -Prevent hypothermia: cover with warm blankets, use heat lamps, infuse warm solutions

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Secondary survey

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-After immediate life threats have been addressed a comprehensive head-to-toe assessment to identify other injuries or medical issues that need to be managed are assessed - F-J

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F

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Full set of vitals -Cardiac monitor -EKG -Rectal Temp (anal sphincter assessment, spinal injury) -SpO2 -NG tube if needed (decompression) -Foley if needed (looking for blood)

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G

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Give Comfort -Warm blankets -Bring family to bedside -Pain meds, ice/heat -Emotional support

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H

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Head to toe Assessment -Top to Bottom -Look, Listen, Feel -AMPLE: Allergies Medications PMH Last meal Events surrounding injury

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I

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Inspection of posterior surfaces -Log roll (support spine)

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J

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Justify walking away - 1:1 always! - Always assessing neurological status - Look for Cushing's Triad: increased BP, decreased HR & RR

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Special Considerations for the Elderly

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-Prone to Falls -Osteoporosis -Post-menopausal -Skin breakdown -Comorbidities

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Disposition

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-Will the patient be admitted, discharged or transferred to a tertiary care facility? -Want pt out of ER asap for comfort and safety

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