Emergency/Trauma Nursing Ch 10 – Flashcards

Emergency departments (ED) are fast-paced and overcrowded environments that care for patients across the life span with a broad spectrum of issues, illnesses, and injuries, as well as various cultural and religious values.

Patients who are uninsured (poor), homeless, and older adults.

The role of the ED is so vital that the Centers for Medicare and Medicaid Services (2010) has a process for designating small, rural facilities of 25 inpatient beds or fewer as critical access hospitals if they provide around-the-clock emergency care services 7 days per week.

Rapid change is the rule. Nurses who are drawn to this environment generally dislike routines and thrive in challenging, stimulating work settings.

Patient acuity ranges from life-threatening emergencies to minor maladies that could be addressed in a clinic, including things such as chest pain, abdominal pain, difficulty breathing, injury, poisoning, headache, and fever.

Because the current health care system is complex, expensive, and difficult to navigate, some patients view the ED as an access route to basic health care, where it serves as a safety net for patients who are ill or injured but lack access to health care.

o Forensic nurse examiners are educated to obtain patient histories, collect evidence, and offer counseling and follow-up care for victims of rape, child abuse, and domestic violence. o The psychiatric crisis nurse team interacts with patients and families in crisis, such as following the sudden illness, serious injury, or death of a loved one, or those with psychiatric complaints, and facilitates follow-up with an appropriate facility.

o Prehospital care providers are typically the first caregivers encountered by the patient before transport to the ED. o Emergency medicine physicians receive specialized education and training in emergency patient management. o Other professional and ancillary staff functions in support roles such as radiology and ultrasound technicians, respiratory therapists, laboratory technicians, and social workers. o Communication with staff nurses from the inpatient units ensures continuity and provides a comprehensive report of the ED experience for the hand-off communication process and patient safety.

• In the emergency department setting, staff and patient safety concerns center on the potential for transmission of disease and on personal safety when dealing with aggressive, agitated, or violent patients and visitors. • Many EDs have at least one security guard present at all times for immediate assistance. • Metal detectors may be used as a screening device and strategically located panic buttons and remote door access controls allow staff to summon help and secure major ED or hospital entrances. • Common patient safety issues in the ED include patient identification, fall risk, skin breakdown in vulnerable populations, and high risk for medical errors or adverse events. • Older adults who are on beds or stretchers should always have all side rails up and the bed or stretcher in the lowest position. Access to a call light or communication system is especially important.

• While awaiting unit bed availability, which may be a long time, basic health needs require attention, including providing nutrition, hygiene, privacy, meeting elimination needs, and protecting skin integrity. • A significant risk for patients of all ages in the ED is the potential for medical errors or adverse events. • To reduce error potential, the emergency nurse makes every attempt to obtain medical history information from the patient, family, or reliable significant others. • When dealing with patients who arrive with an altered mental status, a quick survey to determine whether the individual is wearing a medical alert bracelet or necklace is important.

• Emergency nursing practice requires that nurses are competent in patient assessment, priority setting and clinical decision-making, knowledge of ED operations, technical skills, multitasking, and communications. • The foundation of the emergency nurse's skill base is assessment and accurate discernment of normal from abnormal and understanding the significance of pre-existing disease states. • The nurse often initiates interdisciplinary protocols for life-saving interventions such as cardiac monitoring, oxygen therapy, insertion of intravenous catheters, and infusion of appropriate parenteral solutions and drug therapy.

• The emergency nurse must also be proficient in performing a variety of technical skills (multitasking), sometimes in a stressful, high-pressure environment, such as cardiac or trauma resuscitation, and must be proficient with critical care equipment and procedures. • Patient education as part of the discharge plan is an important part of ED nursing practice.

• The concept of ED triage is based upon sorting or classifying patients into priority levels depending on illness or injury severity. • The three-level triage model categorizes patients as emergent, urgent, and nonurgent. The Emergency Severity Index is a five-tier triage system that uses both acuity and the prediction of resources to rapidly categorize the priority of patients. • Because patients have a variety of health care needs in the ED setting, nursing care needs are highly variable as well. • Certain common care is provided for all emergency patients, including a nursing assessment, and interventions based on treatment protocols, such as application of oxygen, cardiac monitoring, IV access, and collection of lab specimens, before the patient is seen by a physician.

• The emergency nurse needs to be aware of the various cultural values of patients that may impact care, such as religious beliefs and language barriers. • ED nurses are accountable for preventing or reducing risks to older adults while in the ED, such as falls, medication errors, pressure ulcers, and hospital-acquired infections. Communication with the older adult may be challenging if he or she has memory loss or develops acute delirium while in the ED. • The care and management of patients with mental illness poses a particular challenge for the emergency nurse. The main priority is to provide a safe environment for patients, families, and staff. • Some EDs employ registered nurse case managers who screen ED patients and intervene when necessary to arrange appropriate referral and follow-up. • A key nursing role is health teaching, which involves reviewing discharge instructions with the patient and family with consideration of the individual's needs, including reading level, primary language, and visual acuity.

• At the conclusion of the workup, the physician and nurse must collaboratively make a decision regarding patient disposition as an admission, to a specialty care center, or to home. • Patients who are admitted to the ED are treated and stabilized before discharge. Patients may be discharged to their homes or inpatient facilities. • About half of all older adults who visit the ED are admitted to the hospital. • A death in the ED is a sudden and unexpected event that produces a state of crisis and chaos for family and significant others. • Provide support for patients who lose a loved one; consult with the psychiatric crisis team as needed. • If the patient dies, prepare the body and the room for viewing by the family, keeping in mind that some deaths may become medical examiner's cases with restrictions.

• Injury management is a key component of emergency department services. • Trauma centers are categorized as Levels I through IV, based on their resource capabilities.

• The American College of Surgeons defines a Level I trauma center as a regional resource facility that is capable of providing leadership and total care for every aspect of injury, from prevention through rehabilitation. • Level II trauma centers generally reside in community hospitals and are capable of providing care to the vast majority of injured patients. • Level III trauma centers are located in smaller communities and serve as critical links to higher capability trauma centers. The primary focus is injury stabilization and patient transfer. • The function of a Level IV trauma center is to offer advanced life support care in rural or remote settings, such as a ski resort, that do not have ready access to a higher level trauma center.

• A trauma system is an integrated approach to trauma care assuring that all critical elements of trauma care delivery are aligned to meet the injured patient's needs including communication technology, prehospital care, rapid transport to a trauma center, early provision of rehabilitation, and injury prevention, research, and education initiatives. • The mechanism of injury describes the manner in which the patient's event occurred, such as a high-speed motor vehicle crash, a fall from a height, or a gunshot wound. • The two most common injury-producing mechanisms are blunt trauma and penetrating trauma. • Each mechanism has the risk for specific injury patterns and severity that the trauma team considers when planning diagnostic evaluation and management strategies.

• The initial assessment, termed the primary survey, organizes the approach so that immediate threats are rapidly identified and effectively managed, reviewing airway/cervical spine, breathing, circulation, disability, and exposure. • The trauma team then performs a more comprehensive head-to-toe assessment, known as the secondary survey, to identify other injuries or medical issues that need to be managed or that might impact the course of treatment. • Disposition upon leaving the ED may be immediate transport to the operating room or interventional radiology or admission to trauma critical care, step-down, or inpatient unit for continued medical management and nursing care.

Level I trauma center as a regional resource facility that is capable of providing leadership and total care for every aspect of injury, from prevention through rehabilitation.

Level II trauma centers generally reside in community hospitals and are capable of providing care to the vast majority of injured patients.

Level III trauma centers are located in smaller communities and serve as critical links to higher capability trauma centers. The primary focus is injury stabilization and patient transfer.

The function of a Level IV trauma center is to offer advanced life support care in rural or remote settings, such as a ski resort, that do not have ready access to a higher level trauma center.

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.

ANS: B, C, D, E, A 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.

ANS: B Rationale: For any client, the highest priority intervention is to establish a patent airway. Even minutes without an adequate oxygen supply can lead to a brain injury that can progress to anoxic brain death. Assessing for bleeding, starting IV lines, and assessing level of consciousness are all important interventions, but the highest priority is establishing an airway, followed by assessing breathing and circulation.

Suggested Responses: 1. Why are pressure ulcers common in older adults, especially those living in a nursing home? Pressure ulcers are common in older adults because of the risks of immobility, decreased sensation, inadequate nutrition, and moist skin related to incontinence. Delayed healing of impaired skin integrity may take longer in the older adult as a result of chronic diseases such as diabetes mellitus, cardiovascular conditions, and inadequate nutrition. 2. What plan of action do think would help decrease the incidence of pressure ulcer development in the identified highest-risk population? Protecting skin integrity also begins in the ED. Emergency nurses must assess the skin frequently and implement preventive interventions into the ED plan of care, especially when caring for older adults or those who are immobilized. Such measures include interventions that promote clean, dry skin for incontinent patients; mobility techniques that decrease shearing forces when moving the immobile patient; and routine turning to help prevent skin breakdown. 3. What role might you play in implementing this plan as an ED nurse? The ED nurse should do a thorough initial assessment of the skin upon admission to the ED and document the findings. The nurse should keep the patient's skin dry during the stay in the ED. The nurse should also reassess the skin during admission and upon discharge to the admitting unit, home, or long-term care facility. Frequent turning and repositioning will also decrease pressure, and movement should be performed using nonshearing methods. 4. With what members of the interdisciplinary team might this plan be implemented? The ED nurses, ancillary staff (patient care technicians or nursing assistants), transport teams, and physical therapists are members of the team that should be included in the plan of care. 5. What would be a reasonable outcome as a result of your plan of action? The expected outcome will be no evidence of skin breakdown during the patient's stay in the ED. Another outcome is the anticipated goal that an interdisciplinary approach will be required to achieve success.

2. Boarding or inpatient clients Correct: ED overcrowding has become a national problem, with frequent boarding or holding of admitted clients in the ED because of lack of beds in the hospital.

1. Forensic nurse examiner Correct: The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the client's behalf.

1. Blood and body fluid precautions Correct: The emergency nurse uses Standard Precautions at all times when there is the potential for contamination by blood or other body fluids.

1. Assessment Correct: Similar to any nurse in practice, the foundation of the emergency nurse's skill base is assessment. The nurse must be able to discern normal from abnormal rapidly and accurately, and must interpret assessment findings according to acuity and age.

4. Woman bleeding heavily Correct: 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.

2. Consult with Social Services. Correct: If discharge home is not deemed safe, the client may be admitted to the hospital until resources can be organized to provide a safe environment. Social workers or case managers are consulted to investigate resource needs and to plan accordingly.

1. Level I Correct: The American College of Surgeons defines a Level I trauma center as a regional resource facility capable of "providing leadership and total care for every aspect of injury, from prevention through rehabilitation."

4. Monitors the client Correct: Blunt trauma results from impact forces. The energy transmitted from a blunt trauma mechanism, particularly the rapid acceleration-deceleration forces involved in high-speed crashes or falls from a great height, produces injury by tearing, shearing, and compressing anatomic structures. Injury may not be evident right away.

3. Clear the airway. Correct: Even minutes without an adequate oxygen supply in humans can lead to cerebral injury. This can progress to anoxic brain death. The airway should be cleared of any secretions or debris with a suction catheter or manually if necessary.

2. Reduce noise and harsh lighting. Correct: De-escalation techniques involve decreasing stimulation in the environment by reducing noise and harsh light.

Provide an ID bracelet for each patient Use 2 unique identifiers (name, DOB) If pt ID is unknown, use a special ID system

Keep rails up on stretcher Keep stretcher in lowest position Remind the pt to use call light/bell for assistance Reorient confused pt frequently If pt is confused, ask family/sig other to remain w/ the pt Implement skin breakdown prevention measures for at risk pts

Obtain a thorough pt and family hx Check the pt for med alert bracelet/necklace Search pt belongings for weapons/harmful devices when/if AMS

Use STANDARD PRECAUTIONS at all times. Anticipate hostile, violent pt, family, and/or visitor behavior. Plan options if violence occurs, assistance from security

Older Adults usually come to the ED for a worsening existing chronic condition or bc the condition affects their ability to perform ADLs Don't want to "bother" PCPs Sometimes admitted from nursing home/assisted living for procedures: PEG tube insertion PICC line insertion Blood Transfusion Some hospitals direct admit these pts to decrease pt wait time and decrease risk for pressure ulcers/hospital acquired infection