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Study Guide Emergency and Trauma Nursing

Emergency Nursing
Characteristics of Emergency Departments:
y y y Chaotic and rapidly changing Safety net by providing services to insured and uninsured seeking immediate help Critical access hospitals = provide around the cock emergency care services 24-7 & necessary providers of health care to residents not close to other hospitals y y y y y Fast paced Chaotic & many distractions Variety of acuity levels Often over crowded May be temporary bridge to establishing relationship w/care provider room for errors

Most common complaints in ED:
y y Chest pain Abdominal pain y y Fever Headache

Characteristics of ED Nurses
y y y Dislike routine Broader knowledge of disease processes Broader client base from young to old y y Comfortable treating patients anyway Able to wear many hats ² cardio, peds, phsych, trauma

Nursing Team members in ED
Forensic Nurse Examiners (RN_FNE)
y y y y Obtain pt histories, collect forensic evidence, offer counseling and follow up care for victims of rape, child abuse, domestic violence (aka intimate partner violence IPV) Trained to recognize abuse & to intervene on pt behalf SANE or SAFE = sexual assault nurse examiner or sexual assult forensic nurse Interventions: o Providing information about developing safety net o o How to escape a violent relationship Document injuries o Collect physical and photographic evidence Testify in court

o

Psychiatric crisis nurse team
y y Interact w/pt & family in crisis Evaluates people w/psychiatric complaints or mental illness y y Facilitate follow up or adm to appropriate facility Improves quality of care to pt needing psychiatric intervention

Interdisciplinary Team
y y Prehospital Care Providers = EMT/paramedics = valuable source for data Support Staff = techs (radiology, lab, etc) + social workers + other therapists (respir, etc) + case managers

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Study Guide Emergency and Trauma Nursing

Hand off communication = process for patient safety = standardized approach
y y y y Situation (why in ED) Brief medical hx Assessment and dx Transmission based precautions needed y y y Interventions Response to interventions Requires efficient communication skill and respectful negotiation

Staff safety concerns => focus on potential for transmission of disease & personal safety (violent pt, aggressive, agitated, etc) standard precautions at all times + recognizing hazardous plan options for violence, s.a. security conditions and behaving accordingly

Most common pt errors = fall risk & patient identification

Pt Safety:
Patient identification:
y Id bracelet ² gen·lly issued @ triage or bedside y y 2 unique identifiers (name, dob) Use of special id system if pt id unknown

Injury prevention:
y y y y Keep rails up on stretcher Stretcher in lowest position Remind pt to use call light Reorient confused pt y y y If confused pt, ask family member, friend, etc. to remain w/him or her Implement retentive measures if @ risk for skin breakdown NPO ² check for dehydration Search pt belongings when/if have altered mental status

Error risk & adverse events:
y y Obtain thorough pt and family hx Check pt for medical alert bracelet or necklace y

Fall Prevention:
y y y Starts with identifying people at risk for falls then applying appropriate precautions Vulnerable group = older adults + pain meds + sedation + lower extremity injury + syncope Assist pt when moving from supine (flat) position to upright position y y y Siderails up and locked Call light/bell w/n reach Fall risk communicated clearly to visitors & staff members

y

Older adults:
o o o Always have all siderails up Bed/stretcher in lowest position Instruct pt to call for nurse if need assistance  Not to ambulate independently o May have issues of confusion reorient  Ask family member/sig other, sitter to stay w/pt to prevent falls

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Study Guide Emergency and Trauma Nursing

Protecting Skin Integrity:
y y y Begins in ED Assess skin frequently Preventive interventions esp. w/ older adults or immobilized o o o Clean, dry, skin (esp w/incontinent pt) Decrease shearing forces Routine turning to prevent breakdown

Potential for medical errors (& adverse events)
y y Especially med adm Make every attempt to obtain essential medical hx y Search belongings if need = nurse as detective o Incl medications too

Scope of practice/core competencies:
y y Birth through end of life Foundation = assessment o o o Discern norms for abnormal Comorbidities = pre-existing disease states Priority setting    y o o o Depends on accurate assessment And good clinical decision making skills Gained through hands on experience & discussions, case studies, etc

Broad knowledge base Critical care emergencies to less common problems Must learn to recognize and manage legal implications of societal problems May initiate interdisciplinary protocols for interventions    Cardiac monitoring Oxyten therapy May have protocols that all initiation of drug therapy for emergent conditions y y  y y o   Anaphylactic shock Cardiac arrest When needed Obtaining them  IV caths and infusions

Need to know lab and dx tests

Proficiency in variety of skills Critical care equipment Familiarity w/Procedural skills: y y y y y Simple & complex suturing Foreign body removal Central line insertion Endotracheal intubation Transvenous pacemaker insertion y y y y y y y Lumbar puncture Pelvic exams Chest tube insertion Peritoneal lavage Paracentesis Fracture management Etc

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Study Guide Emergency and Trauma Nursing
y y y Clinical decision making o Including backing up why made the decision Includes appropriate delegation Essential Overcoming barriers to effective communication Multi-tasking o Communication o o

Training/certification:
y y y y Basic Cardiac Life Support (BCLS) = CPR + noninvasive airway maintenance Advanced Cardiac Life Support (ACLS) = invasive airway management, pharm, electrical therapies, special resuscitation Pediatric Advanced Life support (PALS) = neonatal + ped rescucitation Certified Emergency Nurse (CEN) = validation core emergency nursing knowledge base

Principles of ED Nursing:
Triage = sorting or classifying pat into priority levels based on illness or injury severity needs quickest eval, tx, prioritization, etc. Use of nursing process:
y assess and dx o accurate and quick assessments needed y y acuity o quickest care acuity has to wait Independently perform triage Following protocols  Presentation suspicious for pneumonia y    o y Rapid dx and tx w/ATB w/n 4h Administration of Oxygen Cardiac monitoring IV ACCESS   Collecting samples (urine, blood, etc) before seeing physician Triage nurse initiation for lab work or dx tests before pt seen by physician o o sorting information planning and implementing

highest acuity

RN as ´gatekeeperµ o o

Initiation of care while pt on stretcher in hallway of overcrowded ED To see if anything changes, develop therapeutic relationship, vital signs change, etc.  Obligation to profession and community

Check on waiting patients o

3 Tiers of triage:
Emergent = condition poses immediate threat to life or limb

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Study Guide Emergency and Trauma Nursing Urgent = pt should be treated quickly but no immediate threat to life at this moment reassessed d/t changes Nonurgent = can tolerate waiting w/o significant risk of deterioration = sprains, strains, simple factures, ´colds,µ rashes Emergency Severity Index = 5 tier system from level 1 (=emergent) to level 5 (=nonurgent) y y Rapid, reliable, clinically pertinent Uses both acuity and prediction of resources to categorize priorities
Examples Respiratory distress Chest pain with diaphoresis Active hemorrhage Unstable vitals Severe abdominal pain Renal colic Displaced or multiple fractures Complex or multiple soft tissue injuries New onset respiratory infections, esp in older adults w/suspected pneumonia Skin rash Strains and sprains ´coldsµ Simple fractures

pt must be

Tier level Emergent = life threatening

Urgent = quick tx but not life threatening

Nonurgent

Care of Patient:
Many different reasons for patient to visit ED, commonalities = y y y Maintaining privacy and dignity o Double gown pt + sheet or blanket Keeping voice low when discussing Medication administration Specimen collection Assistance w/bedside procedures Discharge planning What to delegate to techs Maintaining confidentiality o Nurse responsible for follow up care o o o o o y y

May need to reassess and reprioritize whenever necessary Awareness of cultural values o o Language barriers Religious prohibitions  Jehovah·s witnesses cannot have blood transfusions

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Study Guide Emergency and Trauma Nursing Patient disposition = conclusion of work up by physician
o Admit to facility or different facility  o o o Usually physician call but often in collaboration w/nurse someone stays with pt for 1st 12-24h to be sure no sx neuro deterioration Communicate with next step Head injury w/LOC  Potential risk to pt w/actual or suspected domestic violence May admit pt to hospital if home unsafe

Case managers
y y y y Intervene when necessary to provide referral and follow up Use technology Relationship/decisions, etc. Interventions: o o o o o o Look at insurance, documentation, referrals to primary care, disease managment, medications, appropriate resources including nutrionist, organization o o o o disposition for homeless ppl, victims of domestic violence, etc home health agency referrals Community resources True emergency support as well

Care of mentally ill patient
y y y y y Top priority = safe environment for patients, families and staff Range from anxiety to suicidal and homicidal ideation Unpredictable and problematic behavior Substance abuse may exacerbate Strive to create therapeutic environment thru assessment skills and interventions o y Pharm and non-pharm y Direct observation = trained staff assigned to stay w/patient o y De-escalation techniques = light o o Making pt comfortable Then establish behavioral expectations and set limits  May need reinforcing Creating ´safeµ enviro to prevent pt from harm or harming May need other personnel (social workers, etc) too noise, harsh

Patient and family education: y Teaching:
o o o Emergent role Reviews discharge instruction Wellness and injury prevention strategies  Example: Reinforce need to wear seatbelt w/mva

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Study Guide Emergency and Trauma Nursing Death in ED:
y y During resuscitation may have 1 or 2 family members present o Other code situations may require having someone there for the family Pull tubes Call coroner, morgue, etc. If patient dies, staff makes every effort to prepare body and room for viewing by family o o y y y

Some ED deaths require forensic investigation or medical examiner case Communication = simple, concrete, direct language o Use death or died Intense grief can provoke wide range of responses silence violence Be caring, compassionate, empathetic o

Nurse response to Death in ER:
y y Holistic care Attend to family y y Respectful handling Keep cultural aspects in mind

Trauma Nursing Principles
Trauma = bodily injury
y y y Intentional or unintentional Unintentional = leading cause of death for Americans under 35 yo Intentional = assault, homicide, suicide, etc

Core competency = key component of emergency department sercives
Trauma nursing encompasses continuum of care from prevention to acute to rehab to community reintegration

Trauma Centers = based on MASH system = specialty care facility with competent and timely trauma services to patients, based on designated capacity level. 3 levels: Level I
y y Usually in large teaching hospital in densely populated area Full continuum of care for all pateient care = prevention through rehab y y y y Responsibility to offer professional and community edu programs Conduct research Participate in system planning Often play leadership role in community o o o o Injury management Education Prevention Emergency preparedness planning

Level II
y y y Generally community hospital Capable of providing care to vast majority May not have resources for complex injury management o Transfer to Level I center for care

Level III
y y y Critical link to higher capacity centers Stabilizes injuries Smaller, rural hospitals

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Study Guide Emergency and Trauma Nursing
y y General surgeons and orthopedic surgeons available Major injuries = transfer to I or II center AFTER assessment, resuscitation, stabilization, and sometimes after emergent lifesaving surgery o Typically transfer pt via advanced life support ambulance or medflight Stabilize pt to best degree before transfer o Use AP nurses, PAs, nursing assistants, paramedics y y Limited resources

Level IV
y y Advanced life support care in rural or remote settings Transports to higher trauma centers when able y

All levels:
y y Personnel required to participate in performance improvement Patient safety initiatives Enhancement of quality of care and solve identified problems

Trauma System = organized and integrated approach to trauma care designed to ensure all critical elements of trauma care deliver aligned to meet injured needs including: 
  Access to care through communication technology (enhanced 911 services) Timely availability of prehospital emergency medical care Rapid transport to qualified trauma center     Early provision of rehab services System wide injury prevention, research, edu initiative Also provides structure for disaster readiness Community emergency preparedness

Mechanism of Injury = MOI = manner in which traumatic event occurred 
Prehospital care providers communication standard = report MOI w/hand off o Knowing key details may enable prediction of injury types and outcomes

Two most common MOI = blunt force trauma + penetrating trauma  Blunt force trauma = result of impact forces like mva, falls, assault w/fists, kicks, baseball bat
y y Blast effect (from exploding bomb, etc) also causes Acceleration-deceleration forces o o High speed crashes, falls, Injury by tearing, shearing, compressing anatomic structure Trauma to bones, blood vessels, soft tissue

o body
y 

Penetrating Trauma = injury from sharp objects and projectiles ² something physically penetrates
Examples = knives, ice picks, bullets, pellets, etc. o Fragments (shrapnel) from explosion 

Trauma activation criteria = rapid coordinated resuscitation response d/t injuries associated with life threatening consequences such as gunshot wound to torso or stab wound to neck Primary survey and resuscitation interventions
y Scene safety = basic tenet of emergency care in any environment standard precautions must be worn in all resuscitation situations & @ other times w/exposure to blood and body fluid

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Study Guide Emergency and Trauma Nursing
o Impervious cover gown + gloves + eye protection + facemask + surgical cap + shoe covers if significant blood loss anticipated (like w/athoracotomy) y Primary survey = organizes approach so that immediate threats rapidly identified and interventions applied

ABCDE = airway/cervical spine + breathing + circulation + disability + exposures
A=Airway/Cervical Spine
y Highest priority = establish patent airway o o o Inadequate O supply Protect cervical spine  Manually align neck in neutral inline position y y Jaw thrust maneuver Supplemental O required for all pt requiring resuscitation o o ROT: non-rebreather mask Bag-valve-mask with appropriate airway adjunct + 100% O2 for pt needing ventilator assistance o Pt w/ significantly impaired LOC requires definitive airway ² endotracheal tube  o mechanical ventilation Initially 100% O2, may be lowered after condition improves prepare for endotracheal cerebral injury anoxic brain death Clear secretions/debris w/ suction or manually

If Glasgow Coma Scale score 8 or pt at risk for airway compromise intubation + mechanical ventilation

B= Breathing
y y y y After airway secured, this is next priority Assess breath sounds and respiratory effort Observe chest wall trauma or physical abnormality Assessment determines whether or not ventilatory efforts are effective NOT whether or not pt is breathing o Focus = auscultation of breath sounds + evaluation of chest expansion+ respiratory effort + evidence of chest wall trauma/physical abnormalities y y y Until endotracheal intubation, BVM (Bag Valve Mask for positive pressure ventilation) support esp w/apneic & poor ventilatory efforts CPR disconnect mechanical ventilator and use BVM  o       Lung compliance assess by sense degree of difficulty w/BVM

Chest Decompression (w/needle or chest tube to vent trapped air) Main indication of need = clinical evidence of tension pneumothorax Critical threat to breathing and circulation SX = or absent breath sounds over  affected area Respiratory distress Hypotention Jugular vein distention Tracheal deviation (late sx)  Unrelieved mediastinal shift + death cardiovascular collapse

Causes = barotraumas from BVM/other positive pressure ventilation + blunt or penetrating chest trauma + expansion of simple pneumothorx

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Study Guide Emergency and Trauma Nursing
o 2 ways to decompress chest  Needle thoracostomy y y Quick, temporary used in emergency to vent before insertion of chest tube Large-bore needle (14-16 gauge IV cath) inserted into 2nd intercostals space in midclavicular line o o  Expect ´rush of airµ Documentation of air rush confirms presence of tension pneumothorax

Tube thoracostomy y Chest tube inserted into 5th intercostals space anterior to medaxillary line o o Promotes air and fluid drainage If hemothorax capabilities  prepare chest tube drainage system w/autotransfusion collected pleural blood can be transfused into pt if needed

Anticoagulant added per mfg recommendation to prevent clots

C=Circulation
y Adequacy of HR, BP, overall perfusion o o o y Monitor VS, esp BP + pulse Maintain vascular access by using large bore catheter Use direct pressure for external bleeding Cardiac arrests Myocardial dysfunction Hemorrhage shock

Common threats: o o o

y

Interventions: targeted to restore effective circulation through: o o o Cardiopulmonary resuscitation Hemorrhage control IV vascular access w/fluid & blood as necessary  y o o Best with large bore (16 gauge) peripheral IV line in AC area Other spots = central veins of femoral, subclavian or jugular sites Larger bore needle (8.5 or lower) Intraosseous for critically ill patients o o Drug therapy External hemorrhage = best controlled with firm, direct pressure on site w/thick dry dressing   o o WORKS even w/amputations DO NOT USE TOURNIQUETS UNLESS HEMORRHAGE IS SO SEVERE THAT RISK TO LIMB IS JUSTIFIED TO SAVE LIFE Internal hemorrhage = more hidden complication must be suspect in injured pt or w/shock ROT to assess BP via pulses (when no time for cuff)    o Radial pulse present = BP 80+ systolic Femoral pulse present = BP 70+ systolic Carotid pulse present = BP 60+ systolic    Lactated ringers or NS Warm before adm to prevent hypothermia ROT: significant hypotention after 2L infused consider need for blood product

Hypotension occurs = compensation mechanisms are exhausted

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Study Guide Emergency and Trauma Nursing 
Timely effective intervention critical for life and vital organ preservation

D = Disability
y y Evaluate LPC via: AVPU o o o o y A:Alert V: Voice ² responsive to voice P: Pain ² responsive to pain U:Unresponsive to assess LOC Scores eye opening, verbal & motor response Normal = 15, totally unresponsive = 3 o o Neuro injury Intoxicants

Glasgow Coma Scale o o

y

Causes of LOC impairments: o o Metabolic abnormalities Hypoxia

y

Need frequent assessment/reassessment for rapid intervention if neuro compromise or deterioration

E=Exposure
y y Remove clothing for complete physical assessment Always cut away clothing with scissors in these situations: o o y When rapid access to pt body is critical When manipulating limbs o further damage o Thermal or chemical burns cause fabric to melt into pt skin

Evidence preservation: handle items per institutional policy Collection vital in cases of rape, elder abuse, domestic violence, homicide, suicide, drug overdose, assult risk of hypothermia

y

After clothing removed o 

Body temperature ” 97oF (36oC) Especially issue w/burns o o o Coagulopathy Increased bleeding Slowed drug metabolism Set room temp 75-80O Use heat lamps, warming blankets, etc

y

Hypothermia complicates management by: o o Vasoconstriction Difficulty w/venous access and arterial assessment

y

Interventions for hypothermia: o o o Remove wet sheets/clothing Cover pt with blankets Infuse only warm solutions and blood products o o

Secondary Survey =by resuscitation team to identify other injuries or medical issues needed to be managed or impact on the course of treatment

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